Episode Chapters
- Introduction10:01Cardiology Corner – CHF20:36Electrolyte Emergencies - Part 1 - All Things Potassium20:47Pediatric Pearls – Pericardial Effusion17:10EM:RAP 2018 August Mailbag6:40Testicular Torsion15:33Critical Care Mailbag - The ADRENAL Study5:32Rural Medicine – ETOH Withdrawal and Ice Fog29:17Cocaine Chest Pain: Tachy and ShockyFree Chapter13:25Annals of Emergency Medicine – Methotrexate Toxicity7:40Electrolyte Emergencies - Part 2 - All Things Calcium and Magnesium11:48Beating Burnout16:31Strayerisms – Peripheral Line in Central Vein9:37Community Medicine Rants - Opioids7:44Summary19:38EM:RAP 2018 August German Edition1h, 32mEM:RAP 2018 August Aussie Edition2:27EM:RAP 2018 August Canadian Edition14:57EM:RAP 2018 August French Edition26:58EM:RAP 2018 August Spanish Edition1h, 19m
Nurses Edition Commentary
Kathy Garvin, RN and Lisa Chavez, RN
No me gusta!
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EMRAP 2018 08 August Vol.18 Written Summary 658 KB - PDF
EM:RAP 2018 August Full episode audio for MD edition 211:59 min - 295 MB - M4AEM:RAP 2018 August German Edition Deutsche 92:18 min - 127 MB - MP3EM:RAP 2018 August Aussie Edition Australian 2:27 min - 3 MB - MP3EM:RAP 2018 August Canadian Edition Canadian 14:57 min - 21 MB - MP3EM:RAP 2018 August French Edition Français 26:58 min - 37 MB - MP3EM:RAP 2018 August Spanish Edition Español 79:40 min - 109 MB - MP3EMRAP 2018 08 August Individual MP3 272 MB - ZIPEMRAP 2018 08 August Individual Summaries 935 KB - ZIPEMRAP 2018 08 August Vol.18 Written Summary 658 KB - PDFEM:RAP 2018 August Spanish Written 829 KB - PDFEMRAP Board Review Answers 2018 08 Aug Vol.18 08 284 KB - PDFEMRAP Board Review Questions 2018 08 Aug Vol.18 08 809 KB - PDF
Donald Z., M.D. - August 3, 2018 12:53 PM
Can you give pressors through the peripheral line in central vein if you use a catheter like the catheter over needle in cvp kit? can you place this line and just keep the kit covered and later place the 3pl lumen catheter if you initially place the line sterilely?
Reuben Strayer (@emupdates) - August 3, 2018 2:23 PM
Great questions Donald.
I don't think there's any evidence one way or another on using a peripheral line in central vein for vasopressors, however, we know that administering vasopressors in a peripheral vein is safe, the problem is extravasation. So I would view a peripheral line in a central vein the same way - acceptable to initiate vasopressors through, until formal central access is achieved.
And yes, you can convert to a central line later. See:
https://goo.gl/fMUvv4
Douglas B., JA - September 10, 2018 3:11 PM
Great segment, thank you for the tourniquet Pearl and for spreading the word of the common sense approach to using peripheral catheters in central veins.... Hopefully someone publishes a large case series at some point. My questions relates to your comment that DPL and Dig have gone the way of venous cutdowns.... Dig still holds a special place in my practice for afib patients >48hr who need rate control but who's BP is too soft for CCBs or BBs (or who got hypotensive when I gave Dilt, are still are not adequately rate controlled and fluids doesn't fix their soft BP) but are not unstable enough to warrant DC-CV. I love dig in this scenario because I can give it orally and the patient can go to the ward (as opposed to starting the patient on Amio, which I reserve for sicker patients that are headed for the ICU or another monitored critical care area). My question is, does dig have any role in your practice and if not what do you use for rate control in soft BP afib patients who are not good candidates for BBs, CCBs or DC-CV.
Reuben Strayer (@emupdates) - September 10, 2018 9:00 PM
haha, thanks for calling me out on that Douglas.
dig is a unique AV nodal blocker + inotrope that works beautifully in exactly the scenario you describe and I used to use it all the time for that exact indication. it does take a while to work, and I find that the number of patients who are too sick for dilt are fewer and fewer as I age, perhaps because most of them turn out to have a soft BP *because of the rate* and actually improve their pressure with a CCB. throw in some calcium for good measure. the patients who have a bad EF at baseline and are now in fast afib - those patients should probably be on dig every day, and I still use dig in that (relatively uncommon) scenario. thanks for the comment.
Douglas B., JA - September 14, 2018 11:16 AM
Great tip on adding some calcium before throwing in the towel on the Dilt, I don't typically do that but will give it a try, sounds like it might get me out of a few dig admissions and maybe speed things up a bit for some of my patients. Thanks.