8.30.18 Conference Summary

Burnt and Blasted - Dr. Jacob Avila

Heat Related Illness

    • Heat stress: Flushed, hot, and lightheaded
      • Not clinically significant unless significant co-morbidities
    • Heat exhaustion: more severe than heat stress and can include significant sweating and tachycardia 
    • Heat stroke: Temp >40.6 + Altered mental status + anhidrosis
      • Temperature regulated by the hypothalamus; once temperature set point is crossed, sweating occurs; once a we lose the ability to sweat, the brain and heart begin to decompensate (high output cardiac failure and brain swelling can develop) 
      • Liver injuries are common in heat injuries; if concerned for heat stroke but no evidence of transaminitis on labs, unlikely heat stroke
      • Diffuse inflammatory picture similar to sepsis can occur with hypotension and vasodilation
      • Treatment: rapid cooling to goal <39 degrees celsius; may require aggressive active cooling with intra-peritoneal or intra-thoracic lavage with cooled fluids 
heat stroke.jpg

 

Cold Related Injuries

  • Trench foot: prolonged expose to damp, non-freezing conditions leads to localized, superficial swelling and pain (typically involves the dorsum of the feet) 
  • Chillblains (aka Pernio): similar to vasculitis with deeper skin irritation and more pain 
Chillblains

Chillblains

    • Frostnip: superficial, non-freezing cold injury leading to vasoconstriction and pain with paresthesias of the digits
    • Frostbite: freezing temperatures cause ice crystal formation within the extracellular tissue, resulting in necrosis 
      • Duration of injury is most important contributing factor
      • Risk factors: alcoholics, mentally disabled, winter MVCs 
      • Skin injury will only occur if temperature <0 degrees celsius
      • Grading system (similar to burn grading)
        • 1st degree: superficial with skin redness
        • 2nd degree: superficial with deeper subcutaneous blisters
        • 3rd degree: deep subcutaneous injury with severe pain
        • 4th degree: deep subcutaneous injury with no sensation and necrotic tissue
      • Treatment: indirect heating with circulating water @ 37-39 degrees Celsius over 15-60 minutes
        • Do not warm via mechanical injury (aka don't rub the tissue)
        • Refreezing after partial warming is extremely detrimental, so if necessary, let the tissue stay cold until definite management is possible (initial partial warming, then refreezing will cause significantly more damage and morbidity) 
        • IV fluids, ibuprofen
Frostbite

Frostbite

 

    • Hypothermia
      • Mild: 32-35 degrees with shivering
      • Moderate: 28-32 degrees but ability to shiver is lost 
      • Severe <28 degrees C: loss of consciousness and ability of body to compensate
      • Remove wet clothing first
      • Treatment: Active external rewarming (aka "Bear hugger") and warmed IV fluids 
        • Patients in hypothermia and cardiac arrest have myocardium that often doesn't respond to electricity or medications; thus, emergency physician should continue CPR until active rewarming and then attempt defibrillation or other cardiac arrest medications

Sun Injuries

  •  Solar retinopathy: commonly occurs during solar eclipse causing direct retinal tissue injury from the UV rays
    • Vision lost may be permanent or takes months to recover
Solar Eclipse

Solar Eclipse

 

    • UV keratitis: punctate lesions within the superficial eye with injury pattern similar to corneal abrasion
      • Associated with mountain sports (skiing, snowboarding where snow can reflect brightly) or welders who fail to use proper eye protection 
      • Treat similar to corneal abrasions with topical antibiotics and consider topical anesthetics if injury <24 hours old 
bright ski.jpg

 

Blast injuries

  • Primary: occurs as a direct result of blast waves (shock wave)

    • Causes TM rupture, GI injuries (hematomas), pulmonary injuries (pneumothorax, air embolism, pulmonary contusions), direct axonal injury, direct compartment syndrome

  • Secondary: occurs as a result of projectiles flying through space 
  • Tertiary: displacement of air by explosion wave throws victim against solid objects or environment (buildings, trees, etc.) can topple onto victim (surroundings)
  • Quaternary: immediate medical complications such as asthma exacerbations or breathing difficulty 
  • Quinary: delayed complications such as leukemia, PTSD, etc. 
Blast Injuries

Blast Injuries

 

Battle Injuries

  • Amputations

    • Finger injuries are more likely to be reimplantable because there is less tissue, thus less likely to become necrotic 

  • Lacerations: superficial vs deep; linear vs stellate 
  • Crush injuries: rarely salvageable because of destruction of blood vessels and nerves 
  • Avulsion injuries: most severe and require debridement and, often, amputation 
  • Electrical injuries (current, or the flow of electric charge, is the most important factor)
    • Low voltage: typically household injuries and are most commonly restricted to cutaneous injuries 
      • Delayed bleeding from labial artery injuries can occur when biting on wire/cord (classically occurs in younger, teething children) 
    • High voltage: deep tissue and severe internal injuries
      • Occurs in occupational exposure (i.e. linemen, electricians, etc.)
      • Treatment should occur in burn centers as internal injuries are often underestimated; require aggressive hydration and specialized topical burn care 
      • High mortality 
      • Lightning injuries are less often fatal because the electricity is only in contact with tissue for a very short amount of time (high voltage, but low current) 
electricity.jpg

 

Top Tips and Tricks for Lines and Gateway Blocks - Enter a World of Complete Pain Control: Dr. Jacob Avila

  • Indications: pain control, laceration repair, fracture reductions, abscess drainage, central line placement, dislocation reductions 
  • Maximal dose
    • Lidocaine: 4.5 mg/kg (max 300 mg)
    • Lido w/ Epi: 7 mg/kg (max 500 mg)
    • Bupivacaine: 2 mg/kg 
    • Bupivacaine w/ Epi: 3 mg/kg
    • If you can't remember these doses, search "Core EM"
  • Proper technique
    • Linear transducer (higher frequency so high resolution, but downside is lack of depth)
    • Set up: tegaderm film over probe, 10 or 20 cc syringe, drawing needle, injecting needle, and chlorhexidine to cleanse skin
      • 25 guage 1.5 inch needle is ideal for injecting as this will cause least amount of discomfort for patient
        • Can also use spinal needle (22 or 24 guage 3.5 in) if more subcutaneous tissue or deep fascial blocks
        • "The hands are super important": keep your wrists and hands braced on the patient because these techniques require precision and very small movements of the needle 
    • Gateway blocks
      • Ulnar nerve blocks for medial hand injuries (boxer's fractures, medial laceration, avulsions, etc.)
        • Perform more proximally in the forearm before ulnar nerve splits for more complete anesthesia 
        • Try to inject into the fascial plane right around the nerve (avoid injecting into the muscle) 
      • Median nerve blocks for thenar eminence injuries 
        • Consider doing "hydro-dissections"
      • Radial nerve blocks (injuries to the dorsum of hand); least commonly performed and smallest nerve
        • Look for structure just lateral to radial artery 
      • Posterior tibial nerve block (injuries to the sole of the foot)
        • Place probe on medical aspect of ankle just proximal to the medial malleolus near the posterior tibial artery 
        • Try to perform in the short axis to avoid the calcaneal tendon
      • Superficial cervical plexus block (angle of jaw and posterior ear -> clavicle); can be used for most anterior neck injuries or IJ central line placements (better comfort)
        • Minimally painful
        • Just posterior and deep to the sterno-cleido-mastoid (SCM) muscle
        • Target halfway between the mastoid process and clavicle (near the Adam's apple or where the EJ crosses the SCM)
        • Identify the posterior aspect of SCM and inject just behind 
  • L.A.S.T.: Local Anesthetic Systemic Toxicity
    • Occurs when local anesthetic leaks into local blood vessels
    • Has never been described in emergency medicine literature when ultrasound guidance is used
    • Tongue numbness -> lightheadedness -> hallucinations -> muscle twitching -> unconsciousness ->  seizures -> coma -> respiratory arrest -> cardiac arrest 
    • Always have IV access and continuous cardiac monitoring before starting injection 
    • Treatment: benzos for neurologic symptoms and 1/10th concentration epinephrine initially
    • Life threatening complications should be treated with IV fat emulsion (1.5 mL/kg of 20% follow by 0.25 mL/kg/min; 
    • ECMO if refractory
  • Other resources for Ultrasound-guided nerve blocks
    • NYSORA (New York School of Regional Anesthesia)

US-guided central venous access

  • Always look at anatomy first before set up (avoid complications such as DVT, arterial puncture, etc.)

  • Short axis vs Long Axis
    • 2 axis technique: start short axis and once vessel is entered, switch to long axis to confirm placement
    • Consider "Bevel Down" approach to decrease posterior wall hematomas
  • Technique
    • Adequately visualize the entire vessel
    • Enter skin at acute angle to decrease pain, then drop needle to advance
      • Visualize the needle right as it enters the skin and follow it down to vessel
        • AKA "Sequential needle tip-tracking"
          • "Vanishing target": visualize the tip of the needle within the vessel and vanish before posterior wall
    • Once "flash" occurs, advance angiocath into the vessel (particularly with IJ central lines in hypotensive patients to avoid injury)
    • Find guidewire within the vessel in long axis to ensure the proper location and trajectory 
    • #Protips
      • IJ central lines
        • Always use an angiocath to avoid posterior wall hematomas and for ease of threading guidewire
      • Subclavian central lines
        • Use ultrasound guidance (you will absolutely decrease the chances of pneumothorax and feel more confident)
      • Common femoral central lines
        • There is some overlap between the femoral artery and vein (it just depends on the distance from the inguinal ligament)
        • Most femoral arteries are right over the femoral vein, so again, ultrasound guidance is recommended to avoid complications 
  • Resources:
    • Jacob Avila: http://5minsono.com/
    • Ultrasound GEL- gathering evidence from the literature: http://www.ultrasoundgel.org/

 

August M&M: Dr. Leah Carter

Case 1: Young female presents with headache. She reports she fell yesterday and hit her head. Now has a headache, associated with neck pain and photophobia. ~1wk post partum, diagnosed with Post-Partum Pre-eclampsiaa

 

  • Post-partum Pre-Eclampsia/Eclampsia
    • Can occur up to 6 weeks post-partum
    • Diagnosis: Elevated blood pressure (severe range >160 or >110) +/- severe features
    • Seizure marks transition into eclampsia
    • Which patients are at risk?
      • Patients with a history of preeclampsia are most at risk 
      • Higher BMIs, gestational diabetes, age >40 years are also risk factors for development of eclampsia 
    • Treatment?
      • Benzos for seizures PRN if magnesium fails 
      • Strict BP control
        • Hydralazine, labetalol, nifedipine 
      • Magnesium 4-6 g bolus over 20 minutes, followed by 1-2 g/h drip
        • "MagPie" Trial showed superiority of magnesium for seizures in eclamptic patients
        • Mechanism unclear, possibly related to smooth muscle relaxation 

Case 2: 27 yo F presents with asthma exacerbation. Received albuterol x2, magnesium 2 g, solumedrol 125 mg IV once, and 1 L IV normal saline. Discharged home with oral prednisone. Presented again 14 hours later with same complaints. 

  • IV or PO steroids for asthma exacerbation? 
    • IV Solumedrol is dosed Q6H while PO prednisone is dosed Q24H
    • There is no difference in outcomes between IV and PO steroids, thus the emergency physician should consider giving PO steroids to all patients in the ED who can tolerate oral medications as the risk of bounce-back is decreased 
  • Should I give magnesium in asthma exacerbations?
    • Mg improves hospital admission rates and lung function in severe asthma
    • When looking at all comers, no difference 
  • Does using peak flow help?
    • Better for outpatient management than ED 
    • The ED does a poor job of performing peak flow prior to treatment and routinely performing prior to discharge 
    • Patients that are discharged with poor peak flow tend to have no serious complications or readmission rates
    • ACEP amended their statement - not currently routinely recommended 

Case 3: 61 yo Male presents with CC of numbness. Difficulty walking and R shoulder pain in addition. Symptoms present for 2 days. Decreased lower extremity strength, decreased lower extremity reflexes, ataxic gait. LP performed and showed increased protein.  IVIG initiated for Gillian Barre and he improved and had an otherwise unremarkable stay. 

nerve-GBS.jpg

 

  • How does Guillain Barre present?
    • Usually 1-2 weeks after immunologic insult: viral illness, Zika, influenza vaccine
    • Presents classically as a rapidly progressive ascending bilateral weakness
    • Can present with proximal weakness initially
    • 20-30% develop bulbar symptoms and require ventilatory support
  • How is GBS diagnosed? 
    • Only requires progressive motor weakness and areflexia
      • Does not have to present with ascending weakness 
    • CSF: elevated protein without increase in WBCs
    • EMG can show conduction delay
  • How do I predict respiratory failure? 
    • Risk factors: cranial nerve deficits, bulbar symptoms, rapid progression, and dysautonomia 
    • Patients with negative inspiratory force (NIF) <30 cm H20  should be intubated urgently as likelihood of rapid decline is likely 
    • Consider admission to ICU if any risk factors or high risk features

 

Emergency Medicine Leadership Curriculum, Session 4: Dr. Christopher Miller

  • Reminder of leadership curriculum to date and our 3 previous sessions...
    • Traits and characteristics: trustworthiness, effective communicator, and effective decision-maker are most highly valued leadership qualities per our department survey 
    • Small-unit leadership and importance of knowing your level of training and the strengths of those around you
    • Project management and the Pareto phenomenon: 20% of problems cause 80% of issues 
  • "Project X": delivering service (aka Patient Experience)

    • Ideals: Fast, Cheap and Simple
    • We work in, arguably, the most challenging environment of medicine (THE EMERGENCY DEPARTMENT) and receive the least gratitude for our service
      • Patients talk about their experience. 
      • The psychology of waiting: there is no correlation between the amount of time a patient spends waiting and their overall experience 
        • Behavioral psychology studies show that unfair waits feel longer than equitable waits, solo waits feel longer than group waits, uncertain waits feel longer than known/finite waits, unexplained waits feel longer than explained waits, anxiety makes waits seem longer, pre-process waits feel longer than in-process waits, and unoccupied time feels longer than occupied time 
waiting.jpg

 

    • "THE MORE VALUABLE THE SERVICE, THE LONGER THE CUSTOMER WILL WAIT"
    • Service = Perception - Expectation 
      • How a patient perceives "you" is the variable
    • The "Big 4" variables that matter the most in the ED (per Press-Ganey Questionnaires): patient's needs are anticipated, staff worked together as a team, staff responded with care and compassion, and staff advised the patient of delays (most important variable overall)
    • "Patient experience" is now termed "person community engagement" 
    • High engagement = greater reimbursement (but also better care)
    • "Our department makes 1,120 calls every day. Do you know how many of those calls the public expects perfection on? 1,120. Nobody calls the fire department and says, 'Send me two dumb-ass firemen in a pick-up truck'. In three minutes they want five brain-surgeon decathlon champions to come and solve all their problems." -Chief John Eversole, Chicago Fire Department
  • The change from goodness to greatness is a dynamic process, and occurs over periods of time with slow, but persistent improvement...