Grand Rounds Recap - 4/8/15

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AirCare Grand Rounds

1. Indications for T pod

  • Blunt trauma + unstable pelvis
  • Blunt trauma + shock + pelvic tenderness to compression
  • Blunt trauma + shock + AMS/inability to evaluate pelvic pain

In patients with blunt trauma who are in shock and have AMS, incidence of pelvic fractures is 10%. In patients who die of blunt trauma during transport, open book pelvis fracture is the #1 cause of death (according to our own QI data)

2. AirCare policies

  • FFP transfusion: > 16 yo in trauma/medical/tbi, give FFP first
  • Cyanokit: evidence of smoke exposure + AMS +/or hemodynamic instability (check out this podcast for more info!)
  • Ketamine: approved for RSI and post intubation sedation, but not for procedural sedation (call medical control)
  • Be careful intubating hypotensive patients and consider peri-intubation push dose pressors

3. Tylenol overdose

  • NAC is the antidote
  • If you know somebody took a tylenol overdose, you do not need to wait for a tylenol level prior to initiating NAC
  • Tylenol nomogram is only accurate for pure tylenol overdose
  • What if this patient refuses transport? Does he have capacity?

4. Pearls & Errata

  • Find out trauma pt's temp on your arrival (EMS temp)
  • There are feedback cards in the paperwork folder. Please give these out to squads
  • Do not forget analgesia and sedation in intubated patients. 

GI Bleeding with Dr. Teuber

Ligament of treitz: suspensory ligament for duodenum. Separates upper from lower GI bleeds.

1. Lower GI bleeds account for 25% of all GI bleeds

  • 50% of those are due to diverticular disease (usually painless bleeding, usually resolve spontaneously)
  • Colitis: inflammatory, ischemic, infectious
  • Anorectal disease: hemorrhoids, fissures, fistulas
  • Rare causes: angiodysplasia, malignancy
  • Pediatric causes: Meckel's dievrticulum (rule of 2s), intussusception (red current jelly stools, intermittently fussy), polyposis syndromes, IBD

2. Upper GI bleeds: 75% of pts

  • Melena is seen only if blood has been present in the GI tract longer than 8 hours
  • PUD is the most common cause of UGIB (H.pylori, NSAIDs)
  • Other causes: varices, Mallory Weiss tear, Boerhaave syndrome, Dieulafoy lesion
  • Rare causes: aortoeneric fistula, acute stress gastritis (curling vs cushing ulcers)
  • Pediatric: vit K deficiency, milk protein intolerance, coagulopathy, congential, foreign body or caustic ingestion

3. Glasgow Blatchford Score: applies to UGI nonvariceal bleeding

  • BUN, Hg, SBP, HR > 100, melena, syncope, hepatic disease, CHF
  • If score is < 1, ok to dc home

4. Work up

  • Sick vs not sick based on VS and comorbidities
  • 2 large bore IVs
  • CBC, renal panel, type and screen, liver panel

5. Management

  • Fluid rescuscitation, but move to blood quickly if in shock
  • Involve consultants early for massive bleeds

6. Disposition

  • Normal labs, stable and no active bleeding -> ok to go home
  • Consider PPI drip for UGI bleed (esomeprazole 80 mg bolus and 8 mg/hr drip)
  • Octreotide gtt for variceal bleed (50 microgm bolus and then 50/hr drip)
  • Ceftriaxone for SBP prophylaxis in variceal bleed (has been shown to reduce mortality)
  • Most people will need at least step down level of care as they can decompensate quickly

Vascular Ultrasound with Dr. Lagasse

1. Aorta US

  • Adequate exam: subxyphoid view down to aortic bifurcation with measurements in multiple places
  • Firm pressure can help displace bowel gas
  • Aorta is anterior and slightly to the R of the vertebral body
  • AAA: aorta > 3 cm . Measure from outer wall to outer wall 
    • Iliac artery > 1.5 cm
  • Intraluminal thrombus may cause a false negative: measure outer wall to outer wall
  • May also be able to see aortic dissection, though not very sensitive

2. DVT Ultrasound

  • Adequate exam: 2 pt compression in the groin and in popliteal fossa
  • Not credentialed yet, but keep logging these scans for when we do become credentialed
  • 2 point compression vs whole leg doppler
  • Algorithm for low risk patients
    • D dimer negative: DVT excluded
    • D dimer positive and US positive: anticoagulate
    • D dimer positive and US negative: repeat US in 5-7 days

3 points of compression at CFV: above femoral saphenous junction, at the junction and below the junction

  • Popliteal compression: 1 point is enough
  • Positive study = cannot compress the vein completely
  • Caution: lymph nodes can be confusing because they look like a vessel with echogenic material inside
    • Superficial to deep vessels
    • No accompanying artery

3. Vascular access

  • You will not be able to get the vessel if it is deeper than 2.5 cm with our peripheral catheters
  • 2 tourniquets are your friends and increase odds of success
  • Watch your needle go into the vessel and advance slowly
  • Peripheral IJ: should be placed semi-sterily
    • Consider if you need temporary access or blood and other access has not worked
    • Risk of thrombus
    • Not for people who will be admitted

Difficult Patients and Difficult Patient Interactions with Dr. Bria

According to 1978 literature, there are several types of difficult patients: dependent clinger, entitled demander, manipulative help rejecter, self destructive denier.  There are several medical conditions that complicate our patient interactions, mental health problems being the most common.  Medical encounter is affected by: doc's personality, work style and belief system, cultural gaps between doc and pt, pt character and behavior, external circumstances (wait time)

Clinical empathy in the ED is challenging as we are overcrowded and have limited resources

  • But we are the front door of the hospital and our care reflects the entire hospital
  • Difficult to do service recovery because we do not see the pt again
  • Linked to better outcomes, less litigation and job satisfaction
  • Try to find common ground with the patients that are resistant to your care/advice
  • Give your pt/parent some decision making and an active role in their care

EBM on Pediatric Fever of Unknown Origin with Drs. Grosso and McKean

  • Fever = T > 38C or 100.4F
  • Get a rectal temp
  • Axillary temp is always lower, so if axillary temp > 38, then its always a fever
  • Ear temp is not as reliable
  • Trust parents when they say that their kid was febrile at home
  • Assumptions for the recommendations: vaccinated, full term infant that looks well

1. Neonate: 0 - 28 days old

  • SBI is difficult to predict in a febrile neonate
  • Everybody gets a CBC, UA, CSF, CXR, cultures
  • Empiric antibiotics: cefotaxime 50 mg/kg or gentamicin AND ampicillin 50 mg/kg 
  • HSV is rare, especially if there are no other symptoms of HSV (CSF pleocytosis ( > 19 WBC), high risk mom or delivery (scalp electrode, endometritis)
    • Treat with high dose acyclovir 20/kg

2. Infants 29 - 60 days old

Rochester vs boston vs philadelphia criteria: all apply to low risk infant

Low risk criteria: well appearing, previously healthy, no focal infection

  • CBC with 5-15K
  • UA with < 10 WBC
  • CXR/CSF not necessary
  • Can be treated as outpt if the kid has reliable parents and follow up available in 12-24 hours
  • Can consider a dose of rocephin prior to discharge but only if obtained CSF

If any of those are not abnormal, then the child is high risk and should be admitted for empiric antibiotics

3. Children 3-36 months

  • Fever < 39 is unlikely to have a bacterial source
  • Physical exam is key: you should be able to pick up most sources of SBI (except UTI)
  • Risk factors for UTIs: girls, < 12 mo, T > 39. fever > 2 days. no other source, hx of UTIs, uncircumcised boys, ill appearance, caucasian
  • If you still do not have a source (less than 2% of the kids), chances of bacteremia is 3.3%
    • WBC > 15 and T > 39 will pick up most of these kids with NPV 99.7%
  • FYI, to be considered immunized, you need to have 2 rounds of Hib and PCV