7.10.19 Conference Summary

“Peer Review Remix” - Dr. Riley Grosso

There are 2 types of thought processing:
Type 1 Processing:

  • Fast, autonomous, relies heavily on heuristics and therefore is experienced based, multiple Type 1 processes can occur simultaneously.

  • Most of our ED shifts are spent doing type 1 processing but you can toggle between Type 1 and Type 2 processing when thinking about any one patient

Type 2 Processing:

  • Slower, deliberate, rule-based, under conscious control, can only perform one Type 2 process at a time

  • Less prone to cognitive bias

Cognitive Errors: Predictable deviations from rationality.
Type 1 processing is more prone to cognitive errors such as the following:

  • Anchoring

    • Tendency to lock onto features in the patient’s initial presentation and not change one’s impression despite new information

  • Triage Cueing

    • The triage location (fast track vs acute pod) of a patient influences their care

  • Confirmation Bias

    • Tendency to look for confirming evidence to support a diagnosis

  • Diagnostic Momentum

    • A possible diagnosis is assigned to a patient and through the process of turnover/handoff’s, this leads to the inappropriate exclusion of other possible diagnoses

  • Framing Effect

    • The way in which a complaint is presented by another provider/nursing may influence the physician’s thinking


*Frequent participation in the peer review process allows us to review cases using Type 2 processing - this repetitive practice may allow you to transition certain clinical scenarios from requiring Type 2 processing to Type 1 processing in a safer manner.

*Remember to pause and switch from Type 1 to Type 2 processing if you notice that a particular patient scenario places you at risk for cognitive bias.

“How to Lecture” - Dr. Christopher Miller & Dr. Riley Grosso

Prepare

  • Come up with a goal (single, simple statement that clearly and concisely states what you wish to accomplish with your presentation) or short list of objectives.

    • Will help you stay organized and prioritize what you need to include and therefore, what can be deleted.

    • Think about your audience: What is their motivation? What is their incentive to pay attention? What questions will they have?

Practice

  • You need to actually verbalize the lecture, at least twice from start to finish

  • Talk at a pace that feels slow to you

  • Considering practicing in front of both people who don’t know about your topic (so they can focus on your presentation style) and those who are content experts (for feedback on the content itself)

Prune

  • Remember to go back and CUT stuff from your slides (what are the things that do not contribute to accomplishing the initial goal/objectives you set for yourself)

Punctuality

  • Be on time

  • Know your allotted time and end before it

  • Dress better than your audience

Participate

  • Insert engaging slides/stories/audience participation every 5 minutes to reset the audience

Passion

  • Show interest in your topic and ideally, choose to talk about the things that you are passionate about whenever possible

Tips from Dr. Riley Grosso

  1. Make sure the date and audience on the title slide match the lecture that you are actually giving that day if this is a recycled lecture

  2. Minimize animations in PPT presentations as too many things could go wrong. Instead, make a new slide to incorporate the change instead of adding in animations
    *PRO TIP: Start with the final slide and work backwards, deleting as you go & turn off Auto Fit.

  3. Use color changing to highlight a new piece of information while keeping the rest of the information on the screen for those that are tuning in and out and need to catch up

  4. If you have videos, have them open already so that you can just switch to it. You can use “Snag it” to screen shot the portion of the video that you need and imbed it into the PPT. Always be aware of the audio capabilities of where you are presenting if you plan to show a video.

  5. Nothing looks worse than being surprised by your slides

Delivery Methods

  • Power Point

  • Keynote

  • Google slides

  • Always make a PDF backup of your lecture - this is more likely to work on any computer

  • Chalk talks

    • You really need to be a master of the topic in order to have a successful chalk talk because the audience has more control over the talk. You must be extra prepared in order to steer the audience.

  • Prezi

    • Works best for something where you want to highlight a 10,000ft view as well as zooming in and out of the details. Otherwise, it can be nauseating for an audience and is less useful for straight content.

Delivery Adjuncts

  • Audience Response Systems:

    • Poll Everywhere

      • The powerpoint addition needs to be downloaded onto the computer you are presenting on

    • Kahoot

  • YouTube

  • Handouts

  • QR Code adjunct

    • Great for guiding the audience to a specific website or to a file that includes all of your references in an evidence based talk

  • Mendeley

    • Can use on the website, phone app

    • Allows you to store papers in an organized manner

  • Snag it

    • $49.99 in the app store

    • Very user friendly screen shot app

Tips on Getting Feedback About Your Presentation:

  • Identify people to get feedback from prior to the talk and tell them the specific things you want feedback about

    • Will help those people pay attention in a different way. Directed feedback is always easier than general feedback

  • Videotape yourself - you will pick up on your ticks/quirks that you want to correct

  • If you notice that something in your slides didn’t work or there was a mistake, fix that immediately after your lecture for the next time so that you don’t forget


“Atrial Fibrillation: Developing an ED CarePath for discharge” - Dr. Christopher Peluso, EM3/PGY7

Atrial Fibrillation

  • Abnormal focus of impulse causing irregularly irregular rhythm

  • Why do we care?

    • Increased stroke risk

    • Occasionally can make patients unstable

    • Symptomatic A Fib

  • In the US, we admit 67% of patients with atrial fibrillation as a primary diagnosis. In Canada, only 27% of those patients get admitted.

  • We have the potential to save 3 billion dollars if we have a safe way to discharge those patients who are low risk and have primary atrial fibrillation

How to approach safe discharge for those patients in the ED with primary Atrial Fibrillation:

  1. Make sure that all of the following risk factors for poor outcomes in A Fib are either absent or well controlled:

    • Age

    • CHF

    • Obesity

    • Hypertension

    • Diabetes

    • Hyperthyroidism

    • EtOH Abuse

    • Chronic Kidney Disease

    • Cardiomyopathy

  2. Ensure anticoagulation is started when appropriate

    • CHADS2-VASc2

      • Start anticoagulation with a score of 2 in men & 3 in women > these scores correlate with an annual risk of 2.2% of ischemic stroke

CHADSVASC.png

  • HAS-BLED

    • Score 3 or more: Consult with cardiology regarding anticoagulation given that the risk of bleeding is too high (~2% annually)

HASBLED.png

Treatment of primary Arial Fibrillation:

  • Anticoagulation

    • Do they qualify by CHADS2-VASc2 without a HAD-BLED score of 3 or higher?

    • Social determinants are not necessarily prohibitory

    • DOACs are now the preferred form of anticoagulation in A Fib except in:

      • Mechanical heart valves

      • Mitral Stenosis

      • Renal CrCl <30

      • Liver Dysfunction (Child-Pugh Score for Cirrhosis mortality of C)

    • Rate Control

      • Metoprolol

      • Diltiazem

        • Avoid in heart failure with EF <40%

    • Rhythm Control

      • Amiodarone/Digoxin to chemically convert in patients who remain in A Fib with RVR despite attempts at rate control especially with hemodynamic instability

    • Discharge from the ED

      • Provide 30 days of anticoagulation to patients that you discharge from the ED with primary Atrial Fibrillation. They will need to be anticoagulated for 3-4 weeks before attempts at cardioversion by cardiology

      • Control co-morbitiies

      • Control the rate to <110 bpm

      • Avoid discharge if the patient’s symptoms are severe enough to interfere with their activities of daily living

“Dealing with Pressure: Intracranial Hypertension” - Dr. Michael DeGeorgia

  • Intracranial pressure (ICP) = ICP (vascular) + ICP (CSF fluid)

  • Normal ICP = 5-15 mmHg (this is the pressure gradient across the arachnoid villa)

  • Causes of elevated ICP:

    • Space occupying lesions (hematoma, tumor, abscess)

    • Edema of the brain

      • Vasogenic

      • Cytotoxic

        • Caused by ischemia

      • Neurotoxic

        • Due to ionic dysfunction secondary to primary mitochondrial impairment from head trauma that leads to increase in sodium entering the cell and potassium leaving the cell leading to edema in the cells because water follows sodium

    • Increased CSF volume

    • Increased blood volume

  • Measurement of ICP:

    • Extraventricular drain (EVD) inserted into the ventricles

    • Fiberoptic parenchymal catheter inserted into the frontal white matter

  • Cerebral Perfusion Pressure (CPP) is much more important than the actual intracranial pressure

    • CPP = MAP - ICP

    • CPP Goal = 60-70 mmHg (this is the pressure where intracranial blood vessels will auto-regulate to the smallest vessel radius in order to decrease cerebral blood flow and therefore ICP

  • Cerebral blood flow (CBF) follows the Law of Poiseuille meaning that cerebral blood flow is greatly affected by radius of the blood vessels

    • Blood vessels can vasodilate up to a certain point in order to control blood flow

Law of Poiseuille

Law of Poiseuille


Types of intracranial hypertension

  • Global Intracranial Hypertension

    • Leads to a decrease in CPP and therefore a decrease in oxygen delivery and subsequent tissue ischemia

      • Tissue ischemia is the main problem and main cause of poor outcomes in these patients, not herniation

      • Prone to downward herniation

        • Late finding

  • Focal Intracranial Hypertension

    • Leads to midline shift with causes the fibers of the diencephalon to be pulled and deformed in a way that interrupts function and can lead to decreased consciousness

    • Not an issue of oxygen delivery

    • Distortion of Cranial Nerve 3 is what leads to a blown pupil

Treatment of Intracranial Hypertension:

Traditionally we have been taught:

  • Head of the bed up

  • Decrease BP in order to decrease cerebral blood flow

  • Hyperventilation

  • Mannitol or Hypertonic Saline

Ideally, treatment should be personalized based on whether or not the patient is auto-regulating CBF appropriately because if they are:

  • Increasing BP may actually decrease CBF because vessels will vasoconstrict in response to increased BP and this will decrease CBF and subsequently ICP

If an EVD is in place to measure ICP, you can find that individual patient’s ideal mean arterial pressure (MAP) based on their own auto-regulation or lack of.

How can you tell if someone is autoregulating?
- Increase BP -> decrease in ICP = auto-regulation
- Increase BP -> increase in ICP = lack of auto-regulation

Keeping the principals of auto-regulation in mind, our treatment of intracranial hypertension may need to be modified as follows:

  • Head of bed up

    • Patients with intact auto-regulation may benefit from dropping the head of the bed

  • Decrease BP in order to decrease cerebral blood flow

    • Patients with intact auto-regulation may benefit from an increase in blood pressure due to vasoconstriction leading to decreased CBF and therefore decreased ICP

  • Hyperventilation

    • Traditionally used to decrease CO2 and therefore decrease cerebral blood flow

    • Should be used as a last resort in patients who are deteriorating in front of you and on their way to the OR

    • In certain cases, hyperventilation leading to decreased cerebral blood flow may actually worsen outcomes by decreasing delivery of O2 (especially when diffusion of O2 in the brain is low)

  • Mannitol

    • Raises serum osmolarity, which draws water into the systemic circulation. This will dilute the mannitol itself so it’s effect is only transient (lasting about 1 hour)

    • Use of mannitol can lead to systemic dehydration from diuresis, which can lead to decreased CPP

  • Hypertonic Saline


TREATMENT SUMMARY:
- Maintain ICP <20 mmHg
- Focus on CPP goal of 60-70 mmHg rather than the exact ICP
- Sedation/analgesia +/ paralysis
- Target normal oxygen, normal CO2
- CSF drainage with EVD whenever possible (be aware of the fact that doing this could worsen mid-line shift if you have a unilateral elevation in ICP due to space occupying lesion)
- Hypertonic Saline (3% gtt or 23.4% bolus to target Sodium of 150-160 mEq/L
- Judicious use of Mannitol
- When all else fails -> proceed to decompressive craniectomy