Daily Archives: July 5, 2023

7-5-23 Conference Notes

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  • Room 9
    • Generally for “unstable” patients
    • Specific considerations
      • Trauma -> will need a man scan, intoxicated and difficult exam, open fractures
      • Stroke -> 10-minute goal door to CT time
      • Medical – > hypotension, hypoxia, AMS, seizure, shock
      • Sedations, procedures, cardioversion, etc.
    • PGY-1 roles
      • Help transfer from EMS stretcher to bed
      • ABCs, Exposure, Blankets
      • FAST exam -> use the barcode scanner, save clips, END EXAM, clean probe with grey wipe, interpret and sign in Qpath, /bedsideultrasound pulls interpretation into note
        • If penetrating, then start with cardiac view
        • If blunt, then start with RUQ view
    • PGY-2 and PGY-3 roles
      • Consider am I comfortable waiting several hours for their workup to start resulting?
      • Who to keep (trauma) -> man scan?, trustable exam?, vital sign derangements?, fracture/dislocation needing intervention?, elderly fall on thinner and isolated GSW to the extremities are common rollouts but do a thorough exam first
      • Who to keep (medical) -> hypotension, hypoxia, most respiratory intervention, intubated transfer patients are common rollouts
      • Who to keep (stroke) -> mostly keep all of these unless outside of window (>24 hours)
        • Get their last known normal, SBP, glucose, neuro exam, then call stroke attending
      • Level 1 criteria: confirmed SBP <90, respiratory compromise, blood products in route, GSW to the “box”, GCS <9 due to trauma, Emergency Physician discretion
        • Know the gender! Women receive O- blood. Men receive O+ blood
    • Room 9 Bay 1 -> has the most space, rigid stylet for VL intubations
    • Room 9 Bay 3 -> has chest tube and difficult airway cart
  • Buprenorphine in the ED
    • Removal of X-waiver this past year via the MATE Act 2023
    • Opioids -> synthetic in nature like fentanyl
    • Opiates -> derived from poppy so opium, morphine, and codeine
    • Heroin synthesized in 1874 and thought to be safe and less addictive than morphine
    • Methadone
      • Invented in the 1940s and was created to help with opium and morphine shortage
      • Full opioid agonist. Started being used as maintenance therapy. Dispensed as a daily medication because it is a schedule two drug not covered under original DATA legislation, unlike suboxone which is a schedule three drug and is covered
      • Causes prolonged QT. End of T wave finishes greater than ½ the RR interval
    • Opiate Use Disorder (OUD)
      • Specific criteria from DSM-5
      • Withdrawal timeline: symptom peak at 72 hours (nausea/vomiting/diarrhea, etc.)
        • Start suboxone while they are already in withdrawal
        • Use the COWS score to grade withdrawal symptoms
          • Less than 13 is mild, 13-24 is moderate, 25-36 moderately severe, more than 36 is severe withdrawal
    • Buprenorphine
      • Partial agonist for the mu receptor
      • Ceiling effect for pain control, respiratory depression with minimal euphoria
      • Cannot be injected IV (due to naloxone)
      • Minimal side effects and contraindications (acute liver failure)
      • 2% bioavailability of naloxone when taken sublingually, so does not affect buprenorphine absorption
      • Trying to use opioids after taking suboxone is not particularly effective because buprenorphine is saturating receptors
    • Other MAT options
      • Buprenorphine/Naloxone (Suboxone)
      • Buprenorphine (Subutex)
      • Long-acting Naltrexone IM (Vivitrol)
      • Long-acting buprenorphine SQ (Sublocade)
    • Supportive Care for Opioid Withdrawal
      • Ibuprofen or Toradol (pain)
      • Loperamide (diarrhea), Bentyl (abdominal cramps), Zofran (nausea)
      • Clonidine (anxiety/tremors)
    • What dose???
      • Comes in 8mg (buprenorphine)/2mg (naloxone) and 2mg (buprenorphine)/0.5mg (naloxone)
      • Try to start with 8mg on day one, 16mg (8mg BID) day two, etc.
      • Can start at COWS of 8 (with objective signs) or 12 without
      • Can always start with test dose of 2mg. If they get worse, then likely used opioids more recently than they say or withdrawal is not severe enough. If they get better, then safe for higher dose
      • Precipitated withdrawal -> can either do supportive care or give higher doses of suboxone
  • Air Methods
    • Benefits of an air ambulance -> saves time (most benefit when ground time is >1 hr), ability to give blood products, preserves “golden hour” of resuscitation
    • Tools: blood, antibiotics, RSI, TXA, tube thoracostomy, push dose pressors, dual providers
    • Other circumstances: GCS <8, dissecting AA, already on ECMO, LVADs, prone patients (think ARDS), IABP, organ transplant
    • Considerations: weight restrictions, cardiac arrest, combative patient, weather, decon
  • Chaplaincy Services
    • Bad news: any news that adversely and negatively impacts their view of life
    • Basic steps
      • Gather information
      • Provide information
      • Support patient/family
      • Develop a strategy for treatment and care
    • SPIKES also a good mnemonic for breaking bad news, but meant for oncology patients
      • Setting (secure a quiet location)
      • Perception (determine what patient/family already knows)
      • Invitation (clarify information preferences)
      • Knowledge (give the information)
      • Empathy (respond to emotion)
      • Summary (next steps and follow up plan)