The Search for the Holy Grail: Assessment of Fluid Responsiveness

The Search for the Holy Grail: Assessment of Fluid Responsiveness

Last week our residents and faculty met for journal club in search of the holy grail.. err.. I mean, to talk about ways to assess volume responsiveness.  A couple of weeks back the PGY-1 and 2  residents met and discussed a number of questions they had about the care and management of patients with sepsis.  The discussion hit on a number of key topics: empiric antibiotic selection, timing of antibiotics, choice of vasopressors, etc.  Ultimately the group decided they wanted to take a closer look at non-invasive ways to assess volume responsiveness and guide resuscitation in septic patients.

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Approach to Reading MRI of the Spine

Approach to Reading MRI of the Spine

It's another back pain type of day in Minor Care.  3 hours into your shift and you've seen 6 patient's with back pain.  You quickly evaluate them asking them about red flag symptoms, searching for signs of neurologic injury on your physical exam.  As you talk to Jane, your next patient, you get worried she doesn't have simple musculo-ligamentous back pain.  Jane has a history of IVDU and states her last use was 3 months ago.  She cites some subjective fever and chills over the past several days along with aching low back pain which has been getting steadily worse.  On exam, you find she is febrile with a temperature of 101.4, tachycardic to 110, with a normal blood pressure.  She has midline upper lumbar and lower thoracic spinal tenderness to palpation.

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Grand Rounds Recap - 1/21/15

Grand Rounds Recap - 1/21/15

Evidence-Based Emergency Medicine: Accidental Hypothermia with Drs. Mudd & Riddle

Grading the Severity of Hypothermia

  • Mild hypothermia is defined as 32-35 °C and symptoms include confusion and diuresis
  • Moderate hypothermia occurs from 28-31°C and is associated with lack of shivering, atrial arrhythmias, and worsening changes in mental status (including paradoxical undressing)
  • Severe hypothermia happens when core body temperature is less then 28 °C and is associated with coma, significant decreases in metabolism, and a very low threshold for V-fib
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Grand Rounds Recap - 1/14/15

Grand Rounds Recap - 1/14/15

Oral Boards with Dr. Roche

Case 1 - 37 yo F, G3P2, no prenatal care, somewhere around 3rd trimester, presents with vaginal bleeding. She endorses feeling weak and dizzy and had 1 syncopal episode at home. On arrival, she is tachycardic and hypotensive (80s/60s), has cool extremities with weak peripheral pulse. Fundus is a few cm below xyphoid process. On a sterile speculum exam she has a large amount of bleeding and cervix is dilated to 3 cm. US shows IUP with good cardiac activity. She requires blood rescuscitation and admission to OB for delivery due to placenta previa.

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“I Don’t Care What You Say. I’m Out of Here Doc…”

“I Don’t Care What You Say. I’m Out of Here Doc…”

You take a big breath and walk out of the SRU.  After having just spent the last hour and a half caring for a hypotensive, actively vomiting variceal bleeder, a full arrest that you had to pronounce, and a GSW to the chest that went quickly to the OR, you are dreading to see the state of your Pod.  As you are just about to sneak into your workstation to get your bearings, you’re flagged down by Mr. Finch, the patient in bed 2.

“What can I help you with sir?” <you>

“What do you mean, what can you help me with?  Man just get my paperwork and let me get out of here.  I’ve had it with this place.  I’m tired of being a pin cushion and I’m not going to take this crap anymore.” <Mr. Finch>

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Grand Rounds Recap 1/7/14

Grand Rounds Recap 1/7/14

CPC with Dr. Boyer vs. Dr. Steuerwald

16yoF with 4 days of bilateral lower quadrant abdominal pain and diarrhea that was tachy, dry, and with a diffusely tender abdomen and some right-sided discomfort on pelvic exam with a mild leukocytosis.

Dr. Steuerwald's approach to listening to patient presentations: Pick out the main symptoms, get a time course, and listen for any other true "weirdness" then build your own timeline of events.

  • Don't forget about the "sexy numbers" in everyone, these include the vitals and also key aspects of a disease process (i.e. the EF in a patient with CHF)
  • DDx included appendicitis, PID, TOA, Fitz-Hugh Curtis, Ovarian Torsion, Yersinia enterocolitis
  • Dr. Steuerwald correctly identified the need to get a RLQ US to assess for appendicitis!
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Might As Well Face It: We’re Addicted to SMACC

SMACC Chicago

Social Media And Critical Care

Here at Taming the SRU, where we’ve been SMACC-infatuated for more than a year now, it’s easy for us to forget that many of you out there are still unfamiliar with what the fuss is all about.  SMACC is the Social Media and Critical Care conference.  Its next iteration, the third annual (and first to occur in North America), is coming in late June in Chicago, and wild horses couldn’t keep us away.  Taming The SRU is honored and stoked to be an Affiliated SMACC Website.

Isn’t this just another CME conference, you ask?  Emphatically, no.  Weingart has called it “simply the greatest medical conference in the history of the world,” and we don’t think this is hyperbole.  SMACC aims not only to educate; SMACC aims to entertain, and mostly, to inspire.  To quote smacc.net.au: “SMACC is a high impact academic meeting fused with cutting edge online social media to deliver innovation with education.  The underlying ethos is to provide free online education with open access, in what has come to be known as ‘FOAM’ (Free Open Access Meducation).”  Get this: all sessions will be recorded and released as videos or podcasts online on the affiliated SMACC websites following the actual conference, for free!  And yet, hundreds of us will flock to Chicago to attend in person.  Why?  We’re addicted to the inspiration of FOAMed, and the maximum dose of this inspiration attainable is SMACC, live and in person.  (Plus, we’re sick of just ‘favoriting’ Minh Le Cong’s Tweets, and we want to shake his hand or give him a big ‘ol bear hug.)  This is not your father’s medical conference.  It’s infinitely better.

SMACC also aims to connect people across boundaries, and succeeds in doing so like no conference ever has.  Wherever you practice critical care (prehospital, ED, OR, ICU), SMACC is for you.  Whatever your discipline (student, EMT, medic, nurse, PA, NP, CNS, CRNA, doc), SMACC is for you.  Whatever your specialty, whatever your experience level, whatever country you call home, whatever your clinical setting: as long as you seek inspiration to be as good as you can be at optimizing your sick patients’ outcomes,  SMACC is for you.  Right now, go to the brochure and look at it for just 60 seconds.  Can you get a witness?  You bet.  Listen to this brief podcast in which Bill Knight, Jeff Hill, and I testify about the reasons for our excitement about our upcoming road trip to Chi-town.  Still not sure?  Check out the archives from SMACC 2014 (Gold Coast, Australia).  We think you’ll be convinced.  But, be forewarned: there’s no cure for SMACC addiction.

B Pod Case: Double Vision

 B Pod Case: Double Vision

78 year old male with past medical history coronary artery disease status post stenting, hypertension, hyperlipidemia, chronic kidney disease presents with a chief complaint of double vision, feeling off balance. Patient states he awoke this morning with double vision. He states this sensation of double vision is worse when he looks side to side, and completely resolves when he closes one of his eyes. He does not wear glasses or contacts and denies any eye pain or trauma. Also, since this morning he has felt somewhat off balance, however denies any focal numbness or weakness of extremities. He noted an episode of slurred speech approximately 1 hour prior to arrival that has since resolved. No other difficulties with word finding or language. Otherwise patient denies headache, head trauma, neck pain, chest pain, or shortness of breath. He has not had symptoms like this in the past.

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Right Upper Quadrant Ultrasound

Right Upper Quadrant Ultrasound

You are talking to your new patient, John.  He's a pleasant 30 year old man who, by your estimation appears to be a victim of HGS... Holiday Gluttony Syndrome.  John presented to you in the ED with abdominal pain, nausea, and vomiting.  He goes on to tell you all this started after he chowed his way through a few too many Buckeyes.  You see every Christmas, his mom sends him a far too large tin of Buckeye candies, which John had eagerly eaten and eaten and eaten, until the belly pain hit.

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More than You Ever Wanted to Know About Extra Glottic Devices

More than You Ever Wanted to Know About Extra Glottic Devices

Our good friend Jim DuCanto visited us earlier this year. We spent several days sharing knowledge and perspectives.

Part of our time together was spent recording this podcast. It has been simmering and is finally available for listening. Within, we briefly go through the history of the extra-glottic device (EGD) in general, and then, we talk about the Laryngeal Mask Airway (LMA) and its “descendants” in great detail.

Jim really had a tremendous wealth of knowledge to share…

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Grand Rounds Recap - 12/18/14

Grand Rounds Recap - 12/18/14

Morbidity and Mortality Learning Points with Dr. Stull

1. Should Post-ROSC patients get cardiac cath?

  • Cardiac arrest patients who have STEMI on EKG after ROSC tend to have good outcomes (overall survival and intact neurologic survival) if they get cath'ed.
  • According to latest Australian study (all patients with ROSC from OHCA, not STEMI) OR for overall survival is 2.77 and OR 2.2 for good neurologic outcome
  • VT/VF cardiac arrest patients who do not have a  STEMI on EKG: improved survival and likelihood of good neurologic outcomes if cath'ed within 24 hours.
  • Our cardiology department wants all post-ROSC VF/VT patients to have cath lab activation. All other post-ROSC cases, call cardiology to discuss need for cath lab
  • All post-ROSC STEMI should go to cath lab no matter what their neuro status is
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Prehospital Care, An International Perspective

Prehospital Care, An International Perspective

The State of Affairs

     The morbidity and mortality of trauma on a global perspective is humbling.  Aside from HIV/AIDS and TB, trauma is the chief cause of mortality for 15 to 45 years of age (based on 2002 WHO data).  5.8 million deaths annually.  5.2 million of those deaths, or 90%, occur in low-and-middle-income countries (LMIC’s).  Prehospital care in LMIC’s varies immensely.  Total prehospital time, the training level of prehospital providers, transportation method, and access to emergency medical systems (EMS) are some of the better described aspects of prehospital care in LMIC’s.  The attributes of the prehospital health care delivery system differ significantly on a country by country basis.

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Grand Rounds Recap - 12/10/14

Abscess Management by Dr. Betham and Dr. Derks

1. Should ultrasound be used for abscess management?

  • US changes management in 18% of cases according to 1 paper
  • US + physical exam greatly increases sensitivity and specificity of physical exam alone
  • In people with cellulitis and no signs of abscess: US changes management in 56% of cases according to 1 study
  • Conclusion: in patients where you are not sure if there is an abscess, US can help you make the decision and changes management

2. Methods of Abscess Drainage

  • I&D has been the gold standard
  • Need to incise about 2/3 of the area of fluctuance along lines of skin tension
  • Needle aspiration should not be done due to high failure rate and need for subsequent I&D following needle aspiration
  • Loop drainage: placing a penrose drain vs vessel loop into abscess cavity and tying a loose knot in order to keep abscess cavity open
    • This is less invasive and has similar or possibly lower rates of failure as I&D as well as improved cosmetic result

If you are an EM:RAP listener, this is the video I talked about in the November episode on abscess managment. It goes through the steps of a new technique for draining a cutaneous abscess. I am a huge fan of this procedure and use it on most abscesses that I would have otherwise packed. Why I like it: there is no packing to change, the incisions stay open because of the drain and the incisions themselves are much smaller than we historically use.

3. Should we irrigate abscess cavity?

  • No good evidence for or against
  • Surgeons do irrigate
  • Tap water and saline are equivalent for lacerations, so likely both ok to use for abscesses

4. Should abscess cavity be packed?

  • Higher pain and no difference in outcome with packing according to several small studies

5. Primary Closure of Abscess

  • Usually done with a vertical mattress suture in order to close cavity space and prevent fluid from recollecting
  • Improves time to healing
  • Studies have not shown increase in abscess recurrence or complications
    • BUT these studies come from the OR and surgical literature and most people got a dose of IV antibiotics
  • There is a small RCT done in ED: randomized to packing vs primary closure but use of antibiotics not standardized
    • There was no difference among groups
    • Better cosmesis with primary closure

6. Do these patients need PO antibiotics?

  • Patients who have recurrent abscesses, are immunocompromised or have poor wound care compliance may benefit from antibiotics
  • Consider antibiotics in extreme of age, surrounding cellulitis, immunocompromized patients
  • According to IDSA guidelines, no need for culture or antibiotics in mild disease
  • If pts have systemic symptoms, then they will need antibiotics
  • Recommendations is 5 days of antibiotics (Bactrim+Keflex vs Clindamycon)
  • Patients with valvular disease should get 1 time dose of antibiotic prophylaxis (2 g of keflex PO vs 600 mg of clinda PO): give 30 minutes prior to procedure or within 2 hours after

Other Useful FOAM Resources


Hand and Wrist X-Ray with Dr. Dang

Missed orthopedic fractures account for the largest source of malpractice claims and hand injuries account for 5-10% of ED visits.

ABCS method for Interpretation

  • A: adequacy/alignment. Correct patient and limb with full image without ulnar or radial deviation
  • B: bones. Need at least 2 views
  • C; cartilage and clear spaces. All joints should be uniform
  • S: soft tissues

Tuft fracture: typically due to crush injury

  • No specific treatment. Can splint for comfort
  • Nail bed injury = open fracture and need antibiotics

Mallet finger: forced flexion of extended DIP joint

  • Can be associated with small avulsion fracture
  • Splint in hyperextension

Jersey finger: forced extension at flexed DIP

  • Won't be able to fully flex at DIP
  • Surgical management

Skier's thumb: hyperabduction of thumb with FOOSH

  • Thumb spica splint

Boxer's fracture: metacarpal neck fracture with volar angulation

  • Make sure this is not a fight bite: need antibiotics

Metacarpal neck fractures: need to know degree of angulation as it determines need for ORIF

Scaphoid fracture: most common fractured hand bone

  • Tenderness of anatomic snuff box or with axial loading of thumb
  • 30% may not be apparent on initial x-ray
  • Increased risk of AVN, so splint and follow up for repeat imaging

Triquetrum fracture: can be associated with ulnar nerve injury, splint with a polar wrist splint

Scapholunate dissociation: injury to the ligament connecting the 2 bones

  • Look for increased gap in between scaphoid and lunate ( < 3 mm)
  • Cortical ring sign: scaphoid superimposes onto itself and creates higher density
  • Radial gutter splint
  • Highly associated with lunate and perilunate dislocation
    • Due to hyperextension of wrist
    • Need early reduction and likely surgical repair
    • This is an unstable injury with high risk of re-dislocation and arthritis
  • Perilunate dislocation: apple out of the cup
  • Lunate dislocation: spilled teacup
Perilunate Dislocation. From http://radiopaedia.org/articles/perilunate-dislocation

Perilunate Dislocation. From http://radiopaedia.org/articles/perilunate-dislocation

Lunate Dislocation. From http://radiopaedia.org/articles/lunate-dislocation

Lunate Dislocation. From http://radiopaedia.org/articles/lunate-dislocation

Distal radius fractures

  • Need a thorough neurovascular exam
  • Sugar tong splint to level of MCP joint to maintain finger flexion

Colle's fracture: distal radius with dorsal displacement

  • 60% of cases have ulnar fracture

Smith fracture: distal radius with volar displacement

Radial styloid fx: high association with ligament injuries

Galeazzi fx: distal radius fx with dislocation of radial/ulnar joint


R4 Capstone Lecture with Dr. Chinn

67 yo M with arm pain and numbness after a bug bite. Exam concerning for compartment syndrome. Goes to OR for fasciotomy. Becomes hypotensive on the floor with continued bleeding and oozing from fasciotomy site. Diagnosed with Acquired Factor VIII deficiency

Acquired factor VIII Deficiency

  • Very rare with 1-4 in a million incidence
  • Median age 60-70
  • Mortality 8-22%
  • Majority will require transfusion
  • Caused by development of inhibitors to factor VIII
  • Usually presents with soft tissue bleeding as opposed to hemarthrosis in hemophilia A
  • Majority are idiopathic though can be associated with autoimmune diseases
  • Diagnosis: prolonged pTT with normal PT/thrombin time/platelet count
  • Diagnosed based on mixing study, factor VIII level or inhibitor titers

Treatment:

  • DDAVP and factor VIII infusions do not work as patients have inhibitors and auto antibodies
  • Recombinant factor VIIa: bypasses Factor VIII pathway. Short half life (2 hr)
  • PCC also works
  • Inhibitor elimination: plasmapheresis, immunosuppresion with steroids, IVIG, anti-cancer agents, rituximab
  • Most common cause of death is infection due to immunosuppression

Getting Paid with Dr. Ryan

1. Things that will/could impact EM

  • Hospitals are moving into insurance business in order to control cost
  • Urgent cares are everywhere and stealing our volume
  • Accountable Care Organizations (ACOs)
    • These systems "own" their patients and get paid accordingly
    • Manage their pts in order to keep them out of EDs and hospitals
  • Medicare cuts
  • Medicaid expansion: should increase number of patients that do pay for their care
  • Increase in high deductible plans: pts less likely to go to hospital
  • Bundled payments: likely the future and will encourage efficiency

2. Types of EM groups

  • Independent contractor: you get a higher hourly rate, but it does not include anything (benefits, taxes). Offers lots of flexibility
  • Hospital employee: benefits are great. No group to rally behind you if something bad occurs. 
  • Independent group: very rare
    • Partnership: after x years you are a full partner with occasional buy in
    • Shareholder: shares based on years of service
  • Multi hospital group
  • Mega groups

3. When comparing, you should consider contracts "apples to apples", including: salary, malpractice, health, disability, life insurance, pension, bonus, tuition break, CME

  • Occurrence- based malpractice insurance: covered for all encounters while you are with the group
  • Claims made model: covered while working with the group, if leave the group, then not covered even if you saw the pt while with the group. so need to get a tail (costly)
  • Life insurance: term vs whole

4. Pay models: billings, RVU, salary, hourly, combo

  • RVU components: physician work for a certain diagnosis, expense of physician practice (supplies, computers, nurses, etc), professional liability insurance

Pediatric Simulation/Oral Boards/Procedures

Neonatal LP keys to success

  • Positioning is key! Doesn't matter if it is sitting up or lateral decibitus, whatever you/your holder are comfortable with
  • Leave the baby's diaper on to prevent accidents....
  • Sweet-EZ is your friend
  • Prep a wide area so that you can palpate landmarks once sterile

Oral Boards

7 week old baby presents with vomiting. Arrives at OSH and stops breathing. Gets intubated and is transferred to you. On exam, he has a missing R radius but otherwise warm and well perfused. Glucose is 53, so receives D25. 

T 33.7, P 153, BP 87/54. 

Labs show a pH 7.1 with base deficit 14. lactate is 9.5. WBC 16 with 68% neutrophils and 4% bands. UA negative. 

CXR initialy unremarkable. EKG with R axis deviation. 

The baby then becomes hypotensive with worsening tachycardia and hypoxia. Minimally responsive to fluids, though hypoxia worsens. Repeat CXR shows diffuse pulmonary edema.

Differential diagnosis: sepsis, sepsis, sepsis, metabolic disorder, congenital heart disease, nonaccidental trauma 

Diagnosis: Total Anomalous Pulmonary Venous Return

  • 3 types based on anatomy: supracardiac, cardiac, infracardiac
  • Feel for liver edge after volume resuscitation: If pt develops hepatomegaly, then likely congenital heart disease. 
  • Treat with diuretics and pressors (E, NE) as needed for hypotension.
  • Vomiting is a frequent presenting symptom in cardiac kids

Tips for sick baby:

  • MAP should be close to their gestational age in weeks
  • Antibiotic choice in babies younger than 4 weeks: ampicillin + cefotaxime/gentamicin
  • Antibiotics if older than 4 wo: Rocephin +/- vancomycin

Sim Case

10 day old with poor feeding and increased sleepiness. Grunting with periodic breathing on exam. HR 180s-200s, O2 sat in low 90s.

DDx: sepsis, metabolic, congenital heart disease, NAT

  • Grunting in an infant is their way to do auto-PEEP
  • What to look for in congenital heart disease: BP/pulse in all 4 extremities, pre and post ductal O2 sat, hepatomegaly, rales, murmur
  • Try Hi-Flow O2 for early respiratory distress
  • If you are in the community, do not delay transport
  • RSI in neonates: give atropine and need to wait 3 minutes. Same for lidocaine if concerned for head injury

"Video Laryngoscopy" Needs to Die

"Video Laryngoscopy" Needs to Die

Let the record show, this is not a debate for or against the use of video cameras on laryngoscopes. It’s not really a debate at all. It’s a plea. An honest plea…

The “DL vs. VL” debate has been had. It will continue to be had as our research evolves and our tools evolve (and we will participate). But, I beg of us as a community to pause and collectively consider a point of order: our discussion and debate, and worse our education of novice critical care providers, and even worse our research, is becoming marred by the fact that we aren’t all speaking the same language. We often throw around terms without RIGOROUS attention to detail.

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Interpretation of Hand & Wrist Radiographs

Interpretation of Hand & Wrist Radiographs

You knew that you'd see at least one patient with a FOOSH (Fall On Outstretched Hand) while working in Minor Care.  A nice, thin layer of ice laid down by the "Snow-pocalypse" snow storm that came through last night had already caused several patients to slip and fall.  

John, your first patient of the day, a 24 year old rushing to work this morning, slipped coming down the steps outside his house.  He tells you he landed on his right hand with his arm extended at the elbow and wrist.  He is complaining of pain in the dorsal and radial right wrist.  You go to examine him, noticing no obvious deformities, lacerations, or abrasions.  On palpation, he has tenderness to palpation in the anatomic snuff box and pain with axial loading of the thumb.  Suspecting a scaphoid fracture, you order a wrist x-ray.

While waiting for the film to be developed, you look for a refresher on how to interpret these challenging films.

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Grand Rounds Recap - 12/3/2014

Grand Rounds Recap - 12/3/2014

EMS Protocol Updates for 2015 with Dr. Leblanc

Use of EMS units as transport units

  • If pt is transported to a facility that is not capable of taking care of the pt, you may be able to use the same squad to transport the pt to another facility
  • Need to have an accepting doc
  • May need to send additional personnel with the squad

Hypotension/Shock protocol

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Procedural Sedation Cage Match

Procedural Sedation Cage Match

It's a typical busy post-Thanksgiving shift in the ED.  It seems like patients with acute decompensated heart failure, sepsis, NSTEMI's and a whole host of other ailments are tucked in every corner and crevice of the ED.  Just as you finish putting in orders on the last patient you saw, your next patient rolls by on an EMS stretcher.  You see from your computer that the patient is on a backboard and in a c-collar after what clearly was some form of traumatic event.  He's screaming in pain and holding his left leg flexed at the hip and internally rotated.  "Jeez, I bet that hip is dislocated," you say to yourself.

You know you're going to need to reduce this dislocation, to not do so would risk avascular necrosis.  Tammy, one of the nurses you are working with that day is already 2 steps ahead of you.  "Doc, we're getting everything set up for the sedation, you're going to need for that hip that's out. What drugs do you want us to pull up?"

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Grand Rounds Recap - 11/19/2014

Grand Rounds Recap - 11/19/2014

Mortality and Morbidity Conference with Dr. Gozman

Thrombocytopenia

Always consider medications as a key cause of throbocytopenia

Recommendations for platelet transfusion currently include:

  • Patients on chemotherapy with <10K
  • Patients requiring central venous access with <20K
  • Patients requiring an LP with <50K
  • Patients requiring non-neurologic surgical interventions with <50K
  • Patients requiring CNS surgical intervention with <80K

There is not data to support platelet transfusion in patients with intracerebral hemorrhage on an antiplatetlet agent

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Grand Rounds Recap - 11/13/14

Grand Rounds Recap - 11/13/14

SBIRT (Screening, Brief Intervention, Referral, & Treatment) for Substance Abuse

Why should we care?

  • Prevalence of this disease is impressive with greater than 33,000 deaths attributed to alcohol in 2012 alone (287,000 MVC's in Ohio alone attributable to alcohol)
  • Medical problems attributable to alcohol use costs the US $100,000,000,000 annually (from health care bills to lost productivity)!
  • Approximately 33% of inpatient admissions in a country hospital population were attributable to alcohol
  • One in five Americans can be defined as at risk drinkers
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