Thanks to suggestions from Dr Jason Chuen (@OzVascDoc) multiple sections of this page have been overhauled. Of note, reference to ‘acute expansion’ has been largely removed. ‘Acute expansion’ as a presentation is not a good reason for ED referral or admission, it generally means that the AAA is bigger than when it was last checked. Pain, however, is always an aortic emergency until proven otherwise in a patient with a AAA, but isn’t typically simply due to an increase in size, rather some other another nasty event such as inflammation, rupture, dissection or thrombosis is going on.
Always a favourite topic in the CCC, apnoeic oxygenation via nasal prongs is now bread-and-butter for emergency intubations in the ED (still less so in the OR and the ICU unfortunately…). I’ve expanded the evidence section, including John Dyett’s recent prospective observational study suggesting an NNT of 6 for preventing hypoxaemia (yes, the study design is subject to confounders, but it is getting increasingly difficult to justify NOT doing this!)
We do things differently for cardiac arrests if they happen to occur after cardiac surgery… As well as explaining the key team roles and the important management considerations I’ve updated the enigmatic ‘Other Information’ section. In particular, more justification is provided for why things are done differently after cardiac surgery compared to the standard ALS approach to cardiac arrest.
As Jason Roberts (@jasonroberts_pk) recently reminded me at the ‘2015 Infectious diseases and Critical Care Conference’, getting antibiotic doses right in the critically ill can be very difficult… especially so in patients on ECMO. This is a tricky area with lots of unknowns. The pharmacokinetic effects of ECMO vary with different drugs and drug characteristics, as well as with different types and compositions of ECMO circuit components. The end result can be therapeutic failure, drug toxicity and/or worsening antimicrobial resistance… None of which are good.
This page is a little unsatisfactory… why you ask? Well, because LTCI-CI (not my abbreviation) is probably a big problem but we don’t really know how prevalent or severe it is. Furthermore, although there are various things we can do both inside and outside the ICU to prevent or ameliorate it, it is hard to know how effective those interventions are. More work needed.
The previous separate pages on venous and arterial gas embolism have been combined into one, now imaginatively called ‘Vascular gas embolism’. Always anticipate the possibility of causing a gas embolism when inserting a line in a patient – and take the necessary steps to prevent it. It is bad when it happens, so make sure you know what to do.
OK gang, that’s it until the next installment. Enjoy!
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.