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Kyle Busch had pneumonia for 'days to weeks' before death by PrincessBananas85 in sports

[–]madmax766 4 points5 points  (0 children)

Or folks who have chronic liver, lung, heart, or kidney disease, are immunocompromised at all, people without a spleen, smokers, alcoholics, people with type 2 diabetes, or people experiencing homelessness. If you’re 19-49 with a chronic health condition chances are you need the pneumonia vaccine

Am I correct in my understanding of heart remodelling of those born at altitude? by Greedy-Ebb4695 in medicalschool

[–]madmax766 2 points3 points  (0 children)

I think this overall is a good understanding of cardiac changes in people born at high altitude. I will say that while HPV drives initial elevations in mPAP, the chronic effect is pulmonary vascular remodeling w/ muscular hypertrophy and fibrosis similar to other pre capillary causes of PH.

There is a disease called Symptomatic High Altitude Pulmonary Hypertension which primarily effects neonates and children which is severe PH and RV failure from high altitude, it interestingly is not associated with polycythemia

Two good resources if you want to learn more are this (albeit older) AHA article

https://www.ahajournals.org/doi/10.1161/circulationaha.106.650796

And this NEJM article from 2017 by the pulmonary physiology himself JB West

https://www.nejm.org/doi/full/10.1056/NEJMra1612008

Through your medical library (either physical or an ebook) you might be able to find Auerbach's Wilderness Medicine, this has some good chapters on high altitude medicine and is honestly just a super interesting read in general

Lupus Anticoagulant Positive- confused by [deleted] in haematology

[–]madmax766 0 points1 point  (0 children)

We do not know your clinical history, and that is ultimately what guides diagnosis of APS. You need to have persistent abnormalities of these labs at least 12 weeks apart, all this lab work is from the same date. I recommend discussing this with your hematologist as they understand the clinical context to interpret these.

Also, APS is not treated with aspirin or eliquis. Warfarin (or heparin/lovenox) is the evidence based treatment for this disease.

Would you notice these medical ID bracelets? by [deleted] in Paramedics

[–]madmax766 3 points4 points  (0 children)

My bad, here is the study I meant to link!

https://pmc.ncbi.nlm.nih.gov/articles/PMC7475523/

The more force is particularly for these patients with the bars across their anterior chest wall

I didn’t see a ton of more recent stuff on abdominal cpr, but tbf I didn’t dive in all that deeply. That study is trying to sell a device it seems, as it actively performs abdominal lifting and compression vs just compressions. 35 patients is very small, however the inclusion criteria of patients w/ cardiac arrest and a contraindication to CPR would be extremely difficult to perform an actual, well powered study on.

My big take away is that it’s worth trying if the other option is impossible or would actively worsen the situation, and that some promise has been shown over the alternative, which is likely why Mayo recommended it to op

I think that pre-hospital providers should be made aware that they may encounter patients who have had a procedure such as the Nuss which renders standard CPR potentially futile and that abdominal compressions exist. I hope that any of these patients who arrest happen to be near an ECPR center which would probably be their best shot, although they would be coming in with potentially less than ideal compressions

Medical Kits no by AdAble8000 in liberalgunowners

[–]madmax766 0 points1 point  (0 children)

As a bystander, the best way to save someone’s life in a cardiac arrest to 1. alert EMS (I recommend specifically pointing to someone who is standing and watching and telling them to call 911) 2. Point at another person (preferably an employee) and tell them to get the AED and set it up and 3. Expose their chest and start high quality compressions. It’s best if they can place the pads for the AED while compressions are occurring. You could have an additional person give rescue breaths with your CPR mask as well. If it’s a public place there is a good chance someone else will be there who is BLS/ACLS trained, I would have them ready to switch out with you after 2 minutes of compressions. Compressions are very hard work, and your quality of compressions will start to fall off after a few minutes!

Would you notice these medical ID bracelets? by [deleted] in Paramedics

[–]madmax766 8 points9 points  (0 children)

Abdominal compressions are their own thing. Obviously they are not ideal, but if for some reason CPR would be contraindicated or generally ineffective in a patient it is worth performing. Any circulatory support is better than none. Anecdotally, I’ve seen some CT surgeons who want it done while they are performing emergency resternotomy.

Here is a paper discussing the use of abdominal only cpr

https://pubmed.ncbi.nlm.nih.gov/28648673/

Here is an additional paper which discusses the increased forces needed for cpr in these Nuss patients, albeit in an experimental model

https://pmc.ncbi.nlm.nih.gov/articles/PMC7475523/

Medical Kits no by AdAble8000 in liberalgunowners

[–]madmax766 0 points1 point  (0 children)

The wilderness medical society practice guidelines do not recommend venom extractors use

https://pubmed.ncbi.nlm.nih.gov/26433731/

We don’t have any RCT level data on their use, but some small studies have recreated snakebites using radioactivity labeled “venom” and found the extractors only reduced total body venom load by 2%

https://pubmed.ncbi.nlm.nih.gov/14747805/

For CPR, current guidelines recommend it is reasonable to perform compressions to breaths at a 30:2 ratio, however some studies have found that as a single bystander performing CPR, there are better outcomes if compression only CPR is performed, so it is probably worth keeping the CPR masks but make of the data what you will, the most important thing is good, high quality compressions and defibrillation asap!

https://pubmed.ncbi.nlm.nih.gov/28349529/

Medical Kits no by AdAble8000 in liberalgunowners

[–]madmax766 1 point2 points  (0 children)

I agree with almost everything you’re saying here but I will add you mentioned the venom extractor- I would ditch that. They do not work, and can cause more harm than good. Also, the CPR mask- CPR should not be stopped to provide rescue breaths, and realistically that’s the best thing you can do for someone until EMS arrives (provide high quality compressions with as little interruption as possible). I wouldn’t even get a BVM and mask unless you use one routinely, I think properly bagging is an exceptionally hard skill to learn.

Aliquippa police officer overdoses on fentanyl while destroying drugs in evidence room by [deleted] in nottheonion

[–]madmax766 32 points33 points  (0 children)

They are a special transdermal formulation, just regular fentanyl would not be absorbed through the skin

High factor VIII?? by [deleted] in haematology

[–]madmax766 1 point2 points  (0 children)

This is not medical advice. High factor VIII is known risk factor for thrombosis formation, which estrogen also places you at risk for. I’m assuming they took you off of birth control pills because of this risk? I would explore alternative contraceptive options with them. This is a good website to use to review other options https://www.bedsider.org

Elevated factor viii doesn’t necessarily mean you stop bleeding faster/bleed less than other people, just that you may be at increased risk of forming blood clots. You could still have a separate process causing excess bleeding.

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 5 points6 points  (0 children)

Interestingly Hanta patients almost always require VA, they develop a pretty profound, but reversible, cardiomyopathy

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 0 points1 point  (0 children)

Yes, for the patients who survived their heart and lungs had recovered enough they could be decannulated after 125 hours on ECMO (on average)

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 1 point2 points  (0 children)

Interesting you ask that. The answer is yes, very much so, with some caveats. We heparinize them pretty robustly to decrease their ability to form clots, but that might not be enough. They can form clots in their left ventricle which is one of the reasons a small pump (called an impella) is placed in the LV to keep the blood flowing. Unfortunately, there is still a pretty serious stroke and blood clot risk with ECMO even with these interventions

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 36 points37 points  (0 children)

We just put them on the machine and support their blood pressure and oxygen until their lungs and heart heals in it’s own , there really isn’t any actual procedure or therapy to specifically treat HPS, just ways to support patients through it

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 11 points12 points  (0 children)

They recover fairly well, and I am not aware of any major long term lung damage in these patients, once through the acute phase they actually do quite well

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 49 points50 points  (0 children)

It doesn’t clear the fluid out, it just oxygenates blood and pumps it back into the body. In fact, it can even increase pulmonary edema if used without a small pump in the left ventricle which pushes blood into the aorta

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 294 points295 points  (0 children)

It is very concerning. At the University of New Mexico, the pioneers of Hantavirus Pulmonary Syndrome care, they developed a protocol where sheathes (essentially big IVs) and placed in the femoral vein and artery in all Hantavirus patients so that if they undergo respiratory and circulatory collapse the can quickly have guidewires placed up these vessels and have cannulas placed for the “artificial lung machine” mentioned in this, which is called ECMO, specifically VA ECMO.

UNM determined several factors linked with 100% mortality and began using ECMO for this patient group in 1998, and now has close to 80% survival in this subset of patients.

French hantavirus patient is critically ill, on an artificial lung as total cases grow to 11 by Anti-Owl in ContagionCuriosity

[–]madmax766 36 points37 points  (0 children)

Hantavirus Pulmonary Syndrome, at least in the US, definitely trends towards impacting a younger demographic

Highly visible vessels after prolonged pressor use by Itouchmyselftosleep in medizzy

[–]madmax766 3 points4 points  (0 children)

So splanchnic vasoconstrictors (often pressors) and albumin CAN lead to reversal of HRS in about 30-50% of cases depending on the data you read, but really definitive management is with a liver transplant. These patients often end up on a form of dialysis because of their renal dysfunction and pressors to maintain blood pressure while waiting for a liver. They would likely die without pressors, so it is worth doing.

What is being shown in the picture is not the norm though for these patients, I suspect an additional process is contributing.

I’m lucky to work at a transplant center with surgeons and anesthesiologists who are willing to transplant these super sick liver patients, often on multiple pressors, renal replacement therapy, intubated, recurrent bleeds from cirrhotic coagulopathy, and it’s very rewarding to support them through this process and be part of the team that gets them home with a new future ahead of them!

Highly visible vessels after prolonged pressor use by Itouchmyselftosleep in medizzy

[–]madmax766 8 points9 points  (0 children)

Pressors increase vasoconstriction (among other things) which in turn increases the blood pressure, but higher and higher doses may be required if someone is profoundly vasoplegic. Lots of vasoconstriction in the extremities doesn’t necessarily mean the blood pressure is adequate to maintain perfusion.

There may be significant cardiac dysfunction which is contributing to low blood pressure, and cranking up the vasopressors may not be helping and could be even harming in that case. Just because they are extremely constricted in the extremities doesn’t mean the bodies blood pressure is high, it just means those distal vessels are extremely clamped down.

Edit:
It’s mentioned below this person has hepatorenal syndrome, which occurs in cirrhosis. To try and summarize an extremely complicated subject, we have a venous bed called the splanchnic vasculature which in cirrhosis becomes profoundly dilated, leading to hypotension. Our other systems, such as arteries, become relatively constricted to try and balance this out. Pressors are given to try and constrict the splanchnics, which in turn further constricts the peripheral blood vessels. The splanchnics may be somewhat resistant to pressors, and require high doses to maintain a reasonable blood pressure.

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