This week in grand rounds we discussed all types of critically ill patients, first covering the spectrums of hypothermia and shock. We then had a fascinating case follow up on a patient who developed torsades des pointes, and learned how to perform the HINTS exam and incorporate it into our practice. We then discussed pediatric osteomyelitis and it’s subtle presentation, and finally covered musculoskeletal ultrasound of the shoulder, knee, and ankle.Read More
This week was the last grand rounds of the academic year. We started off with the monthly Morbidity and Mortality conference led by Dr. Colmer. This was followed up by a CPC on Infectious Mononucleosis from Dr. Jensen and Dr. Stolz. Dr. Urbanowicz then discussed if there is a use of platelet function studies in the Emergency Department. The day ended with Dr. Murphy-Crews describing a fascinating case of severe hypothermia and outlining the interventions available to us in the ED for these patients. See you next week!Read More
This week's Grand Rounds opened with Dr. Curry discussing the paucity of literature on double defibrillation in VF. Dr. Mand then led small group discussions about the clinical utility of the pelvic xray. This was followed by Dr. Kreitzer expertly identifying incomplete Brown-Sequard Syndrome in Dr. Banning's CPC. Dr. Liebman discussed an interesting presentation of meningitis in a pediatric patient. Finally, our PEM colleagues led case based presentations of pediatric DKA, cat scratch disease, and a simulation featuring a patient in hypothermic cardiac arrest.Read More
This week kicked off with a Tox filled R4 Simulation where we learned about ASA, digoxin, and hydrofluoric acid toxicities. This was followed by lectures on cardiac disease in diabetes, pediatric pain management strategies, physician burnout and hypothermic cardiac arrest.Read More
This week, Dr. Palmer updated us on operations within the department, and dropped some stroke knowledge with his case follow up of altered mental status in a sickle cell patient. Drs. Scupp and Merriam presented cases on pediatric headache and hypothermia, respectively. Dr. Fananapazir tackled etiologies of fever including UTI and Kawasaki in our combined EM/PEDS lecture. We were honored to receive guest speaker Dr. Catherine Marco from Wright State University, who is senior member of the executive committee of ABEM and lectured on ethical issues of resuscitation.Read More
Morbidity and Mortality Conference with Dr. LaFollette
One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?
- 0.3% occurrence after routine tracheotomy
- Incidence peaks 7-14 days after procedure
Once the patient starts massively bleeding - what's your next move hotshot?
Evidence Based Medicine on Tachydysrhythmias with Drs. Ludmer and Miller
- SVT is an umbrella term that includes AVNRT, atrial fibrillation and flutter, and polymorphic multifocal atrial tachycardia (MAT)
- AVNRT (AV Node Re-entrant Tachycardia) is the correct term for what is commonly diagnosed as SVT,
- MAT usually occurs in critically ill elderly patients with respiratory failure and is a poor prognostic sign, associated with 60% in hospital mortality. Treatment is to treat the causative pathology.
- REVERT Trial: Modified valsalva vs standard valsalva performed in 10 EDs with 428 patients in England. Findings included a 17% conversion with standard methods and 43% with the modified valsalva.
Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.” If you didn’t get a chance to check out the case and the discussion, check it out here. Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng
Q1 - Walk through your initial assessment of this patient. What are the critical aspects of the assessment of this patient?
In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa. As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.” Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries. This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.Read More
Evidence-Based Emergency Medicine: Accidental Hypothermia with Drs. Mudd & Riddle
Grading the Severity of Hypothermia
- Mild hypothermia is defined as 32-35 °C and symptoms include confusion and diuresis
- Moderate hypothermia occurs from 28-31°C and is associated with lack of shivering, atrial arrhythmias, and worsening changes in mental status (including paradoxical undressing)
- Severe hypothermia happens when core body temperature is less then 28 °C and is associated with coma, significant decreases in metabolism, and a very low threshold for V-fib
To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...
Bleeding causes acidosis, coagulopathy, and hypothermia...
Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycleRead More