Enjoy this week’s Grand Round’s Recap. Dr. Murphy started us off with a great Morbidity and Mortality conference with a variety of fascinating cases. Next, Dr. LaFollette taught us some pearls for HEENT emergencies if you are out in the community. Dr. Hunt took us through transfusion reactions and how to manage them, followed by Dr. Hall discussing the management pearls of Nonconvulsive Status Epilepticus. Next, Dr. Connelly taught us how we can incorporate alternative EKG leads into our practice, and Dr. Klaszky finished our day with a nuanced take of how to manage refractory septic shock. It was a jam packed day full of great learning!Read More
This week's grand rounds started off with our EMS team represented by Dr. McMullan updating us on new EMS stroke protocols, an upcoming trial for pre-hospital ketamine use, as well as a refresher on notification calls. This was followed by Dr. Shaw, who made his grand rounds lecture debut discussing the diagnostic and clinical utility of lactate. Drs. Harty and Toth then went mano-a-mano in another installment of the CPC lecture series, during which they discuss the presentation, workup and management of carotid cavernous fistula. Dr. Gorder then presented her clinical soap box, using the example of NG tube placement for SBO as a platform for addressing the impact of dogma within medicine. Our peds EM colleagues then steered the ship for the final 2 hours, discussing 2 oral boards cases (fussiness in a newborn and HSP) as well as putting on a pediatric trauma simulation.Read More
This week in UCEM Grand Rounds: the harrowing story of the desaturating trauma patient with a metal pole impaled through his mouth and neck. Also: making the diagnosis of HIV in the ED. Managing hemorrhagic shock on Air Care. How much did that ED visit or hospitalization cost your patient? Managing tachy-arrhythmias in the setting of cardiac arrest with a pacemaker.Read More
Emergency KT Protocol - The Pharmacology of RSI with Drs. Dang and Renne
Who do we RSI? What do we use? We can be better than etomidate and succ and the protocol in development will drill into the details - here is an overview:
- The most clinically useful categorization of RSI candidates is probably based on hemodynamics
- Hemodynamically unstable patients can be classified as “shock" based on myriad criteria and/or clinician gestalt while patients in whom the adrenergic surge of laryngoscopy could potentiate their pathology (e.g., increased ICP, aortic dissection, active ACS, or hypertensive crisis, etc.) can be classified as “high risk hypertension” for patients with increased ICP
- The hemodynamic classification of a patient determines his/her track down the pathway, but their classification can shift at any point based on clinician discretion (i.e., a well-resuscitated shock patient may later be considered “stable” and managed accordingly)
I don’t know if this has happened to you yet. It happened to me on my first shift as an intern. I hadn’t laid hand on a stethoscope in months. I had just unloaded the cardboard boxes from my rental truck into my new place. As I was settling in to my first few patient encounters one of our nurses approached me to say that a patient had been brought into our area that was extremely agitated. I looked up to see a man being held down by multiple police officers, thrashing and swearing.
“What can I give him?” She said.
“How about a hug?” I replied.Read More
Case Follow up with Dr. Winders
The Sick Patient with Pulmonary Artery Hypertension (PAH)
- PAH defined as right heart catheterization with mPAP > 25mmHg, which can be estimated by echo
- Readily associated with right ventricular failure, measured by TAPSE < 1.8 with M mode over tricuspid annulus
- EKG can also help identify these patients with right axis deviation or right atrial enlargement
Thanks to everybody who commented and contributed to the discussion on our last "Flight!" If you missed out on the case, check it out here. We had a great discussion which we have recapped here. Take a look below and a listen to the commentary provided by Dr. Bill Hinckley in the embedded podcast. Look for our next flight to lift off in the next couple of weeks!
What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?
This first question sparked quite a bit of debate within the community. Everybody agreed that this patient requires sedation, intubation, and more sedation. There was, however, some significant differences in how the providers would go about attaining adequate sedation.Read More
AirCare Grand Rounds
1. Indications for T pod
- Blunt trauma + unstable pelvis
- Blunt trauma + shock + pelvic tenderness to compression
- Blunt trauma + shock + AMS/inability to evaluate pelvic pain
In patients with blunt trauma who are in shock and have AMS, incidence of pelvic fractures is 10%. In patients who die of blunt trauma during transport, open book pelvis fracture is the #1 cause of death (according to our own QI data)Read More
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
There has long been a concern for increases in ICP with administration of ketamine primarily stemming from reports of increased ICP in the Neurosurgery and Neuroanesthesia literature. These increases were described primarily in patients usually with CSF outflow obstruction undergoing elective neurosurgical procedures. In the time since these articles were published, the use of ketamine in a wide variety of patients with neurologic compromise has been reported. In fact, there have been a couple of recent systematic reviews and meta-analyses on this topic. These systematic reviews and meta-analyses have essentially analyzing all the same existing literature (which is generally poor in quality).Read More
It's a typical busy post-Thanksgiving shift in the ED. It seems like patients with acute decompensated heart failure, sepsis, NSTEMI's and a whole host of other ailments are tucked in every corner and crevice of the ED. Just as you finish putting in orders on the last patient you saw, your next patient rolls by on an EMS stretcher. You see from your computer that the patient is on a backboard and in a c-collar after what clearly was some form of traumatic event. He's screaming in pain and holding his left leg flexed at the hip and internally rotated. "Jeez, I bet that hip is dislocated," you say to yourself.
You know you're going to need to reduce this dislocation, to not do so would risk avascular necrosis. Tammy, one of the nurses you are working with that day is already 2 steps ahead of you. "Doc, we're getting everything set up for the sedation, you're going to need for that hip that's out. What drugs do you want us to pull up?"Read More
SBIRT (Screening, Brief Intervention, Referral, & Treatment) for Substance Abuse
Why should we care?
- Prevalence of this disease is impressive with greater than 33,000 deaths attributed to alcohol in 2012 alone (287,000 MVC's in Ohio alone attributable to alcohol)
- Medical problems attributable to alcohol use costs the US $100,000,000,000 annually (from health care bills to lost productivity)!
- Approximately 33% of inpatient admissions in a country hospital population were attributable to alcohol
- One in five Americans can be defined as at risk drinkers