Conference Summary 7/14/21

July 14, 2021 , , ,
  • 7a: Dr Shee – LVADs in the ED
  • 8a: Resident Lectures: Geoff – Bradyarrhythmias / BJ – Trauma
  • 9a: Dr Rizzo – How To Call A Consultant–postponed for another day / Dr Rizzo – SAH podcast (last week’s)
  • 10a: Break / Mallory – Addiction Lecture (Methadone and other opioids)—postponed for another day
  • 11a: Dr Jeong – Core Concept Lecture –postponed for another day
  • Dr Shee – LVADs in the ED
    • LVAD = continuous flow, no pulse, DO have a MAP, use manual cuff or US
      • How to get MAP with US: find radial artery, inflate cuff until no flow, when flow starts as you deflate.. That’s your MAP (70-90 NORM; 80 goal)
      • Sick? Consider a-line
      • Pulse ox–needs a pulse, LVAD pts don’t have a pulse
      • Echo: LV will always be dilated; need to look at RV to see if it can supply the LV with blood OR if there is a giant PE
    • LVAD is bridge to heart transplant, or temporary for condition you probably will recover from (Takotsubo)
    • Volume status? Taking diuretics,diarrhea, etc
    • Pulse index?
    • Anticoagulated, goal INR: 2-3
    • https://rebelem.com/left-ventricular-assist-device/ 
      • CPR should be performed only if absolutely necessary, but remember this might lead to damage of the VAD itself.  There was a small retrospective case series of  8 patients with VADs who received CPR during cardiac arrest, which showed no dislodgement or damage to the VADs, and 4 of the 8 patients surviving with neurologically good outcomes, but larger trials are needed before making this the standard practice. [5]
      • Not perfusing: End tidal <20, MAP <50? —> START CPR
    • Battery alarm going off–you have five battery minutes
      • PI number >3
      • Pump power: 
  • EMCRIT
    • https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/
    • Poor Perfusion
      • When in doubt, consider a fluid bolus. VADS love volume. If you need to improve hemodynamics with a working LVAD, consider preload augmentation and possibly afterload reduction (if MAP is high).
      • Consider inotropes–if you think it is right heart failure, give dobutamine. If you think the patient is septic and has markedly reduced afterload, consider norepinephrine.
  • Low flow: consider sepsis 
    • HIGH FUNGAL INFECTION RATES DUE TO LINE PLACEMENT–get fungal cultures, blood cultures
  • ECG: a lot will have AICD as well–with BB pattern
    • Vtach can be either ventricle and they don’t know/feel it
    • STEMI-LVAD is doing all work, so 
  • Bleeding-
    • GI bleeding
      • Do not reverse anticoagulants–continue giving them blood and they can get scoped. 
    • HEMORRHAGIC STROKE:
      • High chances as on blood thinners and high MAP
    • Embolic stroke
      • Can NOT GIVE TPA—contraindicated on blood thinners, get them to endovascular thrombectomy
  • Infected LVAD?
    • CT surgery: likely want pan scan chest/abd/pelvis

  • TINTANELLI’S ONLY PAGE ON LVAD ^^
  • Geoff – Bradyarrhythmias
    • Case: hypotension, bradycardic ℅ CP
      • What should you first do? IV, O2, monitor, pads
      • Start: atropine, dirty epi, IVF
    • Case: AMS s/p rollover MVC—BP: 175/120, HR 32, O2-92%
      • Cushings: hypertensive, bradycardic, decreased RR
      • Cerebral t waves
    • BRASH syndrome-Bradycardia, Renal disease, 
      • Hyperkalemia tx: 1g CaCl, 3g CaGluc; insulin/dextrose, albuterol–or epi
        • Epi drip, IVF
      • With multi comorbidities/polypharmacy: Consider Beta blocker/calcium channel blocker/digoxin toxicity. 
        • BB/CCB: tx w high dose insulin, intralipid–other treatments as well
        • Digoxin: tx with magnesium, digifab –other treatments as well
    • Step 1:  IV, O2, monitor, pads-defib/pacing; crash cart
    • Step 2:  Stable vs unstable patient
      • MEDICATIONS are faster than procedures (usually)
    • Step 3:  Wide or narrow complex on ECG/Monitor
    • Step 4:  P waves? Present or not
    • Step 5: POSSIBLE CAUSES of bradycardia:  “HE DIE” 
      • Hypothermia
      • Endocrine
      • Drugs
      • Ischemia 
      • Electrolytes
    • Universal protocol
      • Atropine: 0.5mg q IV q5min x3-6 max: 0.04mg/kg ~3mg
        • Antimuscarinic → decreases vagal stimulation
        • ACLS 2020 update: atropine dosing increased from 0.5mg to 1mg
      • Epinephrine: 
        • ACLS dosing = 2-10mcg/min
        • Dirty epi drip vs push dose. 
    • Dopamine: 
      • Increases HR, contractility, CO
      • ACLS dosing: 2-20mch/kg/min
    • Isoproterenol
      • Non-selective beta agonist that can “get a heart rate out of a rock”
      • Dosing: start at 5cg/min (2-10mcg/min)
    • Pacing:
      • Transcutaneous pacing
      • Transvenous pacing
  • BJ – Trauma
    • ABCDE
      • Airway –protecting vs intact
        • Obstruction? ALOC? Trauma to face?
        • Intubate, -C- collar
      • Breathing –ventilation, auscultate
        • Jvd, tracheal position…
        • Chest decompression: tension/massive/open PTX
      • Circulation– 
        • Hypotension == blood loss 
          • Internal bleeding: can give up to 1.5 L; >1.5L increases odds ratio of death
          • Hypotension and BRADYCARDIA == neurogenic shock
        • Check: Central and peripheral pulses
      • Disability: 
        • Neurologic evaluation
        • GCS–higher level = better outcome
        • PREVENT FURTHER BRAIN INJURY by maintaining oxygenation and perfusion
      • Exposure/Environmental: 
        • Fully undress the patient. Cut them off
        • Environmental: hypothermia/ also decontamination
        • Roll patient, feel spine for step-offs/tenderness; place xray plates
          • Look for level of injury
        • Look in between legs, do rectal
    • What to say in ressuss room:
      • A: “Patient protecting airway, no visible obstruction or deformities”
        • “Airway intact”
      • B: “Breath sounds auscultated in bilateral lungs w appreciable chest rise that is equal on both sides”: 
      • C: “ Central pulses intact-distal pulses intact.”
      • D: “ Patient a&Ox3, opening eyes spontaneously, responding appropriately to commands, pupils equally round and reactive to light.”
      • E: “ NO signs of additional trauma on back, no midline TTP of C/T/L spine, no appreciable deformity or stepoff, no visible trauma to perineum, rectal tone intact.”
      • PT CONDITION HAS CHANGED: 
        • Restart the PRIMARY survey. 
  • Dr Rizzo – SAH podcast (last week’s)
  • Live on NY (organ transplant):  1-800-GIFT-4-NY (443-8469)
    • Speaker: Rene Mascoll: 
    • 145 people added to waitlists per day just in our area
    • 1 donor can save 8-9 lives (liver can be two donations)
    • WHEN TO CALL: 
      • Within 1 hour for any of the following: 
        • Potential organ donors: 
          • Loss of 2 or more brain stem reflexes
          • GCS <5
          • Prior to any end of life discussions with patients family
        • Potential tusse donors: have 24 hrs for procurement–keep eyelids closed and head slightly elevated to protect eye/cornea donation
          • all deaths
          • Cardio-respiratory death: pt expired in ressuss 
      • No call is too early: refer all vent-dependent patients at first indication of a non-survivable neurologic or anoxic injury or illness. 
    • **The hospital cannot legally terminally extubate a patient WITHOUT live on new york evaluation. 
    • LONY is HIPPAA privileged—can give HIPPA information on phone or in person.
    • Covid positive donors can give organs to covid negative. 
    • Per LONY, physicians are NOT supposed to talk about organ donation with patients. 
  • DR. KINDSCHUH: 
    • JCO is HERE
    • First annual community outreach: August 11 9am-12noon—Dr. Kindschuh beach house in Breezy point
      • Volunteers needed
      • Planning on some health fair education/show and tell
      • Ideas for education: 
        • Pediatrics: germs/viruses
        • Elderly patients; 
          • How to identify strokes
          • HTN/BG screening
          • Injury prevention in home
    • PR rep: Bridget

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