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We began the new year with Dr. Shearer explaining the program’s policies & procedures. You can find copies under the ‘Policies’ tab above. As for logging procedures, duty hours, presentations and evaluations, use the New Innovations link under the ‘Clinical’ tab.

Our first talk of the year was given by Ram, who lectured on penetrating chest trauma. Below are some points that merit repeating:

• - Unstable patients with stab wounds to ‘the box’  are either hypovolemic, have PTX, or tamponade. So get some blood ordered and get an ultrasound probe.
• - Pericardiocentesis is a pretty cool procedure that has almost no role in trauma at academic centers. The volume of blood that causes tamponade physiology is scant in trauma, and even if you can aspirate that blood, it will rapidly reaccumulate. For medical effusions, pericardiocentesis can be more easily done by ultrasound guidance — I refer the reader to p76 of Dr. Nelson’s ultrasound book, or to Dr. Hoffman’s website.
• - Ram pulled a great slide from Degiannis 2006 (PMID 16773259, figure 1) that lays out your options in penetrating cardiac trauma in various clinical scenarios. After PTX has been ruled out, the lifeless patient needs endotracheal intubation and ER thoracotomy. Accept it, and it will be easier to cut. Dr. Weingart has reviewed this procedure on his website, and he has also listed other indications and contraindications for thoracotomy.

Dr. Rabin delivered her core lecture on emergencies in malignancy.

• - Neutropenic fever is defined as an absolute neutrophil count below 500 and a temperature of 38.4C (or over 38C for more than an hour). Calculating ANC is easy (this calculator and others can be found under the ‘Clinical’ tab above). The admonition to avoid rectal temps in neutropenic adults is not evidence-based, though digital rectal exams remain contraindicated.
• - Work with the patient’s oncologist in deciding ABx therapy in neutropenic patients. Vancomycin should be avoided unless indicated by cultures, course or instability.
• - Be vigilant for tumor lysis syndrome: Order a uric acid and PO4 level on your chemo patients with nonspecific symptoms. Obviously you’ll get a potassium and treat hyper-K appropriately (perhaps avoiding Ca++ unless absolutely necessary) but the urate will need urine alkalinization, and high PO4 gets phosphate binders, plus insulin+glucose.
• - Hypercalcemia (stones, moans, bones, psych overtones) needs treatment if the patient is symptomatic or over 14 mEq. Correct the calcium if the patient’s hypoalbuminemic. Treat with hydration, lasix (after hydration), bisphosphonates, and dialyze if AMS or ARF.
• - Finally, be vigilant for DVT/PE, SVC, and spinal cord mets (said to manifest with back pain that’s worse upon lying down).

Dan presented the first (and second) M+M of the year. He gave a nice introduction to the various kinds of error we are prone to, and how cheese is the answer.

• - Dan also took us through the crash airway, difficulty airway, and failed airway algorithms (you should have a copy of Ron Walls’ book, and parts are freely available online).
• - Like our reluctance with thoracotomy, cricothyroidotomy is something we have to expect, so that it’s easier to cut when we have to. Here’s the NEJM cricothyroidotomy video. Youtube has other videos. And for the hardcore among you, here’s a keychain cric kit I once blogged about.
• - While we can recognize the importance of neuro status checks for our colleagues in neurosurgery, sedating intubated patients is crucial, especially with more planned trips to the CT scanner. The agent of choice? Propofol (the milk of oblivion — rapid on, rapid off, and recommended by the BTF for ICP control). And if propofol is lowering the BP, well, this is one time where pressors in trauma makes sense.

If you want to address some of the topics above, or other aspects from conference, please comment below.

There is a new article in JAMA published this week that attempts to make estimates for the risk of development of malignancy in patients as a result of a single coronary artery CT scan (CTCA) for evaluation of possible coronary artery disease. The is an especially prescient article for emergency medicine physicians given the large number of chest pain complaints that present to EDs and also specifically at our institution since we have now started to perform this test (not to mention that one of the co-authors of the paper is based at our medical center).

Briefly, the paper uses statistical risk modeling (called the Monte Carlo method, more about that later) to make estimates about the risk of development of malignancy as correlated with the level of radiation exposure from each of 4 different type of CTCAs and the age of the patient when the scan was done. Unsurprisingly, the risk of cancer development increased the earlier that the scan was done, but somewhat surprisingly the curve was quite concerning for patients dosed with radiation early in life. Particulary concerning were young females (20 years old) who had twice the RR and thrice the RR of their 40-year old and 60-year old counterparts, respectively, for the development of cancer during their lifetime.

Regarding the statistics, what is interesting is the Monte Carlo method was used for statistical modeling. This is the same mathematical modeling used for risk modeling in the insurance and financial industries, and the results bear striking resemblance. Much as the power of interest compounded over time is the great wealth creator, it seems that the effect of early radiation compounded over time is similarly potent for causing malignancy in later life.

This study is certainly limited in that it studied no real patients and simply extrapolated data from mathematical models. Further the authors did not compare this test with others that may employ similar or slightly lesser amounts of radiation. That being said, it should give pause that all the imaging that is ordered is not without risk, and even if that risk is small for the individual, the population-based risk — given the fantastic numbers in question — is not small indeed.