Lars-Kristofer Peterson, MD

Another take on balanced crystalloids vs. saline

It’s a familiar call ahead to the ED - an adult patient who is febrile, hypotensive, with suspicion towards infection.  While setting up the room, the patient’s bedside nursing team asks if you’d like them to get saline or lactated Ringer’s (LR) ready for resuscitation.  You wonder if there’s any new evidence examining the use of saline versus balanced crystalloids in the emergency department.

Category (Day): 

Pressors and Fluids - Not either/or but both/and

It's a typical day in the ED.  You are asked to see your next patient who is a 60 year old male, recently discharged from the hospital after being treated for cellulitis presenting with abdominal pain and diarrhea.  He’s tachycardic and hypotensive to 75/40.  The patient is mentating well.  After taking a more thorough history your differential diagnosis narrows in on intra-abdominal sepsis associated with significant volume losses.  The lactate returns at 6.  On volume assessment by physical exam and POCUS, the patient is significantly volume down.  You know that getting the antibiotics and fluids on board is the cornerstone of treatment, but they will take some time to be given.  You wonder if you should temporize your resuscitation with pressors during the time it takes for the fluids and antibiotics to be administered.

Crucial Conversations in the ED

EMS calls ahead with reports of an adult patient in respiratory distress.  They are concerned the patient will need to be intubated on arrival.  Recognizing the name, you pull up a previous chart and review the patient’s history.  You realize this is their 10th presentation this year and on reviewing their most recent oncology note you note their oncologist has recommended they consider hospice due to end stage malignancy without further treatment options.  The patient arrives, is in distress, and does not have capacity but can be temporized by NIPPV while decision making occurs.  Their power of attorney comes to the hospital soon after but states they never got around to establishing an advanced directive. How should you approach this conversation?

Category (Day): 

The Furosemide Stress Test

You admitted a 72 year old male to the ICU for septic shock from community acquired pneumonia. He required intubation and mechanical ventilation for failure to improve oxygenation with NIPPV and encephalopathy. He received broad spectrum antibiotics and a 30 cc/kg crystalloid bolus. His MAP was persistently in the 50s despite adequate fluid resuscitation and based on your exam he does not appear hypovolemic. Norepinephrine is started and despite adequate MAP he is oliguric. His only medical history is he was a previous smoker with COPD, HTN, HLD but normal renal function with a Cr of 0.8 two months prior. His Cr on admission is 2.2 and a foley is placed and his UA shows granular casts. He is not acidotic and his electrolytes are normal. 

You are concerned this patient is heading towards renal replacement therapy. He is adequately fluid resuscitated and has a MAP above 65 on a vasopressor but is still not making urine and has signs of ATN on urinalysis. Renal replacement therapy is an invasive procedure and has associated risks. If a patient has a chance to have renal recovery with a more conservative approach then this should be considered.  You wonder if there is a diagnostic test which can be used to assess the potential for renal recovery.

Category (Day): 

NIPPV in Hypoxic Respiratory Failure

A 56 year old male comes to the ED via EMS after noting progressive dyspnea and fever.  In the field, the EMS team notes the patient is hypoxic with an SPO2 of 85%.  Despite the low oxygen saturation, he is only using minimal accessory muscles and he is alert and oriented.  His chest X-ray shows a right lobar pneumonia and he is requiring 6LNC oxygen to maintain a saturation greater than 90%. You know there is significant guideline evidence to support the use of non-invasive positive pressure ventilation (NIPPV) for COPD and CHF exacerbations, but what about patients with other causes of hypoxia such as pneumonia?

Category (Day): 

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.

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