The Urine Drug Screen - Know Thy Limitations

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The Urine Drug Screen - Know Thy Limitations

We are all guilty of ordering them in the ED, but do we really know what we’re ordering?

The Implications of the Urine Drug Screen

1 literature review looked at 7 different retrospective studies describing a total of 1,405 patients and found the urine drug screen did not affect the management of any of these patients while in the emergency department.  However, the data from the UDS can affect a patient’s clinical care outside of the Emergency Department.  For example, if a patient requires psychiatric inpatient care, initial knowledge of drug abuse could affect this patient’s etiology of illness or rehabilitation plan.

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Grand Rounds Recap 2/10/16

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Grand Rounds Recap 2/10/16

R4 QUARTERLY SIMULATION with Drs. Curry, Loftus, Ostro and Strong

We presented a case of a 42 y/o female who presented with altered mental status, hypotension and bradycardia. She was ultimately found to have an unintentional labetalol overdose which she had been taking PRN for headache.

Beta-Blocker Overdose Take-Home Points...

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Grand Rounds Recap 2/3/16

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Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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Grand Rounds Recap 1/27

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Grand Rounds Recap 1/27

Morbidity and Mortality Conference with Dr. Toth

  • Clinical Decision Unit Usage:  We want to keep using our observation protocols for patients that are appropriate for the CDU. These patients must have a priori identifiable endpoints and a plan for care.
  • Discharge vital signs: Revisiting a theme from last month, tachycardia at discharge is associated with badness. Abnormal vital signs must be addressed.
  • Shift Change: Turnover is fraught with increased risks regarding patient care. Be vigilant that your sign out can anchor the oncoming provider.
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Grand Rounds Recap 1/20

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Grand Rounds Recap 1/20

Quarterly Simulation and Oral Boards

How do you approach the undifferentiated patient in arrest?

  • Your demographics and any initial history can differentiate the hyperkalemic arrest from recent chemo from the rhabdo from prolonged down time from overdose, etc.

Running a code is an art and a science

  • Mental modeling is something that causes us angst but it works. Close your loop with your drugs and plan. Being loud with your summary reasserts your control of the situation and can quell the peanut gallery.
  • Assign your roles and know your nurses and medics, introducing yourself mid-compressions is poor form and can decrease code efficiency
  • We like to keep our fingers on the femoral pulse. It decreases pulse check time, let's you dictate timely next moves.
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Grand Rounds Recap 1/13

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Grand Rounds Recap 1/13

R1 CLINICAL KNOWLEDGE ON ESOPHAGEAL EMERGENCIES WITH DR. CONTINENZA

Boerhaave's syndrome: Full thickness esophageal perforation

  • Thought to be due to suddenly increased intra-esophageal pressure

  • 60% of perforations thought to be iatrogenic, most commonly related to upper endoscopy

  • Chest X ray most of the time will have some abnormality, although it may just appear as a pneumonia. Pneumopericardium and obvious signs of mediastinitis may be rare on initial chest X ray, especially early in the disease process or with smaller esophageal tears and less mediastinal inoculation

  • CT scan is diagnostic modality of choice. If unavailable, upper GI series with Gastrograffin (less sensitive than barium though also less inflammatory reaction) is a better option that barium (greater sensitivity, more associated inflammation/potential for mediastinitis). 

  • Treatment is broad spectrum antibiotics as a broad spectrum of oral and pharyngeal bacteria can be involved

  • Mortality is high and increases drastically with delays in diagnosis

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Controlling the Milieu

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Controlling the Milieu

It is a cold, blustery winter night in the ED.  You are the on-duty flight physician as well as ED physician for your particular patient care area, and you get toned out for a scene in a nearby county.  Having arrived on scene, you enter the ambulance to find a middle aged man belted to the backboard with cervical collar on, verbally and physically struggling with the paramedics who are trying to restrain him.  

By report, he was found at the bottom of a deer stand, presumably having fallen out. Initial GCS was 11 (3- 3-5) with a R parietal cephalohematoma and abrasions to his arms and  face.  

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Coming in Low and Slow

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Coming in Low and Slow

You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…

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Grand Rounds Recap 1/6

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Grand Rounds Recap 1/6

Emergency KT Protocol - The Pharmacology of RSI with Drs. Dang and Renne

Who do we RSI? What do we use? We can be better than etomidate and succ and the protocol in development will drill into the details - here is an overview:

  • The most clinically useful categorization of RSI candidates is probably based on hemodynamics
  • Hemodynamically unstable patients can be classified as “shock" based on myriad criteria and/or clinician gestalt while patients in whom the adrenergic surge of laryngoscopy could potentiate their pathology (e.g., increased ICP, aortic dissection, active ACS, or hypertensive crisis, etc.) can be classified as “high risk hypertension” for patients with increased ICP
  • The hemodynamic classification of a patient determines his/her track down the pathway, but their classification can shift at any point based on clinician discretion (i.e., a well-resuscitated shock patient may later be considered “stable” and managed accordingly) 
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The Mid-Shift Rush

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The Mid-Shift Rush

Working overnight in a busy community hospital, you’re starting to hit a mid shift wall.  There are some shifts in the ED where your job is glorious, where every patient has obvious pathology, where your interventions and treatments provide immediate relief of pain and suffering, and where the volume is steady though never overwhelming.  This is not one of those shifts.  Seemingly every patient has had a myriad of vague complaints to the point where you’re considering contacting the local health department to inform them of an exploding epidemic of “weak and dizzy” patients arriving in your ED.  Taking a breath between patients, contemplating whether or not to consume your 5th cup of coffee, you glance over to the triage desk to see 4 squads lined up.  Looking at the EMR you see all 4 of them carry the chief complaint of altered mental status…

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Grand Rounds Recap 12/30/15

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Grand Rounds Recap 12/30/15

Morbidity and Mortality Conference with Dr. LaFollette

Tracheoinnominate Fistula

One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?

  • 0.3% occurrence after routine tracheotomy
  • Incidence peaks 7-14 days after procedure

Once the patient starts massively bleeding - what's your next move hotshot?

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    Grand Rounds Recap 12/16/15

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    Grand Rounds Recap 12/16/15

    "IN JEOPARDY", AN ACS REVIEW - DR. FERMANN

    EKG Changes

    • According to the AHA, there are no diagnostic EKG changes for NSTEMI
    • ST elevations in II, III and aVF  with depression in V2 represents and inferior-posterior STEMI
    • ST depressions in the precordial leads may represent posterior MI
    • Continuous ST segment trend monitoring may pick up very dynamic ischemic changes (though this is almost never done anymore)
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    Grand Rounds Recap 12/9/15

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    Grand Rounds Recap 12/9/15

    Glucose Emergencies

    Remember the "I's" when looking for cause of DKA/HHS: Infection, Insulin lack, Infarction (MI, CVA, Ischemic gut), Indiscretion (EtOH, cocaine), Infant (pregnancy).

    After 2L NS fluid bolus in the hemodynamically stable patient, the corrected sodium should guide fluid choice for further therapy.

    Venous pH, HCO3 and base excess have sufficient agreement to be interchangeable with ABG in the ED.

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    Grand Rounds Recap 12/2/15

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    Grand Rounds Recap 12/2/15

    Air Care Ground Rounds

    Dr. Hinckley - Air Medical Resource Management

    Familiarity and complacency can lead to mistakes. Stay uncomfortable. A policy for preflight walk-a-rounds will be released shortly. 

    E-poc blood gas analyzer is now on AirCare. Think about using it for all patients, but particularly those who are intubated or may be in a state of shock.

    Dr. Powell - Minnesota Tube is coming to AirCare

    Everything you need will be in the Critical Care bag. You can bring all the gear with you into the hospital without having to gather supplies there. No football helmet required.

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    CSF Evaluation in Subarachnoid Hemorrhage

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    CSF Evaluation in Subarachnoid Hemorrhage

    So, what constitutes a “positive” tap when evaluating for subarachnoid hemorrhage?

    Traditional teaching is that a positive tap is Xanthochromia or blood in the CSF

    What exactly is Xanthochromia?

    The word xanthochromia is simply Greek for “yellow color.”  It refers to the yellow color that CSF can take in certain situations.  Some of these situations are listed below:

    • Elevated CSF protein            
    • Jaundice
    • Hypervitaminosis A
    • Rifampin Therapy
    • Elevated Bilirubin
    • Oxyhemoglobin

    What we are especially interested in when evaluating for subarachnoid hemorrhage is bilirubin and oxyhemoglobin.

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