As a continuation of our radiology lecture series, take a look at the excellent instructional modules created by Dr. Anita Goel, PGY-1 resident at the University of Cincinnati Department of Emergency Medicine residency training program. Dr. Goel takes us through the basic anatomy, the particular features of the many different views that can be obtained in hip and pelvis plain film radiography, and a systematic approach to reading these often complicated radiographs.Read More
Management of the GI bleed (a review of the Cochrane Reviews):
- PPI drips have been shown to decrease the rate of rebleed in patients with known peoptic ulcers. It has not been shown to decrease mortality, hospital stay, transfusion need. It also has not been shown to be beneficial in the undifferentiated upper GI bleed and may have a trend toward harm.
- Octreotide doesn't improve mortality but on average decreased transfusion requirement by 1/2u product.
- Antibiotic coverage (treating for gut translocation with ceftriaxone) has been shown to have lowered mortality from infection and all-cause mortality.
- Prophylactic intubation: 2 retrospective chart reviews came up with contrasting results on mortality outcome after intubating for prophylactic reasons (patient was protecting their airway).
A couple weeks back we met for the first journal club of the year in our residency. For this first session, we tackled the clinical conundrum of transfusion ratios in trauma. The question came from a brainstorming session with the PGY-1 and 2 residents, where the following PICO question was derived:
Patients: Victims of both blunt and penetrating trauma in need of blood transfusion as a part of the their initial resuscitation
Intervention: high plasma and platelet to PRBC ratio transfusion
Comparison: low plasma and platelet to PRBC ratio transfusion
Outcome: Mortality (in patient and 30 day mortality)Read More
Radiation in Pregnancy with Dr. Polsinelli
Radiation effects can be deterministic or stochastic.
- Deterministic effects cause direct cell damage (radiation burns, teratogenicity, intrauterine death, genetic material damage). There is no evidence of teratogenicity in diagnostic testing radiation ranges (<50mGy). Genetic damage (causing effects in future generations) is theoretical and has not been reported. IUD is a concern, but on a population based scale there was no noted increase in incidence of fetal demise after large scale radiation event and this cannot be studied in vivo.
- Stochastic effects increase the probability of developing cancer. There is no minimum threshold and increasing dose increases probability. Risk of cancer noted to be ~5% if exposed to 1Gy of radiation. (for comparison maternal radiation is: chest xray = 0.1mGy; CT abd/pelvis 10mGy)
You may have heard of a little get-together happening in Chicago June 23-26th, 2015. And by little get-together I, of course, mean the biggest baddest Social Media and Critical Care Conference in existence coming to the U.S of A for the very first time. If you haven't heard of the SMACC conference, take a look at their conference webpage - http://www.smacc.net.auRead More
Welcome to Taming the SRU’s Global Health section, where our goals are to increase awareness of global health issues, discuss clinical and ethical cases, and develop opportunities for residents to participate in global health electives. We believe global health education is critical to well-rounded medical education. Global health electives (GHEs) often have a profound effect on participants at any level. One study found that 70% of students participating in GHEs subsequently entered primary care residencies or intended to work in resource-limited settings. (1) These experiences lead to enhanced clinical and communication skills, humanism, cultural competency, and understanding of alternative concepts of health and disease. GHEs help trainees foster a deeper understanding of the global collective and how one’s own health is uniquely connected to the rest of the world. (2)Read More
In the video series below, PGY-1 resident, Dr. Gorder, leads us through the key aspects of CT head interpretation. Attention is paid to the development of a rigorous systematic approach to review and interpretation of head CTs to aid in the identification of blood, ischemia, mass, signs of increased ICP, as well as fracture. In the second video, the key anatomic features seen on head CT's are covered.Read More
In the first of two posts preparing for Grand Rounds in the coming week, PGY-1 EM resident, Dr. Polsinelli, guides through the murky waters of radiation exposure during pregnancy. She offers a background on what radiation is, how it's measured, the effects of radiation on the fetus, and radiation doses associated with common diagnostic exams.Read More
Neonatal Resuscitation with Dr. Kamath-Rayne
90-95% of newborns will require no intervention prior to their first breath. 5-10% of newborns will require drying, stimulation, or suctioning to get them to breath. 3-6% will require assisted ventilation with BMV. <1% will require advanced care with intubation, meds, or chest compressions
Golden Minute: within the first minute you want to ensure the baby is breathing spontaneously or have initiated BVM ventilation.Read More
This past Wednesday, I had the pleasure of giving a lecture on FOAM to the UC Emergency Medicine Residency. Well, it wouldn't quite be a lecture on FOAM if I didn't make it freely available to all after I finished it all up. You can check out the lecture slides on slideshare embedded at the bottom of the post. I also recorded the lecture and broke it down into a series of 5-ish minute long videos which you can look at based on your area of interest.Read More
EMS as a Specialty with Dr. Gerecht
"We are in the business of delivering health care to a very unique population, in a very unique environment, in a very unique way" - Dr. Edward Racht
EMS formally became a subspecialty of EM in 2006. The first board certified EMS physicians passed their exams last year (we have 3 in our EMS division).
EMS physicians train in clinical aspects of EMS medicine, medical oversight of EMS, quality management, and special operations.Read More
In 2012 in the Annals of Emergency Medicine, Weingart and Levitan published a review of preoxygenation and peri-intubation oxygenation techniques in the emergency airway management of adult patients. Topics reviewed included the evidentiary support for preoxygenation and denitrogenation, appropriate positioning and patient selection, the utility of positive pressure in select circumstances, apneic oxygenation, as well as a proposed risk stratification approach based on pulse oximetry levels and peri-intubation risk.
A great discussion was had with many excellent learning points, upon which some were elaborated in great detail in the article and some only briefly mentioned. What follows is a brief summary of learning points from the article as well as from the discussion.Read More
- Caused by neurotoxin produced by Clostridium bacteria
- 3 types: food borne, infant and wound
- Pathophysiology: toxin binds to cholinergic cells and prevents release of acetylcholine
- Foodborne illness starts with N, V and D. Similar to gastroenteritis
- Neurologic symptoms: fixed and dilated pupils, ophthalmoplegia, ptosis, bilateral and symmetric facial paralysis that progresses to limbs and trunk, respiratory muscle weakness
- Patients frequently complain of dysphagia, dry mouth and other anticholinegric symptoms
- Infant botulism = floppy baby who is weak, has a weak cry, constipation and does not feed well
- Botulism is easily confused with myasthenia gravis and Miller Fischer variant of Guillan Barre
- Diagnosis: clinical in the ED
- Tensilon test is normal but is helpful in diagnosing myasthenia
- EMG may be abnormal
Utility of the imaging modality aside, abdominal radiographs can be a bit of a challenge to interpret. With a number of possible techniques (cross table laterals, left lateral decubitus, AP, upright, or supine) and a lot of structures to evaluate (is that small bowel or large bowel?, is that a kidney stone or an infamous phlebolith?), it's pretty easy to stare at a film and zone out as you eye moves from one shade of gray to another.
In the embedded video below, PGY-1 resident, Dr. Julie Teuber goes through a standardized approach to reading the abdominal x-ray that hopefully help keep your eyes from going cross-eyed next time you need to interpret an acute abdominal series.Read More
An Update on CHF w/ Dr. Fermann
The phenotype of acute presentation of heart failure can be dramatically different. Consider the difference between the hypotensive patient who has very poor cardiac output now in cardiogenic shock requiring pressors (these have a very poor outcome), the normotensive patient who has slowly become retained fluid, and the acutely hypertensive patient who presents in extremis (who actually does quite well even though they are so sick on arrival).Read More
R4 Simulation Series: Genitourinary Emergencies with Dr. Moschella and Dr. Verzwyvelt
- Fournier's Gangrene (ie necrotizing fasciitis of the perineum): Case simulation of 19 yo M with tachycardia, hypotension, altered mental status found to have erythema, induration, and crepitus of the perineum. Initial steps are aggressive treatment of sepsis (broad spectrum antibiotics to cover skin and gut flora as this is commonly polymycrobial) and early surgical debridement. Either Urology of Acute Care Surgery will mobilize to perform the debridement.
- Oral boards case: Consider ovarian torsion in young female with acute onset pain in lower abdomen or pelvis. You may find adnexal fullness or tenderness on exam. Diagnostic test of choice is transvaginal duplex ultrasound. Remember to include ectopic pregnancy, appendicitis, TOA in your differential.
Some of the challenges to think about when performing these procedures in the aircraft include:
- Positioning: you are stuck at the head of the bed, the patient is packaged, their arms are down to their side, and space is limited.
- Sharps: high risk of accidental injury when in the back of a squad or in the helicopter. Be careful!
M&M Learning Points with Dr. Stull:
- Severe asthma exacerbations require considerable effort to avoid furthering acidosis while attempting to stabilize, secure airway, and maintain oxygenation. Use Mag early as there is evidence that you can reduce admissions by providing this treatment early. Consider BiPAP to improve ventilation while preparing for definitive airway management but there is no evidence that it reduces intubations. Ketamine as the RSI induction agent may provide some bronchodilatory effect but there is not enough data to provide any formal recommendations. For this same reason, ketamine as a post-intubation sedation agent may be appropriate. Vent management is key with a focus on low respiratory rate and short inspiratory times to lengthen the I:E ratio (>1:3) to allow full exhalation. Goal TV 6-8cc/kg, "ZEEP" or low PEEP (0-5mmHg), consider a plateau goal of ~25 if you paralyze
I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).
Here is what Ryan has to say…
In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)Read More
n general, the best way to learn is to challenge yourself. Teaching styles should take into account different learner types and levels
- Beginner: early 3rd year medical student
- Can be an observer initially but transition these learners to the next stage
- Keeps you on point as you have to really know what you are talking about
- Incorporate them into your H+P
- Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
- Advanced:OMP (one minute preceptor) or SNAPPS model