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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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Steve D. -

What is your limit for hypoxia on the walk test? I use that too but sometimes will have COPD patients who go down to 85% but look and feel fine. I usually am okay with sending those patients home

Siamak M, MD -

Hi Rob, I was always taught that Doxy has a big GI upset profile and is poorly tolerated (and therefore leads to low compliance). Can you share your references for recommending Doxy for CAP?

Jeff R. -

What was the reference Jerry mentioned at the end of Jan 2017 ema deep dive RE most cited medical study or paper. I really want to look it up. thanks

Mel H. -

Ioannidis, John P. A. (August 1, 2005). "Why Most Published Research Findings Are False". PLoS Medicine. 2 (8): e124. doi:10.1371/journal.pmed.0020124. ISSN 1549-1277.

Jeff R. -

thanks Mel

cody h. -

I am putting together CAP antibiotic guidelines for the hospital where I work. I am wondering if you have references for the doxycycline dosing? Pharmacodynamics support this, but I have not been able to find any actual clinical evidence. If you have found any I would like to see it. Thanks

Michael A. -

Hi, from New Brunswick, Canada. Any ID chapters perk my ears since January 2011 when I somehow got my self into the chair of our Provincial(provinces=states) Anti-infective Stewardship Committee. I am not an ID specialist but do belong to many 12 Step ID groups.
We are updating our CAP Treatment Guideline using the scoring system, DSCRB65 - D- any chronic disease renal,lung, CHF, Neuro. etc; S - O2 sat <90% on Room Air; C -new onset confusion/ALOC; R - resps>30/min; S - systolic <90/ diastolic <60; 65 - well >60 years. Home if 0-1; admit if 2-3; ICU if 4 or more.
Our sensitvities still almost 100% for S.pneumo but will be suggesting Amoxil 1000mg Q8H; for true Pcn Allergy Cefuroxime oral 500mg Q8H - poor bioavailabilty so Q12 likely insufficient creating good conditions for resistance. We also use a lot of Doxy. And yes the GI upset is a refrain to not try it but won't know unless you do. We avoid FQ, unless high score. or recent Beta/Doxy use. Macrolide's are on but low down as resistance is growing. It is an add-on to a beta-lactam for Moderate/High scores. And CAP is not AECOPD - different core pathogens. Also, generally Atypicals(except Legionnaires which are typically sick) aren't that sick so coverage doesn't have to be a big consideration
We have a great website with great tools and resources. Our Beta Lactam Allergy Management is excellent especially the cross-reactivity table. It really can help to continue to chose Betalactams even in the face of true Penicillin Allergy. CAP should be added later in the spring.
Cheers, Dr. Mike

Angelika U. -

In the talk about cypersecurity, I was wondering if you could share anyones preplan for their disaster response to this, just to get an idea of that would look like. Also, later there was discussion of a preintubation checklist, could you share an example of this too? Thanks

Matthew M. -

Scott and Rob recommended that everybody use an RSI Checklist for all their intubations. However, I don't remember hearing any references for checklists to look at. I made up a mnemonic a couple years ago that I go through, and that I talk out with any interns that I supervise. I wanted to post it here in case it helps anybody. It spells out NO-DESAT, so it should be easy for EM folks to remember.

N – Nasal cannula. Put everybody on nasal cannula during your intubating efforts to provide apneic oxygenation.
O – preOxygenation equipment and BVM. Preoxygenate with nasal cannula and facemask. Set up your bag valve mask with of oxygen.
D – Drugs. Call out your drugs so that your nurse or pharmacist has them at the ready.
E – Equipment. Set up your laryngoscope. Prep your stylet. Check your tube. Backups and Scalpel. You don't have to open them, but you have to know where they are.
S – Suction. Remember to not forget suction.
A – Adjuncts. Oral or nasal airway adjunct ready to help you once you sedate them.
T – Traction or Towels. Maintain C-spine precautions in trauma patients. For others, get some towels to help you position them.

There are probably ways to improve upon this, but so far it hasn't let me down yet.

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