Dr Dee Sanchez

@srrezaie discussion about Andexanet alfa and it’s use in ICH #resusxreunion2024 Always triple check big Pharma funded studies!! The primary outcome was hemolytic efficacy butshowed increased thrombotic events!!

So much excitement this week at #resusxreunion2024 Just concluded the amazing workshops and now to the time for the full conference!

The Ten Commandments of Internship. What would you add?

In PE how to alteplase: @srrezaie plan of action is to give 10mg bolus then 40mg over 2 hours. The idea is to HALF-DOSE your thrombolysis. Thus if you are giving 100mg now then give half dose (ie. 50) @srrezaie #resusfest

PE is an afterload problem. Hypotension with tachy = cardiogenic shock due to RV strain/failure. Thus giving fluids won’t fix PE spiral of death. PPL who think fluids of 500ml for PE are WRONG. only study of support was in 1999 & not on for massive PE. @srrezaie #resusfest

@srrezaie #resusfest PE categories: - Incidental - Segmental - Submassive (RV looks dyfx= anticoag tx) - Massive PE (2 types: hypotensive type which don’t look bad and emergency type which look bad)

In massive pulmonary embolism, should we give fluids or not? Being covered today by @srrezaie at #resusfest

@gagestuntz #resusfest In TTP: ➡️Furosemide can help cuz pt usually are fluid overloaded. ➡️Put a HD line ➡️Draw all labs b4 FFP/PLEX ➡️NO RITUXIMAB or PLT!

How do you manage TTP? - 1. Plasmapharesis 2. Plasmapharesis 3. Plasmapharesis 4. Plasmapharesis 5. Plasmapharesis Jk you can also use steroids, FFP/RBC transfusion, or monoclonal AB. @gagestuntz #resusfest

When trying to diagnose TTP feel free to use the plasmid score as a clinical decision tool. Keep in mind that it is not a validated score. @gagestuntz #resusfest

@gagestuntz #resusfest When you suspect TTP, you need to focus on team based care which means having an intensivists and hematologist working with you in the emergency room.

@gagestuntz #resusfest You want to rule out DIC when you suspect TTP. First pass labs get an ekg, cbc, CMP, troponin, coags and UA.

@gagestuntz #resusfest Pathophys of TTP. 90% mortality rate of untreated. Due to endothelial damage breaks down vEF causing RBC shearing leading to microvascular rupture organ dysfunction and ultimately death. While it presents in a pentad usually only 3 will be commonly seen.

@gagestuntz #resusfest Most commonly seen are SHIGA toxin and DIC but TTP has the most you can do for management.

Case discussion with @gagestuntz at #resusfest. Diagnosis = Thrombotic thrombocytopenic purpura (TTP).

@CriticalCareNow takeaways of post ROSC mgt: Post-ROSC care should be grouped into 3 sequential bundles: 1) 15 minutes post-ROSC, 2) 45 minutes post-ROSC 3) an ICU-level of care in the ED. #resusfest Bundle focus: 1:focuses on stabilizing 2:fine-tuning tx 3: ICU-level mgt

In the event PT needs more time in ED after ROSC: ➡️preserve neuro fx; monitor EEG. ➡️ poor data to support empiric ABX, instead start steroids. ➡️Maint. fluids not needed & can cause harm due to excess fluid in the interstitium.@CriticalCareNow

45min post-ROSC: ➡️focus on fine-tuning tx to max survival by fine-tuning airway management, access, and optimizing MAP (goal is 65). ➡️Adjust vent settings to a tidal volume consistent with PT ideal body weight. ➡️Use vasopressors to maintain MAP at goal. @CriticalCareNow

After ROSC has been achieved do a team debrief. It is crucial to take at least 5 mins to discuss with the entire team what went well, what can be done better, and address any lingering thoughts regarding the case. @CriticalCareNow #resusfest

Airway management after ROSC: ⭐️hemodynamics is more important; focus on airway mgt after hemodynamic stability has been achieved. ⭐️consider swapping out SGAs/EGAs to a formal ETT @CriticalCareNow #resusfest