Conference Notes 11-13-2012

November 16, 2012 Daniel Girzadas

Chastain /Marra ENT Emergencies

FB in the Ear: Enough light is critical to seeing what is going on in the ear. Otoscope lights are generally inadequate. Amplify your light with a head lamp. Dr. Marra prefers using a blunt right angle device to remove ear FB’s. If you touch the ear canal or tm you will lose any cooperation of the patient. The skin of the ear canal is directly adherent to the ear canal bone. Any shearing force will cause hematoma or bleeding. Dr. Marra stated that for ear fb’s you may be better off using a nasal speculum in the external ear canal and a head lamp than using an otoscope. He felt that if you need to sedate a child to remove a FB, you probably should be referring the case to him at that point. He said you don’t want to sedate the child and then not get the FB. When he sees the child in his office he will use a microscope and a blunt right angle tool to attempt removal. If he is unable to remove the FB he will take child to OR for anesthesia. If a patient has a live bug in the ear he will drown the bug with mineral oil. He doesn’t use lidocaine to kill the bug because if the patient gets a TM perforation they could develop severe nausea from the lido.

Epistaxis: First attempt to visualize the nasal septum to see If bleeding is anterior. Neosporin topically is more effective than Vaseline in kids because kids’ noses are frequently colonized with staph. Staph is frequently a cause of recurrent epistaxis in kids. Dr. Marra uses silver nitrate to cauterize the bleeding. Be very limited on how much silver nitrate us use to cauterize to avoid leakage onto the face. In adults the key issue is BP control. If the patient is very hypertensive, you will have limited success in stopping bleeding until BP is lowered. Other key question is which side did bleeding start first. Focus your control efforts on that side. Lovell comment: Pain control and anxiolysis will also be key in controlling BP and bleeding. Look for bleeding on septum, inferior turbinate, and then floor of nose. If it is not in one of those 3 places then is likely lateral to middle turbinate or more posterior. In the office, Dr. Marra will use an endoscope to see where posterior bleeds are coming from. First line treatment for majority of nasal bleeding is still silver nitrate. Dr. Marra will inject lido with epi 2ml in the anterior septum (junction of skin and septum) and floor of nose to stop brisk bleeding in the anterior nose especially if patient is hypertensive. You can also inject at junction of nose to medial orbit angling toward forehead to cause arterial vasoconstriction. In addition use topical vasoconstrictor in nose to temporarily halt bleeding so you can see better. Preferred packs for Dr. Marra are Rhino-rocket and posterior balloon. Problem with posterior balloon is that it retracts back into the nose and can cause alar necrosis or obstruct the airway. If you use the posterior balloon, inflate the anterior balloon first so it doesn’t retract into the oral pharynx. You have to use saline to inflate the posterior and anterior balloons. Air insufflation does not provide enough pressure. You can pack with Vaseline gauze around the anterior nose balloon to secure it better so it doesn’t retract into the nose and cause airway obstruction.

Post tonsillectomy bleeding: Most bleeds that end up in the ER are due to delayed bleeds (days 5-10). Gargling with ice water will stop or decrease 95% of these bleeds. Dehydration is a common factor that needs correction so IV fluids also indicated. Dr. Marra wants most post-tonsillectomy patients admitted for OBS. The basic ED treatment algorithm is have patient gargle with ice water until bleeding stops or until ENT can evaluate patient

Villano Opioid Overdose

700% increase in opioid prescriptions between 1997 and 2007.

Opioids affect pain receptors, respiratory status, gut motility, pupillary constriction, and level of consciousness.

Opioid metabolism is very prolonged in an overdose situation,this includes fentanyl. This is due to altered pharmokinetics in overdose.

Methadone can cause QT prolongation.

No evidence of opioid use for acute pain resulting in chronic dependency.

Toxic effects: respiratory depression which begins with decreased tidal volume, then decreased ventilator rate.

Case 1: Heroin overdose treated with narcan twice. Pt was intubated for hypoxia due to acute lung injury. Any opiate can cause this. It is due to inspiration against closed glottis, hypoxic alveolar damage, and there is some controversy that narcan can also be a factor in this process.

Case2: Methadone OD treated with narcan. Pt had cardiac arrest likely due to torsades from prolonged QT . Methadone prolongs QT interval.

Case 3: Heroin OD treated with narcan. Pt found to have endocarditis while in hospital. Gotta consider endocarditis or HIV in opioid abusers and OD patients.

Case 4: Chronic pain patient with altered mental status treated with narcan. Pt responded and was sent back to jail. Pt returned 3 days later with liver injury from APAP overdose. Don’t forget that patients can be APAP or ASA toxic in addition to opioid toxic.

Narcan: can give subQ, IV (best), intranasal, sublingual. PO is poorly bioavailable. Starting does is 0.05mg to 0.4 mg IV. If no effect, you can increase to 2mg, then 4mg. Can actually go up to 10-15 mg if suspicion is very high for severe opioid OD. In general, start low so as to avoid rapid severe opioid withdrawl. Rapid severe withdrawl can be dangerous to staff and patient.

Case 5: Pt thought to have opioid overdose from wife’s meds and was admitted with opioid overdose. In hospital pt was found to have taken his daughter’s dilantin and was toxic from dilantin. Be sure to question and check for other ingestants/co-ingestants.

Case 6: pt with opioid overdose and treated with escalating does of narcan with good outcome. In general, observe patient for 4-6 hours after narcan. If no recurrence of respiratory or mental status depression, pt can go home. If patient needs second dose of narcan or uses extended release preparation, admit the patient. Put patients who OD’d on methadone, or fentanyl patches or extended release preparation in the ICU. Narcan may be less effective in the elderly due to physiologic differences in seniors.

Pitfalls: Failure to escalate dosing of narcan. Inadequate period of observation for recurrent respiratory depression. Failure to look for acetaminophen toxicity. Unecessary intubation. Incorrect diagnosis.

Coglan: You can inject narcan in sublingual area if no iv access. Lovell comment: Re-emphasize the need to start with low dose narcan to avoid overly rapid and severe correction of opioid toxicity. It puts your staff at risk when pt is rapidly reversed out of a coma . Chastain comment: Take a deep breath before intubating patient and give narcan first. Intubation is not the first line treatment for opioid OD patients. There was a generalized discussion about the fact that narcan should work rapidly in 4-5 minutes. If effect is not rapid then probably opioid toxicity is not the cause of mental status change.

Felder/Urumov/Carlson Dental Lab

Conference Notes 11-6-2012

November 6, 2012 Daniel Girzadas

Conference Notes 11-6-2012

Girzadas Recruiting Season Prep

Lambert Study Guide Resuscitation

Discussion of management of witnessed VF arrest between Harwood and Lambert. If you are by yourself managing the patient defibrillate first. If you have someone else helping you, first start CPR while another person gets the defibrillator.

Procainamide infusion is stopped if you reach 17mg/kg, QRS widens by 50%, pt becomes hypotensive, or arrhythmia is terminated.

Most common common underlying cause of CHF is coronary artery disease.

Cuffed ET tubes in pediatric patients are recommended to eliminate oropharyngeal contamination into the airway.

Co2 detectors on ET tubes can have false negative results if pt has no circulation. Meaning the ET tube can be in the trachea but patient with no circulation is not expiring any CO2

There was a discussion of the appropriate tidal volume for ventilated patients between Lambert and Barounis. Smaller tidal volumes are becoming more recommended 6-8ml/kg for all ventilated patients is now considered lung protective.

There was a discussion of whether or not to sedate patients prior to giving adenosine. No general agreement about the necessity of this. Most did agree that if there is time and adequate help, giving sedation is the kind thing to do to limit pt discomfort with adenosine.

Most common adverse effect of IV amiodarone is hypotension.

IV diltiazem is contraindicated in wide complex tachycardia.

In a choking patient, if they can speak or cough do not intervene. Let them try to clear their throat spontaneously.

Eastvold Acute Decompensated Heart Failure

There are few guidelines regarding acute decompensated CHF. This is because most decompensated CHF patients in the ER are suffering from diastolic dysfunction and most CHF research is on patients with systolic dysfunction.

Pearl #1 Chf is not gout. It is not a one treatment/one approach illness.

Up to 50% of patients arriving to the ED with pulmonary edema are not fluid overloaded. However, afterload mismatch/vascular failure can cause body fluid to be shifted to the lungs even if the patient is not total body fluid overloaded.

In a patient with acute chf who is hypertensive, they are less likely to have systolic dysfunction.

Pearl #2 Pts with CHF and HTN suggest vascular failure and fluid predominantly shunted to lungs with diastolic dysfunction.

5 reasons the patient in front of you doesn’t have chf: no hx of chf, no DOE, no rales, no cardiomegaly, nl ekg, BNP<100. The more of these that are present the less likely it is to be CHF.

BNP may be falsely low due to flash pulmonary edema (it takes time to increase the bnp) or acute mitral insufficiency.

Vascular pedical width (width just below the aortic knob >71mm) and cardiomegaly on CXR increase chance of chf. Using the cardiac or abdominal probe, Ultrasound findings of at least 4 lung rockets/b-lines/headlights/searchlights in the fog are indicative for alveolar/interstitial fluid. Put the probe on the anterior chest bilat. This ultrasound finding can be due to pulmonary edema, pulmonary fibrosis, or Aids lung and a few others.

PT with CHF and a Bun>43, SBP<115, Cr>2.75=22% mortality in hospital. Elevated troponin and hyponatremia are another two markers for high risk CHF.

To categorize CHF patients in the ED look at the BP

CHF with HTN (>140 systolic): Rapid onset. Fluid is in the wrong place (vascular failure). Bipap and nitrates are the work horses for this category. +/- Lasix 20-30 min after treatment started. For the severely dyspneic patient with very high BP, you can load the pt with NTG by giving multiple suplingual sprays.

Normotensive: Gradual onset. Chronic CHF patients. Give NTP or IV NTG and lasix. These patients can have a high mortality though.

Hypotensive: Cardiogenic shock.

CHF with ACS: This does not mean isolated troponin leak. Pt’s should have chest pain, ekg changes or pattern of troponin changes.

Isolated RV failure: nt discussed in this lecture

Morphine: Increases mortality and rate of intubation and ICU admission.

Acute CHF patients only have 20% of normal renal flow. This risks renal injury from lasix if you over diurese. It also may not be much help in patients with vascular mismatch CHF. If you use lasix, start with low dose. If the patient is on lasix at home, match their usual po dose with iv Lasix. Josh feels EMS should not be giving lasix because it is often misused.

NTG is the drug of choice for decompensated heart failure.

IV ACE-I is usually not needed if you are using NTG aggressively.

BiPap has been shown decrease mortality. Use it for patients who arehypoxic and/or dyspneic.

Harwood comment: Give 4 sprays of NTG pretty much out of the gate to the severely hypertensive patient. Intubating a acutely decompensated CHF patient should be considered a failure of EM management.

Tomasello ST Depression on EKG

ST depression in AVL suggests inferior wall AMI. Get serial ekg’s and watch for inferior ST elevation.

High lateral AMI’s are usually due to circumflex occlusions and mostly don’t have much ST elevation because the high lateral region has low voltage generally. Look for minimal st elevation in high lateral leads and inferior st depression.

Think posterior MI with tall anterior R wave, horizontal st depression anteriorly, upright t waves anteriorly. Posterior MI’s affect the posterior or far lateral aspect of the left ventricle.

Discussion about DeWinter wave vs. Wellen’s. Both are related to LAD occlusion and are found anteriorly, but Wellen’s is usually seen when pt is pain free.

With an EKG with diffuse ST segment depressions think either three vessel disease or left main (left coronary prior to bifurcation of LAD and circumflex)occlusion. You need st depression in 6 leads or more with st elevation in AVR to call left main. Most need CABG so don’t give plavix.

Ryan Med Student Review

Conference Notes 10-30-2012

October 30, 2012 Daniel Girzadas

Conference Notes 10-30-2012

Barounis Peds Joint Conference Bronchiolitis

Case 1: 7wk child with bronchiolitis HR=180, T=39, P/O=97%

Is albuterol indicated: Suctioning is critical. Nasal occlusion may make it that you don’t hear wheezing. Dr. Horowitz from ICU said a trial of one albuterol or one racemic epi is reasonable. Dr. Akhter also felt a trial of albuterol is reasonable. If there is a response you can continue with nebs. Dr. Akhter said if child has risk factors for asthma like parental history or food allergies then he is more likely to benefit from bronchodilators. Dr. Roy said this decision making tool is more useful in an older kid. Dr. Roy discussed one hospital system that had a “suction shack” aside from the ED that kids with bronchiolitis would go to multiple times per day for suctioning. He continued that in a child with distress, it is hard not to use bronchodilators. Barounis talked about the Cochrane Review that found that there was no benefit from bronchodilators in bronchiolitis. Dr. Roy said that if there is no response to initial few nebs then stop. Dr. Akhter said though that it can be hard to guage patient resonse to bronchodilators.

Hypertonic Saline: Dr. Bill Schroeder says no evidence for effectiveness. Dr. Horowitz agreed. Dr. Akhter said 3% saline nebs are for bronchiolitis, 7% saline nebs for CF. Barounis showed the Cochrane review that demonstrated 3% saline shortens hospital stay by about a day. Dr. Akhter said that the Cochrane Review may have suffered from author bias. Akhter “I have been less than impressed with the effectiveness of 3% saline. But it is a benign therapy that is safe to use.”

Racemic Epi: Bill Schroeder uses with the sicker kids as a trial of therapy. Occaisionally it helps. Dr. Horowitz uses in kids with nasal plugging predominantly to gain the alpha effect to vasoconstrict the nose and upper airways. Dr. Akhter uses it empirically as a trial and if it helps you can continue. Dr. Roy said this whole discussion is frustrating because there is no treatment that has clear data showing improvement.

Steroids: Dr. Bill Schroeder does not routinely use steroids unless there is a family hx of asthma and child is improving from bronchodilators. Horowitz does not use steroids in a child this age. He will use steroids in an older child who may have asthma. Dr. Roy said no unless there is risk for asthma. Barounis- how about a 12 month old kid who responds to bronchodilators? Akhter said Cochrane review demonstrated no benefit in bronchiolitis. However, if you think it is asthma give steroids. Lovell comment: If steroids are given for bronchiolitis at first visit, then when they come back 2 months later with a respiratory illness steroids are often given again for probably no good reason. Akhter responded that if kids are returning to ED multiple times then they likely do have asthma an may benefit from steroids.

Racemic Epi and Steroids: NEJM Article showed some benefit. Dr. Roy questioned the validity of the study and suspects bias in the study group looking at racemic epi for bronchiolitis. He did not want to give a lot of steroids to possibly prevent some admission.

Dr. Collins question, 3% saline nebs for outpatients? Akhter yes it is safe to use. Harwood question: How many children have died at Hope from bronchiolitis? Horowitz: usually they do fine but some end up on ventilators. Congenital heart disease kids can have problems. Dr. Roy said that he can’t recall any kids dying from isolated bronchiolitis. Dr. Harwood said if kids can feed and their O2 sats are 92% or higher they can be discharged after suctioning. All these kids survive. Very young and those with congenital heart disease are higher risk. Another audience membr comment is that Medicaid will not cover home suction machines this winter. We need to get Nosefrieda devices in the ED.

CXR: Dr. Akhter said the CXR has only about a 1% diagnostic yield in kids with likely bronchiolitis. Bill Schroeder doesn’t routinely get CXR for bronchiolitis. Dr. Horowitz said babies with bronchiolitis can specifically get RUL atelectasis (considered fairly specific cxr finding). He also brought up to not forget about UTI in febrile kids with bronchiolitis.

Should we test for RSV: Sirosek-NO. It has no utility during bronchiolitis season. Dr. Butterly said test may have some risk stratification utility. Dr. Collins said it has no utility when we have single patient rooms. Dr. Roy and Dr. Collins said we should be isolating by symptoms not by RSV testing.

Summary by Dr. Barounis: Suction is mainstay of treatment. Give trial of albuterol, can try 3% saline nebs, avoid CXR, avoid Steroids, avoid testing. Racemic epi can be tried in the very nasal congested kids or sicker kids.

Patel/Katiyar Oral Boards

Case 1 Iron poisoning: Treat with IV fluids, intubation, give deferoxamine, consult poison control. Most common fatal pediatric overdose. Look for a high anion gap metabolic acidosis (It is one of the I’s in MUDPILES). Iron is caustic to gi tract/produces free radicals/disrupts ox-phos in the mitochondria. Check two Iron levels separated by 2 hours. If sustained released or enteric coating get levels several hours later as well. Treat with deferoxamine. This will give you a vin rose color of urine as complexed iron is excreted.

Case2 Herpes keratitis: Need to consult ophthalmologist. Educate patient about potential blindness. Corneal findings can be an ulcer or dendritic pattern.

Case3 Imperforate Hymen: Hymen obstructs menstrual outflow causing hematometria (blood in uterus) or hematocolpos (blood in the vagina). Presentation is adolescent with abdominal pain and amenorrhea. Can be a monthly cycle. Hymen may be bulging in exam. Treatment is surgical incision of hymen.

Lovell comment: With Tox cases, your goal is to figure out the toxin. Get info from parents/family/ems/ pmd or drug store. Always check for visual acuity on all eye cases. Visual acuity is the vital sign of the eye.

Coghlan comment: Be sure to circle back on the tests you order like accucheck. Check blood sugar prior to intubating a patient with altered mental status.

Anneken Electrolytes/Acid Base

Moderate dehydration should be treated with oral rehydration. Solution should have sodium/glucose. Not too much glucose to cause diarrhea

Kids with diarrhea may return to a regular diet as soon as tolerated. It has been shown to shorten th course of diarrhea.

Calcium gluconate is the treatment of choice for wide QRS due to hyperkalemia. It stabilizes cardiac membranes but does not decrease k+ . It is the fastest acting treatment. Insulin/glucose is the best treatment to decrease serum K level.

Severe Hyponatremia (<120) associated with severe symptoms (coma/seizures/focal neuro findings) treat with hypertonic saline. Also use for acute drops in sodium (marathon runners/ecstasy use/polydipsia). Down side to hypertonic saline use is overly rapid correction resulting in Osmotic demyelination syndrome. Harwood comment: He is not using hypertonic saline unless patient is in status epilepticus or not protecting airway. It has been recently been found that ODS can be stopped by giving water.

Sorry I missed the rest of this lecture.

Barounis Electrolyte Emergencies

5 causes of hyperkalemia: renal failure, meds (example pt is on an ace-i and you give them an NSAID), cell death like tumor lysis/ischemic gut/rhabdomyolysis.

Ekg changes due to hyperkalemia: peaked t waves, prolonged QRS, loss of p waves, bradycardia , sine wave, heart block. Elise comment: If ekg is real wide and ugly that is a classic sign of a metabolic problem/diagnosis. There is no linear stepwise change in ekg correlating with K level. However if there are EKG changes, the K level is likely over 6.5.

If giving insulin for hyperkalemia, give 1 amp of glucose for every 5 units of insulin. Example is 2 amps of glucose for 10u of insulin.

IV bicarb works well for hyperkalemia only if patient is acidotic.

If giving calcium, calcium chloride has 3 times more calcium than gluconate. If pt is unstable give calcium chloride IV. Calcium gluconate is broken down in the liver and takes more time (20-30 min) to be effective. Ca Chloride is very sclerosing and otentially tissue damaging. There was a discussion of administration of CaChloride and Cagluconate. It was generally agreed that Cagluconate should be used in patients who don’t have immediately life threatening hyperkalemia. CaChloride should be used in patients with immediately life threatening hyperkalemia.

Down-Up pattern of ST segments is a sign of hypokalemia in addition to U waves and prolonged QT. Hypokalemia can be a cause of death from V-fib. Hypokalemia=Hypomagnesiemia.

If a patient has a K of 3.0, they are whole body depleted of potassium by 300meq. You can’t replete 300meq in the ED. The best you can do is 10meq per hour via a peripheral IV. Max rate of repletion is 20meq/hour via central line. What you can do is give patients some repletion in the ED and figure out why they are losing potassium at home (diuretics). Pt’s should also eat 2 bananas/day or drink OJ every day.

Ecstasy use can result in hyponatremic seizures. More common in women.

If a baseline normal patient has hyponatremia less than 120 and is seizing (acute severe hyponatremia), give hypertonic saline 100ml over 10 minutes. Can push or give IVDrip or IV Pump. Alternative is to give 1 amp of sodium bicarb (has 50meq of sodium just like 100ml of hypertonic sodium). If patient has mild symptoms (weakness, fatigue), just do nothing except consulting nephrology. For all hypontremia patients, never correct more than 10 in a day.

Hypercalcemia: 90% are caused by parathyroid adenoma or other cancer. Treat with 200ml of saline hydration per hour. 2^nd-3^rd-4^th line therapy is diuretics and bisphosphonates and calcitonin.

CAT MUDPILES

Cyanide, CO, APAP, Toluene, Mthanol, Uremia, DKA, Paradehyde, Porpylene glycol, iron, isoniazid, lactic acidosis, ethanol, ethylene glycol, salicylate.

Chastain Electrolyte Abnormality Cases

Seizing patient due to severe hyponatremia: Treat with 100ml of hypertonic saline or 1 amp of sodium bicarb over 10 min. Can repeat if needed.

Conference Notes 10-23-2012

October 24, 2012 Daniel Girzadas

Conference Notes 10-23-2012

Lovell Study Guide Pulmonary

Massive hemoptysis: 600ml of blood in 24 hours. For an ED perspective, hemoptysis that impairs oxygenation/ventilation. Stabilize with likely bleeding side down. Get them to CT and consult IR for bronchial artery embolization.

Tracheo-Innominate Artery Fistula: Usually in the first several weeks after placement of trach (85% occur in first month). Can have herald bleed followed by exsanguination or severe bleeding impairing ventilation. Treatment is putting your finger in trach hole and applying anterior pressure against the sternum. Other option is to over- inflate trach cuff.

Hermmann question followed by Harwood, Lovell comment: You have to work up 100% of patients with Trach tube and bright red bleeding from trach with CTA or bronch. More likely in patients who had trach placed in the last month.

Platypnea: SOB when sitting up. It is the opposite of orthopnea. Elise’s factoid.

Aspiration pneumonia: CXR findings develop in dependent portion of lung. Aspiration initially is a chemical pneumonitis followed by pneumonia. No prophylactic antibiotics and no steroids. There is controversy about NH patients whether to start antibiotics with early signs of aspiration.

FDA approved method of treating hiccups is Chlorpromazine (Thorazine). Harwood method is having patient suck water through a straw while they holding their fingers in their ears. Alternative home method is dry granulated sugar in the back of the throat.

Before you put a chest tube in a COPD’r is make sure what you think is a pneumo is not really a big bleb. If they are SOB treat with nebs and steroids, don’t put in a chest tube.

Deep sulcus sign is highly suspicious for a pneumothorax. The costophrenic angle dips much further inferiorly on the affected side than on the unaffected side.

Catch phrase for Legionella pneumonia: dry cough with diarrhea.

Catch phrase for Strep pneumonia: rust colored sputum

Catch phrase for Staph aureus: post-influenza pneumonia

Catch phrase for Klebsiella: alcoholic or NH pt, abscess

Catch phrase for Mycoplasma: upper airway and lower airway symptoms, bullous myringitis

T B: Pott’s disease is TB to the spine. Scrofula is large lymphadenopathy in the neck due to TB. Gohn complex (pulmonary scarring with hilar adenopathy)is classic CXR finding of latent primary TB. These patients are treated with 9 months of INH similar to newly positive ppd . Reactivation TB is active TB and need 4 drug treamtment. Miliary TB is diffuse lung findings in an immunocompromised patient means TB out of control.

Spontaneous pneumothorax in young stable patient: Catheter aspiration or Heimlich valve techniques are superior to placing a standard chest tube.

Harwood comment: Can you extrapolate this data to iatrogenic pneumothorax? Elise response: yes.

Elise said she would observe any patient treated with catheter aspiration for 6 hours in the ED.

Villano/E Kulstad Oral Boards

Case #1 Acute MI: ASA/O2/screen for contraindications/give thrombolytic. Start IV heparin.

Case#2 Acute Angle Closure Glaucoma: Identify diagnosis, start treatment promptly, consult ophtho. Look for iris bowing forward on slit lamp exam. You can see the light beam with curve over iris. Treat with timolol/apraclonidine/pilocarpine/prednisolone/acetazolamide. If IOP still over 40 give mannitol. Treat pain and nausea.

Case#3 Digital hair tourniquet: Identify affected finger and remove tourniquet. The third toe and third finger are the most common digits involved. There is an association older clothing and mittens. Bill Schroeder comment: use intranasal fentanyl prior to digital block. Removal with fine scissors/scalpel and forceps. Sarah Herron comment: Nair removal takes too long. Bill Schroeder comment: you don’t always know that the tourniquet is hair so Nair may not be effective if not hair. It could be synthetic/thread.

Schroeder Peds Resuscitaiton

ET tube size: (age/4 +4) for uncuffed. (Age/4) +3 for cuffed tube. Easiest way to calculate is a Broslow tape.

EPI dose is 0.01mg/kg or 0.1ml/kg of the 1:10,000 for PEA.

Ketamine sedation is 1-2mg/kg IV.

Treatment for TCA OD is sodium bicarb. Dose is 1meq/kg. Amp of 8.4% bicarb has 1meq/ml or 50meq in an amp.

Lower limits of systolic BP is 70mm hg + (age x2). Under one month is 60mm hg. 90mm hg for ages 10 and up.

Goal of fluid boluses in the first hour for the critically ill can be up to 60ml/kg. This is done by repeated 20ml/kg boluses as needed.

IM versed 0.01mg/KG is the fastest way to get anti-seizure meds into a child with no iv access until you get an IO or IV line.

Atropine for brady arrest dose is 0.02 mg /kg. Minimal dose is 0.1mg and max dose is 1mg.

The first line pressor for peds patient with volume refractory shock is dopamine. The reason is that kids generally have an already high SVR in shock.

Give pyridoxine for refractory seizures in kids. Can be due to B6 deficiency in a neonate or infant. Also can be used for INH related seizures.

D50 in an infant can cause cerebral edema due to hyperosmolarity. It can also cause tissue damage in the extremity if it extravasates. It can also lead to hyperglycemia followed by rebound hypoglycemia.

Succinylcholine may cause bradycardia in young children and infants. Can use with atropine. Can cause hyperkalemia in kids with muscular disorders like muscular dystrophy. Rocuronium is an alternative but has slower onset of action than succinylcholine. Bill personally uses rocuronium on all infants he intubates.

Ductal dependent lesions causing shock in infants can be treated with prostaglandin IV.

Bill Schroeder comment: In a critical case, don’t be calculating doses, use the broslow tape or a pediatric dosing app on your phone.

Klinker/Wolfe Inhaled Medications in Asthma

Atrovent MDI’s have peanut oil and should be avoided in kids with peanut allergy.

Conversion: Albuterol 5mg= 4 puffs Q30 minutes. 10mg=8puffs Q 30min. 15mg=8puffs Q20 min. 20mg=11puffs Q20 minutes.

Home treatment should be 4puffs QID to Q 4hours. If child is having difficulty breathing advise parents to continue to give puffs on the way to the ED. Bill Schroeder said his rule of thumb is if child is requiring 8 puffs at a time or needs mdi tx more frequently than q 4 hours return to ER.

Bronchiolitis: Kids under 4 months are obligate nose breathers. If their nose gets stuffed up, they have a lot of trouble breathing. Don’t routinely do a CXR. Treat with suctioning, maintain hydration, O2 to keep sat over 90%. When suctioning with bulb syringe tell parents to stick it into the nose and aim at the toes. NoseFrida is a suction tool that parents can suck on to remove mucous from the nose. On the NoseFrida website you can find a local store that has this device. Parent who have used this rave about it. Good suctioning can improve upper airway movement and decrease wheezing in lower airways. Antibiotics, CPT and steroids are not recommended. For sicker bronchiolitic patients you can try albuterol or hypertonic nebs.

Conference Notes 10-17-2012

October 24, 2012 Daniel Girzadas

No notes. Advocate Innovation and Research Forum

Conference Notes 10-9-2012

October 9, 2012 Daniel Girzadas

Conference Notes 10-9-2012

McDermott/C. Kulstad Oral Boards

Sorry I missed this Oral Boards Triple Cases but the highlights per Dr. Kulstad were:

Case 1: spinal shock fro cspine injury: treat with iv fluids, pressors if needed. Board Question Alert! Pt’s may be paradoxically bradycardic with hypotension. Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications. An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury. Albeit with little empiric supporting data, guidelines currently recommend maintaining mean arterial pressures of at least 85 to 90 mmHg, using intravenous fluids, transfusion, and pharmacologic vasopressors as needed

Case 2: Heat stroke: Rapid cooling. Altered mental status separates heat stroke from heat exhaustion.

Case 3: Stingray injury: Hot water treatment and don’t close wound. Xray to make sure no fb

Kessen Hand Trauma (Sorry missed a lot of this lecture)

Jersey finger is due to rupture of the flexor tendon. Pt can’t flex finger. Called Jersey finger because football players would get this when tackling someone by grabbing their jersey.

For amputations: get all the pieces and x-ray all the pieces. Digit survival is 12 hours when warm, 24 hours if cooled. Major replant survival is 6 hours warm, 12 hours cold. Keep amputated digit cool by wrapping in saline soaked gauze, place in a plastic bag and put the plastic bag on ice. We have a cool to keep on patients cart.

Harwood comment: MRI can be used to identify FB and many specialists have access to MRI in their offices. Using a tourniquet to get a bloodless field will be less painful for a patient if you keep the cuff pressure only 20 mm hg above the patient’s systolic BP. Current standard of care is that EP’s don’t do tendon repairs in most areas of the US. Hand specialists and ortho specialists will take almost all tendon injuries.

Discussion of Regional anesthesia for the hand. See Diagrams Below

Flexor tendon approach

Web space approach

Levato UTI treatment (I missed a lot of this lecture also)

Uncomlicated UTI’s use macrobid for 5 days or keflex for 7 days. Bactrim has too much resistance to be considered reliable. Cipro should be used only if other options not possible because cipro use has complications of c-diff/neuro effects/tendonopathy/interactions with Coumadin. Use cipro for only 3 days for cystitis.

Collander Unstable C-spine Injuries

Intubate for Cspine fractes C5 or higher.

Rectal tone presence identifies incomplete cspine injuries.

Nexus criteria are 99.6 % sensitive for clinically significant Cspine injuries.

The NLC decision instrument stipulates that radiography is not necessary if patients satisfy ALL five of the following low-risk criteria:

§ Absence of posterior midline cervical tenderness
§ Normal level of alertness
§ No evidence of intoxication
§ No abnormal neurologic findings
§ No painful distracting injuries

Insignificant injuries were defined as those that would not lead to any consequences if left undiagnosed. The NEXUS investigators evaluated 34,069 blunt trauma patients who underwent radiography of the cervical spine comprised of either a 3-view cervical spine x-ray or a cervical spine computed tomography (CT) scan. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value (NPV) of the NLC were found to be 99.6 percent (95% CI 98.6-100), 12.9 percent (95% CI 12.8-13.0), and 99.9 percent (95% CI 99.8-100), respectively

Canadian Cspine rule is 100% sensitive for clinically significant spinal injury.

The CCR involves the following steps:

§ Condition One: Perform radiography in patients with any of the following:
- · Age 65 years or older
- · Dangerous mechanism of injury: fall from 1 m (3 ft) or five stairs; axial load to the head, such as diving accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car
- · Paresthesias in the extremities
§
- · Simple rear end motor vehicle accident; excludes: pushed into oncoming traffic; hit by bus or large truck; rollover; hit by high speed (>100 km/hour [>62 mph]) vehicle
- · Sitting position in emergency department
- · Ambulatory at any time
- · Delayed onset of neck pain
- · Absence of midline cervical spine tenderness

Patients who do not exhibit any of the low-risk factors listed here are NOT suitable for range of motion testing and must be assessed with radiographs.

If a patient does exhibit any of the low-risk factors, perform range of motion testing, as described in Condition Three below.

§ not

In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying clinically important cervical spine injuries

Flexion teardrop fracture: Anteroinferior portion of vertebral body is fractures off. Can have associatated anterior cord syndrome. May have widening of spinous process spaces.

Wedge Compression fracture: Posterior ligament disruption may be associated. Considered unstable if >25% compression of the anterior border of the vertebral body or widening of the spinous processes.

Extension teardrop fracture: Anteroinferior portion of vertebral body is avulsed. Fragment is usually taller than wide.

Hangman’s fracture: Fracture of both pedicles of C2. C2 displaces anteriorly. Usually see in car and diving accidents. Patients can be neurologically intact because there is a wide canal at that level.

C1 Jefferson Burst Fracture: Due to an axial load. C1 is laterally displaced on C2. If sum of total displacement of lateral masses from body of c2 is greater than 7mm that is the criteria.

Occipital-atlantal Dissociation: figure

The Powers ratio is commonly used to assess for atlanto-occipital dislocation (figure 9). It is defined by the ratio of BC:OA, where BC is the distance between the basion and the midpoint of the posterior laminar line of C1, and OA is the distance between the midpoint of the posterior margin of the foramen magnum (opisthion) and the midpoint of the posterior surface of the anterior arch of C1 [17]. A ratio greater than one suggests anterior subluxation.

Another radiologic finding suggestive of an atlanto-occipital dislocation is disruption of the “basilar line of Wackenheim,” a line drawn from the posterior surface of the clivus to the odontoid tip [18,19]. Normally, the inferior extension of this line should just touch the posterior aspect of the tip of the odontoid. If the line runs anterior or posterior to the odontoid tip, this suggests an atlanto-occipital dislocation.

Carlson Salicylate Toxicity

1960’s there was concern for ASA causing Reyes syndrome and people were told not to have asa at home. Toxic ASA exposures decreased for a few decades because people didn’t keep ASA at home as much. Since the 1990’s ASA use has again resurged due to it’s value for cardiac disease.

Board Question Alert! Oil of wintergreen has a very high concentrate of methylsalicylate. 7grams of ASA in a teaspoon!

Enteric coating of ASA prolongs absorption to 4-6 hours and asorption is less predictable.

ASA inhibits cycloxygenase to block prostaglandin synthesis. Toxic levels stimulate respiratory center (respiratory alkalosis), stimulates vomiting center, increased capillary permeability (pulmonary edema) and uncouples oxidative phosphorylation (metabolic acidosis, fever). Pts will develop ketosis and hypokalemia in addition to metabolic acidosis and respiratory alkalosis. Toxic patients also will have tinnitus.

More severe toxicity will cause agitation, dehydration, acid/base disturbances, pulmonary edema.

A death from ASA is a CNS death. ASA is a brain poison.

ASA poisoning gets missed because it looks like sepsis or alteredmental status or chf.

Toxic dose is >150mg/kg. Serious toxicity can be approximated by 1 (325mg) tab per kg. therapeutic level of salicylate is 3-6mg/dl, toxic level is >30mg/dl. Levels correlate poorly with toxicity. Done nomogram is no longer used because it is inaccurate. Don’t use the Done nomogram.

Board Question Alert! If you need to intubate a patient with severe ASA toxicity or any patient who is markedly tachypneic, be sure to set your ventilation parameters to maintain the patient’s minute ventilation so they don’t become more acidotic.

Management: Activated charcoal, additional dose 2 hours later of activated charcoal, alkalinize blood and urine (target urine ph is 7.5-8), need to keep potassium in normal range or you will not be able to effectively alkalinize the urine. You will usually need to hang a lot of potassium. Hemodialysis is indicated for severe overdoses. (acute level>100, chronic level>60, pulmonary edema, renal failure, pulmonary edema, rapidly rising levels, altered mental status and academia.

Mistry FirstNET EMR

Tech support continues thru 10-17. Make sure you work some shifts/see some patients while tech support is her on site.

Chintan went through multiple optimizations of First Net.

Conference 10-2-2012

October 9, 2012 Daniel Girzadas

Conference Notes 10-2-2012

Gottesman/Anderson Oral Boards

Case 1: CO poisoning

Case2: AKA: Treat with IV fluids and glucose

Case3: Morbidly Obese Patient with respiratory failure:

Harwood comment: The lesson of these 3 cases is getting the ABG. It will help you solve all 3 cases. VBG can be used frequently in place of ABG. If you want a CO level on the VBG, make sure to tell the respiratory therapist. They may not run the CO. The caloric content of a bag of D5 is 200 calories, so you may need to give D10 or food or Amps of glucose to correct marked hypoglycemia.

Girzadas comment: For the SuperObese patient be sure to use RAMP positioning and call for back up from anesthesia or other EM physician

Kulstad Study Guide CV Disease

Aortic insufficiency murmur is heard in 32% of patients with aortic dissection.

Best work up for iliac dvt in a pregnant patient is MRI.

Work up for ischemic limb is Vascular consult and CT angio of limb. Heparin is usually indicated. Definitive therapy is thrombectomy and embolectomy. Harwood comment: Just give heparin and consult vascular surgery. Ct angio may be a time waster.

Signs of Aortic dissection: wide mediastinum, tracheal deviation, and aortic shadow beyond calcified wall. Harwood comment: there is a difference between traumatically torn aorta and aortic dissection. Xray findings are not all common to both.

Phlegmasia cerulea dolens: Severe ileo femoral dvt with venous engorgement. Can lead to compartment syndrome and gangrene. Treat with heparin and IR thrombolytics. Phlegmasia alba dolens is called the milk leg. Much less common and is a dvt resulting in decreased arterial perfusion.

High risk patients with concern for dvt who have a negative U/S, they need f/u U/s in 7 days. 2 negative U/S makes risk of PE or DVT less than 1% in 3 monts

Wells criteria and modified Wells criteria: clinical assessment for pulmonary embolism

Clinical symptoms of DVT (leg swelling, pain with palpation)	3.0
Other diagnosis less likely than pulmonary embolism	3.0
Heart rate >100	1.5
Immobilization (≥3 days) or surgery in the previous four weeks	1.5
Previous DVT/PE	1.5
Hemoptysis	1.0
Malignancy	1.0
Probability	Score
Traditional clinical probability assessment (Wells criteria)
High	>6.0
Moderate	2.0 to 6.0
Low	<2.0
Simplified clinical probability assessment (Modified Wells criteria)
PE likely	>4.0
PE unlikely	≤4.0

Data from van Belle, A, et al. JAMA 2006; 295:172.

Most common extremity aneurysm is popliteal . Often bilateral and rarely rupture.

Treatment of aortic dissection: reduce shear force with esmolol and drop MAP to 60. Can add nitroprusside or other agent if needed to get map to 60. Start though with esmolol. Labetalol would be another option.

Be very cautious managing asymptomatic htn. There is a risk of causing stroke with rapid lowering of BP. Restart their medications. If they are untreated you can start a low dose diuretic.

Thrombotic cause is more common than embolic cause of limb ischemia. This is due to good anticoagulation management of patients with Afib and valve replacements.

There is no distinct number that identifies a hypertensive emergency. Emergency is defined by end organ damage. Harwood comment: pre-ecclampsia is a hypertensive emergency with a relatively low bp cutoff. Usually 140/90.

The following eight factors constitute the PE rule-out criteria

§ Age less than 50 years
§ Heart rate less than 100 bpm
§ Oxyhemoglobin saturation ≥95 percent
§ No hemoptysis
§ No estrogen use
§ No prior DVT or PE
§ No unilateral leg swelling
§ No surgery or trauma requiring hospitalization within the past four weeks

Coghlan comment: Why not include cancer in the PERC rules. Barounis response that when Jeff Kline discussed on previous podcast he said cancer did not change the probability in his study.

Harwood and Barounis felt that if a cancer patient has neg perc/neg dimer/neg trop then they likely don’t have a PE. Elise and Barounis disagreed on whether CT would be indicated in this situation. There was some heated discussion between Harwood/Elise/Christine/Barounis on this topic. There was not consensus on whether a CT was absolutely necessary in the cancer patient who has a neg perc/neg dimer/neg trop.

Best treatment for patient with asymptomatic htn who is not on meds currently: HCTZ, Lisinopril . Pharmacy student comment: Lisinopril may be less effective in African American patients. Harwood comment: Chlorthaladone is a thiazide diuretic that is more potent than HCTZ. Consensus was that you don’t need to start potassium therapy with low dose HCTZ or Chlorthaladone. Hypokalemia is not a big problem with HCTZ 25mg or less.

Maslar Dive Medicine

Humans can’t breathe under water through a long snorkel tube because there is water pressure pressing on our chest and increasing the air pressure in our bodies. Our diaphragms cannot overcome this pressure.

Dybarism: most common source of diving problems. Ear squeeze is usually a problem of descent. Ear pain can develop. TM can rupture. Valsalva is treatment for ear squeeze but If you overdo it you can cause round window rupture resulting in hearing loss/vertigo/tinnitus. Sinus pain is usually a problem of ascent resulting in sinus pain. Pulmonary barotraumas can also occur on ascent in a diver breathing pressurized air. The diver needs to exhale as you ascend or the expanding air can cause alveolar rupture. Patients can have pneumomediastinum. Worst case scenario of dysbarism is air embolism. Arterial gas embolism will occur almost immediately upon surfacing. Of all dysbarism injuries, only the air embolism requires hyperbaric treatment.

Diver descending: ear squeeze. Diver ascending:sinus pain, pulmonary barotraumas, arterial gas embolism

Decompression sickness (Bends): Usually involves nitrogen which is most prevalent atmospheric gas and is inert. Joe used the can of coke metaphor to describe decompression sickness. If you open a can of coke real fast you get a lot of bubbles. If a diver surfaces too fast relative to the time they were underwater you get bubbles in the blood/tissues/joint. Interestingly, we don’t really know where bubbles come from or how they hurt us. Gasses coming out of solution with decompression sickness usually affect the spine rather than the brain. Acute stroke symptoms should point more to arterial gas embolism than decompression sickness. Treatment is hyperbaric oxygen to push bubbles back into solution.

Who needs hyperbaric recompression tx: decompression sickness, arterial gas embolism, CO toxicity

Christine comment: If you have to treat a patient with a diving related malady and have questions or need guidance you can call the Diver’s Alert Network (DAN).

Lovell Targeted Temperature Management Post-Cardiac Arrest

Post cardiac arrest syndrome: precipitating disorder, tissue ischemia,

Therapuetic hypothermia: mechanism of action is to slow down brain/heart/overall metabolism and slowing the inflammatory cascades that are negatively impacting brain.

Ice packs have been shown to effectively cool patients. So low tech cooling means have been shown to be just as effective as the hi tech options. We have cold IV saline in the ER to use to start cooling patients early.

Hypothermia therapy either results in patients with good neurologic outcomes or they die. Hypothermia treatment does not result in more patients with a persistent vegetative state.

Number needed to treat for therapeutic hypothermia: good neuro outcome=6, lower mortality=7. These are great numbers!

AHA guidelines: Class 1 recommendation for comatose patients with ROSC after V-Fib arrest. Should also consider with patients resuscitated from other types of arrests.

Complications to be expected: infection and coagulopathy, bradycardia, electrolyte abnormalities, 5-20% rate of seizures, labile BP, hyperglycemia, avoid hyperthermia with re-warming. Keep patients below 37.5C.

Can use therapeutic hypothermia even if prolonged resuscitation and/or unwitnessed arrest or prolonged down time prior to resuscitation or cancer. Elise made a strong point that in all decisions to initiate hypothermia treatment to consider their pre-arrest health status and pre-arrest prognosis. Can even use therapeutic hypothermia when given lytics for PE. Don’t use it for patients who arrested from bleeding because hypothermia will result in coagulopathy. In patients on Coumadin, you don’t need to reverse or correct their inr’s. Plavix does not preclude therapeutic hypothermia. Elise would also cool patients with hemophilia who were not actively bleeding. Patients with risk for head bleed due to trauma need head ct prior to cooling.

PICIS has algorithm for hypothermia. We will have to find out where algorithm will be stored in FIRST NET system.

There is some data to suggest that delay to cooling increases risk of death. Minnesota study shows 20% increase in death with each hour of delay to starting cooling.

New study coming down the pike: Do we need to actually cool pt’s down to 33C or is 36C good enough? European study of 875 patients is looking at this question.

Post-arrest prognostication: You have to wait until 72 hours when using therapeutic hypothermia. Cooling and associated meds can decrease brain function for 72 hours after ROSC.

Harwood question: what is the definition of coma in the post arrest patient? Elise answer: If you give a verbal command with no response or GCS <8.

Can also use hypothermia in neonatal hypoxic ischemic encephalopathy. NNT=7 to reduce death or major neurodevelopmental disability. Can use in Pediatric Cardiac Arrest.

New research to use therapeutic hypothermia for traumatic brain injury.

Remember that there is usually a culprit coronary lesion with cardiac arrest. So patients should go to cath lab after resuscitated V-Fib arrest.

Use left femoral vein for cool guard catheter.

Sam Lam Question: What about patients that re-arrest? Elise answer: if patients re-arrest or require hi dose or multiple pressors then stop cooling. Outcome is dismal.

SEE THE ACMC PROTOCOL ON THE NEXT PAGE

Levato Febrile Neutropenia

Absolute neutrophil count less than 500 is neutropenia. Temp>38 is a fever

ABx choices are Cefipime or Primaxin. Vanco is limited to specific categories listed on form (shock, skin,foreign device infection, mucositis). For beta lactam allergy: aztreonam/cipro/tobramycin. Pick 2 of these three.

Main concern in these patients is on gram neg infections.

Conference Notes 9-18-2012

September 18, 2012 Daniel Girzadas

Conference Notes 9-18-2012

Kutka/Urumov Oral Boards

Case 1: Crytpococcal meningitis in a man with AIDs. Critical actions include ordering cryptococcal antigen and/or india ink test (usual csf studies won’t pick up crytpococcal infection), giving antifungal medication (amphotericin B), rewarming for hypothermia, get a head ct prior to LP.

Andrej’s comments: cryptococcal meningitis is rare if CD4 count is greater than 100. Opening pressure can be high. High opening pressure portends a worse prognosis. Routine CSF studies can be completely normal so cryptococcal antigen and/or india ink studies are essential to making the diagnosis.

Case2: Intracranial hemorrhage. Critical actions include airway management, treat BP, elevate head of bed, treat intracranial hypertension with mannitol.

Andrej’s comments: Treat BP if over 180 systolic with a iv drip antihypertensive medication. Anti-seizure meds not routinely indicated. Some weak data showing worsened outcome with seizure prophylaxis.

Case 3: 7yo with BB gunshot to eye with a retro-orbital hematoma. Critical actions include lateral canthotomy, consult optho, pain management and prophylactic antibiotics.

Elise comment: Think about doing ct scan brain with iv contrast in patients with hx of cancer and immunocompromised patients.

Chastain 7-UP Scan for Hypotension

Non-invasive study to augment clinical evaluation in the hypotensive patient.

7 UP scan includes FAST plus lungs, aorta, parasternal echo views.

When in the sucostal window you should look at the heart for pericardial fluid, RV dilatation, and overall contractility. Paradoxical movement of ventricular septum is also an indication of PE. The septum should move from LV toward RV. If it is moving from RV to LV think PE. Also look at the cava to see if it collapses. More than 50% collapse indicates a CVP less than 10. You should take this measurement as close to the heart as possible. A crude indicator of location is that you should be looking at the ivc right by the liver.

In PSL window if aortic root is more than 4cm think about dissection. Be sure to image this window with enough depth to see the descending aorta. Frequently pericardial fluid will collect in the pericardium anterior to the descending aorta.

Lung windows can help with causes of dyspnea. Use the linear probe in the 2^nd and 3^rd intercostal spaces bilat. No sliding of pleura means pneumothorax. Increased vertical comet tails (B lines) indicates chf. Increase horizontal A lines indicates COPD or Asthma.

Apical view of heart can also show RV dilation and bowing of the septum to the the left.

LUQ view usually needs the probe to be “closer to the bed and closer to the head” than when viewing the RUQ. The spleen/liver tends to be more superior/posterior than the liver/kidney.

Wise Deadly Triad in Trauma

Hypothermia/acidosis/coagulopathy comprise the deadly triad.

Damage control surgery is temporizing procedures to obtain hemostasis.

Hypothermia: trauma causes loss of thermoregulation. Hypothermia exacerbates coagulopathy by decreasing platelet activation and altering enzyme kinetics. It also alters fibrinolysis.

Acidosis: Causes decreased contractility, vasodilation, an worsened coagulopathy. Base deficit >6 and elevated lactate correlates with increased mortality.

Fluids can cause dilutional coagulopathy and hypothermia.

2002 study with sick trauma patients: coagulopthy required BOTH tissue injury and hypotension. Protein C is over-activated in severe trauma that may be the mechanism of the coagulopathy.

Tranexamic Acid: CRASH-2 trial showed all-cause mortality benefit. Benefit in bleeding patients depended on time of administration. First hour had most benefit. After 3 hours may increase mortality.

Elise comment: ACMC does not have tranexemic acid currently.

Permissive hypotension: goal is to maintain BP only to the point of maintaining minimal adequate perfusion. Resuscitation fluids/blood products are restricted. Goal BP is 70-90 systolic. Generally accepted that patients with penetrating trauma should not be resuscitated to normal BP prior to gaining hemostasis.

Damage control resuscitation: permissive hypotension plus damage control surgery plus resuscitation volume is predominantly blood products rather than crystalloid.

Factor 7 was discredited as a resuscitation drug. Erik and Elise pounded Factor 7 into the ground during the discussion. Erik said there is new data supporting further tranexemic acid.

Recommendations: shoot for a lower BP goal, avoid large volumes of crystalloids, use the massive transfusion protocol, give TXA in the first hour, keep patients warm.

TABLE 112-1 -- Categorization and Initial Treatment of Hemorrhagic Shock*

	CLASS I	CLASS II	CLASS III	CLASS IV
Blood loss (mL)	≤750	750-1500	1500-2000	≥2000
Blood loss (% of blood volume)	≤15	15-30	30-40	≥40
Pulse rate	<100	>100	>120	≥140
Blood pressure	Normal	Normal	Decreased	Decreased
Capillary refill test	Normal	Positive	Positive	Positive
Respiratory rate	14-20	20-30	30-40	>35
Urine output (mL/hr)	≥30	20-30	5-15	Negligible
Mental status	Slightly anxious	Mildly anxious	Anxious and confused	Confused and lethargic
Fluid replacement (3:1 rule)	Crystalloid	Crystalloid	Crystalloid + blood	Crystalloid + blood

Chandra Massive Transfusion Protocol (MTP)

Massive transfusion: 10 units of prbc’s in 24 hours, or replacement of 50% of total blood volume in 4 hours. Kids is >40ml/kg prbc’s in 4 hours.

Who gets MTP?: ABC rule includes heart rate >120/bp<90/positive fast/penetrating mechanism. More than 2 criteria activate MTP. TASH score bp<100/hr>120/hgb<7/FAST/ Long bone fx/male gender.

1 unit of prbc’s increases hgb by 1. Patients that receive FFP in a 1:1 ratio with prbc’s have a lower mortality. Consensus for MTP is 1:1:1 ratio for prbc’s: platelets: ffp. Battle field data from Iraq shows improved mortality with this ratio.

ACMC protocol: 10 units prbc’s, 6 units ffp, 1 unit aphoresis platelets, and 2 units of cryoprecipitate. ER or Trauma attending has to order this protocol. The SYMS know how to order this.

Goal of MTP: Map of 65 with adequate perfusion; basically bp of 80/60 with palpable pulses and warm extremities.

Sam Lam comment: He questioned the component make up of the ACMC MTP because it is a little atypical based on trauma data in the literature.

OMI Traumatic Brain Injury

Brain injury classification: Mild GCS=14-15 Mod GCS=9-13 severe GCS=3-8

Canadian head injury rule is a validated tool to identify patients at risk for positive ct or brain injury.

40% of moderate head injury patients(GCS9-13) have abnormal ct findings and 10% require surgery.

Severe head injury patients have the highest likelihood for brain injury and highest potential for benefit from surgery. Get these patients to CT in 30minutes. Tube all these patients. Don’t routinely hyperventilate these patients. PCO2 less than 25 increases mortality.

SAH from trauma are relatively benign. Subdural hematomas tend to have significant underlying brain injury. Epidurals often have little underlying brain injury. Epidurals have great outcomes if manage properly. Epidural hemorrhages may have a lucid period between initial loss of consciousness and later deterioration. CT will be abnormal in these epidural cases from the time of initial injury.

Diffuse brain injury: concussion usually resolves in 6 hours. Diffuse axonal injury due to shearing forces from high speed mvc’s. Initial Ct will be normal despite severe coma. Later CT’s or MRI will show punctuate hemorrhages. Outcome for DAI is poor and any improvement takes months to years.

Monro-Kellie Doctrine: increasing volume inside fixed volume boney skull causes rapid increase in intracranial pressure.

Cerebral perfusion pressure=MAP- ICP. There is little data that medical care impacts outcome of brain injury. Prevention of injury and prevention of secondary injury are keys to limiting morbidity/mortality. Preventing hypoxia is probably the most important thing we can do to prevent secondary injury and lower patient mortality. Hypotension is the second most powerful factor increasing mortality in brain injured patients. After preventing hypoxia and hypotension, there is not much evidence that anything else helps outcome.

ICP monitor: keep ICP less than 20 and CPP>60. Improved outcome in patients who respond to hyperosmolar therapy. This means mannitol at 1gm/kg. Mechanism is osmotic mobilization of water across blood brain barrier. You can get hypotension from mannitol. Hypertonic is an option for osmotic therapy that does not cause hypotension.

Some centers are studying hypothermia and suspended animation for severe brain injury. The current thinking is that patients need low temp cooling for prolonged time (>48 hours).

Brain oxygenation are also being studied.

Hyperventillation: works by dropping pco2 causing vasoconstriction. This causes decreased brain blood flow and reduction in intracranial volume/pressure. It can however cause brain ischemia. So it has gone out of fmavor.

Kascia Nosek comment: If patient is breathing over the vent settings, do you sedate them to avoid hyperventilation? Dr. Omi, yes.

Steroids: no benefit in brain injury.

Anticonvulsants: Phenytoin reduces the incidence of seizures in the first week but not after.

Brett Negro comment: What are criteria for using steroids? Dr. Omi, patients with parenchymal brain injury including subdural hematomas should get phenytoin or phosphenytoin. Keppra may be another option. Anticonvulsants are all stopped at about a week.

Elise comment: Ketamine is probably a good choice for an induction agent in the hypotensive brain injured patient. The risk of increasing intracranial pressure is low and it is less likely to cause more hypotension than etomidate.

Conference Notes 9-11-2012

September 11, 2012 Daniel Girzadas

Conference Notes 9-11-2012

Kettaneh 5 Causes of ST Elevation

STEMI
Benign Early Repolarization: People under 50yo, J point notching, concave up ST elevation, Prominent T waves concordant with QRS
Pericarditis: Diffuse STE and/or PR Depression, Reciprocal changes only in AVR (ST depression and PR Elevation)

For deciding between Early repol and pericarditis: ST segment elevation compared to T wave height ratio in V6 is greater in pericarditis (STE height/T wave height). The T wave in early repol is taller than in pericarditis and the ratio is lower in early repol.

Bundle Branch Block. Sgarbossa criteria: 1mm Concordant st elevation, 1mm Concordant st depression, discordant st elevation >/= to 5mm. Cabrera’s sign: notching in S wave in V3-4. Chapman’s sign notching in the R wave V6.
LV Aneurysm: can lead to sudden cardiac death, arrhythmia, thrombus. Consider after MI, absence of hyperacute T waves.

Other causes: brugada, lvh, hyperkalemia, hypercalcemia, myocarditis.

Girzadas question: Is benign early repol actually benign? Answer: there is controversy but most references feel it is benign . Silverman comment: BER has an emerging literature that shows a possible risk of sudden cardiac death. However, no one knows what to do with this EKG finding. There is no treatment protocol currently for this.

Harwood comment: Pericarditis vs. Early repol use tp segment as your baseline for identifying PR depression. For figuring out the ST to T wave ratio use the PR segment as your baseline. PR depression boosts the ST elevation part of the equation increasing the ratio in pericarditis.

Herrmann 5 Causes of Wide QRS

Harwood comment: The best lead to measure the width of the QRS is the lead with the widest QRS.

Bundle Branch Blocks: QRS>120ms. RBBB can be associated with heart disease and PE but can also be present in normal hearts. RBBB in an acute MI confers increases mortality. If wide and up in V1 it is RBBB. If wide and down in V1 it is a LBBB.
Ventricular Rhythms: PVC’s are common in nl hearts. Rules of malignant pvc’s : frequent pvc’s, couplets/triplets, multiform, pvc on t wave. Ventricular escape rhythms are another cause of wide qrs. Accelerated idioventricular rhythm is associated with reperfusion with TPA.
TCA Overdose:Look for wide QRS generally and tall/wide R wave in AVR
Hyperkalemia: Always consider this if the QRS is wide. The ekg may also show a slow rhythm with loss of p wave.
WPW: Slurred upstroke of the QRS complex (delta wave) due to accessory pathway. Delta wave widens the QRS and shortens the PR interval.

Barounis STEMI Conference

Case 1: LR’s for historical items indicative of AMI is highest for radiation to both arms, radiation to right arm, diaphoresis, and radiation to left arm. Pressure has a relatively low LR of 1.3. chest pain that is reproducible has a LR of 0.4 which lowers the risk but does not make the risk 0. When you don’t have an old ekg to compare with, make an old ekg by getting another ekg to look for evolution.

Comments: The ekg had subtle st depression in 1/AVL. Some subtle st segment straightening inferiorly.

2^nd EKG was diagnostic for inferior STEMI (STE greatest in 3)

Harwood/Silverman Comment: Gotta get a repeat EKGwithin 10 minutes. MD may have to stay at bedside for 10 minutes to get another EKG in high risk patients.

Other guest comment: Women will present with symptoms that can be atypical.

Case 2: Evolving Inferior MI. Cardiology comments an evolving ekg with chest pain should go to cath lab. Recent normal stress test does not preclude AMI. PT should go to cath lab even if ekg improves with ntg if other ER ekg’s were concerning.

Dr. Silverman comment: Don’t delay more than 3 minutes waiting for return call from patient’s primary cardiologist. After a 3 minute delay gotta contact intervential cardiologist on call. He felt safest option is to call STEMI first and after that attempt contact with the primary cardiologist. That way you get both cardiologists as rapidly as possible.

Case3: EKG initially was non diagnostic in a young patient with chest pain. Dr. Silverman advised stat echo in this situation. If echo is nl, ekg is likely not stemi but more likely BER. If echo is abnormal, then pt should go to cath lab.

CT angio for CAD: Cardiologists generally not for it due to radiation exposure and low sensitivity. Dr. Trevedi did say it has a good negative predictive value. Dr. Trevedi felt hypertensive patients with chest pain may be a good pt group to use this test. It give info about aortic dissection in addition to showing the coronary arteries.

Mila Felder’s summary points:

Repeat EKG in 10-15 min if questionable EKG and/ or persistant pain. EKG department and ED techs are accountable for giving it to physician to review. There is follow-up pending to making sure copies of EKGs are placed on the chart.
In case of dynamic EKG and consistent story, activate code STEMI. During the day, the patient's cardiologist may be able to take them to lab if ready to go and able to get to the hospital immediately. Do not delay care/ cath for convenience, and ok to use interventionalist on call to avoid delay in door to cath.
Pay attention to early repolarization (no longer considered benign). In case of consistent story, evaluating heart rate, other lead changes, potassium level, and other historical facts, be suspicious of early MI. Additionally, easy to miss the blocks in conduction when only looking for ST changes.

McKean Syncope

Brugada: Has been diagnosed in patients age 2-82. EKG findings can be transient. Pt’s have RBBB pattern with STE in septal leads. Fever can bring out the findings. Treatment is an AICD.

WPW: Treat with electricity for unstable patients and procainamide for stable patients.

Long QT syndrome: risk of polymorphic V-Tach. Measure from start of Q to end of T. Quick and dirty is QT should be less than 0.5 the RR interval. Treat with AICD.

HOCM: LVH without inciting stimulus. Thickening of intraventricular septum. You can get exertional syncope due to dynamic LV outflow changes. On EKG pt’s will have LVH and deep narrow q waves V4-V6. Treatment is myomectomy and pacer/aicd

PE: Sinus tach is most common EKG abnormality. Also look for RV strain pattern (t wave inversions inferior and anterior-most specific finding). Pt’s may have RBBB. S1Q3T3 is nonspecific.

A number of ekg examples were discussed along with some embarrassing old pictures of residents especially Barounis.

Harwood pimp question: What is LGL? Brian Febbo knew it is WPW with no delta wave. Lown-Ganong-Levine Syndrome is diagnosed by the presence of a short PR interval and normal QRS complex on the surface electrocardiogram (ECG).

Kessen Heart Blocks

Sorry I missed part of this lecture.

Lenegre’s DZ: fibrotic sclerodegenerative change of conduction system progresses to complete heart block

Lev’s DZ: sclerosis of left side of heart in older patients causing heart block

1^st degree av block: PR interval >0.2msec=5 small boxes.

2^nd degree AV block Type 1=Wenckebach. Progressively longer pr intervals. RR interval shortens until the qrs gets dropped. Not treatment indicated.

2^nd degree AV block Type 2: PR interval remains constant before and after non-conducted atrial beat. Atrial rhythm is regular and ventricular rhythm is irregular.

Look for AV block with inferior MI’s.

Harwood comment: SA block is uncommon but it happens. You can only see type 2 Sinus block on an ekg. You can’t see Type 1 or 3 SA block. SA block is different than AV block.

Second degree SA nodal exit block has two types.

§
§ In type II exit block, the P-P output is an integer multiple of the presumed sinus pacemaker input

Sayger/Felder/Katiyar /McGurk Billing and Coding

All pneumonia patients going to ICU require blood cultures before antibiotics.

You need 10 ROS systems for level 5.

Document that you visualized and interpreted the xray and give your interpretation.

Document the number of and type and drug that you used for nebulizer treatment.

You need either a social or family hx to get a level 5.

Keep track of your time you spend with critically ill patients. Any time the attending spends on the care/ordering/discussion/documentation/decision making with the critically ill patient should be counted toward critical care time.

You need 8 organ systems on physical exam to bill a level 5.

Mnemonic: FORTUNATE 4-2-10-8. 4 HPI items, 2 history items, 10 ROS items and 8 physical exam items to bill level 5.

Ryan Medical Student Review Confidential Meeting

Conference Notes 8-28-2012

August 28, 2012 Daniel Girzadas

Conference Notes 8-28-2012

Grippo Ortho Jeopardy

Perilunate Dilocation: Look at the lateral view of the wrist. The capitate/lunate/radius need to line up. If the capitates is dorsal to the lunate the dlx is perilunate. If the lunate is dislocated volarly, it is a lunate dlx.

Supracondylar FX: 60% of peds elbow fxs. Severe fractures that are not treated properly can develop Volkman’s ischemic contracture.

Femoral neck fractures: Have risk of avascular necrosis. Older patients will get a arthroplasty.

Scapholunate DLX: widening of space between scaphoid and lunate. Terry Thomas sign. Treat with radial splint.

Montaggia Fx: Proximal ulnar fx with dislocation of radial head.

Galeazzi Fx: Distal radius fx with dislocation of radio-ulnar joint. Mnemonic is MUGR=montaggia/ulnar fx galeazzi/radial fx

Bennet’s Fx: Intra-articular fx at base of thumb.

Barton’s Fx: Distal radius fx with intra-articular involvement. Usually fx goes thru volar aspect of radius. Can have either dorsal or volar angulation.

Bohler’s Angle: Normal is greater than 20 degrees. If less than 20 degrees that is indicative of a calcaneous fracture. With calcaneal fractures check for compartment syndrome in foot. Also look for other joint and spinal injuries in patients who fell from height.

Lis Franc Fx: tarso-metatarsal FX/DLX. Look for fx at base of 2^nd mt and/or non-allignment of based of second MT and middle cuneiform.

Boxer’s fx: Needs reduction if angulation >40 degrees. If pt has associated fight bite give antibiotic prophylaxis. After reduction place in ulnar gutter splint with finger in flexion.

Lovell comment: Frequently fight bite injuries require OR irrigation and debridement. Harwood added that in the OR it can be determined whether the bite went into the joint space. Both felt IV antibiotics were indicated and hand consult for either OR or Obs admit or Very close follow up. This is high risk medico-legal situation.

Jone’s Fx: Fx of metaphysis/diaphysis junction of 5^th MT. Risk of nonunion. Non-weight bearing for 6 weeks. Needs Ortho follow-up. Psuedo-Jones Fx is basically an avulsion fx of tuberosity of 5^th MT. These heal well and only require cast shoe.

Salter Harris FX: Type 2 is most common. Mnemonic is ME: metaphysis involvement is a 2, epiphysis involvement is a 3. 1 is easy to remember because it is just thru the physis and 4 is also easy because it goes thru both the metaphysic and epiphysis. 5 is a compression injury to the physis.

Pilon Fx: Bad comminuted distal tibial fx due to talus ramming into tibial plafond due to a fall from height.

Chauffeur’s(Hutchinson’s) Fx: Fx of the radial styloid. Used to occur when turning the crank of early model cars.

Barounis Undifferentiated Shock

Shock: Inadequate O2 delivery to meet tissue demand.

Oxygen delivery=(HR x SV) x 1.34 X HGB X SAO2 X10. HGB and O2 Sat are the most important factors for O2 delivery.

Shock is bad because it results in anaerobic metabolism and lactate production. The sodium potassium pump malfunctions. Lactate is the cry of poorly perfused mitochondria.

Types of shock:

Obstructive (tamponade/tension pneumo/pe/auto peep/rv infarct) Eval for this is to listen to breath sounds, use ultrasound. Check EKG for signs of RV infarct; lead III will have more st elevation than lead II. Check for auto-peep on vent.

Distributive shock: (sepsis/cyanide/anaphylaxis) Bounding pulse with hypotension.

Cardiogenic Shock: cool clammy, altered mentation

Hemorrhagic shock: the patient is bleeding.

Approach to shock: Assess heart rate (pulse is not the main issue between 60 and 180), make a volume assessment/obstructive assessment (cvp/U/S of VC /urine output/gingival mucosa), assess contractility with U/S, figure out the SVR (check extremities for warmth/bounding pulse/coolness/decrease pulse)

On ultrasound if IVC collapses more than 50% with inspiration the patient is volume responsive. This assessment is obtained with the subcostal long view of aorta. You also want to check the abdominal aorta/pericardium/rv /morrison’s pouch.

History is unreliable in the assessment of shock. Physical findings are more reliable than history.

PEEP helps push fluid out of the lungs into the right heart. Also the increased thoracic pressure from PEEP helps move blood to abdominal organs/brain/extremities by pressure gradient.

Jim Jensen PharmD Vasopressor Review

Dopamine: Indications septic shock, hypotension without hypovolemia, symptomatic bradycardia. Can cause arrhythmias.

Levophed: More potent alpha agonist. Indicated for septic shock or hypotension due to low svr. Increases myocardial oxygen demand, may cause arrhythmias.

Phenylepherine: Soley an alpha agonist with no beta effects. Last line pressor . Start high dose and titrate down because it is a relatively weak vasopressor. Harwood comment: Only use for this agent is neurogenic shock.

Epinepherine: Mixed alpha and beta agonist. Indicated in ACLS, septic shock after dopamine or norepi, anaphylactic shock.

Vasopressin: Smooth muscle vasoconstriction. Inidcated in ACLS and is an option in septic shock with catecholamine resistance.

If a vasopressor extravasates out of the vessel, you can use phentolamine locally to counteract the effects of the vasopressor. Harwood comment: Give the phentolamine through the IV that extravasated so that the antidote goes right to where the tissue injury has occurred.

Central line is required for Epinepherine drip and norepi drip. Central line not required for dopamine, phenylephrine, vasopressin.

Dobutamine:Beta agonist that increases cardiac contractility/cardiac output and vasodiates. Can cause arrhythmias and hypotension.

Milrinone: Phosphodiesterase inhibitor increasing CAMP. Increases cardiac output but does cause vasodilation.

Plavix vs. Ticagrelor (Effient): Ticagrelor has a stronger antiplatelet effect and has been shown to reduce thrombotic events compared to Plavix. This comes with the cost of higher rate of bleeding. ASA dosing over 81mg decreases the effectiveness of Ticagrelor.

Carlson Toxicology Antidotes

Antidote: Any treatment that lowers the LD50 of a toxin. Direct antidotes act right at the site of the toxins action. Indirect antidotes are supportive such as cooling, oxygenation, folate co-factor replacement etc.

Fomepizole is antidote for toxic alcohols. Blocks alcohol dehydrogenase. Pyridoxine is co-factor antidote for ethylene glycol. Folate is a co-factor indirect antidote for methanol.

Lead poisioning: Antidotes are succimer, BAL, EDTA. In severe cases use BAL and EDTA both. Can’t give BAL to patients with peanut allergy.

Mushroom poisoning with seizure: Antidote is pyridoxine for gyromitra poisioning. Gyromitra acts similar to INH and blocks GABA production.

Clonidine poisoning: Antidote is narcan. May need higher dose. Repeated 2mg doses up to 10 mg. There is controversy about the effectiveness of this antidote.

Hydrogen sulfide poisoning: Antidote is sodium nitrite for the sulfhemoglobinemia. HBO is a second line direct antidote for this as well.

Calcium channel blocker OD: First line tx for severe OD’s is Insulin 0.5U/kg bolus followed by 0.5U/kg/hr drip and supplemental glucose therapy.

Anticholinergic toxidrome: Antidote is benzodiazepines first line. Physostigmine is a direct antidote that should only be used with caution. There is EM literature that shows physostigmine is actually relatively safe in patients with clear cut anticholinergic symptoms without other coingested substances. The problem is that clear cut isolated anticholinergic OD’s are not very common.

Paraquat: Antidotes are Fuller’s earth, bentonite. Don’t give O2 because it will cause pulmonary fibrosis.

Coral snake: Red on yellow, Kill a fellow. Coral snake (elapid) antivenin. Red on black, venom lack refers to a non-venomous milk snake.

Sulfonylurea overdose: Antidote is glucose and octreotide.

Methylene Chloride: Methylene chloride is broken down to CO in the liver. Treat with HBO. Methylene choloride has a long duration of action so patients may need multiple dives.

Lily of the valley, fox glove,and oleander are plant sources of cardiac glycosides (digoxin): Antidote is digibind. Atropine can also work by reducing vagal tone.

Rattle snake bite: Antidote for crotalid bites is crotalid antivenin. Indications for antivenin are local spread, coagulopathy , abnormal vitals. Mnemonic: Spread, bled, almost dead. Give 5 vials minimum. Be prepared to manage anaphylaxis.

Hydroflouric acid: Treat with calcium gluconate. Don’t use calcium chloride because it can cause tissue damage. Pt will have a lot of pain. Can give calcium gluconate via topical gel, local injection, and intra-arterial infusion. Needs hand consult or transfer to burn center.

Methemoglobinemia: Treat with methylene blue. HIV patients with G6PD deficiency on dapsone for PCP can develop methemoglobinemia.

Amanita Phylloides muchroom. Will cause vomiting more than 6 hours after ingestion. Amanita acts like amped up apap resulting in centrilobular necrosis of liver. Antidote is nac.

Organophophates: Treat with atropine and 2-PAM. If you have tachycardia with cholinergic OD think hypoxia as secondary to pulmonary/airway secretions. Still need to give atropine. 2-PAM regenerates acetylcholinesterace.

Willison/Carlson Oral Boards

Case 1. Transverse myelitis. Critical actions were perform detailed neuro exam, rule out cord impingement with mri, foley decompression of bladder. Triad of sudden onset back pain, sensory changes (including allodynia) and weakness/sphincter dysfunction. #1 thing for emergency physician to do is rule out cord compression. Most references advise steroid treatment. Can be a harbinger of MS or sarcoid.

Case2. Depakote(valproic acid) overdose with severely high ammonia level. Critical actions were intubation, check valproic acid and ammonia levels, treat with L-carnitine. Can dialyze for severe cases. Metabolism of depakote requires carnitine. When you use up your carnitine you produce the toxic metabolite ammonia. Giving l-carnitine allows normal metabolism of depakote.

Case3. Molar Pregnancy. Critical actions were give iv fluids, get beta hcg, get u/s and identify molar pregnancy, consult ob-gyne. Molar pregnancies occur 1 in 1200 pregnancies. Increased risk at extremes of age. Two types genetically 69xxx or 69xxy or 46xx or 46 xy. There is a chance of malignancy in both types. Worst outcome is with patients that present with lung mets. BHCG is usually great than 100,000. Uterus is larger than expected for age.

Conference Notes 8-21-2012

August 21, 2012 Daniel Girzadas

Conference Notes 8-21-2012

Schwab/Barounis Oral Boards

Case 1. Toxic Alcohol-Methanol ingestion. Recognize anion gap acidosis. Calculate osmolal gap. Give Fomepizole. Arrange for hemodialysis. Pt required intubation to protect airway. Bicarb drip may be used for acidosis but it is not a critical action.

Case 2. Anterior Shoulder Dislocation. Perform neuro-vascualar exam of injured extremity. Give procedural sedation or intra-articular anesthetic. Use any described reduction technique.

Case 3. Retropharyngeal Abscess. Identify pre-spinal soft tissue swelling. >7mm at C2 or >14 at C6 is abnormal. The pre-vertebral soft tissue width should not exceed the width of the vertebral bodies. CT of neck will give more detail of soft tissues than plain radiograph. Give appropriate IV antibiotics. Intubation is rarely required unless patient looks very sick and is planned to be transferred. Surgical airway may rarely be required.

E Kulstad Work up for PE

The prevailing thought is that we try to identify PE’s to save someone’s life. This idea is based on older data that found PE’s to have a reasonably high mortality. Current data from Jeff Kline 2008 shows that in 13 ED’s in the US and NZ the overall PE mortality is 0.2% (13/8138).

Is PE mortality lower today because of better treatment? There is only 1 controlled trial of anticoagulation for venous thromboembolism. This one study showed no treatment difference between heparin and ibuprofen. The thought is that mortality is better today due to emergency physicians casting such a wide net that we are identifying small clinically insignificant PE’s. That broader group has a much lower overall mortality.

Small peripheral PE’s pose an unknown threat. Small clots may be transient and normal. If we scanned everyone in the audience, we would find a few small PE’s. One study showed a 20% rate of PE in autopsies for persons killed instantly by a traumatic accident.

When using a low specificity test in a population with a low prevalence of disease (ie. CT for PE in low risk patients) false positives exceed true positives. The PERC study showed a 7% prevalence of PE based on imaging. Probably many (most?) of these positive scans were false positives. To make matters worse inter-rater reliability between radiologists reviewing scans to identify PE is not very good. The more likely prevalence based on calculations Erik walked us through is 2.3%.

Assume there is an 80% reduction in mortality of PE due to heparinization. This is likely a gross overestimation of treatment effect. Erik then walked us through calculations of harm and benefit of identifying and treating PE. Risks of harm include renal injury, cancer risks, risks of hemorrhage. The final calculations show that work up and treatment for PE causes more harm than benefit for patients. These calculatons use conservative estimates of harm and generous estimates of benefit. The conclusion is that current practice of working up PE’s has 6X greater chance of harm than benefit.

In the US standard of care probably forces us to persist in working up patients for PE.

Lovell comment: Can we use normal vitals to not pursue a work up? Can we use a higher d-dimer cut off for low risk patients? Erik responded yes to both. You can use a double of the standard d-dimer cut off for low risk patients.

Barounis comment: He got a response from the author Dave Neuman that pt’s with a Well’s score less than 2 need no further work up .

Gourineni Peds Ortho

If pt has limb ischemia due to a fx or dlx you should immediately attempt reduction. Then consult both Ortho and Vascular Surgery. Don’t allow the child to eat or drink in the ER if there is any chance of patient going to OR.

Compartment syndrome: Gourineni feels compartment pressure measurements are not accurate. He prefers the symptom of muscle pain and sign of tense compartment. He also likes the delta pressure which is the difference between diastolic blood pressure and compartment pressure. Pain with passive movement is also a sign he favors. If you suspect compartment syndrome call both the Ortho resident and Ortho Attending. Keep limb at heart level, remove any bandages, reduce any deformity. These patients require surgery in 3-4 hours.

Open fractures: Early antibiotics with ancef is more important than timing of surgical debridement. Open fractures of hand do not require surgery. Irrigation and antibiotics in the ER is adequate for hand or distal extremity open fracutes.

Dislocations: All dislocations need to be reduced in ER. Delay in reduction in elbow/knee/ankle/foot will result in ischemic injury. 40% risk of posterior tibial artery injury in knee dislocations. Make sure joint has good range of motion after reduction. If it doesn’t, Dr. Gourineni wants to know about it.

Fractures: Boney deformity tends to straighten out. Deformity does not improve around elbow. So, all displaced elbow fractures require ORIF. Splints should be long for supracondylar fx’s to proximal humerus. Femur fractures need a splint extending up to chest wall.

Clavicle: most clavicle fx’s are treated non operatively. Surgery is required for skin tenting or posterior sterno-clavicular dislocation.

Proximal humerus fx: 100% displacement and 1cm of shortening will spontaneously remodal. This is due to majority of bone growth at proximal humerus.

Supracondylar Fx: Look at anterior humeral line. If it bisects the condyle there is minimal displacement. These patients can be splinted and discharged with close ortho follow up. If the condyle is posterior to anterior humeral line there is significant displacement and pt should be admitted for surgery. If there is vascular compromise, pt will go to OR in a few hours. Splints should not be at 90 degree flexion. 30-45 degrees is better. Check interosseus nerve and radial nerve function with thumb IP flex/extension or OK sign.

Monteggia Fx-Dlx: Think of this any time you see a proximal ulnar fx. It is the combination of proximal unlar fx and radial head dislocation. If the radial head doesn’t line up with the capitellum it is dislocation.

Elbow dislocation: For all elbow dislocations do the Roberts maneuver. Extend and supinate wrist to remove any boney particles in elbow joint.

Displaced distal forearm fractures will frequently heal and remodel in 2-3 months. You don’t need to reduce most of these. If parents want it reduced and you feel you can reduce it, it is ok to attempt reduction.

Any hip pain should initiate an Ortho consult.

MCP dislocations that are angulated not parallel to bone should be reduced by not pulling the digit but rather pushing the digit closer to the metacarpal bone and sliding the digit back into place.

Lis Franc: If patient has tenderness with torsion of forefoot. Get an xray looking for fx of prox 2^nd metatarsal or non-allignment of middle cuneiform and 2^nd metatarsal. Either way if xray is nl or abnormal splint patient and keep them non-weight bearing with follow up in Ortho clinic.

Joint Aspiration and Reduction Clinic

Conference Notes 8-14-2012

August 21, 2012 Daniel Girzadas

Sorry, I was on Vacation.

Conference Notes 8-7-2012

August 7, 2012 Daniel Girzadas

Conference Notes 8-7-2012

Grippo/Lovell Oral Boards

Case 1: Central Cord Syndrome: Treat with application of cervical collar, ct the cspine for evaluation for fracture. Recognize weakness in upper extremities. MRI to evaluate the spinal cord. Steroids for this injury is controversial. Consult neurosurgery. ICU admit. Identify urinary retention. Central cord is the most common incomplete spinal cord injury. Classic case is old person/hyperextension injury/arms weaker than legs. Check for pain and temp perception in suspected cord injuries.

Case 2: Cardiogenic Shock: Patient with Hypotension and hypoperfusion with AMI. Treat with BIPAP or intubation. Diagnose STEMI. Support hemodynamics with inotrope and pressor (dobutamine/dopamine). Cardiovert unstable VT. Get to the cath lab. These patients look very sick and may have altered mental status.

Case 3: Nasal Foreign Body: Treat with parent giving forceful breath into patient’s mouth. Works 50% of the time with non-sharp edged objects. Multiple other techniques are available to remove the FB (suction, fogarty catheter). Button batteries in nose can cause necrosis.

Harwood comment: Best approach to the steroid issue is discuss that it is controversial and then either give or not give. Probably better to intubate the patient so they can be more safely managed in the cath lab.

BINGISSER Geriatric EM

Dr. Bingisser is a practicing EP in Switzerland. ED’s in Switzerland also have crowding issues.

Seniors take taxis to the ER because it is cheaper than an ambulance. The Rolling Stones took along a geriatrician on their last European tour.

Problems managing elderly patients: poor communication/atypical presentations/broad spectrum of illness/complex interaction of social/medical problems/non-specific complaints/subtle vital sign changes to serious illness.

Triage in the elderly is difficult for the above reasons. Elderly patients are commonly undertriaged. Vital sign abnormalities were commonly unrecognized. Also high risk situations are frequently unrecognized.

Localized weakness: 75% were strokes 25% were stroke mimics. Genralized weakness complaints turned out to include diagnoses from all ICD9 code chapters.

Non-specific complaints: 1 year mortality for elderly patients with nonspecific complaints in Dr. Bingisser’s study was 13.5%. 30 day mortality was 6.4%. In 1210 patients, they made over 300 different diagnoses! Uti was most common cause and over 50% of those also had sepsis. 50% of ED diagnoses for non-specific complaints were incorrect. 6 predictors for serious outcomes of elderly patients with nonspecific symptoms are elevated BUN, low sodium, elevated CRP, history of exhaustion, clinician gestault, chf.

Viswanathan/DKA

I missed this lecture giving Dr. Bingisser a tour of our ER, sorry. But, I did hear,” don’t bolus insulin or Dr. V. will hurt you”.

Roy Peds Vignettes

Case 1: Lethargic 6 month Infant, ddx includes CNS/tox/sepsis/metabolic/trauma/hypoglycemia/inborn errors/intussusception. Toxic encephalopathy can include hypertensive encephalopathy in kids due to post-strep glomerulonphritis. MCAD is a substrate dependent inborn error of metabolism that presents as hypoglycemia when a child doesn’t eat as regularly as normal due to an illness or sleeping longer. Unexplained neuro symptoms in an infant, you should think GI process. Think shigella in a febrile infant with diarrhea and seizure. Classic case of intussusceptions is lethargic kid in second half of first year of life. KUB in intussusceptions may show paucity of gas on right side. Intussusception used to be uncommon in kids under 4 months. However, now with rota virus vaccine it is possible under 4 months. Dr. Roy has seen 5 cases in the last two years in kids under 4 months. If the child has not had a rota virus vaccine, it is unlikely to get intussusceptions under 4 months of age. HUS is another cause of lethargy and seizures in an infant. Think HUS in a kid with gastro that got better then gets sick again 1-2 days later. Check a CBC in a gastro kid who has had a course of illness of 4-5 days to look for low platelets or hemolysis/anemia. CBC findings will precede bun/cr changes. Dr. Roy makes a point about the change in color in kids with intussusceptions or HUS. Kids can also get HUS from pneumococcus.

Unexplained respiratory symptoms in an infant think: Heart-CHF (check the liver for swelling). Myocarditis clues are marked tachycardia, tachypnea, murmur. GERD. Upper airway obstruction such as laryngo-tracheomalacia/sub-glottic stenosis/croup is unlikely in a young infant

Xrays are not necessary in most asthmatics or most simple croupers. Epiglotitis doesn’t bark like a seal. They usually have muffled voice and are drooling because swallowing is painful.

Nausea/vomit/abdominal pain without fever or diarrhea is DKA until proven otherwise.

Fever for 5 days is Kawasaki’s until proven otherwise.

Puffy eyes and puffy hands in kids is a renal problem until proven otherwise.

Do a CBC in a limping kid to eval for leukemia. 1 out of 7 kids with new onset leukemia presents with musculoskeletal pain. Don’t believe the parents’ story of trauma.

Case 2/3: 3 week old infants with vomiting. Think pyloric stenosis. Olive mass in ruq is uncommon. If child has low sodium and high potassium think congenital adrenal hyperplasia. Look for hyperpigmented scrotal skin in kids suspected of congenital adrenal hyperplasia.

Sickle rules: fever warrants admission. Get a retic count to r/o aplastic crisis. Respiratory or chest complaints require a CXR for acute chest syndrome. Check spleen for sequestration crisis. Most of the sequestration crises at ACMC over the last decade have been kids over the age of 10.

Grippo ACLS Update

Switch out your persons doing compressions every 2 minutes. Avoid over-bagging.

Defib with 200J biphasic.

1mg epi or 40u of vasopressin

Amiodarone 300mg IV

PEA: consider causes like pneumothorax, hyperkalemia

Bradycardia: Atropine 0.5mg to 3mg max. Transcutaneous pacing. If you can’t capture with TCP,try epi drip or dopamine drip. Last line is transvenous pacing.

Wide Complex Tachycardia: If unstable with pulse cardiovert. If no pulse defibrillate.

Narrow complex tachycardia: SVT/AFIB with RVR/AFutter/MAT

Wide and Irregular: WPW with AFIB, AFIB with BBB

Harwood comment: Use your right hand to help differentiate RBBB and VT. In RBBB second rabbit ear should be taller like your right hand with the 3^rd finger taller than the index finger. If the first rabbit ear is taller, it is more likely to be V-tach.

Conference Notes 7-31-2012

July 31, 2012 Daniel Girzadas

CONFERENCE NOTES 7-31-2012

CHASTAIN/GIRZADAS ORAL BOARDS

n CASE 1: Ethylene glycol poisoning.

n Intubate (PC)

n Treat with 4-Methyl Pyrazole ( fomepizole 15 mg/kg) or ETOH (PC,MK)

n Arrange Hemodialysis (MK,SBP)

n Give Antibiotics for aspiration pneumonia (MK, PC)

n Anion Gap= Na-(CL + HCO3)<15

n Osmolal Gap= 2X Na + Glucose/18(20) + BUN/2.8(3) + ETOH/4.6(5)

n Measured Value - Calculated Value <20

CASE 2: Femoral artery injury due to GSW

n IV fluid bolus 20ml/kg (PC)

n PRBC transfusion 15ml/kg (MK, SBP)

n Identify Hard Signs of vascular injury and perform ankle/brachial index (MK)

n Trauma/Vascular surgery consultation (SBP, PC)

n Hard signs of vascular injury mandate angiography or surgery.

n Pulsatile bleeding

n Pulsatile hematoma

n Bruit/thrill

n Absent/diminished pulse distal to injury=ABI<0.9

n Ischemic signs (pain, pallor, coolness, paralysis)

CASE 3: Pyloric Stenosis

n Consider Pyloric Stenosis (pmh, olive, BMP, U/S, Upper GI) (PC,MK)

n IV hydration (20ml/kg)

n Admission for planned surgery (SBP)

n Hypo-chloremic/kalemic/natremic metabolic alkalosis

n Today most are diagnosed prior to electrolyte abnormalities

n Males more common 5:1

n Associated with macrolide antibiotics

n Laproscopic Pyloromyotomy

WOOD MEDICAL-LEGAL ASPECTS OF EM

Philosophy: the study of questions that can’t be answered. Religion:the study of answers that can’t be questioned.

Case 1 Chronically ill elderly patient with hypoxia. Husband wants everything done. Autonomy is the primary ethical rule but pt’s have to have understanding. If pt can’t make decision. There is a principal of implied consent in situations of emergency. Husband has the power to decide for wife. But what if husband is demanding futile care? Decision making can only be taken away from husband if he lacks decisional capacity. Answer is to inform husand that further work up/treatment may worsen suffering and palliative care may lessen suffering. It is ok to discontinue ventilator. There is no distinction between action and inaction. Taking patient off ventilator is acceptable. It is ok to give small doses of opioids/benzodiazepines to relieve suffering. Don’t give a large dose that could kill a terminal patient. Document how the patient looks and document your intent to relieve suffering.

Case 2 Man found unresponsive in his car. He is a nurse who is abusing oxycontin. It is ok for doctors to speak with other MD’s if it is in the context of treating the patient. Confidentiality is well supported by law and custom but it is not absolute. Exceptions exist due to societal interest. Doctors are required to report child abuse or turn in weapons. Doctor-patient relationship is much less protected legally than attorney-client relationship. The doc has a duty to turn drugs (evidence) over to the police or security. You are more likely to get sued for not reporting something than for reporting something.

How do you determine decisional capacity. If you have a 0.8 etoh level, there is a legal presumption that you have lost the psycho-motor skill to operate a car. There is NOT the legal presumption that a patient gives up all their rights to leave the ED as long as they are not driving. An etoh level above 0.8 is not grounds alone to forcibly restrain a patient from leaving the ED.

Case 3 16yo female who had sexual encounter. Doctor refused to give post-coital contraception based on his own moral code. There is no statute in any state that says you must be 18yo to consent for medical care. No doctor has ever been successfully sued for non-negligent treatment of kids over 14 without consent from parents. 32 states have a statute saying it is ok for docs or pharmacists to not tell a patient about contraceptive/abortion options if it is against their conscience. If a patient asks the doc if there is a morning after pill option for her, the doc can’t lie and say there isn’t.

Dr. Woods Notes: Notes and Bibliography

Legal and Ethical Issues in Clinical practice.

Joseph P. Wood, M.D.,J.D

Principles of medical ethics

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. 

A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. 

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. 

A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. 

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. 

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. 

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. 

A physician shall, while caring for a patient, regard responsibility to the patient as paramount. 

A physician shall support access to medical care for all people.

Adopted by the AMA's House of Delegates June 17, 2001.

Case of Patient in a Vegetative State

Medical definition

Any person with an illness that is not able to function properly without artificial help.

Legal/ethical definition

As opposed to brain death and comatose, PVS is not recognized as death in any legal system. This ethical grey area has led to several court cases involving people in a PVS, those who believe that they should be allowed to die, and those who are equally determined that, if recovery is possible, care should continue. This ethical issue raises questions about autonomy, quality of life, appropriate use of resources, the wishes of family members, professional responsibilities, and many more.

History

The syndrome was first described in 1940 by Ernst Kretschmer who called it apallic Syndrome.[1] The term persistent vegetative state was coined in 1972 by Scottish spinal surgeon Bryan Jennett and American neurologist Fred Plum to describe a syndrome that seemed to have been made possible by medicine's increased capacities to keep patients' bodies alive.[2][3]

[edit]

Classification

Terminology in this area is somewhat confused. While the term persistent vegetative state is the most frequent in media usage and legal provisions, it is discouraged by neurologists, who favour the terminology of the Royal College of Physicians (RCP) which refers only to the vegetative state, the continuing vegetative state, and the permanent vegetative state.[4]

The vegetative state is a chronic or long-term condition. This condition differs from a persistent vegetative state (PVS, a state of coma that lacks both awareness and wakefulness) since patients have awakened from coma, but still have not regained awareness. In the vegetative state patients can open their eyelids occasionally and demonstrate sleep-wake cycles. They also completely lack cognitive function. The vegetative state is also called coma vigil. The continuing vegetative state describes a patient's diagnosis prior to confirmation of the permanence of the condition. The permanent vegetative state occurs when the vegetative state is deemed permanent; a prediction is being made that the patient will never recover awareness. This prediction cannot be made with absolute certainty. However, the chances of regaining awareness diminish considerably as the time spent in the vegetative state increases (Royal College of Physicians, 1996).

This typology distinguishes various stages of the condition rather than using one term for them all. In his most recent book The Vegetative State, Jennett himself adopts this usage, on the grounds that "the 'persistent' component of this term ... may seem to suggest irreversibility".[2] The Australian National Health and Medical Research Council has suggested "post coma unresponsiveness" as an alternative term.[5]

[edit]

Signs and symptoms

Most PVS patients are unresponsive to external stimuli and their conditions are associated with different levels of consciousness. Some level of consciousness means a person can still respond, in varying degrees, to stimulation. A person in a coma, however, cannot. In addition, PVS patients often open their eyes, whereas patients in a coma subsist with their eyes closed (Emmett, 1989).

PVS patients' eyes might be in a relatively fixed position, or track moving objects, or move in a disconjugate (i.e. completely unsynchronized) manner. They may experience sleep-wake cycles, or be in a state of chronic wakefulness. They may exhibit some behaviors that can be construed as arising from partial consciousness, such as grinding their teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming without any apparent external stimulus.

Individuals in PVS are seldom on any life-sustaining equipment other than a feeding tube because the brainstem, the center of vegetative functions (such as heart rate and rhythm, respiration, gastrointestinal activity), is relatively intact (Emmett, 1989).

(Available on Wikipedia.org with essentially no copyright restrictions).

Conflict with Surrogate Decision-Maker

1) Baruch Brody, Special Ethical Issues in the Management of PVS Patients, 20 L., Med. And healthcare 104 (1992)

2) In Re Wanglie, No. PX-91-283 (Minn.D.Ct. June 28, 1991)

(Hospital sought order to replace Husband as the surrogate decision-maker. Court did not address the substance of the decisions made by the Husband finding that the only materially relevant question was whether the Husband was in the best position to know what the patient would want done if she was able to speak for herself).

3) “The Physician-Surrogate Relationship” Archives of Internal medicine, June 11, 2007

4) “Time to Move Advance Care Planning Beyond Advance Directives” Chest 2000

May a Physician Sedate a Terminally ill Patient to the Point of Unconsciousness?

5) Vacco v. Quill, 117 S. CT. 22293 (US 1997)

6) Quill, T. E., Byock, I. R., for the ACP-ASIM End-of-Life Care Consensus Panel. Responding to

intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids.

Ann Intern Med. 2000;132:408-414.

7) See CEJA Report 5-A-08 Referred to Reference Committee on Amendments to Constitution and Bylaws (Available at www.ama-assn.org)

Privacy and Confidentiality

45 CFR 164.506(a) Healthcare entities (Hospitals, Doctors etc.) May share otherwise protected information on patient if purpose is to facilitate care.

45 CFR 164.510(b) May share information with family or close friend if this facilitates care and patient does not object.

For a good summary of HIPPA go to:

www.hhs.gov/ocr/privacysummary.pdf

Treatment of Minors

“Informed Consent to the Treatment of Minors” Schlam and Wood, Journal of Law-Medicine Vol. 10 Number 2, Summer 2000 (Case Western Reserve University School of Law)

Healthcare Provider’s Right to Follow Their Conscience.

Curlin, Lawrence, Chin, Lantos: Religion, Conscience, and Controversial Clinical Practices; N Engl J Med 2007; 356: 593-600

(745 ILCS 70/) Health Care Right of Conscience Act.

(745 ILCS 70/2) (from Ch. 111 1/2, par. 5302)

Sec. 2. Findings and policy. The General Assembly finds and declares that people and organizations hold different beliefs about whether certain health care services are morally acceptable. It is the public policy of the State of Illinois to respect and protect the right of conscience of all persons who refuse to obtain, receive or accept, or who are engaged in, the delivery of, arrangement for, or payment of health care services and medical care whether acting individually, corporately, or in association with other persons; and to prohibit all forms of discrimination, disqualification, coercion, disability or imposition of liability upon such persons or entities by reason of their refusing to act contrary to their conscience or conscientious convictions in refusing to obtain, receive, accept, deliver, pay for, or arrange for the payment of health care services and medical care.

(Source: P.A. 90‑246, eff. 1‑1‑98.)

(745 ILCS 70/6) (from Ch. 111 1/2, par. 5306)

Sec. 6. Duty of physicians and other health care personnel. Nothing in this Act shall relieve a physician from any duty, which may exist under any laws concerning current standards, of normal medical practices and procedures, to inform his or her patient of the patient's condition, prognosis and risks, provided, however, that such physician shall be under no duty to perform, assist, counsel, suggest, recommend, refer or participate in any way in any form of medical practice or health care service that is contrary to his or her conscience.

Nothing in this Act shall be construed so as to relieve a physician or other health care personnel from obligations under the law of providing emergency medical care.

(Source: P.A. 90‑246, eff. 1‑1‑98.)

A Simpler Ethical Code:

Harry Truman was a different kind of President. He probably made as many important decisions regarding our nation's history as any of the other 42 Presidents. However, a measure of his greatness may rest on what he did after he left the White House.

The only asset he had when he died was the house he lived in, which was in Independence Missouri His wife had inherited the house from her mother and other than their years in the White House, they lived their entire lives there.

When he retired from office in 1952, his income was a U.S. Army pension reported to have been $13,507.72 a year. Congress, noting that he was paying for his stamps and personally licking them, granted him an 'allowance' and, later, a retroactive pension of $25,000 per year.

After President Eisenhower was inaugurated, Harry and Bess drove home to Missouri by themselves. There was no Secret Service following them.

When offered corporate positions at large salaries, he declined, stating, "You don't want me. You want the office of the President, and that doesn't belong to me. It belongs to the American people and it's not for sale."

Even later, on May 6, 1971, when Congress was preparing to award him the Medal of Honor on his 87th birthday, he refused to accept it, writing, "I don't consider that I have done anything which should be the reason for any award, Congressional or otherwise."

As president, he paid for all of his own travel expenses and food.

Modern politicians have found a new level of success in cashing in on the Presidency, resulting in untold wealth. Today, many in Congress also have found a way to become quite wealthy while enjoying the fruits of their offices. Political offices are now for sale.

Good old Harry Truman was correct when he observed, "My choices in life were either to be a piano player in a whorehouse or a politician. And to tell the truth, there's hardly any difference."

WOOD AAEM

AAEM is an outstanding organization representing the board certified emergency physician.

GARRET-HAUSER ETHICAL ISSUES

Breaking Bad News: Ask patient what they are concerned about. It may help discuss bad news.

Warn the patient that bad news is coming. Use non-technical terms so patient can understand. Anticipate the level of their understanding.

ED conversations with patients can veer toward being too blunt due to time constraints. Be cautious about being too blunt. Give enough time to be human with the patient or family.

C. Kulstad comment: When discussing concerning test results like a lung mass on ct, We have an obligation to tell the patient that the most likely diagnosis is cancer based on the test findings. Other faculty agreed with this.

Tell patients what the next step is going to be.

Telling family that someone died: Find out who the family members are in the room. Get some info from family if you need it before you tell them the person died. Gotta use the word dead, died or death so families fully understand the irrevocable nature of the situation.

Family requests for non-disclosure of results to the patient: Ask the family why the request is being made. Negotiate with the family the best way to handle this situation. You can ask the patient if they prefer to get the infothemselves or discuss with the family. You may want to inform families of the standard of truthfulness with patients in this country. You have a duty to ask patients how they want medical information handled. If they want the info given to them, you need to give it to them despite the family’s wishes.

Power of Attorney gives the surrogate the same decisional capacity as the patient would normally have. There cannot be 2 powers of attorney. It can only be one person. There can be a successor named but they cannot make decisions if the power of attorney is present.

Surrogate act allows spouse, adult children or moving down the hierarchy, other family members or close friends to make decisions for a patient with a qualifying condition who doesn’t have decisional capacity.

To fill out the form to withdraw care (like taking out the ET tube or taking out feeding tube) you need two docs to sign off the WITHDRAWL OF CARE FORM that patient has a terminal condition.

Harwood comment: Utilize ethics committee to help with management of difficult clinical decisions when there is some time. Also when breaking news to a family that a patient has died he prefers tell them the patient has died very early in the conversation.

KUTKA M AND M TRAUMA

21yo male shot in buttock.

Get prepared prior to patient arrival even if the EMS report on the radio says “stable vitals”

DDX of Combative behavior: guy is a jerk, intoxication, hypoperfusion. Assume hypoperfusion until proven otherwise.

Even if bleeding seems venous don’t downplay the volume or significance of the blood loss.

Even if it appears to be a “simple” trauma don’t treat it like that. Treat aggressively and discuss your concerns with attending.

When giving blood products in a bleeding patient be sure to give enough prbcs AND ffp and platelets. Follow the massive transfusion protocol.

Criteria for Massive Transfusion: Penetrating mechanism, positive fast, arrival BP<90, arrival HR>120. 2criteria=40% chance and 4criteria=100% chance of needing massive transfusion.

When breaking bad news: discuss with Chaplain, have security with you, limit the # of family members in the quiet room, make sure you have an exit strategy.

Barounis comment: If you order the massive transfusion protocol and don’t use all the blood, it will be sent back to the blood bank to be used again.

Conference Notes 7-24-2012

July 24, 2012 Daniel Girzadas

Conference Notes 7-24-2012

WILLIAMSON STUDY GUIDE RESUSCITATION QUESTION SLAM

Junctional rhythm does not occur in healthy hearts so you have to investigate for ischemia or other pathology.

Brugada Syndrome is a genetic condtion that affects phase 0 sodium channels. Causes sudden death in structurally normal hearts. Affects asian men more commonly. EKG demonstrates RBBB with j point elevation and widening in leads V1-3.

Elise comment: not everything that looks like Brugada is Brugada so you need cardiology to consult on these EKG’s if there is a question.

Treat WPW with afib with procainamide if stable. If unstable, cardiovert.

Norepi is a good pressor to use if you don’t want to increase tachycardia too much. Alpha effects (vasoconstriction) are more prominent.

When resuscitating a patient with septic shock, vasopressors work best with a full vascular bed. Pressors can falsely elevate cvp so be sure you are giving adequate fluids. There is no evidence that trandelenburg position improves pt outcome or cardiopulmonary function. There is some evidence it may worsen cv status. So don’t use it.

For massive transfusions, pt’s should receive prbc’s/platelets/ffp in 1:1:1 ratio.

For pelvic or abdominal injuries you want iv access above the diaphragm. IO in the proximal humerus is a great second line access means is you can’t get peripheral iv access.

Anaphylaxis is an IGE-mediated immune reaction. IM Epinephrine in the thigh (0.3-0.5mg) is the treatment for adults. If you have two of the following: skin/respiratory/gi/cardiovascular symptoms you have anaphylaxis.

Transvenous pacing for an unstable patient with bradycardia or heart block is indicated if transcutaneous pacing at max output is not getting good capture. In the meantime try atropine.

Barounis comment: Check for hyperkalemia if transcutaneous pacing is unsuccessful.

Initial management of rapid afib is rate control with cardizem.

Barounis comment: I would prefer elective cardioversion for acute rapid afib. Elise comment: totally would want to be shocked for rapid afib of less than 48 hours.

BAROUNIS/GRIPPO INTRO TO CODE 44

SORRY I MISSED THIS LECTURE

KETTANEH INTRO TO SEPSIS

SIRS: hr>90, tachypnea, elevated wbc, abnormal temp either hi or low

Sepsis is SIRS plus an infection

Severe sepsis is sepsis with hypotension prior to IV fluids

Septic Shock: severe sepsis not responding to fluid bolus of 20cc/kg

Sepsis patients need at least 20ml/kg of NS with a minimum of 1 liter over 30 minutes.

Broad spectrum in the first hour improves mortality. Delay of antibiotics increases mortality of about 7% per hour.

Early Goal Directed Therapy: has been shown to reduce sepsis mortality compared to standard care. Indication of EGDT is persistent hypotension or lactate >4 despite initial fluids. Place a CVP line above the diaphragm. CVP is a proxy for preload. CVP helps you to optimize volume status. Goal is CVP of 8-12 or 12-15 if the patient is on a ventilator. If CVP less than 8 give more fluids. Next step is to start vasopressors. Vasopressors do not improve mortality. No data to say which pressor is superior. Norepi however is the drug of choice due to less adverse effects. Central venous oxygen satuation is a marker of success/mortality. So get a VBG off your central line. If Scv02 is <70% you got problems. Intubate/Check hgb/start dobutamine as an inotrope. Transfuse if hgb less than 7. 7-10 is a grey zone. Lactate clearance is a reasonable proxy for Scvo2.

No steroid use/not indicated for sepsis. Steroids only if pt’s on chronic steroids and are steroid dependent. Procalcitonin if nl may be a sign you can stop antibiotics but evidence is weak.

Wise comment: if Scvo2 is low, early intubation with neuromuscular blockade is indicated.

C Kulstad: Sepsis patients ned high fluid maintenance rates like 200ml/hr

Lovell comment: If you give fluid bolus to patients give a liter not 200ml bolus. Also use EGDT protocol in our EMR.

Hermann comment: IV infusion pumps do not get the fluids in fast enough. You have to hang fluids with a pressure bag and no pump. Corroborated by Dr. E Kulstad/Lovell

Harwood comment: Questioned that pressors in septic shock don’t improve mortality.

MCDERMOTT SEVERE COPD EXACERBATIONS

Definition: increase in symptoms of cough/sputum/dyspnea. All copdr’s have a decreased FEV1/FVC ratio.

Treatment priority is to ensure oxygenation. Hypercapnea is well tolerated. Get O2 sat to 92% and 95% in dark skinned patients. Can use venti masks but usually 4L pnc is enough to correct oxygenation problems in copdr’s. If you need more oxygen support you gotta think about other things.

Bipap has been shown to decrease need for intubation, decrease risk of nosocomial infection, and decrease mortality. Intial settings are 8-12 inspiratory and 3-5 expiratory. If you need to adjust settings a reasonable move would be 15/7.

Vent management for intubated patients: high inspiratory flow rates and low tidal volumes (5-7ml/kg) and low rates. This will help to minimize airway pressures.

Treatment: Nebs are more effective than in mdi’s in COPD exacerbation. Magnesium can be used. Theophylline has not been shown to improve outcomes in COPD. Chest PT also not indicated in acute COPD exacerbation because it can worsen an acute exacerbation. Steroids have been shown to improve symptoms, lung function and decrease hospital stay. About a third of COPD exacerbations are triggered by bacterial infection so antibiotics are indicated for acute exacerbations. Sputum cultures are not useful. Pseudomonas risk factors:4 episodes/year, recent hospitalization, previous pseudomonas, or severe copd. If risk factors for pseudomonas are present give zosyn, if not then ceftriaxone.

Most common causes of death in an admitted COPD patient: heart failure, pneumonia, PE, then COPD.

Work UP: CXR, EKG, Troponin, CBC, BMP, ABG, +/- Blood cultures.

Girzadas comment: What triggers PE work up (one study showed 20% incidence of pe in COPD exacerbation but my experience does not match that)? Robbie: persistent hypoxia or remarkable risk factors, exam findings, lab or cxr findings suggestive of PE.

Harwood comment: CO2 narcosis is very common due to excess O2 administration. Beware of giving too much oxygen to COPDR’s. If the patient needs to be intubated for CO2 narcosis, they likely will be hard to get off the ventilator. Try bipap first to reduce CO2 retention but for very high PCO2’s it may not work.

PUTMAN SEVERE CHF EXACERBATION

Common ED clinical conundrum is separating out pneumonia/chf/copd.

Bipap has been shows to decrease intubations/admissions/mortality. PEEP helps. 12/5 again is a reasonable starting point for the bipap machine.

Nitroglycerine (both IV and Sublingual) is the key medication treatment. Give 4 sprays of ntg to give a 1600microgram bolus rapidly. Start 50mcg/min drip and titrate up rapidly to around 200 mcg/min. If patient still not improving and BP still up, you can add nitroprusside drip.

Beckemeyer and Harwood comments: Look for improvement from ntg by improved dyspnea and improved blood pressure. You will only be at the very high levels of ntg administration for a short while because BP will start going down. You will need to be alert as to when to start going down on ntg dose.

Diuretics alone can increase mortality. Diuretics can worsen renal function. You need to not give lasix until you have ntg going.

ACE-I ‘s have been shown to improve patient outcomes.

Contraindications to NTG vasodilatation: RV infarct, aortic stenosis, hypertrophic cardiomyopathy, hypotension.

Barounis comment: how do you manage patient pulling off bipap mask? Elise and Christine say give ativan cautiously. If they either keep pulling of mask or become too somnolent you proceed to intubation.

Girzadas comment: Be alittle bit patient for the NTG to work for the first 15 minutes. Most patients don’t need to be intubated. The nitro will work magic if given alittle time.

BAROUNIS ALTERED MENTAL STATUS

SORRY I MISSED THIS LECTURE

Conference Notes 7-17-2012

July 17, 2012 Daniel Girzadas

CONFERENCE NOTES 7-17-2012

MOTZNY EMS STUDY GUIDE

Triage colors: green = walking wounded, red=emergent, yellow=care can be delayed for a few hours, black=dead.

JCAHO requires a hospital disaster plan to be activated 2 times per year.

A disaster is defined when an event overwhelms a facility’s ability to respond appropriately.

The most common important problem in a disaster is communication difficulties.

Mass gathering =1000 or more people at an event. The most common injuryat a mass gathering is dermal injury.

Triage is a dynamic process that requires re-eval and re-assessment of patients.

The command station at a HAZMAT scene should be uphill and upwind from the hazardous materials.

Regarding decontamination; if there is ocular exposure address eye irrigation first. Gross decontamination takes precedence over airway management. Removing clothes is the first and usually most effective step of decontamination.

Class A bioterrorism agent: Anthrax, plague, ebola, small pox, botulism, tularemia.

Radiation: Alpha particles can be blocked by paper or clothing. It is unlikely to give whole body radiation unless ingested. The earliest lab indicator of acute radiation syndrome is decreased lymphocyte count.

Under NIMS, in a disaster situation, materials management is under the responsibility of the Logistics Section of the disaster response team. Logistics is in charge of all the equipement and materials necessary for a disaster response.

START triage algorithms are based on a quick assessment of the patients respirations, perfusion and mental status.

TOERNE ACETAMINOPHEN AND SALICYLATE TOXICTY

Acetaminophen (APAP): Completely absorbed within 4 hours. A 2 hour Tylenol level predicts a 4 hour level. APAP is eliminated by glucuronidation and sulfation. 5-10% is metabolized by the cytochromes to NAPQI which is the toxic metabolite. NAPQI attacks cells in the liver. Glutathione detox’s normally . But if glutathione gets depleted in a Tylenol overdose you get liver damage. Extended relief acetaminophen tab has similar overdose characteristics as regular tab. If your 4 hour level is non-toxic then your 6 and 8 hours levels will likely be non-toxic as well. Still, check 6 and 8 hour levels.

APAP overdose is initially asymptomatic. After 24 hours pt’s develop nausea and vomiting. Time of ingestion is the earliest time, not the latest time of ingestion.

No routine gastric lavage or activated charcoal for APAP overdoses.

Toxic ingestion of APAP=150mg/l at 4 hours to 4mg/l at 24 hours.

N-acetylcystine (NAC) is the antidote for Tylenol overdose. Oral dosing is 140mg/kg initial dose followed by 70mg/kg q 4 hours for 72 hours. Now IV Nac is available with a 21 hour protocol. You can probably stop NAC when serum Tylenol level is less than 10mg/l. NAC can falsely elevate the INR slightly. If patient has signs of liver damage, you give NAC until liver enzymes are less than 1000. Ted recommends using IV acetadote over po NAC. It is just easier.

Liver transplant criteria: Elevated INR, elevated Cr, and encephalopathy. To increase sensitivity to pick up all potential transplant patients is lactate >3.5 or abg <7.3 after initial resuscitation. You will see these abnormalities in late presenting patients or patients in the ICU who are not doing well. If a patient with acidosis or diminished liver function, transfer that patient to a transplant center.

Salicylate (ASA): Oil of wintergreen has a massive amount of salicylate in it’s formulation. ICY-HOT also has salicilyate in it’s formulation.

Treat with IV fluids, Bicarb drip and repeated doses of activated charcoal. You want to alkalinize the serum and urine to ion trap the ASA in the urine. This mechanism also keeps hydrogen ions out of the cns and heart. You need to supplement potassium as well.

ASA uncouples oxidative phosphorylation. Most common cause of death is cardiac dysfunction. Pt’s will have tinnitus. Pt’s will have tachypnea due to metabolic acidosis and primary respiratory alkalosis.

Chronic ASA is very problematic due to whole body burden of ASA.

Harwood Comment: Is there vomiting with oral potassium supplementation in these patients. Ted replied he has not seen that problem.

Indications for dialysis: deterioration, aletered mental status, pulmonary edema, severe acidosis, renal failure, worsening coagulopathy, ASA concentrations of 80-100 mg/dl.

Ted made a comment that there are case reports of ASA toxicity developing in a patient with an initial neg level due to irregular absorption of ASA.

VILLANO SNAKE ENVENOMATION

Red on yellow, Kill a fellow=Coral snake. Red on black, venom lack=non-venomous king snake. Coral snakes are common in the southern US.

Crotalids (Rattlesnakes and others) have elliptical eyes, triangular head, a heat sensing pit, and retractible fangs.

Snake venom: crotalids have proteolytic venoms and can cause systemic toxicity. Elapid venoms are neuro toxins.

Crotalid bites cause local reactions. Can have systemic symptoms as well including hematologic and gi symptoms, rhabdomyolysis.

Elapid bites (coral snakes): pt can be asymptomatic up to 12 hours then develop paralysis.

Poison control center # anywhere in US 1-800-222-1222.

Asymptomatic patients: crotalid bites observe for 8 hours. Elapid bites give antivenin.

Field management: ok to irrigate and splint wound and avoid strenuous exertion, and take a picture if snake if easily available. Don’t use tourniquets, suction, direct handling of snake.

Management: Antivenom, tetanus prophylaxis, avoid blood products unless pt is hemorrhaging to death. Antivenom should be used prior to fasciotomy for swollen limb. Anti-venom is not a weight based dose. Same dose for adults and kids. Patients may have an anaphylactoid reaction from antivenom. 4-6 doses of Crofab antivenom given for spread of swelling, hematologic abnormalities, or unstable vital signs. (spread-bled-almost dead)

Elapid (coral snakes) bites management: look for signs of weakness including respiratory parameters such as low maximal inspiratory pressure, capnography. Everybody gets coral snake antivenin because pt’s can be assymptomatic initially. Repeat dosing based on clinical status. This antivenin can cause anaphylatoid reactions as well.

Non-venomous snakebites: get xray to check for fb. Give prophylactic antibiotics (gram positive coverage).

Gila monster bite: wound care, antibiotic prophylaxis. No anti-venin.

Harwood comment: for the snake mnemonic start with red like a fang mark. Red on yellow, kill a fellow. Red on black, venom lack.

KATIYAR MARINE ENVENOMATIONS

Jelly fish have nematocysts with venom that is painful and toxic to humans. Nematocysts can be rinsed off with vinegar.

Cubozoa: Box Jellyfish is indigenous to northern Australia and SE asia. Clear color. Can cause local reaction and in worst case cardiovascular collapse. Rinse off with vinegar. Don’t rinse with fresh water or urine. Nematocysts need to be removed afterward with tweezers or razor. Give antivenom 1-2 amps IV or 3 amps IM. It is sheep derived. Can cause anaphylaxis or serum sickness.

Irukandji Jelly fish: Irukandji syndrome=30 minutes after stung, low back pain, muscle cramps, hair stands up, anxiety, sweating, tachy, vomit, oliguria, cerebral edema, pulmonary edema. Lasts 5 days to 2 weeks.

Portuguese man of war: Larger than box jelly fish, Blue color. Has blue sail above water. Tentacles may be 100 feet long. Complex venom that is hemolytic and cytolytic. Intense local pain, hemolysis, cardiac conduction abnormality, recurrent urticaria. TX: neutralize with salt water. Don’t use vinegar because it causes 30% nematocyst discharge.

Seabathers eruption: Due to larvae of jelly fish. Contact dermatitis. Pruritic papules. Lasts for 2 weeks. TX with steroids and antihistamines.

Stingray: Has a serrated spine with venom. If you step on them they can sting you. Steve Irwin was killed by one. Local reaction, tremors, convulsions, CV collapse. Tx with tetanus shot, hot water deactives venom (soak extremity), irrigate wound, systemic analgesia, cover gram negs with abx.

Lionfish: Envenomation causes pain, swelling, blistering, weaknss. Treat with hot water and wound care, and tetanus shot.

Stonefish: Highly toxic. Immediate and intense pain, delirium and cardiovascular collapse. Treat with hot water, support vitals, wound care, and tetanus shot, antibiotics.

Sea Urchins: pain and pruritus. Relatively benign envenomations. Treat with hot water. Get xray to check for retained spine. Treat pain.

NIKKI NINO MD DOCUMENTATION

Laceration repair is the most common missing piece of documentation.

For all procedures use the procedure macros in Picis.

Conference Notes 7-3-2012

July 3, 2012 Daniel Girzadas

Conference Notes 7-3-2012

Chandra/Harwood Oral Boards

Case 1. Multiple Blunt Trauma with left hemothorax, splenic injury and epidural hematoma. Management required intubation, left chest tube, identify epidural hematoma/splenic injury. Pt needs to go to OR emergently.

Harwood comment: You can identify epidural hematoma (between dura and skull) by thinking high pressure causes bulging toward the midline. Low pressure subdural (between dura and arachnoid)does not cause a bulge toward the midline.

Case 2. Syncope due to PE/FX toe. Management requires identify CT, give heparin, reduce toe fx.

Harwood comment: S1Q3T3 on EKG and Westermark sign (unilateral oligemia due to clot) on CXR were present in this case.

Case3. Maisonneuve Fx. Identify fracture pattern, splint, urgent ortho consult. Surgery not required emergently but in a prompt fashion.

Asokan Emergency CXR Evaluation

If patient has hx of a fall, a radiologist looks for pneumothorax, pleural fluid, rib fx’s, or vascular injury.

If the trachea deviates toward a soft tissue density, the soft tissue density is likely not a mass but some scarring or buckling.

If a patient has a widened mediastinum due to a dissection, it is because of a mediastinal hematoma. The dissection itself does not cause a widened mediastinum.

Indications for surgery in aneurysm is 6cm in the thoracic aorta and 5cm in the abdominal aorta.

Superior mediastinal widening has a differential of 4T’s: thymoma, teratoma, thyroid, terrible lymphoma.

On lateral view: Posterior infiltrates are in either right or left lower lobe. Anterior infiltrates are in the RML or left lingula. On anterior view: RLL infiltrates should basically be on the diaphragm. RML infiltrate may obscure the right heart border. RUL infiltrate should be at apex.

Hemithorax with whiteout : if trachea deviates to side of white out consider collapse or pneumonectomy. If trachea deviates away consider hemothorax/mass/effusion.

CHASTAIN SIGN OUT

Transfer of information AND responsibility for the patient.

IPASS: illness severity, patient summary, action list, situation awareness, and synthesis.

It is important for the receiving team to ask questions about the case.

Signed out patients need to have a complete H and P note written by the leaving team.

WILLISON EKG

Osborne waves indicate hypothermia

WPW: accessory tract can lead to SVT’s of different types. Antidromic conduction has a wide QRS and requires procainamide or cardioversion.

V1 if RBBB pattern: Taller left rabbit ear suggests ventricular tachycardia.

If you find non-specific st changes in a anatomic distribution, get serial ekg’s to look for st elevation.

AVR with tall/wide terminal r wave think: TCA, or Benadryl or cocaine.

Cerebral T waves: huge deep inverted t waves due to acute intracranial hemorrhage.

Wellens: biphasic t wave in V3 suggests severe proximal LAD lesion. High risk for v-fib on treadmill.

Brugada: Saddleback t wave changes in septal leads. Associated with sudden death. Needs AICD.

WISE HEMOPTYSIS

Gas exchange impaired with >400ml of blood in alveolar space.

Mild hemoptysis without risk factors: CXR and outpt f/u

Causes: bronchitis, pneumonia, abscess, tb, lung carcinoma, pe, behcet, goodpastures, bronchiectasis, warfarin, crack lung, bioterrorism-agents . Top 3 in US: bronchitis, bronchiectasis, cancer, pneumonia. Tops in world: TB

Earlier bronchoscopy= higher yield. CT may be useful in massive hemoptysis. CT plus bronch identified source in 93% of patients.

Lateral decubitus position with bleeding lung on downside may protect the good lung. Selective mainstem intubation or double lumen ET tube may also be effective.

Consider FEIBA for the massive hemoptysis pt on warfarin or other anticoagulant.

Use an 8FR ETT when intubating to allow for bronchoscope.

Barounis comment: Dr. Hanif said you can pass a pediatric foley through the ET tube and pass the foley into right mainstem bronchus and inflate balloon to occlude right bronchus.

KULSTAD/TEKWANI/WATTS STATS

High specificity tests rule in disease. SPIN=specificity, positive results, rules in the diagnosis.

High sensitivity tests rule out disease. SNOUT=sensitivity, negative result, rules out the diagnosis.

Positive predictive values is highly dependent on prevalence rate of a disease. PPV can change despite no change in the sensitivity or specificity of a test based only on the different prevalances.

Bayes’ theorem: new info should be interpreted in light of what is already known. You need to consider the pre-test probability of disease. Can base on the literature or clinical gestault.

Positive Liklihood ratio: prob of + test in presence of dz/prob of + test in absence of disease. If LR is >1 the result is more likely to be positive in a pt with disease than without disease. The benchmark for A very good LR+ is 10. The benchmark for a very good LR- is 0.1.

Harwood Comment: Determining the pretest probability is key to determining an accurate post test probability.

Heart Score for Chest Pain:

History	Highly suspicious	2
	Moderately suspicious	1
	Slightly suspicious	0

ECG	Significant ST-depression	2
	Non specific repolarisation disturbance	1
	Normal	0

Age	≥ 65 years	2
	45 – 65 years	1
	≤ 45 years	0

Risk Factors	≥ 3 risk factors or history of atherosclerotic disease	2
	1 or 2 risk factors	1
	No risk factors known	0

Troponin	≥ 3x normal limit	2
	1 – 3x normal limit	1
	≤ normal limit	0

HEART Score	Risk of MACE	Proposed Policy
0 - 3	0,9%	Discharge
4 - 6	12%	STRESS
7 - 10	65%	ANGIO

We then discussed 8 cases in small groups developing post test probabilities for strep testing, d-dimer, ct for appy, and dopplers for dvt.

JAKUBOWITZ CHF/ASTHMA

Observation status delivers equivalent clinical care to admission at a lower cost.

Asthma Protocol: Bread and butter asthma patient not better in 3 hours should go into this protocol. DC home with albuterol/oral steroids/inhaled steroids/asthma action plan/follow up.

CHF Protocol: Patients with new CHF, abnormal labs, unstable vitals, o2sat <90% are excluded.

Less than 10 patients last year were admitted into each of the CHF or Asthma Protocols.

Observation management may be more expensive for patient than inpatient management. However, some of these protocol patients may not meet criteria for admission.

Conference Notes 6-12-2012

June 12, 2012 Daniel Girzadas

Conference Notes 6-12-2012

JOINT PEDS/EM CONFERENCE NEONATAL EMERGENCIES

Case #1: Hypoplastic Left Heart Syndrome

MISFIT mnemonic : Metabolic, Inborn Errors, Seizures, Formula problems (hypernatremia/hyponatremia), Intestinal disasters, Toxins, Sepsis.

If neonate presents with hx of fever but afebrile in ER. Panel recommended partial septic workup with CBC, blood culture, and urine dip and observation period with recheck of temp. If you admit for obs, if you want to give antibiotics, you have to do LP.

In sick neonate you want to get an ABG.

Go rapidly to IO line if you have difficulty getting IV access in a neonate. Bolus IV fluids in rapid fashion over about 5 minutes. You may have to give by push syringe thru iv/io.

Hyper-oxygenation test is not reliable. It can give misleading results and increase pulmonary flow and worsen patient’s condition. Similarly the BNP test has no utility in this age group. Very ill hypoplasts have normal BNP’s.

Agreement among panel that if patient is unstable don’t do lp prior to antibiotics. But Dr. Collins pleaded to get at least a blood culture prior to antibiotics.

Dr. Roy: If child is grey color (poorly perfused)not cyanotic you have to work up sepsis/cardiac/in-born errors/non-accidental trauma.

Panel: nightmare baby is shocky baby with low normal O2 sat. Gotta treat sepsis and at the same time work up cardiac and in-born errors and non-accident trauma. Panelists suggested giving both antibiotics and prostaglandin if you can’t get a rapid echo and need to transfer patient.

Pre and Post Ductal Pulse Ox measurement (pulse ox on right hand and either foot) can be a sign of ductal dependent congenital heart disease. Could be used in ER. If one measurement is less than 90% or is significantly lower than the other measurement the test is abnormal.

Too much oxygen in these kids is more dangerous than too much fluids. 20cc/kg bolus was considered safe by all panelists.

Case #2: Evaluate for sepsis first because it is most common, congenital heart dz and inborn errors are much less common. Again, ABG was touted as a useful test by the panel in the undifferentiated ill neonate. Panel felt Ammonia level was not a test to be getting in all these kids until you have considered other diagnoses. Ammonia levels can be unreliable in the acutely ill child.

Sam Lam: Inborn error of metabolism kids look sick, vomiting, shocky. Labs will show hypoglycemia and acidosis. Dr. Collins pleads again for blood cultures and antibiotics in this kid because sepsis is still the most common diagnosis. If you do an LP the most important test is the culture. If you have enough fluid then get cell count, gram stain, protein, and glucose. Extra fluid can be saved for HSV pcr later if indicated.

Lovell chiming in to emphasize my favorite pearls from joint Peds/EM conference:

Common things common: r/o sepsis, peds cards problems before worrying about inborn errors of metabolism (really rare) in a sick neonate-think about and treat both. Get the blood culture before antibiotics, but defer the LP in shocky kids-stress of LP can make them worse.

Hyperoxia test probably not helpful due to mixed lesions being able to mount reasonable sats, and putting cyanotic heart lesion kids on high flow oxygen can make them worse (adversely affect perfusion). Instead, think about doing a O2 sat on right arm and either leg (pre/post ductal) to look for discrepancy and pick up ductal lesions.

DAVE CUMMINS MY FIRST YEAR OUT AFTER RESIDENCY

Dave discovered that single coverage ER’s can be a lonely place for a doc.

People don’t really question you that much as an attending.

Pacemaker mediated tachycardia is best treated with a magnet or pacemaker computer rather than cardioverting.

Not every ED operates the same as ACMC. They may manage afib and other problems differently than we do.

Dave had to treat a case of trachea-inominate fistula bleeding. This is frequently a lethal complication of tracheostomy.

From Robert’s Clinical Procedures in EM Text: Control of innominate artery bleeding by digital pressure. Be aware that minor bleeding may be a sentinel event, and a harbinger of a subsequent major hemorrhage. When major bleeding occurs and a cuffed tracheostomy tube is present, overinflation of the tube cuff may temporize (see text). When this is unsuccessful or a cuffed tube is not available, use the illustrated maneuver; digital pressure should be applied to the anterior tracheal wall through the tracheostomy. The index finger is placed within the trachea and then pulled against the anterior tracheal wall, allowing the airway to remain partially open. The artery is compressed between the index finger and the thumb—placed over the neck. Digital compression of the innominate artery is a temporizing procedure, until definitive (operative management) of the bleed is obtained.

Success comes mostly from the relationships you build with others. It has much less to do with how good you are.

Dave’s Top Suggestions for year 1

Be nice
Never yell
Mirror the behavior of your favorite attending
Be decisive and have a plan
Don’t take yourself/status too seriously
Learn everyone’s name quickly
Work less than in Residency
Spoil yourself then SAVE ALOT!!!!!
Get a good financial planner
Develop another work interest.
Be generous with your time/money/espertise
Don’t prescribe narcs or benzos to friends/family

ERIN ZIMNY PALLIATIVE CARE

Palliative care is symptom management, communication, and coordination of care.

ED is critical setting for pt’s with cancer and other terminal illnesses because we initiate the trajectory of care.

Patients with cancer or other chronic illnesses: 94% have physical symptoms, 72% have financial concerns.

Goal: Cancer patients go to ER only once in last 30 days of life.

Palliative Care does the right thing for the patient and also saves $.

Case #1: Hospice Patient in the ER. They may come for increased symptom, new problem, self referral for stress/inability to cope.

New care model for advanced cancer is a relative gradient of cancer therapy and palliative care. This is a change from the past which was cancer treatment alone until it was determined unsuccessful then palliative care.

Hospice Myths: Pt’s have to be DNR to be in hospice. Hospice does not treat infections. Hospice withholds parenteral nutrition. Hospice has to be revoked on arrival to ER.

ER staff should call hospice staff. Identify trigger for ED visit. If deterioration is imminent discuss with pt and family. Give family/patient emotional support. Dispo can be home, hospice, revoke hospice.

IV decadron makes cancer patients feel a lot better. It relieves symptoms from tumor burden. It will also increase appetite.

Treatment of Nausea: There is more than zofran. Benzos, antihistamines, raglan, compazine, haldol 2-5mg IV (blocks the chemoreceptor trigger zone), droperadole is another option.

Treatment of Constipation: Use a combination of a stimulant and a stool softner. Senna and colace is a good combination for constipation prophylaxis. Harwood recommends Pericolace as a combo med with both senna/colace. Methylnaltrexone blocks opioid receptors in gut. Works like a miracle but is expensive. If patient comes to ER with constipation Erin recommends giving lactulose from above and ducolax from below.

Case #2: Dementia Patient

Dementia is a progressive terminal disease which is irreversible. There are identifiable stages. Stage 7c with loss of ambulation and not speaking, they have less than 6 months to live.

It is ok, if in your medical judgment the patient is going to die soon, to decide for the family that the patient is DNR. If they assent to this decision, you make the patient DNR.

Delivering Bad News: Advance prep, build a relationship, communicate well, deal with reactions, encourage and validate emotions. Find out what they know, be frank but compassionate, allow silence/tears, summarize and repeat info, encourage questions.

Things not to say: I understand how you feel. It could be worse. Nothing more can be done. We all die. Avoid euphemisms, use the word death/dead.

Case #3: Patient with metastatic lung cancer in extremis. Husband screaming “do something!”

Erin stabilized patient with intubation and pressors. Then had long discussion with husband. Daughter comes and says “mom never wanted to be on a ventilator”. It was decided to extubate patient in ER. Dyspnea treated with morphine.

Treat dyspnea with: oxygen, fans may be effective, morphine 2-5mg Q15-30 min (this is symptom treatment not euthanasia), ativan 0.5, humidiity , elevate head of bed, educate family, treat secretions with atropine.

Oral morphine 15 mg is a reasonable starting dose q4 hours for cancer patient failing norco.

SubQ dosing of opioids is less painful than IM dosing.

Don’t start a patient new on a fentanyl patch in the ED. You can increase the patch dose for someone already using a fentanyl patch.

ACMC has a Palliative Care Team 684-8117. Dr. Kozyckyj and Lynn Sevic, RN.

SINNOTT SENIOR PEARLS

Conference Notes 6-5-2012

June 5, 2012 Daniel Girzadas

Conference Notes 6-5-2012

STRASBURGER PSYCHIATRIC STUDY GUIDE

Droperidol and haldol can prolong the QT interval and precipitate torsades. Check an EKG prior to giving either drug.

Treat dystonic reaction with benztropine (cogentin) and Benadryl.

Harwood comment: sometimes Benadryl doesn’t work in that case give cogentin and a few for home to prevent recurrence.

Low potency antipsychotics have more sedation and hypotension and anticholinergic symptoms

High potency antipsychotics have more dystonia and tardive dyskinesia.

Harwood comment: It’s ridiculous that there is a question about low potency anti-psych drugs because they aren’t used anymore.

Harwood comment: Most people with panic attacks will not have a persistent resting tachycardia. If pt is persistently tachycardic, check thyroid studies and consider other diagnoses.

3% of patients with steroid psychosis commit suicide.

Conversion disorder: symptom that is a change or loss of function. Recent stressor, symptom not explained by any organic disease. Labelle indifference.

Harwood comment: Consult appropriate specialist to eval patient prior to making diagnosis of conversion disorder and discharging patient.

Munchhausen by proxy: caregiver fabricates illness in those who are in their care. Form of child abuse.

SADPERSONS: mnemonic for suicidal risk. Sex, age, depression/hopelessness, previous, excessive etoh, rational thinking loss, separated, organized attempt, no social support, stated future attempt. Hopelessness, loss of rational thinking, stated future attempt all get 2 points and are higher risk than the other factors which get 1 point each.

TCA overdose: look for wide QRS and tall R wave in AVR on EKG.

Effexor (venlafaxine) has sodium channel blocking effects and will have similar EKG findings to TCA’s.

Discussion on neuroleptic malignant syndrome among attending: cool patient, use benzos, consult tox/neuro, give dantrolene.

COLLANDER 5 SLIDE F/U

Patient with purple urine in foley bag. Urine culture was positive for proteus and e coli. Both organisms susceptible to cipro.

Purple urine bag syndrome: tryptophan metabolized to indole. Liver converts indole to indoxyl sulfate. Bacteria convert indoxyl sulfate to indirubin and indigo. Usually in asymptomatic patients with chronic foley catheters. Constipation predisposes to more uptake of tryptophan so more likely to have purple urine. Multiple gram neg organisms can cause this. Treatment is change out the catheter and burine bag and treat uti. You can use the usual urine antibiotics.

Child with blue urine is likely to be due to food coloring or familial hypercalcemia. Check a calcium level.

RICCARDI M AND M

75 YO male, multiple chronic illnesses, hx of cholangitis. Presents febrile and tachy with green biliary drainage. Antibiotics started.

Cholangitis: bile stasis that develops infection. High rate of sepsis. Stones can act as a nidus for infection. Treatment is biliary drainage and antibiotics.

Charcot’s triad; fever, pain, jaundice. Reynold’s pentad is the addition of hypotension and altered mental status.

80% will respond to antibiotics. 20% require emergent decompression of biliary blockage.

Patient deteriorated in ER. Developed an urticarial rash. Pt was treated successfully for anaphylaxis. It was later learned pt has a pcn allergy.

Anaphylaxis criteria there are three: 1. Acute onset of skin and respiratory or low bp effects. Or 2. Any 2 of skin, gi, respiratory, bp effects after allergen. or 3. Low bp after exposure to known allergen.

Treat with epinephrine 0.01mg/kg in thigh.

Biphasic reactions are possible up to 72 hours out. Patients should be observed for 4-6 hours in ER.

Pt had antibiotics changed, went for ERCP and eventually was dischared from hospital.

Dr. Riccardi discussed the importance of being alert to anchor bias. Just because the patient is triaged to a lower acuity area of the ED does not preclude they may have a serious, or emergent illness or injury. Elderly are more prone to under-triage.

Dr. Riccardi also discussed confirmation bias. The EP is suspicious of a certain diagnosis and uses data collected to confirm this bias. The EP tends to discount non-confirmatory data or not pursue data that would lead to another diagnosis.

Beyesian reasoning may help fight confirmation bias. Does my test results raise or lower my pretest probability?

C. Kulstad comment: Be alert for under-triaged nursing home patients in the hallway.

Joan Coghlan comment: Ask yourself, if I saw this patient in the Critical Care room would I do the same thing? Frequent ED users also require extra vigilance.

McDERMOTT AND LAMBERT ORAL BOARDS

Case 1. Pregnant patient with adominal pain. Distended bladder. Incarcerated uterus. Rarely uterus can’t come out of the pelvis at about 10-12 weeks and will block bladder drainage.

Case2. Lower extremity compartment syndrome. Severe calf pain. Use Stryker to measure compartment pressure. Normal pressure is 0-5. Admit for pressure over 20. Surgery for pressure over 40 or within 20 of diastolic blood pressure.

Case3. Optic Neuritis due to Multiple Sclerosis. Treatment with IV Solumedrol. Fundus will be normal. Pt will have an afferent papillary defect. Pts may have eye pain.

Joan Coghlan comment: Pain out of proportion should make you think either ischemia, compartment syndrome, phlegmasia, tendon rupture. Know the likely disease entities at various gestational ages. Ectopic at 6-8 weeks, uterine entrapment at 10-12 weeks, second trimester is appy or cholecystectomy, third trimester is abruption and previa.

CALLAHAN FOSTERING RESILIENCE

Resilience: the ability to bounce back and endure adversity during residency.

Not resilient resident:

Resilient resident:

Hero’s Journey: Described in 1949 by Joseph Kimble. Start with known (home field) and travel to unknown world (call to adventure), work thru challenges and temptations, reach an abyss (doubt of success), revelation, transformation, atonement, success and return to the known (home field).

Nutrition, aerobic exercise, sleep lead to healthy living but do not guarantee resilience.

Lessons from Athletics: How you think about failure whether it is permanent of fleeting is a part of resilience. 2^nd category is locus of control. If a person takes more internal control of their performance and not blame external factors they are more likely to be resilient. 3^rd category is a sense of hope/optimism/higher purpose.

You have to dispute negative thoughts. Either do it yourself or have a mentor to help you do that.

Decatastrophize problems. Consider worst case scenario, consider best case scenario, and settle on most likely scenario.

Lessons from the military: NAVY SEAL’s are considered the most resilient people on the planet. Optimism, perseverance, responsibility, integrity, support each other during training, self-efficacy (they believe they control their destiny), earned.

Comprehensive Soldier Fitness: Family, physical, social, emotional, and spiritual facets. Military doesn’t have time to wait because currently there are more military deaths from suicide than from combat.

Marty Seligman: Formula for resilience or positive thinking: Content with the past, happy in the present, hopeful for the future. Authentichappiness.com. Dr. Seligman runs the Comprehensive Soldier Fitness program.

Not much data to support specific resilience training. 3 factors do have some support: positive thinking, positive affect, positive coping. 2 other factors also important: realism and behavior control.

Positive coping, support from family/resident class, positive climate in Unit/program, Belongingness in Community/hospital. Physical fitness is not a link to resilience.

Lessons from Medical field: SMART program at Mayo: Attention wanders to threats/pleasure/novelty. Spend a lot of brain power in the past and future. We should switch to the present moment. Gotta override the limbic system. Gotta train the mind to quiet the limbic center. Focus on the current moment. Interpret life with more flexibility, gratitude, compassion, forgiveness, and higher meaning.

Conference Notes 5-29-2012

May 29, 2012 Daniel Girzadas

Conference Notes 5-29-2012

GRIPPO-FELDER ORAL BOARDS

Case 1: Borhaave’s Esophogus. Consider PE, consult surgery, start broad spectrum antibiotics. Pregnancy and ETOH are risk factors for esophageal rupture. Don’t do a barium swallow because arium is not good for the mediastinum. Gastrograffen is preferred to evaluate with a swallow study or chest CT.

Harwood comment: If you see mediastinal air or air in soft tissue either on CXR or CT with this symptom complex, just consult surgery and start antibiotics. The ER doc doesn’t need to order an esophogram.

Case 2: Lyme Disease. Recognize erythema chronicum migrans, treat with doxy for kids over 8 and non-pregnant. 21 day course of doxy, amoxicillin, cefuroxime, or macrolide. Tick has to be on the patient for 36 hours to transmit disease.

Harwood comment: For oral exam with non-critical/toxic patient you don’t have to put an IV in. You may get scored down for system based practice. Think out loud so the examiner knows what you know.

Case 3: Polytrauma. Cspine immobilization, secure airway, chest tube, re-assess vital signs. Always remember to get complete set of vitals including accucheck glucose and UCG. Ask for family/paramedics. Treat pain. Be systematic in your exam for injuries.

BOLTON FUTILITY

Decisions: Respect the patient’s autonomy. The decision should be impartial and follow the Golden Rule (treat others as you would want to be treated) or Platinum Rule (treat other as they would want to be treated). Universable=categorical imperative=moral act that is always right in the same situation. Interpersonal justification=would you be comfortable with your decision if it is written in the newspaper?

Futility= action that has no useful purpose. AMA CEJA: there is no accepted definition of medical futility.

80% of persons die in a medical environment. People prioritize quality of life, touch of family at the time of death. They don’t prioritize prolongation of life at any cost.

Futility problem: patients and families have unreasonable expectations of the capacity of medical care to return the patient to prior state of health. This is based on peoples exposure to TV and movies where CPR and ICU care provide miracle saves. Physicians have a lot of difficulty prognosticating to patients and family with the goal of lower expectations. We frequently abandon patients/families to their own autonomy. (Do what you think is best).

We should help families/patients understand their goals prior to making end of life decisions.

You don’t have to be a DNR patient to be in hospice. It is however somewhat contradictory philosophically. The criteria for hospice is only an expected life span of less than 6 months.

Pt’s don’t have the right to demand treatment. Beneficence: CPR has 0% chance of survival with metastatic neoplasm admitted to the hospital. Justice: Fair resource allocation.

Harwood comment: After every successful resuscitation, look for the underlying cancer.

Girzadas comment: The EP can also factor in the pain or lawsuit that may impact the treating physician from the family.

Barounis comment: Recent case in ER having to decide whether to give post-resuscitation hypothermia in a young patient with metatstatic cancer who had ROSC following CPR. Some ICU personnel complained that the ER staff should not have cooled the patient. Everyone agreed that the case was extraordinarily difficult. Most agreed that if pt was not DNR and resuscitation was done and had ROSC then you have to give hypothermia therapy.

Willison comment: The LET form is very imperfect. Most people at the lecture agreed that the multiple check box format brings up ethical inconsistencies.

WILLISON/SALZMAN TRAUMA RESUSCITATION

Be sure to use personal protection like masks/eye shields/gloves/gowns/shoe covers.

Try to organize your team as much as possible.

Abnormal vitals, pregnant patients, elderly, another fatality, fall over 20 feet, auto vs. ped are all prearrival markers for badness.

To intubate, loesen c-collar but have a second person hold in line stabilization until tube is secured. Then re-apply the collar.

New info: 28 or 32 FR tube was no better or worse than 38 or 40FR tube.

Don’t “rock the pelvis” just give one firm push on the ASIS bilat. If it moves it is fractured.

Fix scalp lacs. Patients can bleed severely and even rarely bleed to death. Tourniquets (BP cuff at 300mm hg) can sometime be life saving but use these rarely and cautiously.

When transfusing large volume of prbc’s, match units of prbc’s, ffp and possibly platelets.

Positive FAST scan, Systolic <90, HR>120, penetrating injuries: 3-4 of these are high risk for needing massive transfusion. 1 probably not.

Penetrating wounds to abdomen/flank/low back/pelvis require rectal exam. Other injuries you can be more selective with rectal exams.

Keep patients warm in ER.

New Thoughts from Scott Weingart for Traumatic Arrest: No closed chest CPR, no acls meds, first airway is LMA, bilat finger thoracostomy, cardiac ultrasound looking for tamponade.

Salzman comments: ED thoracotomy only good for penetrating chest wounds (optimally stab wound to heart) that cause tamponade. Heart is very delicate and it can be easily damaged by a scalpel or by fingers during internal CPR. ED thoracotomy for blunt trauma is futile.

Can consider ED thoracotomy to cross clamp aorta for a patient who has exsanguinated from a limb amputation. Give patient rapid prbc transfusion and do cardiac massage.

Harwood comment: It’s a thought.

Barounis comment/Salzman response: Massive transfusion protocol for untable, hypotensive pelvic fractures should be started in ED. Pt’s with other types of injury, the protocol has to be used more judiciously. If the protocol is initiated you can always back off if bleeding lessens. Patients that need to go to IR are more likely to need the protocol than patients going directly to OR. Level 1 transfuser is a critical tool during resuscitation.

FORT 5 SLIDE F/U

Poly drug overdose including TCA. PT was agitated. Intubated, sedated with propofol. Toxsicon recommended charcoal, serial ekg’s and bicarb for QRS >100ms. Initial ekg was ok/not wide/no terminal prolongation of QRS (big R wave) in AVR. Remained stable over 16 hours in ER. Was extubated and transferred to psychiatry.

TCA: sodium channel block, antihistamine, anti-muscarinic, K efflux blockade, alpha blocker, and gaba blockade effects. “Dirty Drug” has multiple effects.

Treatment: Seizures give Benzos. Hypotension give fluids and pressors. QRS prolongation give sodium bicarb. Dialysis is worthless due to high volume of distribution.

Harwood comment: Bicarb is the main treatment for EKG abnormalities. Brian said if bicarb not helping consider magnesium.

HERRMANN 5 SLIDE F/U

Child with GSW to right thigh. Pt had right femoral arterial injury. Hard signs with loss of distal pulses and pulsatile bleeding. Pt also had abnormal ABI’s. CTA showed injury to femoral artery. Prbc’s transfused. Pt went OR. Surgeons used saphenous vein from contralateral leg in reverse orientation (to negate the venous valves) to fix artery.

ABI has 98% diagnostic accuracy. Measure BP in all 4 extremities. Divide ankle systolic BP by higher of two upper extremity systolic bp’s. ABI<0.9 is abnormal and pt should get CTA or go to surgery.

Hard signs: abnormal pulse, arterial bleeding, pulsatile hematoma, bruit, thrill, distal ischemia.

Barounis comment: Vascular injury signs can wax and wane. These patients are tricky. Need re-exams if the initial decision is to observe so not to miss developing hard signs.

Chastain comment: Compartment syndrome has been known to develop on trauma patients after the initial injury. Stay alert even if you are tired.

KESSEN RSI DRUGS

Pre-treatment: moderates reflexic sympathetic response to laryngoscopy. Phayrnx and larynx are highly innervated with sympathetic and parasympathetic nerves. LOAD: Lido (no study shows neuro outcome improvement/Opioids (fentanyl can be considered for pain) /Atropine (for kids <5yo getting succ)/

Nelson comment: Contrarian view is that all these pretreatment drugs increase complexity and delay intubation.

Etomidate is most hemodynamically neutral sedation drug. Consider Ketamine as an alternative in the septic shock patient to avoid adrenal suppression.

Ketamine provides anesthesia and analgesia. Increases cerebral blood flow. May increase BP. It is a bronchodilator. May elevate ICP. Watch out for emergence phenomenon.

Propofol causes anesthesia and amnesia. May cause hypotension. No analgesic properties.

Versed provides anesthesia/amnesia but not analgesia. Can cause hypotension.

Barbiturates can provide anesthesia/amnesia and analgesia. Hypotension. Suppresses WBC function/recruitment.

Succinylcholine contraindicated in patients who have had severe trauma, burns, neuro injury all more than 72 hours prior to ED visit. These are not a problem if insult occurred the day of ED presentation.

Mistry comment: Many absolute contraindications to succinylcholine are actually relative contraindications and succ is pretty safe.

Rocuronium has less than 1 minute onset. Intubation conditions are similar to succinylcholine.

Sugammadex is a reversal agent for rocuronium that is being tested in Europe. Cuts the spontaneous ventillarion time from 400s to about 200s.

Harwood comment: Kid with severe astha, “Your risk of killing this patient is going up and up” Use etomidate, atropine to decrease secretions, and succinylcholine if airway is not predicted to be overly difficult.

ACMC EM Conference Notes