Brian Driver

Emergency Physician at Hennepin County Medical Center

[Brian Driver @brian_driver]

@AcademicEmerMed @SAEMonline @GitaPensaMD @EMHighAK @MprizzleER @AliRaja_MD @MGottliebMD @MDaware @EMSwami @JohnCSakles @embasic Have to decide whether intubation success and safety trump patient experience. This will vary patient to patient and physician to physician. But for very critically ill patients who require intubation, success might trump experience (& pt might not remember if benzos given IM)

[Brian Driver @brian_driver]

@AcademicEmerMed @SAEMonline @GitaPensaMD @EMHighAK @MprizzleER @AliRaja_MD @MGottliebMD @MDaware @EMSwami @JohnCSakles @embasic If NMBA given first, you could very well have a paralyzed and awake patient, but they'd be fully relaxed and intubation should be smoother. Benzos or other sedatives can be given IM ASAP. So, there's a tension between sedative first and NMBA first if the IV is tenuous.

[Brian Driver @brian_driver]

@doctalk @AcademicEmerMed @MGottliebMD @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @EMHighAK @MprizzleER In this practice, there is usually a 20-30 s delay between NMBA and sedative. Patients usually have no awareness of paralysis without sedation. Refs: https://t.co/HqSKN3vj51
https://t.co/BsyggmziIr
https://t.co/3vWTPAUTJ5
https://t.co/2QyujhLAgT
https://t.co/2YHHMEPvgc

[Brian Driver @brian_driver]

@doctalk @AcademicEmerMed @MGottliebMD @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @EMHighAK @MprizzleER Administering the NMBA before the sedative is not the same as paralyzing a patient before sedating them. There is a practice called the "timing principle" performed in the OR, where the NMBA is administered, and the sedative is withheld until weakness (ptosis or weak grip).

[Brian Driver @brian_driver]

@AcademicEmerMed @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @MGottliebMD @EMHighAK @MprizzleER For several years some physicians in our dept have administered the NMBA first to attempt to avoid the occurrence of sedative-associated apnea prior to complete muscle relaxation. We wanted to study whether NMBA first was assoc with time to intubation.

[Brian Driver @brian_driver]

@embasic @chitwngurl Steve delivered a great talk on pre-ox - excellent review of important pre-ox strategies prior to ED intubation

[Brian Driver @brian_driver]

@MDaware @JayHineMD that’s what we took away - not to avoid ketamine for DSI - but rather to be ready/vigilant in case of complication

[Brian Driver @brian_driver]

@getdec44 @MDaware @AnnalsofEM not sure it’s clear cut that *all* need bmp ; may be room for physician judgement

[Brian Driver @brian_driver]

@screamingmd @MDaware @efunkEM @FLTDOC1 @DrHowieMell I don’t count polyuria as worrisome sx. Agree it should be expected

[Brian Driver @brian_driver]

@efunkEM @MDaware @FLTDOC1 @DrHowieMell I do not if no sx and they are in ED just for glucose value- but this approach not studied

[Brian Driver @brian_driver]

@drgeorgedavis I make sure they have proper meds and supplies, and educate as needed so that they know how to use/take them.

[Brian Driver @brian_driver]

@FLTDOC1 @MDaware @DrHowieMell my practice: as long as the pt appears well, don’t treat unless >600 and focus on outpatient meds & good f/u

[Brian Driver @brian_driver]

@FLTDOC1 @MDaware @DrHowieMell us too - made us wonder what benefit we were actually providing to the patients, if any

[Brian Driver @brian_driver]

@Jeff__Riddell @MDaware @AnnalsofEM we have ongoing RCT comparing loose to tight glucose control in this patient population

[Brian Driver @brian_driver]

@smithECGBlog @EM_ResUS @WICSBottomLine I agree. I would also say: good neuro outcomes are possible, even with prolonged CPR.

[Richard Gray @graydocer]

Thrombin Time is the best screening test for the contribution of dabigratran to bleeding problems #hcmca16

[Brian Driver @brian_driver]

Check visual fields for vague eye complaints. If visual field cut in both eyes, lesion is at or behind the optic chiasm #hcmca16

[Brian Driver @brian_driver]

#hcmca16 Post-LP HA reduced by 1) smaller needle (22g) 2) smaller CSF volume 3) bevel parallel to dural fibers 4) non-cutting needle

[Brian Driver @brian_driver]

#hcmca16 pt has anaphylactoid reaction after eating fish? Think scombroid toxicity- histidine in improperly stored fish agonist @H1 receptor