Urology: Dr. Antonelli and Dr. Crivelli Renal Stones Imaging choices: CT v US Keep in mind pts are likely to get exposed to multiple doses of radiation Lack of consensus on initial imaging CT v US (NJEM 2014 study) Wide variety of practice differentiation in CT protocols
Pain Control: NSAIDs AUA Guidelines: Surgical Management of Stones: Patients (adults or peds) with uncomplicated ureteral stones <10mm should be offered observation, and those with distal stones of similar size should be offered MET with alpha-blockesrs. Strong Recommendation; Evidence Level Grade B
Smaller more distal stones have higher likelihood of spontaneous passage
Less evidence for mid and proximal stones
Evidence is best for large distal ureteral stones
Infected Stones: Nitrite positive urine is most concerning May not have hydro due to dehydration
Regarding new study in progress What to do if you have a patient with an obstructing stone (infected or not):
if you are unsure about infection, don't immediately start antibiotics
Make every attempt to send cultures (UCx +/- BCx) prior to starting antibiotics.
8/22/19 Resus Lab Summary: By: Zachary Aust, MD (Academic Chief Resident, PGY-3) Getting back to some basics...but some more advanced ultrasound! Check it out below.
Fast Hearts and Electricity Dr. Mackey 1.IV, O2, monitor, crash cart/monitor and pads, airway equipment 2. Is the patient stable or unstable? 3.P wave or naw? 4. regular or irregular? 5. Wide or Narrow? General Rule: Unstable->Electricity
Another Approach Stable/Unstable Regular/Irregular Wide/Narrow
SVT: Vagals (Modified Valsalva), Adenosine (6mg, 12mg, 18mg), CCB (Diltiazem/Verapamil) -Dilt: 10-20 mg IV given over 2 minutes (maximum 60mg in 30 minutes..may need infusion) -Verapamil 2.5-10mg (max 20 mg) IV slow -Unstable: Synch Cardioversion 50J then double
VTach: Unstable? Synchronized Cardioversion 200J -Stable: Can also use electricity....probably the go to depending on who you ask. Antiarrhythmic: Magnesium, Amio (See EMA below), Procainamide***(See EMA below)
Cardioversion incrementalized From Dr. Rich Levitan 1)pt 45 degrees head up 2)nasal cannula 3)PAUSE--propofol anesthesia using speech engagement--4 syringes 50mg,PAUSE when they stop talking 4)squeeze chest when they stop speaking,eyes closed (towels/gloves) [pads on chest obviously] 5)sync zap
Squeeze the chest to reduce thoracic impedance during cardioversion..see section 5.2 of AHA/ACC guidelines.
use left arm for propofol....that way you don't need to switch sides between pushing drug and going to left side for squeezing chest. I run 500cc bolus beforehand, like to see line running wide. Suction, airway gear always at bedside (never needed if you PAUSE)
lower impedance by squeezing...see section 5.2 AHA/ACC guideline
Advanced Echo Dr. Roppolo -Looking for a >15% change for possible volume responsive -Measure Left Ventricular Outflow Tract (LVOT) Diameter -Measure Velocity Time Interval (VTI) (Apical 5 chamber view) Use pulse wave doppler (picking out the large negative wave) -CO=HRxSV -SV = area x distance http://5minsono.com/lvot_vti/ Image by Dr. Ben Smith ,@ultrasoundjelly check out more at https://www.ultrasoundoftheweek.com/ http://5minsono.com/rhf/
Slides from Dr. Lynn Roppolo RUSH Exam:Rapid Ultrasound for Shock and Hypotension Dr. Blumberg HI MAP Heart IVC Morrisons Pouch (Fast Exam) AAA Pulmonary
Intubating Micro Skills Dr.Leaf, Dr. Piel, Dr. Aust Incrementalization: To successfully perform a stressful procedure you need to break it down into smaller steps. Performing under pressure is a skill that can be learned/practiced. It is vital to understand that we don’t rise to the occasion but we fall to the level of our training. The bodies natural response to stress can and often does hinder performance. This happens when your task is perceived to be greater than your ability. We can not simply just “act” confident to get around this. What we can do is manage/offload the fear.
Goal: Learn a series of simple but proven maneuvers that you execute each time to decrease cognitive load and increase success rate.
Direct Laryngoscopy Airway Meds have been pushed…..
Box Breathing: 4 count in, 4 count hold, 4 count out, 4 count hold
Grip the laryngoscope lightly (2 finger grip)
Scissor the mouth open
Insert blade right, sweep tongue left
Epiglottoscopy:STEP WISE “Look as you go” down the tongue to uvula to the epiglottis
Valleculoscopy: Seat blade into vallecula and engage the hypo epiglottic ligament
If needed use Bimanual External Laryngeal Manipulation (BELM) to increase space/seat Blade
Laryngoscopy/Lift: Lift Head, BELM
Intubation: Delivery from right side of mouth (Keep view/blade in until tube passes )
If caught on insertion using a stylet, pull back slightly and turn right
If caught on insertion using a bougie, pull back slightly and turn left
Video Laryngoscopy (with Hyperangulated Blade) Airway Meds have been pushed…..
Box Breathing: 4 count in, 4 count hold, 4 count out, 4 count hold
Grip the laryngoscope lightly (2 finger grip)
Scissor the mouth open
Insert blade midline watching the mouth until it rounds the curve
Epiglottoscopy: STEP WISE “Look as you go” down the tongue to uvula to the epiglottis.
Valleculoscopy: Keep epiglottis on top half of screen, looking for 50/50 view
If needed use Bimanual External Laryngeal Manipulation to increase space/seat Blade
Laryngoscopy/Lift:Align camera with trachea
Intubation: Delivery from right side of mouth, LOOKING at the mouth again as you initially insert the tube. If caught on insertion pull back slightly and turn right
Preox/Reox Dr. Salazar -Pt should be positioned with head of bed elevated, -If they have spinal precautions then use Reverse T burg position -Nasal Cannula @ 15 LPM and Non rebreather at >/= 15 LPM (flush rate turn the dial all the way and keep going) Note that some pts won’t tolerate the 15 LPM via NC until unconscious -SPO2 is not 100%? May have shunt…replace NRB with PPV (NIPPV or BVM with Peep) up to 15 cm h20. Do this for 3-4 min Leave NC @ 15 LPM during intubation
-Use your OPA/NPA LMA/SGDs -Two hand seal on BVM, be mindful of over bagging -We should be using PEEP valves and end tidal CO2 wave forms when we are bagging a patient…wave form should be immediately hooked up after intubation. Will also allow you to see if you are ventilating when the pulse ox is low (pulse ox may be low from lag or because we can not oxygenate/ventilate)
Senior Grand Rounds By Justin Evans PGY-3: Asthma Asthma is a chronic disease, they get lung changes over time, more smooth muscle hypertrophy…more smooth muscle…more smooth muscle contractions. Treatment:(General) dosing guide for quick reference -Albuterol: Nebs 5 mg q20 min or 15 mg “hour long” vs MDI: 4-8 puffs q20 min up to 4 hours -Ipratropium Bromide (1500mcg for hour long) -Corticosteroids: Dosing should be IDEAL body weight IV=IM=PO Methylprednisolone 0.5-2mg/kg IV Dexamethasone: 0.6mg/kg up to 18 mg -Magnesium: 2-4G over 10-20 min, can re dose -Epinephrine: 0.1-0.5 mg IM (0.01 mg/kg) -Ketamine: 0.5mg/kg (may have to repeat) -Terbutaline: Loading dose 2-10mcg/kg infused over 10 min Infusion of 0.1 to 10 mcg/kg/min
-Try NIPPV to optimize the sick patients (can use ketamine to help them tolerate), these are patients that are very high risk intubations (hypoxia, acidotic) and challenging to manage on the vent. -If you have to intubate: provider with the most experience should do this. Optimize EVERYTHING you can (oxygenation, positioning etc) if you have to intubate them -Use a large dose of paralytic, want its onset as fast as possible.
Vent Settings: Want to oxygenate and avoid breath stacking/barotrauma Start with low RR, low TV, low to no PEEP Example: RR: 6-8/min TV: 6 ml/kg Insp flow rate >/= 100 L/min I:E > 1:4 FiO2: Titrate to Sat above 90% PEEP: 0.3 mmhg
Peak pressure are susceptible to bronchospasm, may need to increase peak pressure alarm on vent. Plateau pressure (<30 cm H2O normal) more directly represents hyperinflation: measure with inspiratory hold If high decrease RR, increase I:E ration may need to disconnect vent and manually decompress chest
Treatment Deeper Dive Beta Agonist: mainstay -Albuterol -Levalbuterol: More beta 1 selective but much more expensive…also studies have not really shown benefit How to give: MDI with spacer v Neb: Cochrane review No difference in hospitalization rates or peak flow/FEV1 changes In children ED LOS of shorter by 0.53 hours in MDI group Intermittent (5+5+5mg) v Hour Long (15 mg): Hour long seems to reduce hospitalizations, is this due to us not reassessing as frequently?
-Ipratropium Bromide: does not seem to have benefit when used alone but is synergistic when used with albuterol (Duo Neb) -Terbutaline/Epi: Severe asthmatics, probably go for epi. -Corticosteroids: get them on early besides decreasing inflammation down the road they may have a effect of up regulating Beta receptors in the first few hours. Dexamethasone can let up to 3-4 days so this may be able to replace the multiple day dosages of prednisone. -Epi: IM probably better than Sub Q -Ketamine: Use for comfort on NIPPV or for DSI.
Labetalol Keep doubling dosing 10,20,40,80 1:7 a:B 5-min peak BB as anti HTN not good Safe in pregnant
Grand Rounds: Dr. Jacob Avila Ultrasound in Cardiac Arrest POCUS in Cardiac arrest can help you ID reversible causes Guide Resus
Tamponade:An Obstructive Shock Looking for RV diastolic collapse but RA diastolic collapse is the earliest sign. Slow down the clip on the machine to check, Use M Mode. IVC? Sometimes they can have a low CVP but this is not as common
Pericardiocentesis: One of the studies looking at this showed a 15.4 % survival in these patients who got the procedure. Use PSL or apical Use linear or curvilinear
Trauma FAST: Most sensitive view caudal tip of the liver, inferior pole of the kidney Pelvic-Do Sagital LUQ: -above the spleen is where you need to see In this order since it is either positive or negative. Starting in the most sensitive area.
FAST is not just for trauma… Ruptured AAA,Ectopic, bowel Don’t confuse clot for normal Vagal nerve can cause a reflex bradycardia with bleeding in the abdomen
Tension PTX Looking for sliding not movement Lung point highly specific Apnea can cause no long sliding:Get a few big breaths
Pulmonary Embolism Looking for right heart strain** and/or DVT
Data is being extrapolating from alive to dead R heart seems to be enlarging during cardiac arrest regardless of PE or Not
-DVT, Easy to do while compressions are going, if you have a suspicion for PE and you find one most likely your pt has a PE -Don’t keep compressing the clot once you find it
MI -Regional wall motion abnormalities -Walls should be getting fatter and skinnier at the same rate
Pulse Checks Over all we are not great at determining if a pulse is present or not, we also take way longer than 10 seconds on average. -Have a systematic way of using POCUS for pulse checks. -Have someone else counting out loud from 1 to 5 then 5-1, US should be done and off the chest before the count is over -have a towel ready to quickly wipe the gel off to avoid people slipping while doing CPR
Don't feel a pulse but see coordinated cardiac activity? Consider Arterial Line, Pressors this is likely NOT PEA but profound shock.
Remember 10seconds=10seconds, we need to be more strict with our pulse checks in general
Prognostication? Data at this time shows we probably can't just use lack of cardiac motion for pure prognostication. Need to take the whole scenario into account.
Tetanus is Cat C, commonly accepted as safe Resuscitative Hysterotomy (previous Peri-mortem C-Scetion) Targeting both pt outcomes in parallel -20 weeks or greater (Near Umbilicus) -Decreased utility after 5 min Need: Knife, Scissors
Vertical incision from xiphoid to pubis symphysis using scalpel (ideally #10 Blade)
Cut through subcutaneous tissue to get to peritoneal wall
Use fingers to bluntly dissect to peritoneum
Cut through peritoneum vertically (ideally with scissors or use a scalpel to initiate an opening inferiorly)
Deliver the uterus, cut into lower half of uterus vertically to avoid placenta, then use scissors (blunt end towards baby) to extend incision upwards until you reach the baby
Deliver the baby (neonate will likely need resuscitation)
Foundations Pediatric Asthma General Approach to treatment (there will be a decent amount of variability in practice) 1st line: B-agonists/anticholinergics nebs (albuterol/ipratropium bromide),Steroids (IV or PO)
Steroids: prednisolone 1-2 mg/kg PO methylprednisolone 1-2 mg/kg IV dexamethasone 0.6 mg/kg PO
IVF: lots of insensible loss
Need more? Magnesium (50mg/kg up to 2G over 20 min), terbutaline, epinephrine, Bipap, helix.
BIPAP: Consider using ketamine (0.5 mg/kg) IV for BiPAP tolerance and additional bronchodilation
See more at: https://www.chop.edu/clinical-pathway/asthma-emergent-care-clinical-pathway ….More asthma pearls coming in next weeks summary!
Pulmonary Embolism Less commonly thought about risk factors: HIV, Nephrotic/Nephritic syndrome, IVFA, Autoimmune disease. 73% of pts had dyspnea with extortion or at rest, (via PIOPED group), pleuritic pain in 66% Use your clinical PRE test probability to help guide your work up
Low probability? PERC Intermediate? DDimer (Age adjusted) https://www.acep.org/globalassets/new-pdfs/clinical-policies/clinical.policy.suspected.acute.venous.thromboembolic.disease.pdf High: CT-PE or V/Q scan Hemodynamically unstable? Use POCUS (DVT+Echo), empiric anticoagulation may be used in some cases.
Jeff Kline PE Pathway: Good reference/starting point. You will see a very large practice variety here. We plan to cover this much more in depth in the coming months.
After discussing this pathway with a few faculty would add: Probably only anticoagulant if unstable/serious signs of heart strain (along with no other large competing dx). GFR cut off for CTPA is also not absolute (a discussion/debate for another time). https://www.hippoed.com/em/ercast/episode/infectedand/ddimerconfusion http://5minsono.com/rhs/ http://5minsono.com/dvt1/
Trach Complications Early Complications: Post Op hemorrhage/infection SubQ emphysema/PTX Obstruction of tube (incorrect placement) Posterior trachea injury with occlusion from swelling Late Complications: Tracheoarterial fistula (frequently tracheoinnominate artery) can’t miss! May have massive hemorrhage post sentinel bleed. Stenosis from granulation tissue Infection at stoma
Bleeding tracheostomy PPE, Suction ABCs If they have a cuffed tube hyper inflate it, if uncured replace w a cuffed tube then hyper inflate. If this doesn’t work you can try slowly withdrawing the tube with pressure anteriorly. Trying to apply force to the anterior trachea. Not stopped? Try inserting a ETT either oral or via stoma Finally attempt direct pressure (Remove Trach and place oral ETT first/Adequate BVM/LMA). Go to OR while holding pressure
Download resources so you have a checklist!! http://crashingpatient.com/procedures/critical/tracheostomy-and-trach-emergencies.htm/ http://tracheostomy.org.uk/resources/documents
Crashing Pulmonary HTN Check the pump/line. Epoprostenol has short half life. Reduce RV afterload. Keep SPO2% 90-92. Fix dysrhythmias Norepi first if hypotensive Dobutamine/milrinone if normotensive Attempt to (but don’t overshoot) RV preload, use small IVF bolus if hypovolemic Try to avoid NIPPV Hypervolemic? Controlled Diuresis
Massive Hemoptysis: These patients can decompensated quickly. More like to die from asphyxiation rather than exsanguination. When intubating try to main steam the non affected lung. Use bougie to intubate left main steam https://www.emrap.org/episode/emrap2019march/criticalcare
Spilt Conference Dr. Green Neurology 1. Remember Psychogenic Non-Epileptic Seizures (PNES) can be identified by open eyes, protective reflexes, no head turning, no post-ictal state, and no tongue wound; incontinence has a likelihood ratio of <1 and is useless. Crazy people urinate on themselves more than epileptics. 2. When checking the cranial nerves, don't forget finger movement in all 4 quadrants for each eye. 3. Last, even if you have just a vague abnormality on your neuro exam, realize that it may be very significant on scan: get the CT!
Testing the Cranial Nerves 2: Finger count both fields, each eye. Test visual acuity. Marcus Gunn or afferent pupillary defect – light in other eye makes both constrict, but when shined in affected eye it dilates. 3,4,6: EOM 5: light touch of face 7:Symmetric smile, close eyes tight, raise eyebrows, blow out cheeks, whistle 8: Dix-Hallpike-See below 9,10: Look for elevation of the soft palate, symmetric. Gag reflex should be intact. 11:Trapezius function; also sternocleidomastoid, so have the patient turn their head right and left while testing resistance with your hand against their mandible/jaw. 12:Symmetric tongue movement left to right
Dr. Leaf Dizziness Is this Presyncope? Ask about dilation of vision/cone in Tx like full syncope Don’t lock in on this Central v. Peripheral Intermittent Vertigo: BPPV must be BOTH paroxysmal and positional Should go away in about a minuet….probably symptoms last bit longer can walk, may be unsteady at first but resolves Tx with Valium,meclizine Dix-Hallpike: Really need to hold at the position for 1 min Prescribe Epley 3xBID Constant Vertigo: 5Ds-> Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia any of those?->MR neuro Isolated constant vertigo: likely acute vestibular syndrome, recent URI? Check hearing loss
8/1/19 Conference Summary: By: Zachary Aust, MD (Academic Chief Resident, PGY-3) Infectious Disease: Dr. Prokesch -Sir Alexander Fleming, the Nobel prize winner for the discovery of PCN: He predicted/warned that there would come a “era of abuse” leading to increased microbial resistance due to indiscriminate abx use. “In such a case the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope the evil can be averted.” -1945 NYT Pneumonia: CAP->Doxy S.pna Z-pack resistance >50%
HIV, CD4 90-> Admitting?-> Ceftriaxone, Azithro (atypical coverage) How about Bactrim?->Stable on RA? Can wait for in patient treatment Usually want to cover for these pmts for CAP (s.pna still most common cause)
80 year male: Doxy, may meet criteria for admit on age but still treat for CAP
HAP/SNF/VAP: Vanc/Zosyn*** Health care associated pneumonia (HCAP) is not a thing anymore.
Diabetic Foot Wound: -Stable/Fever but fine: Does not need IV abx IMMEDIATELY -Septic: Broad spectrum. -Intermediate: Ceftriaxone Need to ask yourself: What are they going to get stuck on for 6 weeks? Many of these patients will end up having a negative bone bx and be on vanc/zosyn for 6 weeks, need a indwelling line.
Paraplegic w sacral decub worsening smell: Don’t Swab the gunk
When to swab an abscess? Immunocompetent, single abscess don’t cx it Complicated abscess, bad surrounding cellulitis, immunosuppressed: then yes send Admitting: Cx
Cellulitis: Strep more rapid onset than staph (usually take days vs hours w strep) Strep= cephalosporin/PCN….vanc is not the best drug Clinda if PCN allergic is okay Clinda does not have good staph coverage here
Bilateral cellulitis is extremely rare
Swollen joint: Don’t be afraid to tap the joint! Is it an infection then it needs abx
C-tube, fevers, chills: Do not send cx from drain Same for foley cath, need new cx
What do send LP: Cell count, Diff, Glc, Protein, Hx, HSV/West nile (Maybe, expensive will it change our mx) Meningitis with HSV self limited, Encephalitis needs antiviral, can have both Neonates all bets are off Pt with AIDS: Don’t forget opening pressure Send a bunch of fluid and the studies you are most worried about, admit and tell pt there is CSF in the lab in they need more
Urine: Can’t determine infection based on color or smell Yeast on a urinalysis: usually a colonization, Only treat if they have had a urologic procedure recently or going to have one If septic, pus, don’t use micofungin no bladder coverage Need fluconazole or ampho UTI: Complicated v Not
Airway Trouble Shooting -Have a mental model to fall back on in crisis situation instead of random assorted tips and tricks -Know the mini steps of each procedure so you can break down where your problem is Steps: Breath, Scissor, EVLI Problem Phase Solution Can't see anything Epiglottoscopy
Go slow down the tongue/pull back and start again.
Lead with suction for epiglottis camouflage
Uvula will point the way, you are just looking for a sliver of epiglottis
Can't get the view of the cords Exposure (Valleculoscopy then Laryngoscopy/Lift)
blade tip position matters more than force, be sure you are properly seated in vallecula
use external laryngeal manipulation to better set blade then use it to improve cord exposure
Lift the head
Lean back for a better view
use a mac as a miller
Can't get the tube to go where it is supposed to Intubation/Delivery
Use a bougie...even for the easy intubations, get good
learn your dominant eye and make sure your head is aligned properly
make your tube straight to cuff
VL? Being to close will make tub delivery worse pull back
Most common poisoning worldwide,“Flu without a fever”
Start O2 right way, then get carboxyhemoglobin level
Call Tox or consider hyperbarics for Carboxyhemoglobin over 25%
Or over 15% if pregnant
Post intubation sedation Think post intubation analgesia. Fentanyl (higher dose than our order set starts at). Propofol. If the pressor can’t tolerate it low dose pressor. Early Benzos lead to badness down the line for these patients. https://www.emrap.org/episode/emrap2019april/criticalcare
Local Anesthetic Systemic Toxicity Max dosing:
Lido w epi 7 mg/kg
bupivacaine 2 mg/kg
-LAST: classically biphasic but can also go straight to cardiovascular collapse Intralipid, BiCarb for wide QRS
CQI: Spontaneous Bacterial Peritonitis All pts getting admitted for LVP/who have ascites should get a diagnostic paracentesis. Other reasons for Dx Para: New onset ascites, ascites of unknown origin, suspected malignant ascites Pathophys not well understood, may have to do with increased portal pressures, edema of bowel and migration of organism into fluid. SBP has a high mortality (50%) and is common (20% risk admitted pts) Won’t se the classic triad of fever, and pain, and ascites often Must get ascitic fluid for dx Abd pain? Temp >100F? Give empiric abx (3rd gen cephalosporin) even if your neutrophil count is not <250 cells/mm3 Albumin admin: reduction in renal failure and mortality. -Give for any of the following:
Can have a NORMAL glucose (Euglycemic DKA is a thing)
Can have a normal pH/Bicarb.
If dx unclear get lactate/beta-hydroxybutyrate Find Underlying cause, not JUST med noncompliance I.E. MI can tip you over in DKA Treatment: You should have a good enough sense on how to do this without protocol Fluids: Incredibly volume down which can make it harder to treat the underlying pathophys -Give 2-4 L bolus: BALANCED CRYSTALLOID (LR or Plasmalyte) is preferred especially if your pt has underlying renal disease -Maintenance IVF example: Glc>300 LR @ 200 mL/hr Glc<300 LR @ 100 mL/hr+D10W 100mL/hr (halve the LR + same rate of D10W this is essentially D5 1/2LR) Electrolytes: Potassium
K>5: no suplemental K
K 3.5-5: give K 20-30 mEq/L w each IVF bolus
K<3.5 hold insulin/give K 40 mEq w each IVF bolus until K>3.5
Don’t forget to check Mg/Phos. Shoot for a higher Mg and beware that phos will drop during your resuscitation. Insulin:
Remove pts insulin pump
Drip: 0.1U/kg/hr initial (Max 15U/hr) with goal to drop glc 50-70/hr
Bolus? Literature doesn’t support however may be useful if there will be a time delay (>30min) to actually start your insulin drip
Severe acidosis will require higher doses of insulin
Remember the problem is not hyperglycemia, its ketoacidosis and this is what we are treating with the insulin…however it is easier to track glc level at an hourly basis.
ESRD/CHF: Both are not as severely volume depleted
ESRD: K repletion with caution. Insulin is the key here.Hemodialysis is an option but can lead to severe osmotic shifts, will still need insulin
CHF: Keep a close eye on volume status (POCUS), Insulin.
Glc q1 hr
electrolytes q2 hr
Why is my AG not closing? Need more fluids? More insulin/malfunction of insulin infusion Underlying problem which hasn’t been addressed Try to avoid intubating these patients if possible: have a compensatory resp all Try BiPAP or HFNC Intubate for respiratory muscle fatigue
Euglycemic DKA: Glc<250, + AG and ketones SGLT inhibitors, starvation, prolonged n/v, pregnancy, partial tx w insulin before admission Tx: Same as DKA+IV glucose immediately
Things you should do: -Know your carriers AM best Rating: A- is the lowest acceptable ambest.com (908)439-2200 -Complete our malpractice application meticulously and keep a copy include information from previous claims suits and settlements -Ask for a copy of your declaration page -Keep it forever long with all previous policies this includes residency carriers are not required to keep records of your coverage Keep all records related to your claims Write a care full summary of your claims to reuse Keep records of all communication with your carrier Keep a copy of the payment of tail coverage
FOUNDATIONS R1 Foundations RLQ Pain DDx: Appendicitis, kidney stone, pyelo, hernia, psoas abscess, diverticulitis,intussusception, volvulus,referred pain hepatobiliary disease Males: Testicular torsion Females: TOA, ovarian torsion,ectopic pregnancy -Dx of appendicitis is clinical. abx/early surgical consultation may happen prior to CT. -Vitals may be normal even in early appendicitis -CT sensitivity: with IV con 95%, w/o 90-95%. Thin pts/early appy more likely to be false neg w/o con. -Going home?Return precautions that are time/action specific. Repeat abd exam. -Use ultrasound when possible
Ischemic Bowel -Mesenteric vessels have decreased or loss of all blood flow, can be both venous or arterial. -Low perfusion may cause non occlusive ischemia -Classically seen in elderly, w Afib (or CAD/CHF). Pain out of proportion to exam. Sudden and diffuse. -Workup: CT Angio (see extra link below for more information) -Elevated lactate is a late finding. - Mx: ABC, NPO, resuscitation. Replace any electrolyte derangement, treat arrhythmias. Control pain give broad spec abx. Consider heparin, treatment will depend on underlying etiology. If you must use a pressor use low dose dobutamine (or dopamine) Emergent Surgery (general v vascular) and IR consultation.
Diarrhea w HUS Bacterial Diarrhea: Toxin mediated v Invasive. -Toxin: Watery stool, less abd pain, treat symptomatically, prolonged cases may consider ciprr -Invasive: Bloody stool, fever/abn vitals, mod/severe abd pain. IV abx. Hemolytic Uremic Syndrome: Doesn't just happen in children -Microangiopathic hemolytic anemia, thrombocytopenia, renal failure. Can have TTP -Plasmapheresis for severe symptoms. -If E.Coli O157:H7 is suspected dont give antimotility agents/abx.
Unless they are immunocompromised/have legit concern for C.Diff healthy pts with < 2 weeks of diarrhea don't need tested (also pending public health outbreak concerns) -Abx are not indicated with mild disease even if you have a positive PCR/cx for salmonella, campylobacter,shigella, E.coli -If treating be aware that macrolides are becoming more preferred even for travelers diarrhea due to increasing FQ resistance. -Pregnant? Amp or amox treat for listeria.
Cholecystitis -DDx: "hepatitis, hepatic abscess, pyelonephritis, pancreatitis, cholangitis, peptic ulcer disease of the duodenum with perforation or penetration, constipation and appendicitis" -Don't forget about: Pregnancy, MI, PE, PNA, Fitz-Hugh-Curtis syndrome or HELLP syndrome (pregnant pt) -Cholelithaisis (Stones w/o pain) -Biliary colic (stone w pain, no infectious symptoms, pain control and (usually) out pt surgery) -Cholecystitis: inflammation of the gallbladder with BC. Elevated LFTs, WBC, GB wall thickening,pericholecystic fluid. Abx/emergent surgery consult -Choledocholithiasis: stone in the CBD. Similar to above with possibly having jaundice. Tx same as above +/- ERCP v surgery (Emergent). -Cholangitis:Bacterial infection with a biliary obstruction: RUQ pain+Fever+Jaundice (Charcot triad)+ AMS+Hypotension (Reynold Pentad). Same as above, +/- IR perc drain -Old or very sick pt? think acalculous cholecystitis -US first imaging choice.
SBP See above https://www.emrap.org/episode/emrap2019august/mysteryruqpain R2/3 Foundations Necrotizing Pancreatitis DDx for AMS+Fever+epigastric abdominal pain GI: Cholangitis,SBP,Nec panc Pulm: PNA,Empyema Cards:Myocarditis,Thrombosis,Dissection -Necrotizing Pancreatitis: Diffuse v focal nonviable pancreatic tissue, high mortality -Interstitial pancreatitis: No necrosis, edematous pancreas -Pancreatic Pseudocysts: Localized collection of fluid, typically weeks after onset (vs acute collections i.e. abscesses/organized necrosis.
When do I image pancreatitis? -Unclear dx, severe disease/multi organ involvement, no improvement in 48-72 hours, eval for complications. -CT within 72 hours of onset does not r/o necrosis -don't need imaging with mild disease.
When do I give abx? Infection outside pancreas (Cholangitis, bacteremia) Necrosis w no signs of infection? May be sterile/not need abx. Treat w metronidazole,carbapenems,quinolones.
Cholangitis -Track down your source in altered septic patients. -See PEARLS above
Minnesota tube: Sometimes the 3 way stopcock is not air tight, may need to use tape/tegaderm around port OR use bigger stopcock. At parkland we have one that is supposed to go with feeding tubes that fits. -Get used to using these before you have to in real life. I can not stress this enough. Look through our GI bleed box to see what we have. -Find a couple different ways to measure the pressure in the esophageal balloon, resources may differ. -If you want some more hands on practice with these just let me know, we can set up a few sessions outside of conference. https://www.youtube.com/watch?v=4FHIiA_doWU
7/18/19 Conference Summary: By: Zachary Aust, MD (Academic Chief Resident, PGY-3) US Updates SHARP Exam: RLQ Pain Size of ovary> Trans abdominal:Bladder rock to right or left, find iliac vessel with color flow, trace cephalad
Most cysts painless
5cm concern for torsion
Hydronephrosis Appendicites RUQ: Stone/Sludge, ATW, Pericholecystic fluid, Dilated CBD, Sonographic Murphys?: Can also look for pleural effusion FF RUQ? Check Pelvis/Preg Test Pregnancy R1 Foundations Incarcerated Hernia with Bowel Obstruction
incarcerated hernia:painful, unable to be reduced increases risk for bowel obstruction v strangulated:bowel wall ischemia/increase risk of infxn
common risk factors: previous surgery causing adhesions (#1), hernias, malignancies
Pts that may have vague symptoms:very old or young or AMS
Boerhaave Syndrome and Mediastinitis
Up to 1/2 of pts w Boerhaave may not endorse a history of vomiting.
CXR:pneumomediastinum, pleural effusion/pneumothorax usually R>L
If bleeding is not effectively controlled, balloon tamponade with Blakemore or Minnesota tube Intubating the GI bleeder (Scott Weingart. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. EMCrit Blog. Published on June 21, 2009.) 1. Empty Stomach 2. HOB @ 45o 3. PreOx as much as possible..don't want to bag 4. Reduce induction agent, increase paralytic 5. Equipment: All the PPE, Have everything, bougie, LMA, Meconium aspirator, 2 suction set up, scalpel 6. If you need to bag do so gently and slowly, LMA 7. If vomit:Tburg 8: Set up ETT as suction/Use SALAD method if you have the right suction cath:https://emcrit.org/emcrit/ett-as-suction-device/ A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation emcrit.org New device to allow you to suction until you pass through the cords Sigmoid Volvulus
Keep broad ddx for eleberly abd pain don't forget the extra abdominal causes of "Abdominal pain: (GU (bladder/pyleo etc) vascular, pulmonary and so on)
as much as 80% of elderly pts may not have rigidity on physical exam despite visceral perf.
Sigmoid: elderly pt, constipation, tx is decompression with sigmoidoscopy/rectal tube placement: Unstable/bowel necrosis: surgery
Cecal: All ages but usually 20-30 yrs old, more likely to cause necrosis, surgical reduction
Posterior STEMI: ST Depression: V1,2,3. R>S in V1-2, Wide R waves (>30ms), Terminally + T waves, Get posterior EKG
Wellens: Biphasic T waves (A), Deep/symmetric T wave inversions (B) in precordial leads: critical stenosis LAD. Needs Cath lab.
Arrhythmogenic right ventricular cardiomyopathy (ARVC): Epsilon wave, Twave incersion, V1-3: QRS widening, Prolonged S-wave upstroke, episodes of Vtach w LBBB. Immediate cards consult for AICD placement
AFib RVR w WPW: Irregularly Irregular, changing morphology QRS, Delta Waves, very Rapid. Tx: Sync cardioversion/Chemical w procainamide. Do not give beta blockers, Ca channel blockers, amio, adenosine
Med Malpractice and TMB You will hear about a bad outcome ,you will receive a registered letter of intent from a law office DO NOT GO CHART CHECK OR EDIT Immediately inform you med mal carrier (scan/fax... talk to no-one else) -It's normal to feel upset, to not remember the case. Don't confide in one of your partners specifics about the case (Will be asked if you discussed the case with anyone) Time period goes by and you don't hear anything Will get a set time for deposition Don't show up with books/records although the letter will say bring all records Read expert opinion prior When finding your own expert make sure they work in a similar environment to you (or at all) Okay to discuss with someone who has been sued how to cope- not case details, ok/normal to feel bad…..need to cope in a healthy manner Be honest with your attorney Inform TMB of all address changes Do everything by email Document Chaperone for exams Be careful with macros/auto population Check your privileges at hospital (may be different than you credentials) Don't list DDX, MDM is your confessional Time stamp everything Practice different Friday PM till Monday AM If you think the consultant is off base get another one Be the Patient Advocate!
7/11/19 Conference Summary: By: Zachary Aust, MD (Academic Chief Resident, PGY-3) How to approach the year: Be The Magician Be the doctor you would want taking care of yourself and your family. Make the choices that write your story the way you want it. Results and performances that appear magical are come from a mastery and hidden skill. This mastery is earned from intense dedicated study, practice and execution.
Practice how you plan to perform. We don’t rise to the occasion but fall to the level of our training.
Perform like a professional, play nice in the sandbox and learn how to handle in the moment stress
Roll up your sleeves and be ready for things to get weird. Growth happens out side of our comfort zones.
Mind of the Resuscitationist Lecture - emcrit.org emcrit.org This lecture was from the final day of SMACC 2013. It was based on a case I saw at Janus General Hospital. In the lecture I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet ...
Learning How to Learn Learning that is active may be uncomfortable in the moment, but leads to stronger retention. Pay attention, Make efforts to encode the information, practice remembering the information at spaced intervals:
Building the “Perfect” Curriculum - REBEL EM - Emergency Medicine Blog rebelem.com I was asked to give a talk at ACEP 2018 on Building the Perfect Curriculum and given 25 minutes to make this happen. As you can imagine there is no way the entirety of building a perfect curriculum can be done in 25 minutes nor is there such a thing as the perfect curriculum, as we are always evaluating and modifying our current curriculum.
How to Learn and Teach drive.google.com EM Cases Podcast https://emergencymedicinecases.com/learning-strategies-emergency-medicine/ First10EM Make it stick Summary https://first10em.com/making-it-stick/ Building the perfect Curriculum: Rebel EM https://rebelem.com/building-the-perfect-curriculum/ Procedures/Deliberate Practice Skill...
Foundations/Small Groups: Flipped Classroom model, do prep/review of provided resources before coming. Conference time will be used to active learning.
Procedure labs: about once a month but will also be mixing in throughout small group sessions. If you have a particular skill or scenario you want to cover let us know.
Rosh review questions: Will be assigned small amounts post foundations that should cover concepts learned in that session (see above about retrieval practice/spaced repetition)
Get a to do list and calendar doesn’t have to be fancy but get ideas/tasks/appointments out of your head and into something you will look at. Keep your brain space free for more important high level things.
Use podcast apps, RSS feeds to filter through to see only what you want
Have a place to store things you want to review later
Focus on little bits each day rather than trying to binge.
CPT definition: “A critical illness or injury acutely imparts one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s conditions”
Only one doctor can do critical care at one time
Don’t forget to document
Say “Consult” instead of discussion
Health Care Finance
4 models of paying
out of pocket
individual private insurance
employment based private insurance
Medicare Part A: Eligibility
Automatic enrollment at age 65 if eligible
Paid social security for at least 10years
Spouse of the person above
Persons who are totally and permanently disabled may enroll after receiving social security disability for 24 months
People with ALS and ESRD requiring dialysis or transplant are automatically eligible without a 24 month wait
Medicare Part B Eligibility
People who are eligible for Medicare Part B who elect to pay the premium
Some low income people can receive financial assistance
higher income people have higher premiums
>$85,00 for an individual
>$170,000 for a couple
Recheck pt's neurovascular status with a thorough motor/sensory exam
Splint the extremity in question
Make the pt non-weight bearing
Give the pt close ortho follow-up as an outpatient
7/19/18 and 7/26/18 Conference Summary:
EBM: background/foreground question
Background Question: Basic/general question regarding clinical condition, test, or treatment.
Foreground Question: Very specific question regarding specific knowledge to inform clinical action/decision. PICO format: Population, Intervention, Comparison, Outcome
If fracture of the radius or ulnar, must ask self if dislocation:
Vanc/Zosyn doesn’t cover everything. Think about atypicals in cases of PNA with Vanc/Zosyn
Perspective from the inpatient side: giving Vanc/Zosyn can be problematic if culture not obtained yet: some examples include Bone Biopsy
IVDU Abscess – no need for culture, unless bacteremic.
Bilateral cellulitis does not exist - more likely venous stasis.
Get an ABG in COPD to answer a question: is this respiratory acidosis acute or chronic?
ABG bicarbonate is calculated. Look at your BMP bicarbonate for the true level.
Chronic respiratory acidosis? Use the 4:10 Rule when patient is acidotic with elevated PaCO2.
The Bicarb will increase 4mmol/L for every 10mmHg elevation in pCO2 above 40mmHg. If it's not chronic... it's probably acute and thus we need to intervene.
We must be experts in interpreting ABGs as it can change our disposition and level of care for patients.
Make a decontamination decision before the patient arrives to your emergency room.
Symptoms: Wet all over (lacrimation, secretions, vomit, urine, stool) + killer B’s: Bronchorrhea, Bronchoconstriction, Bradycardia
Intubation and Ventilation
Wet all over – expect significant secretions Ventilate – like an asthmatic (bronchoconstriction) Permissive Hypercapnia: Low Rate, Low TV, Low PEEP, FiO2 Titrate Advanced: Avoid High Plateau pressures, Hi Inspiratory Flow Rate
“Atropinize” your patient to smoke out the killer B’s. Atropine 1mg, 2mg, 4mg, 8mg... Pralidoxime 2-PAM 1-2g. Benzos if seizures, no AED.
Alcohol Withdrawal: “Dream Goal – Sedate and NOT intubate” Flavors of Etoh Withdrawal:
Typical withdrawal: hyperalert, shakiness, tremor, elevated HR & BP; 6-8 hours after last drink
Hallucinations: 48hrs to 8 days after last drink, Visual more common than auditory - think large pink lizards
Seizures: onset 12-48 hours after last drink, Grand-Mal.
Delirium Tremens: onset >48 hours after last drink, diagnostic key’s: significant disorientation, autonomic hyperactivity.
Thiamine Deficiency - We miss thiamine it, risk of Wernicke’s
Wernicke’s: ataxia, confusion, ophthalmoplegia (nystagmus more commonly). "When the drunk is gone, the nystagmus should go away." - Dr. Kleinschmidt
Dr. Kleinschmidt treats his ETOH withdrawal patients going fast and heavy: Lorazepam 4mg, 8mg, 16mg, 32mg. Sit at bedside to assess effects. Increase dose every 10 minutes. If prior dose worked, then can repeat dose that worked. CIWA is NOT meant for the acutely withdrawing patient Phenobarbital is old yet novel, read the primary literature to support your opinions
7/5/18 and 7/12/18 Conference Summary:
Tame your Fear List: write down what clinical scenarios you fear most and own them.
Perform mental practice: prepare yourself by seeing that case in your mind before seeing it in real life.
Create Buffer time by having a script with 5 productive tasks to ask your RN and RT to perform when the patient arrives. This can give you time to perform calming techniques. My script is IV, Monitor, O2, CXR/EKG, POC glucose. Perform tactical breathing, say a trigger word, or check your own pulse.
True Ortho Emergencies
When an orthopod, really needs to see the patient tonight at your small community hospital (…cases not to send home with simple follow up)
Definition: In the absence of LVH or LBBB, STEMI is defined as a new STE at the J point in > 2 contiguous leads >2mm STE in men or > 1.5mm in women in leads V2-V3 and/or > 1 mm all other chest or limb leads.
LBBB: New LBBB at time of presentation should not be used as diagnostic of acute MI in isolation. Consider clinical picture and Sgarbossa Criteria:
Inferior STEMI: May be due to occlusion of Right Coronary Artery (RCA) or Left Circumflex (LCx) (depending on heart dominance).
RV Infarction occurs if occlusion of RCA. Get Right sided EKG (see image). STE in V1 is specific, but NOT sensitive for RV infarction. Be cautious about giving Nitro to these patients, consider fluids.
Posterior Infarction may or may not show STE in inferior leads or lateral leads. ST Depression will be seen in V1-V3, for this reason people miss it as a STEMI. Consider obtaining a Posterior EKG.
Diffuse ST depression and aVR elevation: Consider Left main or proximal LAD occlusion. Patient needs cath lab IMMEDIATELY (see EKG below).
- Bicarb ion traps into urine, therefore keep pH alkalemic
If confused and agitated, consider early intubation, hyperventilation (high TV and high RR) to prevent acidosis.
Acidemia leads to increased levels of salicylate in brain. Therefore avoid sedative medications (as they result in hypercarbia) in setting of agitation. Again, consider early intubation.
Level > 100mg/dL is an indication for hemodialysis
http://www.extrip-workgroup.org/salicylates Want to determine if a poison can be dialyzed off? Want the best evidence? This is the website for you – simple, but evidence based. Thank you, Dr. Cao for sharing this valuable resource.
Be safe: do not put patient between you and doorway, always have someone else in room with you, if required to restrain > 5 people to perform safely.
Verbal de-escalate. It is our responsibility, not the RNs.
Orders in Agitation Orderset. Go to orderset and type in "Agitation": Try it. See if you like it.
See highlights from Dr. Roppolo's talk in attachment: