EM:RAP and PVD (August 2018)
AIR: Peripheral Vascular Disease
New This Month…..
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
When you have finished listening to the podcast, answer the following questions:
- Please list three things you learned from this podcast that you were not aware of before.
- Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
- What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
7 comments
a.) The testicular torsion piece was fascinating. I am most surprised that testicles can be saved even days later – the notion that 6 hours is your window is incorrect. Also, remittance of pain is not an indicator that the torsion has resolved, and instead can be likened to the “lucid interval” but the pain returns as the tissue around the testicle continues to die.
b.) cocaine chest pain. careful with nitro, as these pts can be similar to inferior MIs (relying on CO, preload dependent), so as always ensure good access
c.) CHF. BNP rarely helpful, as they will have elevated baseline BNPs. the likely more important test is troponin, to make sure that the CHF exacerbation is noncompliance related, instead of a manifestation of ACS. (interestingly, the EM cases crew recently did a podcast showing how BNP often times has more downside in these pts than upside, as it may be falsely reassuring at times but offers little decision-making utility in the ED)
d.) the section on IV access had a variety of cool tricks. tourniquet, cannulate a tiny hand vein, infuse fluids > engourges more proximal veins. also, i want to try putting a peripheral catheter into an IJ
Please list three things you learned from this podcast that you were not aware of before.
1. I have not considered bicarb in cocaine chest pain (to overcome sodium channel blockade), I generally reach for benzos for tachycardia and treat hypotension with fluids to start
2. Starting a small hand IV, keep the tourniquet up and infuse 100-150 ml, though I (like everyone else here) just use ultrasound BUT I suppose on those cases where there is nothing even with ultrasound this could be good
3. I’ve never used the K of 3 and QTc of 500, must replete rule but this makes sense and I generally replete at 3 anyway but do not compare to QTc
Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
In regard to burnout – I plan to schedule an hour a week for personally replenishing activities
What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
– Dropping the BNP from the work up seems great, makes sense, and I almost never find useful. But I feel like the times I’ve not ordered it and made the dx on history and ultrasound, I get push back from medicine. I agree that the trop is important and even in renal pts when it is likely to be positive, the downside to ASA and trending is pretty minimal in someone you already plan to admit (this isn’t bleeding edge)
1.I was not aware that August was national Catfish month! I did not know that sitting in a position for a long time can lead to the development of compartment syndrome! I had not thought about comparing a QTc to a patient’s plasma potassium replacement although this clearly makes sense. Tomato juice has 14meq of potassium! Orange juice has 10meq!!! The idea of administration of sodium bicarbonate in cocaine chest pain which is a great idea
2. Hypo K, hypo Mg: think food for replacement instead of pills. Serum K always underestimates the actual potassium depletion. Clearly I had missed the Adrenal Study. I thought the ship had sailed on steroids in sepsis but clearly not. Not sure I would be giving steroids in sepsis quite as early as some proponents but I was always surprised in the MICU when patients improved after receiving steroids.
3.Despite the fact that obtaining a BNP is almost always totally useless I doubt that out colleagues in medicine are prepared to abandon it. What does the number mean anyways, This test has never changed my management. US/imaging combined with clinical evaluation are much more useful. I feel like our medicine colleagues are stuck in the past when they ask for this test.
1. a. Compartment syndrome can occur from a person staying in one position for too long.
b. K less than 3, QTC approaching 500. For every 0.3 down in serum you are down 100 mEQ in total body and you excrete a significant amount that you ingest orally. Tomato juice and orange juice for K repletion. If you give K, give Mag. K greater than 6, need to dialyze in house. I like the idea of having a cut off in my head, even for chronic renal patients. Also surprised to hear that chronic hyperK does not have predictable EKG changes and patients may precipitously widen their QRS or arrest.
c. I have never considered using bicarb for cocaine chest pain.
d. 20% of pt presenting with testicular torsion, present with isolated abd/flank!? Yikes.
2. Testicle palpation for all male abdominal pain patients. For female abdominal pain patients, I am very in the habit of considering GU etiology. But I think I have ignored GU etiology for pure abdominal pain in males.
3. a. The risk stratification for CHF exacerbation discharge vs admit (Ottawa Protocol) likely will not influence my practice regarding CHF exacerbations. Even for a score of 0 the risk of an adverse event at 30 days was 3% and that does not take into account the challenges facing our patient population, specifically access to follow up and access to medications. Using it as a way to determine level of care is interesting but I am not sure that risk of adverse event over two weeks is necessarily a good proxy for “what level of care does this pt need right now?”. Specifically if thinking about putting someone on the floor or on step-down, where they will be managed by the same team and rounded on for the same amount of time, I don’t necessarily think a patient who is at an increased risk over the next two weeks must be on step down. It is hard for me to imagine what 24-48 in a higher monitored unit will specifically provide.
b. This is not “bleeding edge” but I thought they missed a good opportunity about diet recommendations for hypoK. Everyone’s go to rec is bananas (and that is what was mentioned in the podcast) but if you look at the table they provided, you see that vegetables like spinach have nearly twice the bang for your buck. For our patients who are often overweight, have varying levels of glucose intolerance and low insight into diet, I think it’s an opportunity to push greens instead of sugar. Plus, increased fiber intake allows for better digestion and electrolyte balance.
SEPTEMBER 2018 EMRAP
1) 3 things I was not aware of:
– European guidelines include Scarbossa’s criteria for evaluating for STEMI in pt’s with pacemakers. Makes sense, something to think about clinical suspicion is high and ECG is tough to determine.
– I was surprised at the rate of inaccuracy of identifying acute coronary occlusions – 25% of cath lab activations have no occlusion, and 25% of pts we call NSTEMI have occlusions. This doesn’t exactly change who we cath or don’t cath, but I will continue to push repeat ECG’s in pts who have ongoing anginal sx.
– I was aware of the fascia iliaca compartment block (thanks Dr. Dewitz!) but have never attempted it. This segment made me realize just how easy and effective it can be for isolated hip fractures, and I’ll keep it in mind in my practice.
2) Areas of practice I would change:
– Use PO steroids whenever possible, no benefit to IV unless Pt cannot take PO.
– Get posterior ECG leads whenever Pt has STD in V1-3 and symptoms c/f angina/STEMI, in order to not miss an isolated posterior STEMI.
– Good reminder to keep voicing my thought process out loud when I’m running trauma/med resus to keep everyone involved in the process and on the same page.
– Try to continue positive self-talk instead of focusing on doubts.
3) Not applicable/too bleeding edge:
– Honestly will probably still use the terminology STEMI/NSTEMI vs OMI for now, but I do think it’s important to keep in mind that physiology behind the disease and not just the ST segment morphology in front of us.
1.- I learned that using BNP for CHF isn’t useful for titrating diuretics and is not as helpful for diagnosis CHF exacerbation as clinical exam findings and imaging. If a known CHF patient admits to medication noncompliance you can probably avoid a big workup and stick to making sure their electrolytes are okay and likely discharge home.
– Hypokalemia causes QT prolongation and if the QTc is more than 550 the patient is more likely to develop an arrhythmia than not and should be closely managed. And foods are effective – you should aim to give 100mEq of potassium for every 0.3 deficit of serum K and you don’t risk hyperK if the person is hydrated and has normal kidney function. For HyperK – dialysis patients may jump right to a sin wave on EKG so they should be watched closely.
– kids get edema in the eyes and may have renal, cardiac, or liver dysfunction, so the differential is broad.
2. I think I need to be more aware of needing testicular exams on my patients with abdominal pain, just like we always think of gyn causes in women with abdominal pain. As a female provider it’s easier to skip this instead of hunting down a chaperone, but I’m going to make this more of a priority. I’m also going to try to think more carefully about making sure I’m appropriately treating pain in the ED. When I first started intern year I was freaked out when an attending asked me to prescribe and opioid to an abdominal pain patient. The first time I prescribed dilauded I really freaked out. Knowing the number needed to harm is 1000 vs 1 being the number to treat, I’m feeling more reassured.
3. I guess the story of the patient in a remote area with no medical providers and needing an MD shipped out to him is probably less likely to happen to me during my career at BMC, but hey, you never know. I’m also wondering… couldn’t they have just given him more alcohol? Why did they keep pushing benzos knowing they would probably run out and he would be a tricky intubation. It seems even this remote area had plenty of alcohol on hand, even if they were short on benzos. I’m curious how that would have played out.
1. All of the electrolyte rules were great. Particularly helpful for me was the Ca stuff, especially chasing down why pt’s are hypoCa. I guess it makes obvious sense but I would not have thought to obtain a PTH level and a CXR in pt’s with hypoCa. Baked potatoes, tomato juice and orange juice have a surprising amount of K. The lack of sensitivity for testicular ultrasound is disheartening, but good to know. If my clinical suspicion is high enough, I’m calling urology. Also learned what ice fog is! Super cool. I love the rural medicine pieces. Also never thought of chronic methotrexate toxicity, so learning about that was really cool.
2. When I give K, I’m going to give Mag 0.5 mg/hr. And I’m preferentially going to try to give K via food. When I suspect testicular torsion, I’m calling urology regardless of US findings. I’m also going to try injecting 100cc of saline into a peripheral 22g so that I can place an 18g in a more proximal IV. When I see any chronic hyperK patient I’m going to jump on any EKG findings since they can have atypical changes first and not in a step wise fashion. Male abd pain will get a testicular exam now as well, which is something I’ve often thought about but never taken the time to do. With a decent percentage of torsion being isolated abd pain initially, I think it’s worth taking the time.
3. The peripheral IJ idea is something I’ve done a few times in the MICU without any evidence base. It is good to know now that it may not be the best infection wise. Without data to support whether or not this increases infection risk, I may think twice before doing it again. That is perhaps not ready for prime time.