EM:RAP and OB/GYN (October 2018)
AIR: OB/GYN
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?
4 comments
1. Ketamine can cause behavioral changes in children after procedural sedation. Higher anxiety level before procedural sedation was a risk factor. And 20% will go home and vomit.
– There is a thing called exercise induced anaphylaxis. It can be only in the setting of certain foods and exercise, but one or the other on its own is not enough.
– Singultus is the medical word for hiccup and we essentially have not solved this super common malady.
2. We are pushed to only loosely close any “traumatic” wound (whatever that actually means, essentially that trauma was consulted on). This has never made sense to me. It’s not like the wound knows if the knife was ill meaning or just clumsy. I will close wounds for cosmetic outcome with good return precautions.
3. Surviving sepsis is so lacking in sufficient evidence of benefit that the wide spread reworking of ED workflow is unwarranted. While I agree with this, it has unfortunately been linked to billing and therefore ignoring it is difficult. Further, it has been accepted on the inpt side, making ignoring it challenging as well. Ultimately, guideline or not, we must be careful with it.
1. I was not aware of the SILENT syndrome (Syndrome of Lithium Effectuated Neurotoxicity): basically ongoing ataxia secondary to cerebellar ataxia and other neurological sequelae following Lithium overdose and toxicity. We often think of reactive airways disease developing as a result of exercise and changes in the weather but never anaphylaxis! I forgot most of what I learned at some point about previa.
2. There is no origin in the ER universe for keeping wounds open. The only literature is from the surgical wound and those papers are talking about wounds that are frankly infected. Close those facial wounds! I may start commenting on class 1-4 wounds in my procedure notes
3. The piece breaking down the update to the Surviving Sepsis Campaign finally provides background to Willie’s lactate vendetta. I’ll admit that I read Willie’s email way back when but not the update on the surviving sepsis campaign. I agree with EM:RAP and Ben that unfortunately throwing large volumes of crystalloid at patients in the ED is clearly not suitable carte blanche. Chasing a lactate is not good medicine if we do not have a clear understanding of why that buildup has occurred in the first place.
1. For SAH Bp target is 100 mmHg if their age is between 50-69 and >110 mmHg if their age is <50. If BP is high with traumatic pt treat pain to address BP. For pt with ischemic strokes we can have permissive HTN with goal of lowering BP by 20% if greater than 220 and BP should be maintained <185 if TPA.
2. There is a rare form of anaphylaxis (Exercise induced anaphylaxis (EIA)) that occurs with or briefly after physical activity. Patients present with typical anaphylactic presentation hives, respiratory and GI swelling, and shock.
3. Procedural sedation with ketamine is not with out complications in kids. About 20% experience vomiting. Most surprising to me is that Ketamine was associated with long-lasting behavioral changes and Anxious children are at higher risk for this complications.
1. When pt’s swallow razor blades they are usually covered in tape. 20% of kids who get ketamine for sedation will vomit. Plastics will remove up to 10L of fat during a lipo suction!
2. I will be more careful when using ketamine in kids, both for behavioral issues afterwards as well as vomiting risk. I will also close traumatic lacs more readily, with an extensive wash out and return precautions. This seems to lack evidence either way and at least that gives potential for cosmetic outcome improvements. I will also try thorazine for hiccups.
3. The surviving sepsis campaign guidelines seem ridiculous. I agree with both Ben and Liam here. While not necessarily “bleeding edge”, I would still disagree with the proposed measures and expectations.