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Hello everyone,

Thank you to those of you who passed up Ponte Vedra or new jobs to come to conference this week. Many thanks to our resident speakers, Matt, Shefali and Bing, and to our faculty presenters — Dr. Spina and Dr. Nassisi. Also thanks to the neurology department for their participation in our joint conference.

Below are some topics from conference that for which I found more resources, or that I just thought warranted repeating.  Feel free to add your own thoughts in the comments section.

EGDT in patients with ESRD — lactate, catheters, and IO access

• -Matt mentioned Shapiro’s 2005 paper correlating lactate and mortality. As luck would have it, I blogged about this paper two years ago — check out the recap (and be sure to read Dr. Park’s and Dr. Weingart’s comments). Bottom line: lactate is our proxy for tissue oxygenation — check it with all your blood cultures, and check the trend.
• - Matt’s discussion covered the variety of dialysis catheters we come across, and matching the eponyms to the clinical significance. You can ask him for pics and explanations, or you can make do with the straightforward guide in Dr. Lisa Marcucci’s book. I also thought Tintinalli had some good tips in Chapter 21.
• Some more great tips, via Dr. Strayer’s recap of the case:

* Oxygen delivery trumps fluid overload considerations. Aggressively pursue your CVP goals, even in the end stage renal disease patient.

* Coagulopathy does not preclude central line placement. The procedure should not be delayed for correction of coagulopathy if the absence of a central line significantly compromises optimal management. In these cases, the subclavian site is the last choice as the vein is non-compressible.

• - Finally, Matt had some fun talking about IO drill and power tools. Sinai uses the EZ-IO — youtube has many helpful videos of this, and here’s one. There’s one in peds resus.

Peds Cardiac Emergencies — The vitals, the hyperox test, PGE1, and a TET spell

• - The four things to get on a suspected on a neonate or infant with suspected cardiac emergency are: 4-extremity BP, upper- and lower- O2 saturations, EKG, and CXR. Also consider the hyperoxygenation test: Give the kid 100% 02 for 10 minutes. If the PaO2 rises to over 150 mmHg, it’s likely a pulmonary problem. If it’s below 100 mmHg, it’s likely cardiac. (Though this makes a lot of sense, if you can find better evidence for its efficacy than this, let me know).
• - Giving PGE-1 can be lifesaving, in reopening a closing ductus arteriosus in those dependent on it. The dose is 0.05-0.1 mcg/kg/min after a bolus of 0.1 mcg/kg.
• - Dr. Spina had some great slides showing the various anatomic abnormalities, but the one I liked best was this memorable drawing of a tet spell.

Reversing anticoagulation in the setting of ICH — our protocols, Vit K myths and reality, and a modest proposal

• - Bing and Shefali both presented on cases requiring reversal of intracerebral hemorrhage. Our protocols for Sinai and Elmhurst are online — use them! Also, Phil has posted a nifty evidentiary table for all the studies that involve reversing bleeds.
• -Vitamin K (from the German koagulationsvitamin), is a slow-onset, long-acting drug, even when given IV. And the IV form is associated with a tiny but real risk of anaphylaxis (and no, slowing the rate or decreasing the dose won’t help the odds). PCC is faster acting and the blood banks shouldn’t give you trouble about releasing it.
• -We’re thinking about a triage protocol where anyone on warfarin with a chief complaint of headache gets moved to the resuscitation bay. If you’re senioring for the first time next week (gulp) be mindful of this scenario.

Skin and soft tissue infections — cultures, MRSA suspects, rabies guidelines, and more

• - Dr. Nassisi gave a great talk on one the areas of her expertise: management of cellulitis, erysipelas, abscess, and soft tissue infections.
• - We’re now culturing (with the culture swab) pretty much all our abscesses, and treating anyone suspected of MRSA (multiple abscesses in recent months, comorbidities like diabetes or confounders like large size, or abscess over a joint space).
• - If there’s a cellulitis overlying your suspected MRSA abscess, cover strep as well as MRSA (bactrim will be inadequate).
• - The Sinai ED antibiotic guidelines are available online, and provide not only guidance, but the rationale for your therapy. Use it.
• - If you’ve got a patient with unilateral calf swelling and are suspecting DVT, but don’t know how to explain their fever, think pyomyositis.
• - Keflex is insufficient prophylaxis for cat (and many dog) bites. After tetanus, irrigation, and informing the patient of the wonders of delayed closure, if the patient is at risk of complication or has comorbidities, prophylax according to our guidelines. If they’re coming in with an already-infected bite, admission is indicated.
• - And if the offending animal can’t be observed, here’s the rabies guidelines. Remember to report.
• - Dr. Nassisi is looking for residents to revise our ABx protocols, and to work with her on an upcoming MRSA edition of EMPractice. It’s a good opportunity –email me to get in touch.

Posted on Sunday, June 29th, 2008 at 12:17 pm by Nick. Filed under Stroke / TIA, Post-Conference Letter, Risk Stratification, Useful Links, Sepsis, Infectious Disease, Blog.
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