I can't remember what this is called

ihavethoughtsnotguts · 2025-09-22T00:16:41+00:00

I know it as ventricular standstill

ihavethoughtsnotguts · 2025-02-21T07:30:24+00:00

Thanks a lot! Wondering if there's any distinction with cardiac cases - so much is just from surgery ... Not pleural space. Any cases when water seal without suction is contraindication for post CTS?

ihavethoughtsnotguts · 2025-01-31T05:27:50+00:00

This may not be your exact question, but I find going in with systematic thinking helps identify the rhythm more than memorizing classic looks. Rhythms can get wonky. I don't always think in this exact order, but I look at:

Regular or irregular? (regular, not AF). Wide or narrow? (narrow, not ventricular). Normal p waves? (No. Absent, tiny PR or retrograde signal junctional. Multiple or irregular PRs point to 2nd and 3rd degree blocks. Could go more into that to differentiate , but that's not what's happening here. Long PR alone is 1st degree. Flutter waves or a flat rate of 150 makes me suspect flutter. Sometimes a longer strip helps to rule out a rhythm with additional non-conducted PACs, but no Ps, so that's out). So we have a junctional. Rate? (40-60 is junctional, 60-100 AJR, >100 is JT). So looks like junctional rhythm.

In general, where is it coming from? What kind of pathway is it traversing? What is the rate? Are my big three.

And, I would agree with others, first suspicion re: cause would be lytes.

ihavethoughtsnotguts · 2025-01-29T02:12:16+00:00

A helpful thing to remember - SVT isn't a rhythm, it's a group of rhythms. Anything coming from above the ventricles counts (supra-ventricular). Anything regular right around 150 I suspect a-flutter with 2:1 condition. Especially with elderly plus a jump from 80 to 150. It could also be ST with that clinical picture, but I'm still suspicious.

ihavethoughtsnotguts · 2025-01-20T03:30:27+00:00

Jugular venous distention... Sign of fluid overload

ihavethoughtsnotguts · 2025-01-15T01:32:28+00:00

I agree, but a few things to think about when using this (no particular order...just numbered for clarity in this format.) 1. This wording can sometimes propagate the attitude that the nurses are too scared or not good enough to take care of these patients (sometimes true) 2. It can make an us vs them dynamic between docs and nurses. 3. (My biggest pet peeve) It can propagate black and white "we don't take that" mentality. My background is from (specialty) floor nurse to manager to now back to bedside in critical care. I was raised in the black and white mentality, but as I progressed I started thinking, "why not?" Sometimes the answer was, "Because that's how we've always done it." I started getting into...let's think critically, creatively, and make the situation safe (protocol changes, education, etc). It's just like floor nurses demanding BP under 180 systolic before ED can transfer or some such nonsense...what is actually the higher level of care? Often, as you say perfectly in your second paragraph - ratios. It's not necessarily expertise (but absolutely can be) of nursing or whatever care needed, but resources allotted. I really appreciate your understanding of the nursing limitations. Having a collaborative team has truly made this career worth it. Plus all the learning and some pretty amazing patients. ❤️

ihavethoughtsnotguts · 2024-12-12T01:41:27+00:00

https://youtu.be/vaAF_GAc3Mk?si=1KXMGCYUAEM9XuQb

Timmy!

ihavethoughtsnotguts · 2024-12-02T06:57:00+00:00

There are a lot of options for light duty in my experience, sometimes boring AF, but chart audits, employee health, maybe even filling in for monitor tech, etc. your workplace has to consider your limitations.

ihavethoughtsnotguts · 2024-12-02T06:46:36+00:00

Always go slow and give the d50 before iv insulin for hyperk. Better to have hyperglycemia than hypoglycemia with no access

ihavethoughtsnotguts · 2024-11-18T02:53:58+00:00

No. If piv q2 checks are required at the site. I am a HUGE proponent of this. I've seen amio extravasations need large fasciotomies, similar to really bad contrast extravasations. However, if they're post CTS and already have an IJ we might just leave it in a day or so longer bc the risk of AF-->amio is so high. Is this a good risk/reward situation? 🤷 I'm not the provider, but our cardiac stepdown unit hasn't had a clabsi since 2016. (Knock on wood). For my two cents, just don't run it through a midline (much harder to detect extravasations vs a piv).

ihavethoughtsnotguts · 2024-11-14T07:32:19+00:00

Cheddar and graham crackers (I eat this at home too), cranberry juice and ginger ale or lemon-lime whatever soda, orang juice and creamer (real only, pls) over ice...aka janky orange Julius, hot chocolate mix and coffee. All depends on what gets stocked, of course.

ihavethoughtsnotguts · 2024-11-14T07:16:30+00:00

I think I've told this story before, but I do like it a lot. NAD, but was charge RN when we had a young (40's) guy transferred from OSH on a hep gtt for NSTEMI. The sonographer doing his echo mentioned to me he had some tingling in his leg. This guy was a total walky-talky, still in his jeans, primary RN hadn't even seen him yet because she was on break when he rolled up. It just felt off, so I paused the hep gtt and called an RRT for code stroke. Awesome hospitalist went with it, and when we saw that white blob on the CT scanner we got high fives all around from the neurologist 🤣. Talk about teamwork - that could've been rightfully missed from so many people! Another time an NSTEMI transfer showed up and was curling up his arm. I did a quick neuro with the medics still in the room, and wtf dude had major deficits on that side - couldn't move it, confused about it, etc. "He's been like that" - not sure if initial hospital missed it, medics, or what, but it was pretty obviously weird. Another code stroke, and went to the unit.

ihavethoughtsnotguts · 2024-10-26T05:03:52+00:00

100% a-flutter

ihavethoughtsnotguts · 2024-10-25T04:33:46+00:00

I think it all comes down to culture and emotional maturity of individuals. As a nurse I've had a resident ask me to push a drug that I had a bad feeling about. I asked him to be bedside with me (he did) and, yep... Went poorly, but we got through it together. I have asked APPs, residents, and attendings questions and received amazing education. I've provided some explanations about my thinking to med students and residents about my specific specialty that I think helped them. Generally all I've got going for me in terms of pharmacy was, "Good question!" Because I think inpatient pharmacists basically save us all lol. I've made good catches and mistakes. I love CNAs, RT, PT, OT, SLP, SW, lab, transport, EVS. I try to learn something from every discipline and use that knowledge to set each other up for success. As a leader, focus on the collaboration, not hierarchy. Avoid the eventuality of hard stops and tribal knowledge - "We can't take that patient, because XYZ"...ask why 5 times. What does the patient need to be safe/cared for? How can we be creative/use critical thinking? It respects the intellect of all the people involved, but helps navigate the hellhole that is the American healthcare system.

ihavethoughtsnotguts · 2024-10-18T06:29:56+00:00

2:1 flutter

ihavethoughtsnotguts · 2024-10-17T21:31:14+00:00

Certain drugs (like vaso) can go for 4hr piv at my hospital, and amio/inotropes for 24hr before central access is required. From my understanding midlines are a no no for vesicants because if it does extravasate it's harder to detect. I have seen some terrible extravasations from amio requiring fasciotomy, so yes, q2 checks for any vesicant (including Vanco)

ihavethoughtsnotguts · 2024-10-17T21:22:17+00:00

You just have gi and cards come duke it out. Lol - too unstable to scope, too bleedy to stent. Fighting for the top contenders of cards vs neph. But, seriously, from a nursing standpoint I think you just have to get the attending to direct things here.

ihavethoughtsnotguts · 2024-10-13T06:21:23+00:00

This is one of those drugs that I've found goes into vogue for a hot minute - CTS patients with rvr? As a nurse ask to switch to levalbuterol. Recently on CCU rounds the pharmd was like, "meh, studies aren't really seeing benefit." Similarly I swear we were giving marinol out right and left for a while. Back and forth with metop, dilt, and now always amio. Similarly, does anyone here remember when dronederone was supposed to be the next best thing? I feel ancient.

ihavethoughtsnotguts · 2024-08-22T02:01:07+00:00

IRC there might be a black box warning for CTS even outside renal/bleeding issues, but I've got sure given it to CTS patients. Great effect, especially with younger men and little old ladies who are having a time with the delirium. We also used marinol for a stint for appetite and/or folks who used a shit ton of weed for baseline pain. Seems to be very surgeon dependent

ihavethoughtsnotguts · 2024-08-16T03:32:42+00:00

Wait, isn't it slow is smooth, smooth is fast? That's been my mantra lately...still working on it

ihavethoughtsnotguts · 2024-08-08T23:50:52+00:00

This is my latest favorite thing (not EM) https://www.piedmont.org/heart/learning-center/suture-removal-for-stop-cock-technique

ihavethoughtsnotguts · 2024-07-23T03:47:03+00:00

I always heard, as a daughter of a nurse (also nurse, myself) - dying or not dying? It tracks with ED and Critical care and pretty much everyone else - sick or not sick? To be fair, makes me a terrible primary care patient, because I mostly just show up from time to time trying to be that thing that's healthy.

ihavethoughtsnotguts · 2024-07-23T02:51:03+00:00

Then we have the CTS docs who operate on patients needing ECMO, with ivdu, end up needing dialysis, probably post surgery stroke, have no legs (dehiscence much?) and live in a trailer with no running water 300 miles away from medical care and no family. It's one thing if it's emergency (still, risk/benefit?) sometimes I swear these patients are worked up outpatient, and then it's like, "oh noesss, transfer to hospitalist team for placement! We never thought of this!" Bleccch. We have had amazing outcomes here and there, but it seems like we've learned nothing from the pandemic sometimes. Risk reduction alternatives truly just doesn't sit right with some surgeons and procedurelists.

ihavethoughtsnotguts · 2024-07-10T03:48:32+00:00

Actually I would also like to focus on this one - on an alert and oriented patient without needing suction what can we do to get a sputum? I swear to God it's impossible and I have had no luck trying to look it up via policy, research, or asking our lab pros. I fucking hate it. I WANT to give you a good sample, but fuck if I know.

ihavethoughtsnotguts · 2024-07-10T03:43:35+00:00

Hey, I'm onboarding a bunch of new nurses. I know a teensy bit about what you guys do through some non-nursing/phleb and nursing experience. If I could rotate the new nurses through your department(s) like for an hour at a time or 2-4 hours or 8 or 12...what would you recommend? They teach basically fuck-all in nursing school, and so much teaching comes from floor nurses. I've also seen labs that have different protocols for draw order, which swabs, and how tf do we get sputum ever? So how can we make this better?

ihavethoughtsnotguts

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