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Conference was a little different this week.  Thanks to all who visited — Sinai EM grad Dr. Roland Merchant of Brown, Professor Paul Klotman, Sinai’s Chair of Medicine, and Dr. Calfee from ID. Also thanks to our own speakers and panelists –Drs. Goodman, Nassisi, Jagoda, Strother and Shoenstein.

Some points I thought bear repeating, or that I want to expand upon:

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Dr. Lewis Goldfrank’s lecture on alcohol withdrawal is now up on the Conference page.  Give it another listen, as Dr. Goldfrank is a very engaging and provocative speaker. And be sure to review our own Dr. Olmedo’s chapter on withdrawal syndromes, which includes a great section on alcohol.

As for my senior lecture, there were many topics I didn’t get to include — so let me just point you to a few excellent articles and some practical tips:

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Some notes from last week’s conference:

If Dr. Hill’s presentation on benchmarking, and where our fine hospital(s) and EDs stand in the scheme of things, please get involved. The regular Operations meetings are a good start. Also, if you enjoyed Dr. Baumlin’s brief segment on Ibex (Picis) and coding of charts, well, there are many ways to pursue your interest.

Termination of Resuscitation is an interesting topic that we don’t talk enough about. Lisa mentioned Morrison’s 2006 validation of a TOR rule in NEJM (PMID: 16885551) — the rule being for EMTs with AED training, that resuscitation should be stopped in out-of-hospital cardiac arrest if there is no ROSC, no shocks administered, and no EMS-witnessed arrest. This multicenter trial of 1240 adults would have terminated resus on 776 patients — four of which ended up surviving (three with good neuro outcomes). So this rule’s PPV is 99.5% but there’s a least a few people alive today who are glad it’s not universally applied.

We have new faculty with an interest in appropriate resuscitation — see abstracts here and here.

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Another fine conference at the ‘hurst; thanks to our presenters — Matt C, Dr. Chung, Dr. Ginsburg, Dr. Iavicoli, and Dr. Chason, and thanks to all for the good turnout.

Let’s start with Tox, since we had a brief preview (perhaps too brief) of our new cyanokit and its use. More below:

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Thank you to our speakers today — Dr. Richardson on research methods, Dr. Weingart on hypothermia, Bing with his journal club presentation (highlighted here), Abiola with trauma talk on the utility of repeat head CTs for recognizing intracranial hemorrhage, and Suzi for her M+M presentation on burn management.

Bing’s journal club presentation and discussion is summarized here — please feel free to add comments.

As for points from Abiola’s and Suzi’s talks, please see below:

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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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So, lots of big things were discussed today, but I’m going to focus on Dr. Judd Hollander’s talk, as it was crammed with insight on a very common problem – achieving disposition on the 8 million patients we seen annually with chest pain (this is national, not just Sinai). Of these 8 million, 3 million are sent home and so we admit 60-65% of chest pain, of which only 15% have real disease… Cardiologists hate us for this, but is there an alternative? What’s the evidence behind what we do?

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There’ll be no recap of Dr. Bobrow’s excellent Grand Rounds lecture — you’ve already got the papers, the abstracts, and now you’ve got the lecture itself. We’re grateful for Dr. Bobrow’s generosity in not only coming to speak to us, but letting us post the audio from his talk online.

As for the resident and fellow presentations on central DI and general pediatric endocrine emergencies (thank Marisa and Karen, respectively), well, there’s not too much I can add, other than to check EMPeds.com for dosing information and sources like UpToDate, and online free text Pediatric Endocrinology for more background on presentation, diagnosis and treatment.

But for Dr. Jagoda’s provocative lecture on TBI and the upcoming ACEP clinical policy, see 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.