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Rural Medicine: DKA and Sepsis

Vanessa Cardy, MD, FCFP, FRRMS and Adrien Selim, MD
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22:42
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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01:46

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EM:RAP 2019 September Written Summary 465 KB - PDF

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Patrick A. -

Hello,
I am a PA in a similar environment, a three bed ED in northern Montana, not as far out as Dr. Cardy, but pretty often just me and two nurses for the floor and the ED and at least an hour to our closest transfer facility. We have POCUS, but I have steered clear of central lines, mostly because they take a fair amount of time and there is little I can't do with good (often US guided) beefy, proximal peripheral IV's. My question is about sepsis and "push doses" of pressors in these septic shock patients. I was reviewing some of Dr. Weingart's postings (here and on EMCRIT, I am a big fan) and he suggested that he didn't like the "dirty" epi drip (1mg in a liter for a 1microgram per ml concentration.) Dr. Weingart didn't say why he prefers push dosing, but it seems to me(and I have used his push dose technique many times) that it is pretty resource intensive, and results in a sort of porpoising of the BP (up and down). Why not mix a "dirty" norepi drip (same 1 mg in a liter) for these patients until more resources are available? It would allow for less resources than push dosing, simultaneous volume administration ( roughly 250mls an hour in Dr. Cardy's patient), less minute to minute variation in MAP and reduce the concentration in the event of extravasation? I would almost never sit on a patient like this any longer than it takes to get appropriate transfer, but like Dr. Cardy, I can be stuck with some sick folks for hours, because of weather and resources. Thanks again so much for all you do for us.

Pat in Montana

Vanessa C. -

Thanks for the message Pat and for listening. We were stuck here with our drips as we had run out of pumps so needed something we could titrate ourselves without using a machine. We could have just let it run in by gravity and adjust flow accordingly but that is also quite challenging on a plane in the dark. Would love to hear about your experiences with push dose pressors if you have some stories to share.

Thanks again for listening

Dallas Holladay, DO -

Thanks for this piece! As someone preparing to transition from a large, urban hospital to rural medicine these pieces help soothe my nerves. A little.

Patrick A. -

The reason I like the “dirty“ drips, is because they’re so easy to titrate without a pump. I used to run EMS 25 or 30 years ago and we didn’t have any pumps for our drips then ( mostly dopamine), so we just learn to calculate our drip and then count the drops per minute based on the size of our set. I would typically use a 10 drop set, and in the case you presented, the 4 µg per minute would work out to about seven drops every 10 seconds. We hold our watch up behind the drip chamber and count while adjusting the rate. There may be some small minute to minute variation of a few drops but generally speaking the administration is pretty reliable, and provides much steadier control than push dosing. We did the same thing in Afghanistan with the TXA drip and we got that second gram in within 15-20 mins of the eight hours.
Because of the short half life of the vasopressors, it just seems to provide much steadier MAP maintenance without having someone dedicated to nothing but the push dosing! Plus it’s super simple to mix.

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EM:RAP 2019 September Full episode audio for MD edition 228:36 min - 247 MB - M4AEM:RAP 2019 September German Edition Deutsche 113:47 min - 156 MB - MP3EM:RAP 2019 September Farsi Edition Farsi 199:37 min - 274 MB - MP3EM:RAP 2019 September Spanish Edition Español 81:07 min - 111 MB - MP3EM:RAP 2019 September Canadian Edition Canadian 19:03 min - 26 MB - MP3EM:RAP 2019 September French Edition Français 20:28 min - 28 MB - MP3EMRAP 2019 September Board Review Answers 135 KB - PDFEMRAP 2019 September Board Review Questions 710 KB - PDFEM:RAP 2019 September MP3 Files 295 MB - ZIPEM:RAP 2019 September Written Summary 465 KB - PDF

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