Grand Rounds Recap 10.12.22

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Grand Rounds Recap 10.12.22

Starting off the week with Drs. Jarrell and Yates defining what advocacy looks like in leadership. Drs Finney and Chuko led us in two case follow up discussions featuring how to deal with early misses and Hickam’s Dictum. Finally the Cincinnati Peds team leads up in simuations of Status Asthmaticus.

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Ketamine Potpourri

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Ketamine Potpourri

In our most recent journal club, we took a look at 3 articles focused on the use of ketamine in the Emergency Department. When treating pain with ketamine, does a rapid administration of ketamine result in more dysphoria? When used for RSI, is ketamine more hemodynamically stable than etomidate? When using ketamine for procedural sedation in adult patients, does pre-treatment with versed or haldol decrease clinically significant emergence agitation?

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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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Procedural Sedation Cage Match

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Procedural Sedation Cage Match

It's a typical busy post-Thanksgiving shift in the ED.  It seems like patients with acute decompensated heart failure, sepsis, NSTEMI's and a whole host of other ailments are tucked in every corner and crevice of the ED.  Just as you finish putting in orders on the last patient you saw, your next patient rolls by on an EMS stretcher.  You see from your computer that the patient is on a backboard and in a c-collar after what clearly was some form of traumatic event.  He's screaming in pain and holding his left leg flexed at the hip and internally rotated.  "Jeez, I bet that hip is dislocated," you say to yourself.

You know you're going to need to reduce this dislocation, to not do so would risk avascular necrosis.  Tammy, one of the nurses you are working with that day is already 2 steps ahead of you.  "Doc, we're getting everything set up for the sedation, you're going to need for that hip that's out. What drugs do you want us to pull up?"

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