Grand Rounds Recap 3.20.24
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“Innovation Meets the Bedside: The Evolution of New Models of Emergency Care Delivery” WITH dr. ben bassin
“What problem are you trying to solve?”
Emergency Critical Care Center (EC3) at the University of Michigan:
Dedicated critical care unit within the emergency department that was created to improve access to timely, high-quality critical care after identifying a gap in emergency care delivery for patients
Reduced risk-adjusted 30 day mortality among all ED patients, lower ICU admission rates
Once downgraded, no increase in transfer to ICU from floor within 24 hours
19x more discharges of DKA
75% of minor intracranial hemorrhage do not require ICU admission, 25% discharged
Reduced mortality for patients with oncologic emergencies
Early palliative care delivery, avoidance of ICU admit for end of life care
Hospital LOS 3.8 days shorter for critically ill patients with GI bleed
Increased compliance with lung protective ventilation bundles
“Future proofing emergency departments: adaptable environments for supporting community crises”
Guiding principles in the design for the new UC ED:
Be completely flexible/adaptable
Maximize modularity
Maintain education missing
High visibility/situational awareness
Adopt smart technology
Ensure security
Handle all EMS
One way flow of patients
Research integration
Mass casualty management
Infection control
taming the sru: Hypothermia WITH dr. grisoli
Hypothermic arrest has a better prognosis in cardiac arrest from other etiologies, especially when patient is an ECMO candidate. Predictions scores such as the HOPE score can be used to guide treatment.
Consider ECMO evaluation early for accidental hypothermia arrest
Effective rewarming with passive and noninvasive active measures such as Arctic Sun are often effective
When a resuscitation warrants deviation for standard ACLS, communicate the reasoning to maintain trust and clarity to help all members of the team actively participate
r4 sim and oral boards WITH drs. finney, gillespie, smith and tillotson
Oral boards case #1: Bacterial Meningitis
Petechial/purpuric rash in the setting of headache and fever is sufficient to begin treatment with consistent history
CT does not necessarily need to be performed if the patient is without focal neurological deficits, papilledema, immunocompromised state, or recent seizure
Kernig's (contraction of hamstrings in response to knee extension) or Brudzinski's (flexion of hips/knees in response to neck flexion) signs are often insensitive but may aid in the diagnosis
In patients with high suspicion of bacterial meningitis, IV steroids are recommended before or with antibiotics, which should include vancomycin and ceftriaxone
Immunocompromised patients require additional CSF testing and broader-spectrum antibiotics, as they are susceptible to a wider range of organisms including tuberculosis, cryptococcus, staphylococcus, and listeria. Antibiotic therapy should include vancomycin, ampicillin, and ceftazidime
Oral boards case #2: Tuberculosis
Conducted via the structure interview format
Goals included verbalizing thought process behind conducting a history & physical exam, dedicated laboratory workup and evaluation and discussing reasoning behind the differential diagnosis
A cavitary lesion is seen on the CXR/CT scan and the participant must describe their rationale for or against admission, level of care and next steps in management
Simulation: RV Spiral of Death
Respect the sick right ventricle and RV spiral of death
Know your pulmonary hypertension type* – PAH vs PH, subtypes, and the impact of treatment (and always look at the medication list)
Treat the underlying cause, and look for a superimposed new trigger
Physiology is your friend – it will tell you what to do
Aggressively treat the low hanging fruit: acidosis, hypoxia, volume, PPV
Choose your vasopressors wisely
Be prepared for the worst and know what mechanical circulatory support “out” you might have
