Critical Care Topic of the Month

VFlutter

VFlutter

Flight Nurse
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Just brain storming as I sit here doing a write up about balloon pumps and browsing the forum. This forum really is great place to learn with providers of various levels and expertise. It would be kind of cool to have a monthly critical care topic where members could discuss, educate, ask questions etc. It would nice to liven up the HEMS/Critical Care section and maybe work towards building a sticky or resource section.

Not sure how it would work necessarily or how topics would be chosen or voted but just thought I would throw it out there.
 
Since I am just now starting to get into critical care I really like this idea.
 
I like the idea a lot

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i'm not a critical care provider but i work on a critical care rig, so I can talk about equipment and things like that, I'm down to learn :D
 
IMG_0274.GIF
 
I might not work in the Critical Care world, but I'd love to learn a thing or two from whatever topics would come from this.
 
Im in. As soon as I can hold an illinois cert again I want to fly. (36 months to get it back if you let it lapse. I didnt do anything illegal)

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GMCmedic said:
Im in. As soon as I can hold an illinois cert again I want to fly. (36 months to get it back if you let it lapse. I didnt do anything illegal)

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Illinois is the worst. Took me a while to get my RN license. And now I work on the IL side
 
Chase said:
Illinois is the worst. Took me a while to get my RN license. And now I work on the IL side
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It is. I only let it go cause I couldnt get in touch with our illinois medical director and Its not required at my current job.

Plus I didnt want to keep track of my hours for 4 years at a time.

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I'll throw a topic out there. Maybe should be a new thread but someone can move it if needed.

In any patient that is hypotensive (MAP less than 65ish), what specific steps do folks move through to systematically treat and/or advise receiving hospital of needs of the patient on arrival?
 
E tank said:
I'll throw a topic out there. Maybe should be a new thread but someone can move it if needed.

In any patient that is hypotensive (MAP less than 65ish), what specific steps do folks move through to systematically treat and/or advise receiving hospital of needs of the patient on arrival?
Click to expand...

1. Assess my patient. Do they look adequately perfused? Mental status, skin quality, ETCO2, etc. Yes, proceed to number 2. No, proceed to number 3.

2. Assess my equipment. Is this a NIBP or Arterial line? Is my patients arm bent or in an awkward position? Did my transducer fall on the floor? Retake, re-zero, confirm manually.

3. Critically think. Is this unexpected or a downward trend? Is your patient peri-arrest? Push dose pressors to buy time. What is the patients disease process? What medications are they on? What do they need to be on? When in doubt give volume. Add pressors and inotropes as need. Correct arrhythmias if indicated.

4. Re-evaluate your interventions

5. Contact hospital and med control.


17. Grab the Methlyene Blue.
 
E tank said:
I'll throw a topic out there. Maybe should be a new thread but someone can move it if needed.

In any patient that is hypotensive (MAP less than 65ish), what specific steps do folks move through to systematically treat and/or advise receiving hospital of needs of the patient on arrival?
Click to expand...
With the other week being the most recent instance. this was the gist...

1. Vitals. Pulse, confirm pressure with a manual verification, mental status, perfusion, MAP estimate.
2. IV accessx2 and fluids started on scene.
3. Causes? None stood out at the time, but her history was beyond anything I had heard of. Didn't seem to be cardiac related. If so, treat accordingly.
4. Reassess. Think about pressors, but city transports are usually done by the time I get any meaningful amount of fluids in someone.
2-5. Anytime. Call a doc and get an opinion on the best treatment path or for permission for something I want to do. In her case, fluids were fine for the 5 minute drive. If someone looks like they are spiraling before I can even leave, it's not in my protocols to use push dose pressors or other temporizing measures. Fluids only. This would be where I'd fast track a bit and call sooner rather than later on the advice/permission and hopefully get options.
 
Here's one way to look at it that can be useful. These steps need to be taken in order: If you have hypotension that you want to treat

1. HR -Too slow? Fix that first

2. Rhythm - not perfusing? Fix that next.

3.Pre-load - volume. Depending on your setting you may have an A line or be able to assess pulse wave variation in ventilated patients. History and assessment will help determine if there have been volume losses.

4. After load - vasomotor tone. Pick one... Phenylepherine, vasopressin then norepinephrine

5. Contractility - Epinepherine

So, the point here is not to give a pressor before you have decided that volume isn't the problem anymore or at all. Likewise, you wouldn't want to start an inotrope before you determined that the vasomotor tone was OK. Obviously, you can do many of these things simultaneously. But they should be taken in that order.
 
A few random thoughts. In catecholamine depleted and severely acidotic patients Vasopressin is very effective. Although controversial if your patient is known to be severely acidotic and is non-responsive to vasopressors then it may be one of the few times IV push Bicarb is necessary, it should improve hemodynamics briefly.

Calcium can be very helpful as well especially if your patient has been massively transfused.

Epinephrine drips can be extremely useful when used correctly. Post ROSC and Massive PEs (That RV squeeeze)

If you are unfortunate to not have Push Dose Pressors, like me, then initiate a Levo/Epi drip prior to intubating a shocky patient. Avoid peri-intubation hypotension and arrest.
 
Chase said:
A few random thoughts. In catecholamine depleted and severely acidotic patients Vasopressin is very effective. Although controversial if your patient is known to be severely acidotic and is non-responsive to vasopressors then it may be one of the few times IV push Bicarb is necessary, it should improve hemodynamics briefly.

Calcium can be very helpful as well especially if your patient has been massively transfused.

Epinephrine drips can be extremely useful when used correctly. Post ROSC and Massive PEs (That RV squeeeze)
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All good points. I give a half unit vasopressin the first time to see what the response will be. Sometimes it works too well. And as far as I'm concerned, giving bicarb to make catechol drips work better isn't controversial. It works. You just need to make sure that you are giving adequate ventilation for the added CO2 load.
 
Im curious to knkw more about what people are using vasopressin drips for now and days (other than 2nd line in sepsis) i recently listened to a podcast from flight bridge that vasopressin may be a good drug to use in traumatic shock.
 
Vasopressin is great for any shock that involves derrangment of Adrenergic receptors. As mentioned acidosis severely reduces receptors affinity for catecholamines. Also like how Milrinone works in similar situations.
 
TXmed said:
Im curious to knkw more about what people are using vasopressin drips for now and days (other than 2nd line in sepsis) i recently listened to a podcast from flight bridge that vasopressin may be a good drug to use in traumatic shock.
Click to expand...

So, the stock answer is refractory vasoplegia, but that doesn't mean a whole lot to folks. It implies that you've gone through phenylephrine and norepi and you still need something that isn't an inotrope. One that I can think of right off the bat is a patient on an ACE inhibitor or ARB that is having some kind of insult that is affecting their blood pressure.

These drugs make the patient uniquely refractory to more conventional efforts at restoring vasomotor tone....thus Vasopressin.
 
For sepsis we currently treat hypotension with pressors and fluid simultaneously. We don't "fill the tank" we press early. And we use levophed first. Vasopressin is our last intervention.

E tank said:
Here's one way to look at it that can be useful. These steps need to be taken in order: If you have hypotension that you want to treat

1. HR -Too slow? Fix that first

2. Rhythm - not perfusing? Fix that next.

3.Pre-load - volume. Depending on your setting you may have an A line or be able to assess pulse wave variation in ventilated patients. History and assessment will help determine if there have been volume losses.

4. After load - vasomotor tone. Pick one... Phenylepherine, vasopressin then norepinephrine

5. Contractility - Epinepherine

So, the point here is not to give a pressor before you have decided that volume isn't the problem anymore or at all. Likewise, you wouldn't want to start an inotrope before you determined that the vasomotor tone was OK. Obviously, you can do many of these things simultaneously. But they should be taken in that order.
Click to expand...
 
TXmed said:
Im curious to knkw more about what people are using vasopressin drips for now and days (other than 2nd line in sepsis) i recently listened to a podcast from flight bridge that vasopressin may be a good drug to use in traumatic shock.
Click to expand...
Why would vasopressin be better for trauma than any other pressor?

And why would you use a vasopressor in a hemorrhagic patient anyway?
 
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