Grand Rounds Recap 12.6.23
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leadership is worthless but leading is priceless: Leadership and the nfl WITH special guest lecturer, nfl players’ association physician director, dr. thom mayer
Don’t aspire to lead, you are already leading!
Leadership in times of crisis is key. Think, act, and innovate.
To be a good leader, you have to determine where your deep joy intersects with the world’s deep need.
Remember who you are and who you represent. It is easy to be influenced by the priorities of others.
ems grand rounds: southwest ohio protocol updates WITH dr. weekley
Ideally, medications will be administered IV or IO, therefore endotracheal tube drug administration will be de-emphasized.
Regarding hypothermic arrests, previous guidelines delayed drug administration, however the new protocol with reflect the current AHA guidelines and recommend normal ACLS during active rewarming.
For hyperthermic patients, goal is to cool patient prior to transport, ideally with immersion or body bag cooling with a goal of improving mental status or core temp < 101. If there is no improvement in 20 minutes, EMS will call medical control regarding further decisions.
In patients with head trauma requiring airway management, the goal is to bag the patient with a goal EtCO2 35-45 and RR 10. If there is concern that the advanced airway will increase agitation and therefore ICP, then it should be avoided prehospital.
The role of TXA in the prehospital setting is somewhat controversial, however the data supports continuing to use TXA in the setting of concern for severe internal or external bleeding.
New recommendations will recommend to remove patients from backboard once a patient is on a stretcher in trauma.
There is a new push for earlier treatment of hypertensive crisis in pregnancy, therefore PO nifedipine has been added to the drug list with protocols on when to use it.
Patients with epistaxis should be managed by first having the patient blow out clots followed by nasal spray into the bleeding nare and placement of nasal clip if available.
Calcium is also now carried in the prehospital setting and should be used when EKGs show signs of hyperkalemia, cardiac arrest with concern for hyperkalemia, and those who have crush injuries.
sports medicine jeopardy WITH dr. betz
Physical exam is key for diagnosing orthopedic injuries.
Occult fractures exist, therefore a high index of suspicion for these injuries is necessary, even in the setting of initially negative plain films.
Read your own x-rays - you know the patient’s exam better than the radiologist!
Don’t forget other can’t miss diagnoses in athletes. While many primarily think of orthopedic injuries in sports medicine, remember that the athlete has other organs!
Young athletes with exertional syncope is concerning. The most common causes of sudden cardiac death in athletes are arrythmias related to anomalous coronary artery, ARVD, and HCM.
r4 capstone: what do you want to do with your life? WITH dr. fabiano
In his R4 capstone, Dr. Fabiano advocates for considering your life and career in parallel to design your career with intention. He challenges the notion that the question "what do you want to do with your life?" is synonymous with "what do you want to do with your career?" He offers the following 5 step framework:
Step 1 - Define your values
What are the defining principles of my life?
This might take a lot of self-reflection to arrive at your core values.
If you're having a hard time, consider reflecting on your existing goals and try to determine common themes.
Step 2 - Outline your goals
What do I want to achieve in my life?
Start with your non-career goals and add in your career goals
Identify - are your goals yours? Or are they someone else's?
Step 3 - Evaluate congruence
Do any of my goals conflict with my values? Or with each other? If so, why?
Consider how and why you might modify a goal to achieve congruence
Step 4 - Assess for cognitive dissonance
Are my actions aligned with my values? If not, why not?
Ask yourself why you're doing what you're doing. Keep asking "why" until you get to a core value.
Modify your actions over time to reduce your cognitive dissonance.
Step 5 - Get creative, hybridize, and align
How can I design my life and career in parallel to align with my values and goals?
Think outside the box. Design your perfect life and then work backwards to reality.
r1 clinical knowledge: prosthetic valve emergencies WITH dr. snyder
For patients with mechanical valve replacement on anticoagulation (almost always warfarin) who experience bleeding, do not administer vitamin K as this will make anticoagulation later difficult to impossible.
For patients who you suspect prosthetic valve associated endocarditis, consider CTA imaging of their chest and brain. CTA of the chest has been shown to have similar sensitivity for detecting vegetations as TTE. CT/CTA of the head can identify complications such as abscess or mycotic aneurysm.
Patients with obstructive valve thrombosis usually require surgery for definitive management. For those who are poor surgical candidates, TPA can be considered in conjunction with CT surgery.
qi/kt: Spontaneous intracerebral hemorrhage WITH drs. artiga and stothers
After concern for stroke is identified, pursue neuroimaging (non-contrast CT head and CT angio head/neck) within 25 minutes of patient arrival to the ED to differentiate between a hemorrhagic or ischemic process. If the patient is diagnosed with a spontaneous intracerebral hemorrhage (sICH), imaging findings such as size, location, hydrocephalus, and midline shift will guide treatments such as mechanical interventions.
Aim to smoothly lower systolic BP to approximately 140 mmHg for patients with sICH, ideally within the first 2 hours after symptom onset. Use caution when treating profoundly hypertensive patients (systolic >220 mm Hg) or those with extensive sICH.
Reverse anticoagulation in sICH within 90 minutes of ED presentation using appropriate agents. Evidence supports the use of PCCs and Vitamin K for warfarin (INCH trial), andexanet alfa for factor Xa inhibitors (ANNEXA-I trial), idarucizumab or PCCs for thrombin inhibitors, and protamine for heparin. If the patient is on antiplatelets, avoid platelet transfusion (PATCH trial) and defer DDAVP to consultants.
Maintain euglycemia and euthermia in sICH patients. The INTERACT3 trial showed improved neurological outcomes with these measures as part of a complete bundle of care for sICH in the emergency department.
With rare exception, patients with sICH should be admitted to a specialized stroke unit (NSICU). Here at UCMC, be sure to collaborate with our Neurocritical Care and Neurosurgery teams to determine if surgical intervention is indicated and initiate NSICU bed planning.
