Geoff Brin

Fledgling Pediatric Anesthesia/PICU doc, he/him

[Geoff Brin @Gomander]

@RiderToast Agreed with the slight modifier of a bit of pay increase for specialties who primarily deal with patients who are extremely unwell/peri-arrest as a regular part of their practice.

[Geoff Brin @Gomander]

@CanadianKayMD Only if you survive the explosion

[Geoff Brin @Gomander]

@crtsbly @screamingmd I’ve seen brief self-limited tachycardia after dexamethasone push in patients under full general anesthetic even, so must be quite the uncomfortable sensation

[Geoff Brin @Gomander]

@embasic Probably also worth mentioning that some patients having a cardiac arrest may still be moving slightly early on or have agonal breathing which can delay recognition. Using failure to verbally respond as a trigger as you mentioned can help prevent this.

[Geoff Brin @Gomander]

@EMinMiami @emily_fri Helpful in these pts to tape the skin away from line insertion point in multiple directions prior to prep, can be done w/o leaving tape in your field. Gives a more taut work area. Traction with dry gauze on the skin opposing dilator advancement helps too

[Geoff Brin @Gomander]

@emily_fri @EMinMiami If you open a few kits for smaller lines leading up to the size of your big line, you can test which catheters/wires/dilators fit and sequentially dilate up without a knick, lower risk of bent wire. Have gone 24G to 7F this way.

[Geoff Brin @Gomander]

@TheGrouchyMedic @DrKanaris @PaedEmergencies @SapnaKmd @DeannaMarie208 @DrSeanBarnes @MiguelrrMD @sgdambrauskas @mr_astvad @PICJournalWatch @ketaminh @pccm_doc Careful consideration of dex in this pt, if leukaemia w/ MM and high tumour burden, need to watch closely for tumour lysis syndrome

[Geoff Brin @Gomander]

@DrKanaris @PaedEmergencies @SapnaKmd @DeannaMarie208 @DrSeanBarnes @MiguelrrMD @sgdambrauskas @mr_astvad @PICJournalWatch @ketaminh @pccm_doc d) upright and lateral CXR, nothing requiring sedation or supine positioning, maybe lateral CT chest + head (given GCS) unsedated. Do not delay transport to CV Sx/ECMO center for investigations. Bldwk CBC + coags / type + screen (bring with on transport)

[Geoff Brin @Gomander]

@DrKanaris @PaedEmergencies @SapnaKmd @DeannaMarie208 @DrSeanBarnes @MiguelrrMD @sgdambrauskas @mr_astvad @PICJournalWatch @ketaminh @pccm_doc a) stable upright atm, check if SpO2 ⬆️ lateral or prone, if resp status ⤵️, CPAP/BIPAP if tolerated, HFNC may even help if others not tolerated. Avoid intubation in remote 🏥
b)pemberton’s
c)mediastinal mass (💀T’s), SVC thrombosis, CHF w/ postural spO2

[Geoff Brin @Gomander]

@DrKanaris @SapnaKmd @sgdambrauskas @MiguelrrMD @PICJournalWatch @pccm_doc @DeannaMarie208 @jez_tong @DrSeanBarnes @ketaminh @mr_astvad Late to this but very intriguing airway! Could temporize w/ nasal BiPAP to aid w/ CO2 clearance, would also prefer to have ENT present. Possible ECMO cannulation pre-intubation if nasal BiPAP effective. Concerned re:nasal anything causing swelling and loss of only patent airway.

[Geoff Brin @Gomander]

@emily_fri Adding as I haven’t seen it yet, tape the fat away for neck lines! Tape the upper chest downward and tape the cheek upward. It creates tension across their neck skin so it’s easier to puncture/dilate/decreases the depth to the vessel. Helpful at smoothing out chunky neck rolls.

[Geoff Brin @Gomander]

@DrKanaris @SapnaKmd @PICJournalWatch @pccm_doc @DeannaMarie208 @jez_tong @mr_astvad @sgdambrauskas @MiguelrrMD @LaCampo4 @LavergneNatalie For all who are intubation/ventilating, what would be your goal PaCO2 in this very alkalotic infant with a low RR. Could the RR of 8 be a marker of physiologic CO2 retention to balance acid base rather than due to low GCS alone?

[Geoff Brin @Gomander]

@DrPatrickRoss Apparently the methylcholine challenge during spirometry testing for obstructive airway disease can also cause people to cough

[Geoff Brin @Gomander]

@DrPatrickRoss @lindamason55 @jlerman77 @JAMA_current Could bronchospasm (even mild enough not to cause a clinically perceptible change in lung compliance) during a light plane of anesthesia be enough of a stimulus to trigger laryngospasm?

[Geoff Brin @Gomander]

@wandering_er Worth mentioning in the case of a patient on V-A ECMO that the risk of VAE is higher, especially with larger central lines (and larger needles) due to the low (and at times negative) CVP. Have seen a pt entrain enough air to overwhelm the oxygenator during a cath procedure

[Geoff Brin @Gomander]

@EM_RESUS Large dicrotic notch on pulse ox being read as double beats could be from the high SVR of a pt with high endogenous circulating catecholamines in response to the low CO from tamponade

[Geoff Brin @Gomander]

@EM_RESUS Sort of looks like electrical alternans with pulse variability with respiration and a narrow pulse pressure. Pericardial tamponade?

[Geoff Brin @Gomander]

@doctimcook @Anaes_Journal @JennieH31968241 Any thoughts on achieving qualitative monitoring in pediatric patients? Particularly less than 1 year of age? Less often needed given the low use of NMB in peds in general but finding a good device is seems challenging and would be useful in PICU as well

[Geoff Brin @Gomander]

@BrandenEngorn @PedsICU_tweets @PedsICUPoll For those who replied yes, would you let them record a video of the procedure on their phone if they ask?

[Geoff Brin @Gomander]

@DrKanaris @PedsICU_tweets @DFTBubbles @henrygoldstein @DeannaMarie208 @pccm_doc @SapnaKmd @DrSeanBarnes @PICJournalWatch @jez_tong @miguelrdgzrubio @sgdambrauskas E) Acute liver failure/coagulopathy 👉 bloody stool, Budd-Chiari 👉 intestinal ischemia, auto-immune hepatitis (rash?) w IBD, infectious colitis, DIC 👉coagulopathy +hemolysis

[Geoff Brin @Gomander]

@DrKanaris @PedsICU_tweets @DFTBubbles @henrygoldstein @DeannaMarie208 @pccm_doc @SapnaKmd @DrSeanBarnes @PICJournalWatch @jez_tong @miguelrdgzrubio @sgdambrauskas A) IV access/blood work (T&S, CBC-D, lytes, venous gas w glucose, BCx, liver enzymes/bili, coags, retic #, periph smear, Cr, urea) followed by crystalloid 10ml/kg watching HR and BP response during bolus. Full monitors watch for arryth if lytes off