Clinical Pearl 84: “Normal” Saline vs Balanced Solutions for Fluid Replacement Therapy
Critical Care Anywhere
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3y ago
Peter Malamet DO On a daily basis in the emergency care setting, we see patients that require fluid replacement. From sepsis, diabetic ketoacidosis, dehydration, etc., we obtain intravenous access and give a few boluses (along with the cocktail of antibiotics, insulin, or vasopressors that is appropriate for the clinical scenario). However, disagreement exists as to which type of fluid is best to use for replacement. This pearl aims to summarize the current evidence comparing the most common crystalloid fluids - Normal Saline and Lactated Ringers. Intravenous fluids were first used in 1832 w ..read more
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Clinical Pearl 82: The DAWN STUDY-A New Error In Acute Stroke Mangement. Rick Figurasin M.D.
Critical Care Anywhere
by
3y ago
A patient presents with stroke like symptoms in the prehospital setting.  Patient was last seen normal about 3.5 hours ago.  Prior to that, family state patient was in his usual state of health - ambulating, conversing - without any difficulty.  You perform a quick assessment His medical history is significant for HTN, DM, and hypercholesterolemia.  Blood sugar is 194.  BP is 195/89 with a HR of 97.  The closest primary stroke center is 20 minutes away.  The closest comprehensive stroke center is 45 minutes away.  To make matters worse, a snowstorm is ..read more
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Clinical Pearl 81: What Is The Best Location for Needle Decompression of a Pneumothorax
Critical Care Anywhere
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3y ago
Case: A 58 year-old male who was the restrained driver of a vehicle struck on the driver’s side with no LOC, no airbag deployment and no other injured parties. The patient is complaining of shortness of breath and left sided chest pain. The patient appears to be in mild respiratory distress on arrival. During the history and while obtaining vitals the man becomes increasingly short of breath and anxious appearing. Initial vitals: HR: 101bpm, RR: 20, SpO2: 98% and BP: 125/80. During your physical exam decreased breath sounds are appreciated over the left chest and no bleeding, ecchymosis or def ..read more
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Clinical Pearl 80: Does Albuterol help in Bronchiolitis?
Critical Care Anywhere
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3y ago
An 11 month old male is having difficulty breathing. The baby appears comfortable but with intercoastal retractions, and nasal congestion. His RR is 42 bmp,  SpO2 is 93% on RA, HR is 120bpm. He has wheezing throughout both lung fields and mother tells you that this is his 4thday with this symptoms. Would Albuterol be your next step in treatment? The scenario clearly shows a child that meets criteria for bronchiolitis; for years we’ve been trying to figure out what can we do to make this patient better, and for years bronchodilators have been one of the first line treatments, but does it ..read more
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Clinical Pearl 79: Nebulized Lidocaine
Critical Care Anywhere
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3y ago
By: Katherine Tokarczyk, MD       Michael Carr, M.D. Lidocaine is well known to the medical community as a first line local anesthetic and cardiac antiarrhythmic agent. It acts by blocking voltage gated sodium channels in neurons (pain receptors) and in cardiac cells. In recent years its other implications have emerged into common practice for various clinicians. It has been used in the past for bronchoscopy to suppress coughing in the peri-procedural period. Perhaps more relevant to the acute care clinician, nebulized lidocaine can also be used to suppress retractable c ..read more
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Clinical Pearl 78: Does Naloxone Really Cause Pulmonary Edema?
Critical Care Anywhere
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3y ago
Case: 23 y/o male who is unresponsive found by his friends in an ally. Policearrive on scene first and find the patient to have a respiratory rate of four andpinpoint pupils. The decision is made to give 0.4 mg of intranasal Naloxone. The respiratory rate has improved to six per minute however his pupilsremain pinpoint and oxygen saturation is only 88% on room air. You administer an additional 0.4 mg IV and place the patient on a non-rebreather mask and shortly after the patient is alert and oriented to person, place, time, and situation. The patient becomes tachypneic to a rate of 30, is satu ..read more
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Clinical Pearl 77: Carbon Monoxide Poisoning: Is the RAD-57 Useful?
Critical Care Anywhere
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3y ago
Currently, the standard for measuring Carbon Monoxide (CO) is CO-oximetry spectrophotometry via blood gas analysis. However the RAD-57 from Masimo, claims the ability to detect CO concentrations using a non-invasive instrument based on light spectrophotometry – a device similar to a pulse oximeter that measures CO. In fact, the device manufacturer claims the RAD-57 has the ability to measure functional O2-Hb as well as CO-Hb (SpCO). The question we ask is whether there is a role in the use of RAD-57 in the detection of CO in a prehospital setting or Emergency Department, and how reliable are ..read more
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Clinical Pearl 76: Ventilation Strategies in Cardiac Arrest
Critical Care Anywhere
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3y ago
You have a patient in cardiac arrest who needs some sort of ventilation or oxygenation strategy.  Three choices exist: 1Passive Oxygenation Asynchronous Ventilation Ventilation with interposed intermittent compression Which do you choose?  First we should acknowledge a few things before we look at the science. 1.      For the noncardiac arrest patient, passive oxygenation is a great thing for patients who are breathing at least 4 times per minute and saturation is at least 93 percent.  If the patient is below these numbers you should bag until you ..read more
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Clinical Pearl 73: Should We Pretreat with IV Calcium When giving CCBs for Stable Afib with RVR
Critical Care Anywhere
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3y ago
Calcium channel blockers have long been an accepted treatment of hemodynamically stable Afib with RVR.  For those patients with borderline blood pressures or for those patients who are especially responsive to the antihypertensive effects of calcium channel blockers, there are few options available to prevent a hypotensive response.  L Type calcium channels are present in the vascular smooth muscle, mycardium, conducting system of the heart, and in the pacemaker cells of the SA and AV nodes.  Of the calcium channel blockers available for clinical use, dihydropyridines require a ..read more
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Clinical Pearl 75: Prehospital Traumatic Arrests
Critical Care Anywhere
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3y ago
Traumatic cardiopulmonary arrests are rare compared to nontraumatic arrests but are still the fifth leading cause of the death in the United States. In 2007, Gonzalez et al evaluated MVC traumatic arrests looking at response, scene, and transport times.  On average, rural trauma mortalities increased when EMS spent more than 10 minutes getting to a scene, 18 minutes on scene, and 12 minutes getting to a hospital.  Similar effects were found in urban areas when EMS spent more than 6 minutes getting to a call, spent more than 10 minutes on scene, and when transport took more than 7 m ..read more
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