Grand Rounds Recap 1.31.24
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Aircare Grand ROunds WITH Drs. Tillotson and Hinckley
Simulation
Communication on arrival to a scene is key, both between you and your flight nurse before you enter the ambulance and with the EMS crew
Reassessing the potential reasons for shock in a trauma is important to pick up causes that are not initially on your mind initially (blood products for hemorrhage, controlling a significant scalp bleed, relieving a possible tension pneumothorax, placing a pelvic stabilizer, etc).
The Aircare package to increase DASH-1A airways includes placing patient on AirCare monitor, apneic oxygenation, 3 minutes NRB, bagging after paralytic given, starting only when patient > 97%, push dose pressors if needed for hypotension before paralytic, and make sure to use the checklist!
Ultrasound:
Make “windows of access”. Keep your upper chest and sternum clear.
Lung and heart views are most critical in HEMS as they determine interventions that change patient care.
Chest down E-FAST is an efficient and faster way to find these intervention needing pathologies.
Once your exam is positive, it is positive in HEMS. Do not need to get all images once you have positive images. Focus instead on treating the patient.
R1 Clinical Knowledge: Dermatology Emergencies WITH Dr. Vaughan
SJS/TEN and DRESS are life-threatening drug reactions that require immediate discontinuation of the drug and specialist involvement
In SJS/TEN, if >10% skin involvement or worsening symptoms, transfer the patient to a Burn Center
DRESS has characteristic multi organ involvement, so a high level of suspicion for complications should be maintained
Involve Dermatology in the ED for any concern for SJS/TEN, DRESS, AGEP, or erythroderma.
R4 Capstone with Dr. Ferreri
Bedside US can allow for rapid diagnosis as well as narrowing of a broad differential
Bedside ultrasound, specifically in the peri-arrest period, can alter direction of resuscitation acutely
Bedside ultrasound provides actionable data for your consultants to act upon
Consider US as an extension of your physical exam
Landmark Studies of EM
For laceration repair, there is no increased risk of infection when repaired with non-sterile gloves, and absorbable sutures for repair in children has a non-inferior cosmetic result compared to its non-absorbable counterpart.
For blood product administration, PROPPR showed that 1:1:1 platelet, plasma, and pRBC administration led to earlier hemostasis along with less death due to blood loss and whole blood compared to separate blood product administration led to decreased death at 24 hours.
When it comes to TXA use in trauma, CRASH-2 and CRASH-3 showed early administration of TXA decreased all cause death in patients with suspected massive hemorrhage and those with head bleeds, along with death due to hemorrhage.
Global Health WITH Dr. Bryant
Take a travel history
Be curious about your patient and where they’re from
Look for peri-travel/migration medical screening labs (in Cincinnati it is from OCHIN)
Tuberculosis can be incredibly hard to diagnose
Eosinophils are trying to tell you something. With eosinophilia highly consider HIV, TB and strongyloides
Respect the strongyloides, if you are considering giving steroids, consider their risk for strongyloides hyperinfection syndrome.
One Pill Can Kill WITH Dr. Otten
The human health hazard is equal to the inherent toxicity of the drug and the time of the exposure.
Certain chemicals can produce life-threatening toxicities in a 10kg toddler following only small ingestions (one or a few pills, one or two gulps).
Toxicology Pearls:
Abnormal mental status = HYPOGLYCEMIA (until you prove otherwise)
Narcan is for decreased respiratory rate, dose = 0.4mg
Wide complex tachycardia + overdose, give bicarb
DECON at scene if possible (80% of contamination is clothing)
Caustic death = airway obstruction
80% of poisoning is supportive care (A,B,C’s)
PPE at all times
Know basic toxidromes
