Pearls From Wednesday Lecture (7/23/2014)

  • 10a Paolo, Program Director Rounds

    • Pharm, “Pt Assist Programs” Rx discount for brand names… “mab” is $$, Profits > Pts? perhaps.
    • Repeat Imaging c Transfers… might be reasonable in select circumstances such as q6 headCT, although clinical reassessment is better anyways. Try to get a formal report rather than repeat!
    • PE & Thrombolysis (update from 2002 study)… 25% Sudden Cardiac Death, previously shown better c anticoagulation?… “I don’t know if it works. Maybe if you’re dying I’ll give you tPa because I’ve got nothing else”. Systematic Review found mild total decreased mortality risk in mild to moderate size PE. …BUT NNT(59, All cause mortality) > NNH(18, major bleeding)
    • Head Trauma & Emesis in Peds… PECARN risks increase bleed risk in Observation vs CT pts, only ~15% truly “isolated vomiting”, lower risk, but still 2/815 had TBI CT abnormalities (SDH, EDH). Timing & # of emesis episodes didn’t matter much. NO WAKE UP @home.
    • Family Watching CPR… family presence started 1980s, was anecdotal, 2010 AHA recommended presence… 2013 study found short term improvement in psych parameters of witnessing family members, now PRESENCE trial (’09 to ’11) showing some long term benefits as well (lower long term grief problems & PTSD). Bottom line: LET FAMILY DECIDE.
    • US in PE (should have DVT study anyways) low sensitivity of Cardiac US alone… MultiOrgan US (lungs, heart, leg veins) compared v CTA. Sensitivity 90%, Specificity 86% (c Wells >orEq4, or pos Ddimer pts).
  • 1230p Research Design, Wojcik
  • 130p Maraffa (Tox)
    • Approach to Poisoned Patient – Clinical Hx!, EKG, pupils, bowel sounds, vitals, skin, APAP lv (4hrs if elevated for Nomogram), ASA lv, check GLUCOSE!
    • Tox as leading cause of heart attack in pts <40yo… Don’t forget Naloxone in ABCs (“B”) & Dextrose in ABCD…
    • Opioids common OD, don’t forget similarity to Clonidine. We have “dirt cheap” heroin epidemic in Onondaga County, especially c Rx narcotic crackdown…
    • EMS systems talking about Naloxone use in the field for reversal (competetive mu antagonist).  Single dose 0.4 to 2mg Naloxone. NYS can do IntraNasal Naloxone via BLS!
    • Neonates can have Sz from Naloxone! Orogastric Lavage NOTproven helpful for any drug to date.
  • 230p D.Cooney, EMS Overview
    • 911 calls routed to nearest Emergency Call Center.  Dispatcher uses dispatch card algorithms to assigned ALS/BLS/priority (lights & sirens?) resources.  EMS goal to start care <10min from call Single v 2 Tier Ambulance systems, here we are single tier NYS (ALS & BLS on rig)

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