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  1. zzyzx

    Brain bleeds: prophylactic care

    I'm wondering what protocols/decisions strategies the neurologists in your ICU/ER use for deciding to use Keppra prophylacticaly for seizures, and mannitol/hypertonic saline? I ask the question because I don't seem to see uniformity in how certain patients are treated. FYI I'm not a neuro ICU nurse, so perhaps I'm ignorant about something basic. 1) Patient has extensive subarachnoid bleed showing on CT. There is no signs of herniation yet. Is it standard of care to give an anti-epileptic prohylactically? Is there evidence that it really will prevent seizures? Would you give mannitol/hypertonic saline, again prophylacticly for expected clinical course? 2) A patient with an extensive intraparenchymal bleed, again with no signs of herniation yet. Do you give Keppra and mannitol/hypertonic saline? 3) A patient who is ALOC, combative with an obvious traumatic head injury, but no CT has been done. Would you give these treatments? If they were posturing, you would give the mannitol/hypertonic saline, correct?
  2. zzyzx

    capnography

    For a neonate, can waveform capnography be used for ET tube confirmation (post intubation and during transport)? I guess I don't see why it shouldn't be, but I don't see any reference to waveform capnography in my NRP book.
  3. zzyzx

    capnography

    Thanks for your responses! What do you guys think is the best way to monitor tube placement during transport of a neonate? In adults waveform capnography is great because you get an immediate alert if the tube is dislodged (i.e., into the hypopharanx). With little babies, it is obviously so much easier to dislodge an ET tube and not realize it. What do neonate transport teams use for monitoring?
  4. zzyzx

    Pedal pulses and posterior tibial

    If you can feel or Doppler a pedal pulse, is there really any need to find a posterior tibial pulse? Likewise, if you can get a posterior tibial pulse, any need to feel for a pedal pulse?
  5. zzyzx

    Pedal pulses and posterior tibial

    I get that, but my understand is that an arterial occlusion of the leg is going to happen in the femoral artery, or in the popliteal artery proximal to the knee. In either case, you'd have no circulation to the lower leg, and thus neither a pedal pulse nor a posterior tibial pulse.
  6. zzyzx

    Pedal pulses and posterior tibial

    Thanks for the reply. My understanding is that we are mainly checking pedal or posterior tibial pulses to make sure the patient hasn't developed an arterial clot higher up in the leg, in which case we would find neither pulse. So, as long as we are finding one pulse, it is safe practice to not bother checking for the other pulse, correct? On my unit everyone automatically documents both, and I'm quite sure hardly anyone consistently checks both pulses. It is awfully time consuming when you can feel one of the pulses but can't feel the other, and then have to spend time trying to find it when you already know that there is good circulation.
  7. zzyzx

    hyponatremic seizure

    Has anyone ever seen a hyponatremic seizure in the ER? I'm just curious on how the patient presented, how long the seizure lasted, if you saw immediate relief from treatments, etc. details.
  8. zzyzx

    Hemiplegia after BP reduction

    I recently heard of a case (if I remember it was the EmCrit podcast, but it may have been another) where a patient with asymptomatic HTN was given hydralazine IVP for a BP of 175/90 in the ED. The patient was admitted for an unrelated complaint (cellulitis) and after the medication his BP was 130 systolic. He was doing fine prior to being sent up stairs, but when he arrived on the med-surg unit, he had developed hemiplegia, so the floor nurse called the doc, who called the neurologist, and after a CT (negative for a bleed), he was given TPA. The neurologist was unaware that the patient had received the hydralazine. The following morning, the patient was unresponsive and was found to have a bleed, likely due to the TPA. The hemiplegia was thought to have been due to the rapid reduction in BP. So my question is, has anyone seen this before? A rapid lowering of BP causing stroke-like symptoms? I have heard of this but never seen it, and it is very common in our ER to lower patient's blood pressures with IV antihypertensives. My second question is why is it such a widespread practice--to give IV antihypertensives even when the patient is asymptomatic---when the current practice guidelines say not to?
  9. What is the point of wearing a mask if you have a patient who is intubated and not coughing anyhow? Is it that you could touch something that has their respiratory secretions on it, and then touch your face?
  10. zzyzx

    albumin and hypotension

    I have always thought that with hypotensive liver patients who also have low albumin levels, the correct treatment is to give albumin. This seems to make sense since they need the protein to maintain the osmotic gradient so that they can keep fluid in their intravascular space. However, now I'm told that repleting albumin will not help with correcting their hypotension, or at least not for long. What am I missing?!
  11. zzyzx

    albumin and hypotension

    Thanks. The fact that albumin does not stay in the vasculature makes it much easier to understand some of the other processes involved. I'm half way through the article now. Very interesting so far.
  12. zzyzx

    albumin and hypotension

    Thanks for all the responses so far. One thing I don't understand is how the albumin gets out of the vasculature. Probably I'm forgetting something from physiology class. I understand how the water that's infused with the albumin goes out of the vasculature into the interstitial space, but aren't the proteins too big to go out? Also I'd like to get some opinions on how the following patients should be treated... 1) Normotensive liver-cirrhosis patient with an albumin of 1.0 and a significant amount of peripheral edema. 2) Hypotensive liver-cirrhosis patient with an albumin of 1.0. His BP is 70 systolic. 3) Hypotensive liver-cirrhosis patient with an albumin of 1.0, BP 70 systolic, who is undergoing CRRT.
  13. zzyzx

    sodium amount in sodium bicarb

    How much sodium is in one amp (50 ml) of sodium bicarb? Is it 3735 mg?
  14. zzyzx

    sodium amount in sodium bicarb

    Thanks for your reply. Since the sodium is not free but bound up with the bicarb, does it have the same effect as if you gave the patient 1150 of sodium only? In other words, would it immediately raise the sodium level, or would it take time for the sodium and the bicarb to come apart?
  15. What is the result of correcting blood sugar levels to quickly in DKA, and also in HHS? I have trouble finding an answer for this. One source says rebound ketoacidosis, and another says brain edema. Also, in peds, has there been a consensus as to the cause of cerebral edema?
  16. zzyzx

    Tracheostomy emergencies

    I just read an article that stated that if an immature trach; ie one less than a week old, is dislodged, then it is unlikely that it can be replaced. However the article doesn't clarify if this is immediate or after say 15 minutes. Anyone have experience with this? Will the tissues around the stoma immediately collapse as soon as the tube is removed? I would also like to hear anyone's experiences with other trach emergencies
  17. zzyzx

    Tracheostomy emergencies

    Thanks for your reply. What would you do in this scenario: a vent-dependant patient is 3 days post trach placement, and while turning him his trach becomes fully dislodged somehow. Would it be incorrect to make at least one attempt and replacing it? Wouldn't you know if you the track was improperly placed if, after replacing it, you got poor compliance when bagging the trach?
  18. zzyzx

    albumin and hypotension

    Thanks for your reply. Okay, so albumin IV is not the correct treatment for hypoalbuminemia, correct? This is also what I've read, but it didn't quite make sense to me. So, the albumin soon just extravasates out of the blood vessels, along with the fluid? I thought large proteins like that would stay in the blood.
  19. Does Dilaudid cause histamine release as morphine does? Or is morphine the only opioid that does this?
  20. zzyzx

    Drugs for acute heart failure

    Hey guys. I'm wondering what the current recommendations are for drug therapy for heart failure. I understand the importance of nitro for a patient presenting with hypertension and pulmonary edema, but what about these other three scenarios... 1) Pulmonary edema, normal BP, no STEMI. 2) Cardiogenic shock: pulmonary edema, hypotension 3) Pulmonary edema, normal BP, STEMI
  21. zzyzx

    Drugs for acute heart failure

    Thanks for you responses. Yes, I have read UptoDate, as well as an older ICU book that I have. I posted the questions here because I wanted to get responses from nurses who have hands-on experience in these situations. There is only so much you can learn from books. As an ER nurse and paramedic, I have had lots of pt's that presented with what can be called sympathetic-induced pulmonary edema. The pt presents with flash pulmonary edema and hypertension. These pt's I really liked getting when I worked on the ambulance because we could turn them around quickly with nitro spray and CPAP, to the point where they would go from being in acute distress on scene to calm and stable by the time we arrived at the ER. However, I have little experience with pt's with cardiogenic shock. The only med on the ambulance that we ever had available to be used was dopamine (and event that was recently it was taken out of our protocols), but I never had occasion to use it in the field. In the ER, I have only seen a couple of patients in cardiogenic shock, and I remember the last one we had the doc ordered an epi drip. I wonder if that is really the right way to treat such a patient, or if dobutamine along with a vasopressor would be better. I know that dopamine has fallen out of favor. In the ICU (where I have never worked), you probably have pt's who have acute heart failure with pulmonary edema, but you have stable BP's. UptoDate says dobutamine is the best drug for this situation. I understand that it has inotropic effects, which of course is what you would want, but that it also vasodilates. When I have asked co-workers in the ER about dobutamine, I have been told that it has fallen out of favor because of its vasodilatory effect, so I was surprised to see that UptoDate recommends it so strongly. (I was also surprised at how strongly they recommend Lasix, since in my experience with flash pulmonary edema patients it is not useful.) Basically, I am not looking for book answers since I already know those myself. I am looking to hear from people with a lot more experience than I have to share their hands-on experiences with these issues. Thanks!
  22. zzyzx

    Drugs for acute heart failure

    I don't know why. Is there something you know that I don't? I ask the question because i see so many different recomnendations, and i wonder which treatments are obsolete and what is current I am not an ICU nurse, and I have very little experience with these patients. Thanks
  23. zzyzx

    Drugs for acute heart failure

    Hey guys. I'm wondering what the current recommendations are for drug therapy for heart failure. I understand the importance of nitro for a patient presenting with hypertension and pulmonary edema, but what about these other three scenarios... 1) Pulmonary edema, normal BP, no STEMI. 2) Cardiogenic shock: pulmonary edema, hypotension 3) Pulmonary edema, normal BP, STEMI
  24. I have little critical care experience. I would like some thoughts about how someone with liver cirrhosis and low albumin levels is best manged with they are septic and hypotensive. Thanks!
  25. zzyzx

    Septic patient with liver failure

    I'd also like to hear about experiences with taking care of septic dialysis patients. Thanks!
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