Grand Rounds Summary 3/2/16

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Grand Rounds Summary 3/2/16

OB-GYN Emergencies with Dr. McKinney

Case 1: 18 wk patient with vaginal spotting who is Rh- but antibody+

Bedside U/S shows fetal abnormality due to Rh alloimmunization with fetal hydrops. Positive antibody screening on gravid female should warrant obstetric consultation. Rhogam administration within 72 hours of bleeding is important.

Case 2: 40 wk female with gestational DM present with crowning fetus who fails to immediately deliver secondary to shoulder dystocia.

Treatment: stop pushing and avoid traction. Initially attempt hyperflexion of legs and suprapubic pressure to release (McRoberts maneuver). Then consider episiotomy because subsequent maneuvers involve twisting the baby to get shoulder into a different plane. 

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Annals of B-Pod: Approach to the Febrile Infant

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Annals of B-Pod: Approach to the Febrile Infant

Imagine it’s your first moonlighting shift at a small rural community hospital. The nearest referral center for both adults and children is 90-minutes away by ground. The annual census of the emergency department is 15,000 patients per year, of which only 5% is pediatric. There are 2 hours left in your 12-hour shift and your energy is all but spent. You are looking forward to winding down at home after an extremely busy and high-acuity shift when your 35th patient of the day checks in. The patient’s chief complaint is fever. You give yourself an internal fist pump thinking that you’re about to see your 12th viral URI of the day and that you’ll be in-and-out of that room no in time. In the midst of your premature celebration you scan the nursing note and see the age of the patient: 6 weeks…You’re hopes of a quick and easy disposition suddenly melt away leaving you with many more questions regarding this patient’s care than answers…You muster your remaining energy and make your way toward the patient’s room.

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Take My Breath Away! Evaluation of Shortness of Breath in the ED

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Take My Breath Away! Evaluation of Shortness of Breath in the ED

There are many chief complaints in the emergency department that can be less than satisfying (*cough* abdominal pain *cough*).  Sometimes such patients end up having a completely benign examination, no significant risk factors found on history, and an encounter that leaves you shrugging your shoulders and telling the patient “bellies will do that sometimes, we don’t always find out why.”

Of course, this is all anecdotal, but the chief complaint on this month’s episode seems to have a more consistent presence of pathology with a wide range of severity.  With such heterogeneous pathophysiology we turn to the mind of Dr. Stewart Wright to discuss the initial approach to the patient with shortness of breath (SOB)...

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A Lonely Road - Recap and Expert Commentary

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A Lonely Road - Recap and Expert Commentary

A couple of weeks back, we kicked off our “Flights” portion of our Air Care Orientation Curriculum.  Dr. Latimer outlined a challenging patient case for use to consider and an excellent discussion ensued.  As a reminder of the case, here’s how it was posed:

Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.

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The Urine Drug Screen - Know Thy Limitations

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The Urine Drug Screen - Know Thy Limitations

We are all guilty of ordering them in the ED, but do we really know what we’re ordering?

The Implications of the Urine Drug Screen

1 literature review looked at 7 different retrospective studies describing a total of 1,405 patients and found the urine drug screen did not affect the management of any of these patients while in the emergency department.  However, the data from the UDS can affect a patient’s clinical care outside of the Emergency Department.  For example, if a patient requires psychiatric inpatient care, initial knowledge of drug abuse could affect this patient’s etiology of illness or rehabilitation plan.

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Grand Rounds Recap 2/10/16

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Grand Rounds Recap 2/10/16

R4 QUARTERLY SIMULATION with Drs. Curry, Loftus, Ostro and Strong

We presented a case of a 42 y/o female who presented with altered mental status, hypotension and bradycardia. She was ultimately found to have an unintentional labetalol overdose which she had been taking PRN for headache.

Beta-Blocker Overdose Take-Home Points...

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Grand Rounds Recap 2/3/16

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Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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Grand Rounds Recap 1/27

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Grand Rounds Recap 1/27

Morbidity and Mortality Conference with Dr. Toth

  • Clinical Decision Unit Usage:  We want to keep using our observation protocols for patients that are appropriate for the CDU. These patients must have a priori identifiable endpoints and a plan for care.
  • Discharge vital signs: Revisiting a theme from last month, tachycardia at discharge is associated with badness. Abnormal vital signs must be addressed.
  • Shift Change: Turnover is fraught with increased risks regarding patient care. Be vigilant that your sign out can anchor the oncoming provider.
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Grand Rounds Recap 1/20

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Grand Rounds Recap 1/20

Quarterly Simulation and Oral Boards

How do you approach the undifferentiated patient in arrest?

  • Your demographics and any initial history can differentiate the hyperkalemic arrest from recent chemo from the rhabdo from prolonged down time from overdose, etc.

Running a code is an art and a science

  • Mental modeling is something that causes us angst but it works. Close your loop with your drugs and plan. Being loud with your summary reasserts your control of the situation and can quell the peanut gallery.
  • Assign your roles and know your nurses and medics, introducing yourself mid-compressions is poor form and can decrease code efficiency
  • We like to keep our fingers on the femoral pulse. It decreases pulse check time, let's you dictate timely next moves.
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"Flights" - A Lonely Road

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"Flights" - A Lonely Road

It is mid July and your first shift as the coveted H2 Doc at Air Care 2 is finally upon you.  It has been an especially warm and beautiful Saturday and you ponder the possible flights for the evening as you take the scenic drive to Butler County Regional Airport. 

You finish checking the aircraft with the flight nurse and sit down to begin the 20:30 brief with the flight crew when the tones drop and you are dispatched for your first flight of the evening, a scene flight to Franklin County, Indiana for an “un-helmeted motorcyclist”. You grab the blood cooler, perform a safety walk-around the aircraft and strap yourself in back

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Grand Rounds Recap 1/13

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Grand Rounds Recap 1/13

R1 CLINICAL KNOWLEDGE ON ESOPHAGEAL EMERGENCIES WITH DR. CONTINENZA

Boerhaave's syndrome: Full thickness esophageal perforation

  • Thought to be due to suddenly increased intra-esophageal pressure

  • 60% of perforations thought to be iatrogenic, most commonly related to upper endoscopy

  • Chest X ray most of the time will have some abnormality, although it may just appear as a pneumonia. Pneumopericardium and obvious signs of mediastinitis may be rare on initial chest X ray, especially early in the disease process or with smaller esophageal tears and less mediastinal inoculation

  • CT scan is diagnostic modality of choice. If unavailable, upper GI series with Gastrograffin (less sensitive than barium though also less inflammatory reaction) is a better option that barium (greater sensitivity, more associated inflammation/potential for mediastinitis). 

  • Treatment is broad spectrum antibiotics as a broad spectrum of oral and pharyngeal bacteria can be involved

  • Mortality is high and increases drastically with delays in diagnosis

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Controlling the Milieu

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Controlling the Milieu

It is a cold, blustery winter night in the ED.  You are the on-duty flight physician as well as ED physician for your particular patient care area, and you get toned out for a scene in a nearby county.  Having arrived on scene, you enter the ambulance to find a middle aged man belted to the backboard with cervical collar on, verbally and physically struggling with the paramedics who are trying to restrain him.  

By report, he was found at the bottom of a deer stand, presumably having fallen out. Initial GCS was 11 (3- 3-5) with a R parietal cephalohematoma and abrasions to his arms and  face.  

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Coming in Low and Slow

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Coming in Low and Slow

You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…

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Grand Rounds Recap 1/6

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Grand Rounds Recap 1/6

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) 
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