EM:RAP and Acute Coronary Syndrome (December 2018)
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?
11 comments
1. I learned that legal cases can be re-opened even 12 years later, which seems absurd and terrifying. Also that rabies immunoglobulin does not travel systemically, so it truly is important to inject it right at the bite site. And I learned about 3rd nerve palsies and how to have a framework for that work up. Also learned what a scapholunate dissociation is and how to get the right xrays for it. And how high flow NC works.
2. I am now more suspicious of fractures in the hand, wrist, elbow, and calcaneous and will obtain extra imaging for those areas. I am also going to be more on the look out for 3,4,6th CN palsies. I will also use high flow NC earlier on kids with bronchiolitis.
3. Most of what I took away from this month seems to be legit and not as opinion based. Perhaps just more rare, which is why I have not run into them yet.
1. Over 50K people die globally per year from rabies. The incubation period for rabies is 1-3 months so worthwhile to treat delayed presentations. High flow works by reducing resistance and increasing efficiency of breathing (and 50% of your airway resistance comes from the nares. What!)
2. I liked the discussion of treatment for EtOH withdrawal, and that it makes more sense to titrate to mental status than to numbers (like heart rate). And that for this reason, Precedex is a terrible treatment for withdrawal because it masks autonomic side effects to make us feel better, but doesn’t treat the pathophys of withdrawal itself.
3. Interesting that HIV PrEP is recommended for IVDU patients who share needles, and the question of whether it is appropriate for ED providers to offer/prescribe this. Large potential benefit but also ideally should be started in a setting with longitudinal follow-up. This question actually came up on a shift in our department a few months ago as well.
1. Medical malpractice is scary and long and can leave you broken. It’s important to go to your own PCP and a mental health provider. And know you are not alone. If your clinical suspicion of fracture is high and initial films are negative, consider some of the rarer views, especially for Calcaneal, scaphoid, radial head, or carpal tunnel fractures. Think about placental abruption in HTN, cocaine use, and trauma. Defined as >20 vs subchorionic hemorrhage <20wks. If you suspect cardiogenic shock, don't forget to start empiric abx. start with levophed drip to MAP 65, considering adding epi. Start thrombolytics only if you don't suspect they will need a procedure like LVAD. If you see a 3rd nerve palsy, think PICA aneurysm and get CT/CTA. The pupil is usually involved in aneurysm. 6th nerve palsy without papilledema get outpatient referral, unless it's a kid, 25% have a mass. Think about ketamine in alcohol withdrawal, it may decrease need for benzos. Rabies treatment involves 4 vaccinations in a short period.
2. I think I'll be more judicious about when I order flu PCR and think about flu more in kids with GI symptoms. I'll probably think more about what a 'negative' xray really means and think more about the physical exam. So far I'm doing EOM on most of my patients, but now I know better what to do if I find something. I've still never used ketamine on a pt, but EMRAP has led me to think about it for many reasons, not just withdrawal and maybe soon enough I'll have a chance.
3. Where and when do to REBOA will probably always be a bit controversial, from what I gather. And I also get the idea that we don't do it much in our ED. I also don't routinely ask patient's if they were around bats, and I'm also not sure the general public is aware that bats carry the highest risk for rabies. I'm guessing this isn't something we treat a lot at BMC, but the treatment certainly isn't bleeding edge – it's pretty straightforward. Also, this isn't exactly bleeding edge – last year's flu shot was only 36% effective? Yikes!
1. I learned that I really don’t know much about ordering ortho xrays. These “extra” views they discussed were new to me and made me take a few minutes to begin reading up on these. I did not know that rabies incubation period was 1-3 months.
2. I think REBOA has a role. The paper from ACEP really torpedoed a lot of work that programs had begun, but the two sessions on this reinforced the need to learn more about this procedure. While it did not change my practice at BMC per se, it did make me look into taking a REBOA course in the future. This is something we should consider including in our PGY4 training as some grads go to Level IIs where this may have a real use while you wait on surgery to drive in.
3. Ketamine in ETOH withdrawal. I like the reminder that GABA is not the only receptor worth hitting and that this is one of the benefits of barbiturates, you hit GABA but also some NMDA. I do think that we should move away from pure benzos or this current benzo mixed with barbiturate cocktail that we are doing and move to pure barbiturate and in that case there may be a role for ketamine as an adjunct. The dosing is important. They are suggesting “pain” dosing and this makes sense as a dissociated ETOH withdrawal pt would be difficult to monitor and ensure you are adequately treating.
Woops the third thing I learned was that influenza positive children should be hospitalized based on normal parameters like hypoxemia and dehydration and not comorbidities. With adults, I generally consider this as well, though it is not the most important factor.
1. This month I learned that sixth nerve palsies can be associated with tumor compression in 25% of cases in pediatrics. It is important to get an MRI in these cases. I also learned that the incubation period for rabies can be as long as 3 months and that if a patient is possibly exposed and have had rabies immunization in the past, they do not need to get a full series of vaccines again. Which begs the question… why are they getting bitten so many times?! I also learned that it is very difficult to distinguish a bad viral pneumonia from bacterial pneumonia in pediatric patients. There is no one clinical criteria that makes a firm distinction possible, although a delayed resurgence of symptoms after partial resolution will make me consider treating for bacterial pneumonia.
2. Now that I have learned more about PrEP, I will consider discussing it with my IVDU patients, which has not been my practice in the past. One way to do this is to put the STI clinic information in the discharge paperwork and to briefly mention PrEP prior to discharge. This is not appropriate for all IVDU patients, but for a select subset I think it would be worth a conversation.
3. Despite the above, I would not prescribe PrEP from the ED because I think initiation requires a long conversation about what PrEP can and cannot do for patients. Specifically, that high-risk sexual behavior still predisposes patients to a variety of other infections and that the efficacy of PrEP decreases when it is not taken as prescribed. Plus, renal function and chemistries need to be followed over time.EM docs should be able to insert endovascular balloons given we are adept at placing central lines and obtaining arterial access with ultrasound. It was interesting to learn that residents at LA county are getting trained in this. I think this is too cutting edge at BMC given the lack of training and the need to have a protocol that is blessed by surgery and our department.
I found the section on cardiogenic shock to be the most useful. It brought up the issue of serial echocardiograms during a resuscitation, which I need to be doing more to see if EF is improving. The section on rabies was a good refresher, as high-risk animal bites (e.g. bats) are something I haven’t seen much of. They do a great job of reviewing all the possible concerning exposures. Finally, the peds flu section was super helpful, as I am at St E’s right now and we are starting to see flu testing needed for kids. I agree with Emily’s comment about being aware of prep being useful for us, but as EMRAP suggests, perhaps the ED is not the right place to start it.
The one-more-film section was above my knowledge level, and I am looking forward to discussing some of these views with our Attendings who have likely had more experience ordering these specific sets (whereas at BMC it seems like they seem to know all the critical views). I am also looking forward to hearing more about people’s personal experience with litigation, as they make it sound truly horrific and personally devastating, which contrasts with what I have heard (“it just happens to everyone”). All in all, a very useful month at EMRAP!
1. I learned a lot on the additional views that can be ordered when you are worried that there is a fracture but traditional AP, Lateral, oblique views don’t reveal what you’re looking for. As I am on elective this month in a location where I am ordering a lot of Xrays, I have started looking up the options for Xray imaging prior to ordering a plain AP and lateral so that next time I might remember to broaden my ordering horizon if needed. I learned that I should probably move to Providence to pursue my ballroom dancing career and that the doc featured in this piece is actually coming to speak with us at conference this spring. Perhaps we could get a little sampler? Seriously, it scared me to know that even after 12 years the statute on limitations had not run out on this case. I thought the piece on high flow oxygen was interesting. I think most people are unaware that it is the agitation of the air that mimics neonatal breathing that allows for the ease of WOB with high-flow nasal therapy.
2. I don’t often consider the use of hi-flow in the ED mostly because most patients do okay with bipap and we need to request hi-flow specifically from RT. Bipap looks like a very uncomfortable system though and if the same effect can be achieved with hi-flow, I may elect to use this in the future in patients with type I respiratory failure who are hesitant to place the mask over their entire face.
3. The two segments on REBOA were very interesting. I think that, as Ben mentioned, this has real-world applications outside of the large university level I medical center in that it could buy time while allied specialties are called in. While this is unlikely to play a role at BMC, it might be an issue for my position next year.
1. Add me to the list of people who had no idea that rabies had a three month incubation period and was unaware of the additional possible FOOSH views (the former I think is incredibly helpful to know… I remain unconvinced of the clinical usefulness of the latter). I also did not know that the rabies immunoglobulin is supposed to be directly injected into the wound itself. I’m hoping that I once knew it and forgot it, since I have given it in the past. Fingers crossed that that patient survived.
2. Echo Ben and Liam about REBOA training. Definitely something that, depending on where I am going to be practicing, I would consider doing a course in. NOT something that will change my clinical practice right now. Like Andy, I do not routinely do serial echos in patients to adjust therapy, and I thought that was a tremendously helpful idea.
3. I have a lot of questions about this whole ketamine for EtOH withdrawal business. I understand the pathophys and understand the subdissociative dosing, but I would be hard-pressed to think of a patient for whom I would be excited about this choice. I personally think the phenobarb load (i.e., the 10mg/kg initial dose) that we are moving for tends to have a LOT more success than the normal EtOH ICU withdrawal protocol we have been using, and I would favor moving toward this more evidence-based approach instead of ketamine. I get that it is maybe still a last-ditch attempt to avoid intubation, but I’m not excited about the idea of signing out DTs on a ketamine gtt to the ICU…
– One more view section where they review the use of additional views to identify fractures when standard views was really eye opening. Andy I completely agree w/t you that this too was a bit over my head. I find that for many of the extremity X-rays that I order I just select the epic order w/t the most views, this is partly due to a knowledge gap on my part as I find that I don’t know which views are the best views to identify fractures. It would be really great at some point (INTERNs on Ortho month) to have a cheat cheat to review extremity standard views and limitations of those views.
– This section in addition to our recent M&M has really humbled me with my US skills. The section emphasized that Placenta abruption is a clinical diagnosis as US may not rule out this diagnosis; if US is neg pt needs observation if suspected. This section highlights the importance of knowing very well the limitations of a diagnostic study so that we can appropriately advocate for our patients.
– Ketamine for alcohol withdrawals section was informative and highlights the versatility of this wonder drug. But I agree with Allie this may be too cutting edge especially because it is mainly based of pathophysiology. More studies need to be done to establish clinical efficacy and safety of ketamine in alcohol withdrawing patients.
1. I was surprised to hear how long the litigation process can take, especially with appeals. A second thing that I did not know was that high-flow nasal cannulas may work by causing turbulent flow and mixing of air within the airway. A third thing was the specific views that can be obtained to better detect certain fractures (although I have a feeling that I will forget them almost immediately).
2. The idea of making REBOA a core emergency physician competency is really cool. That doesn’t change my practice right now, but it very well might in the future. One thing that definitely will change my practice is knowing that rabies treatment can be initiated up to months after a suspected exposure. I had always been under the impression that this must be done within a day or two.
3. I think that the ketamine use in alcohol withdrawal is not quite ready for prime time. The love affair with ketamine in the FOAM world is a bit overzealous and with the reticence of other specialties and disciplines to accept ketamine for indications with more robust evidence this indication is probably not appropriate for widespread use. That being said, it’s an interesting idea to keep on the back burner for extreme cases.