Hemoptysis

Hemoptysis

What is it?  Bleeding below the cords

More specifically, it may be subdivided into Massive and Non-Massive hemoptysis.  And while the definitions of massive vary from paper to paper, it is generally agreed that increasing volume over 24 hours is associated with increased mortality.  However, the literature consistently concludes that patients and providers are poor, at best, at estimating volume.  Thus, the simplest and most effective definition for massive hemoptysis is as such: expectoration of blood causing hemodynamic instability or abnormal gas exchange / airway obstruction.

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Grand Rounds Recap - 2/18/2015

Grand Rounds Recap - 2/18/2015

Hyperthyroidism: 1.3% of the US population has hyperthyroid. Thyrotoxicosis = too much thyroid hormone activity. Remember, T4 is a prohormone and T3 is the bioactive form. Causes of hyperthyroidism are broad and include: inappropriate thyroid stimulation, autonomous release of excess thyroid hormone, excessive release of thyroid stores, extra-thyroid sources of hormone. Hyperthyroidism increases risk of all-cause cardiovascular mortality and incidence of Afib. Diagnosis of hyperthyroid made by TSH <0.1 and high free T4. Iodine uptake test helps to find nodules and differentiate from thyroiditis. 

Thyroid Storm: an exacerbation of thyrotoxicosis leading to multi-organ failure. Mortality is high at 10-30%. Precipitating factors include: thyroid surgery, radioiodine treatment, medication and medication adjustment. Symptoms: febrile, tachycardic, agitation, seizures, psychosis, delirium, transaminitis. Diagnostic scoring system based upon signs and symptoms, not lab values. Treatment: propylthiouricil is available but not commonly recommended due to hepatic toxicity. Methimazole is preferred, but takes several hours to work. In the mean-time, use propanolol to decrease the effects of the hormone (the only beta blocker that crosses the BBB so is ideal at treating CNS symptoms). 1 hour after giving methimazole, can give iodine. 

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Flights - One Road too Far

Flights - One Road too Far

You are working as the UH-doc.  Driving into your shift with the windows down and music playing, you figured the first warm day of the year would result in a busy day for you and the rest of the Air Care 1 crew.  You arrive for your shift, grabbing the radio from the Pod doc when the tones go off for your first flight of the day.  You grab the blood cooler head to helipad, checking your pager you find you’ll be responding to Southeastern Indiana for a “MVC rollover, entraped.”

You strap into the helicopter and fly over the city and to the rolling hills of Southeastern Indiana.  Landing on the 4 lane divided state road, you unstrap and head to your patient who is waiting with the BLS squad.

You open the side door of the EMS truck and head to the head of the bed to assess your patient...

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The Approach to the Foot X-ray

The Approach to the Foot X-ray

Any way you slice it, foot x-rays are a pain to read.  Complicated by a number of overlapping bones, joints, the presence of multiple sesamoid bones, and multiple radiographic views, it's easy to get lost in the weeds trying to sort out normal variant from pathology.  Take a look at this short Blendspace module by PGY-1 Lauren Titone, MD and get a better understanding of the normal anatomy and a systematic approach to reading foot x-rays.

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Grand Rounds Recap - 2/11/15

Grand Rounds Recap - 2/11/15

Repeat 6 Hour Head CT in Mild TBI Patients with Dr. Kreitzer

Mild TBI = GCS > or = 13

  • Incidence of NSG intervention 0.9%
  • Mortality 0.1%

Why Consider a 6 hour CT scan?

  • Pros: quicker disposition, avoidance of unnecessary admission
  • Cons: extra radiation, does not address post concussive symptoms

ACEP policy: mild TBI patients with normal head CT and normal mental status can be discharged home

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Grand Rounds Recap: Critical Care Symposium - 2/4/15

Grand Rounds Recap: Critical Care Symposium - 2/4/15

Pressor Primer with Dr. Hebbeler-Clark

  • Norepinephrine seems to be on top in terms of vasopressor of choice currently (consider it your "easy button")
  • Per Surviving Sepsis Guidelines, Norepi has level 1B evidence as a first line pressor, while Epi is your second line with level 2B evidence and Vasopressin is currently ungraded in terms of evidence level
  • There have been 4 RCT's confirming that Norepi has no mortality difference from Epi and given it's safer side effect profile, use it regularly
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Ketamine Fight Club: Ketamine in TBI

Ketamine Fight Club: Ketamine in TBI

There has long been a concern for increases in ICP with administration of ketamine primarily stemming from reports of increased ICP in the Neurosurgery and Neuroanesthesia literature.  These increases were described primarily in patients usually with CSF outflow obstruction undergoing elective neurosurgical procedures.  In the time since these articles were published, the use of ketamine in a wide variety of patients with neurologic compromise has been reported.  In fact, there have been a couple of recent systematic reviews and meta-analyses on this topic.  These systematic reviews and meta-analyses have essentially analyzing all the same existing literature (which is generally poor in quality).  

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Grand Rounds Recap - 1/28/15

Grand Rounds Recap - 1/28/15

Mortality & Morbidity Conference with Dr. Bohanske

When volumes are high, remember the patient experience can be improved by acknowledging wait times when entering the room and apologizing for their wait.

Transverse myelitis is a result of partial inflammation of the spinal cord that can sometimes lead to necrosis.

  • The disease process is often progressive and function does not always return after treatment.
  • Most commonly this is idiopathic in nature but it is often attributed to a post-infectious inflammatory state.
  • Differential diagnosis should always include cord ischemia versus compression, and diagnosis hinges on a T2-weighted MRI.
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Annals of B Pod: Winter 2015 Issue!

B Pod and the land of clinical uncertainty

This season's issue of Annals of B Pod we highlight clinical cases from our ED's B Pod to feature some complex cases starting with simple chief complaints, emphasizing the point that the sickest patients evolve from the mundane. Flu season continues to plague us and every day we face the question of how far to take the clinical evaluation when we see generic complaints. The decision comes partly from objective data, partly clinical decision rules, and mostly from a non-quantifiable summation that is clinical gestalt. 

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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