Conference Notes 1/28

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  • Termination of resuscitation (Nichols)
    • When to stop resuscitation in out of hospital arrest
      • DNR order
      • No chance of saving them–safety, signs of irreversible death
      • Nothing left to do–unwitnessed arrest, no shockable rhythm, ROSC does not return in the out of hospital setting
    • Stop CPR if:
      • No ROSC
      • No shocks
      • Unwitnessed
  • CCU follow up (French)
    • Arrhythmogenic RV dysplasia
      • 2nd MCC sudden cardiac death in young patients
      • Greek or Italian descent
      • Male:Female= 3:1
      • Presentation
        • Asymptomatic
        • Palpitations
        • Syncope
        • Ventricular dysrhythmias/cardiac arrest
        • FH of unexplained syncope/sudden death
        • RV failure
      • Cards consult–>admission
      • Arrhythmogenic RV dysplasia EKG: V1-V3 T wave inversions, epsilon wave
      • HOCM EKG changes: high voltage, LVH, lAD, tall R wave V1
  • MICU follow up (Schutzman)
    • Myxedema coma
      • Hypotension
      • Bradycardia
      • Electrolyte derangements
      • Altered mental status
      • Give levothyroxine
  • Jeopardy (Daughtery)
    • Activated Charcoal
      • Adsorbs toxins and inhibits GI absorption
      • Must be given in 1-2 hours, but still consider if ingested drug is extended release
      • Contraindications: GI perforation, need for endoscopic procedures
      • Concerns: emesis, CNS depression and aspiration risks
      • Consider risk vs benefit of administration
    • Deferoxamine
      • MOA: complexes with trivalent ions (ferric ions) to form ferrioxamine which is eliminated in urine by the kidneys
      • Indications: iron level >500, metabolic acidosis, lethargy/coma, shock, toxic appearance
      • Can cause urticaria, flushing of skin, hypotension, shock with rapid IV administration, ARDS
    • Itralipids (lipid emulsion)
      • Reversal of local anesthetic systemic toxicity
      • Consider for severe hemodynamic compromise of lipophilic xenobiotics or drugs with significant neurological or CV toxicity–last line
      • 20% emulsion solution
    • Phentolamine
      • MOA: competitively blocking alpha adrenergic receptors
      • Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation
      • Concerns: hypotension, medication safety
    • Levocarnitine
      • Antidote to valproic acid
      • Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity
    • Naloxone for clonidine reversal
      • Big doses- 10mg
      • Consider for reversal of CNS depression 
      • Fluids and vasopressors may also be required
    • Benzodiazepines
      • Midazolam: IV onset of action 2 min
      • Lorazepam: onset of action 5-20 minutes
    • Physostigmine 
      • Reversal of anticholinergic toxicity
      • Primarily for agitation and delirium reversal
      • MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine
      • Have physician and atropine at bedside
      • No significant risk of seizures
      • Low dose, push slow
    • Flumazenil
      • Benzodiazepine overdose or reversal only
      • Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex
      • Not effective on other medications that affect GABA
      • Concerns
        • Could precipitate withdrawal seizures if patient regularly uses benzos
        • Seizure history outside of withdrawal seizures
        • Risk vs benefit–goal of therapy
  • Project ECHO
    • Optimal Aging Clinic will be added to discharge follow up options
    • Have a “what matters” conversation
    • Advance Directives
      • Living will
      • POA
      • POLST/MOST
      • EMS DNR
    • Advanced care planning–ICD code, must spend 16 minutes to bill
    • MOST form
      • A physician’s order
      • Must be honored by all KY healthcare providers in all KY settings
    • State of KY Hierarchy of Decision making authority if no advance directives
      • Court appointed guardian
      • Healthcare surrogate
      • Spouse
      • Adult children
      • Parents
      • Adult siblings
      • Closest living relative
  • ECMO (Ritchie)
    • Components
      • Motor/pump
      • Filter/oxygenator
      • Blender
      • Ventilation–to increase, go up on gas flow aka sweep
      • Oxygenation–to increase, go up on blood flow aka flow
      • Cannulas (single vs double)
      • Circuits
        • Vein-Vein ECMO
          • Is the heart still able to pump
        • Vein-Artery ECMO
          • Heart pump function not ideal
        • Vein-Artery-Vein ECMO
    • VV ECMO 
      • Indications
        • Hypoxic respiratory failure, 50% mortality risk consider ECMO
        • Hypoxic respiratory failure, 80% mortality risk, put on ECMO
        • CO2 retention on mechanical ventilation despite high Pplat
        • Severe air leak syndromes
        • Need for intubation in a patient on lung transplant list
        • Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)
        • Anytime patient is on dangerous vent settings
      • Murray Score: conventional ventilation or ECMO for severe adult respiratory failure 
        • Score of 3–consider transfer to ECMO center
        • Score of 4– ECMO indicated
      • Contraindications
        • No absolute contraindications
          • Mechanical ventilation at high settings for 7 days or more
          • Major pharmacologic immunosuppression
          • CNS hemorrhage that is recent or expanding
          • Non-recoverable co-morbidity
      • When making the decision to begin ECMO
        • Is this condition reversible?
        • Is it a bridge to transplant?
        • RESP score (estimated survival once on VV ECMO)
      • ARDS
      • Ventilator trauma
        • Volutrauma
        • Barotrauma
        • Atelectrauma
        • Biotrauma (cytokine storm, inflammation)
        • Energytrauma (goal for driving pressure 15 or less)
      • Settings once cannulation successful
        • Set flow: 4L
        • Set Sweep: 4L
        • Lung rest settings while on ECMO
        • PC 10/10/10/40%
        • Goals
          • Sat >85%
          • MvO2 >65%
    • VA ECMO
      • Indications
        • Heart failure bridge to recovery, heart transplantation, VAD
        • Cardiogenic shock
        • Myocarditis
        • ECPR
        • Right heart failure
        • PE
        • Medication overdose
      • SAVE score
    • Trans pulmonary pressure
      • Consider in morbidly obese patients
      • May have higher PEEP requirements given pressure from chest wall/abdomen
      • When intubated, they lose the ability to autopeep
    • Page Jewish thoracic or cardiac surgery –consult early

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