Steff McLean

Vancouver 🌄 | RN 😷 | Emergency 🏥 | Après-ski Specialist 🍺

[Vertigo_Warrior @VertigoWarrior]

The terrifying beauty of the Ocean. A thread

⚠️Thread NOT suitable for sensitive people

[Massimo @Rainmaker1973]

Teaching science is fun

Heart blood circulation

[📹 _saturnales_]

[𝗥𝗲𝘀𝘂𝘀𝗠𝗲𝗱 @ResusMed]

Resuscitate Before You Intubate!!!

Remember, our patients in critical condition may often deteriorate following intubation. Ever wondered why? It's usually because they're not adequately resuscitated before the procedure. This tends to happen predominantly with patients needing emergency intubations, as these individuals are often in precarious hemodynamic states and might be volume depleted.

Let's dive a little deeper into the physiology. Ordinarily, our respiratory process operates under negative pressure - when the diaphragm descends, it lessens intrathoracic pressure and draws air into the lungs. Intubation switches this to a positive pressure system where air is forcibly delivered into the lungs by a ventilator. In patients with low intravascular volume, this increase in intrathoracic pressure may precipitate hemodynamic instability. This situation is further exacerbated by sedatives and paralysis, which hinder the body's ability to adapt to these sudden changes.

It's essential to note, though, that this deterioration is seldom abrupt and can often be anticipated.

Whenever possible, which is the majority of cases, always aim to resuscitate before intubation. But be aware, indiscriminate fluid administration is not the answer. A timely bedside echo can ascertain their volume status and assess their right ventricular condition - key information before intubation. Also, remember to use the Shock Index, calculated as heart rate/SBP. A value ≥ 0.9 may indicate the need for further resuscitation.

Emergency intubation, a common Pre-Hospital, ER and ICU procedure, although aimed at supporting the patient, brings about substantial changes to normal cardiopulmonary physiology. This could be detrimental for critically ill patients, unless the necessary precautions are taken during the peri-intubation period.

During positive pressure ventilation, normal cardiopulmonary interactions are disturbed due to the increase in intrathoracic pressure, leading to decreased preload and increased RV afterload.

Patients in need of emergent intubation often come with compromised hemodynamics, maintained mainly by increased sympathetic activity and elevated endogenous catecholamine levels. In addition, their illness often leads to hypovolemia due to decreased intake and increased losses. Sedatives used during rapid sequence intubation can further compromise the sympathetic response.

Failure to address hypovolemia and reduced sympathetic activity can lead to post-intubation hypotension and, in severe cases, cardiac arrest. Hence, thorough planning and preparation are more crucial than the intubation itself. Secure resuscitative access before intubation, preferably using two US-guided 18G IVs. Then, consider using point-of-care echo, especially in patients with SBP < 90 or a Shock Index > 0.9.

These patients may benefit from volume resuscitation using pressure-bagged fluids and low-dose vasopressors to raise BP. Push-dose epinephrine can be useful in situations where adequate pre-intubation resuscitation is not possible, or the sympathetic drive is so high that removing it may cause severe decompensation.

The mantra remains - "Resuscitate before you intubate."

[Steff McLean @steffmclean2]

@FraserRiverFind Crown Royal?

[Golden Girls Quotes @GoldenGirls85]

May all your Christmases

[Steff McLean @steffmclean2]

@petrosoniak @jamesmaskalyk @HumanFact0rz @davidcarr333 @BogochIsaac @KatharineSmart @ASPphysician @DrCarolynSnider @CatStepCatStep @alandrummond2 HCW will be subject to increasing violence, abuse, assault. We will leave in greater numbers, the public will suffer and no one will notice. People will increasingly fight for survival and be left with a terrible lifeless system. Alone and afraid.

[LADbible @ladbible]

Despite not being able to speak properly, this baby still managed to have a full-blown conversation with his dad 😄😂

🎥: Shanieke Pryor

[Steff McLean @steffmclean2]

@j_mcelroy It’s tough being rich, housed, and live in a beautiful part of Vancouver. Isn’t it ? 🙄

[Steff McLean @steffmclean2]

@carlyraejepsen Run Away w/ Me, Gimmie Love, Emotion, Boy Problems, I Really Like You, Too Much, Want You in my Room, Party for One, Happy Not Knowing, Feels Right, Julian, Fake Mona Lisa, Let’s Sort the Whole Thing Out, Call me Maybe, Talking to yourself, Cut to the Feeling!! 😃

[Steff McLean @steffmclean2]

@carlyraejepsen See you in Vancouver! 😃😃

[Grease @GoGrease]

In loving memory of our Sandy, Olivia Newton-John.❤️

[Kevin Mcleod @dockevinmcleod]

Nurses are hugely underpaid for the work they are expected to do. We need to fix this. It’s crushing us not having enough nurses. If nurses can’t afford to live here they aren’t going to work here.

[Adrian Bliss @adrianbliss]

Welcome to the stomach

[Monica Lewinsky (she/her) @MonicaLewinsky]

fuck you roberts.
fuck you thomas.
fuck you alito.
fuck you kavanaugh.
fuck you gorsuch.
fuck you coney barrett.

[Steff McLean @steffmclean2]

I get mad imposter syndrome when I see my name in the “Instructor/Faculty” section of an APA title page. Anybody else? 😅

#NewInstructor #NewFaculty #NursingEducation

[Dr Eric Levi @DrEricLevi]

Burnout is not a mental illness.

Burnout is a chronic occupational psychological injury.

Burnout therefore is a workplace safety issue.

Unless we consider burnout an issue of workplace safety, we will never move from individual resilience focus to workplace solutions.

[Fred Schultz @FredSchultz35]

He’s going places. 😂😎🕺🔥

[Steff McLean @steffmclean2]

“People respond to leadership when their purpose is made clear, their talents are used, their efforts are recognized, their accomplishments are rewarded, and their leader cares”

[Justin 🚄🎵🔋🌈 @not_taylorx]

What do you envision for Vancouver for #Transport2050? I think @TransLink can go much farther and ambitious than their current plans. That’s why I came up with #Transport2050Reenvisioned. So we can connect more people, faster. Thank you @j_mcelroy for publishing!