More on EMCrit
Now on to the Grilling
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit 342 – More Cardiac Arrest Mastery with PO Berve – Pre-Tidal CO2 - January 27, 2023
- EMCrit – Ghali Grills 2 – Should You Tube the Patient in Severe Hemorrhagic Shock if there is a Delay to OR? - January 21, 2023
- EMCrit 341 – AVAPS (Average Volume Assured Pressure Support)NIPPV with Alex Bracey - January 11, 2023
Fascinating discussion. How obtruded or to what GCS (fully aware how limited the GCS is as a scoring tool on this setting) do u need this pt to avoid post intubation awareness? How do u decide ongoing management strategies for anaesthesia/ sedation until surgery is about to begin?
I just noticed the auto correction! Obtunded not obtruded!
Use clinical judgements for intubating rather than using blood gas values and also if the predicted course of the pathology is expected to worsen rather intubate after proper resuscitation with use of blood products before use of pressors…
Brilliant discussion there,few points since iv been caught many tyms between ED/OR for hemorrhagic cases and intubations 1. Ketamine is best way to go but it can have cardiodepressant effect in grade 3 to 4 hem shocks where there is catecholamine depletion setting in 2.already lactates high, u dont want to wait and let respirstory muscles fatugue causing further resp( co2 accum) plus muscle fatigue lactate ( metabolic) acidosis 3.RSI is best ,i want airway secure, aspiratiin from full stomach & altered mentation of shock 4. Id require direct vasopressors than indirect ones cuz cats already depleting. Ketamine needs catecholamines… Read more »
appreciate your comments!!! I have a review of the putative cardiodepressant effects of ketamine in the works–I have reviewed all of the extant literature for this work. I have yet to find any clinical evidence of the oft stated idea of negative inotropy at commonly used doses. At the doses that are actually required to dissociate patients in the midst of critical illness, I cannot imagine any cardiodepressant effect. We now have RCTs demonstrating hemodynamic stability in very sick patients–I predict, the catechol depletion unmasking neg inotropy idea will fall away just like the increased ICP myth, For #5–that was… Read more »
I’d like to thank you guys for this post—it makes me think about the various tools/meds/methods to handle these cases. I’ll add this. I want monitoring. I want an arterial line. I want an IV larger than an 18 gauge or the IO. Of course, I want it all!! (JK). Charge ahead without proper IV access and monitoring and you’re off to the races with CPR. With ultrasound, this should not be such an obstacle to obtain appropriate IV access and an arterial line. Nice blog entry—thanks again!
Hey Jim! Thanks for listening and for your comments brother. Agree and in general if there is time Arterial Lines are invaluable in these patients. By the way we did place a femoral A-line in the patient that sparked this discussion. Yup need bigger than 18’s and IOs just simply do not cut it for these patients at all. Blood is just far too viscous to flow through the bone marrow with any reasonable alacrity. I’m with you 100% re: US-guided lines but just to be clear for the readers bc I think this needs to be said (I know… Read more »
Given resuscitation with blood products, which pressors are you choosing in a RSI scenario? Vasopressin? Push Phenyl?
Hi, Peter. Neither of those options although we do have decent evidence that these patients probably eventually become catecholamine depleted and Vasopressin in particular may be a good choice later on. But in this ultra acute phase I think Epinephrine probably has the best overall physiologic profile for the purposes of RSI.
Thank you for a great post, and an interesting discussion. I have long taught trainees (and been taught at LAC) that RSI should occur in OT, so it was interesting to get some different insights. I work in Sydney where the experience of large volumes of patients in haemorrhagic shock patients is low (in comparison to other busy places) per centre. So therefore I often encounter anaesthetists using quite liberal amounts of metaraminol (alpha agonist sim to phenylephrine) to counter the effects of their choice of anaesthetic, usually propofol (!!) plus inhaled gas. I have mentioned considering these patients similar… Read more »
Matt, see the old podcasts with Rick Dutton on the site–they discuss this intensely. TLDR-avoidance of vasopressors in young patients with intact catechol system is the way to go. In fact, gently shedding their endogenous catechols is the goal. In older pts, things may shift as they may have a vasodilated milieu.