Wednesday Lectures, 04/29/2015

TTHM 11.4 PDR/TLLT  (4/29) An Update on Blunt Abdominal Trauma

10a ~ Paolo

Case Study, Ibeam to the chest

Second FAST exam increases sensitivity in blunt abdominal trauma…

Trauma CTs, PanScan utility? Appears to have Mortality benefit, but may have bias relating to selecction & diagnosis lead time…

Repeat CT without Contrast? Pretty good for hollow viscous injury…

FAST ~ find nothing then nothing changes, PanCT not going away, hollow viscous doesn’t need contast…

ATLS circulation & hemorrhage control…

Early aggressive crystalloid resuscitation, not great for blunt trauma.  More IVF, the worse they did… 1L challenge ok, then dose~effect response with worse outcomes somewhere <5L total.  In elderly people, >1L can increase mortality!  Resuscitate too the BP… 3 studies in humans on permissive hypotension… 1994 significant, but trials 2&3 say no difference… Left with anecdotal evidence otherwise… EMS giving RBC vs crystalloid, did much much better.

Permissive HoTN NEVER in context of TBI!!!  “Salt water continues to not carry oxygen.”

Hemodynamic Resuscitation 1:1:1? If you live long enough to get 1:1:1, mortality is skewed by selection bias of survival…

PROPER Study in JAMA prospective on 1:1:2 (RBC) only difference was death dt hemorrhage… less in the 1:1:1?! but no overall mortality benefit between groups.

TXA! CRASH2 trial lysine analog to inhibit fibrinolysis… Early administration by EMS may be efficacious, but not as useful dt by the time of Massive Transfusion Protocols… effective but can cause clots.  “Any drug that causes you not to bleed will cause you to clot”.

Early initial studies always show maximum benefit, minimal harm…

 

11a ~ PSQ (Kajla, Shaw)

Read your own films… Signout Radio calls ?EPIC funtionality… Beware complex presentations in elderly ppl with atypical symptoms…

 

1230p ~ TLLT (Schenker)

*Ibuprofen v Ketorolac? Efficacy similar… Gout Indomethacin NOT better than other NSAIDS.

Placebo of IV/IM versus po meds? Anecdotally, maybe, but poor evidence.  ALL NSAIDs cause bleeding.  We want to block COX2, but spare COX1 if possible…

*EM Dental: Front incisor fractures most common… #s 1 to 32 or Orthodontic R upper 1 to 8…

Ellis fractures: 1) Enamel, 2) Dentin, 3) Pulp, deeper need more intensive therapy.

Tooth Concussion ~ mechanism can cause tooth to be mobile in socket

Subluxation (loose) vs Luxation (displacement)… tooth can be jammed into alveolar bone…

Wisdom teeth can cause Pericoronitis or Operculum… can become infected, Penicillin or Clinda recommended…  “Vincent’s Disease” (ANUG) not to be confused with Herpetic Gingivostomatitis…

Alveolar Osteitis, aka “Dry Socket” should have Abx until dental follow up.

Ludwig’s Angina & Cavernous Sinus Thrombosis can be severe dental complications…

Post Extraction Bleeding, apply pressure, silver nitrate, surgicell or gel matrix foam…

Tongue Lacs may need deep & superficial sutures…

Lip lacs beware Vermillion border…

Dental Anesthesia, blocks… Oral Candidiasis (thrush)

Gingival Hyperplasia c phenytoin or CCBs…

Leukoplakia, progressing to squamous neoplasm on tongue…

“Magic mouthwash” ~ Viscous Lidocaine, Benadryl, Maalox (swish & spit)

 

130p ~ Journal Club (Haswell)

*Some benefit from Thoracotomy in select group of blunt trauma ED pts…

Having prior vitals or less CPR time helpful for outcomes.  Long down times are prognostically poor… uncertain for Thoracotomy vs base survivability… Only 1/2 of the surviving thoracotomies had possible beneficial interventions related to thoracotomy.

*Presyncope pts: who had poor outcomes?

Surprisingly high discharge rates in Canada? Followup access better?

Physicians do a good job at calling some things like PE, DVT, but poor at determining poor sequelae of syncope & presyncope.

 

230 ~ Faculty Grand Rounds (Sarsfield)

Stan Goettel (~Jay Scott) ~ ACLS & PALS… Instructor classes during TLLT/Admin…

Review of EM Clerkship… Observing H&Ps, clerkship goals & objectives, LCME objectives…

Developing plans, giving feedback, list of common complaints…

New Eval Cards & Give Feedback “This is Feedback”…

Signout Protocol? Need to be standardized?

*ALWAYS assign receiving resident/Attending BEFORE talking about the pt.

Typically we have one resident run signout & assign new residents, another resident comments.

When pts are discussed prior to assignments or designation as a “SIGNOUT” patient, this can cause miscommunication & confusion.

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