9.6.18 Conference Summary

ED Pharm: Cardiac Arrest Drugs - Christy McKenzie, PharmD

vfib strip.png
  • Pressors

    • Epinephrine

      • Per systematic review and meta-analysis: increased ROSC but not survival to hospital discharge or neurologic recovery

    • Vasopressin

      • No significant benefit compared to epi alone --> removed from algorithm

  • Anti-arrhythmics -- use in cardiac arrest remains controversial

    • Amiodarone

      • No difference in outcomes overall but favorable to lidocaine in survival to hospital admission

    • Esmolol for refractory vfib

      • Increased sustained ROSC but no difference in survival to discharge or neurologic recovery

      • Bolus: 0.5mg/kg, infusion: 0-100mcg/kg/min

  • Thrombolytics

    • Not recommended for undifferentiated cardiac arrest

    • If PE suspected, no consensus

    • Tenecteplase trials - conflicting data for ROSC; no difference in hospital discharge or neurologic recovery

    • Alteplase favored at UHCMC

      • if first dose isn't effective, can give 2nd dose 30 minutes later

  • Adjunct Therapies (none routinely recommended)

    • Sodium Bicarb

      • Consider in presence of hyperkalemia, metabolic acidosis, TCA toxicity

      • Bicarb drip: 150 meq in 1L D5W (bicarb + NS = hypertonic)

    • Calcium

      • No difference in outcomes

    • Magnesium

      • Recommended only in torsades

    • Cyanokit

      • Consider if patient in cardiac arrest pulled from house fire (dose: 6-10g hydroxocobalamin)

    • Potassium not recommended

ice.jpeg

 

Tox Series: Beta Blockers and Calcium Channel Blockers  - Dr. Zean Chen, PGY1

 

pill.jpg

Beta blockers

  • Mechanism of action:

    • Blocks beta receptors in heart (B1) and periphery (B2); lose selectivity at higher doses

    • Decreases gluconeogenesis/glycolysis

  • Effects: hypotension, bradycardia, HYPOglycemia, bronchospasm, CNS depression

  • Special considerations:

    • Propranolol: blocks Na channels --> QRS prolongation --> treat with sodium bicarb

    • Sotalol: blocks potassium channels --> QTc prolongation --> monitor for torsades, can treat with lidocaine

IMG_B02982E86452-1.jpeg
  • Treatment:

    • Resuscitate! Fluids, atropine, pacing, pressers, airway management as needed

    • High dose Insulin Euglycemic Therapy (HIET)

      • Insulin (1u/kg) + dextrose (0.5g/kg dextrose)

    • Glucagon

    • GI decon (charcoal if <1 hr of ingestion, lavage)

    • Phosphodiesterase inhibitor

    • Consider intralipid or methylene blue for refractory cases

 

CALCIUM CHANNEL BLOCKERS

  • Types: dihydropyridine and nonhydropyridine; lose selective at high doses

  • Mechanism of action: binds to slow calcium channels in cell membranes (myocytes, vascular smooth muscle)--> vasodilation, negative chronotropy/inotropy/dromotropy; also suppresses insulin release from pancreas

  • Effects: hypotension, bradycardia, heart block, HYPERglycemia

  • Treatment (similar to BB)

    • Resuscitate! pressors as needed

    • Calcium

    • *HIET, glucagon, intralipid, methylene blue

 

First Trimester Pregnancy Point of Care Ultrasound - Dr. Jessica Rockwood

  • Primary objective: identify IUP

  • Always obtain sagittal and transverse views and fan through; need to see posterior cul-de-sac

  • What confirms IUP ?

    • gestational sac + yolk sac (5-6 wks), fetal pole (>6 wks), fetal heart beat (>6 wks), double decidual sign

    • ***gestational sac alone does NOT equal IUP

iup.jpg

 

  • HCG Discriminatory Zone

    • Obtain pelvic US regardless of HCG level

    • No level is too low to r/o ectopic (ACEP clinical policy)

    • Look for serial increase

  • Pregnancy of unknown location

    • Could be: early normal IUP, ectopic pregnancy, non-viable IUP

    • If stable, need 48 hr follow-up for repeat HCG and US (Beta Book)

    • If unstable, establish large bore IV, resuscitate, T&S, FAST exam, call OB

  • Ectopic pregnancy

    • Tubal pregnancy by far the most common

    • Risk factors: PID, tubal surgery/ligation, advanced maternal age, IUD, prior ectopic

    • Heterotopic pregnancy is rare but still consider; increasing incidence with IVF

    • US findings:

      • Specific: extrauterine GS with yolk sac +/- fetal pole/embryo +/- cardiac activity

      • Nonspecific: free fluid, tubal ring, ring of fire, complex mass

  • Molar pregnancy

    • Complete: high HCG, complex mass/multiple hypoechoic structures

    • Partial: may go unmissed

    • Often associated with other complications in pregnancy

 

EM/Trauma Conference: SIMULATION - Dr. Riley Grosso, Dr. Matthew Stull

  • Patients with significant facial injuries at high risk for inability to protect airway, even if initially intact

    • Anticipate complications and be proactive

  • Consider awake fiberoptic intubation, especially if oropharyngeal blood/edema/disruption of anatomy (DL, VL likely difficult)

    • Ketamine is s good option!

    • Push paralytic once tube is through cords

    • Always have multiple backups (surgical airway)

 

Meta-Cognition - Dr. Riley Grosso 

 

  • Types of thinking

    • System 1

      • Intuitive/automatic; our default

      • Efficient, requires little thought or energy

      • Prone to error and bias

      • Difficult to teach

    • System 2

      • Analytic, methodical, slow, requires conscious effort

      • More reliable

 

Power (Half) Hour - Dr. Andrew Schaub, PGY-3

Case 1. Graves Ophthalmology - proptosis

  • Thyrotoxicosis: clinical hyperthyroidism

  • Thyroid storm -- endocrine emergency

    • Fever ( >106), AMS, cardiovascular instability

    • Treatment: propanolol 1-2mg IV --> PTU (or methimazole) --> KI or lithium 300mg --> hydrocortisone 100mg IV or dexamethasone 2mg IV

Case 2. Pericardial Effusion

alternans.jpg
  • Low voltage, electrical alternans on EKG

  • Common risk factors: malignancy, uremia, inflammatory disease

  • Perform point-of-care ultrasound

  • Pericardiocentesis if signs of tamponade/hemodynamic instability

Case 3. High Pressure Injection Injury

  • High pressure injection injury

    • Often due to glue guns,

    • Initial injury largely superficial and appears mild but tissue damage often subcutaneous and difficult to visualize

    • Requires extensive debridement in the OR

Case 4. Corneal Abrasion

abrasion.jpg
  • Superficial vs deep

  • Proparacaine 0.5% preferred over tetracaine (less initial burning)

  • Update tetanus

  • Consider topical abx, especially if contacts lens use (cover for pseudomonas)

  • Close ophtho follow up

Case 5. Blunt Cardiac Rupture

  • Exceedingly rare

  • Vast majority die shortly after arrival to hospital