Grand Rounds Recap - 4/22/15

Oral Boards Practice Cases

Case 1 - 22 yo F in a "coma" with normal vital signs. Not responding to Narcan and Dextrose. Found in a garage. On exam, she has sluggish and dilated pupils. pH 6.98, pCO2 29, bicarb 2

High concern for toxic alcohol ingestion: consult DPIC and nephrology for dialysis

 Calcium oxalate crystals in urine.  By NASA/JSC [Public domain], via Wikimedia Commons

Calcium oxalate crystals in urine.  By NASA/JSC [Public domain], via Wikimedia Commons

  • Fomepizole is the antidote for ethylene glycol only
  • Can use ethanol drip to treat both ethylene glycol and methanol
  • Replace folate aggressively and early 
  • Methanol is metabolized to formic acid, if you give folate you can prevent methanol from going down the formic acid pathway

If you intubate this patient, make sure you put her on the correct vent settings to compensate for metabolic acidosis (higher than normal RR)

Acidosis with high anion gap and osmolar gap -> likely toxic alcohol

Epic tip: when you order toxic alcohol panel, ethylene glycol is not part of it, so order separately

Case 2 - 7 yo F, pedestrian struck.  Vitals: HR 140s, O2 sat 94% on NRB, BP 90/55.  Small amount of blood pooling in the airway. GCS 7-8.  Diminished lung sounds with crepitus, abdomen is distended with bruising.  R ptx on exam -> needle decompression -> chest tube.  Blood transfusion is initiated.  + FAST.  Repeat vitals: BP 80s/50s, HR 130s. Intubation: ketamine and sux.  Repeat BP after 1 u pRBC: 90s/50s

  • Don't forget to do a full head to toe exam on a trauma patient as you will miss injuries. Don't get distracted by positive findings unless they are life threatening and require immediate intervention.
  • Intubating on oral boards: name size of tube, technique and induction drugs. Do not forget post intubation management and confirmation of tube position.

Case 3 - 41 yo M with sore throat, T 100.2, P 105, BP 150s/80s, RR 22, O2 sat 92% on NC.  Pt appears to be in respiratory distress on exam.  Symptoms: pain when eating, shortness of breath and hoarse voice.  He is in fast track area, so move him out to get more acute care/monitoring

HEENT exam: trismus, normal posterior oropharynx on limited view, handling secretions. Submandibular tenderness with pain on tracheal manipulation. Stridor on exam and muffled voice, though able to speak in full sentences

VBG is normal

Management: IV fluids, broad spectrum antibiotics (Unasyn), decadron, ENT consult

Differential diagnosis =  deep space neck infection vs Ludwig's angina vs angioedema vs epiglottitis

  • Lateral neck x-ray: thumbprint sign
  • NP scope: large and swollen epiglottis
  • Pt desats during attempt at fiberoptic intubation and requires a cricothyrotomy

In epiglottitis, do not use supraglotic airways as this can worsen laryngospasm.  Most adult cases of epiglottitis are indolent and will likely not require intubation

Kids who get this are more sick if this is H.flu: tripoding, drooling and will need to go straight to the OR for a trach

Tips: if the examiner is prompting you, they are trying to help you and you are likely missing something or need to talk to the family

  • All patients should get a fingerstick glucose and pregnancy test if female
  • Do not guess doses of medications: they will penalize you if you are wrong, just ask to consult a standard reference text

Simulation with Drs. Hill and Miller

Case 1 - 50s yo M in cardiac arrest, 15 minutes down time. IGel in place.  VTac on monitor -> shock x3, amiodarone, Epi, Ca -> ROSC.  IGel exchanged for endotracheal tube.  Post ROSC care: EKG with STEMI, post-ROSC pressors (Epi or NE), A. line, cooling.  Cath lab activation

Case 2 - Roll over MVC.  HR 110s, GCS 12-13. O2 sat 93%, BP 80s/30s. Exam: pelvis tender -> Tpod placed. IV access unable to be established: IO placed and blood resuscitation started.  Pelvis x-ray with open book pelvic fracture.  Subclavian trauma cath established.  Continued blood resuscitation (massive transfusion) and TXA given.  FAST negative.  Management: IR vs OR with ortho/trauma

Debriefing Highlights

  • Curveball - resuscitation leader was blind folded
  • Be direct in assigning roles to everybody on your team and be explicit in giving orders
  • Use closed loop communication as often as possible
  • "I want you to do X and tell me when it's done" can help you keep the communication loop closed

CPC with Drs. Scupp and Srivastava

28 yo M with severe abdominal and chest pain. He is 2 week s/p ventral hernia repair and discharged yesterday from readmission for post-op pain. Hx of GSW to abdomen s/p ex-lap 1 year prior, including SMV injury.

  • Exam: normal vitals, moaning in pain, abdomen is mildly distended, soft and minimally tender 
  • Labs normal except for platelets 936 and lactic acid 3.6.
  • Test of choice: EKG that showed an inferior STEMI
    • Cath showed a 100% RCA thrombus

STEMI in young patients

  • Risk factors: male, DM, smoking, family history
  • Literature has shown that the quicker your patients get an EKG (less than 10 minutes), their outcomes are better, so consider institutional protocols based on chief complaint and age for obtaining EKGs in triage

EBM Quick Hit: Number Needed to Treat with Dr. Niziolek

Incidence: number of new cases of disease

  • aka absolute risk of contracting the disease

Relative risk: incidence of disease in exposed patients/incidence in nonexposed

  • Relative risk reduction = 1 - RR

Absolute risk reduction: event rate in control group - event rate in intervention group

NNT = 1/ARR

  • Number of patients that need to be treated to have impact on 1 person

NNT for ASA in STEMI 41.6

NNT for TXA in reducing death due to bleeding is 125

NNT for TXA in reducing all cause mortality is 66.67

www.thennt.com


Maintenance of Certification and Lifelong Learning with Dr. Stettler

Resource: www.abem.org

1. Initial certification

  • Step 1: register to take the written boards by end of residency
  • Step 2: qualifying exam (written boards) - fall after graduation
  • Step 3: oral boards: spring or fall the following year

2. License renewal: varies across states

  • Pay money and certify CEU (continuing education unit)

3. Continuous certification

  • LLSA test: must do 8 tests in 10 years
  • 25 hours of CME/year
  • Recertification exam every 10 years
  • Practice improvement and professionalism activities yearly (there is usually a system in place for this from the employer)

4. How do you keep up

  • There are a lot of options: journals, review courses, books, conference, FOAM, etc
  • It doesn't matter what you do, but you have to do something 

5. How do you make yourself keep up?

  • Different for clinical vs academic faculty
  • After you leave residency, no one will challenge you except for yourself
  • Pick what works for you and do it as soon as you get out of residency to establish a routine
  • Learn and stay up to date by asking yourself "why do I do X?"