6.13.19 Conference Summary

Grand Rounds

-Dr. Chris Colwell, EM Chief/Vice Chair UCSF, Zuckerberg San Francisco General Hospital & Trauma Center

Mass Casualty and Disaster Management: Lessons Learned from the Colorado Shootings



  • CDC disaster: serious disruption of societal functioning that exceeds the local capacity/resources to respond

  • Disaster management: change from priority for to access to — need to start triaging and rationing care

  • Continuum of medical care

    • Conventional care - usual care

    • Contingency care - functionally equivalent

    • Crisis care - care to the level possible; inadequate resources

Mass casualty management

  • Command Post - must be the 1st step (at the scene and at the hospital)

  • Triage - do the greatest good for the largest number of victims

    • Need common language

    • Black = dead or death imminent - might need to overlook, not the best use of resources (**exception = lightening strikes)

    • Red = severe injuries associated with significant morbidity/mortality, need urgent treatment

    • Yellow = moderate injuries likely not leading to significant morbidity mortality but still clearly need medical management

    • Green = minor injuries (‘walking wounded’), may be transported

  • Treatment (*depends on size and scope of event)

    • Hemorrhage control

    • Address airway

    • Immobilization (no back board)

    • Allocating resources

      • Put most experienced surgeon or EM physician in charge for triage (rather than actively treating victims)

    • Alternate care sites for more minor injuries

  • If there an active shooter, anticipate where they may go

Lessons Learned from Columbine/Aurora shootings

  • Temptations

    • Rush and treat - is the scene safe?

    • Rush and transport - not always the best option to go to the hospital

    • Rush to scene - remember the rest of the city still needs care

  • Organization

    • Everyone will arrive. Staging and crowd/vehicle control is important.

  • Resources

    • Victims AND providers - water, food, clothing, equipment, destination for families, etc

    • Only separate families unless you absolutely have to

  • Media

    • Onslaught will occur (scene & hospital for weeks); can aid and/or hinder

    • Prepare! nothing is ‘off the record’

  • Aftermath

    • Debrifing, incident review

    • Staff support. Don’t underestimate the impact this can have!

  • Hospital preparedness

    • Surge capacity. Clear out the ED!

    • Designated areas, remember triage is a dynamic process (status can change)

    • Documentation - tracking, photos

  • Response

    • Highlight the victims!

High Altitude Illness

  • Pathophysiology

    1. Hypoxic ventilatory response

      1. Hyperbaric hypoxemia —> altered fluid homeostasis & relative pulmonary hypertension —> HAPE

  • Acclimization - changes in response to prolonged exposure, culminates in 4-7 days

  • Incidence depends on altitude, rate of ascent, underlying factors, etc.

  • Risk factors: COPD, pulmonary HTN, sickle cell disease, CAD (*Asthma/pregnancy associated with complications but NOT increased risk)

Acute Mountain Sickness

  • Risk factors include exertion, younger age, obesity, underlying lung disease

  • Symptoms mimic those of acute viral illness/hangover

  • Diagnosis is clinical, vitals and exam usually normal

  • Treatment

    • Don’t ascend, prevent progression, improve symptoms

    • Oxygen

    • Acetazolamide, dexamethasone better in preventing than treating

HACE (high altitude cerebral edema)

  • Life threatening!

  • Neurologic deficits = HACE

  • Often associated with pulmonary edema

  • Treatment

    • Descent is essential!

    • Oxygen (hyperbaric as temporizing measure)

    • Steroids

High altitude pulmonary edema

  • Life threatening, most lethal

  • Sx: dry cough, DOE, early fatigue, vital sign changes usually late

  • Relatively normal heart (unlike CHF) with pulmonary edema

  • 2nd night at altitude most common

  • Risk factors - heavy exertion, rapid ascent, underlying pulmonary disease, etc

  • Treatment

    • Must descend

    • Niefedipine, PDE-5 inhibitors to augment nitric oxide (pulm vasodilator)

    • Diuretics may help

Trauma Sedation



  • Options includes: benzos, antipsychotics (haldol), dissociatives (ketamine)

  • Always consider causes: head trauma vs shock vs behavioral vs intoxication

  • Benzos need to be used very carefully

    • Can cause hypoventilation, hypoxia, and hypotension- none of which is safe in trauma

  • Antipsychotics

    • Haldol can help

  • Ketamine

    • Proven to be safe in ICP

    • Easy to give IM/IV, sometimes even can be given by EMS

    • Also a good choice for an induction agent when you need to intubate

CPC: Dr. Abe Feshazion, PGY2 vs Dr. Linda Katirji


Young male who presents with a month of cyclical fevers. Temp as high as 101F. Associated with low back pain.

  • Vitals: afebrile, tachy to 130, 117/78, RR 20, T 102.7F

  • PMH/PSH:Asthma, ED, DJD, osteoarthritis, HLD, knee surgery

  • Recent travel to New Orleans —two days after travel: malaise, R arm/neck/groin pain after eating seafood and alcohol

  • Exam: Mild low back tenderness to palpation, mild wheezing, sweaty, warm on exam, post nasal drainage

  • Vitals normalized after Tylenol

  • Labs: INR 1.6, elevated monocytes, hematuria on UA


Dr. Katirji Differential:

  • Most likelies: hyperthyroidism, hyperparathyroidism, autoimmune disorder, neoplasm infectious

    • Infectious causes: malaria, west nile virus, Dengue fever, syphilis, gonorrhea, hepatitis, Chikungunya, Chagas, babesiosis, Typhoid fever, leptospriosis

      • Many of these diagnosis (typhoid, Chagas, chikungunya, dengue fever) fit this presentation but are difficult to diagnose in the ED and require PCR for IgA/IgM/IgG testing

  • Final Diagnosis: Chagas disease

    • Test ordered: peripheral smear

Rebuttal by Dr. Feshazion

  • Test ordered: CT abdomen/pelvis with IV contrast

    • Final radiology read: concerning for diskitis and vertebral osteomyelitis, recommend MRI for further eval

  • Admitted to medicine for IV abx and MRI

    • Group A strep, TB, HIV, syphilis all negative; ESR and CRP elevated

    • MRI confirmed diskitis and vertebral discussion

    • Transferred to main campus for NSGY eval, who recommended IR guided culture

    • Group B strep isolated, ID recommended long term PICC therary with 6 weeks of abx therapy; Keflex thereafter



Vertebral osteomyelitis/diskitis

  • Generally, hematogenous spread

  • Risk factors: IVDU, hx of infective endocarditis, DDD, prior spinal surgery

  • Clinical features: prolonged symptoms for weeks to months (pain that is often slowly progressive, often afebrile, paresthesias)

  • Lab findings: leukocytosis, elevated CRP & ESR

MRI is often necessary for diagnosis (gold standard - most sensitive/specific)

  • Initial biopsy for culture can be negative 40% of time and require additional biopsy

Pediatric Ultrasound: Little People, Big SonoWorld - Dr. Marina Shpilko

———General tips to scanning kids: warm gel, distraction, parent cooperation. Goal = reduce crying

Pyloric stenosis

  • Hypertrophy of muscular layer of pylorus and failure to relax leading to gastric outlet obstruction

  • Male predominance, usually diagnosed age 2- 6 weeks (consider up to 6 months)

  • Signs/symptoms: “projectile vomiting”, palpable olive-shaped mass

  • Ultrasound — 90-96% sens/spec, modality of choice!

    • Linear probe

    • Two planes

      • Long axis pylorus = transverse relative to body, indicator toward 8 o’clock position

        • Canal (hyperechoic line): normal =~14 mm

        • Muscle thickness: normal = 3 mm (think “PY” = 3.14mm)

      • Short axis - rotate probe 90 degrees, look for ‘donut sign’

    • Pearls:

      • Place patient in lateral decub helps pull bowel gas out of the way

      • First scan w/ empty stomach, then feed (to allow for better visualization of stomach and movements)

    • Pitfalls: off-axis, pylorus may be posterior

Long axis pylorus - em.emory.edu

Long axis pylorus - em.emory.edu

Short axis pylorus - em.emory.edu

Short axis pylorus - em.emory.edu


  • Telescoping of one segment of bowel into another, resulting in obstruction and ultimately necrosis can occur

  • Most common age 6 months - 2 years of age but can occur at any age

  • Signs/Symptoms

    • Classic triad =(intermittent) abd pain, vomiting, drawing up legs

    • ‘Currant jelly’ stools

    • Palpable sausage-shaped mass

  • Ultrasound = test of choice (even among novice radiologists), high sensitivity/specificity (90s, 100%)

    • Linear probe

    • Image in two planes

      • Short axis: hypoechoic ring with central echogenicity (target/donut sign)

      • Long axis: stacking appearance of multiple layers of bowel (pancake sign, pseudo kidney sign)

    • Graded compression, systematic scanning of abdomen

    • Pitfalls

      • False positive: bowel wall thickening, enlarged lymph nodes, other organs may be mistaken for intussusception

      • False negative: poor visualization, intermittent intussusception



EBM: Anaphylaxis - Dr. Steve Morgan, PGY3

  • Immunologic vs non-immunologic vs idiopathic

  • Diagnosis - mostly clinical, signs/sx mostly cutaneous (80-90%)

    • Danger signs: cardiovascular, respiratory symptoms

  • Acute management

    • Airway —> breathing, circulation

    • Trendelenberg

    • Consider oxygen

    • Epinephrine (1:1000)

      • IM preferred (best absorption) 0.3-0.5mg

      • IV bolus 20-60mcg, slow push

      • IV infusion 0.1mcg/kg/min

    • Benadryl, H2 blocker, solumedrol

  • No clear evidence for appropriate monitoring period for patients presenting with anaphylaxis

  • Clinical pathway

    • Anaphylaxis that resolved promptly and completely with treatment, observation times have been customized based on the severity of the reaction and access to emergency care

    • Biphasic anaphylaxis - reaction occurring up to 72 hours post exposure without repeat exposure. Monitoring period not clear.

      • Rare, no significant difference in mortality for pts monitored <8 hours or >8 hours. Patients whose symptoms resolved were discharged. Early steroids is controversial. (Pourmand, 2018)

      • Hypotension associated with development of biphasic reactions. Food less likely. (Lee, 2015)

  • Who is appropriate for CDU?

    • Stable clinical appearance

    • Grade II and III

    • Consider risk factors for biphasic reactions

    • Consider social factors and ability to obtain meds

    • Need a-scope while in the ED

  • During CDU admission

    • Patient education, ensure they are leaving with an epi-pen, emergency action plan, referral to allergy clinic

Power (Half) Hour - Dr. Lauren McCafferty, PGY3

Case #1

  • Elderly female presented for progressive abdominal pain/distention and now having bilateral lower extremity edema. Having difficulty moving around because of symptoms. No infectious sx, weight loss, n/v, dysuria, change in bowel habits, neuro deficits.

  • CT showed:

  • Diagnosed as massive ovarian cyst, taken to OR. 40cm removed

  • Ovarian cysts

    • Types

      • Simple vs complex

      • Physiologic, hemorrhagic, dermoid, endometrioma, ovarian malignancy

    • Diagnosis: ultrasound (consider FAST) —> MRI (CT less helpfu)

    • Complications:torsion, rupture +/- hemorrhage, obstruction 

    • Conservative vs surgical mgmt dependent on type, size, complications, etc. 

Case #2

  • Middle aged male tripped and fell, striking his anterior chest on furniture.. Several hours later having difficulty breathing & worsening pain. Very focally tender to palpation over mid-lower sternum.

  • Point-of-care ultrasound revealed:

Sternal fx.gif
  • Sternal fracture on ultrasound

    • Place probe long axis over sternum at point of max tenderness/pain 

    • Look for disruption of bony cortex

    • Shown to have up to 100% sensitivity & specificity (much better than x-ray)

    • Pitfalls: know anatomy ( sternomanubrial & xiphosternal junctions)

  • Aggressive pain control, look for associated intrathoracic injuries (often associated)

Case #3 - Dr. Laura Throckmorton, PGY1

  • 29 yo F presented for abdominal pain

  • Vitals normal, exam unremarkable, including abdomen

  • Imaging

point-of-care ultrasound showing large heterogenous mass in LUQ

point-of-care ultrasound showing large heterogenous mass in LUQ

CT showed: mesenteric volvulus, thickened bowel wall, free air

CT showed: mesenteric volvulus, thickened bowel wall, free air

  • Course: went to OR for large portion of small bowel resection

  • Midgut volvulus

    • Whirlpool sign (ultrasound): SMV spiraling clockwise around SMA

  • Intussusception in adults

    • Exceedingly rare (<1%), high mortality

    • Primary: normal anatomy

    • Secondary: anatomic abnormality (usually due to masses, diverticula, etc)

    • Often diasgnosed as SBO on CT, usually diagnosed in OR

    • Ultrasound - ‘target sign’