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

Bradycardia: Versed for external pacing


  • No more activated charcoal
  • Cyanide: give cyanokit  when both decreased level of consciousness and hypotension
  • Narcan: can give IN, no more than 1mL per nostril per dose 

OTC medications: if pt requests OTC med for minor medical concern and they have no signs or symptoms of significant medical condition

Imminent delivery

  • Viability = 24 wks
  • Do not suction baby unless respiratory distress
  • Mom and baby go to SAME hospital whenever possible

Head or spinal trauma: can use hypertonic saline if pupil difference, decreased level of consciousness and evidence of head trauma

TXA: there is now a protocol for adults (only for trauma)

  • Emphasis on vital signs  (SBP < 90, HR > 110) and timing (within 3 hours from injury)
  • Not for peds

Peds submersion in ice water

  • If there is ice, the patient has to be transported to CCHMC on Burnet (ECMO availability)
  • < 30 minutes, no ice on water and no signs of life can be transported to closest ED

Spine immobilization

  • AMS, intoxication, distraction, midline spine tenderness, neurologic injury à need backboard

Airway Protocol Updates

  • The term "rescue airway" is gone.  Replaced by "supraglottic airway"
  • No more than 2 intubation attempts…for now
  • Do not stop compressions if CPR in progress 

Hemorrhage control

  • Tools: tourniquet, wound packing, hemostatic gauze, TXA

Medication Changes

  • Removed medications: lasix, dopamine
  • Added medications: TXA, hypertonic, LR, narcan autoinjectors

Termination of resuscitation of trauma: transport if ROSC or may benefit from ED thoracotomy

  • Bag, manual C spine immobilization, bilateral needle decompression, IV/IO with saline, then put on monitor
  • PEA > 40 should be transported transport
  • PEA < 40 or asystole should be pronounced

The 2014 Southwest Ohio EMS Protocols can be found here on

We will post the 2015 SW Ohio EMS Protocols once they are finalized!

Bell’s Palsy with Dr. Stettler

History and Physical         

  • Isolated unilateral facial paralysis/weakness that is rapid onset, though not instant
  • Can have associated neurologic symptoms: taste disruption, vague sensory disruption (tingling, numbness, pain), mild HA, change in hearing
  • Has to be both upper and lower face
    • Detect subtle upper face weakness by testing rapid blink: affected eye does not work appropriately

Prognosis related to severity, treatment and Increasing age

  • 50-70% recover no matter what you do
  • Typical duration of symptoms 3-4 months


  • Steroids
    • Everybody should get them, the earlier the better
    • Regardless of timing of onset
    • Increase likelihood of recovery by 20%
    • 25 mg prednisolone PO BID x 10 days  OR
    • 60 mg prednisone x 5 days, then taper over 5 days
  • Antivirals??? You can give them, probably does not help


  • Consider ENT follow up if complete paralysis, otherwise PCP or if there is no recovery by 3 months

Imaging in Neurologic Emergencies with Dr. Stettler

 CT head

  • Useful for early ischemic changes
    • Loss of insular cortex
    • Loss of grey-white differentiation
  • Gold standard for evaluation of hemorrhage?
    • T2 MRI may better visualize a hemorrhage while CT head is normal

 Diffusion MRI - Sensitivity of 14-67% in TIA,Higher rate of positive study with longer duration of symptoms

CT perfusion: CT with contrast bolus

  • Tracks passage of contratl bolus and shows hypoperfusion
  • May help stroke team make decision on whether to treat if outside the window
  • Positive within minutes of stroke onset
  • Much more sensitive than CT head < 6 hours

Facial Trauma with Dr. Krishnan

Penetrating injury: usually midface/zygoma and due to high velocity

Blunt injury: usually nose and mandible

60% of facial trauma pts have some other traumatic injury

  • 20-50% have head injury
  • 1-4% have C spine injury
  • Blindness in 0.5-3%
  • 25% of women with facial trauma are victims of domestic violence

Open wound management:

  • Laceration behind line of outer limbus à watch out for parotid duct and facial nerve injuries
  • Suture choices
    • Absorbable in kids (plain gut)
      • Minimal scientific data
    • Ethilon/prolene for skin 
    • Silk to tie off vessels
    • Gut for mucosa (3 or 4)
    • Vicryl for deeps
  • Do not use soap: use a prep agent or betadine
  • Be careful to remove all foreign bodies
  • Establish contours and margins: lip, eyelid, nasal and ear margins should be reapproximated as closely as possible
  • Facial nerve injury should go to OR

Scalp wounds: wash out aggressively

  • Minimal tissue elasticity
  • Drain or pressure dressing to minimize hematoma formation (high risk of infection)
  • Large avulsions will need some sort of graft/flap repair

Periorbital/eyelid lacs

  • Align eyebrow border
  • Eval for globe, lacrimal duct/gland injury


  • Can have difficult to control bleeding
    • Anterior: pressure, afrin and packing
    • Posterior: consult, Foley bulb
  • Make sure to drain septal hematoma as it can cause septal perforation and necrosis
  • Close in layers: mucosa, cartilage, skin
  • Align alar rim
  • Ok to use vasoconstrictors


  • Repair muscle if involved
  • Approximate vermillion border
  • If > 1/3 of lip missing à needs a flap


  • Large defect may need a flap for coverage
  • Always cover cartilage
  • If cartilage defect, obtain 24 hour follow up

Ok to close facial lacs later: 24 hours probably safe

  • Can delay if will be used for surgical access to underlying fracture

Facial fractures

  • Zygoma and nasal bones will fracture with low impact injuries
  • Supraorbital, mandible and frontal bones require higher impact
  • Skeletal buttresses determine fracture pattern

Key history questions: pain with eye movements, numbness/tingling in face, pain with biting down

PE important nuances: septal hematoma, count teeth, CSF leak, face stability

Imaging: panorex, CT

Nasal fracture: most will require some sort of repair

  • No nose blowing when go home
  • Outpatient follow up

Zygomatic arch fracture

  • Can impinge on corner of mandible and pt won't be able to open their mouth

Lefort fractures

  • I: upper jaw horizontal
  • II: upper jaw and nose
  • III: skull and face separated

Mandible fractures: trismus and malocclusion, numb lip

  • Need antibiotics
  • Usually bilateral

Dental trauma

  • Assess for occlusion: underlying facial fracture
  • No need for antibiotics, but make sure tetanus UTD
  • Do not disrupt periodontal ligament
  • Dentoalveolar fracture
    • Arch bars

Useful FOAMed Resources for Lacerations and Dental Trauma

Pericarditis/Myocarditis with Dr. Shah

Pericardium = serous and collagenous layers with fluid filled space in between

Keeps heart in mediastinum and protects from infection

Many different causes of pericarditis:  VINDICATE

  • Vascular: post-MI (immediate vs delayed (dressler))
  • Infectious/idiopathic: usually viral, TB
  • Neoplastic: lung ca
  • Degenerative
  • Iatrogenic: procainamide, hydralazine
  • Congenital
  • Autoimmune: lupus, connective tissue dz, RA
  • Trauma
  • Endocrine/metabolic: thyroid, uremia


  • Clinical: CP radiating to back due to diaphragmatic irritation
  • PE: friction rub
  • Testing: ECG, CXR, Echo

 EKG is abnormal in 90% of acute pericarditis

  • Stage 1: PR depression in II, aVF, V4-V6 with ST elevation in I, V5-V6

  • Stage 2: PR depression, T wave inversion, normal ST segment

  • Stage 3: T wave inversions

  • J point notch: benign early repolarization

  • ST:T ratio > 0.25 is highly suggestive of pericarditis

  • No reciprocal ST depression (except aVR and V1)

  • PR elevation in aVR

 CXR: look for cardiomegaly/waterbottle heart to detect effusion

Echo:  Subxyphoid/apical 4 chamber views the best


  • Treat underlying cause
  • NSAIDs: ibuprofen, ASA, indomethacin
    • Give GI prophylaxis
  • Colchicine: 0.5 mg BID x 2-3 months
    • Decreases recurrence rate
    • May be used for prophylaxis in pts with recurrent pericarditis
  • Glucocorticoids
    • Increases recurrence
    • Indicated: autoimmune, renal failure, failure of standard therapy

Hospitalize if:

  • Immunocompromised
  • Anticoagulation
  • Large effusion
  • Non-idiopathic etiology

Pericardiocentesis only if tamponade, no role for diagnostic

Great FOAMed Resource for more information about Pericarditis - LITFL with Amul Mattu video

Myocarditis: inflammatory cardiomyopathy

  • Frequently associated with pericarditis
  • Can have signs of CHF
  • Diagnosis: endocardial biopsy
    • Frequently have troponin elevation, though not diagnostic
    • Echo
  • Treatment: underlying cause
  • Treat CHF symptoms: ACE, diuretics, salt restriction, digoxin
  • Red flags: tachyarrhythmia, heart block, CHF

Case Follow up with Dr. Betz

45 yo M, unhelmeted ATV roll over, + EtOH.  He has significant facial trauma, L flank and L thigh.  He also has notable left eye swelling with mild proptosis and can’t open his left eye spontaneously

  • GCS 12, hemodynamically stable
  • CT head: diffuse SAH, bilat SDH and multiple contusion

No visual acuity and IOP 60-90 after a lateral canthotomy IOP pressure down to 30

Retrobulbar hematoma: postseptal hemorrhage

  • Usually post traumatic but also seen after eye surgery
  • High risk of permanent blindness: 50%
  • Can cause orbital compartment syndrome and proptosis on exam
  • Leads to orbital nerve ischemia
  • Clinical diagnosis: APD, elevated IOP, decreased vision, proptosis
  • Treatment: lateral canthotomy
    • Cut lateral canthus and inferior canthus
    • Need: lido with epi, hemostat, scissors, forceps
    • Local anesthesia, devascularize with needle driver/hemostat and cut down horizontally to orbital rim, then look for inferior canthus and cut vertically
  • Give PO antibiotics (augmentin)
  • Eye drops to lower IOP
  • Steroids if optic neuropathy

P-values with Dr. Strong

Conventional Clinical significance – 0.05

Determining p value

  • Depends on type of data
  • Needed variables: Degrees of freedom and chi squared
  • Chi squared = comparison of observed result to expected result
  • Degrees of freedom = measure of variability
    • Based on number of categories/variables you are looking at

What matters when interpreting the data?

  • Your knowledge of the subject matter 
  • The effect of size 
  • Replication 
  • Alternative hypothesis: how plausible is your alternative hypothesis
  • The exact p value

CPC with Drs. Richardson and Benoit

13 yo F presenting with difficulty breathing x 6 days though on further history has had it for 3 months.  Also complains of pleuritic pain, no cough, no fever.  The symptoms are worse when lying down and some choking episodes when lyingdown

  • ROS: RUE weakness, hoarse voice
  • Normal vitals
  • PE: tachypnea with diminished breath sounds
  • Neuro: difficulty looking up with proximal BUE weakness

During the course of her care she becomes more tachypneic and tachycardic, has pooling of oral secretions with a notable respiratory acidosis on VBG.  She is placed on NIPPV but ultimately fails and ends up requiring intubation

Diagnosaurus app: very helpful in coming up with differential diagnosis

  • GBS: no ascending paralysis, normal reflexes, timing doesn’t fit (usually days not months), no preceeding infection
    • Though kinda fits Miller Fischer variant, but still no hyporeflexia
  • Botulism: hyporeflexia, should be acute, fixed and dilated pupils
  • Myasthenia gravis: everything fits
  • Tick paralysis: ascending paralysis, hyporeflexia, tick exposure, less chronic
  • Poliomyelitis: flaccid paralysis, hyporeflexia, preceding viral illness
  • MS: hypereflexia, visual loss, decreased sensation
  • Hypothyroidism/myxedema coma
  • Organophosphate poisoning 

Winner:  Myasthenia Gravis: 20 per 100,000 people

Disorder of NMJ: Antibody against AcH receptor à decreased muscle cell depolarization, or Ab against MuSK receptors

Diagnosis = tensilon test

  • Edrophonium = cholinesterase inhibitor
  • 1-2 mg, if no response can give up to 10 mg (0.15 mg/kg)
  • Reversed with atropine if the patient develops bradycardia
  • Should improve neurologic deficits and usually easiest to see in ptosis
  • Need to have objective neurologic findings to perform the test

Symptoms: worsen as day progresses

  • Bulbar weakness: dysphagia or hoarseness
  • Eye: ptosis
  • Respiratory distress
  • Weakness

 Physical exam

  • Abnormal CN, strength exam
  • Normal reflexes and sensory exam
  • Provocative tests
  • Ice pack test: for ptosis
  • Repetitive nerve stimulation with EMG: repetitive stimulation decreases muscle action potential

Myasthenia crisis

  • Usually precipitated by infection or other physiologic stressor
  • Drug interactions: abx, antipsychotics
  • Do a NIF to evaluate respiratory function
    • Intubate if -30 or worse
    • BiPaP can be useful in early crisis
  • Succinylcholine is safe to use for intubation but use higher dose (2 mg/kg) as efficacy is less predictable
  • Roc/vec: use half dose as effect prolonged
  • Treatment
    • Pyridostigmine: Ach-e inhibitor

    • Immunosuppresion
      • IVIG
      • Plasmapheresis