Grand Rounds Recap 08.05.20
/Bedside Teaching: Dr Paulsen - R4 Case Follow Up: Persistent Arrest with Dr. Gleimer - Air Care Grand Rounds: CODE STEMI and Simulation
BEDSIDE TEACHING with DR. PAULSEN
There are many teaching challenges: lack of availability and time, lack of familiarity with site logistics, variable preceptor and student experience, unrealistic expectations for yourself, and undefined expectations for your learner.
Preceptor clinical efficiency correlated with preceptor willingness to teach, interpersonal skills, and learner perception of clinical teaching, and NOT with preceptor’s perceived availability or actual patient volume.
Consider doing the following in order to optimize the learning environment: set goals and expectations, seek encounters that are in-line with learner-centered goals, balance supervision and autonomy, label teachable moments and feedback, circle back to learner’s objectives, and provide positive and critical feedback with strategies for improvement
Bedside teaching is optimized when you pick one thing to teach per patient encounter/discussion: knowledge, communication, procedural skill, attitude, and behavior are a few examples.
Different teaching methods:
Differential diagnosis via S.P.I.T. - serious, probably, interesting, treatable
One-minute preceptor - get a commitment, probe for supporting evidence, teach one general principle, provide positive feedback, correct errors/suggestions for improvement
Direct observation and provide specific feedback
Activated demonstration via procedures or bedside encounter - asked focus questions at bedside and debrief after
Tips for creative teaching in the COVID Era:
Telemedicine
observe from a distance
convert the patient encounter to an oral boards encounter
present the H&P and ask the student for their A&P
Teaching scripts: save interesting EKGs/POCUS/CT images to teach from, use electronic resources, create morning report-style cases, run your board out loud to teach task sequencing, give documentation pearls while you dictate, teach about consultant communication, hypothetical change in setting/resources, share life-long learning strategy, and discuss your approach to on-/off-shift wellness.
R4 CASE FOLLOW UP with DR. GLEIMER
Middle aged male presenting with a cardiac arrest from home, found unresponsive. He received bystander CPR up until EMS arrival, at which point he was placed on the LUCAS device with an iGel airway placed. He was noted to be in Vfib and received multiple shocks, amiodarone, and epinephrine without ROSC. Upon arrival in the ED, family was present at bedside while he was intubated and a CVC and A-line were placed. Bedside echocardiogram demonstrated meager cardiac activity, and he was noted to have significant metabolic and respiratory acidosis. Despite receiving magnesium, potassium, calcium, amiodarone, lidocaine, norepinephrine, and epinephrine, he remained in cardiac arrest. The decision was made to administer systemic tPA, and he then achieved ROSC. He was transported to the cath lab for intervention, received drug-eluting stents with appropriate flow, and was discharged home on hospital day 4 neurologically intact.
LUCAS device use during code
LINC trial: prospective RCT with 1300 patients
Similar 4 hour survival rate
Mechanical CPR did not result in improved effectiveness compared with manual CPR
MECCA trial: prospective RCT, 1274 patients
Similar ROSC and 24H survival rate
Systemic tPA for cardiac arrest
GUSTO-1: prospective RCT, 41000 patients
Alteplase vs older thrombolytic
1% decrease in absolute mortality, NNT 100
Current consensus does not support use
Consider in resource-poor settings, high suspicion PE / ACS, unstable patients, “last resort” therapy
Family presence during resuscitation
Prospective RCT with 570 family members
Frequency of PTSD was higher in control group (AOR = 1.6)
Frequency of anxiety and depression higher in the control group
Quality of CPR was not affected
AIR CARE GRAND ROUNDS with DRS. GOTTULA & SKROBUT
Myocardial ischemia with Dr. Gottula
100% STEMI cases have near total occlusion with insufficient collateral circulation vs. 25-30% of NSTEMI cases
Door-to-balloon time goal is <90 minutes
If first medical contact to PCI is estimated to be >120min, fibrinolytics are recommended
Who needs emergent PCI?
STEMI
NSTEMI with electrical or hemodynamic instability, refractory to maximal medical management
STEMI equivalents: hyperacute T-wave changes, posterior MI, multilead ST depression with coexistent ST elevation in lead aVR, characteristic diagnostic criteria in the setting of LBBB
Post-thrombolytic care
Transport to PCI-capable facility
Maximizing medical intervention
ENSURE ADMINISTRATION ON ALL STEMI PATIENTS ON AIR CARE:
Aspirin: All ACS patients should receive non-enteric coated aspirin 162-325mg with NNT of 42 for mortality benefit
Anticoagulation (heparin infusion): 60-70U/kg IV loading dose + 12-15U/kg/h infusion
Discontinue infusion for transport, only continue if bolus
May substitute heparin for other agents (enoxaparin, bivalirudin) per cardiology
Oxygen: Goal SpO2 >94%. Avoid hyperoxia, which can increase infarction size and increase recurrent infarction and dysrhythmia
Electrolytes: Ensure normokalemia with goal K >4.0mEq/L and normomagnesemia with goal Mg >2.0mg/dL
Always place patients on defibrillator pads!
CONSIDER ON STEMI PATIENTS ON AIR CARE:
P2Y12 inhibitors: per interventional cardiologist as it has potential to delay CABG in high risk patients
Analgesia:
Nitroglycerin: used for ongoing chest pain - do not use in patients with hypotension, suspected inferior and/or RV MI, or recent phosphodiesterase inhibitor use (within 24-48hr)
Opiates
Morphine has demonstrated to increase mortality
Fentanyl decreases antiplatelet agent concentration
Statin: Atorvastatin 80mg pre-treatment before PCI has demonstrated decrease in major adverse cardiac events and increased coronary flow after PCI
How to reduce time of transport for these patients:
Document the time of EKG diagnosed STEMI
Hot load the patient
Goal ground time at transferring facility <10 minutes
Cardiac Arrest During Aeromedical Transport Simulation with Dr. Skrobut
Always place pads before loading the patient into the aircraft in unstable / STEMI patients
Be efficient, be fast and be safe
Ensure the patient had received a heparin bolus and aspirin
If available and will not slow down transport, request a second anti-platelet agent, potassium repletion (if needed) and atorvastatin (80 mg)
Do not need to continue heparin gtt as it slows down transport
When coding a patient in the helicopter it is important to clearly delineate roles between you and your nurse
Focus on high quality compression and early defibrillation as these interventions save lives
30:2 compressions is non-inferior continuous compressions
MD starts compression at head of bed.
Be sure to swap out as needed to maintain adequate quality of compressions
Nurse runs zoll monitor administers shocks as indicated
Place Igel if able and attach to vent circuit (Default settings RR 12 TV 500 Peep 5 FiO2 21%) hook to oxygen source and increase O2 delivered to 100%
If unable to place iGel, continuous CPR = 30:2 bagging
Nichol G, Leroux B, Wang H, et al. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med. 2015;373(23):2203-2214. doi:10.1056/NEJMoa1509139
The person not doing compressions can draw and administer medications
Have pilot notify dispatch of “CPR in progress” and to have extra staff available at receiving hospital. Helicopter will need to be shut down before extra personnel can assist with the transport and CPR as they are not “hot load” trained.
What to do if the patient dies?
If they code before loading the patient into the helicopter take them back to the ED/ICU and run the code at the sending hospital (hospital where you picked the patient up from)
If they code after being loaded in the aircraft, perform CPR and transport them to their accepting/receiving facility (where the patient was accepted to be transferred to). Ensure the pilot informs dispatch/the accepting hospital
