Grand Rounds 5.8.24

r1 clinical knowledge - r4 capstone - research grand rounds - the art of em - Community corner - PEM Lecture

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r1 Clinical knowledge: transplant complications WITH dr. gabor

• Time-sensitive peri-transplant emergencies:

  • Bleeding fistula- stop the bleed.

  • Flood syndrome- start fluids, give antibiotics, consult surgery.

• Have a high suspicion for infection in transplant patients. Immunosuppression can blunt the typical immune response.

• Be careful with fluid resuscitation in renal transplant patients who can be at risk for volume overload.

• At most risk for opportunistic infection within 6 months from transplant as immunosuppression medications are taking effect.

• Immunosuppression meds can have their own adverse side effects.

• Rejection can present similarly to infection.

• Usually presents consistent with failure of that organ.

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r4 capstone: Death, dying, and navigating grief in residency WITH dr. kein

• Learning points: 

  • The Emergency Medicine community is amazing

  • Allows update the family, even if that means staying late after your shift

  • Your patient is also a person

  • Talk about code status early in the encounter, especially for the patient who you think is at risk for decompensation

  • Sometimes, it is ok to not offer interventions that will not alter the patient’s clinical outcome

• Navigating grief in residency: 

  • Let people care about you

  • Give yourself grace

  • Give others grace

  • Find a non-medicine outlet

  • This feeling is not permanent 

  • Life doesn't stop for residency 

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Education research WITH dr. hill

•  Three main categories of education research

  • Assessment- how do we assess learners?

    • Development and Validation of a Lecture Assessment Tool for Emergency Medicine Residents (Hill et al.)

      • Developed a tool to help with assessing resident-delivered lectures.

    • Validity Evidence for a Team-Leading Assessment Tool in Pediatric Emergency Resuscitation Using Video Review (Hartwell et al.)

      • Assessed and provided feedback of pediatric resuscitations based on video review.

  • Approach - how do we teach learners?

    • Using Slack to Facilitate Virtual Small Groups for Individualized Interactive Instruction (Hill et al.)

      • Utility of using slack as communication tool to facilitate small-group, case-based discussions between residents led by faculty.

  • Environment- what is our learning environment like?

    • Is Boarding Compromising Our Residents’ Education? A National Survey of Emergency Medicine Program Directors (Goldflam et al.)

      • Most responding program directors viewed boarding in the ED as having a negative effect on resident education- such as hindering ability to handle high patient volumes.

• Ways to get involved?

  • SAEM Education Research Interest Group

  • Become a peer-reviewer for AEM Education & Training

  • ERE (4th Thursday of every month)

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Art of EM: Cincy-isms WITH dr. adan and lang

• Skeletal traction pin

  • Benefits

    • May reduce pain

    • Improve reduction/operative outcomes

    • May reduce bleeding

  • Cons

    • Increased pain

    • Risk skin injury, infection, neuro-vascular injury

  • For hip fractures, data does not appear to show benefit for pain or operative outcomes, with strong evidence to back it.

  • For mid-shaft femur fractures, traction appears to may reduce blood loss and pulmonary complications, but the available data is very scarce.

  • Overall, our aim should be to first do no harm and get the patient to the OR for definitive management as soon as possible with appropriate pain control until then.

• Hypertonic saline in TBI

  • Is it safe?

    • 3% HTS appears to be safe for peripheral IV administration and does not require a central line.

  • Is it effective?

    • 3% HTS will lower ICP about 25-30% in about 15 minutes and does not appear to be more efficacious compared to mannitol.

    • Of note, HTS is more effective in trauma patients because it is used as a resuscitative fluid as well.

  • Should it be given in the prehospital setting?

    • The available data does not support any benefit of administration of hyperosmolar therapy in the setting of a TBI.

    • Guidelines also support not administering HTS in the pre-hospital setting, yet the available data is weak.

  • What do we do at UC?

    • Recommend HTS for signs of brain herniation (not just poor GCS alone)

      • pupillary changes, posturing, CT evidence of midline shift, etc.

• Chest x-ray

  • Portable one-view CXR

    • significant increase in portable one-view CXRs since the COVID-19 pandemic.

    • based on one study, one view portable films tend to miss nodules, effusions, emphysema, and PNA, compared to two-view films (Bossart, et al.).

  • PA versus AP views

    • PA films reduce heart magnification, scapula moves out of the lung fields, inspiratory effort is easer, and rotation is less likely.

    • AP films are more convenient to perform.

• Sedating the agitated patient

  • One versus two agents?

    • combination of antipsychotic with a benzodiazepine appears superior compared to either medication administered alone (Korczak et al.).

  • Which agent to choose?

    • When administered IM, midazolam administration appears superior in terms of time to sedation (Nobay et al.).

      • yet also patient arouses the earliest.

    • One study comparing haldoperidol plus lorazepam versus droperidol plus midazolam (Thiemann et al.)

      • droperidol plus midazolam has higher percentage of sedated patients at 10 mins (compared to the other treatment group).

    • IM ketamine appears to be highly effective for the severely agitated patient (Barbic et al.)

      • needs to be dosed appropriately 4-5mg/kg IM.

      • variable rates of subsequent intubations based on available data.

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community corner: issues in young women’s health WITH dr. roche

• Sensitive exams in the ED:

  • ask permission and explain why you are asking to perform the exam.

  • move slowly and acknowledge discomfort.

• Practice Variations in Pregnancy of Unknown Location:

  • Incorporate US early into your evaluation of the patient.

    • even if the b-HCG level is below the “discriminatory zone” but there is suspicion for an ectopic.

  • Establish a pre-test suspicion before ordering tests.

• Vaginal bleeding in 1st trimester:

  • occurs in 25% of pregnancies.

  • accounts for 3% of ED presentations for young females.

  • various causes based on timing (aside from ectopic and throphoblastic disease):

    • 10-14d: implantation bleeding

    • 2-8 weeks: anembryonic pregnancy

    • 8-12 weeks: subchorionic hemorrhage

  • when a miscarriage is identified, be an advocate for your patient.

    • our patients deserve options other than expectant management (consider OBGYN consult for potential medical therapy and surgical options).

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Pediatric EM lecture: foreign bodies WITH dr. Lendrum

• Nasal FB Removal

  • Mother’s kiss (blowing in mouth with opposite nostril being occluded)

    • about 50% effective, yet also helpful for improving FB visualization

  • High-Flow Oxygen into unaffected nostrils

    • close mouth

    • increase oxygen to 10-15lpm

  • Instrument removal

    • Will need afrin, local lidocaine, suction set-up

    • Round FB

      • right angle curette

      • Dermabond on one end of a Q-tip

      • Katz extractor

    • Soft FB

      • alligator forceps

      • rod magnet for metallic FB

• Ear FB Removal

  • When do you need an ENT consult in the ED?

    • sharp objects

    • object touching TM

    • signs of trauma to ear canal (bleeding)

    • button batteries that can not be quickly removed

    • need multiple attempts (multiple attempts increase risk of complicated removal)

  • Techniques

    • irrigation (need to ensure TM is intact prior to performing irrigation)

      • kill insect with 2% lidocaine, alcohol, or mineral oil

    • suction

      • using Frazier suction with a soft tip

    • glue

      • dermabond at the end of a blunt wood stick

      • careful not to glue to external ear canal

    • instrument removal (need visualization of object prior to attempting)

      • alligator forceps

      • bayonet forceps

• Aspirated & Ingested FB’s

  • Esophageal FB

    • usually at the thoracic inlet (60-80%)

    • biplane x-rays to diagnose (neck, chest, abd)

      • perform even if object is not expected to be seen on x-ray (look for secondary signs of ingestion and signs of injury)

      • further work-up depends on suspicion (esophagram and/or CT)

    • Emergent endoscopy (within <12h)

      • Esophageal

        • button battery

          • pre-removal administration of honey (10ml every 10 mins) or carafate solution

        • symptomatic (drooling)

        • sharp object

        • food impaction

      • Gastric

        • symptomatic button battery

        • sharp (glass, toothpick, razor)

        • multiple magnets

    • Urgent endoscopy (within 12-24)

      • Esophageal

        • asymptomatic coin ingestion

      • Gastric

        • asymptomatic button battery

        • large/long object (at or greater than 5cm)

        • history of IBD or previous abd surgeries

    • Non-urgent endoscopy

      • asymptomatic, small object in stomach

      • pointed? repeat x-ray in 48-72 hours

      • coins? elective removal in 3-4 weeks

  • Airway FB

    • Tracheal

      • acute respiratory distress, stridor

    • Bronchial

      • wheezing, cough, decreased breath sounds

    • Management

      • consider decubitus chest x-rays for diagnosis (look for hyperinflation of the unaffected lung)

      • rigid bronchoscopy by ENT

• Other FB’s

  • Hair Tourniquet Syndrome

    • caused by more than just hair

    • peak incidence in 2-6 months

    • management

      • Unwind if you can grasp the thread

      • Depilatory Cream (Nair) leave on for 3-8 minutes, yet avoid in open skin and it may cause skin irrigation/minor burns

      • Incision

  • Fishhook

    • push-through technique

      • grab the exposed end of the fishhook with hemostats

      • advance the fishhook until the barbed end comes out of the skin

      • use the wire cutters to cut the hook/barb

      • back the hook out of the skin

    • other methods

      • String technique

      • Needle cover technique