Program Director’s Rounds: Articles

Intracranial Bleeds after Minor and Minimal Head Injury in Patients on Warfarin
J Emerg Med. 2015 Feb;48(2):137-42.
doi: 10.1016/j.jemermed.2014.08.016.
Epub 2014 Nov 4.
PubMed
Full Text

Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes.
JAMA Intern Med. 2015 Mar 1;175(3):428-36.
doi: 10.1001/jamainternmed.2014.7657.
PubMed
Full Text

Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections.
N Engl J Med. 2015 Mar 19;372(12):1093-103.
doi: 10.1056/NEJMoa1403789.
PubMed
Full Text

Community-acquired pneumonia requiring hospitalization among U.S. children.
N Engl J Med. 2015 Feb 26;372(9):835-45.
doi: 10.1056/NEJMoa1405870.
PubMed
Full Text

Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease.
N Engl J Med. 2015 Mar 14. [Epub ahead of print]
PubMed
Full Text

Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial.
Lancet Neurol. 2015 Apr;14(4):361-7.
doi: 10.1016/S1474-4422(15)70018-9.
Epub 2015 Feb 12.
PubMed
Full Text

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Journal Club Articles

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http://onlinelibrary.wiley.com/doi/10.1111/acem.12565/epdf
The Effect of Laboratory Testing on Emergency Department Length of Stay: A Multihospital Longitudinal Study Applying a Cross-classified Random-effect Modeling Approach
Ling Li PhD, et al
Article first published online: 6 JAN 2015
DOI: 10.1111/acem.12565

http://onlinelibrary.wiley.com/doi/10.1111/acem.12604/epdf
The Use of Subdissociative-dose Ketamine for Acute Pain in the Emergency Department
Billy Sin PharmD et al
Article first published online: 25 FEB 2015
DOI: 10.1111/acem.12604

Wednesday Lectures, 3/25/2015 (Sim, Tox, & Grand Rounds Day)

10a ~ Tox ASA & APAP (Marraffa)
APAP: NAC (IV v po) now 24 hours after ingestion(s).
We overtreat many ppl c NAC, probably ok.
Activated Charcoal can interfere c oral NAC? so IV NAC more often given now.
starting NAC “within 8 hours of OD & no one gets sick”. Wait for the 4 hr level.
NAC doesn’t taste bad, just smells terrible. IV NAC comes in D5W so beware Sodium balance for cerebral edema, Sz risk, etc… IV NAC could also have anaphylactoid rxn if given too fast!
Oral NAC delivers to liver, so maybe more direct first~pass…
Fulminant Hepatic Failure goes to Rochester… Kings College Criteria…
Lactate >3.5 c APAP tox, or Lactate>3.0 after Resuscitation is 90% predictive (sensitive) for mortality.
Continue NAC until AST <1000, or until AST/ALT 150mg/kg, Life Threatening >500mg/kg? No HalfLife in OD bc it becomes saturable, Zero order kinetics (Michaelis Menten model)
ASA uncouples ATP synthase pathway & causes Resp Alk, Met Acidosis, tinnitus (Lv >30), neuroglycopenia, keep so keep >euglycemic! pH 100mg/kg.
ASA (“Done”) Nomogram exists but not very reliable…

11a ~ Faculty GR Pt Experience (Frechette, Hospitalist)
Learning to Convey Empathy! (a.k.a. being a good actor)
Press Ganey, Innovation… Storytelling in the patient experience…
consider humor in medicine in relating to patients, although be careful.
HCAHPS Medicare survey tool being used to create hospital accountability & create incentives.
Press Ganey different, independent company. Best doctor scores always the best hospitals. Doctors are symbolic of a hospital’s worth?
“Did the doctor treat you with courtesy & respect?”
“Did the doctor listen carefully? …explain things?”
*Pts want CONFIDENCE in their doctors. (Maybe gray hair helps)
*Pts want sense that their care is well COORDINATED. Organize the messages & people.
*Pts want to perceive our EMPATHY.
Be adaptable, “chameleon”…
Tell stories to relate personal experiences. Being a patient creates sympathy, which can support empathy.

12p ~ TQM (Goldberger)
Safety in the ED now that Security carries Vocera…
ED is a potentially dangerous job, assault stats…

1230p ~ SIM EXTRAVAGANZA (Rodriguez) ~ Log Procs!
Rodriguez Sarsfield CVC IJ SC Femoral
EShaw LP, LP
Prince ChTube DPL/Paracentesis

Wednesday Lectures, 3/18/2015 (Joints & Rheum Day)

TTHM 10.2 (3/18) Joints & Rheum Day

 

10a ~ Ankle (Laporte)

Ottowa Ankle Rules

Maissonneuve Frx ~ Distal Tibia, Proximal Head of Fibula, c injury of syndesmosis

Weber classifications (A, B, C) for ankle distal fibular frx

Tibia Pylon Frx

Achilles Tendon Rupture

Arthrocentesis of Ankle…

1030a ~ Septic Arthritis & Gout, MonoArticular Arthritis (Army)

Tap it!  Beware alternate diagnoses, GC even in elderly population.

Podagra is 1st Toe Gout (negative biorefringence)… vs Pseudogout (Ca pyrophosphate disease, POS biorefringence)

Acute Gouty attacks treated c NSAIDs, possibly steroids… Diet recommendations…

Septic Joints mostly Staph, Strep, ~10% polymicrobial

Abx choice varies depending on joint & bacterial involvement

11a ~ Small Groups (Weidman, Rodriguez)

Extremity Trauma, splinting, cast removal exercises…

1230a ~ Jr/Sr Sessions (Lavoie, Weidman)

Metatarsal Fractures >3mm displacement or 10* Angulation might be reduced before immobilization, Lisfranc Injury can be ligamentous, or frx… Cuneiform & 2nd metatarsal alignment; up to 10% may get a foot compartment syndrome, pain with passive movement?…

Jones & PseudoJones 5th metatarsal frxs

Achilles avulsion or tear splinted in “Equinus” position 45* plantar felxed short leg splint.

Bohler’s Angle in Calcaneal fracture should be normal 20 to 40*.

Distal Fibular Fractures Weber A, B, C depend on position relative below, at, or above tibial mortise. A can be managed conservatively ~ sprain.  B & C need more thorough splinting & likely surgical intervention, non weight bearing until SG followup.

TibFib frxs high risk for compartment syndrome.  Likely SG & OBS…

Open Fractures ~ Gustilo Classification (I, II, III~abc) & Abx NOW, within 3 hrs!

Ancef still recommended, with potential broader spectrum, depending on exposure…

130p ~ Hip & Femur (MacConaghy)

Femoral Neck Frx, disruption of “Shenton’s line”

Allis Technique for Hip Reduction

Check big fractures for small punctures! Open needs Abx!

Femur Frx can bleed out! Avg blood loss 1L, can go to ~3L

2p ~ Knee (Knutsen)

Lachman > Drawer Test

McMurray & Apley tests for meniscal injury

Plan for internal derangements: knee immobilizer, Ortho followup for outpt MRI

Pain control, DC?…

crutches & advance weight bearing as tolerated after initial RICE…

Tibiofemoral joint dislocation is bad! reduce ASAP…

CTA needed after reduction dt high risk for vascular injury!

Patellar Frx & Patellar Tendon rupture need rapid repair for fxnl restoration…

Tibial plateau frxs can be occult but serious, talk to Ortho…

230p ~ Rheum Emergencies (Rossettie)

~feedback to rossetta@upstate.edu, por favor.

3p ~ Foot (Prasad)

Lisfranc junction, Chopoff’s joint?, Torus fracture…

Jones frx, pseudojones…

Wednesday Lectures, 03/04/2015

TTHM 9.4 (3/4/15) Program Director Rounds

10a ~ How ED Docs Think (Paolo)

Quick Decisions on very limited information

Acquire knowledge (horizontal) vs vertical knowledge by analogy.

Simple Probability & Bayesian Probabilities… IF … THEN … to get odds…

Experience & Environment & Emotion affect decision making.

Forward Driven (data) > Backward (hypothesis) Driven

“Thinking Fast, Thinking Slow” (Croskerry, Type 1 “Intuition”, & Type 2 “Analytical” decision making) “Blink” (Malcolm Gladwell)

Heuristics ~ methods of processing information

Like ACLS… IF/THEN Algorithm medicine.

Errors based on Heuristics, Individual Bias, & Perceived risks…

“Framing Effect” of Biased option presentation, difficult to identify & reduce…

Think about your own biases!

 

1045a ~ Epiglottitis Case Presentation (Mangano)

Keep the differential broad & utilize available resources (i.e. Anesthesia @ CGH)

 

11a ~ PSQ (Martini/Shaw/Adcock/Weidman)

 

12p ~ EPIC Tips (Michael Longo)

My Dashboards useful for internet resources

New Themes!  ED Map coming in April.  PSY paperwork can be found by searching “forms” under orders menu!

 

1230 ~ TLLT (Kinariwala)

Platelet Transfusion on AntiPlatelet Therapy (Clinical Controversy) in setting of Traumatic ICH

Neurosurgery recommends reversal.  Neurology does not, within same institution.

Clopidogrel ADP antagonism…

One Unit Plt TF raises Plts count ~30K, & estimated half will be functional?

ASA & Plavix not well associated c increased Trauma Mortality, unlike Coumadin!

Platelet function testing can be sent to lab, but no POCT & probably not super useful.

?Desmopressin to increase Plt fxn?

*Efficient H&P… Sensitivity, Specificity, LR Review…

 

130p ~ Journal Club (Pryor)

*ARISE trial: does EGDT reduce mortality at 90 days vs “standard care” in Australia/New Zealand, Hong Kong… NO Significant Difference, no additional benefit.

Perhaps now because standard of care reflects pieces of EGDT in community practice (including early Abx, IVF resuscitation, Cultures, Lactate, Pressors & Monitoring prn…)

*Intra Arterial treatment of acute ischemic stroke: Netherlands phase 3 trial included mechanical or chemical thrombolysis/thrombectomy, within 6 hrs of CVA onset, outcomes based on Modified Rankin Scores & then NIHSS at 24 hrs & 57 days…

Typical care included IV tPA, but trial group had intra arterial interventions c preliminarily positive results.

 

230p ~ Faculty Grand Rounds (Brenner)

Decision Making Capacity & Surrogate Decision Making

What is Ethical vs. What is Legally Required?

*Respect for Autonomy, vs.

*Beneficence ~ doing what is in the pt’s best interests (sometimes pt may not know what they want or what would have most desirable outcome for them)

“CAPACITY” is a MEDICAL decision.  “COMPETENCE” is a LEGAL decision.

Capacity: Dr. Bernie Lowe @ UCSF: Consider Mental Status,  Reasoning, Psychiatry consult…

CURVES Mnemonic: Choose & Communicate, Understand, Reason, Value, Emergency, Surrogate)…

*Consider “.Capacity” or “.CURVES” smartphrase!

Family Health Care Decisions Act of 2010 (FHCDA) determines Hierarchy of next of Kin.  In NYS: Spouse, Adult Children, Parent, Siblings, Close Friends, 2PC…

(initially based on inheritance law)  <http://www.nysba.org/FHCDA/&gt;