Earlier this month, our ED pharmacist gave a detailed lecture on procedural sedation. One of the drugs discussed was ketamine, a dissociative anesthetic that is often the drug of choice among emergency medicine doctors for joint reductions, chest tubes, and other short, painful procedures. One of the reasons ketamine has become so commonly used is because of its limited effects on respiratory mechanics.  Given this advantageous property, ketamine has been utilized for “procedural sedation” for the purpose pre-oxygenation during resuscitations. This term as term has been coined Delayed Sequence Intubation (DSI).

Imagine you are walking into room 9 after receiving an EMS report about a delirious elderly male with suspected pneumonia who has been hypoxic en route by despite supplemental oxygen. Patient rolls in and looks sick with O2 sats in 70s on nasal cannula. Vitals are as follows: BP 104/72, HR 95, RR 26. As you try to place a nonrebreather, he swats it away. You have decided this patient needs intubation and consider rapid sequence intubation (RSI) with bag valve mask ventilation during the paralysis period with hopes of obtaining first pass success prior to patient critically desaturating and becoming hemodynamic unstable leading to cardiac arrest. You also realize that BVM alone without PEEP valve will unlikely raise O2 sats in this shunted patient and BVM during apneic period during RSI increases risk for gastric insufflation and aspiration. Then, you remember reading this blog on DSI. You ask the pharmacist to draw up a dose of 1mg/kg of ketamine, which is then administered by slow IV push(to avoid apnea) which subsequently results in a calmed patient in about 30 seconds. You place the patient on 15L NC as well as non-invasive mask CPAP with sats now 96% on the monitor and continue this method for 3 minutes to allow for adequate denitrogenation. Succinylcholine is then administered and then after a 45 second period of apneic oxygenation with nasal cannula still in place, patient was intubated without complication.

This method of separating the induction agent from the paralytic to allow for adequate pre-intubation preparation was described by Weingart and colleagues in a prospective observational study published in Annals of Emergency Medicine. The authors reported clinically and statistically significant increases in 02 sats using DSI with ketamine. Again, ketamine was used due to its ability to allow for the continuation of spontaneous breathing after administration. Below, I have listed take home points but highly recommend reading the article to gain a better understanding of this concept as well as the limitations with this study. (link to article and podcast at bottom of post, possible future journal club selection?)

Take home points:

• Start ketamine dosing at 1mg/kg, with 0.5mg/kg aliquots thereafter until dissociation occurs (Typically achieved by 1.5mg/kg)
• In patients with high blood pressure and tachycardia, may want to add small dose of a benzo, labetalol, or avoid ketamine altogether and use an agent like dexmedetomidine
• Recommend against etomidate or propofol or sedation agents such as midazolam because the non apnea-inducing dosages of these agents may be very different among these patients
• Two choices for pre-oxygenation: 1) 15L Nasal cannula plus 15L non-rebreather. If sats do not improve to greater than 95%, then shunt physiology present. Switch to option 2) 15L Nasal cannula with non-invasive CPAP settings 5cm to 15cm or BVM with PEEP valve
• DSI also applicable for the agitated, trauma with suspected head injury who is disrupting the resuscitation (especially now that the increased intracranial pressure phenomenon from ketamine is in question). One could argue this patient is dangerous to immediately paralyze, and therefore, DSI can be utilized to decrease 02 consumption while simultaneously calming the room and allowing for proper positioning of patient for intubation.
• It is possible to avoid intubating some patients (COPD, asthmatics) as evidenced by the study, although not currently a recommended aspect of DSI

In conclusion, I would advocate adding DSI to your toolbox for those uncooperative patients requiring intubation who have failed initial attempts at preoxygenation by placing a mask on their face. Additionally, as the COVID-19 pandemic continues, it will be interesting to see if evidence supports using this method in those patients with agitation from significant hypoxemia and perhaps already low functional residual capacity at baseline. At the time we take our oral boards, RSI will likely still be the correct pathway for these scenarios, however, this concept seems to gaining traction in EM literature and is worth considering in room 9 under certain circumstances

Link to Article : https://emcrit.org/wp-content/uploads/2014/07/dsi-article.pdf

Head and Neck Trauma – Dr. Sizemore

• signs of basilar skull fracture: hemotympanum, raccoon eyes (intra-orbital bruising], battle sign(retroauricular bruising) or cerebrospinal fluid leak (oto- or rhinorrhea, halo/ring)
• patients with LeFort II fractures and LeFort III fractures should have a CTA to screen for BCVI
• penetrating neck trauma
  • Know anatomy associated with zones of neck (I,II,II)
  • Early airway control should be considered in patients with hard signs
  • Hard Signs > OR
  • Soft Signs > CTA
  • Zone I injuries can result in pneumothorax
• do not probe wounds with active bleeding as may dislodge clot
• if direct pressure cannot control bleeding, consider placement of a foley catheter and balloon inflation

Intro to Research: An Overview – Alyssa Thomas and Dr. Huecker

• interns, start thinking about project ideas now. Pick something that interests you
• remember, there are different type of “research” projects
• human subjects
• quality improvement
• program evaluation
• All members of the research team must have a valid CITI Human subjects and HIPPA research training
• Great resource when time for writing paper : https://www.strobe-stamenent.org

Delivering Bad News – Dr. Coleman

• These conversations are nuanced, demanding, personally impacting
• Dr. Hueckers ABCs
• Awareness: focus on this one thing, they know if you are distracted
• Blueprint: have a blueprint based on studies and based on experience, then modify based on circumstances
• Compassion: Stay composed and expect tough responses
• SPIKES, a six step protocol/mnemonic for delivering bad news mnemonic
• Set up (Structure)
  • mental rehearsal
  • sit down
  • control the situation
  • maintain eye contact
• Perception/Professionalism
  • before you tell, ask
• Invitation
  • break it down, a little at a time
• Knowledge
  • be direct, avoid “passed away”
  •  use plain language, avoid medical jargon
• Emotions
  • Keep your cool, safety first
• Summary
  • Explain what happens next
  • Ask to be excused and how to reconnect

Social Media – Dr. Capocaccia       

• Please follow us on twitter: @UofLEM and Instagram:uoflem
• Will be posting “white board talks” and conference pearls on twitter
• Please send Dr. Capocaccia any images pertaining to wellness that we can share on social media with applicants

How Emergency Doctors Think – Dr. O’Brien

• classic thinking “what does the patient have?” (obtain history, perform physical exam, differential diagnosis, testing, final diagnosis)
• in the ED, the classic model breaks down for a variety of reasons
  • chaotic environment, “anyone, anything, anytime, anywhere”
  • can average 4000 clicks over ten hour shift using EMR
  • Constant interruptions/task switching
  • Frequently responsible for ten or more patients
  • Patients are unknown
• instead, we should ask “what does the patient need?” and whether or not any immediate action is required
• pearls
  • Be the nicest, calmest person in the resuscitation room
  • Rule-out first: diagnose second
  • Focus on smaller list of smaller list of life threatening diseases related to chief complaint
  • If you can, sit at the bedside to collect history
  • Perform an uninterrupted physical exam
  • Avoid diagnostic testing when able using rule-use tool
  • Only order tests that will affect disposition/exclude life threatening/most likely
  • Allow 2-3 minutes of interrupted time to mentally process each patient
  • Mentally process one patient at a time to process disposition
  • You can carry many patients but try to carry a max of 5 “undecided” patients
  • Listen to nurses
  • Avoid the biggest obstacle to the correct diagnosis, the previous diagnosis
  • Avoid inheriting someone else’s thinking on a patient
  • High risk times – sign out, hand offs, high volume, fatigue
  • High risk patients – hostile, violent psych, drug abuse

Dr. Baker – The Lecture Lecture (Tips for Giving Presentations)

• If using powerpoint:
  • avoid wordy slides, rather use simple slides that are visually appealing that supplement content
  • when importing images, utilize websites such as Pixabay to access free high quality images
  • if using videos, do not paste link onto slide. Instead, use software such as capto to put videos directly onto slide.
  • Try creating a story board before making slides
• Prior to presenting, record yourself
• Stand up, move around
• Plan to end early to allow for questions
• See Dr. Baker’s post below for more resources

Dr. Dan Grace – Post-Intubation Desaturation (Room 9 Follow up)

• Differential for the alarming vent/deterioration after intubation: think DOPE
• Displacement/dislodgement –see if tube has migrated, check EtC02, obtain chest xray, video scope verification
• Obstruction – think mucous plug, vent tube kink, make sure patient not biting down, try passing a suction catheter through tube
• Pneumothorax – auscultation, US, chest xray
• Equipment failure – disconnect from vent and bag, If it is “too easy” to ventilate, suggests air leak or dislodgement, if too difficult, think obstruction.
• Other things to consider: chest wall rigidity from fentanyl → give Narcan and breath stacking →disconnect vent and apply pressure to chest

Cordis and Subclavian Central Line Sim– Dr. Webb and Davenport

• Cordis: aka sheath introducer, preferred catheter in hemorrhagic shock resuscitation, provides faster flow rate given large diameter and short length
• Also used for transvenous pacing in unstable bradycardia
• The steps differ from those of a triple-lumen central line, in that the dilator and catheter are inserted together into the vessel.
• Subclavian Central Venous Access – Ideal for trauma patients with pelvic and intra-abdominal injuries and c-collar
• Contraindications -significant trauma or injury to the clavicle or first rib. And If there is concern for coagulopathy or thrombocytopenia, arterial injury is dangerous, as this site is non-compressible
•  Locate a spot 1-2cm below the clavicle where the proximal 1/3 and distal 2/3 of the clavicle meet. The needle should travel parallel to the floor towards the suprasternal notch. Use the contralateral hand to provide downward traction on the needle tip to facilitate clearance of the inferior edge of the clavicle.

Dr. Adam Ross – Percutaneous Pigtail Catheters for Spontaneous Pneumothorax

• essentially 14 Fr chest tubes with curved tip that is inserted using Seldinger technique and is less traumatic/painful to patient than traditional chest tubes
• important to secure the ipsilateral arm above the patient’s head using soft restraints
• two options for insertion: target at or above the 4th/5th intercostal space along the anterior axillary line as in traditional chest tubes or can use an anterior approach (2nd intercostal space, midclavicular line)
• can attach to either Heimlich valve or chest drainage system to suction post-instertion
• guidelines recommend against prophylactic antibiotics except in cases of trauma, where there are conflicting data.
• See Dr. Ross’s post below for resources

Here are the links to the videos/references from my Pigtail Lecture today:

•https://www.emrap.org/episode/pigtailchest/pigtailchest : This is EMRAP’s video that I showed in the lecture of Dr. Sachetti placing a pigtail in a patient.

https://vimeo.com/72761317 : This video is placement of the straight Cook catheter that we currently have.

https://emcrit.org/emcrit/pigtail-video/ : this is Dr. Weingart’s video of actual placement of a pigtail in a real patient

https://emcrit.org/emcrit/pigtails/ : this link is Dr. Weingart’s discussion of pigtails in general

Abdominal Trauma, Dr. McKinney

Penetrating trauma

• OR if unstable, peritonitis, evisceration, evidence of GI bleeding, GSW traversing peritoneum or retroperitoneum, or penetrating object still in place on arrival
• Local exploration of anterior stab wounds can identify peritoneal violation
• X-ray can screen for retained foreign bodies, free air under the diaphragm, or coexisting thoracic injury
• FAST uses peritoneal free fluid as a marker for injury and cannot specifically check for retroperitoneal, diaphragmatic, solid-organ, or hollow viscus injuries.
• DPL, although not done frequently, can be performed in patients who do not have indications for immediate laparotomy and who have an unreliable or equivocal exam.

Blunt trauma

• unstable with positive FAST/DPL > Massive transfusion protocol, OR
• stable with positive FAST/DPL > +/- blood products > CT
• injuries that may be missed on CT : pancreatic, bowel/mesentery, bladder rupture, and diaphragm rupture.
• diaphragm injury: rare, may be noted on CXR by the presence of bowel in the chest cavity, Left-sided injury more common than right because the liver is protective. Left-side injuries typically require operative intervention to prevent the herniation of abdominal contents.
• seatbelt sign think hollow viscous injury, CT has poor sensitivity for diagnosis. Discuss case with trauma, patient will likely receive admission for serial abdominal exams
• Splenic injury: most common injured organ in blunt trauma. Lower grades are typically nonoperative and are treated with observation
• ecchymosis over the flank (Grey Turner sign) or periumbilical region (Cullen sign) are suggestive of retroperitoneal hemorrhage

Genitourinary Trauma, Dr. Kuzel

• kidney: most common injured GU organ, often see gross hematuria, flank ecchymosis, and lower rib fractures. obtain CT Abd/pelvis W, GRADE I-III usually non op, discus with trauma
• ureteral: 90% penetrating, often does not present with hematuria. CT abd/pelvis W> consult urology > surgical repair
• bladder: associated with pelvic fractures, look for hematuria and lower abdominal/scrotal bruising.  Gold standard test: cystogram. Extraperitoneal injuries managed w/ bladder catheter drainage alone, intraperitoneal > surgical exploration/repair
• urethral injuries: Males>Females,straddle injury mechanism, and pelvic fractures. Look for blood at meatus, swollen penis. Single attempt at foley may be attempted. Diagnosis made with retrograde urethrogram. Injuries either posterior vs anterior. Consult urology, Suprapubic catheterization may be required initially, may need OR
• testes/scrotal – blunt: obtain Doppler US, if testicular rupture > OR. Penetrating: often undergo immediate exploration
• penile: fracture- cracking sound, pain, discoloration > US. Amputation -have 8-12 hours for reimplantation

Chest Trauma, Dr. Selk

• Blunt aorta injury : majoirty die in the field. Check for asymmetric pulses, diastolic murmur. CXR followed by CT chest W.  Tight HR and blood pressure control, esmolol often first choice .Surgical or endovascular repair ultimate treatment for a traumatic aortic injury
• pulmonary contusions – SOB, tachypnea, might see patchy infiltrate on CXR, better seen on CT, tx: pulm toilet, mech ventilation in those with severe respiratory compromise
• cardiac contusions – get EKG. if abnormal, get cardiac biomarkers. If isolated injury, okay to discharge
• clavicle fracture – if less than age 2, think NAT
• hemothorax – consider autotransfusion in shock

EMS Radio Communications, Dr. Orthober

• various type of EMS agencies (fire based, private, hospital based, third service, provider, community based) and levels of providers: first responder, EMT, EMT advanced, paramedic
• typical EMS ambulance staffing – BLS crew (EMT + EMT) or ALS crew (EMT + Paramedic)
• Things paramedics can’t do – Chest tube, surgical cric, perimortem c-sec, central lines
• a paramedic shall not terminate in hypothermia, cold water drowning, lightning/electrical injuries
• in arrests, ask for end–tidal C02, ROSC unlikely if less than 10
• for trauma patients,, ask about hypotension and achycardia, GCS?
• for medical patients, use vitals and mental status to help guide room 9 decision
• for stroke patients: LKN? anticoagulated? collateral riding in with them?
• general pediatric considerations – penetrating trauma > 13 years to ULH (or look like an adult), blunt trauma > 15 years to ULH,  although this is a moving target
• nasal intubation: remember phrase, “if in ain’t hubbed, it ain’t in”
• don’t discount mechanism on radio
• Kentucky EMS DNR- has to be original copy – obligated to transport to hospital without one of these

Survivalist’s Guide to the Pediatric ED, Dr. Lund

• Add order sets to favorites, get HPI and discharge do phrases
• Admissions: bed slip > tigertext > talk to admit team > choose dispo > order “ready for dispo”
• asthma: avoid decadron first time wheezers, get xray first to evaluate for neck mass
• neonatal fever (familiarize age considerations for testing/mgmt)
• neutropenic fever- CBC, blood cultures, cefepime within 1 hour
• healthychildren.org – good resource for normal newborn habits
• toxic, lethargic, irritable – use the descriptions with caution
• Tylenol 10 to 15mg/kg/dose, ibuprofen 5-10mg/kg/dose (>6 months of age)
• high dose amoxicillin (90mg/kg/day, BID) for AOM, pneumonia
• know 4-2-1 rule for MF calculation, typically use D5NS or D51/2NS

SANE Services, Amanda Corzine

• male or female victims of sexual assault age 12 and older (as long as have menses)
• Rape kit collection within 96 hours (4 days) of assault
• currently have 100% SANE coverage by nursing staff, at all of UofL health facilities and all Norton ERs
• same exam whether reporting or not reporting to police, kits are kept for 1 year
• level of alertness required for exam/consent. Search warrant for unconscious patients if suspicion high
• can go on to EPS if waiting for sane exam and otherwise medically clear, do not delay transfer
• always collect patient underwear, external and internal vaginal swabs with vaginal assault
• unlikely will have 24/7 SANE coverage when leaving residency, try to observe and familiar with an exam process now!
• toulidine blue dye – adheres to injured tissue helps injury identification by as much as 60%
• HIV PEP regimen Truvada and isentress (pharmacy can help with prescriptions at discharge)
• do NOT accept a transfer of patient for sole purpose of SANE exam

Conference Introduction- Dr Shaw

• Expectations
  • Come prepared
  • Deliver as if you are giving it at a regional/national meeting
  • Stay within time frame given
• Changes to conference for this year ***Full details in e-mail***
  • Will be given 2 days a semester (6 month period) that you can attend via Zoom
    • recurring meeting ID and password in e-mail
    • Please keep camera on during conference
    • Allowed 2 conference days a semester that you can attend via Zoom
    • FOAMed on 3^rd Thursday of each month
    • Will continue journal club during conference
    • EMCAT (the Emergency Medicine Curriculum Assessment Tool)
      • Link in email
      • Eval_Session_ID is the date of the lecture, followed by the presentation title, followed by presenter
      • Evals are anonymous but please keep professional
      • Conference curriculum will be online, link in email (word document will still be sent each month via email)

Sedation in the ED – David Roy, PharmD

• Know dosing, adverse effects, and benefits of the following sedatives:
  • Benzodiazepines
    • Provide amnesia, anxiolysis, and sedation but no analgesia
    • Drawbacks: respiratory depression, apnea, hypotension, variable response
  • Propofol
    • Reduces ICP and has anticonvulsive properties
    • Drawbacks: hypotension, myocardial depression
  • Ketamine
    • Amnestic, analgesic, sympathomimetic properties
    • Utility in pts with asthma/COPD, hypotension, status epilepticus
    • Look for nystagmus as sign achieved dissociation
    • Drawbacks increased secretions, caution in CV disease (hypertension, tachycardia)
  • Etomidate
    • Remember 15 (onset 15 secs, duration 15 minutes)
    • Hemodynamically neutral
    • Drawbacks: adrenal suppression, myoclonus
• Practicing using different agents during residency to get comfortable with them
• If remember RSI dosing, procedural duration doses are typically half and duration typically half as well

How to: Room 9 – Dr. Turner

• Familiarize yourself where equipment and supplies are located
• Examples of types of patients needing room 9: unconscious patients, GSWs(examine head to toe for wounds if rolling out), stab wounds, open fractures, STEMIs, and strokes
• familiarize with level 1 criteria and understand it’s purpose
• Provider roles: as intern -primarily US/procedures, upper level – team leader
• have a system that works for you and do it the same every time
• review imaging as soon as possible on these patients, don’t wait for the radiologist
• if you roll out patient, it is your patient

Transfer of Care, Dr. Platt

• happens more than you think! A patient can have multiple transfers of care for during ED stay
• good TOCs are clear, brief, timely, and complete
• for sample verbal handoff structure, look up IPASS
• use transfer of care note in Cerner at during sign-outs
• watch your tone and bias when talking to consults
• lead/frame the consult the way you want patient care to go
• if consulting medicine, be direct that you are consulting them for “admission”

US Basics, Jessica Kotha

• US generally safe. However, in first trimester, use M mode (not doppler) when calculating fetal heart rate
• linear probe (high frequency ), good for veins, soft tissue, ocular exam
• curvilinear probe (lower frequency) sacrifice resolution for depth, RUSH Exam
• Basic modes: 2-D (B-mode), M-mode (motion), doppler (Color, power)
• types of artifacts (posterior acoustic shadowing, reverberation, mirroring, etc)
• troubleshooting images: try more gel or pressure, adjust depth/gain
• RUSH exam: Heart, Inferior vena cava (IVC), Morrison’s/FAST abdominal views, Aorta, and Pneumothorax (HI-MAP).
• subxiphoid view- most sensitive for pericardial effusion
• familiarize yourself with findings of tamponade (diastolic RV collapse) as well as R heart strain for PE (RV dilation, McConnell’s sign)
• Look for lung sliding AND lung point when looking for pneumothorax
• measure aorta from outer wall to outer wall when evaluating for AAA

Greetings from your friendly emergency medicine department internist! For those of you who don’t know me, I am an internist and medical director of the ED hospitalist service aka “Gold Medicine.” As someone who was completely in love with emergency medicine prior to realizing that I was someone who enjoyed continuity of care (for the most part!), being an internist/hospitalist in this great department is the best thing ever for me. This department is full of incredible faculty, staff, and residents, and you should be proud to be a member of it. You will learn so much, and from good people.

As an internist, I have a perspective that is a bit different from those of the other faculty in this department. I want to be a resource for all of you, as I know internal medicine patients can be quite challenging at times. I would love to know of topics that you would like for me to write about on this blog and/or teach about in didactics. If I approach you with follow up on a patient you admitted to my team, I am doing it because I think it would be a good learning opportunity for you to see what happens after admission, particularly because some of these patients can still be quite ambiguous when you release them to the “upstairs world” (the rest of the hospital, outside the ED) as I call it.

For the new interns, I would like to give you some tips on how to call your internal medicine colleagues for an admission. People generally want to hear the “bottom line up front” (BLUF). When you call for an admission or consult, immediately tell us you that want to admit a patient and for what reason. Then give a concise summary that includes the patient’s age, gender, relevant PMHx, the high points of the patient’s presenting symptoms and events, and relevant labs and imaging. I don’t want to hear about a patient’s normal alk phos or RDW, and if an admitting doc is grilling you on such obscure details, then, well, they are being unreasonable. We do not want to hear a meandering stream of consciousness presentation that leaves us scratching our heads and wondering if you know what is going with your patient, so please be prepared when you call. Be sure to have easy access to any other pertinent information so you can quickly answer questions asked of you. If you remember nothing else from this: BLUF.

One of the best ways to peeve an admitting or consulting physician is to grab them while you see them in the ED and say “Hey I have this patient I need to admit” and then know nothing about your patient as you try to tell your consultant about the patient on the fly. Another way to frustrate an admitting or consulting physician is to call on a non-crashing patient before pertinent labs or imaging are resulted—especially things that could actually change management and even admitting team. Yes, it is important to be efficient, but sometimes you can be premature in calling for an admission and that is not good either.

Remember that until a patient has a bed slip, that patient is your responsibility. Replete that potassium (and please check a Mg++ level in your profoundly hypokalemic patients and replete accordingly). Bolus that patient with DKA who is dry as a bone. Get those antibiotics in that septic patient. Do that LP on the encephalopathic patient with a fever who has no other obvious source of infection. Order the head CT on that encephalopathic patient who you think is in alcohol withdrawal—you’ll catch some subdural hematomas along the way for sure. Place a central line in that shocky patient who needs pressors or inotropes ASAP. Remember that in the ED, you are going to be able to accomplish many patient care tasks much more quickly than will happen on the floor or even in the ICU. You will save lives or at least prevent further morbidity by being proactive.

We are all here to take excellent care of our patients who also happen to be mothers, fathers, brothers, sisters, sons, daughters, fiancés, aunts, uncles, friends, etc. to someone. This can be difficult to remember when a patient is being “difficult,” combative, “non-compliant,” or downright disrespectful—but when this is the case, remind yourself that there is usually a reason they are acting in such a way. As one of my favorite authors, Gregory Boyle, puts it in his book Tattoos on the Heart: “You stand with the least likely to succeed until success is succeeded by something more valuable: kinship. You stand with the belligerent, the surly and the badly behaved until bad behavior is recognized for the language it is: the vocabulary of the deeply wounded and of those whose burdens are more than they can bear.” Those words truly changed my perspective in dealing with these “difficult” patients, and perhaps I can talk about this more in depth at a later date.

Lastly, just remember that we truly are all in this together. Thank goodness there are so many types of docs with different interests, gifts, and talents. Be the better person and always be respectful, even if the person on the other end of the phone is being rude and grouchy. Make friends with your fellow EM residents but also make friends with residents in other specialties; the personal and professional relationships you foster in residency will often last a lifetime and that is just the coolest.

I leave you with the words of Leslie Knope (my alter ego): “What I hear when I’m being yelled at is people caring loudly at me.” I just hope that you don’t get too much loud caring as your intern years begin and as your residencies progress! : )

Until next time,

Dr. McGee