Question
A large part of critical care and ICU management revolves around hemodynamic monitoring and support. But…..we typically don’t use traditional blood pressure (systolic and diastolic) numbers directly.
We use MAP!!!
Swan-Ganz Catheter
Other Known Aliases – pulmonary artery catheter
Definition – intravenous catheter that is maneuvered through the right side of the heart into the pulmonary artery.
Clinical Significance – This catheter can directly measure several important hemodynamic variables in critical illness:
It is “floated” through the right side of the heart using the flow of the blood to carry it into the pulmonary artery. This migration has a very characteristic pressure pattern to know where the catheter is in the vascular system.
History – Named after two physicians from Cedars-Sinai Medical Center, Jeremy Swan (1922-2005), an Irish American cardiologist, and William Ganz (1919-2009), a Slovak American cardiologist. Dr. Swan received his medical doctorate from Castleknock College and went on to become faculty at the Mayo Clinic before joining the faculty at Cedars-Sinai Hospital in Los Angeles. Dr. Ganz attended Charles University School of Medicine in Prague in 1938, but was closed in 1940 after the Nazi occupation of Czechoslovakia. Being jewish, he was then sent to a Hungarian Nazi labor camp and was actually scheduled to be sent to Auschwitz in 19944 before his escape. After hiding and waiting out the war, Dr. Ganz returned and graduated from Charles University in 1947 at the top of his class. He practiced in communist Czechslovakia until 1966 when he secretly defected to the US with his wife and sons. His first and only position as a physician in the US was at Cedars-Sinai Hospital, where he met Dr. Swan who got the idea of the catheter from watching the wind play with the sails of boats in the marina. Dr. Ganz had already published research on the use of thermodilution as a way to measure cardiac output and in 1970, they published their landmark article in the NEJM. It should be noted that German surgeon Werner Forssmann first demonstrated the safety of this type of catheter, by doing it on himself in 1929.
References
Question
You are winding down your 8a-8p shift in the fast track section of your emergency department when a 19-month girl is brought in my her father after falling out of a shopping cart at Home Depot at around 7:15pm. Her father saw her fall and couldn’t catch her before she hit the ground. She immediately began crying and her father denies any loss of consciousness or vomiting. She cried for approximately 30 minutes and her father started to worry that she is now “sleepy”. Other than the sleepiness, her behavior has been normal per her father.
Physical examination does not reveal any periorbital or posterior auricular ecchymosis and there is no hemotympanum. There are no other abrasions or ecchymosis present and her eyes are open and she can track your movements. There is no palpable depressions or crepitus on the skull. She is moving all extremities, reaching for her toys, and saying “Daddy” towards her father.
Answer
This simple and most evidence-based answer is no…..not according to PECARN. The Pediatric Emergency Care Applied Research Network study of 2009 evaluated over 40,000 children of various ages to determine high yield clinical findings that best predicted clinically important traumatic brain injury on CT scan. The original negative predictive value in children under 2 with the following findings was 100%:
In our patient, you could make the argument to observe in the emergency department as she is “sleepy”, but it is close to bedtime and I would use shared decision making with the father to decide on discharge with good instructions vs observation for 4-6 hours.
References
Osborn Wave
Other Known Aliases – J-wave, camel-hump, hypothermic hump
Definition – positive deflection occurring at the junction between the QRS complex and ST segment, commonly referred to as the J point
Clinical Significance – Osborn waves are classically seen in hypothermia with a core body temperature < 32°C (90°F), but also can be present in severe hypercalcemia, traumatic brain injury, and pericarditis. It is usually most prominent in the precordial leads.
History – Named after John J. Osborn (1917-2014), who was an American intensivist, and received his medical doctorate from Johns Hopkins University in 1943. He completed a nine-month residency in pediatrics before serving as an Army medical officer in World War II in the Pacific Theatre. He first published his preliminary animal research on hypothermia in 1943 before his military service, and picked it back up after returning stateside. He practiced from New York University to Stanford University and was a founding member of the Society of Critical Care Medicine. His research fostered the initial golden age of intensive care medicine and he worked on heart-lung machine designs, as well as hemodynamic monitoring devices. His eponymous paper was published in 1953 entitled “Experimental hypothermia; respiratory and blood pH changes in relation to cardiac function”
References
Question
You are winding down your 8a-8p shift in the fast track section of your emergency department when a 19-month girl is brought in my her father after falling out of a shopping cart at Home Depot at around 7:15pm. Her father saw her fall and couldn’t catch her before she hit the ground. She immediately began crying and her father denies any loss of consciousness or vomiting. She cried for approximately 30 minutes and her father started to worry that she is now “sleepy”. Other than the sleepiness, her behavior has been normal per her father.
Physical examination does not reveal any periorbital or posterior auricular ecchymosis and there is no hemotympanum. There are no other abrasions or ecchymosis present and her eyes are open and she can track your movements. There is no palpable depressions or crepitus on the skull. She is moving all extremities, reaching for her toys, and saying “Daddy” towards her father.
Ottawa Rules
Other Known Aliases – none
Definition – Set of clinical decision instruments to help predict pretest probability in various injuries and need for further radiographical studies
Clinical Significance – There are four Ottawa Rules clinical decision instruments that are currently used:
History – Named after The Ottawa Hospital Research Institute and the University of Ottawa over series of publications from 1992-2001. These publications have been validated numerous times and shown to decrease health care costs, unnecessary radiographic studies, and decrease throughput time in the emergency department. The brain behind these studies is Ian Stiell, a Canadian physician researcher who received his medical doctorate from the University of Ontario and completed his residency at McGill University. With over 370 publications to his name, he is a powerhouse in the realm of emergency medicine research.
References
Question
You have a patient in the ED with an aortic dissection and are managing them while awaiting the cardiovascular surgeon to arrive.
Answer
For a deep dive into aortic dissections, check out the podcast
References
Question
You have a patient in the ED with an aortic dissection and are managing them while awaiting the cardiovascular surgeon to arrive.
Wes Johnson, MSPAS, PA-C, (soon to be), DHSc was a former student of mine at UAB and was a respiratory therapist prior to PA school. He is the Regional Director of Clinical Education for Island Medical Management Emergency group in North Alabama. He won the Preceptor of The Year award from UAB in 2016 and currently finishing up his doctorate degree from A.T. Still University.
Twitter – @wesj2288
For the purposes of this podcast and post, we will be using the Puritan Bennett 840 ventilator (pictured below). All the term we use are synonymous with all vents, but the screens will be different.
Puritan Bennett 840
(For this section, refer back to the vent picture above)
Mode: AC
Vt: 6-8 mL/kg based on pt’s IBW
Rate: 12-16 bpm
FiO2: 100%
PEEP: 5.0
At the 5-minute mark:
PAINE Podcast and Medical Blog 