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Post by tyson on Jul 13, 2015 13:30:46 GMT -5
Couple questions
1. I've had a couple of cases of elderly patients come into the ED severely dehydrated, tachycardic and in heart failure with elevated BNP's. In a couple of these patients, they had 4+ pitting edema, but not really much on the lungs. My question, do you diurese or hydrate these types of patients first? Fluid overloaded, but clinical signs of dehydration, turgor, skin tenting, dry tongue, cracked lips....etc...
2. Regarding ECG's, when looking at st depression, does anyone place any weight on the type of depression it is? E.G. from some of the reading i've done, flat st depressions are much more likely to be ischemic than up-sloping st depressions or downsloping st-depressions.
3. Finally, do we have an intubating laryngeal mask airway at any of the hospitals? I've watched a couple of videos and it seems like it might be something handy and easy to use in difficult intubations. Anyone used one?
Tyson
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Post by pbruss on Jul 14, 2015 8:06:58 GMT -5
in my opinion: 1. treat teh clinical signs first but go slowly. as long as their lungs are clear you have some room with fluids reguardless of what labs say. also if the heart is working hard in these old people who is already weakn it wont have time to dill and or empty commpletly which could make the heart swell and make the BNP go up.
2. yes planar depression is more concerning for something bad, but a lot of it depends on the history and change from an old EKG. unfortunately some time you have to actually talk to the patient to see how relevant the EKG is
3. we do have the LMA's. have not used one since residency but when i did use them it was to buy some time in a patient who is hard to tube and hard to bag.for intubations dont forget the simple things, like lma and buggies
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Post by jpollock on Jul 14, 2015 10:12:39 GMT -5
1. Usually I do a small bolus (250cc) if I think it might help. That way you might notice improvement but shouldn't get into too much trouble. Bedside cardiac ultrasound can give you some hints as well. Is the heart hyperdynamic or barely contracting? This helps me decide when to give more fluids vs start pressors. One other thing you can do is the passive leg raise (http://www.ccforum.com/content/19/1/18). Basically you just lift the patients legs in the air for a couple minutes and see if it helps their vital signs. this is a great predictor of fluid responsiveness since it is like giving a reversible 300-500cc bolus. If it helps the HR and BP then you know they need more fluid, but if it doesn't help or makes things worse, when you put the legs back down the 'bolus' is taken away.
2. In my opinion EKG changes are still EKG changes regardless of the shape. However, this is a useful point you can bring up when talking to cardiology about a patient you are worried about
3. In my experience, when I have asked for an intubating LMA I usually just get a regular LMA, so it is something to check beforehand. When I have used them they have been about 50/50 success rate. It seems to work better when you put the bougie down first and feel the tracheal rings clicking (you can try this with a regular LMA too before you pull it out when you are planning to upgrade to a tube). Personally I prefer the bougie method or just to pull the LMA out and do direct visualization because I like to know it is in the right spot before I start pumping air in it
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Questions
Jul 14, 2015 21:00:42 GMT -5
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Post by DD on Jul 14, 2015 21:00:42 GMT -5
3. All the ORs have them Tyson but I don't think the ERs do. UTMC might. Crack the difficult airway carts and look for them. They look like a regular Lima but have an extra weird tube thingy. I've never used one personally. Just LMAs. I think if a tube is that bad you should probably reach for the bronchoscope.
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Questions
Jul 15, 2015 15:39:05 GMT -5
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Post by tyson on Jul 15, 2015 15:39:05 GMT -5
Thanks! Appreciate the responses. Very helpful
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Post by meeendeee on Dec 11, 2015 9:33:15 GMT -5
don't forget ivc collapse via u/s. lumbrezer uses it a lot to guide his fluid resuscitation.
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