Grand Rounds Recap 2/17/16

morbidity and mortality conference with Dr. Denney

Tracheostomy Exchange/Replacement:

Dealing with tracheostomies and their associated tubes can be daunting. Keeping a few things in mind can make life much easier. Have a basic familiarity with the components of the trach and have a few questions in mind to ask:

  1. Is the patient post-laryngectomy? If yes->the patient can only be intubated from below as they have a complete separation of the aerodigestive tract. If no, you maybe able to intubate from above or below, though remember that placing these patients on NIPPV will not be very effective.
  2. Is there a cuff and what is the size of the tube? A cuff or balloon can inflate allowing for increased ventilatory pressure if needed on mechanical ventilation. If the patient is failing to ventilate with an uncuffed trach in place, trach exchange is warranted.
    • The size is broken into two components: Inner Diameter (ID) and Outer Diameter (OD). The ID for ED purposes is as large as possible, allowing for increased ventilator flow and the possibility of bronchoscopy. The OD is important as it lets you know how big the hole is--passing anything bigger through it can cause trauma.
  3. How old is the trach? A stoma needs 3 weeks to mature. Passing anything through the stoma prior to 3 weeks require extreme caution so as to not create a false passage.

If you're contemplating a trach exchange, take into account anatomical factors as well as the patient's likelihood of decompensating quickly. Tenuous patients may require a needle-over-wire Seldinger exchange. Use something with high compliance such as an Arrow Exchange catheter to reduce trauma to the airway. 

Atrial Fibrillation with RVR

Atrial fibrillation/flutter  with RVR is often a compensatory response--just like sinus tach. The cardiology literature of rate control vs rhythm control was conducted in uncomplicated patients i.e. their arrythmias were not provoked by an underlying medical cause. 

Consider diagnosing and treating the underlying cause of the atrial fibrillation/flutter + RVR before reflexively reaching for chemical or electrical control of the rhythm. Treating the rate in patients with an underlying provocative factor for their arrythmia (sepsis, CHF, ACS, PE, etc) is likely harmful to these patients. 

Medical Holds

Signing a medical hold is a big deal, as it takes away a patient's autonomy in exchange for protecting them from the consequences of a potentially poor and inadequately understood decision. 

Signing a hold requires that a provider deems the patient to not have medical decision making capacity and requires immediate medical attention. 

For a patient to have capacity they must be able to:

  1. Communicate a choice
  2. Understand the basic differences between options
  3. Acknowledge the consequences of those options
  4. Show some sort of reasoning to arrive at a choice.

Ultimately there is no gold standard for doing this and no validated tools to help with this in the ED. Keeping the principles above in mind, it is up to us to approach our patients on individual basis and as always act in what we perceive to be their best interests.

Check out this previous TamingtheSRU post for further reading...

Contraindications to Anticoagulation

When discharging a patient home from the ED on a new anticoagulation regimen, be sure to clarify if they have any relative contraindication (life threatening GI bleed, prior head injury or bleed). These medications have a steeper risk/benefit curve and decisions to anticoagulate should require shared decision making from PCPs and potentially consulting services. 

ICH after tPA

6% of patients receiving TPA will have a symptomatic ICH. 

Aortic aneurysm can mimic acute stroke due to embolic phenomenon or dissection into the carotids/vertebrals. TPA is likely harmful in these patients as it may potentiate bleeding and worsening dissection in addition to warding off any potential surgery consults.

Keep in mind that the patients with aphasia or who are intubated may not be able to complain of chest pain, and look out for red flags such as syncope preceding the stroke symptoms as well as hypotension and wide mediastinums on chest X ray. 

R4 Capstone with Dr. Toth

We learn a lot of medicine in 4 years of residency, but the biggest challenges of each year are often not the ones we anticipate going into our new roles. Everything works better if you make a conscious effort to develop and reflect on the interpersonal skills.

Awareness of your own emotions, controlling your emotions, and managing the expectations and emotions of others are some of the basic tenets of emotional intelligence. These concepts can be a huge determination in successful leadership.

Think about how your actions/words/emails will be perceived by all parties, and think about what motivates the person you are interacting with. Finding common ground and understanding their perspective will allow for collaboration and mutually beneficial outcomes.

Taming the SRU R3 Case Follow-up with dr. thomas

Heat Emergencies

Heat Cramps

-Presents as cramps, sometimes hours after exposure, often due to hyponatremia secondary to sweating.

Heat Exhaustion

-Presents as headache, lightheadedness, fatigue, nausea, tachycardia and tachypnea.

-Core temperature can be elevated but is typically close to normal.

Heat Stroke

-Presents with symptoms similar to heat exhaustion, but also accompanied by altered mental status and confusion.  Occasionally can progress to loss of consciousness and seizures.

-Temperature typically elevated about 40 degrees Celsius.

Types of Heat Stroke


-Typically seen in elderly and disabled due to either medication use or exposure it elements without ability to remove self from the situation.

-Body heat builds up slowly over multiple days

-Frequently patient will be hypernatremic and dry, possibly with a respiratory alkalosis.  


-Typically occurs in healthy, young people in hot environments when heat builds up faster than it is removed. Sometimes damage to hypothalamus can occur.

-Patient sweat heavily and sometimes attempt to rehydrate, frequently with hypotonic fluids.

-Patients may be hyper or hyponateremic, not always dry.  Can have a metabolic acidosis related to exertion.


-Primary treatment is cooling and rehydration if volume depleted.

-Ice bath or mist cooling is optimal, but stop cooling efforts around 39 degrees to prevent accidental hypothermia.

-Benzos or Thorazine can be used to prevent shivering and aid in cooling

Peripheral vs Core Temperatures: Remember that peripheral temperatures can be influenced by a number of factors such as perfusion, environment and previous cooling attempts. Peripheral temperature may not represent core temperature.

R1 Clinical diagnostics lecture on ua and Uds with dr. randolph

See Dr. Randolph's excellent asynchronous post on the urine drug screen...