Grand Rounds Recap - 9/3/2014

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Grand Rounds Recap - 9/3/2014

EMS as a Specialty with Dr. Gerecht

"We are in the business of delivering health care to a very unique population, in a very unique environment, in a very unique way" - Dr. Edward Racht

EMS formally became a subspecialty of EM in 2006. The first board certified EMS physicians passed their exams last year (we have 3 in our EMS division).

EMS physicians train in clinical aspects of EMS medicine, medical oversight of EMS, quality management, and special operations. 

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Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown

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Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown

In 2012 in the Annals of Emergency Medicine, Weingart and Levitan published a review of preoxygenation and peri-intubation oxygenation techniques in the emergency airway management of adult patients.  Topics reviewed included the evidentiary support for preoxygenation and denitrogenation, appropriate positioning and patient selection, the utility of positive pressure in select circumstances, apneic oxygenation, as well as a proposed risk stratification approach based on pulse oximetry levels and peri-intubation risk.

A great discussion was had with many excellent learning points, upon which some were elaborated in great detail in the article and some only briefly mentioned.  What follows is a brief summary of learning points from the article as well as from the discussion. 

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Grand Rounds Recap - 8/27/2014

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Grand Rounds Recap - 8/27/2014

Botulism

  • Caused by neurotoxin produced by Clostridium bacteria
  • 3 types: food borne, infant and wound
  • Pathophysiology: toxin binds to cholinergic cells and prevents release of acetylcholine
  • Symptoms
    • Foodborne illness starts with N, V and D. Similar to gastroenteritis
    • Neurologic symptoms: fixed and dilated pupils, ophthalmoplegia, ptosis,       bilateral and symmetric facial paralysis that progresses to limbs and trunk, respiratory muscle weakness
    • Patients frequently complain of dysphagia, dry mouth and other anticholinegric symptoms
  • Infant botulism = floppy baby who is weak, has a weak cry, constipation and does not feed well
  • Botulism is easily confused with myasthenia gravis and Miller Fischer variant of Guillan Barre
  • Diagnosis: clinical in the ED
    • Tensilon test is normal but is helpful in diagnosing myasthenia
    • EMG may be abnormal
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The Approach to Abdominal X-rays

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The Approach to Abdominal X-rays

Utility of the imaging modality aside, abdominal radiographs can be a bit of a challenge to interpret.  With a number of possible techniques (cross table laterals, left lateral decubitus, AP, upright, or supine) and a lot of structures to evaluate (is that small bowel or large bowel?, is that a kidney stone or an infamous phlebolith?), it's pretty easy to stare at a film and zone out as you eye moves from one shade of gray to another.

In the embedded video below, PGY-1 resident, Dr. Julie Teuber goes through a standardized approach to reading the abdominal x-ray that hopefully help keep your eyes from going cross-eyed next time you need to interpret an acute abdominal series.

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Grand Rounds Recap - 8/20/14

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Grand Rounds Recap - 8/20/14

An Update on CHF w/ Dr. Fermann

The phenotype of acute presentation of heart failure can be dramatically different. Consider the difference between the hypotensive patient who has very poor cardiac output now in cardiogenic shock requiring pressors (these have a very poor outcome), the normotensive patient who has slowly become retained fluid, and the acutely hypertensive patient who presents in extremis (who actually does quite well even though they are so sick on arrival).

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Grand Rounds Recap - 8/13/2014

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Grand Rounds Recap - 8/13/2014

R4 Simulation Series: Genitourinary Emergencies with Dr. Moschella and Dr. Verzwyvelt

  • Fournier's Gangrene (ie necrotizing fasciitis of the perineum): Case simulation of 19 yo M with tachycardia, hypotension, altered mental status found to have erythema, induration, and crepitus of the perineum. Initial steps are aggressive treatment of sepsis (broad spectrum antibiotics to cover skin and gut flora as this is commonly polymycrobial) and early surgical debridement. Either Urology of Acute Care Surgery will mobilize to perform the debridement.
  • Oral boards case: Consider ovarian torsion in young female with acute onset pain in lower abdomen or pelvis. You may find adnexal fullness or tenderness on exam. Diagnostic test of choice is transvaginal duplex ultrasound. Remember to include ectopic pregnancy, appendicitis, TOA in your differential.
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Grand Rounds Recap - 7/27/2014

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Grand Rounds Recap - 7/27/2014

M&M Learning Points with Dr. Stull:

  • Severe asthma exacerbations require considerable effort to avoid furthering acidosis while attempting to stabilize, secure airway, and maintain oxygenation. Use Mag early as there is evidence that you can reduce admissions by providing this treatment early. Consider BiPAP to improve ventilation while preparing for definitive airway management but there is no evidence that it reduces intubations. Ketamine as the RSI induction agent may provide some bronchodilatory effect but there is not enough data to provide any formal recommendations. For this same reason, ketamine as a post-intubation sedation agent may be appropriate. Vent management is key with a focus on low respiratory rate and short inspiratory times to lengthen the I:E ratio (>1:3) to allow full exhalation. Goal TV 6-8cc/kg, "ZEEP" or low PEEP (0-5mmHg), consider a plateau goal of ~25 if you paralyze
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Liquid Plasma aka "Never Frozen Plasma"

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Liquid Plasma aka "Never Frozen Plasma"

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

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Grand Rounds Recap - 7/23/14

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Grand Rounds Recap - 7/23/14

n general, the best way to learn is to challenge yourself.  Teaching styles should take into account different learner types and levels

Learner levels:

  • Beginner: early 3rd year medical student
    • Can be an observer initially but transition these learners to the next stage
    • Keeps you on point as you have to really know what you are talking about
    • Incorporate them into your H+P
    • Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
    • Advanced:OMP (one minute preceptor) or SNAPPS model
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Logistics are Critical

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Logistics are Critical

Not much gets me as fired-up anymore as trying to optimize them. While I like to think that it’s because they are integral to our mission and are the ultimate weapon in our quest to go from “good to best”, it’s really just my borderline OCPD (just kidding…sort of).

Long story short, I spend a lot of time thinking about clinical and operational logistics in HEMS – it’s become my thing. My goal with this post is to share some of that thinking with others who might want to build off of our ideas in hopes that those colleagues (i.e. you) will share their ideas that they are really excited about with us at some point.

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Grand Rounds Recap - 7/16/14

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Grand Rounds Recap - 7/16/14

Oral Boards Case with Dr. Blomkalns

The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling "sick". His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4

(normal is less than 1.2).

His K is 6 and Cr is 1.9. EKG shows LBBB.

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Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH

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Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH

Why Should You Care?

  • Headache approximates 2% of presenting complaints to the ED, and SAH is identified in approximately 1% of those patients with headache in the ED.
  • Overall mortality of SAH is high, estimated at 25-50% of patients dying within 6 months
  • If not fatal, SAH leaves approximately 33% of survivors with some appreciable neurological deficit affecting their ADLs.
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The Glories of End Tidal CO2

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The Glories of End Tidal CO2

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

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