Bret P. Nelson, MD, RDMS, FACEP

Courtesy of Bret Nelson

Twitter: @bretpnelson

Website: SinaiEM.us

YouTube: SinaiEMultrasound

Bret Nelson is a Professor of Emergency Medicine, Chief of the Emergency Medicine Ultrasound Division at the Icahn School of Medicine at Mount Sinai, Chief Editor of the ultrasound education website, www.SinaiEM.us. He is on the board of directors of the Society for Clinical Ultrasound Fellowships and active in the American College of Emergency Physicians (ACEP)'s Ultrasound Section and is among the authors of ACEP's Emergency Ultrasound Guidelines. Served on the Board of Directors of the World Interactive Network Focused on Critical Ultrasound (WINFOCUS) and was Chair of the American Institute of Ultrasound in Medicine’s Point of Care Community of Practice

Authored several books, Manual of Emergency and Critical Care Ultrasound, Emergency Medicine Oral Board Review Illustrated, Atlas of Handheld Ultrasound, and Acute Care Casebook.

Dr. Nelson has lectured throughout the world on the use of point-of-care ultrasound to aid medical decision-making and improve patient safety. His research interests include ultrasound and medical education.

Want to take a Ultrasound Guided Peripheral IV Intensive Course?

We have one coming up! Saturday October 13, 2018

We're providing a 4:1 attendee to instructor ratio in a 4 hour training program so you get tons of hands on experience to learn this awesome skill! Spots are limited! Sign up and complete info here at EventBrite 

Resus Nurse Podcast and Blog Discount: ResusNurse10

USG PIV Course10132018 PDF

Missed 021 Nurses Placing Ultrasound Guided IV Access w/Bret Nelson, MD Episode? Click Here

"This isn't some brand new skill. This is a technique through which you can optimize your existing skills in venous access." ~Bret Nelson

How to Start a Nurse Ultrasound IV Training Program?!

Nurse Driven Program

Nurses interested in ultrasound should be the course director(s).

Doesn't necessarily have to be the unit Nurse Educator.

If working with MD, have multiple Course Directors or MD can be there to help out initially.

Nurses can and should drive this program.

Nurses teaching nurses a new skill offers insight that providers aren't able to provide.

Only takes 1-2 Nurses to drive practice change within a unit!

Multidisciplinary Course Directors and/or Instructors (RN and MD)

Both nurses and physicians bring a lot of their own skills to the table.

Combining skills, we learn from each other and ultimately become better at obtaining IV access with ultrasound use.

ED Initiative for ED Nurses and ED Culture Utilizing Multidisciplinary Support

A positive initiative that improves patient care.

We created a culture where once a nurse finishes competency, they are able to place ultrasound-guided IV access on their own. Sometimes, you run into trouble and usually it's because the patient has limited veins, so they are still able to ask for help. Have another person look with the ultrasound. It's okay to ask for help!

This has also increased more collegial respect between disciplines and increased teamwork.

Nurse buy-in and Physician buy-in

We decided to make this program optional for nurses.

Currently we only have this program for our adult population in the ED.

Nurses love the program and so do our patients!

Support from Nursing and Physician Leadership

Talk to your Nursing and Physician Directors of your department.

Keep them in the loop.

I have found Leadership to be extremely supportive and helpful.

Nursing Policy and Nursing Education

Written policy for nurses is important to have in writing within your department/institution.

Work with your Nursing Director and/or Nursing Education in order to develop policy if it's not already written or change/expand existing policy.

Know your policy. Some may restrict this skill to nurses working in specific departments.

Bret P. Nelson, MD, RDMS, FACEP

Courtesy of Bret Nelson

Twitter: @bretpnelson

Website: SinaiEM.us

YouTube: SinaiEMultrasound

Bret Nelson is a Professor of Emergency Medicine, Chief of the Emergency Medicine Ultrasound Division at the Icahn School of Medicine at Mount Sinai, Chief Editor of the ultrasound education website, www.SinaiEM.us. He is on the board of directors of the Society for Clinical Ultrasound Fellowships and active in the American College of Emergency Physicians (ACEP)'s Ultrasound Section and is among the authors of ACEP's Emergency Ultrasound Guidelines. Served on the Board of Directors of the World Interactive Network Focused on Critical Ultrasound (WINFOCUS) and was Chair of the American Institute of Ultrasound in Medicine’s Point of Care Community of Practice.

Authored several books, Manual of Emergency and Critical Care Ultrasound, Emergency Medicine Oral Board Review Illustrated, Atlas of Handheld Ultrasound, and Acute Care Casebook.

Dr Nelson has lectured throughout the world on the use of point-of-care ultrasound to aid medical decision-making and improve patient safety. His research interests include ultrasound and medical education.

"10 years ago a patient will say, 'Only Mary on the 9th floor is going to get near my vessels'....now the patients say, 'I'm a tough stick, so use ultrasound.'

It's almost like anyone can get a pass from the patient's perspective...ultrasound is the great equalizer." ~Bret Nelson

Can RNs perform USG PIV safely? Yes!

Within Nursing Scope of Care!! Yes!!

American Institute of Ultrasound in Medicine (AIUM) White Paper in conjunction with:

American Academy of Physician Assistants (AAPA)

American Association of Critical Care Nurses (AACN)

American Association of Nurse Anesthetists (AANA)

American Society of Diagnostic and Interventional Nephrology (ASDN)

American College of Emergency Physicians (ACEP)

American Society of Echocardiography (ASE)

Association of Physician Assistants in Cardiovascular Surgery (APACS)

Association for Vascular Access (AVA)

Infusion Nurses Society (INS)

Renal Physicians Association (RPA)

Society of Diagnostic Medical Sonography (SDMS)

Society for Vascular Ultrasound (SVU)

Emergency Nurses Association (ENA) Clinical Practice Guideline for Difficult IV Access

Why Nurses?

Nurses are masters at IV insertions

Ultrasound is another tool in the tool belt for difficult IV access.

Ultrasound is a natural progression for nurses who are experienced in obtaining IV access

Nurses have the best tricks to get those tough IV lines like applying heat.

Nurses already use other technology including infrared light, LED, and head lamps

Journal articles show high success rate!

~85 after approximately 10-15 attempts

~95% after approximately 20-25 attempts

Too many articles - click here for dropbox link and easy download.

Empowering nurses with an advanced skill

Nurses are able to identify a patient as a hard stick and obtain IV access with ultrasound without waiting for a physician to place the IV.

Nurses who need to develop their IV skills have a skill to strive for.

Patient Satisfaction

Nurses are able to identify patients who are a hard stick. Patients have reduced failed attempts prior to an ultrasound guided placed IV access.

Essentially, patients get stuck less but get good results. Patients know they are a hard stick - they are happy.

Who Should be getting USG PIV?

Patients who have difficult intravenous access.

*If you can place an IV in a conventional or traditional method, do it. ~Yun Cee

Identified difficult IV access populations:

Oncology/Chemotherapy

Sickle Cell

Renal/Hemodialysis

Obese

Repeat Hospital Admissions

Shock

IV Drug Abuse

Diabetic

Edematous

Dehydration

Pediatric

Reduces CLABSI by NOT placing central venous lines because you have peripheral IV ac...

Sergey M. Motov, MD, FAAEM

Courtesy of Sergey M. Motov, MD

Twitter @painfreeED

Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally

 

Missed Episode 011? Low Dose Ketamine for Pain - Administration Explained! Click Here

Missed Episode 018? Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More Click Here

A Candid Conversation on having a Hydromorphone-Free ED with Sergey Motov, MD FAAEM

This episode was recorded earlier in the year at the same time as the Deep Dive Continuous Sub-Dissociative Dose Ketamine discussion.

Are people forgetting how powerful hydromorphone is?

Some people do forget, majority have not been educated.

Why are we now using so much hydromorphone?

This medication was basically thrown at us. "Use it. It’s a great and safe medication alternative to morphine." Without actual explanations of equi-analgesic conversion, potency, or lipophilicity (lipid solubility) in comparison to morphine.

Morphine 8mg or Hydromorphone 1mg?

There’s something mental about giving a single digit dose of an opiod versus double digit.

It’s much easier to prescribe 1mg, 2mg, 3mg…6mg of hydromorphone than let’s say 10mg of morphine without understanding that hydromorphone 2mg = morphine 16mg.

Hydromorphone 1mg = Morphine 8mg

Hydromorphone 2mg = Morphine 16mg

48% ED attendings lack pharmacological understanding or validity of why they are using one opioid over another

Opioid-Naive Patients

First-line medication - should NOT be hydromorphone

Initial hydromorphone dose should be 0.2-0.4mg (If you must, for opioid-naive patients)

Conversion: Morphine 2-4/5mg dose

How to administer opioids? Titrate at Specified Intervals *Clinical Pearl

Single dose of opioids will not do the trick. No matter how you dose it (weight based or fixed).

Start with a lower dose. Reeval every 10-15 minutes. Ask the patient if they need more. Give another dose as needed. Repeat.

No need to wait 4 hours for the next opioid dose.

Morphine peak time ~20 minutes

Hydromorphone peak time ~15 minutes

Morphine, hydromorphone and fentanyl are pure mu receptor agonists with no analgesic ceiling.

Titrate opioids up until one or two things will happen: Pain is optimized or they stop breathing

Clinical Example:

Patient received 3 doses of morphine: 4mg, 4mg, 4mg. Still has pain. Now what? You want to give an opioid. Which one?

Some may switch to hydromorphone. But why?

Hydromorphone is not any different than morphine except for potency.

The most potent opioid is fentanyl. Problem is fentanyl has a shorter half life so will have to re-dose more often.

Consider adding non-opioid analgesic modalities

If you do switch to hydromorphone - remember to add previous morphine doses and convert equianalgesia for total dosage. i.e. Morphine 12 mg (4mg x3) + Hydromorphone 1mg (Morphine 8mg) = Morphine 20mg

Opioid-Induced Hyperalgesia

The longer a patient uses opioids to treat pain, the patient will most likely develop hyperalgesia and will ultimately require a higher dose to treat their pain which will eventually lead to tolerance and possibly addiction. Constantly requires a higher dose.

Hydromorphone has a Higher Abuse Potential than Morphine

Hydromorphone is 10x more lipophilic than morphine.

Penetrates the blood brain barrier significantly faster and saturates the mu receptors faster.

It translates to a euphoria,

Nursing Intubation Checklist - Yes, Really.

Over the years I’ve developed a personal Nursing Intubation Checklist that I have for myself when preparing for RSI, DSI, or an awake intubation. This has saved my ass while working on very sick patients. Some of my checklist items cross over with the provider’s checklist. I’m sure it will evolve and I will update as needed.

You may still be scrambling, but you can save yourself from going into a panic mode if your patient starts crashing and you’re trying to do everything so you don’t need to start compressions - tall order.

Generally, I don’t hand over the intubation meds to the doctors until MY checklist is complete. There’s almost always time with DSI and awake intubations. With RSI you may not have as much time and you may need to hand over the intubation meds before finishing your checklist - the patient needs the airway NOW.

Do you have a Nursing Intubation Checklist?

Looking forward to having feedback and a discussion as to what should be added or taken away.

Intubation has 4 main Parts

The Decision to Intubate

Setting Up for Intubation

Intubation

Post Intubation Care

Some of my thoughts on Intubation

Communicate with your provider as to what the plan of care is:

BP low - do we need push dose pressors or vasopressors before and/or after intubation?

Are we anticipating central line or A-line?

Post Intubation Care is the most critical part of intubation (in my opinion) and it's VERY NURSING HEAVY.

Providers should stick around and watch the patient. Patients like to crash right around this time.

If your provider is not your ED Provider, they really need to stick around and not go upstairs.

The more you have set up PRIOR to intubation, the SMOOTHER your post intubation care.

Soooo Nursing Heavy that there will be a separate episode on Post Intubation Care...stay tuned!

Here’s my Nursing Intubation Checklist

2-3 IV lines

I prefer 3. Sometimes I even put in 4 or 5. Just depends on what I need or anticipate.

Especially if they are very sick and you have a sneaky suspicion that you will need a NE drip for a crashing BP. You may need PDP but if you already have a drip ready to go - even better!

Mentally think which medications and how many lines you need. Not all medications are compatible through the same line.

Pet Peeve Alert! If a provider tells you, don’t worry about the extra IV line, we’ll put in a central line afterwards - don’t listen to them!

If your patient is sick enough that the provider is already anticipating the need for a central and/or A line - you betcha you will need those extra IV lines while it takes them 20-30 minutes to put in that central line.

Your patient may not have 20-30 minutes to spare if they are that sick because remember, you are doing a lot of medication adjustments for post intubation care.

Make sure these are actually good lines. If they are not, this is the time to put in an ultrasound guided peripheral IV line or two.

Traumatic Arrests or Hemorrhagic Shock may require 18 gauge or larger IV lines for massive blood transfusion.

Pet Peeve Alert! But my rule of thumb is, if you can DEFINITELY get a 20 gauge in - I’d rather that you get the IV line rather than trying to only go for an 18 gauge or larger and then blowing all of your lines. This is not the time to have your ego in the way of patient care.

The larger IV lines, if still required, can be placed after intubation with ultrasound guided peripheral IV placement in this situation.

Your provider should also be thinking about inserting a cortis so you can rapidly infuse blood products through that line.

If you're the provider - communicate this thought process to your nurse.

Verbal Orders of Intubation Medications AND Post-intubation sedation.

Both set of orders PRIOR to intubation - you will have a smoother transition for your patient during...

Sergey M. Motov, MD, FAAEM

Courtesy of Sergey M. Motov, MD

Twitter @painfreeED

Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally

Missed the Low Dose Ketamine for Pain - Administration Explained! Episode? Click Here

We wanted to do a Follow-Up Episode about Sub-Dissociative or Low-Dose Ketamine (SDK) Infusions.

Then this research got published...

Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department

Authors: Motov, Sergey; Drapkin, Jefferson; Likourezos, Antonios; Beals, Tyler; Monfort, Ralph; Fromm, Christian; Marshall, John

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Publication Date: March 3, 2018

Sergey is back and talks about his research and findings...

Impressive Pain Reduction >3 on Numeric Pain Scale

60 Minutes, 65% of Patients

120 Minutes, 68% of Patients

How does Continuous SDK Infusion Work?

"Ketamine's rapid onset, and super rapid saturation of N-methyl-D-aspartate (NMDA) receptors and will give you an initial jolt of pain relief.

But if you do it relatively slowly, the saturation will be a little slower, but it will last much, much longer.

That's why I believe the results of patients experiencing significant reduction of pain at 60 and 120 minutes, a direct consequence of this particular way of giving ketamine."

- Sergey Motov, MD

Most Patients Enrolled in Study Received a Loading/Short Bolus Infusion prior to Continuous SDK Infusion

Who received the most benefits? Patients with...

Oncology/Cancer Pain (Chronic and Metastatic)

Oncology patients normally have multiple modalities to treat their pain.

Can have very high baseline PO opioid doses (i.e. morphine 300mg PO, fentanyl patches). Administering morphine 4mg or hydromorphone 1mg IVP will do absolutely nothing for these patients.

The opioid dose needed is so high that the side effects are intolerable (i.e. nausea, vomiting). Increase CNS depression, respiratory depression, morbidity, and mortality in very high, inhumane doses.

Continuous Sub-Dissociative Ketamine Infusions can be used as an adjunct therapy

FYI: Ketamine comes in PO form (pill and liquid)

Ethical Alert!

Concern for abuse is real, don't prescribe it. Highly addictive and highly abused.

Just know that it's out there, may have application to some chronic oncology patient population.

Abdominal Pain (Pancreatitis, Intractable, Unknown Etiology)

Sub-Dissociative Ketamine is the most beneficial modality for chronic intractable pain with or without non opioid adjunct therapy with functional abdominal pain (i.e. secondary to toxicology emergency).

Psyche component for unknown etiology abdominal pain?

Simple conversation with biofeedback, psycho-social counseling, encouragement, and reassurance

Normal Physical Exam

May not need any interventions

Sickle Cell Crisis Pain

Use of continuous SDK infusion decreases opioid needs by 50%

Barriers:

Admitted Sickle Cell Crisis Patients will not get SDK infusions on inpatient units and will go back to hydromorphone PCA pumps

Inpatient Providers' and Nurses' familiarity and understanding of SDK infusions

Convincing Patients to try SDK as adjunct therapy for pain

Interdepartmental protocol.

Work Around:

Admit patients to an observation unit with SDK protocols in place.

Utilize Clinical Nurse Educators to develop nursing policy.

Interdisciplinary SDK protocol can be developed with ED Medical Director, ED Nursing Director, and Pharmacy.

Who is Arlene Chung, MD?

Courtesy of Arlene S. Chung, MD, MACM

Arlene S. Chung, MD, MACM 

Arlene is an Associate Residency Director for the Mount Sinai Emergency Medicine Residency Program in New York City.

She has a passion for physician wellness and has made advocating for well-being a central focus of her career. She holds leadership roles in multiple regional and national wellness organizations and has lectured extensively on physician wellness, developed mindfulness curricula for students and residents, and published on the current issues surrounding wellness and burnout and possible solutions for the future.

Twitter @ArleneSujin

What is Airway: True Stories from the Emergency Room?

Arlene is also one of the co-founders of a non-profit organization known as Airway: True Stories from the Emergency Room. Airway originally began in 2015 as a series of free New York City-based storytelling events for EM physicians with the mission of creating community, decreasing stigma, and fostering resilience through the vulnerability and shared experiences of storytelling. Airway events have since been organized in cities across the country and at multiple regional and national conferences including the AAEM Scientific Assembly, FemInEM Idea Exchange (FIX), and the NY ACEP Scientific Assembly.

AIRWAY LIVE NYC EVENT

AIRWAY and RESUS NURSE Podcast Listener CONTEST!!

Arlene and I want to hear YOUR stories! Send us a pitch at [email protected] with your name and email address! We'll select our favorites and air them at a later episode!

Deadline: May 31, 2018

Now Listen to the Episode...Be Prepared to Laugh and Cry...

Cite this post as:

[cite]

"This used to be merely intuition...even a minute or two at low MAPs may be too much and certainly waiting 20 minutes for pharmacy to send up a drip is probably way too long...and your kidneys may actually be getting damaged in that short period of time." - Scott Weingart, MD

Who is Scott Weingart, MD?

Courtesy of Scott Weingart, MD

Scott D. Weingart, MD FCCM FUCEM DipHTFU

Scott is an ED Intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO.

He is currently an attending in and chief of the Division of Emergency Critical Care at Stony Brook Hospital. He is a clinical associate professor of emergency medicine at Stony Brook Medicine and an adjunct associate professor at the Icahn School of Medicine at Mount Sinai.

He is best known for talking to himself about Resuscitation and Critical Care on a podcast called EMCrit, which has been downloaded > 19 million times. EMCrit Twitter Team @emcrit

What is a MAP? (Mean Arterial Pressure)

Average pressure in a patient’s arteries during one cardiac cycle

Really good number to measure organ perfusion

Systolic BP is a useless measurement in super hypotensive patients

Calculations:

MAP = CO x SVR

MAP = SBP + 2(DBP)/3

Low MAPs should be treated as an Emergency = Requires Good Nursing!!

What is a minimal MAP for adequate perfusion?

No one knows!! 

Minimal MAPs (what we think and have made up) to adequately perfuse 3 main organs. Use this as a loose guideline. May have to individualize for each patient.

 

Brain

MAP 60-65

but can go lower for a bit of time before damage

MAP 40 starts to have altered mental status

Heart

MAP 60-65

Kidney

MAP 65

super sensitive to low MAPs

May not be able to measure output in ED if kidneys were hit hard and due to shunting

In the ED, we like MAP 65...

because the organs will have minimal perfusion and we often don't know what the medical history is or have had 24 hours of patient observation.

 Normal MAP + Low SBP + Normal DBP = Okay

Organs are being perfused

Low MAP + Normal SBP + Low DBP (Ex: 100/20) = Badness

Can be in cardiac arrest if you don't pay attention and do something ASAP

Low MAP, How long is too long?

New Anesthesia literature that shows a minute or two may be too much.

Concern for kidney injury

Hearts may dislike low MAP esp. Pts with cardiac history.

React quickly to low MAPs (MAP 40s and 50s)

No barrier to treating low MAPs

No Harm in treating low MAPs

Can start peripheral NE drip and if in 45 minutes, NE drip is titrated off - no harm done to Pt

Wait and See approach with fluids doesn't work

Fluids don't last to maintain MAPs, it will drop 30-60 minutes later

Harm to keep Pt at low MAPs

"Permissive Hypotension" A confusing term

No one is really in a permissive hypotension state lower than the minimal MAP 65

Trauma

A confusing term because the trauma studies still show that a Pt is being perfused and hovering around MAP 60-65

Term came about because fluids were restricted instead of giving bunch of fluids - but BPs were normal

Some say the clot is formed so don't break the clot - still BPs are at MAPs that we talked about

Bickell study on penetrating trauma Scott mentioned

Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma by D. Kudo

Rick Dutton Approach for penetrating trauma management as described by Scott

Keep your patient from being vasoconstricted

Organs are not being perfused with higher MAP but in fact exsanguinating due to vasoconstriction

Manage by hovering around a MAP 60-65 and perfuse organs

MAP <65 give product (like 1 unit of PRBC, FFP, etc.)

MAP >80 (or whatever upper limit you decide), give them some anesthetic and dilate them.

Fentanyl is an indirect vasodilator

"I find it very gratifying to treat because you can see the effects of your treatment right in front of your eyes. And your patients can go from very sick to well within a matter of hours." - Marc Probst, MD

Who is Marc Probst, MD?

Courtesy of Marc Probst, MD

Marc Probst, MD, MS is an Academic Emergency Physician at The Mount Sinai Hospital in New York City.

Dr. Probst is funded by a career development grant from the National Institutes of Health (NIH).

His interests include syncope, shared decision-making, and Halloween.

Twitter @probstMD

 

Diabetic Ketoacidosis (DKA)

Biochemical Findings

Hyperglycemia

Ketosis

(High anion gap) Metabolic Acidosis

Parameters to treat DKA

Blood glucose >250mg/dL

Elevated anion gap w/albumin adjustment >10

Serum bicarbonate <18mEq/L

*Positive serum/urine ketones

pH <7.3

Causes

Lack of insulin

Poorly controlled DM

Barriers include access, insurance, expensive, etc.

Undiagnosed DM

Disasters

Infection

Mesenteric Ischemia

Cardiac (MI)

Intoxication (cocaine, ETOH)

Iatrogenic (steroids, HCTZ, SGLT2, antipsychotics)

CVA

Pregnancy

Hyperthyroidism

Click here for a nice review at emdocs

Ketosis vs. DKA

Pt can have an elevated blood glucose but not in DKA

See if they really are acedotic first - check for ketones

Ex: blood glucose 500+, pH 7.4, no ketones in serum/urine

Look at baseline labs (compare history)

Ex: Renal failure patients can live in a lower pH

Euglycemic DKA

Normal blood glucose

Has Anion gap

What's the worse that can happen?

Cerebral Edema (documented in Pediatrics)

Death

1% mortality rate and a 5% mortality rate for elderly

Symptoms

Nausea/Vomiting (can cause mixed acid-base disorder)

Combination of metabolic acidosis and metabolic alkalosis

Abdominal Pain

Altered Mental Status/Confusion

Frequent Urination

Excessive Thirst

Weakness/Fatigue

Respiratory Status - Kussmal respirations (fruity breath)- tachypnea to blow off CO2

Mental status

If they are intubated, want to match RR to pre-intubation status

Bipap? -Consider High flow nasal cannula to maximize "blowing off CO2."

Look at respiratory drive to determine airway intervention

Dehydration

Dehydration & electrolyte imbalances due to osmotic diuresis

Glucose-mediated osmotic diuresis

Nausea and vomiting

Poor PO intake.

Work-Up

POCT Blood Glucose

POCT Urinalysis

Labs

VBG

ABGs are unnecessary

VBGs are a more accurate representation of what is going on in the tissues

Chemistry Panel including Mg & P

Urinalysis

Add. Labs/Diagnostics if you suspect underlying cause, etc.

Serum ketones (suspect/known anuria secondary to dehydration or renal failure)

Troponin

EKG

Blood/Urine Cultures (suspect infection)

Lactate Level (suspect infection)

Anion Gap

Anion Gap = (Na) - (Cl + HCO3)

Click here for easy Anion Gap Calculator w/albumin adjustment

What is an Anion Gap?

Too many unmeasured anions causes metabolic acidosis.

Etiologies of increase organic acids:

MUDPILES: methanol, metformin, uremia, diabetic ketoacidosis, ethylene glycol, salicylates, and starvation.

ESKD

What’s a normal anion gap?

3-11mEq/L

Hypoalbuminemia affecting anion gap calculation - adjust for albumin

Albumin is a major source of unmeasured anions and clinically significant for treatment

A drop in albumin by 10 g/L will cause the anion gap to fall ~ 2.5mEq/L at constant pH

Management -  Lots of Nursing (Step-down or ICU)

Telemonitoring

Hourly fingersticks

VBG/BMP every 1-2 hours

In my own clinical practice I don’t find hourly labs to be useful

Mental Status & Respiratory status

Adjust Insulin Drip

Watch out for Hypokalemia and Hypoglycemia (Clinical Pearl!)

Management = Fluids, Insulin, Electrolytes

Fluids

How much Fluids? How aggressive? What’s the concern? (Controversial in Pediatrics!)

New RCT trial coming out comparing aggressive vs. gentle fluid resuscitation in Pediatric population w/DKA.

Markus dela Cruz, RN

Mark is an ED Nurse extraordinaire who turned into a Cath Lab RN. He is also found working in PACU units and still works some ED shifts. Mark also considers himself a foodie and likes exploring Queens, NY. Mark works at a Level 1 Trauma Center that is also a STEMI receiving center in Queens, NY.

Fun fact: When I first started working, there were rumors that Mark can get an IV line with a full set of labs on sick patients with NO tourniquet! To this day, I believe this may be more truth than fiction.

Disclaimer: This is how Mark and I manage our STEMI patients going to the Cardiac Cath lab for PCI. These are suggestions. Follow your institution’s policies.

"The minute that fellow or that doctor opens up that vessel - you see the color returning, pt's vital signs are stabilizing, and the pain is completely gone. I'm having goosebumps telling you this. " - Markus dela Cruz, RN

Need to listen to Part 1?

Listen to Part 1 of my discussion with Markus dela Cruz, RN where we went over all the nitty gritty details on how to send your STEMI patient to the Cath lab STAT!

PCI Post Cardiac Arrest

Who is eligible?

Patient Viability

How long patient was down for?

Safe for patient?

PCI will be adding more stress to the heart

Involve Family for shared decision making

Considerations

Send your patient ASAP!

Send your patient with a secured airway

Cath Lab MDs are unable to assist with a code or intubation - they are scrubbed in.

May only have 2 nurses running the code.

Pt most likely in cardiogenic shock

If Pt codes during transfer and/or at the Cath lab - Door to balloon time of <90 minutes still applies.

Send Pt with 3 or more IV medlock lines

Undress Pt completely

Coordinate All Essential Personnel for Transfer to the Cath Lab Post ROSC

Respiratory Therapist

Transporter

Prep your patient as much as possible so the Cath Lab can perform PCI quickly!

Now Listen to the Episode...

Cite this post as:

[cite]

Markus dela Cruz, RN

Mark is an ED Nurse extraordinaire who turned into a Cath Lab RN. He is also found working in PACU units and still works some ED shifts. Mark also considers himself a foodie and likes exploring Queens, NY. Mark works at a Level 1 Trauma Center that is also a STEMI receiving center in Queens, NY.

Fun fact: When I first started working, there were rumors that Mark can get an IV line with a full set of labs on sick patients with NO tourniquet! To this day, I believe this may be more truth than fiction.

Disclaimer: This is how Mark and I manage our STEMI patients going to the Cardiac Cath lab for PCI. These are suggestions. Follow your institution's policies.

Your Patient's Going to the Cath Lab!

How can we ensure the fastest and smoothest transition from the moment your patient is identified as a STEMI and accepted to the Cardiac Cath lab?

PCI (Percutaneous Coronary Intervention) is the treatment of choice for a repercussion of a patient having an active MI. It is a life-saving procedure.

You may be a receiving facility getting transfers.

If your facility does not have a Cath lab, you will transfer to a facility that does.

3 Sites of Entry: Right Radial Artery and Bilaterally Femoral

This is a CMS reportable event and the door to balloon time is within 90 minutes.

Preferably, you get your patient into the Cath lab WELL before the 90 minute mark because your Cath lab team have a lot to do.

Prepping Your Patient

Get your patient butt naked! Seriously, no underwear! (A running theme!)

IV Medlocks

Minimum 2 IV medlocks. 3 is super!

Avoid Right Wrist and Right Hand.

Left arm preferred

Vitals also include:

Weight All medications given in the Cath lab are weight-based.

Height intra-aortic balloon pump is sized by height

EKGs (just leave the leads on! You'll be repeating these!)

Defibrillator Monitoring (use radiolucent pads)

Telemonitoring & transport monitoring (esp. your cardiogenic shock pts)

Not all facilities have fancy defibrillator monitors that also have BP and Pulse Ox. If you do, obviously use it!

History Ask the patient and/or EMS what meds were given (esp. aspirin dose)

Consent

Can we trust the Cath fellow with the original?

If we have time, I usually make copies and tape it to the top of the stretcher and get it scanned in the ED Chart.

Secure all property and jewelry with family member or security - label and seal the property bags.

Keep left chest wall and right wrist clear of all jewelry.

Document in chart where property went.

Medications

All Patients with STEMI

Aspirin 325mg PO

If EMS gave 2 baby aspirins (81mg each), give another 2 for a full dose of 325mg

Heparin Bolus IV

Most facilities are weight-based, but some still give the standard 5000 units IV

Heparin IV Myth-Buster!

Always administer bolus dose heparin by IV. Never subcutaneous!

IV Heparin helps prevent the existing clot to not get larger and prevents new clots

aPTT in anticoagulated therapeutic range is the goal!

Don't wait for an aPTT/INR result before administering Heparin IV.

Pts need to be anticoagulated because PCI attracts clot formation.

Cath labs have fancy machines that measure aPTT and INR in real time and can adjust heparin as needed.

ACT (Activated Clotting Time) Machine

Worse case, heparin's antidote (protamine sulfate) is readily available in the Cath lab.

If PCI w/Stents

Loading doses of clopidogrel (Plavix) and ticagrelor (Brilinta)

Additional Medications

Heparin Drip

When did you start it?

What's the current dosage/rate?

If the pt received thrombolytics and you are a receiving hospital, pt should most likely be on a heparin drip to prevent further clots. Speak with Cath fellow/cardiology/EM MD.

NSTEMI patients boarding in your ED may be on a heparin drip. Check aPTT every 6 hours and adjust drip as needed for anticoagulated therapeutic levels - goal...