What's wrong??

[Planktonmd]

---

Members don't see this ad.

I know that many people are concerned about the match and I realize that this is the time of the year where this forum becomes a disaster but this is too much, we need some stimulating discussions, how about some clinical stuff?
Let's hear about your clinical experiences.
Tell us about that patient you could not intubate or that guy who crashed and you never knew why.
Tell us about your attending that insists that his way for taping the ETT is the ONLY right way, or about the technique that you prefer to insert an A line in 2 minutes.
Let's talk about anesthesia.

 

[proman]

It takes you 2 minutes to put in an a line?

 

[Planktonmd]

It takes you 2 minutes to put in an a line?

😀
How long does it take you smart arse??

 

[bostonblaz]

76 y/o for tkr. had femoral nerve block under u/s pre-op, 15 cc of 0.5% marcaine. great block brofre induction. case is unremarkeable. in pacu pt with 9/10 pain on the back protion of her knee. surgeon would like us to do a sciatic. turn her on her side, look for a while with u/s and cant see anything convining. decide to use nerve stim and for some reason i can't recall the name of the aproach but you palapte the "sit" bone and look for plantar flexion of foot. got a twitch at .29 mAmps, pulled back half a cm and had a twich at .35 mAmp. aspirate inject every three cc's to a total of 15cc of 0.5% marcaine, went in great, never got back blood. when i relased the pressure on her skin and try to put the u/s on her to see where the local went she is shaking, i pulled the blanket down to see if she was shivering and she was having a seizure, on the monitor when i can make out the ecg she is in a wide complex tachycardia, whats next??

 

[Planktonmd]

76 y/o for tkr. had femoral nerve block under u/s pre-op, 15 cc of 0.5% marcaine. great block brofre induction. case is unremarkeable. in pacu pt with 9/10 pain on the back protion of her knee. surgeon would like us to do a sciatic. turn her on her side, look for a while with u/s and cant see anything convining. decide to use nerve stim and for some reason i can't recall the name of the aproach but you palapte the "sit" bone and look for plantar flexion of foot. got a twitch at .29 mAmps, pulled back half a cm and had a twich at .35 mAmp. aspirate inject every three cc's to a total of 15cc of 0.5% marcaine, went in great, never got back blood. when i relased the pressure on her skin and try to put the u/s on her to see where the local went she is shaking, i pulled the blanket down to see if she was shivering and she was having a seizure, on the monitor when i can make out the ecg she is in a wide complex tachycardia, whats next??

😀
Great!
Thank you!
So, can you tell us what Local anesthetic you injected?

 

[Planktonmd]

😀
Great!
Thank you!
So, can you tell us what Local anesthetic you injected?

Oh, I see it, it's Bupivacaine

 

[Planktonmd]

So, here is where we are:
Bupivacaine injected for a sciatic nerve block, patient has a seizure and wide complex QRS what would you do next???

 

[pgg]

So, here is where we are:
Bupivacaine injected for a sciatic nerve block, patient has a seizure and wide complex QRS what would you do next???

Airway, O2, benzo, intralipid, CPR if needed, phone call to risk management when the dust settles.

 

[aredoubleyou]

Airway, O2, benzo, intralipid, CPR if needed, phone call to risk management when the dust settles.

exactly. ACLS with intralipid.

Was she fat?

 

[Planktonmd]

exactly. ACLS with intralipid.

Was she fat?

How much intralipid?

 

[nutmegs]

How much intralipid?

1mL/kg, repeat up to 3 times? then the rest of a 500mL bottle infused over the next 15 minutes, for a roughly 70kg person. I think.

 

[Gern Blansten]

Many would recommend 1.5 ml/kg. There certainly are no studies that will show a best dose, but a couple of case reports demonstrate the effectiveness of 1.5

 

[Bertelman]

I know that many people are concerned about the match and I realize that this is the time of the year where this forum becomes a disaster but this is too much, we need some stimulating discussions, how about some clinical stuff?...

FWIW, I think since all the "Rank my list" threads have died, the match stuff is pretty well-controlled v. prior years. I've found much more density of midlevel, political and job prospect threads at this point than ever before.

Having said that, of course I want more clinical threads and off-topic discussions.

Pre-op'd a pt. for CABG/AVR this evening. Saw his two fat sons sitting in a chair, and his obese wife pacing around the room with a BK bag in her fist sucking down a Whopper and some fries. I wanted to take a snapshot of that room and make it a poster for everything that is wrong in this country today. Send it to Obama, and tell him THAT'S why our healthcare is so expensive.

 

[proman]

😀
How long does it take you smart arse??

Anywhere from 10 seconds to infinity.

 

[RxBoy]

Pre-op'd a pt. for CABG/AVR this evening. Saw his two fat sons sitting in a chair, and his obese wife pacing around the room with a BK bag in her fist sucking down a Whopper and some fries. I wanted to take a snapshot of that room and make it a poster for everything that is wrong in this country today. Send it to Obama, and tell him THAT'S why our healthcare is so expensive.

You don't understand... the problem is:
1) Burger King's Advertising
2) Public education's failure to inform him on the risk of unhealthy diet.
3) Doctor's failure to educate him on the health risk of fatty foods.
4) If he has private insurance: Health insurance's outrageous premiums costs, which he would of for sure used to buy vegetables and lean meat.
5) If he has medicaid: Government not taxing enough wealthy people to fund a top notch PCP who would of spent time discussing his diet and sex life instead of managing his dangerously uncontrolled diabetes and HTN.
6) His olfactory, taste, and hypothalamus's incredible ability to overcome his frontal lobe.

The patient was just an innocent bystander. We need more tax dollars to stop people from hurting themselves.

 

[huktonfonix]

Anywhere from 10 seconds to infinity.

I call BS. thats like saying I can do an epidural in less than a minute. Yeah, sure thats from local to catheter. doesnt include opening and prepping the materials and site.

 

[cubs3canes]

Airway, O2, benzo, intralipid, CPR if needed, phone call to risk management when the dust settles.

Hypothetically...what would you give first in the above situation and the patient was bradycardic...interlipid or atropine? (maybe a recent board question)

 

[Bertelman]

You don't understand... the problem is:
1) Burger King's Advertising
2) Public education's failure to inform him on the risk of unhealthy diet.
3) Doctor's failure to educate him on the health risk of fatty foods.
4) If he has private insurance: Health insurance's outrageous premiums costs, which he would of for sure used to buy vegetables and lean meat.
5) If he has medicaid: Government not taxing enough wealthy people to fund a top notch PCP who would of spent time discussing his diet and sex life instead of managing his dangerously uncontrolled diabetes and HTN.
6) His olfactory, taste, and hypothalamus's incredible ability to overcome his frontal lobe.

The patient was just an innocent bystander. We need more tax dollars to stop people from hurting themselves.

WTF? Believe me, I understand all of those things (although some are BS). The point of my post is that as long as we have behaviors like that, our healthcare will be through the roof if we continue to provide fruitless therapies that support those behaviors.

It doesn't take an MD to tell you BK will kill you. It takes a junior high level health class. It also takes the willpower to say no.

 

[cchoukal]

Hypothetically...what would you give first in the above situation and the patient was bradycardic...interlipid or atropine? (maybe a recent board question)

this was on the ITE in a peds case. I said atropine.

 

[thegasman]

WTF? Believe me, I understand all of those things (although some are BS). The point of my post is that as long as we have behaviors like that, our healthcare will be through the roof if we continue to provide fruitless therapies that support those behaviors.

It doesn't take an MD to tell you BK will kill you. It takes a junior high level health class. It also takes the willpower to say no.

I think he was being sarcastic

 

[proman]

I call BS. thats like saying I can do an epidural in less than a minute. Yeah, sure thats from local to catheter. doesnt include opening and prepping the materials and site.

Ease up Tiger. I know we all scrub the Chloroprep for 30 seconds just like the manufacturer says. We're talking about actually putting it in not prepping, gloving, draping with sterile towels, flushing the connector, putting it in, connecting the tubing, taping it in, looping the connector, drawing back the air in the tubing, zeroing the transducer, flushing the tubing, collecting your sharps and trash and then documenting it.

 

[G0S2]

Anywhere from 10 seconds to infinity.

That's my experience and for some crazy reason that is truly frustrating, the strong pulses move toward the infinity end.

 

[powermd]

WTF?
It doesn't take an MD to tell you BK will kill you. It takes a junior high level health class. It also takes the willpower to say no.

It's not that simple. If it were, we'd probably be in better shape than we are (pun intended). Corporate america spends millions of dollars on psychological studies to target their advertising more effectively and overcome willpower. Deny all you want, but it works- even on you. Truly free will is an illusion. You can try to overcome it, but it's not easy. Particularly for the uneducated.

Better education is important, but we need to do more here. We need to stop training people to make bad decisions. The trouble is, in this country, we also value this idea of "freedom of choice". No matter what the outcome of the choices will be. Heart disease, emphysema, etc. That's why we can't ban cigarettes entirely. People want that choice, regardless of how bad it is for them personally, and the taxpayers that ultimately clean up the mess. At least they can't advertise on TV anymore. They shouldn't be able to advertise period. Neither should BK/KFC/TB/MDs/oreos/cheetos/lays/etc/etc/etc. But where do you draw the line?

 

[huktonfonix]

Ease up Tiger. I know we all scrub the Chloroprep for 30 seconds just like the manufacturer says. We're talking about actually putting it in not prepping, gloving, draping with sterile towels, flushing the connector, putting it in, connecting the tubing, taping it in, looping the connector, drawing back the air in the tubing, zeroing the transducer, flushing the tubing, collecting your sharps and trash and then documenting it.

the point being, Im pretty sure thats what plank meant when he said 2 minutes for an aline.....i hope

 

[Bertelman]

I think he was being sarcastic

Now I see it. It was too early in the a.m. when I posted.

It's not that simple. If it were, we'd probably be in better shape than we are (pun intended). Corporate america spends millions of dollars on psychological studies to target their advertising more effectively and overcome willpower. Deny all you want, but it works- even on you. Truly free will is an illusion. You can try to overcome it, but it's not easy. Particularly for the uneducated.

Better education is important, but we need to do more here. We need to stop training people to make bad decisions. The trouble is, in this country, we also value this idea of "freedom of choice". No matter what the outcome of the choices will be. Heart disease, emphysema, etc. That's why we can't ban cigarettes entirely. People want that choice, regardless of how bad it is for them personally, and the taxpayers that ultimately clean up the mess. At least they can't advertise on TV anymore. They shouldn't be able to advertise period. Neither should BK/KFC/TB/MDs/oreos/cheetos/lays/etc/etc/etc. But where do you draw the line?

I'm not sure if it has been passed yet, but for a time they were looking at decreasing the density of "fast-food" restaurants in LA county. As you can imagine, there are an inordinate amount of these in poorer areas. Of course there are some difficulties in defining what is fast food, but I think attitudes like this are a start.

I think once the govt begins to consider providing "universal health care", they should take more action towards dictating how our health is maintained. Tax fast food like cigarrettes. Allow a certain density of fast food restaurants per capita. Dictate the percentage of food products sold at these restaurants to maintain a certain ratio of foods that are healthy. Public Health policy should be considered in healthcare policy.

We'll never make America smart, but we can limit the dumb choices we make.

 

[RxBoy]

Now I see it. It was too early in the a.m. when I posted.

I am right there with you Bertelman. Was def being sarcastic.

I never knew how bad the system was until I started ER this month. Its a primary care for the indigent.


Me: Why did you come to the ER instead of going to your primary care doc?
Patient: I don't have to pay when I go to the ER.
Me: Well they are probably going to send you a bill.
Patient: HAHA, who pays bills?

 

[pgg]

Hypothetically...what would you give first in the above situation and the patient was bradycardic...interlipid or atropine? (maybe a recent board question)

If I had help, everything gets done simultaneously. 🙂

If I was by myself, no help was available, and I had seizing hypotensive bradycardic patient after a big dose of bupivacaine ... I'd probably skip the atropine and go straight to epi, flush it in with the intralipid, and hit the airway next. The drugs (including intralipid) are in our block carts and I could realistically have them in the IV within 30-40 seconds. Airway next, then on to the rest of BLS/ACLS.

Local anesthetic toxicity is notoriously difficult to fix with ordinary resuscitation techniques. ACLS is handwaving and hope in this situation; intralipid is the cure. Therefore, my approach would be to get the intralipid in ASAP.

 

[SexPanther]

Anywhere from 10 seconds to infinity.

True dat. Sometimes the a-line is the most frustrating procedure I do.

 

[aphistis]

True dat. Sometimes the a-line is the most frustrating procedure I do.

Only sometimes? You're better at it than I am.

 

[Licoricestick]

If I was by myself, no help was available, and I had seizing hypotensive bradycardic patient after a big dose of bupivacaine ... I'd probably skip the atropine and go straight to epi, flush it in with the intralipid, and hit the airway next.

I'd give intralipid first, (1.5mL/kg bolus, repeat if persistent asystole, then 0.25mL/kg/min infusion for a hour, however as yet there is no optimal dose for intralipid defined) and hold off on the adrenaline unless there was no response or I was uncertain about LA toxicity being the cause (which given the case as presented seems unlikely).

Why hold the adrenaline? Firstly it is the intralipid not the adrenaline that will fix this patient and I'd rather myself (and the other pairs of hands that will be rocking up because I called a code) were aiming to get the most appropriate drug in as fast as possible and secondly Guy Weinberg (the guy behind much of the research on intralipid for LA toxicity) is suggesting that adrenaline may make lipid rescue LESS effective. Unforutnately that study isn't available yet (See www.lipidrescue.org and go to "Post your cases" then "A resuce useing Celepid 20%"...his comment is the first response to the case).

 

[ProRealDoc]

If I had help, everything gets done simultaneously. 🙂

If I was by myself, no help was available, and I had seizing hypotensive bradycardic patient after a big dose of bupivacaine ... I'd probably skip the atropine and go straight to epi, flush it in with the intralipid, and hit the airway next. The drugs (including intralipid) are in our block carts and I could realistically have them in the IV within 30-40 seconds. Airway next, then on to the rest of BLS/ACLS.

Local anesthetic toxicity is notoriously difficult to fix with ordinary resuscitation techniques. ACLS is handwaving and hope in this situation; intralipid is the cure. Therefore, my approach would be to get the intralipid in ASAP.

I feel vindicated with my choice of answer.