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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The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

80% of heroin users start by abusing prescription medications – this is OUR problem         

Prescription medication overdose is now the leading cause of death from injury and the number of deaths from drug overdoses has increased every year since 1999. Estimates suggest between 6 and 12 million Americans receive prescription drugs either without prescription or without the intent of relieving pain. This article focuses on the ED provider’s role in this epidemic and offers strategies for improving training and education surrounding these medications. While heroin abuse tends to draw more attention, it is important to note that 80 percent of heroin users started their addiction by using prescription medications.

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Cyanide Poisoning - Recognition and Treatment

Cyanide Poisoning - Recognition and Treatment

Hey everybody! Dr.’s Hinckley, Steurwald, and myself sat down recently to talk a little bit about hydroxocobalamin (Cyanokit) and put together the attached podcast. 

Here are a few take home points and additions regarding this cherry-colored elixir of wonder: 

  • Think about hydroxocobalamin in your hemodynamically unstable or otherwise SICK patients who have a history of smoke exposure in an enclosed space or a known industrial exposure to CN containing material. This stuff works fast and can be life saving.
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Interpretation of Ankle Radiographs

Interpretation of Ankle Radiographs

A 43 year old female presents to the ED after "rolling" her ankle while gardening.  She states that she was stepping down on a shovel when her ankle rolled.  <She describes to you and inversion type injury.>  Being a diligent, studious physician, you quickly run through the Ottawa Ankle Rules while you obtain the remainder of you history and physical.  She was unable to bear weight immediately after the accident and is, likewise, unable to do so here in the ED.  She has no pain with palpation over the medial malleolus but does have significant pain and tenderness with palpation of the lateral malleolus.  You quickly decide that this patient will need ankle radiographs to further investigate the possibility of fracture.  

But, what views should you order? And, once you get the films back, how do you interpret them.  Check out the excellent video embedded below, made by Dr. Claire O'Brien, PGY-1 in the University of Cincinnati Dept. of Emergency Medicine Residency Training program, to find out!

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Grand Rounds Recap - 11/5/14

Grand Rounds Recap - 11/5/14

Background of the simulation: eclamptic seizure leading to cardiac arrest

  • Eclampsia should be high on the DDx of seizure for women of child bearing age without past history of seizures
    • Eclampsia typically follows the 1/3 rule: 1/3 occur after 20 weeks gestation, 1/3 occur antepartum, and 1/3 occur postpartum (up to 4 weeks)
    • Be aggressive about seizure management with benzodiazepines and use magnesium (4-6g MgSO4 IV over 10 minutes, followed by a drip for neuroprotection)
    • Follow magnesium levels clinical using reflexes and respiratory rate
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Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

A 68 year-old man presents by squad with shortness of breath.  He is noted to have a nearly quiet chest with very poor air movement, to be using accessory respiratory muscles, and to be slightly lethargic.  Quick perusal of old records discloses a history of severe COPD, steroid and O2 dependence, HTN and ulcer disease.  The squad reports that his O2 sat was 86% at the scene, improving to 92% on a NRBM and two nebs.

His vitals are:  p 138, r 22 and labored, bp 156/96, O2 sat 92% on a high-flow NRBM.  His POC renal returns with a pCO2 of 88.  His estimated weight is about 175 lbs.

A decision is made to intubate. 

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EMS Scope of Practice

EMS Scope of Practice

Recently, I had the pleasure of sitting down with Dr. Dustin Calhoun, EMS faculty member within the Department of Emergency Medicine at the University of Cincinnati.

Dustin had been responsible for an EMS fellow didactic session covering EMS scopes of practice and EMS licensure. While on the surface these topics may seem a bit “boring,” I found our examination of the complexities quite interesting. In fact, I found the session so useful that I asked Dustin to record this podcast with me (and I’m a former EMT!).

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Grand Rounds Recap - 10/22/14

Grand Rounds Recap - 10/22/14

Acetaminophen can be one of the most dangerous drugs in overdose, as the toxic dose of acetaminophen is 250 mg/kg

There are 4 stages of acetaminophen overdose:

  • Stage 1 from 0-24 hours when labs may be normal but the patient has nonspecific symptoms such as nausea, vomiting, and fatigue
  • Stage 2 from 24-72 hours when labs may be normal or be trending upward but the patient is asymptomatic
  • Stage 3 from 72-96 hours when significant metabolic derangement can occur such as profound metabolic acidosis, florid liver failure, and AKI.
  • Stage 4 takes place only if you are able to get them through the acute illness precipitated in Stage 3 when hopefully recovery takes place, though there is no guarantee of liver recovery
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Ebola Preparations: The Greater Cincinnati Area EMS Provider Perspective

Ebola Preparations: The Greater Cincinnati Area EMS Provider Perspective

As we are all coming to realize, there is a tremendous amount of information to digest when it comes to preparations for potential Ebola cases...

I sat down with Dr. Don Locasto and Dr. Dustin Calhoun to discuss their work with the PHEMAC committee. PHEMAC stands for "Public Health EMS Medical Directors Advisory Council." They exist specifically to deal with situations like this within our region.

PHEMAC recently released an update to all regional EMS providers. The goal of the update was to distill down all of the information out there into a useable form for our local teams. The text is available below.

Our discussion summarizes these initial recommendations, as well as makes suggestions for staying up-to-date as more recommendations are released. You can listen to the podcast here, or by subscribing to us through iTunes.

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Grand Rounds Recap - 10/15/2014

Grand Rounds Recap - 10/15/2014

Prescription Drug and Opiate Epidemic with Dr. Shawn Ryan

The US is the #1 country in the world for opiate prescription drug utilization

  • The numbers quoted are likely greatly underestimated due to inconsistent documentation
  • Death rate from opiate pain medication (OPM) has quadrupled in the time span of 1999-2010
  • Death rate in 2012 was 5.6 per 100,000
  • In 2011, 44 people per day died from opiate overdose in the US
  • In 2007, unintentional opiate overdose became the leading cause of death in the US for young population
  • OH death rate has grown faster than the national rate. At this time 5 people/day die in OH from opiate overdose
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