Grand Rounds Recap - 10/1/2014

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Grand Rounds Recap - 10/1/2014

Consultant of the Month Series: Ear Emergencies with Dr. Golub

Auricular hematoma

Blood separates the cartilage from the perichondrium which supplies the blood-flow to the cartilage. This can lead to cartilaginous ischemia, infection, deformation (cauliflower ear). Treatment: I+D: make cuts parallel to natural lines in the helix to reduce visible scarring. Place a bolster to close the new potential space. Bolster stays for 7-10days. Keep on Keflex while bolster in place and f/u with ENT. 

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Neurologic Emergencies in the Air

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Neurologic Emergencies in the Air

Several months ago, I sat down and talked about the management of neurologic emergencies in the prehospital environment with Dr. Erin McDonough, an Emergency Physician and Neurointensivist who attends both in the ED and the Neurosciences ICU, and is a member of the Cincinnati Stroke Team.  In the brief podcast found below and on iTunes, we covered a wide range of topics including blood pressure management in spontaneous ICH, aneurysmal SAH, and ischemic stroke and some of the more rare complications associated with tPA administration.

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How to Read Hip and Pelvis X-Rays

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How to Read Hip and Pelvis X-Rays

As a continuation of our radiology lecture series, take a look at the excellent instructional modules created by Dr. Anita Goel, PGY-1 resident at the University of Cincinnati Department of Emergency Medicine residency training program.  Dr. Goel takes us through the basic anatomy, the particular features of the many different views that can be obtained in hip and pelvis plain film radiography, and a systematic approach to reading these often complicated radiographs.

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Grand Rounds Recap - 9/24/2014

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Grand Rounds Recap - 9/24/2014

Management of the GI bleed (a review of the Cochrane Reviews): 

  • PPI drips have been shown to decrease the rate of rebleed in patients with known peoptic ulcers. It has not been shown to decrease mortality, hospital stay, transfusion need. It also has not been shown to be beneficial in the undifferentiated upper GI bleed and may have a trend toward harm. 
  • Octreotide doesn't improve mortality but on average decreased transfusion requirement by 1/2u product.
  • Antibiotic coverage (treating for gut translocation with ceftriaxone) has been shown to have lowered mortality from infection and all-cause mortality.
  • Prophylactic intubation: 2 retrospective chart reviews came up with contrasting results on mortality outcome after intubating for prophylactic reasons (patient was protecting their airway). 
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Transfusion in Trauma: One Ratio to Rule them All??

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Transfusion in Trauma: One Ratio to Rule them All??

A couple weeks back we met for the first journal club of the year in our residency.  For this first session, we tackled the clinical conundrum of transfusion ratios in trauma.  The question came from a brainstorming session with the PGY-1 and 2 residents, where the following PICO question was derived:

Patients: Victims of both blunt and penetrating trauma in need of blood transfusion as a part of the their initial resuscitation

Intervention: high plasma and platelet to PRBC ratio transfusion

Comparison: low plasma and platelet to PRBC ratio transfusion

Outcome: Mortality (in patient and 30 day mortality)

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Grand Rounds Recap - 9/17/2014

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Grand Rounds Recap - 9/17/2014

Radiation in Pregnancy with Dr. Polsinelli

Radiation effects can be deterministic or stochastic. 

  • Deterministic effects cause direct cell damage (radiation burns, teratogenicity, intrauterine death, genetic material damage). There is no evidence of teratogenicity in diagnostic testing radiation ranges (<50mGy). Genetic damage (causing effects in future generations) is theoretical and has not been reported. IUD is a concern, but on a population based scale there was no noted increase in incidence of fetal demise after large scale radiation event and this cannot be studied in vivo.
  • Stochastic effects increase the probability of developing cancer. There is no minimum threshold and increasing dose increases probability. Risk of cancer noted to be ~5% if exposed to 1Gy of radiation. (for comparison maternal radiation is: chest xray = 0.1mGy; CT abd/pelvis 10mGy)
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What is Global Health?

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What is Global Health?

Welcome to Taming the SRU’s Global Health section, where our goals are to increase awareness of global health issues, discuss clinical and ethical cases, and develop opportunities for residents to participate in global health electives.  We believe global health education is critical to well-rounded medical education.  Global health electives (GHEs) often have a profound effect on participants at any level.  One study found that 70% of students participating in GHEs subsequently entered primary care residencies or intended to work in resource-limited settings. (1)  These experiences lead to enhanced clinical and communication skills, humanism, cultural competency, and understanding of alternative concepts of health and disease.  GHEs help trainees foster a deeper understanding of the global collective and how one’s own health is uniquely connected to the rest of the world. (2)

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Interpretation of Head CTs

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Interpretation of Head CTs

In the video series below, PGY-1 resident, Dr. Gorder, leads us through the key aspects of CT head interpretation.  Attention is paid to the development of a rigorous systematic approach to review and interpretation of head CTs to aid in the identification of blood, ischemia, mass, signs of increased ICP, as well as fracture.  In the second video, the key anatomic features seen on head CT's are covered.

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Radiation in Pregnancy

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Radiation in Pregnancy

In the first of two posts preparing for Grand Rounds in the coming week, PGY-1 EM resident, Dr. Polsinelli, guides through the murky waters of radiation exposure during pregnancy.  She offers a background on what radiation is, how it's measured, the effects of radiation on the fetus, and radiation doses associated with common diagnostic exams.

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Grand Rounds Recap - 9/10/2014

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Grand Rounds Recap - 9/10/2014

Neonatal Resuscitation with Dr. Kamath-Rayne

http://helpingbabiesbreathe.org/

90-95% of newborns will require no intervention prior to their first breath. 5-10% of newborns will require drying, stimulation, or suctioning to get them to breath. 3-6% will require assisted ventilation with BMV. <1% will require advanced care with intubation, meds, or chest compressions

Golden Minute: within the first minute you want to ensure the baby is breathing spontaneously or have initiated BVM ventilation. 

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Enter the FOAM

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Enter the FOAM

This past Wednesday, I had the pleasure of giving a lecture on FOAM to the UC Emergency Medicine Residency.  Well, it wouldn't quite be a lecture on FOAM if I didn't make it freely available to all after I finished it all up.  You can check out the lecture slides on slideshare embedded at the bottom of the post.  I also recorded the lecture and broke it down into a series of 5-ish minute long videos which you can look at based on your area of interest.

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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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