Procedural Sedation Cage Match

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Procedural Sedation Cage Match

It's a typical busy post-Thanksgiving shift in the ED.  It seems like patients with acute decompensated heart failure, sepsis, NSTEMI's and a whole host of other ailments are tucked in every corner and crevice of the ED.  Just as you finish putting in orders on the last patient you saw, your next patient rolls by on an EMS stretcher.  You see from your computer that the patient is on a backboard and in a c-collar after what clearly was some form of traumatic event.  He's screaming in pain and holding his left leg flexed at the hip and internally rotated.  "Jeez, I bet that hip is dislocated," you say to yourself.

You know you're going to need to reduce this dislocation, to not do so would risk avascular necrosis.  Tammy, one of the nurses you are working with that day is already 2 steps ahead of you.  "Doc, we're getting everything set up for the sedation, you're going to need for that hip that's out. What drugs do you want us to pull up?"

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Grand Rounds Recap - 11/19/2014

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Grand Rounds Recap - 11/19/2014

Mortality and Morbidity Conference with Dr. Gozman

Thrombocytopenia

Always consider medications as a key cause of throbocytopenia

Recommendations for platelet transfusion currently include:

  • Patients on chemotherapy with <10K
  • Patients requiring central venous access with <20K
  • Patients requiring an LP with <50K
  • Patients requiring non-neurologic surgical interventions with <50K
  • Patients requiring CNS surgical intervention with <80K

There is not data to support platelet transfusion in patients with intracerebral hemorrhage on an antiplatetlet agent

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Grand Rounds Recap - 11/13/14

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Grand Rounds Recap - 11/13/14

SBIRT (Screening, Brief Intervention, Referral, & Treatment) for Substance Abuse

Why should we care?

  • Prevalence of this disease is impressive with greater than 33,000 deaths attributed to alcohol in 2012 alone (287,000 MVC's in Ohio alone attributable to alcohol)
  • Medical problems attributable to alcohol use costs the US $100,000,000,000 annually (from health care bills to lost productivity)!
  • Approximately 33% of inpatient admissions in a country hospital population were attributable to alcohol
  • One in five Americans can be defined as at risk drinkers
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The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

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The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

80% of heroin users start by abusing prescription medications – this is OUR problem         

Prescription medication overdose is now the leading cause of death from injury and the number of deaths from drug overdoses has increased every year since 1999. Estimates suggest between 6 and 12 million Americans receive prescription drugs either without prescription or without the intent of relieving pain. This article focuses on the ED provider’s role in this epidemic and offers strategies for improving training and education surrounding these medications. While heroin abuse tends to draw more attention, it is important to note that 80 percent of heroin users started their addiction by using prescription medications.

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Cyanide Poisoning - Recognition and Treatment

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Cyanide Poisoning - Recognition and Treatment

Hey everybody! Dr.’s Hinckley, Steurwald, and myself sat down recently to talk a little bit about hydroxocobalamin (Cyanokit) and put together the attached podcast. 

Here are a few take home points and additions regarding this cherry-colored elixir of wonder: 

  • Think about hydroxocobalamin in your hemodynamically unstable or otherwise SICK patients who have a history of smoke exposure in an enclosed space or a known industrial exposure to CN containing material. This stuff works fast and can be life saving.
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Interpretation of Ankle Radiographs

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Interpretation of Ankle Radiographs

A 43 year old female presents to the ED after "rolling" her ankle while gardening.  She states that she was stepping down on a shovel when her ankle rolled.  <She describes to you and inversion type injury.>  Being a diligent, studious physician, you quickly run through the Ottawa Ankle Rules while you obtain the remainder of you history and physical.  She was unable to bear weight immediately after the accident and is, likewise, unable to do so here in the ED.  She has no pain with palpation over the medial malleolus but does have significant pain and tenderness with palpation of the lateral malleolus.  You quickly decide that this patient will need ankle radiographs to further investigate the possibility of fracture.  

But, what views should you order? And, once you get the films back, how do you interpret them.  Check out the excellent video embedded below, made by Dr. Claire O'Brien, PGY-1 in the University of Cincinnati Dept. of Emergency Medicine Residency Training program, to find out!

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Grand Rounds Recap - 11/5/14

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Grand Rounds Recap - 11/5/14

Background of the simulation: eclamptic seizure leading to cardiac arrest

  • Eclampsia should be high on the DDx of seizure for women of child bearing age without past history of seizures
    • Eclampsia typically follows the 1/3 rule: 1/3 occur after 20 weeks gestation, 1/3 occur antepartum, and 1/3 occur postpartum (up to 4 weeks)
    • Be aggressive about seizure management with benzodiazepines and use magnesium (4-6g MgSO4 IV over 10 minutes, followed by a drip for neuroprotection)
    • Follow magnesium levels clinical using reflexes and respiratory rate
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Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

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Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

A 68 year-old man presents by squad with shortness of breath.  He is noted to have a nearly quiet chest with very poor air movement, to be using accessory respiratory muscles, and to be slightly lethargic.  Quick perusal of old records discloses a history of severe COPD, steroid and O2 dependence, HTN and ulcer disease.  The squad reports that his O2 sat was 86% at the scene, improving to 92% on a NRBM and two nebs.

His vitals are:  p 138, r 22 and labored, bp 156/96, O2 sat 92% on a high-flow NRBM.  His POC renal returns with a pCO2 of 88.  His estimated weight is about 175 lbs.

A decision is made to intubate. 

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EMS Scope of Practice

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EMS Scope of Practice

Recently, I had the pleasure of sitting down with Dr. Dustin Calhoun, EMS faculty member within the Department of Emergency Medicine at the University of Cincinnati.

Dustin had been responsible for an EMS fellow didactic session covering EMS scopes of practice and EMS licensure. While on the surface these topics may seem a bit “boring,” I found our examination of the complexities quite interesting. In fact, I found the session so useful that I asked Dustin to record this podcast with me (and I’m a former EMT!).

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Grand Rounds Recap - 10/22/14

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Grand Rounds Recap - 10/22/14

Acetaminophen can be one of the most dangerous drugs in overdose, as the toxic dose of acetaminophen is 250 mg/kg

There are 4 stages of acetaminophen overdose:

  • Stage 1 from 0-24 hours when labs may be normal but the patient has nonspecific symptoms such as nausea, vomiting, and fatigue
  • Stage 2 from 24-72 hours when labs may be normal or be trending upward but the patient is asymptomatic
  • Stage 3 from 72-96 hours when significant metabolic derangement can occur such as profound metabolic acidosis, florid liver failure, and AKI.
  • Stage 4 takes place only if you are able to get them through the acute illness precipitated in Stage 3 when hopefully recovery takes place, though there is no guarantee of liver recovery
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Ebola Preparations: The Greater Cincinnati Area EMS Provider Perspective

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Ebola Preparations: The Greater Cincinnati Area EMS Provider Perspective

As we are all coming to realize, there is a tremendous amount of information to digest when it comes to preparations for potential Ebola cases...

I sat down with Dr. Don Locasto and Dr. Dustin Calhoun to discuss their work with the PHEMAC committee. PHEMAC stands for "Public Health EMS Medical Directors Advisory Council." They exist specifically to deal with situations like this within our region.

PHEMAC recently released an update to all regional EMS providers. The goal of the update was to distill down all of the information out there into a useable form for our local teams. The text is available below.

Our discussion summarizes these initial recommendations, as well as makes suggestions for staying up-to-date as more recommendations are released. You can listen to the podcast here, or by subscribing to us through iTunes.

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Grand Rounds Recap - 10/15/2014

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Grand Rounds Recap - 10/15/2014

Prescription Drug and Opiate Epidemic with Dr. Shawn Ryan

The US is the #1 country in the world for opiate prescription drug utilization

  • The numbers quoted are likely greatly underestimated due to inconsistent documentation
  • Death rate from opiate pain medication (OPM) has quadrupled in the time span of 1999-2010
  • Death rate in 2012 was 5.6 per 100,000
  • In 2011, 44 people per day died from opiate overdose in the US
  • In 2007, unintentional opiate overdose became the leading cause of death in the US for young population
  • OH death rate has grown faster than the national rate. At this time 5 people/day die in OH from opiate overdose
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B Pod Case Reports: 22 Year Old with Difficulty Swallowing

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B Pod Case Reports: 22 Year Old with Difficulty Swallowing

Chief Complaint

Difficulty Swallowing

History of Present Illness

The patient is a 22 year old female with no significant past medical history who presents to the ED with a chief complaint of dysphagia.  The patient first noticed difficulty swallowing solid foods 2 weeks ago. She states that she felt like food was getting caught in her throat.  Initially she only had difficulty swallowing solid foods and was able to eat soft foods and liquids.  However, she reports that over the course of two weeks her condition gradually worsened to the point where she could no longer tolerate fluids. She states that she has pain in the back of her throat when she attempts to swallow.

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