MONDAY POTD EXTRAVAGANZA

APNEIC OXYGENATION (AO): What is it, and is it even necessary????

• APNEIC OXYGENATION (DEFINITION TIME BOYS!):  Providing 15L NC during the act of intubation (while your blade is in the dudes/dudettes mouth. Thought to decrease odds of desaturation thus preventing the need for bagging (YUK) during intubation.
• ANESTHIOLOGISTS  still bag people almost every intubation. Yet most of those people have been fasting for hours and don't have anything to throw up. We don't have that luxury.
• HYPOXEMIA (result of desaturating during intubation)  can lead to cardiopulmonary arrest. Then you're in deep doodoo. So does throwing a NC on them really help???

BUT JOSH, THIS IS STANDARD OF CARE!$#$^%*&$

WHY NOT JUST PUT ON A NC FOR INTUBATING?????? WHY ARE YOU WASTING DR. PRINCE ROCHLIN'S TIME????

Well we may not have to, and may be harming patients by delaying intubation.

There were 2 papers recently studying apneic oxygenation. (links to critical evals at end of email)

1. FELLOW TRIAL (2011) :150 patients randomized to AO or none. Since center, prospective, randomized, HOWEVER IN ICU. These patients all got PRE-OXYGENATION to 100% for 3 minutes. FOUND NO DIFFERENCE IN:
   • Lowest O2 level, incidence of desaturation, and even HOSPITAL MORTALITY (wow these people are awesome researchers!)
2. ENDAO TRIAL (2017):   200 patients randomized to AO or non. Single center, prospective, randomized. in the ED. Again, all pre-oxygenated. FOUND NO DIFFERENCE IN:
   • Incidence of desaturations, Mortality within 24 hours and Hospital Mortality (see sweet data that follows)

JOSH IT SEEMS LIKE YOUR TELLING ME THAT WE CAN JUST CUT NASAL CANNULA'S OUT OF THE BUDGET FOR INTUBATIONS, SAVE A BUTTLOAD OF MONEY FOR THE HOSPITAL, BE A HERO, AND SAVE SOME GOD DAMN LIVES!

Kind of? Both of these papers glossed over the fact that these patients were pre-oxygenated with either NRB, NC+NRB, HFNC, or BiPAP. Only NRB or BiPAP would require an extra step of putting a NC on in intubation. So if you've already got a NC on, there's no harm in leaving it on. If not? Maybe next time just go for the tube rather than taking those extra 10-15 seconds to put on the NC. 

Thursday POTD AWESOMENESS

TODAYS VERSION OF PEARLS OF THE DAY IS A REQUEST FROM DOCTOR BOWEN AND OUR ROYAL NORWEIGAN CHIEF ASTRID "CURED FISH" HAALAND

SGARBOSSA CRITERIA :

another [dumb] eponymous topic (see yesterday's email about Brugada)

BASICS

• Allows you to diagnose cardiac ischemia in a LBBB EKG
• He was probably some old white cardiologist
• IMPORTANT: There are the original criteria and the modified. Today we will be discussing MODIFIED

EKG FINDING IN LBBB (NORMAL)

• Widened QRS, QRS down in V1 and (possibly) up in V6
• Appropriately discordant T-waves
  • The T waves will usually be REBELS and don't listen to their parents and go the OPPOSITE WAY of the EVIL QRS. That's what discordant is yo.
  • BUT they aren't that bad, they don't want to be like Dr. Bowen and be pure evil, they are usually <5mm (or< 25% of the S wave) in the opposite direction
• NORMAL LBBB EKG

SGARBOSSA CRITERIA (MODIFIED) FOR IDENTIFYING LBBB WITH ISCHEMIA PUT IN TECHNICAL TERMS (SORRY)

• ≥ 1 lead with ≥1 mm of concordant ST elevation
• ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
• ≥ 1 lead anywhere excessive discordant STE, (≥ 25% of the depth of the preceding S-wave).
  
  I KNOW, THIS CRAP MAKES NO SENSE
  SO LETS BREAK THIS DOWN INTO THINGS EVEN JB CAN UNDERSTAND
• Any ST segment elevation that goes SAME DIRECTION as the QRS is BAD (middle picture above)
• Any ST segment DEPRESSION is BAD (right picture above)
• Any ST segment that goes SUPER OPPOSITE is bad
• THANK YOU FOR READING ALL THESE THINGS THIS WEEK, LOOK FORWARD TO WEEK 2 OF PEARLS OF THE DAY COMING TO AN EMAIL INBOX NEAR YOU NEXT WEEK! ***CROWD GOES WILD WITH APPLAUSE***

HEART STOPPING POTD WEDNESDAY!!!!!

THANK YOU TO CAROLINE FOR A TRULY HEART WARMING M&M THIS MORNING ABOUT PROLONGED QT AND ALL THE DISASTERS THAT IT CAN CAUSE...

SO LETS TALK ABOUT SOME MORE CARDIOLOGY STUFF AND SYNCOPE, BECAUSE WE ALL LOVE IT RIGHT? AND THAT WE ALSO LOVE CAPS LOCKS!

BRUGADA SYNDROME

Also a heart stopping condition (....yeah I went there), causing syncope, not commonly seen in the ED, but when you see it you HAVE TO recognize it.

SO, when you get an EKG and see this...... you'll know what to do.

WHAT IS IT?????

• GENETIC DISORDER, CAUSING CONDUCTION PROBLEMS IN THE HEART

HOW TO DIAGNOSE IT?

• In the ED, the only way is by EKG. There are 3 types of Brugada so for every patient who syncopizes you need to make sure you check for all of them. There are genetic tests to confirm, but for our sakes, EKG EKG EKG

SO WHAT? THEY HAVE INTERESTING EKG AND THIS RARE DISEASE (OR MAYBE NOT SO RARE). DISCHARGE WITH NSAIDS AND PMD FOLLOWUP RIGHT?

• It actually is thought to be THE most common cause of sudden unexplained death
• These people are at EXTREMELY high risk of ventricular arrhythmias (VF, VT), and the first presentation is usually SYNCOPE

THESE PEOPLE NEED AICD's and PRONTO. LIKLEY CARDS ADMISSION VS ACUTE CARDS F/U WITH ED CONSULTATION

• No medication has shown to really effectively prevent the arrhythmias.
• STILL, average age of death of these peeps is 41.

Lesson of the Day??? With Syncope, BE AFRAID, BE VERRRRRY AFRAID