Grand Rounds Recap - 10/22/14

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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

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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

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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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B Pod Case Reports: 22 Year Old with Difficulty Swallowing

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B Pod Case Reports: 22 Year Old with Difficulty Swallowing

Chief Complaint

Difficulty Swallowing

History of Present Illness

The patient is a 22 year old female with no significant past medical history who presents to the ED with a chief complaint of dysphagia.  The patient first noticed difficulty swallowing solid foods 2 weeks ago. She states that she felt like food was getting caught in her throat.  Initially she only had difficulty swallowing solid foods and was able to eat soft foods and liquids.  However, she reports that over the course of two weeks her condition gradually worsened to the point where she could no longer tolerate fluids. She states that she has pain in the back of her throat when she attempts to swallow.

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Grand Rounds Recap - 10/8/2014

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Grand Rounds Recap - 10/8/2014

Quarterly Sim with Dr. Frank Fernandez

82yoF with multiple medical problems including Grave's Disease who accidentally stopped her Synthroid arrives altered, hypothermic, and bradycardic.

Differential diagnosis for profound hypothermia is fairly short: Environmental vs. Hypometabolism (sepsis is typically a mild hypothermia)

  • The typical myxedema coma precipitants are infection, medication changes, or cold weather
  • Sepsis + bradycardia, should make you think about hypothyroidism
  • Consider evaluating hypothyroid patients for other metabolic issues as they are often co-morbid, especially SIADH
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Suction Assisted Laryngoscopy and Airway Decontamination with Jim DuCanto, MD

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Suction Assisted Laryngoscopy and Airway Decontamination with Jim DuCanto, MD

Recently, one of our FOAMed friends came to visit the University of Cincinnati. Jim Ducanto is well known for his innovations and general wealth of airway management knowledge. One wonderful thing that Jim shared with us during his visit was an airway mannequin that he “modified” to be able to puke…yes…puke. Not sort of puke…but REALLY PUKE!! Here is what Jim has to say regarding the motivation for building the device as well as lessons we learned while doing it’s “beta-test”.

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Ebola

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Ebola

Ebola.  Synonymous with Terror, Class A Bioterrorism Agent Extraordinaire.  The Republic of Guinea and surrounding countries are in the midst of the deadliest, most widespread outbreak ever.  Death totals are rising every day, and each new death is a new record that with any luck will never be eclipsed.  

To quote the man that discovered and named Ebola after a river in the Congolese jungle,

“Soap, gloves, isolating patients, not reusing needles and quarantining the contacts of the ill - in theory it should be very easy to contain Ebola”

        - Peter Piot

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Grand Rounds Recap - 10/1/2014

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Grand Rounds Recap - 10/1/2014

Consultant of the Month Series: Ear Emergencies with Dr. Golub

Auricular hematoma

Blood separates the cartilage from the perichondrium which supplies the blood-flow to the cartilage. This can lead to cartilaginous ischemia, infection, deformation (cauliflower ear). Treatment: I+D: make cuts parallel to natural lines in the helix to reduce visible scarring. Place a bolster to close the new potential space. Bolster stays for 7-10days. Keep on Keflex while bolster in place and f/u with ENT. 

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Neurologic Emergencies in the Air

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Neurologic Emergencies in the Air

Several months ago, I sat down and talked about the management of neurologic emergencies in the prehospital environment with Dr. Erin McDonough, an Emergency Physician and Neurointensivist who attends both in the ED and the Neurosciences ICU, and is a member of the Cincinnati Stroke Team.  In the brief podcast found below and on iTunes, we covered a wide range of topics including blood pressure management in spontaneous ICH, aneurysmal SAH, and ischemic stroke and some of the more rare complications associated with tPA administration.

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How to Read Hip and Pelvis X-Rays

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How to Read Hip and Pelvis X-Rays

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.

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Grand Rounds Recap - 9/24/2014

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Grand Rounds Recap - 9/24/2014

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). 
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Transfusion in Trauma: One Ratio to Rule them All??

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Transfusion in Trauma: One Ratio to Rule them All??

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)

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Grand Rounds Recap - 9/17/2014

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Grand Rounds Recap - 9/17/2014

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)
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