Dr Dee Sanchez @DeeOptimal
MD, MIS, PMP, NREMT, NASM-CPT, FAWM Candidate | EM PGY1| IG= @drdee2022 | Passions: #wildernessmed #medinformatics #ems #emergencymed #tweetsnotmedicaladvice instagram.com/drdee2022?utm_… Poznan, Poland Joined February 2015-
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@srrezaie discussion about Andexanet alfa and it’s use in ICH #resusxreunion2024 Always triple check big Pharma funded studies!! The primary outcome was hemolytic efficacy butshowed increased thrombotic events!!
The Ten Commandments of Internship. What would you add?
In PE how to alteplase: @srrezaie plan of action is to give 10mg bolus then 40mg over 2 hours. The idea is to HALF-DOSE your thrombolysis. Thus if you are giving 100mg now then give half dose (ie. 50) @srrezaie #resusfest
PE is an afterload problem. Hypotension with tachy = cardiogenic shock due to RV strain/failure. Thus giving fluids won’t fix PE spiral of death. PPL who think fluids of 500ml for PE are WRONG. only study of support was in 1999 & not on for massive PE. @srrezaie #resusfest
@srrezaie #resusfest PE categories: - Incidental - Segmental - Submassive (RV looks dyfx= anticoag tx) - Massive PE (2 types: hypotensive type which don’t look bad and emergency type which look bad)
In massive pulmonary embolism, should we give fluids or not? Being covered today by @srrezaie at #resusfest
@GageStuntz #resusfest In TTP: ➡️Furosemide can help cuz pt usually are fluid overloaded. ➡️Put a HD line ➡️Draw all labs b4 FFP/PLEX ➡️NO RITUXIMAB or PLT!
How do you manage TTP? - 1. Plasmapharesis 2. Plasmapharesis 3. Plasmapharesis 4. Plasmapharesis 5. Plasmapharesis Jk you can also use steroids, FFP/RBC transfusion, or monoclonal AB. @GageStuntz #resusfest
When trying to diagnose TTP feel free to use the plasmid score as a clinical decision tool. Keep in mind that it is not a validated score. @GageStuntz #resusfest
@GageStuntz #resusfest When you suspect TTP, you need to focus on team based care which means having an intensivists and hematologist working with you in the emergency room.
@GageStuntz #resusfest You want to rule out DIC when you suspect TTP. First pass labs get an ekg, cbc, CMP, troponin, coags and UA.
@GageStuntz #resusfest Pathophys of TTP. 90% mortality rate of untreated. Due to endothelial damage breaks down vEF causing RBC shearing leading to microvascular rupture organ dysfunction and ultimately death. While it presents in a pentad usually only 3 will be commonly seen.
@GageStuntz #resusfest Most commonly seen are SHIGA toxin and DIC but TTP has the most you can do for management.
Case discussion with @GageStuntz at #resusfest. Diagnosis = Thrombotic thrombocytopenic purpura (TTP).
@CriticalCareNow takeaways of post ROSC mgt: Post-ROSC care should be grouped into 3 sequential bundles: 1) 15 minutes post-ROSC, 2) 45 minutes post-ROSC 3) an ICU-level of care in the ED. #resusfest Bundle focus: 1:focuses on stabilizing 2:fine-tuning tx 3: ICU-level mgt
In the event PT needs more time in ED after ROSC: ➡️preserve neuro fx; monitor EEG. ➡️ poor data to support empiric ABX, instead start steroids. ➡️Maint. fluids not needed & can cause harm due to excess fluid in the interstitium.@CriticalCareNow
45min post-ROSC: ➡️focus on fine-tuning tx to max survival by fine-tuning airway management, access, and optimizing MAP (goal is 65). ➡️Adjust vent settings to a tidal volume consistent with PT ideal body weight. ➡️Use vasopressors to maintain MAP at goal. @CriticalCareNow
After ROSC has been achieved do a team debrief. It is crucial to take at least 5 mins to discuss with the entire team what went well, what can be done better, and address any lingering thoughts regarding the case. @CriticalCareNow #resusfest
Airway management after ROSC: ⭐️hemodynamics is more important; focus on airway mgt after hemodynamic stability has been achieved. ⭐️consider swapping out SGAs/EGAs to a formal ETT @CriticalCareNow #resusfest
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