R4 Simulation Series: Genitourinary Emergencies with Dr. Moschella and Dr. Verzwyvelt

  • Fournier’s Gangrene (ie necrotizing fasciitis of the perineum): Case simulation of 19 yo M with tachycardia, hypotension, altered mental status found to have erythema, induration, and crepitus of the perineum. Initial steps are aggressive treatment of sepsis (broad spectrum antibiotics to cover skin and gut flora as this is commonly polymycrobial) and early surgical debridement. Either Urology of Acute Care Surgery will mobilize to perform the debridement.
  • Oral boards case: Consider ovarian torsion in young female with acute onset pain in lower abdomen or pelvis. You may find adnexal fullness or tenderness on exam. Diagnostic test of choice is transvaginal duplex ultrasound. Remember to include ectopic pregnancy, appendicitis, TOA in your differential.
  • Priapism procedure lab: A dorsal penile block can be achieved by placing wheals of local at the base of the penis in the 11 and 1 o’clock positions. Initial step is to drain the corpus cavernosum using a butterfly needle and syringe (18-23G will work). You can drain from anywhere along the penis but do not go through the glans. You only need to drain one side as they are connected. You can also irrigate with cold water or phenylephrine (2cc into 98cc NS bag; then inject 1cc into cavernosum) if the initial drainage does not achieve detumescence. Send a blood gas from the drained blood as pH is one of the most predictive factors in future erectile function.

Case Follow up with Dr. Doerning

  • 32yo Hispanic F with “worst headache of life” associated with photophobia and nausea without fever or meningismus. CT and CTV were performed and negative. LP showed: Tube 1 35k RBC; Tube 4 33k RBC and 67 nucleated cells. Subsequent CTA showed 2 saccular aneurysms that were repaired with a craniotomy and clipping.
  • Tips: there is no defined ratio of RBC to WBC to help determine traumatic tap versus SAH. Xanthochromia takes 6-12 hours to develop and is subjectively measured, so hard to rely on it. A traumatic LP should have: normal opening pressure, no xanthochromia, diminishing progressive RBC count.

Case Follow up with Dr. Mudd

  • 29 yo M restrained driver who arrived hypotensive receiving blood transfusion. FAST positive in Morrison’s pouch and splenorenal view. Additionally, FAST showed “spine sign” which is the ability to see the vertebral bodies in the thorax due to presence of fluid. Patient stabilized, brought to scan, and found to have traumatic dissection of his aorta. He subsequently underwent intubation, line, esmolol gtt, and TVAR (thoracic aortic endovascular repair) which went well and was discharged home on day 6!
Case Follow up with Dr. Scupp

  • 33 yo F with 2 weeks of viral syndrome (cough, fever, two ED presentations for “I don’t feel well”, vomiting, myalgias). Found to have prominent cervical LAD. Remained tachycardic despite IV fluids (120s – 140s) and elevation of Cr and mild transaminitis identified. Inpatient team sent IgM an IgG which were both positive and lead to diagnosis of acute CMV.
  • Acute CMV can look like EBV but monospot is negative. The vast majority of patients are asymptomatic but severe illness can lead to hepatitis, pneumonia, pancreatitis. Can see in immunocompentent people but most common in the immunocompromised (15-20% of all BMT patients). Also keep it in the differential for HIV with CD4 <400 and neonates (TORCHES).
"Kawasaki symptoms B" by Kawasaki_symptoms.jpg: Dong Soo Kimderivative work: Natr (talk) - Kawasaki_symptoms.jpg. Licensed under CC BY 2.0 via Wikimedia Commons.

Kawasaki symptoms B” by Kawasaki_symptoms.jpg: Dong Soo Kimderivative work: Natr (talk) – Kawasaki_symptoms.jpg. Licensed under CC BY 2.0 via Wikimedia Commons.

Kawasaki Disease with Dr. Chan

  • An acute self-limited vasculitis of unknown etiology.
  • Most common demographics: young children (mean 2yo), more boys than girls, most common in winter and spring.
  • If left untreated up to 1/4 develop coronary artery aneurysms or ectasia which can lead to MI, sudden death, ischemic heart disease.
  • Diagnostic criteria: 5 days of fever + 4 of the following: extremity changes (erythema or swelling of hand/feet), polymorphous exanthem, conjunctivitis (bilateral non-exudative), changes in lips or oral cavity (dryness or strawberry tongue), lymphadenopathy. Additional testing can include ESR and CRP, LFTs, echo.
  • Treatment options: high dose ASA (80-110mg/kg/day) followed by low dose ASA (3-5mg/kg/day) AND IVIG. All patients need to be admitted.

Cervical Spine Injuries in Children with Dr. Chan

  • These injuries are rare in peds (<1% of blunt trauma)
  • Location of injury varies by age. <8yo high c-spine (c1-4) is most common. >8yo low c-spine (c5-7) is most common. This is due to the fulcrum of the weight of the head, weaker neck muscles, and poor protective reflexes.
  • Canadian C-spine rules were derived, tested, and validated in adults so are not useful in kids.
  • NEXUS was validated in all ages, but only 3,000 of the 34,000 patients were under 18yo. Actual injuries were found in 88 patients under the age of 2 and 817 under the age of 8. While this still yielded 100% sensitivity the confidence interval is much wider due to the low incidence of injury.
  • PECARN: 540 cases with matched controls suggest imaging if any high risk factors: AMS, focal neuro deficit, torticollis, substantial torso injury, predisposing condition, or high risk MVC.
  • Imaging
    • Start with xrays (2-3 view). If negative, can get CT
    • How good are xrays?
      • Restrospective subanalysis of PECARN 90% sensitivity. Children <8 sensitivity only 83%
    • Don’t use flex/ex films. Based on retrospecive look at NEXUS - 6 new injuries identified, but already had positive findings on 3view
    • When to CT?
      • High pre-test probability (unable to get reliable exam, high mechanism, multisystem trauma)
      • Further eval of +plain films
      • Can’t obtain adequate plain films
    • Normal variants on imaging
      • C1- posterior arch fuses by 3yrs; anterior arch fuses by 10yrs.
      • Pseudosubluxation of C2 on 3 is common
      • Wide predental space (between dense and C1)
      • Growth plate between body of C2 and dens
      • Anterior wedging can be normal
"Emergency Thoracotomy" by Cothren and Moore; licensee BioMed Central Ltd. - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459269/figure/F2/. Licensed under CC BY 2.0 via Wikimedia Commons.

Emergency Thoracotomy” by Cothren and Moore; licensee BioMed Central Ltd. – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459269/figure/F2/. Licensed under CC BY 2.0 via Wikimedia Commons.

Consultant of the Month with Dr. Makley: ED Thoracotomy and REBOA

  • Goals of damage control resuscitation: stop the bleeding, stop the contamination, quick into the OR and quick out of the OR.
  • ED thoracotomy: 4th intercostal space from the sternum to the bed.
  • Clamshell: start with a triage chest tube of the right chest. If drains hemothorax, then extend the incision across the sternum with Lebsche knife.
  • Tip: placing an OG tube can help differentiate between an empty aorta and the esophagus.
  • Goals: direct inspection of injury, open cardiac massage (2x the cardiac output of closed chest CPR), relieve tamponade, repair cardiac injury, control lung hemorrhage, cross-clamp of the aorta.
  • Best outcomes seen in stab wounds to the heart with shortest CPR time. Current UC protocols: Blunt <10min CPR, Penetrating <15 min of CPR, non-torso trauma <5 min of CPR.
  • High risk procedure for you and the patient. Risks to patient: lacerations to heart, phrenic nerve transection, damage to esophagus, lung laceration, laceration of internal mammary arteries. Risk to you: incidence of your skin to patient blood contact 50%! Incidence of your blood to patient blood contact 6-10%.
  • REBOA (Resuscitative endovascular balloon occlusion of the aorta) = “the new thoracotomy”. This may help in damage control resuscitation when the patient still has a pulse. The balloon goes into the chest, so don’t use this if severe chest trauma. This is newly available in the UCMC trauma OR and hopes to move to the SRU.
  • This requires an arterial line, so if you are sticking for a femoral line and get artery, go ahead and thread the a-line which can then be dilated up to accept the REBOA (14F sheath, 120cm catheter).
  • See article for more details about the procedure: Stannard, et al. Journal of Trauma 2011. PMID: 22182896

Air Care Grand Rounds

Procedure kits that we carry in the black bag:
Some of the challenges to think about when performing these procedures in the aircraft include:
  • Positioning: you are stuck at the head of the bed, the patient is packaged, their arms are down to their side, and space is limited.
  • Sharps: high risk of accidental injury when in the back of a squad or in the helicopter. Be careful!
Helicopter equipment: as flight team members we need to be able to perform tasks that are usually not done by physicians: spiking fluids, hanging blood, drawing up meds, assembling bristo-jets, etc. The more of this you can do during a stable patient interaction the smoother things will go when you encounter the super sick patient requiring lots of intervention.
Balloon pump: [http://tamingthesru.com/transporting-intraaortic-balloon-pump-patients-by-air-care/] Take your time loading the device and recognize that due to the very short cables it is best to keep the device in the aircraft. Utilize extra help from the transferring and receiving facilities to ensure the loading and unloading of these patients is smooth. Review the physiology and function of the IABP here: [http://ca.maquet.com/clinician-information/e-learning-programs/accredited/theory-program/]
Traumatic arrest: manage the airway, get access (go for the IO), double needle decompression [http://tamingthesru.com/needle-thoracostomy/]  followed by double finger thoracostomy, and pericardiocentesis. No role for ACLS drugs in these patients. Work these patients on scene and terminate the resuscitation if unsuccessful. [http://tamingthesru.com/resuscitation-of-penetrating-trauma-patients/]

I.C. Cordes Airway of Horrors with Dr. Carleton

  • The failed airway
    • Can’t intubate, but can oxygenate – you have time
    • Cant intubate, can’t oxygenate (CICO) - you have no time
  • The surgical airway: takes time and practitioners are reluctant to do it (8-10 attempts made prior to cric)
    • SMART pneumonic to evaluate for difficult cricothyrotomy
    •  Surgically altered airway
    •  Mass inside or outside the airway
    •  Access (can you actually get to the membrane?)
    •  Radiation therapy
    •  Trauma
  • Indications for cricothyrotomy
    • Massive tracheobronchial bleeding
    • Severe mid-facial trauma
    • Oropharyngeal edema
    • Foreign body obstruction of the upper airway
    • Anatomic variants
    • Masseter spasm/clenched teeth
    • Failed airway without other rescue options
  • Tip: Preferable to use an ETT for cricothyrotomy over a trach tube as the trach tube is rigid and designed to go through a tracheostomy.

Open technique (no drop)

  1. Find cartilage
  2. Vertical skin incision
  3. Find cartilage again- tactile
  4. Horizontal incision through CTM (inferior CTM and blade facing caudally) 
  5. Insert trach hook along the blade to grab superiorly (inferior margin of thyroid cartilage)
  6. Dilate
  7. Intubate
Rapid Four Step Technique
  1. Find cartilage
  2. Stab straight down horizontal through the skin and membrane
  3. Slide trach hook down the blade and hook the inferior cartilage (cricoid cartilage)
  4. Intubate through non-dilated hole
Bougie technique
  1. Slide trach hook down blade
  2. Hook the superior margin of the cricoid cartilage
  3. Remove blade, insert bougie
  4. Slide ETT over bougie

imageCPC with Dr. Grosso and Dr. Powell

  • 21yo Spanish speaking M with chief complaint of 2 weeks of abdominal pain, some vomiting, mild headache. Noted on exam to have normal vitals, mild jaundice, photophobia, and diffuse abdominal tenderness. Labs remarkable for eosinophilia with normal WBC, direct hyperbilirubinemia, and mild hyonatremia at 134 with mild thrombocytopenia at 140k. CT abdomen completely normal.
  • Test of choice: CT head showed obstructive hydrocephalus. Followup MRI showed cystic structure in the 3rd ventricle which was shown on pathology to beextraparenchymal neurocysticercosis.
  • Neurocysticercosis: 92% of cases are seen in Latino patients. The 3 most common presenting symptoms are: seizure (66%), hydrocephalus (16%), headache (15%). It is the most common cause of seizure worldwide.

EBM Quick Hit: Subgroup Analysis with Dr. Lafollette

  • Goal: identify a specific useful patient population so you can anwer the question: “does this study fit the patient in front of me?”
  • It is by definition a secondary analysis. They can be designed a priori or post-hoc. If post-hoc, ask yourself “is the intervention making an artificial subgroup?” (eg: a study of tight glycemic control shows shorter ICU stay in the control group. But, did the intervention group have longer ICU stays because of the tight glycemic control?)
  • The more subgroup analyses that are performed increases the likelihood of false positive results. Consider the test of interaction which increases the p-value stringency. The initial study p-value is divided by the number of subgroup analyses. Use this new lower p-value to judge the subgroup results.
  • Remember that the initial study design matters. If the initial study design was poor, the subgroups are still based on a poor study.

International Medicine with Dr. Winston

  • International medicine refers to health work abroad with a focus on infectious diseases, prevention, maternal and infant health, water, and sanitation.
  • Global health is the overlap between public health and international medicine. It is more inclusive of research, knowledge sharing, prevention, sustainability, overall health improvement and health equity.
Quick Hit on Ebola with Dr. Widners
  • Transmitted via bodily fluids, but current recommendations include airborne precautions (N95) to protect yourself.
  • If you suspect Ebola call the CDC at 1-770-488-7100
  • More info available at: http://www.cdc.gov/ebola
M&M Learning Points with Dr. Stull:
  • Severe asthma exacerbations require considerable effort to avoid furthering acidosis while attempting to stabilize, secure airway, and maintain oxygenation. Use Mag early as there is evidence that you can reduce admissions by providing this treatment early. Consider BiPAP to improve ventilation while preparing for definitive airway management but there is no evidence that it reduces intubations. Ketamine as the RSI induction agent may provide some bronchodilatory effect but there is not enough data to provide any formal recommendations. For this same reason, ketamine as a post-intubation sedation agent may be appropriate. Vent management is key with a focus on low respiratory rate and short inspiratory times to lengthen the I:E ratio (>1:3) to allow full exhalation. Goal TV 6-8cc/kg, “ZEEP” or low PEEP (0-5mmHg), consider a plateau goal of ~25 if you paralyze.
  • Pancreatitis can be diagnosed by the presence of 2 of 3 criteria: lipase elevation >3x the upper limit of normal, historical features, or CT changes consistent with pancreatitis. Remember that acute pancreatitis should have an etiology. Imaging with a RUQ ultrasound takes <10 min and provides >95% sensitivity and >88% specificity to diagnose cholelithiasis when performed by emergency physicians. Positive RUQ ultrasounds may also reduce subsequent CT imaging. Remember that good discharge instructions are key (both verbally with the patient and written).
  • Consider early anticoagulant reversal in patients with evidence of bleeding or at high risk for life-threatening bleed. We saw an interesting case of a high c-spine fracture without evidence of bleeding but who was reversed due to very high risk of epidural hematoma formation. PCCs are useful to reverse novel oral anticoagulants, for fast reversal needed most commonly in intracranial bleeding, and hemophilia. Dabigatran is dialyzable. Vit K and FFP are effective for warfarin reversal. The dose is approx 10cc/kg but that is dependent on the INR (higher INR requires more).
  • PE miss rate is >10% in the ED. PEs that are missed in the ED are most commonly seen in the elderly and altered patient populations. If PE is missed in the ED the patient has a much higher mortality and morbidity rate (stroke, intubation, death) compared to those diagnosed early.
"Haemophilus parainfluenzae Endocarditis PHIL 851 lores" by This file is lacking author information. - http://phil.cdc.gov/PHIL_Images/02122002/00007/PHIL_851_lores.jpg. Licensed under Public domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Haemophilus_parainfluenzae_Endocarditis_PHIL_851_lores.jpg#mediaviewer/File:Haemophilus_parainfluenzae_Endocarditis_PHIL_851_lores.jpg

“Haemophilus parainfluenzae Endocarditis PHIL 851 lores” by This file is lacking author information. – http://phil.cdc.gov/PHIL_Images/02122002/00007/PHIL_851_lores.jpg. Licensed under Public domain via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Haemophilus_parainfluenzae_Endocarditis_PHIL_851_lores.jpg#mediaviewer/File:Haemophilus_parainfluenzae_Endocarditis_PHIL_851_lores.jpg

Endocarditis with Dr. Gozman
  • 3 types of endocarditis: native valve endocarditis, IV drug users, and prosthetic heart valves. IV drug users have higher rates of psuedamonal, fungal, or polymycrobial etiologies. While obtaining multiple blood cultures is key (recommendation is 3 sets over an hour) they may be negative in 5-10% of patients and that number may be as high as 50% if the patient has been on recent antibiotics. Use the Duke criteria to help make the diagnosis but always consider endocarditis if the patient is an IVDU and has a fever.
  • Initial broad spectrum antibiotic therapy should include gentamycin if the patient is an IVDU and rifampin if the patient has a prosthetic valve.
  • Surgery is indicated if: severe valve disease causing CHF, relapsing prosthetic valve disease, severe embolic complications, fungal disease, or new conduction abnormalities.
Seizure Update with Dr. Bonomo
  • Workup for an initial seizure should include: glucose, sodium, pregnancy test, LP if immunocompromised (HIV regardless of CD4, dialysis, recent hospitalization, steroids), CT.
  • Up to 15% of patients can have negative CT but significant findings on MRI. If you are concerned about ischemic stroke (up to 20% of adults and kids with acute ischemic stroke will have seizure at the onset) consider a MRI DWI sequence which is very rapid.
  • AEDs reduce the risk of second seizure. Keppra has the fewest side effects if you feel like you wish to start one from the ED. No good data on benzo bursts after a seizure.
  • Status epilepticus definitions now state any clinical or EEG seizure lasting greater than 5 min or 2 back to back seizures without return to baseline. Consider early intervention and early neurology consultation for “impending status” or “ultra early status” if seizure has not self terminated in 2-3min.
Drowning and Dive Medicine with Dr. Roche
  • Disease spectrum ranges from drowning without morbidity, drowning with morbidity, drowning death.
  • Don’t focus on what the water source was, but: saltwater tends to produce more surfactant washout and requires 3-5 days for surfactant to build back up and freshwater is more cytotoxic to the lung parenchyma. No need for empiric antibiotics for water aspiration unless brackish water.
  • ED management of submersion injuries include: NIPPV, bronchodilators, exogenous surfactant might play a role, and high index of suspicion with plan to admit patients for observation if abnormal vital signs or respiratory signs/symptoms.
  • Diving injuries can be divided into big bubble issues (pulmonary barotrauma, arterial gas embolism, pneumomediastinum) and small bubble issues (decompression sickness). Big bubble issues most commonly seen in inexperienced divers, shallow dives, and surfacing too fast with immediate symptoms. Small bubble issues most commonly seen in commercial divers, deep dives, and have delayed onset of symptoms.
  • Treatment for dive injuries include: oxygen, supportive care, hydration, and hyperbarics to push the gas back into solution.

“Gray575″. Licensed under Public domain via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Gray575.png#mediaviewer/File:Gray575.png

Ultrasound Guided PIV with Dr. Carleton
  • Has been proven in emergency departments to improve speed of access, decrease number of attempts, and decrease central line use in patients who only received central lines for poor peripheral access. Success rate quoted at 97% (although took 3 attempts, only 46% successful on first attempt).
  • Options include: basilic, cephalic, median cubital, median bacilic, and median cephalic veins.
  • Ideally you want to end up with 1-2.5cm of catheter inside the vein. This requires choosing the appropriate length catheter from the start. Remember high school trig: if you are entering the skin at 30 degrees you will need twice the amount of catheter as the vessel is deep (hypotenuse = 2x depth). If you enter steeper, say 45 degrees, your length is slightly less but requires square root calculations.
  • Don’t try for anything deeper than 1.5 cm
Dr. Steuerwald and Dr. Gerecht in front of Air Care 1 at UCMC

Dr. Steuerwald and Dr. Gerecht in front of Air Care 1 at UCMC

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

In most hospital-based clinical environments the answer to all of these questions in some form includes the use of PLASMA.

For the “transport resuscitationist” the question then becomes how do you manage these same patients in the prehospital environment? The “transport resuscitationist” asks why should the care of these critical patients be any different at the scene of an accident or during transport?

Earlier this year as a result of the hard work of many dedicated professionals at UC Health Air Care & Mobile Care and the University of Cincinnati Medical Center, each of Air Care’s 3 helicopters began transporting 2 units of type A plasma to complement its existing 2 units of pRBC’s and TXA.

In this podcast, we discuss some of the important logistics in bringing this advanced transport medicine to the patient. Additional details and resources are below.  Please feel free to contact EMS Fellow and Flight Physician Ryan Gerecht, MD, CMTE at ryan.gerecht@uc.edu with any questions.

  1. Plasma: the liquid, noncellular portion of whole blood, which contains coagulation factors, water, electrolytes, and fibrinogen.
  2. Fresh Frozen Plasma (FFP or FFP24): plasma that is separated and prepared from whole blood and then frozen within 8-24 hours of collection to allow long-term storage. Prior to administration, FFP must be thawed to a liquid state, which takes approximately 45 minutes.
Traditional obstacles to utilizing plasma in the prehospital environment:

1) As noted above, it takes approximately 45 minutes to thaw FFP for administration. This delay created in thawing FFP as well as the logistical obstacles of actually thawing plasma in a helicopter, limits its use in the emergency situations frequently encountered in the prehospital and transport environment.

2) Once thawed from its frozen state, plasma has a shelf-life of only 5 days. Thus for remote based air craft that may be a considerable distance from a blood bank, this requires a complex and costly courier system to constantly replenish and recirculate the plasma prior to expiration while ensuring such a valuable resource is not wasted.

The solution: Liquid Plasma or “never frozen plasma

Liquid plasma is plasma that is separated and prepared from whole blood in a liquid state and is never frozen. It is FDA approved and is stored at 1-6ºC for up to 40 days. Because liquid plasma is stored in a liquid state, it is ready for immediate administration, thus making it ideal for the transport environment.

In addition, research suggests that its hemostatic profile is as good if not better than thawed plasma.

See: Better Hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. By Matijevic et al. J Trauma Acute Care Surg. 2013 Jan;74(1): 84-90

Air Care Logistics:
  • 2 remote based helicopters with 2 units of type A liquid plasma + 2 units pRBC’s + TXA
  • 1 hospital based helicopter with 2 units of type A thawed plasma + 2 units pRBC’s + TXA
  • Plasma and pRBC’s are stored in a portable cooler with ice packs during transport. These coolers have been tested and approved by the blood bank to ensure that it maintains the appropriate temperature for several hours.
  • pRBC’s are already affixed with a temperature dot to monitor temperature of all blood products contained within the cooler.
  • At the helicopter base, the blood cooler is maintained in a blood bank calibrated refrigerator.
  • At the time of donation, plasma that is going to be made into liquid plasma has to be treated a little differently than plasma that is going to be frozen. Thus it requires some pre-planning on behalf of the blood bank.
  • Air Care & Mobile Care is the only department at University of Cincinnati Medical Center (UCMC) that uses liquid plasma.
  • Air Care buys liquid plasma from the blood bank for $65 per unit.
  • Liquid plasma is labeled with an imaged paper system for permanent tracking/record keeping by the blood bank.
  • The blood bank at UCMC keeps on hand 5-7 units of replacement liquid plasma for Air Care utilization 24/7.
Why type A plasma?

AB plasma is the universal donor; however, its supply is inherently scarce compared to other blood types. Further decreasing the supply of AB plasma is the utilization of only male plasma as part of TRALI reduction strategies.

On the other hand, Type A plasma is more plentiful & statistically more likely to match a recipient blood type.  The anti-B present in type A plasma is known not to be as strong an antibody as the anti-A present in type O or B plasma. Furthermore, the anti-B in type A plasma is thought to be diluted out in the recipients circulation and could be bound to the patients own soluble antigens since 80% of the population makes soluble A or B antigens. Thus to meet the growing plasma demands, major trauma centers around the US are switching to type A plasma.

See: Emergency use of prethawed Group A plasma in trauma patients. By Zielinski et al. J Trauma Acute Care Surg. 2013;74(1):69-74

*** By protocol and at the request of our blood bank, Air Care does NOT transfuse type A liquid plasma on patients who weight < 50kg. The concern is that the anti-B antibodies present in type A plasma could have an adverse effect simply because there is not as much circulatory volume in these smaller adults / pediatric patients.***

Air Care & Mobile Care Transfusion Strategy

Air Care strives to achieve the following goals when resuscitating the acutely bleeding trauma patient.

  • 1:1 plasma and pRBC transfusion ratio
  • When possible transfuse plasma and pRBC simultaneously. If this is not possible secondary to limited IV/IO access then transfuse plasma first
  • Transfusion of blood products (plasma and pRBC) take precedence over TXA when IV/IO access is limited
  • Except in patients with concomitant TBI, resuscitation is guided by a permissive hypotension strategy.

See attached Air Care & Mobile Care Plasma Protocol

A special thank you to Dr. Bill Hinckley, Ms. Ruda Jenkins, Dr. Bryce Robinson, Dr. Patricia Carey, and Ms. Helen Hancock who together made plasma on Air Care a reality.


ACMC Liquid Plasma Policy


About the Authors
Steuerwald Small

Dr. Mike Steuerwald


Dr. Mike Steuerwald is an EMS Fellow in the University of Cincinnati Department of Emergency Medicine.  He is a graduate of the UC Department of Emergency Medicine Residency Training Program and former Resident Air Care Medical Director

Follow him on Twitter @MikeSteuerwald

Follow him on Google+


gerecht headshot

Dr. Ryan Gerecht


Dr. Ryan Gerecht is also an EMS Fellow in the University of Cincinnati Department of Emergency Medicine.  He is a graduate of the UC Department of Emergency Medicine Residency Training Program and former Resident Air Care Medical Director.  He is a past winner of the Jean Hollister EMS Award presented by SAEM (2013)

Follow him on Twitter @RGerecht

Follow him on Google +

Residents as Teachers with Dr. Palmer

In general, the best way to learn is to challenge yourself.  Teaching styles should take into account different learner types and levels

Learner levels:
  • Beginner: early 3rd year medical student
    • Can be an observer initially but transition these learners to the next stage
    • Keeps you on point as you have to really know what you are talking about
    • Incorporate them into your H+P
  • Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
  • Advanced: OMP (one minute preceptor) or SNAPPS model
What learners require from preceptors: empathy, enthusiasm, humor, respect, fairness, flexibility, consistency, dependability, support and warmth
     - You do not have to be all these things all the time but always try to start off strong
Learner Needs: space and time, concrete illustrations, control over pace, allow time for reflection, feedback, awareness of past experience level, contribute to care
Participation, repetition and reinforcement enhance learning
Constraints to teaching in the ED: lack of time, space, interest or resources
One Minute Preceptor Model: Start by laying groundwork for their presentation
  • Get a commitment: what do you think is going on, what lab test would you like to order, what is the disposition, etc
  • Probe for supporting evidence: why do you think this is going on, etc
  • Teach a general rule
  • Reinforce what was done well
  • Correct mistakes
SNAPPS: Learner Centered
  • Summarize H+P
  • Narrow differential diagnosis
  • Analyze differential diagnosis
  • Probe preceptor (ask questions)
  • Plan for management
  • Select a case related learning point


Complications of Bariatric Surgery with Dr. Watkins
Tachycardia = peritonitis in an obese patient, until proven otherwise
Bypass patients are always vitamin deficient. Always think Thiamine (B1) deficiency in a vomiting patient and just give a bypass patient Thiamine when they are in the ED
Do not give NSAIDS to bypass patients as this increases risk of stricture
Bariatric patients do not need a lot of PO contrast as their stomachs are small
Obese patients have lots of complications in every body system. There is a 95% improvement in their quality of life and 89% reduction in 5 year mortality after bariatric surgery
Roux-en-Y Gastric Bypass Source: U.S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Roux-en-Y_gastric_bypass.png

Roux-en-Y Gastric Bypass
Source: U.S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Roux-en-Y_gastric_bypass.png

Gastric Bypass: stomach is stapled into a small pouch and connected to distal intestine

There is no digestion/absorption until later in the intestine, meaning that these patients have lots of vitamin deficiencies
Early complications: leak, GI bleed, wound infection, Pulmonary (PE, hypoventilation, sleep apnea)
  • Leak presents with abdominal pain, tachycardia, fever and dyspnea
    • Diagnose with gastrograffin UGI
  • GI bleed: usually managed conservatively if > 48 hours after surgery
  • Gastric Remnant distention: rare and potentially fatal if ruptures
    • Can be due to ileus or obstruction
    • Symptoms: pain, hiccups, shoulder pain, tachycardia, SOB
    • Needs immediate decompression
  • PE: pt’s at higher risk as they are hypercoagulable 2/2 high estrogen
Late complications: malnutrition, obstruction, stricture, fistula, marginal ulcer, cholelithiasis, nephrolithiasis, kidney stone, hernia, dumping syndrome, hypoglycemia
  • Internal hernia: increased risk after laparoscopic procedure
    • Incidence 3-5%, most common cause of SBO
    • Symptoms: postprandial crampy pain that can be preceded by symptoms of intermittent mild obstruction
    • CT: mesentary swirling
  • Marginal Ulcer: at site of gastrojenjunostomy
    • Present with epigastric pain and dysphagia
    • Jejunum does not have an acid buffer
    • Treat with PPI/sucralfate for 3-4 months
  • Dumping syndrome: due to high osmolar food bolus into the small intestine
    • Crampy pain, diarrhea, nausea, vomiting, flushing, hypotension, tachycardia, diaphoresis
Vitamin deficiencies after bypass: very common to have thiamine deficiency, anemia and Ca deficiency
Adjustable Gastric Banding Source: .S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Adjustable_gastric_banding.png

Adjustable Gastric Banding
Source: .S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Adjustable_gastric_banding.png

Gasric Sleeve: #1 surgery for weight loss
  • Take out 80% of the stomach
  • Appetite suppressive
  • Complications: leak, bleeding, volvulus, GERD, motility issues
Gastric Bands: Adjustable ring around stomach
Complications: upper pouch dilation, erosion, port problems
  • Dilated pouch: symptoms of severe GERD due to increased pressure
    • Diagnose with UGI
  • Erosion: this occurs when the band is too tight
    • Symptoms: weight regain, no restriction with maximal fill
    • This does not present with peritonitis as it seals itself
    • Treatment: band removal
    • Commonly associated with port infection
  • Issues with the port: saline leak, infection, tube disconnect
When is it safe to use BiPaP in these patients? After 1 week in Bypass surgery and after 1 month in sleeve patients, though overall this is very provider dependent


Clonidine Overdose with Dr. Axelson
Mechanism of action
  • Central alpha agonist: this leads to negative feedback to NE/E and hypotension
  • Peripheral alpha2 agonist
  • Leads to release an a beta-endorphin that acts as an agonist to opioid receptors
It can be tough to tell clinically clonidine vs opioid overdose
Should you give Narcan to clonidine overdose? Sure but it may not work because it only works on peripheral receptors so will only work early. You might see hypertension in children but this will usually autocorrect.

CPC with Dr. Baxter and Dr. Mudd
44 yo M with chronic back pain and wrist arthritis presents with 2 weeks of N, V, D, minimal dyspnea on exertion and cough. Has a Hg 8.6, WBC 5, Cr 1.7, proteinuria. Most significant complaint was dyspnea on exertion, so the pt got an EKG and CXR that showed cardiomegaly. Diagnostic test of choice is echocardiogram which showed a large pericardial effusion with tamponade. He gets admitted to the hospital with ultimate diagnosis of Lupus.
SLE: there are 11 diagnostic criteria and if you have 4/11, you can diagnose with Lupus.
Pericarditis is one of the diagnostic criteria and pericarditis with effusion is common in Lupus but tamponade is rare.
Acute complications of lupus:
  • ACS: most common cause of death, Relative risk 6
  • Pulmonary: alveolar hemorrhage, ARDS, respiratory failure
  • Cricothyroid joint arthritis, angioedema
  • Cardiac tamponade
  • Renal failure
  • Infection
Somatoform Disorders with Dr. Betham
0.5-2% of patient encounters include some component of factitious symptoms
Somatization disorder: the patient has multiple unrelated complaints in several body systems.
  • Usually in young females
  • The pt is not aggressive
  • The pt is not consciously lying about their symptoms
  • There is no external gain
Malingering: patient consciously make up their symptoms for external gain
Factitious disorder: The patient consciously fabricates symptoms for primary gain (psychological gain in order to play the sick role)
Munchausen disease: 2 types
  • Classic peregrinating migrating
    • Commonly seen in males
    • Patients are aggressive and grandiose
    • Patient undergo lots of aggressive testing and have a poor prognosis
  • Common nonperegrinating
    • Commonly seen in females with some medical training
    • Patient is not aggressive
    • The patient has chronic health problems, high incidence of substance abuse and personality disorder
Management in the ED
  • Focus on objective data
  • Avoid risky tests and treatments
  • Be consistent
  • Establish limits
  • Focus on whats best for the pt
Digoxin Toxicity with Dr. Loftus
The pt presents with feeling “unwell”, vomiting and irregular heart rate. HR varies from 145 to 38 to 101 to 83 to 26. Labs show K 2.5, Cr 3.6, Ca 13.3
  • Digoxin works by blocking Na/K ATPase. This leads to increase in intracellular Na which inhibits Na/Ca exchanger and decreases intracellular Ca.
  • Hypokalemia and hypomagnisemia can worsen digoxin toxicity even with a normal level
  • Hyperkalemia is a marker of badness. K > 5.5 is an indication for digibind.
Stone heart theory: We used to believe that you cannot give Ca to dig toxic patients however that is no longer believed to be true. While Ca is not recommended to use in hyperK patients with dig toxicity, it is unlikely to be harmful
Digoxin toxicity can cause ANY arrhythmia
  • Scooped ST segment
  • PAT with AV block
  • Sinus bradycardia with SA block
  • Transcutaneous and transvenous pacing may be dangerous in these patients as digoxin creates an irritable myocardium and pacing can cause a higher risk of V. Fib

Indications for Digibind

  • Life threatening arrhythmia
  • K > 5.5
  • Renal failure
Bidirectional Ventricular Tachycardia - associated with digitalis toxicity.  From: Edward Burns. Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/bvt/

Bidirectional Ventricular Tachycardia – associated with digitalis toxicity.
From: Edward Burns. Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/bvt/

Ramsey Hunt Syndrome (aka Herpes Zoster Oticus) with Dr. Toth
This is a polycranial neuropathy secondary to VZV or HSV

  • Usually affects CN 7, 8, 9, 5, and 6 (in order of frequency)
  • 20% of the patients present with pain only without any cutaneous findings
  • Treatment: acyclovir and prednisone
  • Can give gabapentin for pain
  • Lidocaine eye drops for pain