Conference Notes 5-29-2012

GRIPPO-FELDER ORAL BOARDS

Case 1:  Borhaave’s Esophogus.    Consider PE, consult surgery, start broad spectrum antibiotics.    Pregnancy and ETOH are risk factors for esophageal rupture.   Don’t do a barium swallow because  arium is not good for the mediastinum.  Gastrograffen is preferred to evaluate with a swallow study or chest CT.

Harwood comment: If you see mediastinal air or air in soft tissue either on CXR or CT with this symptom complex, just consult surgery and start antibiotics.   The ER doc doesn’t need to order an esophogram.

Case 2: Lyme Disease.  Recognize erythema chronicum migrans, treat with doxy  for kids over 8 and non-pregnant.  21 day course of doxy, amoxicillin, cefuroxime, or macrolide.   Tick has to be on the patient for 36 hours to transmit disease.

Harwood comment:  For oral exam with non-critical/toxic patient you don’t have to put an IV in. You may get scored down for system based practice.  Think out loud so the examiner knows what you know.

Case 3: Polytrauma.  Cspine immobilization, secure airway, chest tube, re-assess vital signs.   Always remember to get complete set of vitals including accucheck glucose and UCG.  Ask for family/paramedics. Treat pain. Be systematic in your exam for injuries.

BOLTON   FUTILITY

Decisions: Respect the patient’s autonomy.  The decision should be impartial and follow the Golden Rule (treat others as you would want to be treated) or Platinum Rule (treat other as they would want to be treated).   Universable=categorical imperative=moral act that is always right in the same situation.  Interpersonal justification=would you be comfortable with your decision if it is written in the newspaper?   

Futility= action that has no useful purpose.   AMA CEJA: there is no accepted definition of medical futility.

80% of persons die in a medical environment.  People prioritize quality of life, touch of family at the time of death.  They don’t prioritize prolongation of life at any cost.

Futility problem: patients and families have unreasonable expectations of the capacity of medical care to return the patient to prior state of health.   This is based on peoples exposure to TV and movies  where CPR and ICU care provide miracle saves.   Physicians have a lot of difficulty prognosticating to patients and family with the goal of lower expectations.   We frequently abandon patients/families to their own autonomy. (Do what you think is best).

We should help families/patients understand their goals prior to making end of life decisions.

You don’t have to be a DNR patient to be in hospice.  It is however somewhat contradictory philosophically.  The criteria for hospice is only an expected life span of less than 6 months.

Pt’s don’t have the right to demand treatment.  Beneficence: CPR has 0% chance of survival with metastatic neoplasm admitted to the hospital.  Justice: Fair resource allocation.

Harwood comment:  After every successful resuscitation, look for the underlying cancer.

Girzadas comment:  The EP can also factor in the pain or  lawsuit  that may  impact the treating physician from the family.

Barounis comment:   Recent case in ER having to decide whether to give post-resuscitation hypothermia in a young patient with metatstatic cancer who had ROSC following CPR. Some ICU personnel complained that the ER staff should not have cooled the patient.    Everyone agreed that the case was extraordinarily difficult.   Most agreed that if pt was not DNR and resuscitation was done and had ROSC then  you have to give hypothermia therapy.    

Willison comment:  The LET form is very imperfect.   Most people at the lecture agreed that the multiple check box format brings up ethical inconsistencies.

WILLISON/SALZMAN  TRAUMA RESUSCITATION

Be sure to use personal protection like masks/eye shields/gloves/gowns/shoe covers.

Try to organize your team as much as possible.

Abnormal vitals, pregnant patients, elderly, another fatality, fall over 20 feet, auto vs. ped are all prearrival markers for badness.

To intubate, loesen c-collar but have a second person hold in line stabilization until tube is secured.  Then re-apply the collar.

New info:  28 or 32 FR tube was no better or worse than 38 or 40FR tube.

Don’t  “rock the pelvis”  just give one firm push on the ASIS bilat. If it moves it is fractured.

Fix scalp lacs. Patients can bleed severely and even  rarely bleed to death.  Tourniquets (BP cuff at 300mm hg) can sometime be life saving but use these rarely and cautiously.

When transfusing large volume of prbc’s, match units of prbc’s, ffp and possibly platelets.

Positive FAST scan, Systolic <90, HR>120, penetrating injuries: 3-4 of these are high risk for needing massive transfusion.  1 probably not.

Penetrating wounds to abdomen/flank/low back/pelvis require rectal exam.  Other injuries you can be more selective with rectal exams.

Keep patients warm in ER.

New Thoughts from Scott Weingart for Traumatic Arrest: No closed chest CPR, no acls meds, first airway is LMA, bilat finger thoracostomy, cardiac ultrasound looking for tamponade.

Salzman comments: ED thoracotomy only good for penetrating chest wounds (optimally stab wound to heart) that cause tamponade.  Heart is very delicate and it can be easily damaged by a scalpel or by fingers during internal CPR.   ED thoracotomy  for blunt trauma is futile.

Can consider ED thoracotomy to cross clamp aorta for a patient who has exsanguinated from a limb amputation.  Give patient rapid prbc transfusion and do cardiac massage.

Harwood comment: It’s a thought.

Barounis comment/Salzman response: Massive transfusion protocol for untable, hypotensive pelvic fractures should be started in ED.      Pt’s with other types of injury, the protocol  has to be used more judiciously.   If the protocol is initiated you can always back off if bleeding lessens.  Patients that need to go to IR are more likely to need the protocol than patients going directly to OR.   Level 1 transfuser is a critical tool during resuscitation.

FORT   5 SLIDE F/U

Poly drug overdose including TCA.   PT was agitated.   Intubated, sedated with propofol.   Toxsicon recommended charcoal, serial ekg’s and bicarb for QRS >100ms.   Initial ekg was ok/not wide/no terminal prolongation of QRS (big R wave) in AVR.   Remained stable over 16 hours in ER.   Was extubated and transferred to psychiatry.

TCA: sodium channel block, antihistamine,  anti-muscarinic, K efflux blockade, alpha blocker, and gaba blockade effects.  “Dirty Drug”   has multiple effects.   

Treatment: Seizures give Benzos.   Hypotension give fluids and pressors.   QRS prolongation give sodium bicarb.   Dialysis is worthless due to high volume of distribution.

Harwood comment: Bicarb is the main treatment for EKG abnormalities.   Brian said if bicarb not helping  consider magnesium.

HERRMANN  5 SLIDE F/U

Child with GSW to right thigh.  Pt had right femoral arterial injury.  Hard signs with loss of distal pulses and pulsatile bleeding. Pt also had abnormal ABI’s.  CTA showed injury to femoral artery.   Prbc’s transfused.  Pt went OR.   Surgeons used saphenous vein from contralateral leg in reverse orientation (to negate the venous valves) to fix artery. 

ABI has 98% diagnostic accuracy.   Measure BP in all 4 extremities.   Divide ankle systolic BP by higher of two upper extremity systolic bp’s.   ABI<0.9 is abnormal and pt should get CTA or go to surgery.

Hard signs: abnormal pulse, arterial bleeding, pulsatile hematoma, bruit, thrill, distal ischemia.

Barounis comment: Vascular injury signs can wax and wane.  These patients are tricky.  Need re-exams if the initial decision is to observe so not to miss developing hard signs.

Chastain comment:  Compartment syndrome has been known to develop on trauma patients after the initial injury.  Stay alert even if you are tired.

KESSEN  RSI DRUGS

Pre-treatment: moderates reflexic sympathetic response to laryngoscopy.  Phayrnx and larynx are highly innervated with sympathetic and parasympathetic nerves.  LOAD:  Lido (no study shows neuro outcome improvement/Opioids (fentanyl  can be considered for pain) /Atropine (for kids <5yo getting succ)/

Nelson comment: Contrarian view is that all these pretreatment drugs increase complexity and delay intubation.

Etomidate is most hemodynamically neutral sedation drug.  Consider Ketamine as an alternative in the septic shock patient to avoid adrenal suppression.

Ketamine provides anesthesia and analgesia.   Increases cerebral blood flow.  May increase BP.  It is a bronchodilator.  May elevate ICP.   Watch out for emergence phenomenon.

Propofol causes anesthesia and amnesia.  May cause hypotension.  No analgesic properties.

Versed provides anesthesia/amnesia but not analgesia.   Can cause hypotension.

Barbiturates can provide anesthesia/amnesia and analgesia.   Hypotension.  Suppresses WBC function/recruitment.

Succinylcholine contraindicated in patients who have had  severe trauma,  burns, neuro injury  all more than 72 hours prior to ED visit.  These are not a problem if insult occurred the day of ED presentation.

Mistry comment:  Many absolute contraindications to succinylcholine are actually relative contraindications and succ is pretty safe.

Rocuronium has less than 1 minute onset. Intubation conditions are similar to succinylcholine.

Sugammadex is a reversal agent for rocuronium that is being tested in Europe.  Cuts the spontaneous ventillarion time from 400s to about 200s.

Harwood comment: Kid with severe astha, “Your risk of killing this patient is going up and up”    Use etomidate, atropine to decrease secretions, and succinylcholine if airway is not  predicted to be overly difficult.