Lars-Kristofer Peterson, MD

BVM v. ETT in Cardiac Arrest and Pneumonia

A patient is brought in by ambulance in cardiac arrest.  As is your practice, you start CPR and focus on bag valve mask ventilation (BVM) while the code gets started.  The patient is resuscitated and eventually intubated as they were not conscious after return of spontaneous circulation.  You wonder, if use of BVM is associated with an increased risk of pneumonia given that the airway isn’t defended as well compared to a cuffed endotracheal tube.

Category (Day): 

Updates in anaphylaxis

A 46 year old woman arrives at the ED with hives, hypotension, difficulty breathing, and stridor after eating dinner with her family.  She is allergic to shrimp, and thought she had avoided it when she ordered from her favorite restaurant.  However, shrimp dishes are on the menu and she wonders if there was cross contamination.  Unfortunately, she couldn’t find her epinephrine auto-injector at home so her family drove her to the ED.  Immediately recognizing anaphylaxis, you give her a dose of IM epinephrine and she improves within several minutes.  After seeing she has stabilized, you wonder how long should she be observed and what the evidence is behind the use of antihistamine and glucocorticoid therapy.

Category (Day): 

When the PLT get LOW

A 72 y/o male with PMH type 2 diabetes, CAD, HFrEF, HTN, and HLD is admitted to the MICU for frequent neurologic monitoring after an endovascular thrombectomy for an acute ischemic stroke caused by thrombosis of the M2 branch of the left MCA. While reviewing his chart, you notice that the patient was recently admitted for 1 week about 10 days ago for dyspnea secondary to acute decompensated heart failure. You also note on his admission labs that he is newly thrombocytopenic, with a platelet count of 80,000. His last platelet count on discharge was 250,000, and he has never been thrombocytopenic before. What is causing his thrombocytopenia?

Category (Day): 

BVM - Do no harm

It’s been a busy day in the ED and you’ve had several cardiac arrests come in back to back.  EMS calls in with another one just as they’re hitting the door.  The patient is an adult, but you notice the BVM they’re using is much smaller than what you’re used to seeing.  The medic says “The day has been so bad, we didn’t have time to get back to base to restock the rig.  We only had a pediatric BVM.”  Knowing that safe ventilation includes limiting tidal volumes and pressures, you wonder what the implications of using a pediatric BVM are.

A relaxing RCT

You sign out to the overnight team at midnight and stay an hour or so completing a laceration repair and finishing your charts.  It's been a chaotic afternoon and evening and the patina of COVID-19 didn’t make things any better. After your shift (and appropriate decontamination) you pass your hospital’s new resiliency resource room.  You wonder, “What would be more relaxing right now? Doing some deliberative coloring, petting a dog, or just heading home?”

To art line or not to art line?

You are working in a busy ED when a patient who is 54 arrives with an acute onset headache associated with syncope but no focal neurologic deficits.  His physical exam is unremarkable but his BP is mildly elevated at 175/80. The patient’s head CT is consistent with an aneurysmal subarachnoid hemorrhage.  You begin anti-hypertensive treatment, but wonder how reliable non-invasive blood pressure measurement is in this patient.

Category (Day): 

Finding language when there are no words

During the current pandemic, physicians are findings themselves interfacing with the public and talking about topics they never thought they would have to consider.  One way to prepare for this is to develop a library of phrases ahead of time which can be used in the appropriate context. It can also be helpful to generate analogies to common objects/systems to assist the general public in understanding critical care concepts.

Hands on defibrillation

A 58 year old male arrives to the ED in cardiac arrest.  CPR is in progress and you are concerned about the amount of time needed prior to defibrillation to stop compressions, ensure all personnel are not touching the patient or the bed, delivering the shock, and then restarting CPR.  It occurs to you that the pads could deliver a shock while CPR is in progress, but wonder about the safety and efficacy.

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