Grand Rounds Recap - 12/3/2014
/EMS Protocol Updates for 2015 with Dr. Leblanc
Use of EMS units as transport units
- If pt is transported to a facility that is not capable of taking care of the pt, you may be able to use the same squad to transport the pt to another facility
- Need to have an accepting doc
- May need to send additional personnel with the squad
Hypotension/Shock protocol
- Push dose Epi regardless of type of shock - 1 ml of cardiac Epi into 9 mls of NS flush
- 1 ml q1-2 min
- For more info - EMCrit Podcast on Push Dose Pressors
- No more Dopamine!
Bradycardia: Versed for external pacing
Toxicology
- No more activated charcoal
- Cyanide: give cyanokit when both decreased level of consciousness and hypotension
- Narcan: can give IN, no more than 1mL per nostril per dose
OTC medications: if pt requests OTC med for minor medical concern and they have no signs or symptoms of significant medical condition
Imminent delivery
- Viability = 24 wks
- Do not suction baby unless respiratory distress
- Mom and baby go to SAME hospital whenever possible
Head or spinal trauma: can use hypertonic saline if pupil difference, decreased level of consciousness and evidence of head trauma
TXA: there is now a protocol for adults (only for trauma)
- Emphasis on vital signs (SBP < 90, HR > 110) and timing (within 3 hours from injury)
- Not for peds
Peds submersion in ice water
- If there is ice, the patient has to be transported to CCHMC on Burnet (ECMO availability)
- < 30 minutes, no ice on water and no signs of life can be transported to closest ED
Spine immobilization
- AMS, intoxication, distraction, midline spine tenderness, neurologic injury à need backboard
Airway Protocol Updates
- The term "rescue airway" is gone. Replaced by "supraglottic airway"
- No more than 2 intubation attempts…for now
- Do not stop compressions if CPR in progress
Hemorrhage control
- Tools: tourniquet, wound packing, hemostatic gauze, TXA
Medication Changes
- Removed medications: lasix, dopamine
- Added medications: TXA, hypertonic, LR, narcan autoinjectors
Termination of resuscitation of trauma: transport if ROSC or may benefit from ED thoracotomy
- Bag, manual C spine immobilization, bilateral needle decompression, IV/IO with saline, then put on monitor
- PEA > 40 should be transported transport
- PEA < 40 or asystole should be pronounced
The 2014 Southwest Ohio EMS Protocols can be found here on tamingthesru.com/hems-and-ems
We will post the 2015 SW Ohio EMS Protocols once they are finalized!
Bell’s Palsy with Dr. Stettler
History and Physical
- Isolated unilateral facial paralysis/weakness that is rapid onset, though not instant
- Can have associated neurologic symptoms: taste disruption, vague sensory disruption (tingling, numbness, pain), mild HA, change in hearing
- Has to be both upper and lower face
- Detect subtle upper face weakness by testing rapid blink: affected eye does not work appropriately
Prognosis related to severity, treatment and Increasing age
- 50-70% recover no matter what you do
- Typical duration of symptoms 3-4 months
Treatment
- Steroids
- Everybody should get them, the earlier the better
- Regardless of timing of onset
- Increase likelihood of recovery by 20%
- 25 mg prednisolone PO BID x 10 days OR
- 60 mg prednisone x 5 days, then taper over 5 days
- Antivirals??? You can give them, probably does not help
Disposition
- Consider ENT follow up if complete paralysis, otherwise PCP or if there is no recovery by 3 months
Imaging in Neurologic Emergencies with Dr. Stettler
CT head
- Useful for early ischemic changes
- Loss of insular cortex
- Loss of grey-white differentiation
- Gold standard for evaluation of hemorrhage?
- T2 MRI may better visualize a hemorrhage while CT head is normal
Diffusion MRI - Sensitivity of 14-67% in TIA,Higher rate of positive study with longer duration of symptoms
CT perfusion: CT with contrast bolus
- Tracks passage of contratl bolus and shows hypoperfusion
- May help stroke team make decision on whether to treat if outside the window
- Positive within minutes of stroke onset
- Much more sensitive than CT head < 6 hours
Facial Trauma with Dr. Krishnan
Penetrating injury: usually midface/zygoma and due to high velocity
Blunt injury: usually nose and mandible
60% of facial trauma pts have some other traumatic injury
- 20-50% have head injury
- 1-4% have C spine injury
- Blindness in 0.5-3%
- 25% of women with facial trauma are victims of domestic violence
Open wound management:
- Laceration behind line of outer limbus à watch out for parotid duct and facial nerve injuries
- Suture choices
- Absorbable in kids (plain gut)
- Minimal scientific data
- Ethilon/prolene for skin
- Silk to tie off vessels
- Gut for mucosa (3 or 4)
- Vicryl for deeps
- Absorbable in kids (plain gut)
- Do not use soap: use a prep agent or betadine
- Be careful to remove all foreign bodies
- Establish contours and margins: lip, eyelid, nasal and ear margins should be reapproximated as closely as possible
- Facial nerve injury should go to OR
Scalp wounds: wash out aggressively
- Minimal tissue elasticity
- Drain or pressure dressing to minimize hematoma formation (high risk of infection)
- Large avulsions will need some sort of graft/flap repair
Periorbital/eyelid lacs
- Align eyebrow border
- Eval for globe, lacrimal duct/gland injury
Nose
- Can have difficult to control bleeding
- Anterior: pressure, afrin and packing
- Posterior: consult, Foley bulb
- Make sure to drain septal hematoma as it can cause septal perforation and necrosis
- Close in layers: mucosa, cartilage, skin
- Align alar rim
- Ok to use vasoconstrictors
Lip
- Repair muscle if involved
- Approximate vermillion border
- If > 1/3 of lip missing à needs a flap
Ear
- Large defect may need a flap for coverage
- Always cover cartilage
- If cartilage defect, obtain 24 hour follow up
Ok to close facial lacs later: 24 hours probably safe
- Can delay if will be used for surgical access to underlying fracture
Facial fractures
- Zygoma and nasal bones will fracture with low impact injuries
- Supraorbital, mandible and frontal bones require higher impact
- Skeletal buttresses determine fracture pattern
Key history questions: pain with eye movements, numbness/tingling in face, pain with biting down
PE important nuances: septal hematoma, count teeth, CSF leak, face stability
Imaging: panorex, CT
Nasal fracture: most will require some sort of repair
- No nose blowing when go home
- Outpatient follow up
Zygomatic arch fracture
- Can impinge on corner of mandible and pt won't be able to open their mouth
Lefort fractures
- I: upper jaw horizontal
- II: upper jaw and nose
- III: skull and face separated
Mandible fractures: trismus and malocclusion, numb lip
- Need antibiotics
- Usually bilateral
Dental trauma
- Assess for occlusion: underlying facial fracture
- No need for antibiotics, but make sure tetanus UTD
- Do not disrupt periodontal ligament
- Dentoalveolar fracture
- Arch bars
Useful FOAMed Resources for Lacerations and Dental Trauma
Pericarditis/Myocarditis with Dr. Shah
Pericardium = serous and collagenous layers with fluid filled space in between
Keeps heart in mediastinum and protects from infection
Many different causes of pericarditis: VINDICATE
- Vascular: post-MI (immediate vs delayed (dressler))
- Infectious/idiopathic: usually viral, TB
- Neoplastic: lung ca
- Degenerative
- Iatrogenic: procainamide, hydralazine
- Congenital
- Autoimmune: lupus, connective tissue dz, RA
- Trauma
- Endocrine/metabolic: thyroid, uremia
Diagnosis
- Clinical: CP radiating to back due to diaphragmatic irritation
- PE: friction rub
- Testing: ECG, CXR, Echo
EKG is abnormal in 90% of acute pericarditis
Stage 1: PR depression in II, aVF, V4-V6 with ST elevation in I, V5-V6
Stage 2: PR depression, T wave inversion, normal ST segment
Stage 3: T wave inversions
J point notch: benign early repolarization
ST:T ratio > 0.25 is highly suggestive of pericarditis
No reciprocal ST depression (except aVR and V1)
- PR elevation in aVR
CXR: look for cardiomegaly/waterbottle heart to detect effusion
Echo: Subxyphoid/apical 4 chamber views the best
Treatment
- Treat underlying cause
- NSAIDs: ibuprofen, ASA, indomethacin
- Give GI prophylaxis
- Colchicine: 0.5 mg BID x 2-3 months
- Decreases recurrence rate
- May be used for prophylaxis in pts with recurrent pericarditis
- Glucocorticoids
- Increases recurrence
- Indicated: autoimmune, renal failure, failure of standard therapy
Hospitalize if:
- Immunocompromised
- Anticoagulation
- Large effusion
- Non-idiopathic etiology
Pericardiocentesis only if tamponade, no role for diagnostic
Great FOAMed Resource for more information about Pericarditis - LITFL with Amul Mattu video
Myocarditis: inflammatory cardiomyopathy
- Frequently associated with pericarditis
- Can have signs of CHF
- Diagnosis: endocardial biopsy
- Frequently have troponin elevation, though not diagnostic
- Echo
- Treatment: underlying cause
- Treat CHF symptoms: ACE, diuretics, salt restriction, digoxin
- Red flags: tachyarrhythmia, heart block, CHF
Case Follow up with Dr. Betz
45 yo M, unhelmeted ATV roll over, + EtOH. He has significant facial trauma, L flank and L thigh. He also has notable left eye swelling with mild proptosis and can’t open his left eye spontaneously
- GCS 12, hemodynamically stable
- CT head: diffuse SAH, bilat SDH and multiple contusion
No visual acuity and IOP 60-90 after a lateral canthotomy IOP pressure down to 30
Retrobulbar hematoma: postseptal hemorrhage
- Usually post traumatic but also seen after eye surgery
- High risk of permanent blindness: 50%
- Can cause orbital compartment syndrome and proptosis on exam
- Leads to orbital nerve ischemia
- Clinical diagnosis: APD, elevated IOP, decreased vision, proptosis
- Treatment: lateral canthotomy
- Cut lateral canthus and inferior canthus
- Need: lido with epi, hemostat, scissors, forceps
- Local anesthesia, devascularize with needle driver/hemostat and cut down horizontally to orbital rim, then look for inferior canthus and cut vertically
- Give PO antibiotics (augmentin)
- Eye drops to lower IOP
- Steroids if optic neuropathy
P-values with Dr. Strong
Conventional Clinical significance – 0.05
Determining p value
- Depends on type of data
- Needed variables: Degrees of freedom and chi squared
- Chi squared = comparison of observed result to expected result
- Degrees of freedom = measure of variability
- Based on number of categories/variables you are looking at
What matters when interpreting the data?
- Your knowledge of the subject matter
- The effect of size
- Replication
- Alternative hypothesis: how plausible is your alternative hypothesis
- The exact p value
CPC with Drs. Richardson and Benoit
13 yo F presenting with difficulty breathing x 6 days though on further history has had it for 3 months. Also complains of pleuritic pain, no cough, no fever. The symptoms are worse when lying down and some choking episodes when lyingdown
- ROS: RUE weakness, hoarse voice
- Normal vitals
- PE: tachypnea with diminished breath sounds
- Neuro: difficulty looking up with proximal BUE weakness
During the course of her care she becomes more tachypneic and tachycardic, has pooling of oral secretions with a notable respiratory acidosis on VBG. She is placed on NIPPV but ultimately fails and ends up requiring intubation
Diagnosaurus app: very helpful in coming up with differential diagnosis
- GBS: no ascending paralysis, normal reflexes, timing doesn’t fit (usually days not months), no preceeding infection
- Though kinda fits Miller Fischer variant, but still no hyporeflexia
- Botulism: hyporeflexia, should be acute, fixed and dilated pupils
- Myasthenia gravis: everything fits
- Tick paralysis: ascending paralysis, hyporeflexia, tick exposure, less chronic
- Poliomyelitis: flaccid paralysis, hyporeflexia, preceding viral illness
- MS: hypereflexia, visual loss, decreased sensation
- Hypothyroidism/myxedema coma
- Organophosphate poisoning
Winner: Myasthenia Gravis: 20 per 100,000 people
Disorder of NMJ: Antibody against AcH receptor à decreased muscle cell depolarization, or Ab against MuSK receptors
Diagnosis = tensilon test
- Edrophonium = cholinesterase inhibitor
- 1-2 mg, if no response can give up to 10 mg (0.15 mg/kg)
- Reversed with atropine if the patient develops bradycardia
- Should improve neurologic deficits and usually easiest to see in ptosis
- Need to have objective neurologic findings to perform the test
Symptoms: worsen as day progresses
- Bulbar weakness: dysphagia or hoarseness
- Eye: ptosis
- Respiratory distress
- Weakness
Physical exam
- Abnormal CN, strength exam
- Normal reflexes and sensory exam
- Provocative tests
- Ice pack test: for ptosis
- Repetitive nerve stimulation with EMG: repetitive stimulation decreases muscle action potential
Myasthenia crisis
- Usually precipitated by infection or other physiologic stressor
- Drug interactions: abx, antipsychotics
- Do a NIF to evaluate respiratory function
- Intubate if -30 or worse
- BiPaP can be useful in early crisis
- Succinylcholine is safe to use for intubation but use higher dose (2 mg/kg) as efficacy is less predictable
- Roc/vec: use half dose as effect prolonged
- Treatment
Pyridostigmine: Ach-e inhibitor
- Immunosuppresion
- IVIG
- Plasmapheresis