Category Archives: Featured-TOTW

TOTW: Central Venous Access Device (CVAD) Access

TOTW: Central Venous Access Device (CVAD) Access
Posted on: September 22nd, 2022

TOTW: Central Venous Access Device (CVAD) Access

Accessing CVADs for critically ill patients can be a lifesaving tool that can be used by ACPs. However, this procedure is not without risk and should only be performed if IV access is unobtainable.

Recall from our teaching on IO access that SWORBHP Medical Council defined as IV attempt as applying a tourniquet, then looking and feeling for a vein. The same applies for CVAD access. Please also document your findings on IV attempt, so the rationale for CVAD access is clear.

A non-exhaustive list of potential complications from utilizing a CVAD is as follows:  The line being non-functioning, or infected (maybe this is the cause of the sepsis the patient is experiencing).  There is also risk of air embolism, introducing infection and causing hemorrhage (recall that units may have instilled heparin).

Interested in knowing more about CVAD access? Stay tuned for an upcoming SWORBHP Podcast on this very topic.

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TOTW: Pediatric Cardiac Arrest and When to Transport

TOTW: Pediatric Cardiac Arrest and When to Transport
Posted on: May 30, 2022

TOTW: Pediatric Cardiac Arrest and When to Transport

The ALS PCS Cardiac Arrest Medical Directive allows for some clinical judgement when it comes to managing pediatric cardiac arrests. SWORBHP Medical council recommends scene management when it comes to rhythms that are amendable to defibrillation. In cases where defibrillation is not required (hypoxia, sepsis, etc.), paramedics can consider early transport.

This direction allows more paramedic flexibility in assessing each situation. We understand that there are many factors that impact the decision to transport or stay-and-play. Location of call (2 minutes from hospital versus ½ hour), underlying suspected cause of arrest, scope and experience of responders (PCP vs ACP etc). Documentation of your decision-making process is valuable so we can better understand and support your thinking and care when we review these calls.

For a deep dive on the evidence behind when to transport in pediatric cardiac arrest (and more!), check out the latest SWORBHP Podcast, with special guest Dr. Sara-Pier Piscopo, pediatric emergency medicine fellow.

 

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TOTW: Analysis Trainer Tool

TOTW: Analysis Trainer Tool
Posted on: May 20, 2022

TOTW: Analysis Trainer Tool

Check out this cardiac rhythm analysis trainer tool by firebaseapp.com. This tool asks you to manually interpret ~30 rhythms of simulated cardiac arrest. Your results are generated for you at the end, along with time-to-shock. Give it a try today!

https://simul-shock.firebaseapp.com/

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TOTW: If You Can See Blood in the Urine: NSAIDs are Contraindicated

TOTW: If You Can See Blood in the Urine: NSAIDs are Contraindicated
Posted on: March 31, 2022

If You Can See Blood in the Urine: NSAIDs are Contraindicated

From your 2021 MCME Interactive day:

If you can see blood in the urine (pink or red!) then NSAIDs are contraindicated. The OBHG Companion Document says “trace urine” is not considered an active bleed. However, trace urine by definition cannot be seen by the naked eye and is only detectable via urinalysis. Therefore, if a patient tells you they saw blood in their urine, withhold ibuprofen and ketorolac.

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TOTW: PPH Management Changes if Placenta is IN or OUT

TOTW: PPH Management Changes if Placenta is IN or OUT
Posted on: March 11th, 2022

TOTW: PPH Management Changes if Placenta is IN or OUT

From your 2021 MCME Interactive ECB session:

If the placenta is IN (has not been delivered) DO NOT perform external uterine massage (a.k.a. fundal massage). This can damage the placenta and cause further bleeding, as portions of the placenta may be retained and inhibit the uterus from contracting down.

Instead, complete your oxytocin stimulating techniques (skin-to-skin, nipple stimulation/latching) and if this is unsuccessful, external bimanual uterine compression and transport to hospital.

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TOTW: Capnography Can Assist with Ventilation Optimization

TOTW: Capnography Can Assist with Ventilation Optimization
Posted on: February 11th, 2022

TOTW: Capnography Can Assist with Ventilation Optimization

From your 2021 MCME Online module on Capnography:

Capnography waveform can help you optimize your ventilation technique. The following waveform shows hypoventilation by the provider, with the ETC02 rising. If you see this, reassess your mask seal, technique and ventilation rate.

Check out the 2021 MCME Precourse on Capnography for more great tips to help your practice.

Capnography

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TOTW: D10 Administration

TOTW: D10 Administration
Posted on: February 4th, 2022

TOTW: D10 Administration

D10 can be given EITHER by IV slow push, or infusion. Consider available equipment, patient condition and competing treatment priorities when choosing your management strategy.

For example: If your patient is obtunded, you may consider giving it via IV push. If the patient is confused but alert (and you have available resources), you may consider giving it via infusion. The method of D10 delivery is a clinical judgment decision.

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TOTW: Pediatric ETT Size Equation Changes with Cuffed Tube

TOTW: Pediatric ETT Size Equation Changes with Cuffed Tube
Posted on: January 28th, 2022

TOTW: Pediatric ETT Size Equation Changes with Cuffed Tube

The new Equipment Standards have indicated a move to CUFFED tubes for the pediatric population.
We wanted to highlight the corresponding equation for ETT size selection. This equation helps predict the appropriate size ETT and accounts for cuff inflation.

ETT Size Equation: (Age/4) + 4 *subtract 0.5 for cuffed tube

Example: 6 year-old: (6/4) + 4
=5.5 *subtract 0.5 for cuffed tube
=5 cuffed tube

OR

ETT Size Equation: (Age/4) + 3.5

Example: 6 year-old: (6/4) + 3.5
= 1.5+3.5
= 5 cuffed tube

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TOTW: RSR Pattern Explained

TOTW: RSR Pattern Explained
Posted on: January 21st, 2022

TOTW: Appropriate Discordance Causes STEMI Mimic in LBBB

From your 2021 MCME Online module on Bundle Branch Blocks:

A question came up regarding what is RSR.

RSR is a “QRS” complex with an R-wave (upward deflection), followed by an S-wave (downward deflection), followed by another R-wave (upward deflection).  This pattern is seen in lead V1 in Right Bundle Branch Blocks.

Check out the 2021 MCME Precourse on Bundle Branch Block for a deeper dive on this ECG finding.

 

Lead V1 with RsR pattern

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TOTW: Treat What You Can

TOTW: Treat What You Can
Posted on: January 14th, 2022

From your 2021 MCME Interactive day:

Treat what you can from a patient presentation.

We taught the Differential Diagnosis algorithm this year to help you generate potential causes for patient complaints. However, you may not always come to a clear cause of a patient’s symptoms.

Despite this, you still have tools in your toolbox to employ! For example, a patient with hypoxia can be treated with oxygen without knowing the exact cause.

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