Grand Rounds Recap 2/3/16

Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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Grand Rounds Recap 1/27

Grand Rounds Recap 1/27

Morbidity and Mortality Conference with Dr. Toth

  • Clinical Decision Unit Usage:  We want to keep using our observation protocols for patients that are appropriate for the CDU. These patients must have a priori identifiable endpoints and a plan for care.
  • Discharge vital signs: Revisiting a theme from last month, tachycardia at discharge is associated with badness. Abnormal vital signs must be addressed.
  • Shift Change: Turnover is fraught with increased risks regarding patient care. Be vigilant that your sign out can anchor the oncoming provider.
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Grand Rounds Recap 1/20

Grand Rounds Recap 1/20

Quarterly Simulation and Oral Boards

How do you approach the undifferentiated patient in arrest?

  • Your demographics and any initial history can differentiate the hyperkalemic arrest from recent chemo from the rhabdo from prolonged down time from overdose, etc.

Running a code is an art and a science

  • Mental modeling is something that causes us angst but it works. Close your loop with your drugs and plan. Being loud with your summary reasserts your control of the situation and can quell the peanut gallery.
  • Assign your roles and know your nurses and medics, introducing yourself mid-compressions is poor form and can decrease code efficiency
  • We like to keep our fingers on the femoral pulse. It decreases pulse check time, let's you dictate timely next moves.
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"Flights" - A Lonely Road

"Flights" - A Lonely Road

It is mid July and your first shift as the coveted H2 Doc at Air Care 2 is finally upon you.  It has been an especially warm and beautiful Saturday and you ponder the possible flights for the evening as you take the scenic drive to Butler County Regional Airport. 

You finish checking the aircraft with the flight nurse and sit down to begin the 20:30 brief with the flight crew when the tones drop and you are dispatched for your first flight of the evening, a scene flight to Franklin County, Indiana for an “un-helmeted motorcyclist”. You grab the blood cooler, perform a safety walk-around the aircraft and strap yourself in back

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Grand Rounds Recap 1/13

Grand Rounds Recap 1/13

R1 CLINICAL KNOWLEDGE ON ESOPHAGEAL EMERGENCIES WITH DR. CONTINENZA

Boerhaave's syndrome: Full thickness esophageal perforation

  • Thought to be due to suddenly increased intra-esophageal pressure

  • 60% of perforations thought to be iatrogenic, most commonly related to upper endoscopy

  • Chest X ray most of the time will have some abnormality, although it may just appear as a pneumonia. Pneumopericardium and obvious signs of mediastinitis may be rare on initial chest X ray, especially early in the disease process or with smaller esophageal tears and less mediastinal inoculation

  • CT scan is diagnostic modality of choice. If unavailable, upper GI series with Gastrograffin (less sensitive than barium though also less inflammatory reaction) is a better option that barium (greater sensitivity, more associated inflammation/potential for mediastinitis). 

  • Treatment is broad spectrum antibiotics as a broad spectrum of oral and pharyngeal bacteria can be involved

  • Mortality is high and increases drastically with delays in diagnosis

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Controlling the Milieu

Controlling the Milieu

It is a cold, blustery winter night in the ED.  You are the on-duty flight physician as well as ED physician for your particular patient care area, and you get toned out for a scene in a nearby county.  Having arrived on scene, you enter the ambulance to find a middle aged man belted to the backboard with cervical collar on, verbally and physically struggling with the paramedics who are trying to restrain him.  

By report, he was found at the bottom of a deer stand, presumably having fallen out. Initial GCS was 11 (3- 3-5) with a R parietal cephalohematoma and abrasions to his arms and  face.  

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Coming in Low and Slow

Coming in Low and Slow

You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…

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Grand Rounds Recap 1/6

Grand Rounds Recap 1/6

Emergency KT Protocol - The Pharmacology of RSI with Drs. Dang and Renne

Who do we RSI? What do we use? We can be better than etomidate and succ and the protocol in development will drill into the details - here is an overview:

  • The most clinically useful categorization of RSI candidates is probably based on hemodynamics
  • Hemodynamically unstable patients can be classified as “shock" based on myriad criteria and/or clinician gestalt while patients in whom the adrenergic surge of laryngoscopy could potentiate their pathology (e.g., increased ICP, aortic dissection, active ACS, or hypertensive crisis, etc.) can be classified as “high risk hypertension” for patients with increased ICP
  • The hemodynamic classification of a patient determines his/her track down the pathway, but their classification can shift at any point based on clinician discretion (i.e., a well-resuscitated shock patient may later be considered “stable” and managed accordingly) 
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The Mid-Shift Rush

The Mid-Shift Rush

Working overnight in a busy community hospital, you’re starting to hit a mid shift wall.  There are some shifts in the ED where your job is glorious, where every patient has obvious pathology, where your interventions and treatments provide immediate relief of pain and suffering, and where the volume is steady though never overwhelming.  This is not one of those shifts.  Seemingly every patient has had a myriad of vague complaints to the point where you’re considering contacting the local health department to inform them of an exploding epidemic of “weak and dizzy” patients arriving in your ED.  Taking a breath between patients, contemplating whether or not to consume your 5th cup of coffee, you glance over to the triage desk to see 4 squads lined up.  Looking at the EMR you see all 4 of them carry the chief complaint of altered mental status…

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Grand Rounds Recap 12/30/15

Grand Rounds Recap 12/30/15

Morbidity and Mortality Conference with Dr. LaFollette

Tracheoinnominate Fistula

One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?

  • 0.3% occurrence after routine tracheotomy
  • Incidence peaks 7-14 days after procedure

Once the patient starts massively bleeding - what's your next move hotshot?

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    The Approach to Shoulder Radiographs

    The Approach to Shoulder Radiographs

    The first snowflakes of the year are falling as you head into your midday Minor Care shift.  Slipping on an icy patch of compacted snow and nearly falling as you head from your car to the ED entrance, you have a sneaking suspicion what the day will bring: falls, slips, and trips.  Indeed, you settle down to the computer, log in to your EMR and pull up the minor care screen to see 2 unseen patients with the chief complaint of “Fall”...

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    Global Health Case Files #3

    Global Health Case Files #3

    Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.

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    Annals of B-Pod: Mastering Minor Care

    Annals of B-Pod: Mastering Minor Care

    Under Pressure: A Tonopen Tutorial

    Prepare

    1. Find your Tonopen. At our shop the Tonopen lives in the cabinet in the attending office.

    2. Adequate corneal analgesia is key. Instill tetracaine in both eyes prior to using the Tonopen.  

    3. If you are assessing the patient for corneal abrasions, perform the fluorescein exam prior to using the Tonopen as the Tonopen may inadvertently cause small abrasions.  

    4. Place a cover over the tip. It slides on like a condom and then roll the ridge into the grove.

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    Annals of B-Pod: Quick Hit Case

    Annals of B-Pod: Quick Hit Case

    Open Globe and a Discussion about Traumatic Hyphema

    The patient is a male in his 40s who presents after sustaining an injury to his right eye with a fishing hook. He states that a three-barbed hook pierced his eye while fishing with his friend. On gross inspection, the hook was noted to have pierced the inferior eyelid causing an obvious right open globe and there was a large hyphema. While he was initially able to count fingers at four feet in his superior visual field, his visual acuity quickly deteriorated to light perception only. Extraocular movements were intact and caused movement of the hook. Ophthalmology was consulted and a CT was obtained. The patient was then taken to the OR for anterior chamber washout, open globe repair, and removal of the fish hook. He was discharged following the surgery with next day follow-up with ophthalmology.

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