Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

April Conference Pearls

May 1, 2018

With the cooperation of Mother Nature, we had another great month of conference in April! Here are some pearls and follow-up resources from April 2018 EM Conference at Stony Brook.

 

M&M: Seizures as CC for ruptured AAA

-With enlarged aorta, everything bad is the aorta until ruled out

-Once you have done everything possible, no barrier to CT table

     -EMCrit Podcast 9: Can you take sick patients to CT:

          -https://emcrit.org/racc/sick-pts-to-c/

Diagnostic Momentum

-Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-80. PMID 12915363

Code Stroke vs Code Aorta Alert

-Be aware, AHA, Neuro, and hospital policies are generally geared toward tPA delivery

-tPA studies in strokes:

     -http://www.thennt.com/nnt/thrombolytics-for-stroke/

-AHA/ASA 2015 Guidelines for who gets tPA and exclusion criteria (PMID 26696642)

     -http://stroke.ahajournals.org/content/early/2015/12/22/STR.0000000000000086

-Endovascular therapy in strokes:

     -http://rebelem.com/endovascular-therapy-for-acute-ischemic-stroke/

     -https://emcrit.org/emnerd/em-nerd-case-corporeal-clock/

-Public reads this - NYTimes: https://www.nytimes.com/2018/03/26/health/stroke-clot-buster.html

     -EMNerd editorial: https://emcrit.org/emnerd/em-nerd-behind-veil-science/

 

Grand Rounds: Mechanical Ventilation by Dr Aydin

Summary slides:

-Reassess the patient with any compromise

     -Check the ETT placement

     -Check for breath sounds

     -Check the SpO2 and/or ABG

     -Check the PAP, Pplat, and auto-PEEP

-Correct hypoxemia >> hypercapnea

     -Caveat: neuro/brain or cardiac patients

-Use PEEP to recruit alveoli

-RR in a tachypneic patient - keep it high

-Ensure gas change is sufficient to meet the metabolic demands

     -PaO2 > 55 mmHg

     -SpO2 > 88-95%

-Adjust vent settings to reduce risk of further decompensation or injury

     -Lung protective ventilation = “low” tidal volume ventilation

 

-EMCrit Podcast 19: Non-Invasive Ventilation:

     -https://emcrit.org/racc/niv/

-EMCrit Dominating the Vent 1 and 2:

     -https://emcrit.org/racc/vent-part-1/

     -https://emcrit.org/racc/vent-part-2/

-EMCrit Podcast 16: DOPES for desaturation on vent:

     -https://emcrit.org/racc/finger-thoracostomy/

 

-ARDSNet ARMA trial - classics are often discussed but seldom read:

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-8. PMID 10793162

     -http://www.nejm.org/doi/full/10.1056/NEJM200005043421801

 

If you master the fundamentals above, Dr Aydin mentioned APRV; here's an intro, but get some expert guidance afterwards:

-Habashi NM. Other approaches to open-lung ventilation: airway pressure release ventilation. Crit Care Med. 2005;33(3 Suppl):S228-40. PMID 15753733

-Frawley PM, Habashi NM. Airway pressure release ventilation: theory and practice. AACN Clin Issues. 2001;12(2):234-46. PMID 11759551

-Jain SV, Kollisch-singule M, Sadowitz B, et al. The 30-year evolution of airway pressure release ventilation (APRV). Intensive Care Med Exp. 2016;4(1):11. PMID 27207149

     -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875584/

-Zhou Y, Jin X, Lv Y, et al. Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome. Intensive Care Med. 2017;43(11):1648-1659. PMID 28936695

     -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633625/

     -https://emcrit.org/emnerd/cc-nerd-case-inverted-premise/

 

-LITFL on prone positioning (NEJM PROSEVA trial is what Dr Aydin was referring to):

     -https://lifeinthefastlane.com/ccc/prone-position-and-mechanical-ventilation/

     -http://www.nejm.org/doi/10.1056/NEJMoa1214103

 

Mock Oral Boards

10 Commandments by Dr Mallon:

1: Never interrupt the examiner

2: Remind examiner no patient to examine ("what do I see," etc); look at given visual stimuli carefully

3: Recheck vitals often - small changes matter

4: Ask open ended questions

5: Easy points - reflex arcs: abx = culture, scrape = wound care/abx/tdap, ETT = CXR/RT/ABG/vitals/sedation, fracture = splint/analgese

6: Secondary survey; "normal" = move on

7: Up front: H/H, FSG, beta-hcg, T&S, +/- narcan

8: Don't think out loud; instead, communicate with RN/consultants/family

9: Get history - EMS, PD, patient, F&F, old records

10: Get results of ordered tests; compulsive = safe

 

Case 1: Myxedema Coma

-Don't forget the process, e.g. CO poisoning in this case's ddx

-Remember stress dose steroids along with IV levothyroxine

-If combining pressors with IV levothyroxine, watch for deadly arrhythmias

 

Case 2: Status epilepticus in a child

From AIR Series: https://www.aliemu.com/courses/neurology-part-2-headaches-seizures-and-other-2016/

-https://emcrit.org/racc/status-epilepticus/

-https://emergencymedicinecases.com/emergency-management-of-pediatric-seizures/

 

Case 3: Eclampsia

From AIR Series: https://www.aliemu.com/courses/obgyn-2015/

-https://canadiem.org/tiny-tip-preeclampsia/

 

Case 4: Boerhaave's

-https://lifeinthefastlane.com/pulmonary-puzzle-003/

 

 

Critical Care - Dr Weingart

GI Bleed

-18 gauge peripheral IV (esp under pressure) beats a hematoma from a failed 16 gauge, esp in a pt in shock

     -Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right?. Emerg Med J. 2011;28(3):201-2. PMID 20581377

-Match tempo of interventions to tempo of the disease

-Call for stat pack whenever using fridge blood

-Clinical status justifies blood, not Hb

     -3 big indications: Hemodynamic instability, ongoing unquantifiable losses, organ dysfunction 2/2 poor perfusion.

     -Transfusion goal trials exclude exsanguinating patients, e.g. exclusion criteria of:

          -Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21. PMID 23281973

               -http://www.nejm.org/doi/full/10.1056/NEJMoa1211801

-In CHF patient, give the blood

     -If you're forced to intubate, so be it; it’s one less barrier to GI's scope, and now you have a secured airway

-Low dose pressors may be indicated as part of balanced resusc in elderly (autonomic dysregulation) to prevent overtransfusion

-Do you reverse aspirin:

     -From ICH literature, no reversal unless you're doing a procedure on them

          -Baharoglu MI, Cordonnier C, Salman RA, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016. PMID 27178479

     -If exsanguinating, doing massive transfusion (1:1:1) anyway

-Blood products are not benign. 1:1:1 for non-massive transfusion patients worsens outcomes:

     -Inaba K, Branco BC, Rhee P, et al. Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg. 2010;210(6):957-65. PMID 20510805

 

Posterior STEMI

-http://hqmeded-ecg.blogspot.com/2009/04/pure-isolated-posterior-stemi-not-so.html

 

EKGs: Syncope - Dr Meyers

-http://resus.me/wobbler/

 

Senior Grand Rounds: Normal Saline - the Devil's Urine by Dr Alva

-https://emcrit.org/pulmcrit/smart/

 

PGY2 EBM - Agitated Patient - Dr Leonard

-Generally, attempt verbal de-escalation as well as increased manpower before pharmacotherapy

From AIR Series: https://www.aliemu.com/courses/psychobehavioral-2017/

-http://rebelem.com/chemical-sedation-of-the-agitated-patient/

 

Pediatric Core Content - Dr Bober

-Feeding tube for urine catheterization

-Parent's kiss for nasal foreign body

-Tdap: 11-12 years age (6th graders)

     -CDC vaccination schedule: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

-Child should speak 6 words by 2 yr

-Child should walk by 18 mo

-Child should be rolling over by 6 mo

 

Pediatric Environmental - Dr Bober

-https://www.aliemu.com/courses/environmental-2015/

-https://www.aliemu.com/courses/environmental-2018/

 

Ultrasound - Biliary - Dr Secko

-https://docs.wixstatic.com/ugd/fa3e7b_8746c2fe15b04767bed8079c7e98af59.pptx?dn=RUQ%20ultrasound.pptx

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