Grand Rounds Recap 9.27.23
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pediatric airways WITH dr. dean
Intubation attempts should follow distinct, slow, and deliberate steps.
Safety during intubation must be paid attention, which has led to safety checklists in the pediatric world. Examples of these safety measures include adequate preoxygenation, minimizing duration of attempt, limiting intubations to trained providers, and using video laryngoscopes.
Recognizing patients who are at particularly high anatomic or physiologic risk prior to intubation attempt may decrease complications further.
landmark studies in em WITH Drs. Benoit, Ferman, and Freiermuth and Heidi Sucharew, PhD
It is important for us to understand which high impact studies have influenced our practice to be what it is today.
These landmark studies in EM review targeted and systemic thrombolytics in patients with MI, stroke, and PE.
Myocardial infarction
GISSI trial: In those who present with STEMI within 12 hours of symptoms, there was a reduction in mortality in those who received thrombolysis with streptokinase.
GUSTO: In those who present with STEMI within 6 hours of symptom onset, mortality was lower in those who received tPA + heparin than those who received other thrombolytic combinations.
DANAMI-2: In those who present with STEMI, primary coronary angioplasty is superior to thrombolysis, even if the patient requires transfer to a PCI capable facility (as long as this transfer occurs within 2 hours).
Stats quick hit: There are several advantages and disadvantages to using composite outcomes in studies and should be examined appropriately.
Ischemic strokes and endovascular therapy
IMS-3: In those with moderate to severe ischemic stroke who received tPA, there was no difference in those who underwent endovascular therapy and those who did not.
Stats quick hit: Futility stopping rules save time and resources by using data to find the probability of reaching the desired outcome. This study did stop early using these rules.
MR CLEAN: In those with stroke with confirmed proximal arterial occlusion, endovascular therapy does improve outcomes, regardless of receiving IV thrombolytics.
Pulmonary embolism
PEITHO: In normotensive patients with acute PE and intermediate risk of adverse outcome, those who receive TNK had lower mortality, however higher risk of clinically significant bleeding.
DOACs vs LMWH: In those who require anticoagulation to prevent recurrent VTE, DOACs are non-inferior to standard anticoagulation.
Stats quick hit: Hypothesis setting allows investigators to evaluate for superiority, non-inferiority, or equivalence.
EBM in the prehospital setting WITH dr. richards
Structure guideline evaluation tools are important to evaluate and implement EBM.
Implementing EBM in the prehospital setting requires attention to:
Scope and purpose
Stakeholder involvement
Rigor of development
Clarity of presentation
Applicability
Editorial independence
High heterogeneity between EMS systems impacts implementation of guidelines and protocols including rural vs urban settings, paid employees vs volunteers, and ALS vs BLS trained squads.
Open access publications are essential to continuing to spread EBM within this space and beyond.
Cpc WITH drs. de castro and thompson
Euglycemic DKA is a rare presentation that may often be missed due to the false reassurance of a normal glucose level
Characterized by euglycemia, acidosis, and ketosis
Patients who experience nausea or vomiting or develop metabolic acidosis in the setting of SGLT-2 inhibitor use should be evaluated for the presence of ketones in serum or urine
Mainstay of management and treatment are similar to that of DKA, with emphasis on dextrose containing fluids to maintain normoglycemia
Recognizing the underlying precipitating event is just as important as recognizing the hyper/euglycemic acute emergency
R1 Diagnostics and Therapeutics: Pneumothorax WITH dr. vaughan
Management of pneumothorax depends on etiology, patient stability and symptoms, as well as the size of the PTX.
Pigtail catheters are equal to large bore chest tubes, especially for isolated pneumothorax, and are associated with less pain and lower complication rates.
Tension pneumothorax is a rare diagnosis and requires emergent management with needle decompression.
Chest x-ray, POCUS, and CT can all diagnose pneumothorax; POCUS will lead to fastest diagnosis and CT will be most sensitive for identifying PTX.
Secondary spontaneous PTX have a poorer prognosis.
r4 capstone WITH Dr. GIllespie
Patients are some of our best educators.
Practice skills of observation. You can pick up a lot while obtaining your interview and talking with a patient by observing the patient in their environment.
The physical exam is not dead; the physical exam is the key to clinical diagnoses, and can provide hints to a greater picture.
If you cannot change a situation, change your approach to it
You will not always have control over your circumstances, but you will always have control of you and your approach to it.
This is true for problem-solving on the go, which happens every day in emergency medicine
This is also true for residency – these years can be hard, but it is our job and responsibility to make the most of it and to come to shift in a mindset ready to learn
If a mechanism makes sense, try it!
You must understand the parts to understand the machine.
Time quantity does not necessarily equal time quality
Look at and carefully listen to patients, sit with them when able; even in time pressured scenarios.
Interpret in context… carefully.
Be invested in palliation and end of life care; these are essential skills
It’s okay to have a damage control mode. Sometimes you will have to give things up.
There will always be new and never-before-seen pathology and problems. Practice struggling. Discomfort is a good thing.
Do what makes you happy in medicine and find a way to preserve it. Each of us finds happiness and meaning in our work in different ways – whatever the stimulus is that makes this true, hold onto and preserve this.
