In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south.
2nd Vasopressor Stop Point
Rapid Ultrasound for Shock and Hypotension (RUSH) Exam
The RUSH Exam will allow rapid diagnosis of the cause of non-trauma hypotension
Abdominal Compartment Syndrome
See this crashing patient chapter for more on Abdominal Compartment Syndrome
- Is there actually hypotension? Consider femoral a-line. Consider dissection/vascular obstruction at the site of BP Measurement.
- Systolic Anterior Motion
- Consider Tox
- Is this actually cardiogenic shock from ischemia/MI rather than sepsis
- Is there occult right ventricular failure that could be treated (e.g. with pulmonary vasodilation)?
- Is there low cardiac output and impaired perfusion (e.g. mottling)? In that case, additional vasoconstriction may simply aggravate matters.
- Is there a failure of surgical source control or incorrect antibiotic selection?
- Is the patient on adequate adjunctive therapy (stress-dose steroid, possibly thiamine/ascorbate)?
- Is there a pH abnormality that merits correction (e.g. treatment of hyperchloremic metabolic acidosis with bicarbonate)?
- Is there autoPEEP
- Is there clinically significant hypocalcemia?
Cognitive Stop Points for the Resuscitationist
Use this method whenever the situation doesn't add up or is going bad:
- Announce you have no idea what the f**k is going on
- Eliminate ALL assumptions
- Troubleshoot like an engineer
My friend Clay Smith of the KeepingUp Podcast has just put out a new, FREE!, IOS app called Upshot that combines his literature reviews and podcasts into one beautiful package.
Did you Like this Episode? Then tweet the hell out of it:
Podcast 87 is a Mind of the Resuscitationist Episode on Stop Points and Engineers http://t.co/GjMhiLVB
— the EMCrit Crew (@emcrit) November 26, 2012
Now on to the Podcast…
- EMCrit 303 – A Bounceback Case with Mike Weinstock - July 23, 2021
- EMCrit 302 – Pain Management Update with Sergey Motov - July 15, 2021
- EMCrit 301 – The Five Fears with Rob Orman (Mind of the Resuscitationist) - July 1, 2021