Blog Archives

Lightning Rounds: Submersion Injuries

8/24/2016

Especially in the summer, children, and young men are at higher risk of submersion injuries.

Management of a drowning victim

When a patient is identified in an active drowning situation;

Call for backup: Scene safety and utilization of appropriately trained personnel is important to prevent additional victims.
Drowning victims have alveolar collapse due to surfactant removal.
"Dry Drowning" refers patients who drown with laryngospasm, preventing active water movement into the lungs.
Submersion for longer than 10 minutes predicts a much worse outcome than those submersed < 10 minutes.
Patients should be observed for 4-6 hours after a partial drowning event.

drowning_epidemiology.pdf
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multiorgan_dysfunction_drowning.pdf
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Preoxygenation & Apneic Oxygenation

8/24/2016

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Adapted from Will Denq's Grand Rounds presentation August 24th, 2016

A discussion of preoxygenation as well as the role of high flow nasal cannula and apneic oxygenation in the emergency setting.

Source: http://www.esicm.org/ (Shutterstock)

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Acute Chest Syndrome in Sickle Cell

8/17/2016

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Adapted from Colton Hood's August 17th 2016 Grand Rounds lecture.

One of the most common and severe complications of sickle cell disease, clinically may resemble a pneumonia, and can develop suddenly, and is more common in patients with asthma or those with prior acute chest events. Typically presents with cough, shortness of breath, and rales accompanied by a new infiltrate on chest X-ray.

Mortality of acute chest syndrome is 9% in adults, and can lead to pulmonary hypertension, right heart failure, and risk of sudden death.

Source: http://www.ssajm.org/text.asp?2014/1/3/111/138930

Evaluate patients with sickle cell disease with acute onset of lower respiratory tract disease with or without fever for acute chest syndrome, including chest x-ray and pulse oximetry to measure oxygen saturation (NHLBI Consensus-Panel Expertise)

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Lightning Rounds: Syncope

8/17/2016

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Appropriate Syncope Workup

EKG
Electrolytes: Not predictive of poor outcomes, and should not be part of your workup without a clinical suspicion.
Head CT: Only useful in those with neurologic deficits or focal symptoms during the syncopal episode, or those with trauma. ACEP Choosing Wisely.
CBC: Anemia is predictive of poor outcomes, and patients should be evaluated if at risk for anemia (elderly, females with heavy menses, GI bleeds, or a concerning history). Utilized in the San Francisco Syncope Rule.

EKG Abnormalities in Syncope

Tachyarrhythmias
Bifascicular block or conduction delay
Bradycardia/AV block
Prolonged or shortened QT interval
Brugada pattern (RBBB with ST elevation)
WPW
Hypertrophic cardiomyopathy: sharp, deep Q waves in lateral leads,
Ischemia
ARVD: Epsilon wave or negative T waves in precordial leads: Right sided cardiomyopathy, Typically presenting in young patients with a history of syncope.

Epsilon Wave

Disposition of Syncopal Patients

ACEP Risk Factors in Syncope

Suspected or diagnosed cardiac cause of syncope
- Abnormal EKG
- History or cardiac disease (CHF, low EF, new murmur)
- Exertional Syncope
- Sudden onset without a prodrome
Anemia or other lab abnormalities
ACEP Clinical Policy for Syncope Management

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COPD Exacerbations & Antibiotics

8/17/2016

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Adapted from Molly Graham's August 17th 2016 Grand Rounds presentation.

Treatment of acute COPD exacerbation

Acute exacerbations are characterized by sustained (48 hours or more) worsening of shortness of breath and coughing, with or without sputum. The most common cause is a viral or bacterial infection.

Therapy with short-acting beta2 agonists and anticholinergic bronchodilators
Oral corticosteroids (e.g., prednisone 25-50 mg/day) for less than two weeks in most moderate to severe COPD patients. A dose of 30–40 mg of prednisone equivalent per day has been used in practice.
Antibiotic use is based on risk factors; evidence shows that antibiotics improve outcomes in those with critically ill COPD exacerbations, however mild or moderate exacerbations are not improved by antibiotics.

Risk Factors

Age >65
FEV1 <50 % of predicted
> 4 exacerbations / year
Ischemic heart disease
Use of home oxygen
Chronic oral steroid use
Antibiotic use in the past 3 months.

Source: British Columbia COPD Guidelines

Common Co-morbidities in COPD

Procalcitonin Levels

Peptide inflammatory marker currently being evaluated for use as a POC marker for inflammatory and infectious disease.

Evaluation of COPD exacerbations with procalcitonin can decrease antibiotic use.

A PCT <0.1ng/mL indicates patient outcomes will not be improved with antibiotics.

Procalcitonin for COPD.pdf
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From the TR: CT before Lumbar Puncture

8/12/2016

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Before every lumbar puncture many providers reactively get a CT to rule out a mass or reduce the risk of herniation, However, not every patient requires a CT.