Comments for Resus M.E!

Comment on Making Things Happen from SMACC 2013 by Yen Chow (@TBayEDguy)

Yen Chow (@TBayEDguy) — Tue, 21 May 2013 04:53:53 +0000

Love this talk!!!

Comment on RSI haemodynamics in the field by Yen Chow (@TBayEDguy)

Yen Chow (@TBayEDguy) — Sat, 18 May 2013 12:17:33 +0000

Even in the very hypertensive patient, I wonder if ketamine would really add that much fuel to the fire or is it just a drop in the ocean? Do you run more risk with crashing the BP with a full dose of propofol? Do you risk having a bad airway attempt and inadequate induction with using midazolam and spike your ICP, BP / risk hypoxia hypoventilation even more? Etomidate is not available much and though we used to have it in our shop but it never seems to be around lately.

A good study would be helpful at least in the routine intubations with full dose ketamine.

Anecdotally, I don’t recall it being a concern with past intubation with full dose K whereas I do recall with procedural sedation analgesia with ketamine noting tachycardic responses. Are our emergency intubation patients just a different kettle of fish with ++sympathetic overload already that ketamine does not really do much in addition?

Is the ketamine retrieval data published? It would be great to be able to review and reference data in the literature.

Comment on RSI haemodynamics in the field by Minh Le Cong

Minh Le Cong — Sat, 18 May 2013 04:48:22 +0000

LOL…I am glad the recent awake FOI did not harm your frontal lobe
its not a bad idea for a retrospective study in fact in all seriousness!

I just know doing our ketamine retrieval sedation registry audit..its very uncommon for a hypertensive red flag to be seen in our cases..and we do a lot of them! And sometimes our total doses ( over whole retrieval) far exceed RSI induction doses

I have not done a prehosp RSI with propofol in about 2 years and even then I still wonder why I did it?!

Comment on RSI haemodynamics in the field by Cliff

Cliff — Sat, 18 May 2013 04:34:46 +0000

I just emailed Karel, Anthony and Brian about the same question!

I said: “We should really look to see if this is replicated with our use of ketamine. I wouldn’t be surprised either way. The temptation is to assume it is, but we don’t know unless we look.”

I haven’t noticed a similar response after ketamine, and we also use 3 minute obs cycles.

But it could be confirmation bias, since I am a card-carrying member (and Chapter Leader) of the KetaMinh Kult.

A bit like the propofol fans who don’t notice their patients keep arresting on induction.

Comment on RSI haemodynamics in the field by Minh Le Cong

Minh Le Cong — Sat, 18 May 2013 04:26:34 +0000

thanks Cliff. I have not really noticed much of a hypertensive response to RSI when using ketamine as induction. Certainly not as much as noted in this study where etomidate used. I must admit..since using ketamine as my main induction RSI agent for several years now..I rarely need or think I need to give fentanyl or morphine pre or peri RSI.

what has been your observation in your own practice?

Comment on Awake intubation by Karel Habig

Karel Habig — Wed, 15 May 2013 04:40:30 +0000

I guess you will want me to sign-off your Advanced Airway currency…….

Comment on Difficult intubation on ICU by Yen Chow (@TBayEDguy)

Yen Chow (@TBayEDguy) — Sat, 11 May 2013 23:02:35 +0000

I think the use of standardized essential checklists (efficient and not too long too!) as well as rational plans for airway management are keys to safe airway management with DASH1A+ (sans hypoxia, hypotension, hypoventilation, aspiration, multiple attempts, best first attempt success at definitive airway [hat tip Bill Hinckley @UCAirCareDoc]).

I think also that although airway management and choices are very complex and variable and dependent on individual situations, it is important to recognize common patterns, practice in simulation in order to gain expertise and be able to react quickly but flexibly. Similar to mastering chess, kung fu, jazz or any language, you learn the vocabulary and practice sentences and soon you are fluent in conversations and flexible enough to react reflexively to old familiar situations and react to new situations with new innovative solutions if required.

Comment on Predicting volume responsiveness by roger harris

roger harris — Thu, 09 May 2013 09:37:45 +0000

Yeah agree that TPTD is more for those with too much time on their hands like us Intensivists but Pulse Contour Co has really got some legs. The new versions have come a long way and in combination with clinical exam / Echo / lactate / SCVO2 make for powerful tools to help guide resus in complex cases like sepsis.
Really love the fact that you are pushing the case for recognising all the down-side to both over and under fluid resuscitation. thanks

Comment on Predicting volume responsiveness by Cliff

Cliff — Thu, 09 May 2013 07:52:57 +0000

Thanks Roger. I was really thinking about techniques that would be readily applicable in the ED. I might need some convincing about realistic application of TPTD in most EDs. As for pulse contour, I probably need to have a play with the latest generation kit. I only have experience with first gen LiDCO – make of that what you will!
Cheers
Cliff

Comment on Predicting volume responsiveness by roger harris

roger harris — Thu, 09 May 2013 06:44:48 +0000

Thanks Cliff
We need a session on CO at #smacc2014. I covered a little on this in my talk on CO in the Resus room and think that both NICOM and Pulse Contour have a lot to offer in the Resus room. I love TPTD but this is another step again. I don’t really know how NICOM would perform in the ED but the Technology is great and I know Scott Weingart likes it. I think the role for Pulse Countour is really evolving and the 3rd generation algorithms are getting really interesting….. Maybe a podcast