A practical view of PEEP

This video made the rounds of social media some time ago, but it seems that not everyone had an opportunity to see it.

I was running a table-top scenario with a Graduate Paramedic recently and the discussion turned to the virtues of Non-Invasive Ventilation and pre-oxygenation strategies using PEEP valves, which reminded me of this great video;

As the idiom suggests, a picture is worth a thousand words.

If you would like to dive a little deeper, check out these links to the wonderful Life In The Fast Lane Critical Care Compendium pages on Non-Invasive Ventilation and PEEP.

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Recognising cardiac arrest

I attended a cardiac arrest recently with a Graduate Paramedic who commented that our patient’s agonal respirations made it challenging to palpate their carotid pulse (or lack thereof).

This led me to reflect on the difficulty the general public encounter when trying to figure out if a person who suddenly collapses is just ‘having a turn’ or something more sinister is at play – and what a fantastic job our call-takers do sorting this out without being in front of the patient.

(Un)fortunately I’ve witnessed more than one cardiac arrest, and no two have presented identically.

Almost 18 months ago, I linked to this fantastic article on EMS 12-Lead that takes you through 10 cardiac arrests which have been caught on video;

http://www.ems12lead.com/2014/11/11/sudden-cardiac-arrest

I think it’s worth reviewing these videos (and their associated dialogue) semi-regularly, and for those who are relatively new to the profession, remember that experience is what you get when you don’t have any !

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Apparently, prior to arrival, our case looked something like this..

Who (or what) is ViCTOR ?

You might be familiar with the expression “kids are just small adults” – reasonable in a few respects, but with regard to vital signs, you would already know they’re very different.

The service I work with is a few days away from introducing a new clinical approach for paediatric assessment, and this revision affirms that categorising the little tykes into just a couple of different categories is not the way forward.  If you think about it for a moment, it’s not really reasonable to expect that a 1 year old should have the same resting heart rate as an 8 year old !

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Apologies to fans of ‘How I Met Your Mother’

The Victorian Children’s Tool for Observation and Response was developed through a collaboration of the The Royal Children’s Hospital and Monash Children’s Hospital to bring consistency to charting and alerting of paediatric vital signs.

Based on evidence established by observing more than 14,000 paediatric admissions, ViCTOR specifies age-specific vital sign limits for 5 different categories of paediatric patients – Small and Large Infants, and Small, Medium and Large children.

While the addition of more categories might initially seem daunting, these map directly to well-understood (and easy to remember) stages of development; Infants who are “Head Rollers” or “Head Holders”, Pre-School, Primary School and Secondary School children.

What I think is most encouraging though, is that our revised clinical approach won’t require practitioners to commit these new vital-sign ranges to memory – we are taking this opportunity to introduce decision-support tools (checklists and other references) into our regular practice.

This is a load off our minds, as well as providing a tremendous advantage in safety.

Here is a neat set of ViCTOR introduction videos with some great tips for getting a reliable vital signs in specific age ranges;

https://www.victor.org.au/victor-back-to-basics/

Or for more general information about how ViCTOR is used in hospitals, take a look here;

All about synthetic cannabinoids

Speaking of acute agitation, I was thinking about the last few times I’ve sedated patients to enable their safe management to hospital, and at least a few of those cases involved the patient having consumed synthetic cannabinoids (by one name or another).

It’s a happy coincidence that the team at ALiEM have just posted this great backgrounder;

http://www.aliem.com/2016/synthetic-cannabinoid-use-reaches-new-heights

I did know that there were literally hundreds of analogues out there, but I didn’t realise that the main reason that their effects are so variable (read unpredictable) is that the distribution medium (the plant matter) contains a random amount of the active compound.

It’s an (un)lucky dip – and I haven’t heard of anyone who sells this stuff accepting returns..

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Managing acute agitation

Stop laughing, you’ve probably heard someone suggest that this might be a good way to administer sedation to acutely agitated patients.

I think once you’ve had to do this more than a few times, you realise that the ongoing management doesn’t stop when the patient settles – they’re now relying on us to ensure their safety, which can feel somewhat paradoxical given that (at some level) we were probably feeling uneasy only moments earlier.

This post from Tim Leeuwenburg discusses some lessons learnt from when things go wrong and introduces some valuable points to consider;

http://kidocs.org/2015/03/lessons-for-management-of-acute-agitation-in-rural-eds

The take-away here is that we should be thinking about managing acute agitation as a procedure that is a continuum of our care, not an end-point in our management.

If this is starting to make sense, you might be interested to know that ALiEM have an entire self-paced learning module in their ALiEMU which steps you through Procedural Sedation and Analgesia in the ED;

http://www.aliemu.com/modules/procedural-sedation-agents-in-the-ed

Some time ago, I got at least $1,000 of free advice from an outstanding pre-hospital practitioner – to paraphrase – if you can anticipate what happens next,  you won’t get an unwelcome surprise !

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Nobody looks at aVR

A couple of weeks ago, I mentioned that aVL is a great place to check for reciprocal changes that you might not see in lead I if you are suspicious of an inferior STEMI.

RebelEM have just posted a podcast by Amal Mattu where he takes you through the significance of subtle changes in aVR – a lead that it seems many practitioners ignore;

http://rebelem.com/is-st-segment-elevation-in-lead-avr-getting-too-much-respect-with-amal-mattu

(By the way, I think Amal Mattu’s ECG Weekly program is fantastic value !)

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aVR does look lonely..

Acute coronary syndrome

I think there is a lot to be said for going back to the start of a knowledge base and reviewing the basics again.

(You might find this especially useful as a backgrounder if you were about to transition from 3-lead to interpreting 12-lead ECG)

Here’s an excellent presentation (especially the first 37 minutes !) from the Louisville Lectures which will take you through coronary perfusion, ECG interpretation and STEMI;

https://www.blubrry.com/louisvillelectures/11193829/acute-coronary-syndromes-101-with-dr-brown

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