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RV failure / pHTN

lbarlow
Thu, 20 Apr 2017 20:00:13 GMT

This was a very interesting emcrit to me and I have listened to it several times prior to this podcast club. It has practical information that I can use on the SS night shift, which is how I measure the worth of any podcast and the context I use to process the information. I can immediately think of 3 instances of acute death in patients on the south side, which, upon reflection over the months since they occurred, I think were related to RV failure and 1 of the 3 maybe could have been thwarted (or at least post-poned) by better understanding of what I was dealing with. They were an unmanaged congenital heart disease, a SC acute chest, and one likely undiagnosed PAH. I am certain there have been more that I just haven’t spent the time contemplating on. So, here are my thoughts on some points from the podcast- Existing pHTN patients- If a patient come into the ED and says “Hi, I’m visiting from South Carolina and I think my veletri pump is broken” I will plan to call pharmacy and see what they recommend and what is available, and then call my attending physician to disc uss those recommendations. The odds of me jumping in and ordering inhaled nitric oxide or some other random medication that pharmacy recommends without calling someone first is zero. POCUS- This is good. We all know it can take hours (days?) for an echo to result and just forget it if you are on night shift. Using this can at least give you an idea of what you are facing when you roll up on an RRT that is crashing. The specific things to look for that are pretty obvious- septal bowing, D sign, gigantic IVC, etc, can at least give you some quick idea of not only what is going on, but also an idea of how disastrous your intubation has potential to be. Unfortunately sometimes getting decent windows of the population of Georgia can be challenging. Pressors/inotropes- I enjoyed this section of the pod cast. I like the idea of using milrinone as opposed to dobutamine in these patients to avoid the tachycardia. Avoiding tachycardia is beneficial in several ways- obviously you don’t want the stress on the heart, but your nurses will be so much happier and it will lower the volume of pages you get overnight asking for something to treat the heart rate. However I would feel anxious using milrinone for the first couple of times because I have never used it, and I have only seen it used a few times on the SS so I am not sure how confident I would feel about turning the nurses loose with it either. They mentioned in the podcast about the idea of using vaso and titrating it as a way to avoid tachycardia. If other people in our group want to do it then great, let me know how it goes, but I am not going first. However theoretically it sounds like a good idea. Fluids- this leaves me in kind of a quandary. If I roll up on a strange patient who is hypotensive then I am going to start a 1L bolus 9.9 out of 10 times, and usually the stat team or who ever arrived first has already done this anyway. It is unlikely I’ll think, hmmm maybe this patient on the floor with a BP of 60/40 has RV failure and I shouldn’t load them up with fluids. However, if you are proficient with the POCUS then maybe you can at least limit the fluids based on what you see and know to start pressors earlier. Intubation- This is not ideal, but has to be done from time to time. I think that using the intubation checklist is great for all patients, but I can really see it saving the day on these patients. Like he mentioned in the show notes, pressors already going for a slightly hypertensive patient seems like a good idea, especially on the SS where I don’t see awake intubation coming any time soon. Also when you use the checklist you already have good control of your room and everyone’s roles are established so they know what to do when things go south. Another general benefit of listening to this pod cast is that it reminds you to think about pHTN when you are working these patients up. Also, that pHTN can be present in patients that we already know what is going on with them. Such as- when you are going to intubate your chronic COPD patient you can think hmmm, even though I don’t have an echo report to look at, this patient has chronic COPD and is at risk for RV strain/pHTN so lets take a quick look with the bedside US. Thanks y'all for sharing your thoughts about the podcast. I am looking forward to feedback.