@emswami.bsky.social
EM doc | Resuscitationist | Medical Educator | EMRAP Managing Editor He/Him/His Instagram: @EMSwami
@emswami.bsky.socialBest way to improve outcomes in cardiac arrest is w/ early defib + high-quality CPR
-Key: max your compression fraction
-Poor defib coordination can eat at hands on time
-Precharging defib reduces hands off time + incr compression fraction ➡️ improved rate of ROSC
@jtrebach.bsky.socialReposted by @emswami.bsky.socialA 5-year-old male presents to the emergency department with inability to move his arms/legs and difficulty breathing. Family reports they found him ingesting these fireworks (see image). What lab do you expect to be abnormal and why? ☠️☠️☠️☠️☠️
@emswami.bsky.socialCremasteric Reflex in testicular torsion
-Sensitivity ranges from 21-100% (PMID: 40537283)
-Clearly, inadequate to rule out the diagnosis of torsion
@emswami.bsky.socialOptimal ETT Shape w/ standard geometry blade (DL or VL) is 25-35 degrees (PMID: 17079788)
-Straight to cuff w/ 25-35 degree angulation
-Anything beyond that increased the risk of difficult or impossible tube delivery
@emswami.bsky.socialABIs in Extremity Trauma
-Normal ABI greater than 1.0. ABI less than 1.0 should prompt immediate surgical evaluation + CT Angio
-Critical part of evaluation. If abnormal should prompt rapid evaluation by surgery + CTA
@emswami.bsky.socialCalcium doesn’t stabilize cardiac myocytes in hyperK
-Ca restores Ca dependent propagation
-Doesn’t matter clinically as Ca2+ will reverse hyperK induced ECG changes
-Ca2+ is still the treatment of choice in hyperK w/ significant ECG changes like QRS widening
@emswami.bsky.socialLaryngoscope Grip
-Proper technique makes lifting easy
-Choke up on handle (fingers as close to where handle meets blade as possible)
-2 Fingers on for placement then 3rd + 4th applied when lifting
-This technique uses mechanical advantage to make lifting easy
@emswami.bsky.socialCalling a Good Consult
-Introduce yourself/be polite
-Start with the end: diagnosis/clinical question 1st to frame conversation
-Close the loop: make it clear what you want (admission, ED consultation, follow up)
@emswami.bsky.socialRelative Adrenal Insufficiency
-Key point: consider this diagnosis in every patient presenting w/ shock
-Typically occurs in patients on low dose daily steroid
-Chronic steroid use suppresses intrinsic steroid synthesis.
-Tx: hydrocortisone 100 mg IV
@emswami.bsky.socialFluid Load in Severe Asthma
-Intubation + mech vent switches pt from negative to positive pressure vent ➡️ ⬆️ intrathoracic pressure + drops preload
-In severe asthma, huge insensible losses due to ⬆️ work of breathing
-Consider early fluid load to avoid HD decomp
@emswami.bsky.socialYEARS Algorithm in Active Cancer (PMID: 42437322)
-YEARS: If “No” to clinical signs of DVT, hemoptysis + PE, can double d-dimer upper limit
-RCT 700 patients w/ cancer showed 1.8% miss rate w/ YEARS (same as standard group)
-Potential reduced CTPA rate by 22%
@emswami.bsky.socialLet’s Play Right Drug, Wrong Dose:
-Rocuronium
Wrong dose: 0.6 mg/kg
Right dose: 1.2 mg/kg (paralysis onset less than 60 sec)
-Epinephrine in Anaphylaxis
Wrong dose: 0.3 - 0.5 mg IM
Right dose: 0.5 mg IM - simplify decision in critical scenario
@emswami.bsky.socialDo bougies incr risk of airway injury?
-Poor technique/blind placement of a bougie can cause airway injuries. Same is true of ETT + rigid stylets
-RCT data (PMID: 29800096 + 34879143): 2000 patients, no airway injuries
@emswami.bsky.socialBrisk trach bleeding = tracheoinnominate fistula
Initial Management
-Call vascular/CT surgery
-Overinflate trach balloon to tamponade innominate (works 85% of time)
-Intubate from above, remove trach + place finger into stoma to compress innominate anteriorly
@emswami.bsky.socialAortic Dissection Management
Rally Consultants: CT surg, Cards, Vascular, IR
POCUS for tamponade
Anti-impulse therapy
-Analgesia 1st
-Anti-tachy tx: esmolol bolus + infusion w/ target HR 50-60
-AntiHTN tx: clevidipine/nicardipine w/ target SBP ~ 90-100 mm Hg
@zentensivistilko.bsky.socialReposted by @emswami.bsky.socialAnother location to get hung is the anterior ring especially when using hyperangulated. There, the trick is to load the ett against the natural curve of the rigid stylet. As it comes off the stylet it will want to bend posteriorly and stay off the anterior tracheal rings.
@emswami.bsky.socialScenario: you’re intubating, great view, place tube but can’t advance it?
Often occurs due to the ETT bevel (or bougie coude tip) getting hung up on the arytenoid cartilage.
Easy fix: back up ~ 1 cm and rotate ETT 90 degrees counterclockwise.
@emswami.bsky.socialPeripheral or IO is fine but if I’ve got a central that’s great. Wouldn’t delay administration to get one in
@emswami.bsky.socialHypokalemic Cardiac Arrest
-Critical to get stat lytes
-No guideline recs on potassium dosing in these cases
-My dose: 40 mEq IVP (have heard anywhere from 20-60 mEq)
-Consider holding epinephrine as it pushes potassium into cells + can exacerbate hypoK
@emswami.bsky.socialIntraosseous lines vital in critically ill patients
-Use “1, 2, IO” approach: 2 shots at peripheral IV then put in IO. Ensures we don’t waste time getting access
-Location: prox humorous w/ better flow rates than prox tibia.
