Is the HR fast because of shock or afib? It can be hard

Have you ever had a septic patient with afib at baseline and now there heart rate is elevated? Well is their heart-rate elevated due to uncontrolled afbi or is it tachycardia for a low stroke volume? This is a tricky situation. If you blindly treat the HR and it is shock the patient could get more hypotensive. If you ignore the HR the patient might develop a tachycardia induced cardiomyopathy. 

What to do? Well, you could consider giving a short acting beta blocker like esmolol to see if there is a change in hemodynamics. These situations are hard so watch the video for a full rundown on this. 

Check out the video for more information.

Post-Arrest BP

Dr. Rory Spiegel, an EM Critical Care physician, discusses post-arrest care and the optimal blood pressure for patients who have been resuscitated from cardiac arrest. Previous retrospective studies suggested that higher MAPs were associated with better outcomes, but these findings were confounded by the overall health status of the patients. Dr. Spiegel highlights three recent small randomized control trials that compared lower and slightly higher MAP targets but found no significant difference in outcomes. He emphasizes a recently published large randomized trial that investigated blood pressure targets in comatose survivors of cardiac arrest.

Dr. Spiegel questions the effectiveness of identifying an ideal MAP for specific patient populations, citing previous studies in sepsis and other conditions that have failed to determine an optimal blood pressure target. He explains that MAP, although commonly used as a surrogate for perfusion, does not accurately represent micro-hemodynamics. Different organs have varying resistance, affecting their perfusion, and disease states can further complicate the relationship between macro-circulation and microcirculation.

Overall, Dr. Spiegel suggests that while MAP is frequently measured and easily accessible, it may not be the best indicator of perfusion. He highlights the need to consider micro-hemodynamics and individual organ perfusion in each patient's management.

Check out his amazing video now!

Mastering the Monitors

This podcast by Dr. Scott Weingart from the ResusX:ROSC conference delved into the nuances of cardiac arrest monitoring, specifically focusing on A-line monitoring and end-tidal CO2 monitoring. Scott emphasized that monitors often provide misleading data, necessitating practitioners to understand how to correctly interpret these readings. The speakaer revealed that diastolic blood pressure during cardiac arrest cannot be trusted from the machine numbers. Instead, it should be discerned from the waveform, particularly at the upstroke of systole. Likewise, the end-tidal CO2 reading from the monitor is also inaccurate and must be observed from the peak measurement. The speaker concluded by pointing out certain waveform patterns that can reveal if a patient is being over-ventilated or if small airway tubes have collapsed.

5 Key Takeaways:

1. **Understanding Monitors**: Monitors are invaluable in cardiac arrest situations but can be misleading. Understanding the intricacies of how they work and how to read them correctly is crucial for medical practitioners.

2. **A-line Monitoring**: The diastolic blood pressure during cardiac arrest should not be taken directly from the monitor's readings. Instead, practitioners should focus on the waveform, specifically looking at the upstroke of systole.

3. **End-tidal CO2 Monitoring**: Similar to A-line monitoring, the end-tidal CO2 number given by the monitor can be inaccurate. The peak measurement on the waveform should be used instead.

4. **Waveform Patterns**: Practitioners should also look out for distinct patterns in the waveforms that indicate specific conditions. For example, a plateau phase at the beginning of the exhalation indicates over-ventilation, while a consistently increasing plateau phase could suggest collapse of the small airway tubes.

5. **Interpretation over Numbers**: The key message is to focus on waveform interpretation rather than blindly trusting the numbers provided by cardiac arrest monitors. Accurate interpretation of the waveforms can greatly aid in the proper management of the patient's condition.

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