EM:RAP and Pharmacology of ACS (January 2019)
AIR: https://www.aliemu.com/courses/acute-coronary-syndromes/
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.
https://www.emrap.org/episode/ema2019january/abstract1
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?
5 comments
1. I Particularly enjoyed the piece on resuscitation/CPR on a ski slope. I have a great appreciation for the coordination and the skill of the ski patrol getting people off a mountain, on a sled, with skis on. They administer medication in temperatures where I often cannot feel my hands and are quick to adapt to situations when required to do so like in this case when frozen blood in tubing required quick troubleshooting and action. At Telluride the ski patrol has been trained to reduce shoulders on the mountain at the point of injury – without analgesia or sedation. They have over a 95% success rate. We can learn a lot from our EMS colleagues.
2. Pedi GYN: Estrogen withdrawal in neonates causing shedding of the uterine lining, Topical estrogen for separation of labial fusion.
3. We never think of new hypotension in the setting of acute aortic dissection particularly relative hypotension (a normotensive BP in an elderly patient with a history of hypertension and chest, back or migratory pain). This is an ominous sign as it is an indication of radiation of the dissection proximally and hemorrhage into the pericardium.
What would you change?
1. I must admit that the diagnosis of CO poisoning is hardly ever high on my differential. It should be. Think about our patient population. They are the least likely to have CO detectors in their homes and probably the most likely to use unconventional methods of heating in our “modern” society. What makes this more concerning is the fact that, during the months when flu and viral illness are at their peaks, CO can mimic these presentations. I’m away at the moment and having a hard time recalling whether our blood gas machines lay out the differential for Hgb concentrations. In Ireland, we performed and analyzed our own blood gases in the ED and the machine would produce a print out with COHgB and MetHgB which was very useful in picking these cases up. Need to think about this more.
2. Are we in danger of passing on disease when we place USIVs at the bedside? I am concerned that we actually are. In practice, our ultrasounds are absolutely disgusting. 40% of people don’t use probe covers or anything at all. A Tegaderm on the probe cover is not sterile – think about how we put these on, there is nothing sterile about it. I am not so concerned about passing on bacterial infection from normal skin flora. I AM concerned about passing on HCV, HBC or HIV. Just because there is no blood visible on the probe, it does not mean that we cannot pass on these viruses on to patients. We use USIVs on patients who have VERY high rates of HCV. We then happily move on to the next patient after briefly spraying the probe for two seconds and throwing it in a corner. ACEP, AIUM etc all suggest a single use protective cover. We are not doing this in the trauma room – ever. The bottles of lube should be removed from the machines. 3M who makes Tegaderm has washed their hands of responsibility here. The pore size is 22 micrometers which is equal to 22,000 naometers. THIS PORE SIZE WOULD ALLOW 180 HIV VIRIONS or 338 HCV VIRIONS to march through each pore in the tegaderm. I would never allow someone to come near me with an US machine and a tegaderm as a cover at BMC. I won’t ever be using them again.
3. IV vs PO antibiotics for cellulitis. I often think that we admit a lot of patient’s for cellulitis that do not need to come into the hospital for IV medication. I understand that many of our patients are homeless and have additional social needs but, what is the difference in the same antibiotics that we give via the mouth or IV (many of them have great bio-availability via the oral route). All the trials that looked at oral vs IV Abs for cellulitis showed that oral medications are superior to IV (they were old, but lets put on our thinking caps and extrapolate a little bit). I think admitting patient’s for cellulitis a lot of the time is crazy and plan on limiting this practice in my future practice.
What is too cutting edge?
The piece on the use of Ketamine in the pre-hospital setting seems a bit too cutting edge for my practice moving forward. There are just too many variables to account for which makes me uncomfortable making the call from medical control to administer Ketamine over the radio to control an agitated patient.
1. Turns out our USIVs are NOT sterile, even when we put tegaderm on the probe. I would have never thought about how large the viral particles are vs how porous the tegaderm is. I’ve seen people visit from other services and put in USIVs without sterile gel and sometimes without a probe cover. But now I’m like… hmmm maybe my ‘sterile’ placement isn’t much better because I’m just using tegaderm. I also learned that your typical CO picture from med school is wrong – pts don’t actually turn pink, it actually looks more like the flu! Don’t trust an O2 sat on these patients. Take a good history and think about exposure. I also learned to stick to PO antibiotics for cellulitis and expect it to get worse before it gets better. I witnessed a very heated discussion on this in the pedi ED when pharmacy asked why IV abx were started on cellulitis. Turns out pharmacy was right, even though the attending would not budge.
2.I’m reconsidering how I do ultrasound IVs, though I’m not sure we have better resources for keeping probes sterile. I’m going to try to stick to PO abx if I have a pt with good circulation, no GI surgeries and still with good absorption. I’ll probably think about learning how to ski so that I can do ski patrol like Liam and be the first person to respond on asynchronous learning with a 5000 words response. Also to resuscitate skiers in cardiac arrest. Also workplace violence is real. I’ve already seen people get assaulted. Thankfully I’ve had people watch out for me and give me a heads up when I pick up a patient who could be violent. We gotta watch out for each other!
3. Hmm. I can’t think of anything too bleeding edge. I do think some things are harder to adopt here like just sticking to PO abx. I feel like people will always ask you for BPs on all extremities for concern for aortic dissection, but turns out that’s not useful!
I absolutely loved the piece about the cardiac arrest with the Ski Patrol. I think this brings up a great issue of how out-of-hospital providers are faced with very distinct challenges, many of which we may not think of (frozen blood in the suction tubing, intubating while lying next to a pt, etc). The biggest take away for me is to never discredit the actions of EMS. They do not have a beautifully designed resuscitation bay with functioning equipment and huge resources. I think this piece provides an important nod to the team dynamics that allow them to do their job at such a high level. Similarly, the rural medicine segment described the incredible challenges of a remote airway disaster. Regrettably, they seemed to pin some blame on the rural nurse for noting cervical lymphadenopathy instead of thyroid enlargement. Once again, a rural nurse in upper Canada should not be held to a standard that we aren’t even that good at meeting. Admittedly, I will be checking thyroids more now.
Perhaps the most actionable segment for me was on the IV/PO abx for cellulitis. On numerous occasions I have started IV abx because the pt was sent from a specialty clinic, and honestly I didn’t have the guts as a junior resident to go against a PCP recommendation. Armed with this information, I feel more empowered to treat these pts with PO and now even know that I am potentially harming them by starting down the IV route.
The aortic dissection piece contributed a key physical exam finding that I will start to look for in those pts I am concerned about: the murmur. I have only had a few resus bay dissection rule-outs, but in every case I have looked most for pulse deficits, neuro signs, extremity circulation and done only a cursory check for a murmur. The finding of a new murmur will now be something I look for.
1. -Apparently urethral prolapse in pediatric female patients is a thing. Don’t try to manually reduce, use topical estrogen instead
-I knew cigarette smokers had higher levels of carboxyHgb than the general population, but apparently hookah smokers are even higher (15-20%!) Almost as high as the threshold for treating…
-You can’t rely on unequal arm BPs in diagnosing aortic dissection; looks like it has a pretty high false positive rate
2. The segment on best practices for US IVs was mind boggling. Apparently Tegaderms are useless as barriers against HIV, HCV, HPV…yikes! I honestly never considered this. Should I start using sterile probe covers for peripheral US IVs instead? Or maybe I’ll try the the sterile glove trick. Don’t think I’ll use Tegaderms anymore though.
3. The IV vs PO abx for cellulitis segment is interesting. This isn’t “bleeding edge” in the sense that there seems to be plenty of evidence saying PO abx work just fine…but I definitely have seen push back especially from referring & inpatient providers in general with this idea that IV is somehow “stronger” or more effective.
1. I haven’t seen (or even heard of) several of the “common” pediatric gyn complaints that were described, including labial fusion and urethral prolapse, which both can be treated outpatient with topical estrogen. The chapter also mentioned confidence and reassurance is most helpful in discussing these pathologies with patients — I probably would have been scratching my head what to do if I saw either of these in the ED prior to this podcast, which probably wouldn’t inspire either confidence or reassurance.
Wow, the ultrasound IV chapter was a little terrifying, in that the tegaderm I’d been using to cover the probe cover has pores large enough to let in HIV and HCV. At this point, I’ve done dozens of ultrasound IVs on patient who are positive for these diseases — yikes! (And seeing that BMC recently switched from the cleaning spray to the wipes due to the spray not adequately cleaning the probes — double yikes!)
PO antibiotics for cellulitis work just as well as IV antibiotics (“non-inferior”); and the erythema of cellulitis can be expected to continue to get worse on antibiotics for the first 1-2 days after initiation of antibiotics.
2.
I’ve already started trying to use sterile gloves for ultrasound IVs. At Lahey, this was somewhat easier because the gloves are a light color and it’s easy to see the central mark on the probe through the glove; it’s a little more tricky with the dark green gloves at BMC.
I’ve seen so may flu/URI symptoms in the past few months, and CO was never on my differential. I will definitely consider this going forward, especially if multiple family members (“sick contacts”) came down with symptoms all at the same time.
I generally try to discharge pediatric patients (and their parents) myself instead of having the nurse doing it. After listening to the pediatric lawsuit chapter, I plan to try to make this more of a policy for myself, and include stricter return precautions for pediatric patients, especially the 0-2 year old age group; as well as document any improvement prior to the patient’s discharge.
3. The use of ketamine to sedate agitated patients pre-hospital seems a little “bleeding edge” for BMC. The quick onset of ketamine is very appealing, as waiting 15 minutes for benzos to kick in when a patient is really agitated can really seem like forever. The Hennepin studies I believe were all observational, so I would be interested in seeing RTC trials of ketamine vs benzos like versed/ativan/haldol.