Author Archives: Chelsea Garrison

Push Dose Pressors

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Are you all tired of hearing about sepsis yet?  How about the fact that we apparently suck at sepsis?  However, I think we can all recognize when someone comes in with severe septic shock.  You know, the sick, hypotensive, altered patient with a source of infection.  With a low blood pressure, we just need to keep pushing more fluids right?  Just keep pushing them until they are in pulmonary edema.

Well, what could we possibly do to improve outcomes?  The longer they are hypotensive, the more end organ damage they are going to sustain, and the worse the outcomes.  I know that most of you all listen to EMCrit.  If you don’t, you should.  So while waiting for that central line to be placed by our intern (and we know that can take a while, j/k interns, I love you) and waiting for the levophed gtt to be started, we can be like Weingart and give some push dose pressors.  Not only could they be used for that septic patient needing a boost in BP, but can also be used for the peri- or post-intubation or sedation patient that becomes hypotensive.

Epi-It’s not ideal to give code dose epi to someone with a pulse.  Instead take a 10 mL syringe and fill it with 9 mL of NS.  Then draw up 1 mL of epi from the cardiac amp.  This gives you 10 mcg/mL of epi.  Now, give 0.5-2mL (5-20mcg) q1-5 min until improved BP.

Phenylephrine- Draw up 1 mL of phenyl from a vial that is 10 mg/mL and put in a 100 mL bag of NS.  This gives you 100mL of phenylephrine at the concentration of 100mcg/mL   Now you draw up 10mL into a syringe at push 0.5-2 mL (50-200mcg) q1-5 min.

And for your convenience, here is a link to a PDF from EmCrit with the instructions on how to mix these.  Take a pic, keep it on your phone.  While doing this, don’t forget patient safety.  Make sure you’re labeling your syringes when you mix up push dose pressors.  Avoiding medication errors is always plus.

Also, until you are comfortable doing this, make sure you are collaborating with your attending and the pharmacist if they are there at the time.

Finally, read this article on safety considerations in push dose pressors.

And for added fun, read all room9ER posts in Danny DeVito’s voice.  It makes everything better.

 

Neonatal Airway

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I’m currently on peds anesthesia and behind on reading Annals, which worked out in my favor.  I was looking through the February 2017 issue and there’s an EM:RAP commentary about the neonatal airway.  So I figured I would give you all the highlights from that article.

  • At birth, an oxygen level of 60% is normal.  There’s a nice chart showing the oxygen saturation and how it increases after birth.
    • 1 minute- 60-65%
    • 2 minutes- 65-70%
    • 3 minutes 70-75%
    • 4 minutes 75-80%
    • 5 minutes 80-85%
    • 10 minutes 85-95%
  • Remember when doing BVM on a neonate, not to press too hard on their face.  Their nose is not stiff and they are obligate nose breathers.  So don’t close off their airway by pressing too hard.
  • Don’t worry about using a paralytic in the neonate.  You can either time passing the tube through the cords or just push it through.
  • Tube size/Blade size
    • Normally in peds we use the formula (age in yrs/4) + 4
    • For neonates, they suggest the 0-1-2-3 rule: Use a 0 straight blade in a 1-2 kg newborn with a 3.0 mm uncuffed tube
    • They also recommend resting your pinky on the cric to provide your own cric pressure since neonatal airways can be very anterior
  • How far to pass the tube
    • 1 kg neonate- 7 cm
    • 2 kg neonate- 8 cm
    • 3 kg neonate- 9 cm

Urine Drug Screen

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So while on my ICU months this year, I had upper levels that were very insistent that we needed to get a urine drug screen on everyone.  I would try to make the point that it most likely was not going to change our management of the patient at all.  My point was often ignored and after countless urine drug screens obtained during those months, most if not all proved to be of no utility.

Interestingly, Foamcast just put out a podcast about false positives and false negatives on the UDS.  What I found most interesting was that ibuprofen can cause a false positive for just about anything under the sun including cocaine, PCP, THC, and barbiturates.  Also, the benzos tested on this really only test for oxazepam which is a metabolite of diazepam.  So Ativan, Klonopin, and Xanax won’t show up.

Here is the link if you want to read the whole thing.   https://foamcast.org/2016/04/26/episode-48-urine-drug-screen-cocaine-and-pcp/