We had a great month of conference to start out the calendar year! Here are some pearls and follow-up resources from January 2018 EM Conference at Stony Brook.
Essentials of EMCrit - Lots at https://twitter.com/EssentialsofEM in addition to below
Live Cric - Dr Weingart
-https://emcrit.org/emcrit/surgical-airway/
Ventricular Storm - Dr Gray
-3 or more sustained episodes of VT/VF in 24 hours
-Approach: electricity, reversible causes, antiarrhythmics, chill them out
-Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2016 - PMID 27354046
-https://emcrit.org/racc/65947/
LR for HyperK - Dr Farkas
-In ED, start with LR when have no info. When labs back, switch to isotonic bicarb
-https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/
-https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/
-https://emcrit.org/squirt/brash
TTP and DIC - Dr Deloughery
-With thombocytopenia, ask if it's TTP or DIC
-TTP
-overactive platelets
-ADAMTS13 is missing
-primary problem
-Dx - Terrible triad: MAHA (high LDH + schistocytes), thrombocytopenia, end organ damage
-Tx - plasma exchange; FFP and steroids while waiting
-No platelets...they feed the fire!
-DIC
-increased thrombin generation
-overactivation of coagulation
-secondary problem
-Dx - high INR/PTT/dimer and low platelets/fibrinogen
-Tx - treat primary cause
-Support coagulation - Magic 5: fibrinogen > 150 (give cryo), PLT > 50, Hct > 21, aPTT < 1.5 x control, INR < 2-3
Team Dynamics - Dr Hicks
-4 lines of conflict
-Positions, strategies, or opinions
-sit rep - leader shares state of situation as (s)he sees it
-tactical pause - leader asks "what am I missing"
-Mistrust or undeveloped comm
-don't be passive aggressive nor man-splain
-consistent, short, direct phases don't mean you're impolite
-Power issues and personal agendas
-hot debrief: process and safety issues
-cold debrief: interpersonal and team issues teased out
-Personality clashes
Anemia Workup - Dr Deloughery
-Production - retic count
-Destruction - coombs, LDH, haptoclobin
-Iron deficiency - ferritin
-Macrocytic - folate (homocysteine), B12 (methylmalonic acid)
BRASH - Dr Farkas
-"BRASH" is his word, not yet in literature
-synergistic response to renal failure, hyperK, and AV nodal blocker
-Metabolic therapies: epi infusion, IV Ca, insulin/dextrose
-Fluid prn: isotonic bicarb if < 24; LR if bicarb > 24
-Nephron bomb if severe hyperK; if mild, then not as aggressive
-In anuric and persistent hyperK, dialyze
-https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/
Mental Prep for badness - Drs Gray and Hicks
Walking down the hall: near field focus - what are immediate issues and plan for them
-review scripts (trauma arrest, ACLS, etc)
-review procedures you might do
In the bay, decrease arousal level:
-take a deep breath
-say something positive to yourself
-trigger word to focus self
-Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers' Performance Under Stress. Ann Emerg Med. 2017 - PMID 28460863
Patients about to come in: prebrief
-What do we know
-What do we do
-What do we change - contingency
-Roles assignment
Perimortem C-section - Drs Gray, Weingart, Boudourakis
-https://emcrit.org/racc/peri-mortem-c-section/
BLAST Speaker 1: Bougie
-Bougie all your intubations
BLAST Speaker 2: VT vs SVT with aberrancy
-CRAM to distinguish VT vs SVT with aberrancy. May be SVT if all "no":
-Concordance in all precordial leads
-R-S > 100 msec
-AV dissociation anywhere
-Morphology
-When in doubt, treat as if VT
BLAST Speaker 3
-https://emcrit.org/racc/pulmonary-hypertension-right-ventricular-failure/
MCI for unprepared - Dr Gray
-Create inside and outside team
-Designate areas where people go
-Outside team: ID patients, triage them, deliver them inside
Status epilepticus - Dr Farkas
-https://emcrit.org/pulmcrit/status-epilepticus-2/
Early trauma resusc - Dr Hicks
-Clot formation, not BP chasing
-Controlled resuscitation
-Pick your poison (brain vs hemorrhage)
-Harris T, Davenport R, Mak M, Brohi K. The Evolving Science of Trauma Resuscitation. Emerg Med Clin North Am. 2018;36(1):85-106 - PMID 29132583
-Schreiber MA, Meier EN, Tisherman SA, et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015;78(4):687-95 - PMID 25807399
Thoracotomy - Drs Hicks, Weingart, Boudourakis
-https://emcrit.org/racc/procedure-of-thoracotomy/
-https://emcrit.org/racc/john-hinds-on-crack-the-chest-get-crucified/
-https://emcrit.org/racc/abbreviated-ed-thoracotomy-tray/
Sim Day:
Central Lines:
-http://emcrit.org/central-lines/
-http://emcrit.org/podcasts/central-line-show/
-http://emcrit.org/podcasts/central-lines-placement-tips/
-http://emcrit.org/wee/central-line-micro-skills-deliberate-practice/
-https://emcrit.org/emcrit/microskills-dilation/
Cocaine toxicity in body packer + trauma - Sim War case:
-1 hour 18 min mark onward for
https://emergencymedicinecases.com/episode-5-renal-colic-toxicology-update-body-packers/
TCA Overdose:
Links from AIR Series Tox 2015: https://www.aliem.com/2015/01/air-series-toxicology-module-2015/
-https://emergencymedicinecases.com/critcases-massive-tca-overdose/
-https://emcrit.org/racc/tricyclic-antidepressant-overdose/
Grand Rounds by Dr Farkas: BRASH, Status Epilepticus, and Lactated Ringer's
-https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/
-https://emcrit.org/pulmcrit/status-epilepticus-2/
-https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/
-https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/
Interesting Case by Dr Simms: ruptured AAA presenting as a seizure
“There is no disease more conducive to clinical humility than aneurysm of the aorta.” - Osler
-RUSH your sick patients
-PMID 21293775, 24360026, 18272117 show seizure as possible CC
DVT Ultrasound by Dr Reardon
-Slides @ https://www.stonybrooksono.com/resources
-AEUS DVT Lecture: https://vimeo.com/52819569
EKGs: Bradycardia by Dr Meyers
-DDx includes DIE: Drugs (e.g. beta blocker, Ca channel blocker, digoxin), Ischemia, Electrolytes (e.g. hyperK)
PGY2 EBM: CTCA/CCTA and Chest Pain by Dr McKenna
-https://emcrit.org/emnerd/case-anatomic-heart/
-https://emcrit.org/emnerd/the-case-of-the-anatomic-heart-part-2/
-http://rebelem.com/chest-pain-coronary-ct-angiography-ed/
-https://coreem.net/journal-reviews/ccta-1-year-outcomes/
-EMRAP Feb 2017: Cardiology Corner: ACS State of the Art Part 1 and 2 by Amal Mattu
-Stony Brook ED Chest Pain Algorithm (kallus.com/er -> Admin Policies):
http://www.kallus.com/er/administration/ACS.pdf
EBM: Observational studies: can’t live with them, can’t live without them by Dr Singer
-http://www.cebm.net/blog/2014/04/03/study-designs/
FOOSH by Dr Mallon
AIR Series 2016: Upper Extremity Ortho:
-https://www.aliem.com/2016/07/air-series-orthopedics-upper-extremity/
Thyroid Disorders by Dr Alexeeva
From AIR Series 2014: Endocrine (https://www.aliem.com/2014/10/air-series-endocrinology-2014/):
-https://www.aliem.com/2013/11/thyroid-storm-treatment-strategies/
-https://www.aliem.com/2013/10/diagnosing-hyperthyroidism/
Adrenal/Pituitary Disorders by Dr Sherman
-https://emcrit.org/racc/steroids-for-septic-shock-preadrenal/
-http://www.criticalcarereviews.com/index.php/meetings/493-ccr-meetings/ccr-meeting-2018/3023-adrenal-trial-results
-https://emcrit.org/emnerd/cc-nerd-case-relative-insufficiency/
Vascular Trauma by Dr Morley
-Accuracy of Physical Examination, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta-analysis - Acad EM 2017 - PMID 28493614
-Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed - EM Clinics 2017 - PMID 29132576
Billing by Dr Morley
-ACEP "What Every Graduating Resident Needs To Know About Reimbursement":
https://www.acep.org/graduating-resident-reimbursement/#sm.00001ijs79y86jcxls4881r908yks
-ALiEM ED Charting and Coding: Medical Decision Making (MDM): https://www.aliem.com/2016/11/charting-and-coding-medical-decision-making/
Alkalosis by Dr English
-https://lifeinthefastlane.com/wp-content/uploads/2012/08/acid-base-disorders-worksheet3.pdf
-https://emcrit.org/podcasts/acid-base-i/
-https://emcrit.org/podcasts/acid-base-part-ii/
-https://emcrit.org/podcasts/acid-base-part-iii/
Eponymous fractures by Dr Mallon
-Rosen's 9e Table 42.1 Common Fracture Names and Their Origins
Critical Care Journal Club/Case Discussion by Dr Wright/Thompson/Eraso
-Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-93 – PMID 9482291
-https://emcrit.org/racc/scape/
-https://emcrit.org/racc/when-to-wean-cpap-scape/