Grand Rounds Recap 3.6.24
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r2 quality improvement/knowledge translation: Hypoglycemia with drs. beyde and wolski
Hypoglycemia: blood glucose of <70 mg/dL. Beware of relative hypoglycemia in patients who live at very high blood glucose levels - they may have symptomatic hypoglycemia with a blood glucose that is normal for the majority of the population.
There are many medical and pharmacologic causes of hypoglycemia (see the upcoming approved pathway for more!). There are also many costs to hypoglycemia, both in terms of financial burdens on hospitals/caretakers/patients, and in terms of morbidity and mortality.
Soon you’ll be able to view our whole pathway on the QI/KT page, but for now, we hope everyone remembers these points:
1) Get labs and an EKG on everyone presenting with hypoglycemia.
2) If you’re concerned for sulfonylurea use, consider octreotide.
3) Diabetes Educators are often available to come to the ED to share knowledge with your patients.
4) If you think a patient can be discharged, consider changing their insulin regimen in conjunction with their PCP.
5) If you’re discharging, prescribe glucagon!
Finally, we hope you check out our discharge resources - in this facility, they are currently a dot phrase under either of our Epic profiles, and will soon be a formal discharge instruction sheet.
r1 clinical knowledge: Syncope rules with dr. kotei
Syncope: transient loss of consciousness due to cerebral hypoperfusion, characterized by swift onset, short duration, and spontaneous complete recovery.
Perform a thorough cardiac and neurological exam, and interrogate cardiac devices on all syncope patients. ECG is a must for EVERY syncope patient. The 6 can’t miss ECG diagnosis for syncope:
MNEMONIC: “QT-BRIDE”:
Prolonged or shortened QT
Brugada or AV Blockade
Right heart strain
Ischemia/Infarction
Delta wave (seen in WPW)
Epsilon wave (seen in ARVD)
Clinical decision making tools:
San Francisco SR: likely to increase admission rates for syncope. It is not specific enough in defining specific findings on the ECG that should be considered high risk. The commonly missed diagnosis after validation was dysrhythmias.
Canadian Syncope Rule: suggests a troponin, which can be tricky to interpret in certain patient populations. It also requires the subjective input of the ED physician based on his or her gestalt.
Evaluation of Guidelines in SYncope Study: not generalizable enough and should be used solely as a triage tool. This tool was developed by a cardiologist and so there could be comparable differences between EKG interpretations by cardiologists vs ED physicians in the emergency setting.
Keep in mind special populations such as the elderly, children and pregnant women who may have slightly different physiology leading to syncope. For example breath holding spells in pediatrics, loss of autonomic sensitivity in the elderly, loss of vasculature compliance in the elderly, and compression of the IVC by a gravid uterus.
Diagnosis of the exact cause of syncope is not easy in the ED so focus less on making a diagnosis and more on being able to sort between high risk and low risk.
Can’t miss ED diagnosis for syncope
Brady/tachy dysrhythmia, arrhythmias such as ARVC, channelopathy (Brugada)
Acute MI
Structural heart disease (ex. critical AS, ASD, HCM)
Arrhythmogenic right ventricular cardiomyopathy
Pulmonary embolism
Thoracic aortic dissection
Transient occult shock
Sepsis
Hemorrhagic shock (ex. ruptured ectopic, massive GI bleed, ruptured AAA)
Neurologic causes (ex. spontaneous SAH, TIA of basilar artery)
r3 taming the sru: Traumatic cardiac tamponade with dr. glenn
Utilize time between pre-hospital notification and patient arrival to prepare team members, establish roles and plans for “if-then” scenarios.
Cardiac tamponade:
Target a SBP goal of 90
A pericardiocentesis in traumatic tamponade should be reserved for situations in which definitive surgical intervention is not immediately available. The procedure is generally limited secondary to clots that have formed in the pericardium.
Missed pericardiocentesis via the sub-xiphoid approach is often secondary to either too steep of an angle or aiming too laterally. Insert at 45 degrees and aim at the left mid-clavicular line.
Extreme caution should be used when intubating these patients and your threshold to intubate should be much higher than normal. If intubation is necessary, consider whether an awake intubation can be performed and if a spontaneous mode is feasible. In situations in which it is not, aim for using the lowest TV and PEEP as possible.
A standard CVC can be used as a surrogate to a pericardial drain.
visiting lecturer- ohio acep: you champion your whole career with dr. bryan graham
ACEP can offer significant benefits to emergency medicine physicians during their career
EM professional and legislative advocacy
Working towards identifying and managing issues that include, but are not limited to scope creep, workforce issues, increasing threat of private equity and contract management groups
EM policy makers
Heavily involved with physician reimbursement
Involvement available at all levels: medical student, resident and faculty
R4 capstone: the truth about wellness WITH dr. mcdonough
Wellness: the full integration of physical, mental and spiritual well-being
It is about fueling the body, engaging the mind and nurturing the spirit
Resilience: the ability to recover from or adjust easily to misfortunate or change
The process and outcome of successfully adapting to difficult or challenging life experiences, especially tough mental, emotional and behavioral flexibility & adjustment to external and internal demands
Self-care: ability to care for oneself through awareness, self-control and self-reliance to achieve, maintain or promote optimal health and well-being
The practice of taking an active role in protecting one’s own well-being and happiness, particularly during periods of stress
5 areas of self care: physical, emotional, social, spiritual, psychological
Consider a world where you choose hard over easy, choose discomfort over comfort
Sharing our emotions reduces our stress while making us feel closer to those we share with and providing a sense of belonging. When we open up our inner selves and people respond with sympathy, we feel seen, understood and supported.
Dr. McDonough’s pro-tips: sleep, eat well, exercise, practice gratitude, practice mindfulness, practice healthy venting & avoid dumping, lean into discomfort, be wary of delayed gratification & seek first to understand
How to do this:
Write down a component of self-care that you hope to adopt/improve
Write a concrete plan, start conservative, put it on your calendar, identify how best to hold yourself accountable
One implemented, pick two or more self-care components that you hope to tackle in the future
