Hart/Girzadas   Oral Boards

Case 1.   15yo female suffered blast injuries in an explosion.   Patient required intubation fordyspnea, respiratory distress , and bloody sputum secondary to blast lung injury.  Patient also had a traumatic amputation of the right upper extremity that was hemorrhaging.  A tourniquet was applied to stop bleeding.  Patient was resuscitated with PRBC’s and IV LR.  Patient also had 2nd degree burns on right side of body of about 20%.   Parkland formula was started.

*Blast Injury Categories

> Mortality increases from 8% to 49% when blast occurs in an enclosed space

>  Blast Lung Injury is the most common primary blast injury causing death

>  Traumatic Amputations portend a much higher mortality from blast injury

>  Military data demonstrate that tourniquets decrease mortality from a hemorrhagingextremity from 90% to 10%.

Case 2. 5 month old child presents with bloody stool, shock, and metabolic acidosis.  Patient had an anion gap acidosis and markedly elevated LFT’s and LDH.   History revealed that grandma was giving excessive amount of ferrous sulfate supplementation.   Serum Iron level was 600.  Patient was treated with IV fluids and IV Deferoxamine.  

*CAT MUDPILES

Case 3. 35yo male presents with left hand puncture wound on the palmar surface.  A paint gun fired into his palm when he was cleaning the nozzle.  The patient has severe pain.  Treatment for high-pressure injection injury included pain control, IV antibiotics, TDAP updated, emergent surgical debridement in the OR.

*High pressure injection injuries can look innocuous on first look.

*Xrays can show the extent of subcutaneous spread of pain or grease.

Regan    M&M

Tension pneumothorax is treated initially by a needle thoracostomy followed by a chest tube.  A common complication of chest tube placement is the tube can slide up into the subcutaneous tissue and not actually enter the pleural space.   You have to make sure the tube passes thru the ribs.

*Chest tube that never passed thru ribs and is the in subcutaneous tissue. After tube placement you need to feel all the way around the tube and be sure it passes thru the ribs.  It is amazing how easily the tube can pass up thru the subcutaneous tissue and feel like it is in the pleural space.

Harwood comment:  Any time the paramedics place a needle thoracostomy in the field, the patient should get a chest tube when they arrive in the ED.

If you are managing a bloody airway, you may need to use direct laryngoscopy rather than video laryngoscopy.  Blood can obscure video laryngoscopy.

When breaking bad news to families in heartbreaking situations, don’t hesitate to get support for yourself.  Some days our job can be terribly sad and emotionally disturbing.  Reach out to our faculty, chaplain, a crisis worker or co-workers for support.

Alexander      EKG Basics

*Basic Step-wise approach to EKG interpretation

Ari suggested the Rule of 4 for initial EKG interpretation

4 Features: Clinical context (patient age, chest pain), rate, rhythm, axis

4 Waves: P, QRS, T, U

4 Intervals: PR, QRS, ST, QT

Ari then demonstrated this approach on a number of EKG’s.   If you would like further EKG training, Ari has an excellent EKG teaching blog (Christ-ECG.com) linked to the ACMC EM website (click on Enlightenment)

Regan/Hart       Intro to Codes

Code 30:  The onset time of stroke is the “last known normal.”  If a patient wakes up with stroke symptoms, the onset of symptoms is not the time of waking but rather the last time the day prior that the patient felt normal or a family member noted them to be normal. 

Check a blood sugar in anyone who you can’t have a conversation with, anyone with a seizure, and anyone with neurologic findings.

There are phone apps and paper copies of the NIH stroke scale to make it easier to perform in patients you have a concern for stroke.

Girzadas comment: You may want to use the NIH stroke scale as the new standardized neurologic exam.  If you start doing it on all your patients with neurologic complaints you can get pretty fast at performing the exam.  Some non-stroke patients may need some additional exam components such as halpike or gait testing.

In the setting of acute stroke within 4.5 hours, if you get a stat CT head and the scan shows no hemorrhage, you should consider and discuss with neurology team about moving next to getting a CTA.  CTA will evaluate for the opportunity for interventional thrombectomy up to 6 hours out from onset of stroke symptoms. CTA is used to identify large proximal clots in the MCA.  These types of clots are the ones amenable to thrombectomy.

TPA outcomes: 1 in 3 patients will have some degree of improvement.  6 in 100 will have bleeding (some studies show higher rates of bleeding).   1 in 100 will have death or serious disability secondary to bleeding.

As of 2015, all contraindications to TPA are relative.  However, you need to weigh risks carefully.  If the patient has had prior ICH or is anti-coagulated you will probably evaluate the risk of TPA as outweighing the benefit.

Code 44:  Basic preparation: Assemble your team ASAP.   Get IV access.  Start O2.  Get them on a monitor/pulse ox and get an EKG.  Check the blood sugar.  Be sure you have airway tools in the room.

Holland       Hypertensive Emergencies

Deweert      5 Slide Follow Up

Holland       Admin Update

Unfortunately I missed these 3 excellent lectures.