Grand Rounds Recap 5.24.2017

Grand Rounds Recap 5.24.2017

Grand Rounds kicked off this week with Dr. Axelson's final M&M of the year where we learned about hypertensive emergencies, 2nd & 3rd trimester vaginal bleeding, the care of the sick asthmatic, which bronchiolitics can go home and how exactly to treat the many forms of UTIs. Drs. Kircher and Murphy-Crews continued the learning with a case follow-up about intubating patients with airway stents and pediatric head injury, respectively. Our joint EM-Peds lecture rounded out the day with visual diagnoses in peds. 

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Grand Rounds Recap 9/14

Grand Rounds Recap 9/14

This week we had a special visit from Dr. Darren Braude from the University of New Mexico Department of Emergency Medicine to speak on special topics in airway management. He introduced us to the idea of Rapid Sequence Airway (RSA) and other novel thoughts on extraglottic devices.  We then had a chance to dive in to our regularly scheduled program with topics ranging from tuberculosis to ED operations to complex febrile seizure.  Enjoy!

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Grand Rounds Recap 8/31

Grand Rounds Recap 8/31

Burns, bubbling airways and bradycardic arrests: all part of this week's grand rounds that brought plenty of knowledge our way. This week we heard from Dr. Dale, burn surgeon, about the latest in burn management. Dr. Carleton ran through some of his hardest airway cases for an infallable mental model of intubation. Our R3s gave a practical session on transvenous pacer placement and Dr Kircher gave us his clinical soapbox of pneumonia management.

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"Protect Me" - Flights Case 4

"Protect Me" - Flights Case 4

Welcome to the Fourth Case in our Air Care and Mobile Care Flight Orientation Curriculum for 2016! 

It is a beautiful sunny Memorial Day and you arrive early for your C-pod shift, energized by the knowledge that you will be getting out early with time to enjoy the day. Your patients are an enjoyable mix of pathology and acuity and everyone is quite polite and gracious. The tones drop just before it is time to hand over the radio to the dedicated flight doc and you can’t but marvel at your good fortune. You grab the blood and head up to the helipad for your flight...

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Out of Hospital Cardiac Arrest - Part 1

Out of Hospital Cardiac Arrest - Part 1

The UC Division of EMS has recorded a series of podcasts to celebrate EMS Week 2016.  We are honored to be able to engage EMS Providers throughout the world with this forum.  If you practice pre-hospital medicine, we would like to say thank you and that we appreciate everything you do to provide a high level of care to ill and injured patients in a wide variety of austere environments.  For this podcast, we were joined by Dr. Dustin Calhoun, Associate Director of the UC Division of EMS, as well as two of this year’s UC EMS Fellows, Dr. Mike Bohanske and Dr. Justin Benoit.

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Favorite Positions!

Favorite Positions!

Multiple casualties are brought to you from a house fire.  There are four victims:

  1. A 5’11” 70 kg woman with a GCS of 8
  2. A 5’9” 140 kg man with circumferential burns of the chest and neck
  3. A 20 month-old with a pedi-GCS of 10
  4. An elderly, 5’6” 65 kg man with no burns, but a history of severe CHF and complaining of chest pain and dyspnea

You determine that they all require intubation for various indications.  You choose RSI as the method for all except the morbidly obese patient, who you intend to intubate awake, with sedation and topical airway anesthesia.

Question:

How would you position each of these patients to optimize your chances of successful intubation on the first attempt?

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Flights - One Road too Far - Curated Comments & Expert Commentary

Flights - One Road too Far - Curated Comments & Expert Commentary

Thanks to everyone who chimed in for our first ever "Flight"!!  If you didn't get a chance to read the case, take a look here.  There was some excellent discussion on how best to care for the blunt polytrauma patient.  Below is the curated comments from the community and Dr. Hinckley's take on the questions posed to the community.

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Grand Rounds Recap: Critical Care Symposium - 2/4/15

Grand Rounds Recap: Critical Care Symposium - 2/4/15

Pressor Primer with Dr. Hebbeler-Clark

  • Norepinephrine seems to be on top in terms of vasopressor of choice currently (consider it your "easy button")
  • Per Surviving Sepsis Guidelines, Norepi has level 1B evidence as a first line pressor, while Epi is your second line with level 2B evidence and Vasopressin is currently ungraded in terms of evidence level
  • There have been 4 RCT's confirming that Norepi has no mortality difference from Epi and given it's safer side effect profile, use it regularly
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Grand Rounds Recap - 1/28/15

Grand Rounds Recap - 1/28/15

Mortality & Morbidity Conference with Dr. Bohanske

When volumes are high, remember the patient experience can be improved by acknowledging wait times when entering the room and apologizing for their wait.

Transverse myelitis is a result of partial inflammation of the spinal cord that can sometimes lead to necrosis.

  • The disease process is often progressive and function does not always return after treatment.
  • Most commonly this is idiopathic in nature but it is often attributed to a post-infectious inflammatory state.
  • Differential diagnosis should always include cord ischemia versus compression, and diagnosis hinges on a T2-weighted MRI.
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More than You Ever Wanted to Know About Extra Glottic Devices

More than You Ever Wanted to Know About Extra Glottic Devices

Our good friend Jim DuCanto visited us earlier this year. We spent several days sharing knowledge and perspectives.

Part of our time together was spent recording this podcast. It has been simmering and is finally available for listening. Within, we briefly go through the history of the extra-glottic device (EGD) in general, and then, we talk about the Laryngeal Mask Airway (LMA) and its “descendants” in great detail.

Jim really had a tremendous wealth of knowledge to share…

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Suction Assisted Laryngoscopy and Airway Decontamination with Jim DuCanto, MD

Suction Assisted Laryngoscopy and Airway Decontamination with Jim DuCanto, MD

Recently, one of our FOAMed friends came to visit the University of Cincinnati. Jim Ducanto is well known for his innovations and general wealth of airway management knowledge. One wonderful thing that Jim shared with us during his visit was an airway mannequin that he “modified” to be able to puke…yes…puke. Not sort of puke…but REALLY PUKE!! Here is what Jim has to say regarding the motivation for building the device as well as lessons we learned while doing it’s “beta-test”.

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Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown

Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown

In 2012 in the Annals of Emergency Medicine, Weingart and Levitan published a review of preoxygenation and peri-intubation oxygenation techniques in the emergency airway management of adult patients.  Topics reviewed included the evidentiary support for preoxygenation and denitrogenation, appropriate positioning and patient selection, the utility of positive pressure in select circumstances, apneic oxygenation, as well as a proposed risk stratification approach based on pulse oximetry levels and peri-intubation risk.

A great discussion was had with many excellent learning points, upon which some were elaborated in great detail in the article and some only briefly mentioned.  What follows is a brief summary of learning points from the article as well as from the discussion. 

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The Glories of End Tidal CO2

The Glories of End Tidal CO2

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

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