Grand Rounds Recap 11/4

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Grand Rounds Recap 11/4

A Walk Down the Difficult Airway with Dr. Carleton

Case 1: Morbidly obese young female presents after overdose - tachycardic and unresponsive to sternal rub but maintaining saturations at 92% on a non-rebreather.

Difficulties in the morbidly obese and implications for airway management...

Use your rules for airway assessment

  • 2 fingers of mouth opening - remainder of 3-3-2 cannot be determined due to habitus
  • both MOANs for BVM and RODS for EGD predict difficulty with ventilation due to the restrictive physiology of her habitus
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Respiratory Monitoring - An Introduction to Pulse Ox and Capnography

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Respiratory Monitoring - An Introduction to Pulse Ox and Capnography

First a bit of physics....

Both pulse oximetry and capnometry rely on the Beer-Lambert Law. 

  • In 1760, Johann Heinreich Lambert proved that the absorbance of light through a material is proportional to the thickness of the material.  
  • In 1852, August Beer proved that the absorbance of light through a material is proportional to the concentration of the attenuating substance in the material.
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Grand Rounds Recap 10/21

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Grand Rounds Recap 10/21

Morbidity and Mortality Conference with Dr. Curry

Acute Coronary Syndrome in Pregnancy

Epidemiology

  • Incidence reported at about 6/100,000 deliveries
  • Maternal mortality is between 5-9%
  • 75% are STEMI
  • 2/3rds are anterior wall MI (LAD or LM as the culprit vessel)

Risk Factors

Many of these are typical ACS risk factors but are less prevalent in the pregnant population

  • Older age (>35 years old for pregnancy is considered older age....yikes)
  • Hypertension
  • Diabetes
  • Obesity
  • Smoking
  • Dyslipidemia
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Global Health Case Files #2

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Global Health Case Files #2

Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.

Case #5

32 yo M PMH HIV p/w LLE >RLE swelling & pain x 1 year.  Recent HIV+ and recently started ARVs.  CD4=40.  Pt denies trauma.  No history of DM or CHF.  No fevers, chills, N/V, abd pain, diarrhea.

PE:  37CHR-86BP-124/82RR-12

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Grand Rounds Recap 10/14

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Grand Rounds Recap 10/14

Simulation with Dr. Hill

Case 1: 45 yo male comes to the ED after being found down at the mall s/p defib x2 for a V fib arrest per EMS with a King Airway in place and undergoing active CPR. In the ED you achieve ROSC after defib x1 for Vfib and then PEA with multiple arounds of epinephrine. EKG shows inferior STEMI.  

Case 2: EMS calls with advanced noticed for GI bleed presents tachycardic and hypotensive, actively bleeding with melanotic stool and hematemesis. 

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Sepsis Under Fire

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Sepsis Under Fire

This is our first of 2 cases exploring the care of patients with sepsis in the Emergency Department.  Similar to our "Out on a Limb" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (November 11th), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

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Grand Rounds Recap 10/7

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Grand Rounds Recap 10/7

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. 
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Fighting the Bugs

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Fighting the Bugs

This is our first of 2 cases exploring the care of patients with sepsis in the Emergency Department.  Similar to our "Out on a Limb" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (November 11th), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

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The Agitated Patient

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The Agitated Patient

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.

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Ventilator Management Simulation Debriefing

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Ventilator Management Simulation Debriefing

Case 1 - "Bucking the Vent"

You have inherited a patient in the VA MICU at signout.  The patient presented with spontaneous bacterial peritonitis and altered mental status and was intubated for airway protection and hypoxic/hypercarbic respiratory failure.  The patient’s altered mental status has resolved but the patient remains intubated waiting for a second large-volume paracentesis that can’t be done over the long weekend at the VA. The RT calls you asking for a one time dose of 5mg Versed, but on a quick glance at the chart, the patient has been getting these Q2 hours for the last several days.  You go to the bedside and find an agitated patient motioning to take out the tube.  “He’s bucking the vent doc!”

Vent settings: AC-VC: TV500  RR12  PEEP8  FiO2 30%

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Grand Rounds Recap 9/30/2015

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Grand Rounds Recap 9/30/2015

September Morbidity and Mortality Conference - Dr. Toth

Cases reviewed were from the month of August. We saw greater volume in 2015 than 2014 with longer ED hold times. We reviewed multiple cases including:

Acute Inflamatory Demyelinating Polyneuropathy

  • Pain is a common presentation, and cranial nerve palsies are not infrequent, but they usually follow weakness and numbness of the extremeties.
  • The diagnosis is in large part clinical, with progressive areflexia and sensory loss being the hallmarks. CSF studies showing albuminocytologic dissociation is confirmatory.
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What is Useful in the ED to Help Diagnose or Rule Out Septic Arthritis?

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What is Useful in the ED to Help Diagnose or Rule Out Septic Arthritis?

History

There are many risk factors for septic arthritis including age >80, Diabetes, Rheumatoid Arthritis, recent joint surgery, prosthesis, cellulitis.  The absence of risk factors does not make septic arthritis less likely in an acute monoarticular arthritis

Physical

Monoarticular arthritis is often characterized as a warm, painful, swollen joint with limited range of motion.  No studies to date have quantified specificity data on the physical exam.  Therefore, clinicians must use their own clinical gestalt when interpreting physical exam findings.

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Interpreting Chest X-rays

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Interpreting Chest X-rays

There isn't a day that goes by in the ED that a patient does not get a chest x-ray.  Whether the indication is chest pain, shortness of breath, cough, or line placement or intubation, interpreting chest radiographs is a critical, necessary skill for anyone working in the Emergency Department.  Here you will find a brief video explaining how to interpret CXRs and 6 practice cases.

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