Wednesday Lectures, 7/22/2015

TTHM a1.4 PDR (7/22)

 

10a ~ PDR (Paolo)

General advice: *don’t forget about cric as option; *hypotension in the field = bad.  *Beware “stable for CT scan” in Trauma… *get BOTH Thorax & Lumbar spine MRI for Cauda Equina (spinal Sx do NOT well/localize!)… *Neuro & Rheumatology subjective Sx difficult to test or quantify… *Recheck Vital Signs (esp prior to DC) & *Nursing Notes most frequently missed data…

Notice of intent ~ makes you very angry.  1st step in a lawsuit, must respond within given time period…  (dukesw@upstate.edu EMS intubation project).  NYS NOI within 90 days of “event upon which the claim is based”.  NYS Lawsuit must be initiated within 1 year & 90 days of “event upon which the claim is based”. http://www.nycourts.gov/courts/6jd/forms/srforms/ntc_howto.pdf

 

11a ~ TQM (Shaw)

*Rare disease happens rarely, which means that it does happen.

*Epistaxis & HTN usually NOT HTN Emergency.

 

1230 ~ ED Admin (Joslin)

*Community Perspective (including EMS).  Appear Capable? Accessible? Compared to other Hospitals/EDs? What influences pt’s decision to come here? EMS? (No “take me to Crouse” resident joke shirts i.e.)… Greetings? Capabilities? Professional? Radio/Resource contacts/consults.  How do we handle EMS refusals? (There is a refusal policy/algorithm.)

*Hospital Perspective ~ Pt is “hospitalized to…” rather than ADM or OBS, if uncertain…

*Patient Perspective ~ worst day of their life. acknowledge.  learn about costs to help pt.  Decrease their length of stay, communicate.  Avoid unnecessary costs… i.e: “pt may take own home meds”.  Joslin hates CK-MB. (CK & CKMB ~ $102)

*Group Perspective ~ Team Health at St. Joes… different group models.  CROUSE is Hospital-based.  UHEM Physicians Group @ UH… Coding Charts… Charts are Level II, III, IV, V, Critical Care (30 to 60 minutes, high risk)…  LWOBS bad for business.  “Calling a consult is not a benign procedure”.  Avoid extraneous labs.  Don’t fish for nonemergent diagnoses.  “Pt condition improved after fluid administration” shows reevaluation, intervention, complexity…

 

130p ~ Bath Salts (Kloss)

Lecturing on Lecturing… doing conferences can be fun!  Syracuse as bath salts capital of the nation… new kids on the block ~ phenylethylamines ~ “25B” is one of the new ones ~ “AB Fubinaca” ~ “2ci, 2ce” = “Smiles”…

Substituted cathinones ~ “bath salts”… Leukocytosis c stress response.

*Can precipitate serotonin syndrome if pt on antidepressants… “wet dog shakes” autonomic instability leading to seizures…  MDMA identification charts “for law enforcement use only”.  Where do ppl purchase them? Alibaba… Darkwebs… Ebay… Bulk purchase as “Research Chemicals” “not for human consumption”… some ppl purchase precursor compounds… i.e: GBL to GHB… i.e: “Aqua Dots”  LegalBuds.com

*Spice/K2 ~ early synthetic marijuana

*Bath Salts/Plantfood ~ Cocaine/Ecstasy or LSD alternative

*Salvia ~ Diviner’s Sage ~ Mexican Mint ~ mild hallucinogenic

*Khat, Kratom ~ Asian Hallucinogen & Opiates…

John W Huffman ~ JWH-018

Syracuse Smoke Shop Industry ~ Twisted Heads on N. Salina, S. Salina, Tebb’s Headshop… in jail for Tax evasion. “Cloud 9”, “420 Emporium”

“Legal Buds” & “Herbal Smoke” since early 2000s…

Concentrations can vary 0.2 to 3% per serving of same chemical!!! Extremely variable chemicals & effects!  There have been reports of STEMIs & AKI!  Paranoia, agitation vs catatonia… VA “Primary Care Plus” often full workup, may include send-out urine cannabinoid tests in psychosis…

Dopamine ~ Pleasure

Serotonin ~ Hallucinations

“Krypton Kratom” in Sweden had Tramadol and Kratom (~opiate)

Crack free base & weak acid such as vinegar or lemon juice make better

Fun websites ~ EROWID.com ~ StreetRx ~ Opiophile

 

230p ~ Shock (Johnson) ~ “inadequate tissue perfusion”

*Hypovolemic ~ Blood Loss (chest, abd, pelvis, floor), Dehydration (I/O balance) ~ US exam

Massive Transfusion Protocol

*Cardiogenic ~ MI, arrhythmia, CHF ~ US exam

*Distributive ~ Neurogenic, Vasodilation, Anaphylactic, Septic ~ “warm”, hyperdynamic

*Obstructive ~ PE, tamponade, PTX, venous return ~ JVD

Needle, relieve obstruction…

…& remember adrenal insufficiency

Maximum IVF rate through wide short lines, rapid infusion ~500cc/minute max!

*MTP 1:1:1 ratio of PRBC:Plts:FFP typical, although other ratios possibly more ideal?

*TXA IS used if Trauma within 3 hours of massive trauma.  Consider calcium, cryoprecipitate, Factor VII, FEIBA, PCC… TXA validated by CRASH-2 trial (Lancet 2010).  End points of resuscitation somewhat unclear.  Repeat ABCs.  Recheck tubes & interventions.  Trace procedures & lines.

Troubleshooting: ABCDE… consider steroids!

Unable to intubate? = Cric.

Traumatic tamponade ~ thoracotomy > pericardiocentesis.

Stabilize fractures in Trauma Bay!

Don’t mess around with colloid!

 

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