Conference Notes 12-17-2013

Happy Holidays Everyone!  No Conference next tuesday. 

Cash                Trauma Lecture

47 yo male struck by an auto.  Vitals were stable and no injuries to head/chest/abdomen.   Pt did have severe mangling injury to right lower extremity.

Control hemorrhage with direct pressure or tourniquet.   Tourniquets have been shown to improve survival.  Transient nerve palsy can be a complication from a tourniquet.

Don’t miss a second injury.  The patient was found in surgery to also have an open fracture and tendon injuries in the left lower leg.    Harwood comment: To avoid being distracted by a horrific injury, cover up the injured limb with a sheet or blanket and focus on the ABC’s.  After ABC’s addressed, uncover severe injury and address it.

Testing the peripheral nerves of the upper extremity: Rocks-Paper-Scissors.    Rocks checks the median nerve,   Paper checks the radial nerve, and scissors checks the ulnar nerve.    Girzadas comment: You also need to have them do the  OK sign as well to check the anterior interosseus nerve.

ABI’s check for arterial injury:  if <0.9 you need to do some imaging to assess for vascular injury. 

Open fracture increases the risk of osteomyelitis and limb loss.   Start antibiotics at time of initial evaluation.  Irrigate with NS, apply moist sterile dressing, spint and update tetanus.  These have to go to the OR within a few hours.

Open Fracture Grading System

Harwood comment: This system is not intuitive for the average ER doc.  This injury was severe and patient had to go to the OR no matter what the grade.  If the consultant is giving you a hard time about your  description of the injury, text them a picture.

Factors that increase risk of limb loss: delay in revascularization, blunt trauma, high velocity bullet, older patient, shock, limb ischemia, resource limited environment, and multi-casualty event.

By definition, the mangled extremity has 3 of 4 anatomical components injured.  (bones, vessels, nerves, soft tissue)

Mangled Extremity Score of 7 or higher suggests a low likelihood of limb salvage. With severely mangled extremities, functional recovery of the patient is more likely with amputation.

Protecting amputated digit or extremity in the ED: Wrap part in saline soaked gauze.  Place wrapped part in plastic bag.  Place plastic bag on ice in a cooler or other container.  Keep the container holding the amputated body part with patient on their cart so body part  is not lost.  

The patient in this case elected to attempt slavage of his limb despite orthopedic recommendation to amputate.  51 days later pt underwent BKA following multiple surgeries and complications.

Case 2: 60 you male with leg trapped under car when the car slipped off jack.  Pt looked well and limb seemed to be ok as well,  but pt was admitted to observe for rhabdomyolysis.    Pt did develop rhabdomyolysis.   CK is usually 5X normal with rhabdo.   Pt’s can be hypovolemic and develop hyperkalemia.  Patients can develop renal failure.   Follow K+ to avoid severe hyperkalemia and possible cardiac arrest.  Treat with IV fluids as soon as possible.  Even start IV fluids in the field prior to limb rescue from crush mechanism if possible.   This optimizes hydration of kidneys prior to  CK and potassium release.

Compartment syndrome: perfusion is compromised when compartment pressure gets within  30mm/HG of diastolic BP (Delta pressure).    Normal compartment pressure is 0-8mm/HG.  Pt will need fasciotomy if delta pressure is less than 30.


Febbo          Management of the Agitated Patient

Violence is usually preceded by anger, resistance, and verbal confrontation but still can be difficult to predict.  Risk is increased with males, substance abuse and previous history of violence.

Attempt de-escalation with clear, calm speech, offer food, agree with patient as much as possible, and remove aggravating factors from situation.

Physical restraint is a bridge to chemical restraint.

Search for underlying causes of agitated  behavior.  FIND ME mnemonic:   functional, infectious, neuro, drugs, metabolic, endocrine.

Quick Screening for organic disease: Disorientation, abnormal vitals, clouded consciousness, age over 40 with no prior psych history.

You ideally should have 5-6 people to physically restrain a person.   Leg restraint should be tethered to opposite side of cart to prevent  pt from kicking  leg laterally.

Chemical restraint:  Much  discussion about different approaches to chemical restraint.   All faculty felt Geodon (ziprasidone) and ativan were the most common combination for sedation but Brian made the point that this combo is not recommended by the most recent ACEP guideline.  This was based on expert’s  concern about combining atypical antipsychotics and benzos.  (A quick/very imperfect google search  could not find a direct recommendation against this combo, so I don’t know what the right answer is about this combo.  Be careful to monitor for over sedation and arrhythmias if you use it, I guess. Attendings' anecdotal experience has been that it is safe. )    Geodon is well known to cause prolonged QT (don’t give it IV/more likely to cause prolonged QT).   Benzos are a class D in pregnancy.   Everyone felt succinylcholine was virtually never needed as a last resort unless you don’t have enough security support in a very violent patient.  Elise felt ketamine  4mg/kg im is now the last resort drug instead of succinylcholine.     Ketamine is a bridge to getting IV access and dialing up other antipsychotics.

Excited delirium syndrome:  Usually male, underlying psych disorder and using sympathomimetic drugs.  Pt’s are severely agitated and have super-human strength.  Hyperthermia, hypovolemia, acidosis and rhabdomyolysis are frequently present.    High risk for death.   Terminal rhythm is most commonly brady-asystolic.

Attending discussion about the medication choices for chemical restraint.  They all have downsides.


Dose (mg)     

Onset (min.)     




 2-10 IM


 20 Hours



 5mg IM      


 20 Hours      

 FDA Warning


 2mg ODT 


 20 Hours



 5-10 mg IM


 30 Hours 

 CNS Depression 


 10-20 IM 


 2.5 Hours 

 QT prolongation 


 5.25-15 IM


 75 Hours 



 2-4 IM 


 14 Hours


     * Source: “Physician’s Desk Reference”

ACEP Article resource

DenOuden                   Progressing from Resident to Attending

Identify what clinical situations you fear , write those down , and then specifically work on those areas.

Identify the weaknesses of the system of your new ER.    Prepare for those weaknesses.

Issues identified by recent grads: No such thing as bypass at other hospitals.  You will have to respond to codes in the hospital.  Some times there will be no videolaryngoscopy.  You likely will have to learn to work with midlevels.   Ultrasound is not available in every ED.  You will have to transfer more patients.  

Crash Cart medicine: 

Use IO when you need it.

Case 1: 22yo with severe asthma.  Diaphoretic, hypoxic, altered mental status slightly.     Altered mental status is due to hypoxia, hypercarbia, and exhaustion.  Bipap was started. Usual asthma meds given (albuterol, solumedrol, magnesium)  Consider IM epi as well prior to IV access (2 epipens gives optimal dose).  Use passive oxygenation if you attempt intubation.  Put a high flow nasal cannula in place for all phases of intubation.  It significantly prolongs the time to desaturation.    Another strategy is Delayed sequence intubation using Bipap and ketamine (low dose 0.5mg/kg). Goal is to improve conditions (full oxygenation/lowest possible pCO2) prior to intubation.   You can combine both these strategies and use a high flow nasal cannula under the bipap mask.

Case2: 66 yo female with fever, pneumonia on CXR and elevated lactate.  Sepsis management begun.   Pt coded 6 hours later.  Ct showed diffuse colonic thickening.  Stool showed C-Diff.   Should we consider C-Diff in all older patients with abdominal pain, fever, diarrhea?  Should we treat empirically in high risk patients?   Send stool for testing!

Tricks of the Trade:  When getting the rectal temp also do a hemoccult and put some stool in a cup to send to lab.   You can add sterile saline to hard stool to soften it up for the lab so they can run the test.  Christine comment: there are patients who are C-diff positive who are not clinically ill with diarrhea so you have to use some clinical judgement if you are using this saline trick.

No sedation shoulder reduction:  Cunningham technique with shoulder massage.  You can also do intraarticular injections of lidocaine.

Ring removal: Wrap elastic tourniquet around finger for a few minutes, have pt hold their hand above their head.  It frequently removes enough edema to get ring off finger.

Painless abscess I&D: Aspirate fluid from abscess first to relieve pressure. Then inject lidocaine.  Let is take effect for a few minutes and then I&D.

Ntg spray has 400mcg per spray.  Good way to get quick ntg in a CHF patient prior to having IVNTG drip started.

Case 3: 70 yo male, hypotensive in extremis.  Diagnosis is sepsis.   Crash cart pressor initial dosing:  EPI 1mcg/min, Norepi is 10mcg/min, Phenylepherine is 100mcg/min.  A milligram of any of these drugs diluted in one liter of saline give you 1mcg/ml.

Case 4: 34 yo female bit by a bee and develops anaphylaxis.  Epi is the key.   Epipen is the place to start and most of the time will be all you need. If you need an epi drip; 1mg of epi in a liter of saline makes 1mcg/ml.   Give 2-4 mcg/min.    I drop per second is 3mcg/min.     

Carlson                       Toxicology Case Conference

Suicide rates decrease during the holiday season.

Unintentional toxic exposures to young children increase during the holidays.

Case 1: Unresponsive 3yo found on living room floor.  Dexi=20.   Patient had ingested eggnog spiked with etoh.   Pediatric etoh exposures increase during the holidays.  Kids are very sensitive to etoh.   Hand sanitizers have been reported to cause severely high etoh levels in kids.   One adult ingested hand sanitizer and had an etoh level of 800!   Hypoglycemia is common with etoh ingestion in kids due to their limited glycogen stores.

Case 2:  2 people at a party with nausea and vomiting after eating creamy appetizer.  It turns out it wasn’t due to food.   They were CO toxic  because the flue of the fireplace was not opened properly.  Elise comment: Use the finger probe device or get a venous blood gas to check CO level.  No need to do an arterial blood gas.   Andrea comment: Check the most symptomatic person first. If they are ok everyone else is likely to be as well.

Case 3: Poinsettias ingestions are very unlikely to be life threatening.   They can cause GI upset but are not lethal.   You would have to eat hundreds of  leaves to get sick. Andrea said there is no risk of lethality from ingestion.    There is a latex analogue in poinsettias that can cause allergic reaction in latex sensitive.  

Case 4:  European Mistletoe berries can be toxic.  American berries are not toxic.    No reported cases of death from ingestion of European mistletoe.    Mistle toe berries (European and American) can cause gi upset and mild neuro findings.  Not considered lethal.

Case 5:  Holly leaves are non-toxic.   Berries can cause GI upset and drowsiness. 

Pretty much all Christmas plants are not going to cause any serious toxicity.

Case 6: Kid ate a Styrofoam gingerbread ornament and some lights.   Christmas tree bubble lights contain methylene chloride.  Methylene chloride gets metabolized to CO.  Kids can get pretty high CO levels from methylene chloride.  Methylene chloride is also found in decorative spray snow.  

Case 7: Kid was drooling after playing by Christmas tree.  The child was found to have an esophageal ornament impaction.  Kids will also swallow button batteries.  These need to be removed in a few hours.  Recently battery companies have made improvements of batteries.   They are smaller and pass the pyloris more reliably.   The battery seals are much better and won’t leak for weeks.   Esophogeal batteries need to come out in a few hours.  In the stomach and bowel, kids can be observed.    Bill Schroeder comment: If a child ingests rare earth magnets, they can cause perforation of the bowel.  They frequently  require surgical removal.    In general  foreign bodies  get stuck at C6 chricopharyngeus,   T4 aortic arch,  GE junction T10-11.

Fort/Watts                         Oral Boards

Case1  Epistaxis due to thrombocytopenia secondary to leukemia.  WBC=47   Plt=16.  Management: Platelet transfusion given. Nasal packing placed.  T&C in case prbc transfusion is needed.  

Case2   Subdural hemorrhage on Pradaxa.   Management:  FEIBA, vitamin K and neurosurgical consultation.   Surgery is indicated for big subdurals (5mm), mass effect, severe symptoms.  There was a discussion about management of Pradaxa bleeding that is life threatening.  There is a lot of controversy on this topic.  However it is recommended to give high dose FEIBA 25u/kg.   Can give factor 7 as well.   Vitamin K is not indicated with Pradaxa bleeding.  This is different than the warfarin coagulopathy protocol which recommends vitamin K in addition to FEIBA for warfarin coagulopathy.

Case3  Cyanotic infant.  Pt with recent URI symptoms and cough.   DX=Pertussis.  CXR is usually normal.  Treat with macrolides or bactrim.  Kids less than 6 months can have apnea and bradycardia.   Labs can show a high lymphocyte count.