10.18.18 Conference Summary

Ultrasound in Cardiac Arrest - Dr. Marina Shpilko

  • High quality chest compressions + early defibrillation are key for shockable rhythms

  • Point-of-care ultrasound primarily useful in non-shockable rhythms — use to diagnose life-threatening, reversible pathology (think H’s & T’s) and guide management

    • Especially useful for PE, pericardial effusion, tension PTX, hypovolemia, as well as in setting of trauma

    • Pulmonary embolus

      • PE present in 5% cases of arrest, primary presenting rhythm is PEA

      • Early thrombolytics associated with increased rates of ROSC

      • If no signs of right heart strain, unlikely PE

      • Poor data on use of lytics in PEA arrest

  • Hemodynamic monitoring during CPR

    • Coronary perfusion pressure (CPP): surrogate for myocardial perfusion (diastole) — indicator of adequate CPR

      • CPP = aortic diastolic pressure - RA pressure

      • Goal CPP >20 — predictive of ROSC

      • Ways to measure:

        • Tactile pulse check — often a poor measure

        • A-line DBP — most accurate

        • EtCO2

    • POCUS can serve as adjunct

      • Rapidly assess cardiac activity/function, volume status, guide use of pressors in post/peri-arrest period — serially/in real-time

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  • “Cardiac standstill” = absence of any visible movement of myocardium, excluding movement blood in cardiac chambers or isolated valve movement

  • REASON Trial: prospective multi-center study looking at out-of-hospital cardiac arrest

    • 14.4% survived to admission, 1.6% survived to discharge

    • Cardiac activity on initial ultrasound associated with increased survival (3x as likely to survive if present)

    • Absence of cardiac activity confers poorer prognosis but chance of survival is not zero

    • Patients who underwent procedures based on US findings (i.e. pericardiocentesis for tamponade, chest tube for ptx, lytics for right heart strain, etc) had increased survival rates

  • POCUS helps guide appropriate hand (or mechanical device i.e. Lucas) placement for chest compressions

    • Inadequate placement or migration during CPR can lead to unnecessary complications (abdominal organ injury) and inadequate CPP (such as from aortic compression) i.e. inadequate CPR

  • Cons of POCUS during CPR?

    • Previous studies demonstrated focused cardiac ultrasound causing significantly prolonged duration of pulse check

    • Increased provider awareness with consequent push to establish protocols/more efficient utilization of US during CPR

  • Recap: Role of POCUS in cardiac arrest

    • Diagnose life-threatening pathology

    • Hemodynamic monitoring during CPR

    • Guide appropriate hand (or mechanical device) placement for chest compressions

    • Prognostication

    • Protocolized efficent and rapid utilization


Intern Super Track Series: UTI - Dr. Stephanie Hutchinson

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  • Lower UTI: cystitis

    • dysuria, hematuria, frequency, urgency

  • Upper UTI/pyelonephritis: infection beyond the bladder

    • urinary sx + fever, n/v, flank pain, CVA tenderness

  • Classification

    • Uncomplicated UTI: lower +/- upper tract infx in young, healthy, premenopausal, non-pregnant female with normal anatomy

    • Complicated UTI: male, pregnancy, anatomical abnormality, obstruction, diabetes, renal failure/transplant, immunosuppression, hospital-acquired

    • Complicated pyelonephritis: renal infection c/b abscess, stone, necrosis, emphysematous infection

  • Acute uncomplicated cystitis

    • Testing

      • Not indicated in low risk patient with convincing history

      • Urine culture only indicated if concern for resistant organism

      • STI testing with any vaginal complaints

    • Treatment:

      • Macrobid 100mg BID x 5 days

        • Avoid in pyelo, elderly, CrCl <30, 1st/late 3rd trimester pregnancy

      • Bactrim DS BID x 3 days efficacious but high local resistance

  • Acute complicated cystitis

    • Diagnosis: urinary sx + pyuria or bacteriuria on UA

      • Send culture!

      • If male having recurrent UTI, consider prostatitis

    • Treatment:

      • Beta lactam 7-10 days (Cephalexin 500mg 4x/day, cefpodoxime 200mg BID)

      • Bactrim DS BID if low resistance

      • Consider fluoroquinolone if concerned for prostatitis

  • Urethritis

    • Dysuria most common +/- urethral discharge (purulent suggests gonorrhea), itching, burning; if ulcers think HSV

    • Diagnosis = presence of 1 of following: muco/purulent discharge, 2+ wbc gram stain urethral swab, + leuk esterase or 10+ wbc on UA

    • Treatment: ceftriaxone 250mg IM + azithromycin 1g PO (azithro 2g PO for severe pcn/cephal allergy); partners need tx

  • Acute bacterial prostatitis

    • Most commonly affects males 20-40 followed by over age 60

    • Sx: fever, chills, malaise, myalgias, dysuria, frequency, cloudy urine, incontinence or retention, pelvic/perineal pain

    • Diagnosis: DRE — edematous and tender prostate + sx of prostatitis; avoid prostatic massage

    • Treatment: *Minimum 2 wk duration (up to 6 wks) **Treat empirically until culture results return

      • STI suspected: doxy 100mg BID + IM ceftriaxone 250mg once or cipro 500mg BID

      • Less likely STI: cipro 500mg BID, levaquin 500QD, or bactrim DS PO BID

        **avoid cipro if high resistance

  • Pyelonephritis

    • Urinary sx + fever, n/v, flank pain, CVA tenderness

    • Diagnosis: usually pyuria, wbc casts indicates renal involvement, +/- blood

    • Treatment: cephalexin 500mg BID 10-14 days, bactrim* DS BID x14 days, cipro* 500mg BID x 7 days, levaquin* 750mg QD x 5 days (give initial dose of 1g ceftriaxone because of local resistance); in sicker pts, consider admitting for IV antibiotics

  • UTI in pregnancy/asymptomatic bacteriuria

    • >10^5 CFU on two urine cultures (limiting in ED), poor data on tx based on UA alone

    • Associated with poor outcomes if untreated, so usually err on the side of caution and treat

    • Treatment (3-7 days): cephalexin 500mg BID, fosftomycin 3g once, macrobid 100mg BID (in 1st tri /after 36 weeks)

    • If concern for pyelo, need to admit for IV antibiotics

***Treatment duration: uncomplicated < complicated UTI < Pyelo < Prostatitis

EM/Trauma Series: MSK Trauma - Dr. Ben Boswell

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  • Always remember ABCs and ATLS

  • Imaging

    • Need minimum of 2 views! ‘One view is no view’

    • CT: better osseous detail, multiple planes

    • MRI: less practical for trauma, good soft tissue and bony detail, time consuming

    • Ultrasound: can identify fractures, dislocations, soft tissue injuries quickly at bedside

  • Vascular injuries

    • Risk for hemorrhage/shock — monitor closely and resuscitate!

    • Popliteal/axillary/brachial arteries at high risk

    • 5 Ps - pain, pallor, paresthesia, pulselessness, poikilothermia

    • Hard signs? call surgery immediately

    • Soft signs need further workup

    • ABIs — ankle/brachial, 0.9 or greater is normal

      • if abnormal, consider CTA/MRA, US doppler, surgery

  • Nerve injury

    • Common

    • Axillary, radial, median, ulnar, peroneal nerves especially vulnerable, associated with particular extremity injuries

  • Compartment syndrome

    • = diastolic - compartment <30mmHg

    • Life/limb threatening!

    • Associated with fractures, crush injuries, burn injuries

    • Pain out of proportion! Passive stretch causes pain, woody feeling, sensory deficits

    • Most common: tibial plateau fracture causing anterior compartment syndrome

  • Pelvic fracture

    • 3 month mortality 3x higher in trauma pts with pelvic fx

    • Rare to have isolated pelvic fracture — look for other injuries (hemorrhage most common)

    • Lateral compression — stable, usually associated with bladder rupture

    • AP compression (‘open book’): unstable. Frequently associated with thoracic/abdominal injuries

    • Vertical shear: unstable

    • Workup: pelvic xray —> CT

    • Retrograde cystourethrogram prior to inserting foley

    • If unstable fracture, bind pelvis, anticipate hypotension

    • FAST exam:

      • if positive, needs OR

      • negative + stable vitals: CTA

  • Open joint (traumatic arthrotomy)

    • Periarticular injuries can extend into joint — have high suspicion

    • Testing: xray, CT (air in joint = high sensitivity), joint load testing

    • “Golden 6 hours’: surgical debridement and washout in < 6 hours

    • Irrigate in ED, tetanus, abx - often cefazolin but consider alternatives if exposed to water or high risk for contamination

  • Open fracture

    • Communication with outside

    • Usually obvious but not always

    • Assess for crepitus, look for air on x-ray

    • Golden 6 hours, management similar to open joint (abx, tetanus, wound care)

  • Knee dislocation

    • Types:

      • Anterior most common, usually from hyperextension injury

      • Posterior 2nd most common, often associated with popliteal injury

      • Medial/lateral less common

    • Very unstable injury; requires disruption of four ligaments

    • Peroneal nerve injury occurs in 25% cases

    • Reduce immediately! don’t wait for x-rays

    • Spontaneous reduction occurs in 50% cases

    • Check ABIs

      • if < 0.9 —> CTA

      • if weak pulses/ischemic signs —> stat OR

    • Serial exams — ischemia time >8 hours associated with 85% rate of amputation

  • Hip dislocation

    • Posterior: shortened/internally rotated, sciatic nerve often injured

    • Anterior less common: externally rotated and abducted

    • Several reduction techniques including Allis, 'Captain Morgan’, Rochester method

    • Dispo once reduced: if able to ambulate, patient can be discharged with outpatient f/u

    • H/o Arthroplasty? call ortho

  • Posterior sternoclavicular dislocation

    • Life threatening and often missed

    • Need reduction ASAP in OR

    • Dysphagia and dyspnea are warning signs

    • Seen in high collision sports

  • Fracture/dislocation

    • Reduce immediately if vascular compromise; 'make it straight’!

  • Amputation

    • If amputated digit available, wrap is moist sterile gauze and place on ice

    • Consult hand surgery

    • Ischemia time

      • Warm: 12 hrs for digit, 6 hrs weight bearing joint

      • Cold: 24 hrs digit, 12 hrs weight bearing joint

    • Indications for re-implantation: minimal ischemia time, thumb, multiple digits, proximal to wrist, pediatrics

    • Contraindication: crush, prolonged ischemia, single digit, severe contamination, elderly, vascular disease