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Thanks to Bing, Dr. Okuda and Dr. Strother for a wonderful day of sim cases this week. Special thanks to all who had to tolerate my acting.

A few questions came up during the discussions, and, I’ve been trying to research with limited success.

The first question concerned antibiotics for heat illness. Certainly in ambiguous cases, where there is altered mental status with moderately high temperature, antibiotic coverage is mandated. But in our case, of the athlete on a hot day? It was asserted that the heat stress leads to gut flora dissemination, and antibiotics are warranted. But I could find no reference for this, and my usual sources are silent on the issue of prophylactic antibiotics.

The second question revolved around safety factors for emergent sedation. Specifically, I wondered if the risk of aspiration in emergent procedural sedation had been quantified in adults. It turns out there’s a lot of opinion on this matter, but not a lot of data. More below:

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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.

At our last Journal Club, Tom presented a 2005 paper from JEM on new CT scanners in the evaluation of SAH. The paper was called Subarachnoid Hemorrhage Diagnosis By Computed Tomography and Lumbar Puncture: Are Fifth Generation CT Scanners Better at Identifying SAH? by Boesiger and Shiber, and it appears in Journal of Emergency Medicine (2005: Vol. 29, No. 1 pp23-27).

The article is motivated by the fact that 1% of headache patients in the ED have SAH. Most are traumatic, but those that aren’t are usually from Circle-of-Willis aneurysm ruptures, which often kill or disable otherwise healthy people. EM physicians hate that sort of unsettling risk, and the situation is further complicated by the 20-50% of SAHers who present with a sentinel bleed. So there’s a real opportunity to help some potentially moribund patients —  but if you ask most interns, they’ll say they’re shoving too many needles into the backs of people who probably just needed some exedrin.

Maybe we can change our practice, based on recent upgrades in CT scanner technology. These authors were the first to look at the new scanners with an eye toward sensitivity in SAH diagnosis. More below…

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Lynn was telling me about a case she saw this year – if I recall, it was a young man who developed uncontrollable hiccuping after an inguinal hernia repair. I don’t know what happened to the guy, but I saw my first hiccuping patient shortly thereafter. As I surf the web, I keep coming across remedies for this unusual but vexing complaint:

• Methylcellulose (to expand the stomach) 
• NG Tube (to decompress the stomach)
• An implantable vagal nerve stimulator
• Pressing on the ears while drinking through a straw
• Digital rectal massage (also reported in Annals of EM)
• Chlorpromazine 25-50mg IV (the only FDA-approved agent for intractable hiccups)

Our anesthesia colleagues have looked at this issue, as hiccuping in the OR is a pressing concern. Unfortunately, a systematic review (Kranke, Eur J Anaesthesiol 2003 Mar;20(3):239-44) turned up lots of anecdotes, but only one (inconclusive) RCT:

A large variety of interventions have been proposed for the treatment of hiccup during anaesthesia and sedation. However, perioperative treatment is still based on empirical findings and no treatment is ‘evidence-based’. Thus, no valid recommendations for the treatment of hiccup can be derived. Uncontrolled observations are inadequate to establish treatment efficacy.

More drug suggestions below, along with some background on hiccups…

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I wanted to highlight the NEJM’s new (well, 6 months old) internet feature, Videos In Clinical Medicine. You ought to be able to access these videos after logging into the Sinai library (with MSSM-ID and life number) and then heading over the NEJM’s recent videos page.

Many of the videos feature the work of Gary Setnik, MD, an early figure in EM. The most recent one (from Oct 26th, Vol 355, No. 17) is on basic laceration repair – so maybe it’s something you can show to your beleaguered 4th year med student while you’re busy with other things. Other videos may be more relevant to us, including thoracentesis, LP, A-line placement, and knee arthrocentesis. The videos can also be downloaded in formats for Palm OS, Windows, and iPod.

Clinicalcases.org, a very useful collection of links, videos, simulators and more, also has a page full of procedure video links, as well as some physical exam videos that may be worth brushing up on.  

If you’re aware of any other good online resources like this, let me know or share ‘em with Ted, who’s compiled a list of his own.