Grand Rounds Recap - Minor Care Symposium - 9/23
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This week was a tour of all the little things that make the ED a fun place to work. We're not talking about ECMO or REBOA, we're talking minor care.
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Grand Rounds Recap 9/16
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Air Care Grand Rounds
What do I need to assess before I load this patient in the heli?
- Does your patient need plastic? (ETT, needle/finger thoracostomy)
- Get breath sounds / anticipate your possible interventions you may need
- Is your patient in shock?
- Don't have a lactate? Hyperglycemia in the absence of diabetes, thirst and diaphoresis should lend you towards 'yes'
Grand Rounds Recap 9/9
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Case Follow up with Dr. Winders
The Sick Patient with Pulmonary Artery Hypertension (PAH)
- PAH defined as right heart catheterization with mPAP > 25mmHg, which can be estimated by echo
- Readily associated with right ventricular failure, measured by TAPSE < 1.8 with M mode over tricuspid annulus
- EKG can also help identify these patients with right axis deviation or right atrial enlargement
Grand Rounds Recap 9/2
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Evidence-Based Medicine: Meningitis with Drs. O'Brien and Teuber
- In one study, 95% of people with meningitis had 2 of fever, headache, meningismus but only 44% had all 3
- CT prior to LP? The American College of Radiology says do it for papilledema, altered mental status, focal neuro deficit, immunocompromised stated, history of CNS disease.
Grand Rounds Recap 8/26
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M&M with Dr. LaFollette
Case 1: Troponin Use in ESRD
- Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
- Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
- Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
- Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.
- Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality
STEMI and STEMI Equivalents, i.e. Who Needs the Cath Lab Now!
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1. The ACC/AHA Criteria (1) (2)
ST-elevation in 2 contiguous leads that is:
Men < 40: 2.5 mm ST-elevation in V2 or V3, 1 mm in any other lead
Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead
Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead
STEMI's have a 90-minute door-to-balloon time mandate from the Center for Medicare Services (CMS). To be good stewards of our resources we need to be familiar the false positive STEMI patterns. Ultimately, however, some degree of over triage and activation for false positives is expected and (potentially even) desirable.
Read MoreGround Rounds Summary 8/19/15
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Simulation - Clonidine Overdose
- 30 yo FM presents after having taking a handful of pills with the following VS: HR 45, BP 83/60, RR 8, 100% RA, T 98. FS101. It gets better—there's a baby behind that baby bump.
- Ddx for AMS, hypotension and bradycardia? Tox, hemoperitoneum, spinal shock, myxedema coma, and a quite atypical sepsis.
- By EMS report this lady reportedly took a handful of unknown pills in an effort to harm herself. Remember to consider clonidine overdose in addition to beta blockers and calcium channel blockers. This lady found herself a bottle of clonidine and a near successful suicide attempt.
Grand Rounds Summary 8/12/15
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VISITING LECTURER SERIES WITH DR. MATT DAWSON
1) On Technology, Emergency Medicine, and New Frontiers
Today’s tech explosion is leading to health innovations that may make some big differences leading to big changes. Here’s a sneak peak:
In the near future drones may roam the sky to deliver life saving epi pens, defibrillators and instructions of how to use them. Until SkyLab takes over...
Portable ultrasound? Pocket VL? (Hey don't we already have those...)
CHEER Trial: Too young to die? Try ECMO. Australia did and in a trial of 26 people, 14 went on to live and many with excellent neurologic recovery.
TEE: A small number of point of care ED docs are using this successfully to better evaluate causes of shock with good results, low risks (0.03% perf rate), and little training
Thromboelastography aka The TEG
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What is TEG?
Thromboelastography (TEG) measures the dynamics of clot development, stabilization/strength, and dissolution. Assuming the body’s ability to achieve hemostasis is a function of these clot properties, TEG provides specific, real-time indicators of a patient’s in vitro hemostatic state. This is in contrast to routine screening coagulation tests such as aPTT and PT/INR which are run with blood plasma alone and therefore do not take into account the cellular components of clotting.
Read MoreGrand Rounds Summary 8/5
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Taming the SRU Case Follow-Up: GSW to the Head with Dr. Grosso
- In one census: 66% of violent deaths are suicide, with 30k suicide deaths annually in the US
- ~50% of suicide attempts include firearms
- GSW to head mortality is 80%, and 71% die on scene
- ~40% of those who survive to hospital have favorable outcomes
- Favorable prognosis: GCS>8, normal pupillary reaction, absence of coagulopathy of trauma/hemodynamic instability
Grand Rounds Summary - July 29th, 2015
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Morbidity and Mortality Pearls with Dr. Curry
Nephrolithiasis
Incidence in the US is 0.5-1% (lifetime risk 10-15%). There is a 2:1 male predominance and the recurrence rate is fairly high (37% at 1 year, 50% at 10 years and 75% at 20 years).
Patients at risk for poorer outcomes with ureterolithiasis are those with risk factors for diminished renal function, history of difficulty with stones/urologic intervention and symptoms of infection.
Read MoreMoonlighter - Recap
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This is our final recap of our "Out on a Limb" Case Series! If you missed the initial "Moonlighter" case and discussion you can check it out here. There were a number of great responses to the questions which we'll recap below.
Q1 - What are your options in handling this situation?
You have a few options in handling this situation. As many of the respondents chimed in, the wound definitely needs to be cleaned out and closed and the patient requires antibiotics as soon as is reasonably and safely possible, especially since the injury is already 6 hours old. The first option is to complete a sedation and multilayer repair in the ED yourself. As many people point out, this is not an excellent proposition unless there are extreme extenuating circumstances.
Read MoreTrouble Abroad - Recap and Commentary
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The responses provided so far have been phenomenal, both insightful and provocative. I am truly impressed. As mentioned by several of my colleagues, many of these cases are deeply personal, not only because they involve highly vulnerable populations, but also because they may put clinical providers in harm’s way. When we begin to discuss ethics, especially global health ethics, there is often no single correct answer to a given scenario. We often deal with hard science and hard facts but sometimes you just have to go with your gut and do what you think is right. If you missed the first case and initial discussion, check it out here.
Read MoreGrand Rounds Summary - July 22
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Dr. Miller - Leadership Curriculum
"Give me six hours to chop down a tree and I will spend the first four sharpening the axe" - Abraham Lincoln
In order to lead the team, you need a reflection of what you need to improve as a leader:
- In a survey of academic chairs, communication, decision making, collaboration and trustworthiness were the top rated characteristics
- In a survey of UC EM residents and faculty confirmed that these apply to every level of training
