Clinical Pearls: Shock
Diagnosing the type of shock your patient is exhibiting is clutch when it comes to appropriately treating. Yes, Levophed is our quarterback when it comes to pressor selection, for good reason. But you need to have a darn good understanding of what it can and cannot do, when it is not the ideal choice and when there are better or adjunctive measures that must be undertaken quickly to save your patient. It all starts with coming to an accurate diagnosis. Often in real world practice this is hard to do as multiple states can co-exist, iatrogenic factors obfuscate, and no one piece of data is the be all end all. As with most things in medicine, you have to piece together the data to form the picture. This article reviews the pathophysiology, shares a hemodynamic chart, and overviews how to differentiate shock states.
Clinical Pearls: Ventilator Modes 101
There are a number of reasons why ventilators are confusing, and I’ll break down how to simplify these factors in this blog post. But the big takeaway is this: just because a patient seems controlled well on the vent does not mean he is; do not leave the task of interpreting the vent and the patient’s response to the vent to others. It is incumbent on you to educate yourself about what the knobs, numbers, and waveforms mean in order to better treat your patient. Let’s talk vent basics and it starts with understanding the mode.
Clinical Pearls: Is It Time To Extubate, An Objective Approach
I spent a lot of years working at the bedside in the ICU. I can tell you one thing a nurse won’t tolerate and that’s an agitated and intubated patient. IYKYK. It’s scary, it’s physically taxing for you, and it’s not good for the patient. So naturally I would immediately call the provider with the “can we extubate” query when they woke up fighting. In my mind they were awake, right? Let’s liberate them from the ventilator!
This is only one scenario in which the clarity I gained in NP school blew my mind at how naive I was as a nurse. Maybe naive isn’t the right word, uninformed perhaps? IDK, I think my point is I didn’t realize there was a systematic approach to assessing extubation readiness. I didn’t properly think through all the reasons why a person would need a vent, nor appreciate all the ways in which a person can fail an extubation attempt. One key factor I learned is that objective medical analysis of the diagnosis and current exam is crucial in predicting risk and then weighing the risk/benefit ratio to determine what is safest for the patient. In this post I’ll walk you through the step by step process of performing this assessment to eliminate as much doubt as possible and set your patient up for success. Skip to the end for a bedside checklist.
Clinical Pearls: Calcium Channel Blocker Overdose
Toxic levels of calcium channel blockers typically induce massive cardiogenic and distributive shock and pressors alone often won't save them. High dose insulin therapy enters the chat here. Think 700 units of rapid onset insulin IV per hour 🤯. Yep, it's gonna be an all hands on deck kind of patient my friends. Read this article to learn about the whys, whos, and hows of CCB overdose mgt.
Clinical Pearls: Intubation Starts Here
Beyond practicing the technique of intubating, nurse practitioners should spend time learning to identify the patients at risk of cardiac arrest. If you can put a finger on the major risk, there are definite strategies you can employ to improve odds of success without decline. In this article, I discuss specific approaches to: GIB/vomiting, hypoxia, shock, asthma, and metabolic acidosis.
Clinical Pearls:What’s up with the lactate?
In 2001 a research article was published expounding early goal directed therapy as a treatment strategy for sepsis. Key points in the article suggest that physical exam findings are subpar for directing resuscitation and that measures such as lactate, SCVO2, base deficit, and pH are more accurate measures of adequate treatment. There were certainly other factors, and the take home message was to find the source and start antibiotics early, but volume resuscitate until tissue hypoxia improves was the practical application of this research. As a result lactic acidosis has become a bad omen to be feared by all. Several guideline updates have since been published, the most recent in 2021 with weak evidence to suggest using lactate as an end-point measurement. Practically speaking though, the word is out that a high lactate = bad bad badness. I’m not saying it isn’t bad, but there are plenty of reasons why an elevated lactate alone is not the end of the world. In this post we’ll discuss causes for lactate elevation, what should be cause for alarm and what shouldn’t, and how to manage it.
Mentors: Game Changers?
What is the most insightful thing someone ever told you? When I try to narrow down my answer to this I struggle. I lost my mom when I was twenty four years old. It was traumatizing and also character building. She was my mentor in all ways and without her presence I have struggled in my life, particularly with making hard decisions. Thankfully I have had some career-guiding, life-changing people come into my life at exactly the right moments. The story I share most often is in regards to deciding to go back for a masters degree. A friend of my moms (who happened to be a nurse at the hospital where I worked) said “Briana, what’s your hangup?” I told her the big issue was the burden I would put my husband and children through for two straight years. Especially the girls who wouldn’t see as much of me. Her response “Honey, two years will pass whether you are in school or not, where do you want to be in two years? And what will teach your girls more, being present for all the events or role modeling how hard things are done?”
Okay universe, I hear ya.
In this post I will discuss the difference between a mentor and a coach, what they can offer you, how to find one, and how to make the most of your time.
Clinical Pearls: VBG vs ABG
There is a legitimate reason why ER providers consistently order a VBG over an ABG and the ICU provider then may or may not believe the VBG choosing to tack on an ABG instead.
Many patients in the hospital require assessment of their acid base balance and oxygenation/ventilation status which is best quantified from serum arterial samples. Additionally, the ABG provides expedited lab results such as hemoglobin, potassium and other electrolytes, and lactic acid. These values are very helpful in making a rapid diagnosis and treatment plan. A venous blood gas seems to be the standard replacement for an arterial blood gas in the emergency department. It does offer some benefits, but has limitations as well which should be acknowledged.
The focus of this article is to describe the pros/cons of using a VBG as a surrogate, the exclusion criteria, and the method of converting a VBG to an ABG.
Clinical Pearls: DIC
One of the rare and weird things in medicine that combine a dramatic constellation of opposites. Caring for someone in the throes of badness from two dichotomous problems leaves one in a state of floundering. Do I treat the clotting or do I treat the bleeding? What will kill them first? It’s universally known that getting the diagnosis of disseminated intravascular coagulation is a dreaded event. DIC is a downstream complication that arises late in the game with several diagnoses that we see in the ICU, and unfortunately in our maternal population. Every time an OB calls our team to see or transfer a patient to ICU my shoulders instantly feel tense. Let’s talk about the pathophysiology behind this dreaded state and what our treatment options really are.
Clinical Pearls: Liver Failure
Oh the ways the liver can fail. As a new nurse practitioner this one was hard to get down. Cardiology is generally seen as the bee all end all when it comes to keeping our bodies running, but I’d like to talk about the under appreciated liver. Hepatology is fascinating because the normal function of the liver is supremely multi-faceted. Throw in a little pathology and any number of pathways can be deranged and within those any degree of severity can be seen. From acute to chronic to acute-on-chronic, severity can run the gamut. Decompensated cirrhosis is a common killer in most ICU’s. Given how poorly understood this disease state is, I’d like to talk about the complexity, progression, prognosis, and management of liver failure in the intensive care unit.
Clinical Pearls: Evaluating For Intubation
When is it time to say it’s time? I think back on the really bad days of the pandemic when I walked from room to room asking myself this question repeatedly. Honestly, for intensive care unit level covid that’s what it felt like - a few random meds that typically didn’t help, supportive care, and careful vigilance for when it was time to go on the dreaded vent. Our patients feared it, our families feared it; it was the elephant in the room every time you walked in. Outside of covid pneumonia, there are a million reasons why a patient needs mechanical vent support and failing lungs are just one component. This is a very common question I get asked when I am training a nurse practitioner student Here’s how I approach evaluating a patient for intubation need.
Clinical Pearls: Waveform Capnography
End tidal carbon dioxide (ETCO2) measures exhaled carbon dioxide, it therefore reflects the efficacy with which CO2 is pumped back to the lungs (indirect measurement of cardiac output) and then exhaled (ventilation). Waveform Capnography is a continuous tracing, or waveform, of ETCO2. It is very useful when assessed as a trend.
Clinical Pearls: Pleural Effusions
Pleural effusions can be a big barrier to improving respiratory status in the ICU. Deciding how and when to treat them becomes easier once you break down how to diagnose and treat.
Clinical Pearls: Tachycardia
Knowing how and when to treat tachycardia (perhaps one of the most common calls you’ll get) is crucial. Sometimes not treating is the best answer.