Welcome to the 100th
edition of ResusNation!!!
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Ear Today, Gone Tomorrow
You may have heard that too much furosemide can screw up your ears...but have you ever wondered why? Well, the pathophysiology of furosemide-induced ototoxicity centers primarily on the inhibition of the Na+/K+/2Cl- cotransporter (NKCC1) within the stria vascularis. This inhibition disrupts the endocochlear potential crucial for mechanotransduction, leading to altered K+ recycling and disruption of the +80-100 mV potential necessary for hair cell function.
The blood-labyrinth barrier's penetration by furosemide, particularly notable during rapid intravenous administration, can precipitate cochlear dysfunction. This typically manifests initially as high-frequency hearing loss (>4000 Hz). The synergistic interaction with other ototoxic agents, especially aminoglycosides, demonstrates a multiplicative risk profile through complementary mechanisms of cochlear injury.
Risk factors for ototoxicity include concurrent nephropathy (reducing drug clearance), concomitant ototoxic medication administration, baseline cochlear dysfunction, and total daily dosage. The ototoxic effects may present as either reversible or irreversible cochlear dysfunction, depending on dosage and duration of exposure.
Furosemide is well tolerated in most patients, but understanding these mechanisms is important, particularly for patients with pre-existing otologic conditions or those receiving concurrent ototoxic therapies.
Welcome to the 100th edition of ResusNation!
Why K+ Repletion Is Failing You
As a physician, I've encountered numerous cases where potassium replacement doesn't follow the textbook rule of "10mEq = 0.1 increase in K+ level." Through years of clinical experience, I've discovered that concurrent magnesium supplementation is often the missing piece in these puzzling cases. Even when serum magnesium appears normal, cellular magnesium depletion can significantly impair potassium replacement by affecting the sodium-potassium exchanger and renal handling of potassium.
In severe hypokalemia, it's crucial not to rely solely on serum magnesium levels, as they don't accurately reflect total body stores. By proactively supplementing magnesium alongside potassium in these cases, I've achieved more predictable and efficient potassium repletion. This approach has repeatedly proven effective in my practice, especially with critically low potassium levels that seem resistant to standard replacement protocols.
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Have you been looking to master the nuances of Airway Pressure Release Ventilation (APRV)? In this episode, Dr. Steven Haywood simplifies APRV, from setup to weaning, while uncovering the tricks and tips to maximizing lung recruitment and oxygenation. Whether youâre optimizing care for ARDS patients or learning to avoid pitfalls like overdistension or lost ground during ventilator disconnects, Steve's talk offers actionable strategies for critical care success. Tune in and elevate your understanding of advanced ventilator management!
Check out the entire video from Steve Haywoon now!
Are Bougies the Ultimate Wingman?
When you're emergently intubating a patient, you got to get it right on the first pass. But what's often debated whether to use a bougie routinely or save it as a backup device. An international research team sought to get that answer by analyzing 18 studies with over 9,000 patients to determine if using a bougie on the first attempt leads to better success rates. Today, we're talking about their findings, published in Annals of Emergency Medicine.
This study showed that that using a bougie on the first intubation attempt increased success rates by about 11% compared to standard approaches using just a rigid stylet. This benefit was consistent across different clinical settings, including emergency departments, intensive care units, and operating rooms. The advantage was particularly strong for difficult airways - when doctors had limited visibility of the vocal cords, using a bougie first increased success rates by 60%.
However, bougie use did come with some trade-offs. Intubation took slightly longer (around 13 seconds more on average in emergency settings) when using a bougie. There was also a small increase in minor complications like lip lacerations, though no increase in serious airway injuries was found. Importantly, using a bougie did not increase rates of dangerous complications like dangerously low oxygen levels or cardiac arrest.
These researchers commented that since it's often difficult to predict which patients will have challenging airways beforehand, routinely using a bougie first may be safer than waiting to use it as a rescue device. This fact appears especially true in emergency settings where there is limited time to assess the airway and patients are often critically ill.
Here's my takeaways:
- A bougie-first approach improves first-attempt success rates by about 11% overall and by 60% in difficult airways, suggesting it should be considered as a standard rather than rescue device
- While bougie use adds a short time delay, it does not increase rates of serious complications like hypoxemia or cardiac arrest
- The benefit appears greatest in emergency settings where airways are often more challenging and there's less time for assessment
- Proper training and experience with bougie technique is likely important for optimizing its benefits while minimizing delays
Want to read it for yourself? Check out the full article "Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis" in the Annals of Emergency Medicine, February 2024.
ResusNation Unite!
All-Access members of ResusNation are invited to join Haney Mallemat for an online interactive session this Thursday, january 23 at 1pmEST. Bring your cases, questions, or just listen in to what other members are talking about. We'll meet on the Kajabi app so we can all talk face-to-face. And don't worry if you can't make the meeting, it'll be recorded for you to watch after the fact. If you are an All-Access member, you'll receive an email with your private link soon.
Not a member? Then it's time to sign up because membership comes with privileges. You'll get access to monthly hangouts, access to our grand rounds library, access to post-grand rounds Q&A with the faculty, 5 monthly videos, and so much more.
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What do you do when a patient in shock doesnât respond to vasopressors? In this episode, Dr. Anand Swaminathan dives into the art of the âcognitive pauseââan essential step when managing a patient with refractory shock. From acidosis and hypothyroidism to occult bleeding and adrenal insufficiency, Swami outlines a systematic approach to uncover hidden causes that could change the course of care. If youâre ready to sharpen your resuscitation skills and tackle the toughest cases, this episode is for you!
Check out this video from Anand Swaminathan from ResusX:ReVolved now!
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