Category Archives: UL EM Residency

Conference 07/14/2021

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RSI Pharmacology – Jade Daugherty, PharmD

Sedatives

Etomidate:
– Does not inhibit sympathetic tone or myocardial function. Minimal BP and HR changes|
– RSI: 0.3 mg/kg; Procedural sedation 0.1 – 0.2 mg/kg
– Onset 30 – 60 seconds; Peak 1 minute; Duration 3 – 5 minutes
– Can see myoclonus, dose dependent, can be blunted w/ opioids and benzos. Resolves upon paralysis. May cause difficulty w/ procedural sedation.
– Other adverse effects: N/V, lowers sz threshold, mild decrease in IOP and ICP, adrenal suppression (single dose can cause effects for 24 – 72 hrs)
– Consider avoiding Etomidate in Sepsis patients (see CORTICUS trial)

Ketamine:
– Analgesic and amnestic properties
– Nystagmus with amnestic doses
– RSI: 1 – 2 mg/kg
– Exerts sympathomimetic effects: increased HR, BP, CO by lessens reuptake of catecholamines. May not see this in catecholamine depleted patients
– Also causes bronchodilation and anticonvulsant effects

Propofol:
– Short acting sedative hypnotic that enhances GABA activity
– No analgesia; amnestic effects
– Onset 30 sec; Duration 3-10 min
– RSI 1 mg/kg
– Safer in pregnancy
– Adverse effects: hypotension
– Decreased cerebral O2, decrease in IOP and ICP, bronchodilation and anticonvulsant effects

Benzos:
– No analgesia. It does possess anxiolysis, anterograde amnesia, anti-convulsant properties
– Onset 2 – 3 min; Duration 45 – 60 min
– Midazolam preferred: RSI 0.1 – 0.3 mg/kg

Paralytics

Depolarizing Blockers – Succinylcholine:
– Be aware of hyperkalemia; therapeutic dose can raise serum potassium 0.5 – 1 mEq/L
– Consider avoiding in burns and crush injuries (delayed rise in serum K), as well as ESRD on HD, sepsis
– Small increase in ICP
** Special considerations: may require higher doses in Myasthenia gravis
** Pseudocholinesterase deficiency -> results in prolonged paralysis (several hours). NDMB (Roc/Vec) are safe for use

Rocuronium – non-depolarizing neuromuscular blocker:
– Dose 0.6 – 1.2 mg/kg (~1.0 mg/kg)
– Onset 60 – 90 seconds; Duration 30 – 60 minutes

Vecuronium – non-depolarizing neuromuscular blocker:
Needs to be reconstituted
– Dose 0.08 – 0.1 mg/kg (~ 0.1 mg/kg)
– Onset 2 – 3 minutes; Duration 25 – 45 minutes

If you use the longer acting paralytics, sedate appropriately

Guide to Pediatric ED – Dr. Penrod
– EPIC Order Sets: “Peds ED Treatment ____”
Examples: Neonatal Fever (0 – 7 d, 7 – 28 d, > 28 d), Sepsis, Status Epilepticus, Asthma, NAT, Trauma, DKA, more

– Discharge teachings: Get dot phrases from other attendings (i.e. Sandy Herr)

– Admission: bed request > .admitresidentnotification > TigerText (login: phys___@Norton) > ask admit resident when they call if it is ok to put in “ready for dispo” order

– Tylenol 15 mg/kg q6 hrs; Ibuprofen 10 mg/kg q 6 hrs – can alternate q3 hrs
– Versed: PO 1 mg/kg/dose, IN 0.2-0.3 mg/kg/dose, IV 0.1 mg/kg/dose
– CTX: Meningitis 50mg/kg/dose q12hrs, non-meningitis 75 mg/kg/dose daily
– Amox: 50 mg/kg/day, daily for GAS pharyngitis; 90 mg/kg/day divided BID for PNA and AOM

– IVF bolus: 22 cc/kg over 1 hr
– mIVF “4-2-1”: 4 cc/kg/hr for first 10 kg, 2 cc/kg/hr for second 10 kg, 1 cc/kg/hr for each additional kg

Abdominal Ultrasound – Dr. Baker
RUQ US: just below the R costal margin, or X minus 7 mm (7 mm to right of xiphoid process)
Maneuvers to assist: deep breath, left lateral decub
Portal triad (portal vein, hepatic artery, CBD < 7mm normal & > 10 mm + 1mm/decade life abn) makes an exclamation point w/ GB

Cholecystitis: gallstones, anterior* wall > 3mm, sonographic Murphy’s, pericholecystic fluid

Choledocolithiasis: “double barrel” sign

*important to measure anterior wall as posterior acoustic enhancement makes the posterior wall appear thicker due to fluid filled structure enhancing conduction of sound waves

SANE Lecture – Amanda Corzine, MSN, SANE-A
Assault exams/kits done within 96 hours/4 days, sometimes up to 5 days
All male/females 12 yrs and older

Center for Women and Familes (CWF) respond to SA and DV victims as an advocate

Patient may choose to report or not to police. Kit will be destroyed in 1 year if they choose to not report.

Dry swabs for wet surfaces, wet swabs for dry surfaces. Don’t package wet evidence, allow it to fully dry.

Place swab in envelope cotton part down. Do not lick envelope.

EMS Radio Calls Part 2: Dr. Orthober
– Discontinuing IV after Dextrose given: is patient now AAOx4, decisional, clear reason for hypoglycemia, have family members

Hypothermia

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Patient presents in cardiac arrest. Found outside on Broadway (all hypothetical). While moving him into EMS truck, patient lost pulse, went into cardiac arrest. Multiple defibrillation and code drugs later, patient maintained to be in v fib. Presents intubated, GCS 3T. On quick secondary survey, patient cold to touch and mottled/cyanotic extremities. ET tube confirmed by auscultation and chest rise. Chem 8 shows nl K, other labs unremarkable. Rectal temp unable to read. Bladder temp reads 75. Go.

We’ve learned some hallmarks of rewarming cardiac arrests. The main point to come is that it will be a slow process that takes a ton of resources. You can find the grading system of hypothermia online; however, here we are specifically talking about severe hypothermia <28C without vitals. Here are my following recommendations:

  1. Have plenty of people in line to do chest compressions, unless you can swipe a Lucas machine from EMS
  2. Start active rewarming early, as it takes a very, very long time. We used the gaymar blanket below the patient, applied the ARCTIC SUN (typically used to cool post cardiac arrest, but can also warm), bear hugger. This sounds like a lot but you will be surprised that this may only warm the body 1-4 C an hour if you are lucky. Keep a temperature sensing foley in or use the one on the Arctic sun. CONTINUE CHEST COMPRESSIONS.
  3. According to Tintinalli’s you can give up to 3 doses of code drugs/defibrillations until above 80. I’ve seen places in the literature to not start shocking again until you have them above 80 degrees and some say as high as 32 C (89F).
  4. Start prepping for more advanced warming. Hypothetically if you were in a place that has ECMO, you would send them straight there as that has the quickest rewarming period of all interventions. However, if you do not have ECMO, then proceed to other means. When doing chest tubes, we preferentially avoided to L side as we were continuing chest compressions and placed 2 on the R side. One anterior mid clavicular line at 2nd intercostal and the other large bore tube on posterior axillary line at 4th/5th. Theoretically I always imagined a closed circuit to continuously reuse and pump warm water in. This was not the case. You can use the rapid transfuser to warm  1L NS and let it run to gravity into the anterior chest tube while clamping the posterior tube, Keep 500cc to 1L in the chest for 15 minutes then let it run into the atrium and bolus another 500cc in. KEEP A TAB ON THE AMOUNT OF FLUIDS GOING IN AS WELL AS OUT. You can also place an NG tube and put war m(40-42C) fluid into the stomach for rewarming. 500cc-1L in the bladder Q15-20 minutes.
  5. Once they get to able 80-ish degrees you may see some change on end tidal or rhythm strip itself. Now begin your regular ACLS, but keep rewarming.
  6. There isn’t much to be found on whether or not to continue with code drugs during the sub 80F. Tintinalli’s is vague on it as well as they note to continue with if it seems to be working. I would opt not to fluid them with epinephrine until you get the body warmed and some warm blood flowing.

Overall: the old adage holds up. “They are not dead until they are warm and dead”

  1. Place a foley for temp
  2. Get Chem 8 to see if resuscitation viable (K>12=not viable)
  3. See if ECMO available
  4. Get med students or a LUCAS machine
  5. Start passive and active rewarming immediately

Sources: Tintinalli’s

Spaced Repetition

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21st century learning. This is a follow up and an expansion on what Martin touched on the other day. There will be a separate post that follows with an easy means of implementation.
Background information:
http://en.wikipedia.org/wiki/Forgetting_curve
http://en.wikipedia.org/wiki/Spaced_repetition
Or skip to a Life in the fast lane post which provides similar info:
http://lifeinthefastlane.com/2011/11/learning-by-spaced–repetition/
A Wired magazine article on spaced repetition software:
http://www.wired.com/medtech/health/magazine/16-05/ff_wozniak?currentPage=all
A review of spaced recall with numerous citations:
http://www.gwern.net/Spaced%20repetition
A department of education report illustrating the implementation of spaced repetition:
http://ies.ed.gov/ncee/wwc/pdf/practice_guides/20072004.pdf
Free open source, cross platform, spaced repetition software, Anki:
http://ankisrs.net/
A guide to making flashcards for effective spaced repetition:
http://www.supermemo.com/articles/20rules.htm
A couple general articles on spaced repetition:

Donovan, J. J., & Radosevich, D. J. (1999). A meta-analytic review of the distribution of practice effect: Now you see it, now you don’t. Journal of Applied Psychology, 84(5), 795-805.

Stahl SM, Davis RL, Kim DH, Lowe NG, Carlson RE, Fountain K, Grady MM. Play it Again: The Master Psychopharmacology Program as an Example of Interval Learning in Bite-Sized Portions. CNS Spectr. 2010 Aug;15(8):491-504. PMID:20703196.

Several articles by a Harvard Urologist about the implementation of spaced repetition in medical education:

1: Kerfoot BP. Adaptive spaced education improves learning efficiency: a
randomized controlled trial. J Urol. 2010 Feb;183(2):678-81. doi:
10.1016/j.juro.2009.10.005. PubMed PMID: 20022032.


2: Kerfoot BP. Interactive spaced education versus web based modules for teaching
urology to medical students: a randomized controlled trial. J Urol. 2008
Jun;179(6):2351-6; discussion 2356-7. doi: 10.1016/j.juro.2008.01.126. Epub 2008 
Apr 18. PubMed PMID: 18423715.


3: Kerfoot BP, DeWolf WC, Masser BA, Church PA, Federman DD. Spaced education
improves the retention of clinical knowledge by medical students: a randomised
controlled trial. Med Educ. 2007 Jan;41(1):23-31. PubMed PMID: 17209889.


4: Kerfoot BP, Brotschi E. Online spaced education to teach urology to medical
students: a multi-institutional randomized trial. Am J Surg. 2009
Jan;197(1):89-95. doi: 10.1016/j.amjsurg.2007.10.026. Epub 2008 Jul 9. PubMed
PMID: 18614145.


5: Kerfoot BP, Fu Y, Baker H, Connelly D, Ritchey ML, Genega EM. Online spaced
education generates transfer and improves long-term retention of diagnostic
skills: a randomized controlled trial. J Am Coll Surg. 2010
Sep;211(3):331-337.e1. doi: 10.1016/j.jamcollsurg.2010.04.023. Epub 2010 Jul 13. 
PubMed PMID: 20800189.

Science of Learning

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To all the new interns:

You are starting a new phase of your education. One that is largely self directed. We have our core texts, Rosen’s, Tintinalli’s, and Harwood-Nuss, which you will pick one of and begin to work through. We also have the supplemental, but extremely mandatory books like Robert’s and Hedge’s Procedures in Emergency Medicine. This post is a suggestion to add one more book up front and potentially make your time reading more valuable.

Make It Stick

 

The purpose of this post is to save you from wasting hundreds of hours reading and rereading to find that little has stuck at the end of it. The pre-eminent point of this book is that recall trumps repetition. Actively trying to remember is a hundred fold more productive than rereading.

Here’s a quick summary of other points:

  • Learning is deeper and more durable when it’s effortful. Learning that’s easy is like writing in sand, here today and gone tomorrow.
  • We are poor judges of when we are learning well and when we’re not. When the going is harder and slower and it doesn’t feel productive, we are drawn to strategies that feel more fruitful, unaware that the gains from these strategies are often temporary.
  • Rereading text and massed practice of a skill or new knowledge are by far the preferred study strategies of learners of all stripes, but they’re also among the least productive. By massed practice we mean the single-minded, rapid-fire repetition of something you’re trying to burn into memory, the “practice-practice-practice” of conventional wisdom. Cramming for exams is an example . Rereading and massed practice give rise to feelings of fluency that are taken to be signs of mastery, but for true mastery or durability these strategies are largely a waste of time.
  • Retrieval practice—recalling facts or concepts or events from memory— is a more effective learning strategy than review by rereading. Periodic practice arrests forgetting, strengthens retrieval routes, and is essential for hanging onto the knowledge you want to gain.
  • When you space out practice at a task and get a little rusty between sessions, or you interleave the practice of two or more subjects, retrieval is harder and feels less productive, but the effort produces longer lasting learning and enables more versatile application of it in later settings.
  • Trying to solve a problem before being taught the solution leads to better learning, even when errors are made in the attempt.
  • People do have multiple forms of intelligence to bring to bear on learning, and you learn better when you “go wide,” drawing on all of your aptitudes and resourcefulness, than when you limit instruction or experience to the style you find most amenable.
  • When you’re adept at extracting the underlying principles or “rules” that differentiate types of problems, you’re more successful at picking the right solutions in unfamiliar situations. This skill is better acquired through interleaved and varied practice than massed practice.
  • In virtually all areas of learning, you build better mastery when you use testing as a tool to identify and bring up your areas of weakness.
  • Elaboration is the process of giving new material meaning by expressing it in your own words and connecting it with what you already know. The more you can explain about the way your new learning relates to your prior knowledge, the stronger your grasp of the new learning will be, and the more connections you create that will help you remember it later.
  • Rereading has three strikes against it. It is time consuming. It doesn’t result in durable memory. And it often involves a kind of unwitting self-deception, as growing familiarity with the text comes to feel like mastery of the content.
  • It makes sense to reread a text once if there’s been a meaningful lapse of time since the first reading, but doing multiple readings in close succession is a time-consuming study strategy that yields negligible benefits at the expense of much more effective strategies that take less time. Yet surveys of college students confirm what professors have long known: highlighting, underlining, and sustained poring over notes and texts are the most-used study strategies, by far.
  • Rising familiarity with a text and fluency in reading it can create an illusion of mastery. As any professor will attest, students work hard to capture the precise wording of phrases they hear in class lectures, laboring under the misapprehension that the essence of the subject lies in the syntax in which it’s described. Mastering the lecture or the text is not the same as mastering the ideas behind them . However, repeated reading provides the illusion of mastery of the underlying ideas. Don’t let yourself be fooled. The fact that you can repeat the phrases in a text or your lecture notes is no indication that you understand the significance of the precepts they describe, their application, or how they relate to what you already know about the subject.

Summary above from: https://rkbookreviews.wordpress.com/2014/06/06/make-it-stick-summary/

I’ve made sure everyone has access to this book. If anyone has any questions, feel free to email me.

Rosen flashcards

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8400 flashcards based on the 7th Edition of Rosens Emergency Medicine Concepts and Clinical Practice.

The flash cards are attached. Here is the site I got them from:

A post on how to use them with anki:
A post on ‘Life in the Fast Lane’ on the use of anki in EM:
An alternative method for someone who doesn’t want to get into flashcards or the software but would like a good study guide, the text files can easily be turned into tables for quick review. I attached an example.
If anyone has any questions, let me know.

January Admin Project

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Most of you that have done admin work or paid attention to trends in DED, you probably have noticed that many months the majority of deaths in the ED stem from catastrophic brain damage, from both traumatic or spontaneous causes.  Over 80% of my DED’s were related to severe neuro injury, so I looked at some of our common practices in handling head injuries and spontaneous bleeds and very quickly noticed that we don’t really follow any consistent patterns in caring for these folks.

Many of these patients have non-survivable injuries no matter what we do, however there are some simple interventions that might be beneficial to some cases.  For instance, elevating the head of the bed >30 deg (but not more than 40) can drop ICP by 8-10mmHg, and loosening or removing an unnecessary c-collar can actually further decrease ICP by 2-5 mmHg.  These are all evidence based, and while only effecting small changes, could help improve some patient’s outcomes.  In addition, in discussing this with Neurosurg faculty and looking at the literature, our practice of pre-medicating head injury patients with Lidocaine is based on an old, underpowered and poorly applicable study, that used only 20 patients with known brain tumors, and is really not proven or necessary.

The following are some suggestions in dealing with Neurosurgical cases.  These are practice parameters, and should be considered with every case, but this is not something that will be made standard of care, as each case should be handled appropriately at the individual physician’s discretion.  However, if these interventions are not implemented, Dr. Coleman and Dr. Nauta both recommended documenting your rationale in your MDM.  Also, the studies that support these practices, and some of the poorly done studies that are the basis for some of our current practices, are listed.

 

Increased Intracranial Pressure Protocol

Level 1
Elevate Head of Bed (30 – 40°)
Check C-collar Fit, remove as soon as possible (can ↓ ICP 2 – 5 mm/Hg, collar not necessary in isolated GSW to head, and coexistent c-spine injury rare)
Temp Normal (maintain < 98.0°F)
PaCO2 35-38 mmHg (based on EtCO2 or ABG)
Control Pain/Sedation Package if Intubated (Fentanyl)
Pre-intubation Lidocaine (100mg IV) only if known tumor
Urgent Neuro Imaging
Ocular Ultrasound (Optional, do not delay definitive imaging)

Level 2 – Perform in conjunction with NES consult
Osmotic Therapy*
Mannitol – 1g/kg over 10 minutes (if hypertensive)**
Hypertonic Saline 3% – 250mL over 10 – 15 minutes (if normo or hypotensive)***
Sodium Bicarb (2 amps over 10 minutes)****
Foley catheter, replace fluid losses
Normal Saline 0.9% (No LR, D51/2NS, etc.)
Maintain Na ~ 150
Phenytoin load (15 – 20 mg/kg) only in patients with seizure or posturing
Steroids only in the case of known tumor

*Normal physiologic osmolarity range is approximately 280 to 310 mOsmol/L.
**Osmolarity of Mannitol is 550 mOsmol/L.
***Osmolarity of 3% saline is 1027 mOsmol/L
****Osmolarity of 2 amps NaHCO3 in NS is 1790 mOsmol/L

Level 3 – Perform in conjunction with NES consult, requires ICP monitoring
Propofol (or Phenobarb) gtt titrated to low levels of sedation scales (50-200 mcg/kg/min)
BIS monitoring
CPP Optimization (CPP= MAP – ICP) greater than 55 – 60

Level 4 – Only NES/NeuroAnesthesia applicable
Decompressive Craniectomy
Induced Hypothermia
Pentobarb coma (burst suppression)
Moderate Hyperventilation (Reserved as temporizing measure for patients actively herniating)

HOB
Feldman Z, Kanter MJ, Robertson CS, et al. Effect of head elevation on ICP, CPP, and CBF in head-injured patients. J Neurosurgery. 1992;76:207-211.

Ng I, Lim J, Wong HB. Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurg.2004;54:593-598.

Rosner MJ, Coley IB. Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg. 1986;65:636-641.

Moraine JJ, Berre J, Melot C. Is cerebral perfusion pressure a major determinant of cerebral blood flow during head elevation in comatose patients with severe intracranial lesions? J Neurosurgery. 2000;92:606-614.

C-Collar
Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein dimensions.  Acad Emerg Med. 2010 Jan;17(1):100-2.


Mobbs RJ, Stoodley MA, Fuller J.  Effect of cervical hard collar on intracranial pressure after head injury.  Aust J Surg. 2002 Jun;72(6):389-91.

Temp
Shiozaki T, Hayakata Taneda M, et al. A multicenter prospective randomized trial of the efficacy of mild hypothermia for severely head injured patients with low intracranial pressure.JNeurosurg. 2001;94:50-54.

Clifton GL, Miller ER, Choi SC, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344:556-563.

Metz C, Holzschuh M, Bein T, Woertgen C, et al. Moderate hypothermia in patients with severe head injury: cerebral and extracerebral effects. J Neurosurg. 1996;85:533-541.

Marion, DW, Penrod, LE, Kelsey, SF, et al. Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med. 1997; 336:540-546.

Polderman KH, Joe RTT, Peerdeman SM, Vandertop WP, Girbes ARJ. Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med. 2002;28:1563-1573.

Resp Rate
Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. 1991;75:731-739.

Newell DW, Weber JP, Watson R, Aaslid R, Winn HR. Effect of transient moderate hyperventilation on dynamic cerebral autoregulation after severe head injury. Neurosurg.1996;39:35-43.

Diringer MN, Yundt K, Videen, TO, et al. No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury. J Neurosurg. 2000;92:7-13.

Muizelaar JP, Van Der Poel H, Li Z, Kontos HA, Levasseur JE. Pial arteriolar vessel diameter and CO2 reactivity during prolonged hyperventilation in the rabbit. J Neurosurg. 1988;69:923-927.

Osmotics
Smith HP, Kelly DL, McWhorter JM, Armstrong D, et al. Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg. 1986;65:820-824.

Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline in the treatment of severe refractory post traumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med. 2000;28:1144-1150.

Peterson B, Khanna S, Fischer B, Marshall L. Prolonged hypernatremia controls elevated ICP in head-injured pediatric patients. Crit Care Med. 2000;28:1136-1143.

Simma B, Burger R, Falk M, et al. A prospective randomized, and controlled study of fluid management in children with severe head injury: lactated ringer’s solution versus hypertonic saline. Crit Care Med. 1998;26:1265-1270.

Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma. 2001;50:367-383.

Quereshi AI, Suarez JI, Bhardwaj A. Malignant cerebral edema in patients with hypertensive intracerebral hemorrhage associated with hypertonic saline infusion: a rebound phenomenon? J Neurosurg Anesthesiol. 1998; 10:188-192.

Sedation and Paralysis
Hsaing JK, Chestnut RM, Crisp CB, et al. Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary. Crit Care Med. 1994;22:1471-1476.

Temkin NR, Dikmen SS, Wilensky AJ. et al. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990;323:497-502.

Pittman T, Bucholz R, Williams D. Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head injured children. Pediatr Neurosci. 1989;15:13-17.

Goodman JC, Valadka AB, Gopinpath SP, et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma. 1996;13:549-556.

Ward JD, Becker DP, Miller JD, et al. Failure of prophylactic barbiturate coma in treatment of severe head injury. J Neurosurg. 1985;62:383-388.

Cruz J. Adverse effects of pentobarbital on cerebral venous oxygenation of comatose patients with acute traumatic brain swelling: relationship to outcome. J Neurosurg.1996;85:758-761.