Grand Rounds Recap 5.1.24
/Leadership curriculum - r4 capstone - r3 taming the sru - airway academy grand rounds - pharmacy updates
Leadership curriculum: promoting yourself WITH drs. hill and lafollette
We need to be able to promote our accomplishments throughout our careers.
This is because our self-perception of ourselves typically differs from what others perceive of you and so you may not automatically get that promotion.
Furthermore, hard work does not always lead to extrinsic rewards you expect.
But, how do you maintain humility while promoting yourself and your achievements?
Stick to the facts in terms of your achievement.
Acknowledge how others have helped, and will continue to help you, along the way.
Participate in altruistic promotion.
The concept of promoting yourself through promoting others along the way (aka dual promotion).
An example is “here are the fantastic things that my team accomplished”.
This helps promote yourself, while maintaining also personal humility and building relationship with others along the way.
You can also promote yourself by cultivating purposeful sponsorship.
Recruit someone more senior to yourself to help bring you into a sphere that you others would not have been in.
This typically requires you to be honest about yourself and open to constructive feedback, as you may not always be ready for the promotion/task you are seeking sponsorship for & your sponsor may voice that.
r4 Capstone WITH Dr. Stark
Learn from your poor patient outcomes. Forgive your misses but don’t forget them.
Talk about your hard cases with others. Guilt, shame, loneliness, and fear are normal emotions and are better processed when processed together.
Don’t let external judgement let you change how you judge yourself.
r3 taming the sru: traumatic arrests WITH Dr. wright
Trauma is the 3rd leading cause of death in the US and Canada.
typically young, white, and males.
Most traumatic arrests occur within 5 minutes of the traumatic event.
Factors associated with worse outcomes in the setting of a TCA:
Firearm involvement
Self-inflicted injury
PEA with a rate <40bpm
Wide-complex rhythm (excluding VT)
Number of pre-hospital procedures
Role of chest compressions in TCA:
Chest compressions are unlikely to be helpful in the setting of a traumatic cardiac arrest.
hypovolemia, PTX, and cardiac tamponade are common causes of death in the setting of a traumatic arrest and CPR is unlikely to be beneficial in any of these causes based on available animal studies.
who may benefit from CPR in traumatic arrest?
isolated head injury, asphyxia or any other cause of a likely hypoxic respiratory arrest
blunt cardiac injury
underlying medical cause for the arrest
Role of US in TCA?
may be useful in decisions to terminate resuscitative efforts and/or identifying reversible pathology.
absence of cardiac activity on US contends an extremely poor prognosis.
meanwhile, pseudo-PEA may be associated with a favorable outcome.
Role of epi in TCA?
overall, controversial and understudied.
does not appear to increase long-term survival based on available data.
Role of an ED thoracotomy in TCA?
benefit is greatest for penetrating thoracic trauma.
no survival benefit when looking at all types of traumatic cardiac arrests.
Indications per American College of Surgeons:
penetrating thoracic trauma w/ prehospital or hospital arrest.
any TCA that occurs after arrival to the ED.
profound persistent hypotension with no OR available.
Relative indications:
Penetrating abdominal trauma with prehospital or hospital TCA.
Any prehospital TCA that has “signs of life” upon arrival.
Blunt thoracic trauma with prehospital arrest.
Performed within 10-15 minutes of arrest.
airway academy grand rounds WITH dr. adan
Notable recent airway articles:
DSI with ketamine in trauma patients requiring intubation has shown improved oxygen saturation during intubation attempts compared to standard RSI. Also shown to increase first-attempt success rate (Bandyopadhyay et al.).
During an airway exchange, consider adding an Aintree intubation catheter over the typical Cook catheter. This will ideally serve as a gap filler and add rigidity to the overall set-up, allowing the ETT to be more easily railroaded over the airway exchange catheter-Aintree combination (Higgs et al.).
Compared DL view at any given moment to the VL view using a visual analogue scale measuring the amount of visible glottic opening. Found the VL is often better than the DL view, especially when using the Glide platform (Malpas et al.).
The “anterior” airway:
true anterior airways are an anatomic issue and can be screened for using the 3-3-2 rule for predicting a difficult airway.
sometimes the problem may not be anatomical, but rather may be due to suboptimal laryngoscopy leading to a poor view.
additionally, our equipment leads to a better view than we otherwise would get and that may lead to difficulty with tube delivery itself.
2-curve model
primary curve is before the glottis and mainly creating by the tongue.
this is followed by the secondary curve that tilts downward beyond the glottis into the trachea.
we need to be able to overcome these two curves to achieve successful laryngoscopy.
How can you overcome an “anterior” airway?
proper tongue sweep
head manipulation- including a head lift and/or sniffing position
application of BURP
“relax” your view: while obtaining the best view, we may be pushing the airway more anterior, therefore relaxing your view may help with tube passage
adjust the curve of the ETT: a hockey stick curve may help with tube delivery
rigid stylet: may consider using a rigid stylet with standard-geometry video laryngoscopy
hyperangulated blade
If faced with an “anterior” airway try to AVOID:
blind/semi-blind tube passage
using a bougie device
pharmacy updates
Asymptomatic bacteriuria (ASB)
definition
presence of one or more bacteria growing in urine, regardless of the presence of pyuria, in the absence of signs/symptoms of a UTI
these signs/symptoms include: frequency, urgency, dysuria, suprapubic pain, CVA pain, tenderness with fever
of note, AMS does not qualify as a symptom of a UTI
other things that can cause pyuria and/or symptoms include:
STI’s
TB
interstitial cystitis
bladder cancer
ABS is more common in
women
elderly patients
those with urogenital abnormalities
institutionalized patients
who should be screened, and then subsequently treated, for ASB?
pregnant women
those undergoing endourological procedures
catheter-associated asymptomatic bacteriuria
those with indwelling catheters are typically colonized by microorganisms within one month of catheter placement
suspect catheter-associated asymptomatic bacteruria if there is presence of bacteria WITHOUT associated symptoms (unlike a catheter-associated UTI)
why should this matter to us as emergency medicine providers?
inappropriate treatment of ASB results in:
increased healthcare costs
increased antibiotic resistance
increased Clostridioides difficile infections
Study looking at the effect of time of initiation of Hyperinsulinemia Euglycemia Therapy (HIET) for hypotension due to BB and/or CCB overdose:
Late initiation of HIET (after the median time of 5.9 hours from presumed ingestion to therapy initiation) was not associated with increased mortality when compared to early initiation (before the median time of 5.9 hours from presumed ingestion to therapy initiation).
While not statistically significant, there was a trend towards shorter ICU stay, overall hospital stay, and lower norepinephrine requirements when patients are started on early HIET.
Of note, APACHE II scores and BMI appear to be independent risk factors for death in the setting of CCB/BB overdose.
Study looking at the cost and efficacy of rocuronium dosing in RSI:
compared high dose (>1.2mg/kg) versus standard dose (equal to or less than 1.2mg/kg) of rocuronium.
high dose was associated with higher cost per patient.
no statistically difference in adverse effects including first intubation success rate.
there was also a statistically significant increase in time to start post-intubation sedation for patients in the ED receiving high-dose paralytic.
