THE MORNING REPORT

The Best in FOAM Education

  • Shah, MD

January Conference Pearls


We had a great month of conference to start out the calendar year! Here are some pearls and follow-up resources from January 2018 EM Conference at Stony Brook.

Essentials of EMCrit - Lots at https://twitter.com/EssentialsofEM in addition to below

Live Cric - Dr Weingart

-https://emcrit.org/emcrit/surgical-airway/

Ventricular Storm - Dr Gray

-3 or more sustained episodes of VT/VF in 24 hours

-Approach: electricity, reversible causes, antiarrhythmics, chill them out

-Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2016 - PMID 27354046

-https://emcrit.org/racc/65947/

LR for HyperK - Dr Farkas

-In ED, start with LR when have no info. When labs back, switch to isotonic bicarb

-https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/

-https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/

-https://emcrit.org/squirt/brash

TTP and DIC - Dr Deloughery

-With thombocytopenia, ask if it's TTP or DIC

-TTP

-overactive platelets

-ADAMTS13 is missing

-primary problem

-Dx - Terrible triad: MAHA (high LDH + schistocytes), thrombocytopenia, end organ damage

-Tx - plasma exchange; FFP and steroids while waiting

-No platelets...they feed the fire!

-DIC

-increased thrombin generation

-overactivation of coagulation

-secondary problem

-Dx - high INR/PTT/dimer and low platelets/fibrinogen

-Tx - treat primary cause

-Support coagulation - Magic 5: fibrinogen > 150 (give cryo), PLT > 50, Hct > 21, aPTT < 1.5 x control, INR < 2-3

Team Dynamics - Dr Hicks

-4 lines of conflict

-Positions, strategies, or opinions

-sit rep - leader shares state of situation as (s)he sees it

-tactical pause - leader asks "what am I missing"

-Mistrust or undeveloped comm

-don't be passive aggressive nor man-splain

-consistent, short, direct phases don't mean you're impolite

-Power issues and personal agendas

-hot debrief: process and safety issues

-cold debrief: interpersonal and team issues teased out

-Personality clashes

Anemia Workup - Dr Deloughery

-Production - retic count

-Destruction - coombs, LDH, haptoclobin

-Iron deficiency - ferritin

-Macrocytic - folate (homocysteine), B12 (methylmalonic acid)

BRASH - Dr Farkas

-"BRASH" is his word, not yet in literature

-synergistic response to renal failure, hyperK, and AV nodal blocker

-Metabolic therapies: epi infusion, IV Ca, insulin/dextrose

-Fluid prn: isotonic bicarb if < 24; LR if bicarb > 24

-Nephron bomb if severe hyperK; if mild, then not as aggressive

-In anuric and persistent hyperK, dialyze

-https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/

Mental Prep for badness - Drs Gray and Hicks

Walking down the hall: near field focus - what are immediate issues and plan for them

-review scripts (trauma arrest, ACLS, etc)

-review procedures you might do

In the bay, decrease arousal level:

-take a deep breath

-say something positive to yourself

-trigger word to focus self

-Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers' Performance Under Stress. Ann Emerg Med. 2017 - PMID 28460863

Patients about to come in: prebrief

-What do we know

-What do we do

-What do we change - contingency

-Roles assignment

Perimortem C-section - Drs Gray, Weingart, Boudourakis

-https://emcrit.org/racc/peri-mortem-c-section/

BLAST Speaker 1: Bougie

-Bougie all your intubations

BLAST Speaker 2: VT vs SVT with aberrancy

-CRAM to distinguish VT vs SVT with aberrancy. May be SVT if all "no":

-Concordance in all precordial leads

-R-S > 100 msec

-AV dissociation anywhere

-Morphology

-When in doubt, treat as if VT

BLAST Speaker 3

-https://emcrit.org/racc/pulmonary-hypertension-right-ventricular-failure/

MCI for unprepared - Dr Gray

-Create inside and outside team

-Designate areas where people go

-Outside team: ID patients, triage them, deliver them inside

Status epilepticus - Dr Farkas

-https://emcrit.org/pulmcrit/status-epilepticus-2/

Early trauma resusc - Dr Hicks

-Clot formation, not BP chasing

-Controlled resuscitation

-Pick your poison (brain vs hemorrhage)

-Harris T, Davenport R, Mak M, Brohi K. The Evolving Science of Trauma Resuscitation. Emerg Med Clin North Am. 2018;36(1):85-106 - PMID 29132583

-Schreiber MA, Meier EN, Tisherman SA, et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015;78(4):687-95 - PMID 25807399

Thoracotomy - Drs Hicks, Weingart, Boudourakis

-https://emcrit.org/racc/procedure-of-thoracotomy/

-https://emcrit.org/racc/john-hinds-on-crack-the-chest-get-crucified/

-https://emcrit.org/racc/abbreviated-ed-thoracotomy-tray/

Sim Day:

Central Lines:

-http://emcrit.org/central-lines/

-http://emcrit.org/podcasts/central-line-show/

-http://emcrit.org/podcasts/central-lines-placement-tips/

-http://emcrit.org/wee/central-line-micro-skills-deliberate-practice/

-https://emcrit.org/emcrit/microskills-dilation/

Cocaine toxicity in body packer + trauma - Sim War case:

-1 hour 18 min mark onward for

https://emergencymedicinecases.com/episode-5-renal-colic-toxicology-update-body-packers/

TCA Overdose:

Links from AIR Series Tox 2015: https://www.aliem.com/2015/01/air-series-toxicology-module-2015/

-https://emergencymedicinecases.com/critcases-massive-tca-overdose/

-https://emcrit.org/racc/tricyclic-antidepressant-overdose/

Grand Rounds by Dr Farkas: BRASH, Status Epilepticus, and Lactated Ringer's

-https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/

-https://emcrit.org/pulmcrit/status-epilepticus-2/

-https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/

-https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/

Interesting Case by Dr Simms: ruptured AAA presenting as a seizure

“There is no disease more conducive to clinical humility than aneurysm of the aorta.” - Osler

-RUSH your sick patients

-PMID 21293775, 24360026, 18272117 show seizure as possible CC

DVT Ultrasound by Dr Reardon

-Slides @ https://www.stonybrooksono.com/resources

-AEUS DVT Lecture: https://vimeo.com/52819569

EKGs: Bradycardia by Dr Meyers

-DDx includes DIE: Drugs (e.g. beta blocker, Ca channel blocker, digoxin), Ischemia, Electrolytes (e.g. hyperK)

PGY2 EBM: CTCA/CCTA and Chest Pain by Dr McKenna

-https://emcrit.org/emnerd/case-anatomic-heart/

-https://emcrit.org/emnerd/the-case-of-the-anatomic-heart-part-2/

-http://rebelem.com/chest-pain-coronary-ct-angiography-ed/

-https://coreem.net/journal-reviews/ccta-1-year-outcomes/

-EMRAP Feb 2017: Cardiology Corner: ACS State of the Art Part 1 and 2 by Amal Mattu

-Stony Brook ED Chest Pain Algorithm (kallus.com/er -> Admin Policies):

http://www.kallus.com/er/administration/ACS.pdf

EBM: Observational studies: can’t live with them, can’t live without them by Dr Singer

-http://www.cebm.net/blog/2014/04/03/study-designs/

FOOSH by Dr Mallon

AIR Series 2016: Upper Extremity Ortho:

-https://www.aliem.com/2016/07/air-series-orthopedics-upper-extremity/

Thyroid Disorders by Dr Alexeeva

From AIR Series 2014: Endocrine (https://www.aliem.com/2014/10/air-series-endocrinology-2014/):

-https://www.aliem.com/2013/11/thyroid-storm-treatment-strategies/

-https://www.aliem.com/2013/10/diagnosing-hyperthyroidism/

Adrenal/Pituitary Disorders by Dr Sherman

-https://emcrit.org/racc/steroids-for-septic-shock-preadrenal/

-http://www.criticalcarereviews.com/index.php/meetings/493-ccr-meetings/ccr-meeting-2018/3023-adrenal-trial-results

-https://emcrit.org/emnerd/cc-nerd-case-relative-insufficiency/

Vascular Trauma by Dr Morley

-Accuracy of Physical Examination, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta-analysis - Acad EM 2017 - PMID 28493614

-Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed - EM Clinics 2017 - PMID 29132576

Billing by Dr Morley

-ACEP "What Every Graduating Resident Needs To Know About Reimbursement":

https://www.acep.org/graduating-resident-reimbursement/#sm.00001ijs79y86jcxls4881r908yks

-ALiEM ED Charting and Coding: Medical Decision Making (MDM): https://www.aliem.com/2016/11/charting-and-coding-medical-decision-making/

Alkalosis by Dr English

-https://lifeinthefastlane.com/wp-content/uploads/2012/08/acid-base-disorders-worksheet3.pdf

-https://emcrit.org/podcasts/acid-base-i/

-https://emcrit.org/podcasts/acid-base-part-ii/

-https://emcrit.org/podcasts/acid-base-part-iii/

Eponymous fractures by Dr Mallon

-Rosen's 9e Table 42.1 Common Fracture Names and Their Origins

Critical Care Journal Club/Case Discussion by Dr Wright/Thompson/Eraso

-Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-93 – PMID 9482291

-https://emcrit.org/racc/scape/

-https://emcrit.org/racc/when-to-wean-cpap-scape/


Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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