Grand Rounds Recap 03.03.21
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R4 Case Follow Up WITH Dr. Li
Following up on patients can be an educational experience
Can learn inpatient course
Can see if patient returns to ED if discharged
Can help tune your clinical sense
Dr. Kurt Smith was a prior resident at UCEM who followed up on every patient he saw during residency
Followed up on every patient he saw who was admitted and looked at ED diagnosis and discharge diagnosis
Had increasing percent matching diagnosis as he progressed through residency
Balancing best medical care and best thing for the patient
Case example of flying a patient on Air Care with concern for stroke whose family had no transportation to hospital, no telephone, and patient was aphasic
Risk and benefit decisions in real time for should we stop the helicopter so family can ride to the hospital, knowing this would increase time of transport and delay in treatment in case it was a time sensitive pathology such as ischemic stroke
Seeing next step management for admitted patients
Case of Ogilvie’s with dilated sigmoid to 24 cm
ED management includes labs, conservative treatment, involving consultants, and admission
Inpatient management included conservative treatment and then neostigmine
Ogilvie’s syndrome is also called acute colonic pseudo-obstruction
Perforation rates 1-3% with Ogilvies
When dilation of colon is over 14 cm, up to 23% may perforate
Perforation carries high mortality and morbidity
Patients typically have multiple comorbid conditions
Treatment:
Conservative: NPO, NG tube, rectal tube, electrolytes, rehydration
If refractory, neostigmine has been studied to be effective in rapid colonic decompression
If still no resolution, colonoscopy can be used
Technically difficult, and 3% perforation rate
If still no resolution, surgical cecostomy can performed
Don’t be afraid to get the appropriate consultant on board for predicted clinical course
Patient with large cellulitis and phlegmon or possible developing abscess on CT
Surgery was consulted and there was no abscess to drain at this time
Followed patient while inpatient
Eventually went to OR and drained 500cc of purulent material
Pathology takes time to present
Case of an ESRD patient presenting with chronic MSK pain
Troponin elevated and was admitted
12 hours after initial ED presentation, became hypotensive
ESRD patients have a 100-300x mortality rate due to sepsis when compared to the general population
R1 Clinical Treatments: Migraines WITH Drs. Diaz and Shaw
Please see Dr. Diaz’s post that accompanies the lecture.
Migraine treatments beyond the ‘migraine cocktail’
Ketamine - Literature review and outcomes
Low Dose Ketamine Does not Improve Migraine in the ED: A Randomized Placebo-controlled Trial
Not better than placebo
The THINK (treatment of headache with intranasal ketamine trial): A randomized controlled trial comparing intranasal ketamine with IV metoclopramide
Ketamine not superior
A comparison of headache treatment in the ED: Prochlorperazine versus ketamine
Prochlorperazine was superior to ketamine
Propofol - Literature review and outcomes
Propofol for migraine in the ED: A pilot randomized controlled trial
Time to discharge was significantly lower in the propofol group
Propofol for treatment of acute migraine in the ED: a systematic review
Propofol is safe and has shown efficacy for migraine treatment
Valproic acid - Literature review and outcomes
Intravenous sodium valproate for acute migraine in the ED: a meta-analysis
Inferior to metoclopramide, ketorolac, and prochlorperazine
Comparable to dexamethasone and sumatriptan
Magnesium - Literature review and outcomes
Management of adults with acute migraine in the ED: The american headache society evidence assessment of parenteral pharmacotherapies
No recommendation can be made regarding the role of IV magnesium
Ketorolac vs. Magnesium sulfate in migraine headache pain management; a preliminary study
Magnesium was superior to ketorolac
MAGraine: Magnesium compared to conventional therapy for treatment of migraines
There was no difference between magnesium vs metoclopramide or prochlorperazine
Sphenopalatine Ganglion block - Literature review and outcomes
Sphenopalatine ganglion block for the treatment of acute migraine headache
The majority of patients were pain free after 15 min
Noninvasive sphenopalatine ganglion block for acute headache in the ED: a randomized placebo-controlled trial
There was no difference between groups (bupivacaine vs saline) assessed at 15 minutes. (Secondary analysis showed at 24 hours, more patients in bupivacaine group were headache free)
Droperidol - Literature review and outcomes
Droperidol for the treatment of acute migraine headaches
Droperidol performed at least as well as comparison drugs
Haloperidol - Literature review and outcomes
Treatment of headache in the ED: Haloperidol in the acute setting (The-HA study): a randomized trial
Haldol is more effective than placebo
A RCT of IV haloperidol vs IV metoclopramide for acute migraine therapy in the ED
Haldol is as effective as metoclopramide
IV fluids - Literature review and outcomes
IVF for the treatment of ED patients with migraine headache: a RCT
There was no difference between groups (1L NS vs 10mL NS)
Benadryl - Literature review and outcomes
A Randomized trial of diphenhydramine as prophylaxis against metoclopramide-induced akathisia in nauseated ED patients
Prophylactic diphenhydramine did not decrease the rate of akathisia
Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a RCT
Adjunct diphenhydramine resulted reduction in the incidence of akathisia
Diphenhydramine in the treatment of akathisia induced by prochlorperazine
Diphenhydramine was associated with rapid improvement in symptoms
Antidopaminergics
Management of adults with acute migraine in the ED: The american headache society evidence assessment of parenteral pharmacotherapies
IV metoclopramide or prochlorperazine should be offered to adults in ED with acute migraine
IV metoclopramide vs dexketoprofen trometamol vs metoclopramide + dexketoprofen trometamol in acute migraine attack in the ED: a randomized double blind controlled trial
Combo treatment was superior to either medication
The efficacy and safety of prochlorperazine in patients with acute migraine: a systematic review and metaanalysis
Prochlorperazine was more effective than placebo and other active comparators
NSAIDs
Management of adults with acute migraine in the ED: The american headache society evidence assessment of parenteral pharmacotherapies
IV ketorolac may be offered to adults who present to an ED with acute migraine
Ketorolac in the treatment of acute migraine: a systematic review
Ketorolac may not offer benefit over other standard migraine therapies
Triptans
Management of adults with acute migraine in the ED: The american headache society evidence assessment of parenteral pharmacotherapies
Subcutaneous sumatriptan should be offered to adults who present to the ED with acute migraine
Not for patients with cardiovascular risk factors or active chest pain
R2 CPC WITH Drs. Gressick and Roche
Case: Middle aged female with hx of hep C presents with AMS. Found down at home. Abrasions to face. EMS narcan with possible response.
Vitals show tachypnea and SpO2 96% on 4L NC. Afebrile and HDS
Physical exam shows: abrasions on face, minimally responsive female, bruising on both thighs, abrasions on knees and ankles, pupils 2-3mm bilaterally and responsive. Eyes have a downward gaze. Grimaces and turns head from side to side in response to noxious stimuli.
Lab studies shows: Mild respiratory alkalosis, normal glucose, minimal ast/alt elevation, BMP unremarkable, mild leukocytosis 12.3, ingestion labs normal, EKG unremarkable
Imaging studies show: CXR with nonspecific basilar airspace disease, XR of ankles show no acute fractures, CT head, c-spine, CTA head and neck were normal, CT max face normal, CT chest showed retained airway secretions, CT abd/pel showed ‘diarrheal state’
Moved to SRU. Given broad spectrum antibiotics. Vomited.
A test was ordered…
Urine drug screen
Diagnosis: polysubstance overdose with trauma
Admitted to MICU. Narcan drip. EEG and MRI negative.
Discharged on HD#4 with a normal mental status
Management of Long Acting Opioid Overdose
Methadone has a half life of 8-59 hours
Adverse effects includes arrhythmias such as torsades
Urine methadone and serum methadone levels do not correlate well. Typically has no impact on clinical course or ED treatment
Not all lab UDS tests for synthetic opioids such as methadone
Naloxone has a short half life, about 0.5-2 hours depending on route of administration
Narcan drip: titrate to effect
There is an MDcalc calculator where you input the initial bolus dose and it helps give an hourly rate to start with
Air Care Grand Rounds WITH Drs. Hinckley, Gottula, Skrobut
Trauma with Dr. Hinckley
MARCH algorithm
Massive (external compressible) hemorrhage
Direct pressure
Devices
Tourniquet, combat gauze, T-pod
Physical exam sensitivity for pelvic fracture is 26%
Specificity is 99%
Stabilize the pelvis of any patient with a blunt mechanism and pelvic injury/instability on exam, hemorrhagic shock and pelvic/low back pain, hemorrhagic shock and AMS
Airway
Respiratory
The big question: is there a tension pneumo or hemothorax
Thoracostomy
Needle > 14 gauge
Anatomic landmarks
100% at 5th ICS vs 57.5% at 2nd ICS (success rate at these locations on a cadaver study)
We’ve moved to anterior/mid axillary line at the 5th ICS at Aircare
Helps avoid big vessels in mediastinum at 2nd ICS
Indications
Spontaneously breathing
Awake: progressive severe respiratory distress with hypoxia
Comatose: progressive severe hypoxic respiratory failure AND
At least 2 indicators of a PTX
Chest wall trauma
decreased/absent breath sounds
Ultrasound evidence of PTX
JVD
Tracheal deviation
Traumatic cardiac arrest
Needle vs finger
Finger thoracostomy gives consistent access to pleural space
Re-expansion visually and tactically confirmed
Avoids re-tension by obstruction
Indications for finger
Traumatic cardiac arrest
Refractory tension physiology despite needle attempts
Circulation
TXA
MATTERs study: overall 30 day mortality 17.4% v 23.9%, NNT = 15, no fatalities from VTE
CRASH-2: Mortality 14.5% vs 16% (p=0.0035)
Time to TXA, quicker = mortality benefit
Air Care Indications
Opening blood cooler and less than 3 hours from trauma
Blood products (2 liquid plasma, 2 pRBC)
Give when there is hemodynamic instability
Trauma
GI/Ob/surgical and other hemorrhages
Liquid plasma can help with warfarin reversal as well
Air Care Indications
Concern for hemorrhagic shock based on HPI/PE/mechanism and at least 1 of the following:
Shock index >1
SBP < 90
Provider gestalt (worsening AMS, +FAST, low ETCO2, high glucose, elevated lactate, etc)
Actively warm to avoid hypothermia
Avoid crystalloid
Goal SBP >90 or MAP >65
If TBI, ‘permissive hypotension’ is contraindicated. Aim for normotension
Do not wait for hemoglobin drop
Head Injury/Hypothermia
Prehospital Obstetric Trauma with Dr. Gottula
General Rule #1 = cant have a stable fetus without a stable mom
Prioritize stabilizing maternal status
General Rule #2 = should I be giving this life saving medication to a pregnant woman?
Nearly every med that would benefit the prehospital pregnant patient is safe and beneficial. ACOG supports this
General Rule #3 = healthy pregnant women look healthy… until they don’t
General Rule #4 = Know how much blood she has lost and communicate with receiving facility
From time of onset
How much at home? En route?
Obstetric trauma occurs in 1/12 pregnancies
⅔ is MVCs
No other single diagnosis has a higher mortality in pregnancy
⅓ admitted will deliver during that admission
Stick to MARCH, approach this systematically, focus on maternal stabilization
Airway
Increased nasopharyngeal edema, have suction ready
Enlarged tongue and epiglottis, consider decreasing ETT size
Increase risk of gastric aspiration
Breathing
Increased RR, TV, MV, O2 consumption
Decreased FRC, arterial PCO2, serum bicarb, respiratory compliance
Goal O2 sat > 95%
If thoracostomy is needed, do two ICS higher in patients >20 weeks pregnant
Circulation
Increased plasma volume (40-50%), erythrocyte volume (20%), HR, Cardiac output
Decreased supine venous return, arterial blood pressure, SVR
If blood is required, O- blood should be used
Placental abruption
When mom survives, this is the most common cause of fetal death
Painful vaginal bleeding, though bleeding can be ‘concealed’
US is not sensitive for diagnosis
Fetal monitoring
Continuous monitoring should be initiated ASAP
ACOG recommends at least 2-6 hours
Walk Around Training with Lead Pilot Bob Francis
Inspections
Shore power cord disconnected
Doors and access panels secured
Cowlings and latches secured
Fuel cap secured
Condition of all air intake screens
Check for evidence of fluid leakage
Condition and security of take off area
Air Care pediatric trauma simulation with Dr. Skrobut
Pediatric shock can be more subtle and may only present with tachycardia and prolonged capillary refill. Be sure to transfuse compensated hemorrhagic shock.
The pediatric FAST exam is less sensitive than in adults. You can improve sensitivity by doing serial exams-- especially for any decompensation.
Dosing for blood and plasma is 10cc/kg. Be sure to set up a push pull system by using a three way stopcock and 60cc syringe between blood tubing and buddy light warmer to ensure proper dosing. Repeat as needed.
TXA data isnt as robust in children but still part of our protocol. Dosing is 15mg/kg max 1g
Hypertonic saline dosing is 3-4cc/kg
Always be sure to have a reference card or application ready for equipment selection, medication dosing, and vent settings. It is best to write these down for your patient before you arrive at the scene.
