EM:RAP and Cerebrovascular Accidents (March 2019)
AIR: https://www.aliemu.com/courses/cva2019/
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/emrap2019march/toxicology
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 was not aware of the extent that the facia/iliacus nerve block depended upon diffusion of local anesthetic in a planar distribution. I was concerned to hear that 25% of giant cell arteritis presents without any of the classical symptoms. I loved hearing that there is now a mini-PCR machine that we could use in our own ED to rule out active TB and MDR TB. This, I think, woiuld be money well spent in our department when considering our patient population demographics.
2. I was encouraged to hear that 36degrees C produces outcomes which are just as good as those when a patient is cooled to 34 degrees C. This takes the pressure off to get the arctic sun applied and functioning properly while the patient remains in the ED. I found the section on massive hemoptysis very helpful. This is one of those presentations that scares shitless. As in the initial management of an air embolus, patient positioning is important as a temporizing measure to maintain gas exchange.
3. I don’t think any of the segments this month represent ideas or practices that are far outside accepted norms in emergency medicine. Employing these ideas into practice is the challenging bit. Old beliefs and practices are slow to die and I imagine that this will be the case with cooling, need for admission, quant gold and sputum culture for suspected TB
I very much appreciated the section on TTM. This is a controversial topic in the ICUs right now, and the targeted temp seems to vary by Attending. Per James Murphy, BMC is in the process of rolling out a hospital-wide policy shooting for 36C. My personal experience has been that nursing objects to a range (I previously would say “anything between 34 and 36”) and that did not go over well. Now I feel empowered to say “36C is our target.” That said, their point about fever is well-taken, and I am interested to learn more about if it is easier to hit 33C than 36C because of the reduced risk of fever.
The section on procedural competency does not hugely relate to residents (especially junior residents), as we haven’t been training long enough to have “forgotten” how to do procedures, but does serve as a good reminder of the importance of mentally rehearsing the rare procedures that we are likely to do but perhaps only once or twice in training (eg lateral canthotomy). I loved the section on nerve blocks, and actually yesterday Tuyen and I did a fascia iliacus block in B1. Hugely helpful to have this segment before. I am going to start using their saline hydrodissection method as it preserves your lidocaine for once you get to the target vessel. Also shout out to Zaid who did a teaching session about LAST after we discussed this segment.
1. a. Visual symptoms in 60+ population need to be treated for GCA. IV steroids if current vision loss, PO if transient. Consult your neuroophtho people. b. Cooling patients is foreign to me as an intern, but I learned that ROSC patients from something shockable should be cooled. 32-36 have similar outcomes, but going colder can avoid shivering and you are more likely to be at goal temperature than if you go higher. They even cool people during cath (does that happen here?) c. Hemoptysis is scary! Consider intubation and prepare for cric if patients are losing O2 sat, but it may be useful to keep patient awake and let them clear their airway. They won’t likely exanguinate, but you need to worry about them asphyxiating. You could even try to selectively intubate unaffected lung. Use a big tube to intubate so that bronch can do through. d a bonus fact – pregnant patients rarely are tachycardic. They have low BPs, worse in 2nd trimester. They have a large blood volume that can give falsely low lactate. They have baseline high WBC count. They could have pyelo, appendicitis, PID. Also put in left lateral decub.
2.I will probably think about refreshing my skills more regularly. It’s only intern year, but I can see how our skills drop even one month off-service. I will probably start high dose steroids more on old patients with transient vision loss. And I won’t be reassured if they don’t have systemic symptoms.
3. I think shared decision making is really tricky in our patient population. I was all for this when I started intern year and it kept coming back to bite me. Sometimes working through the details with a patient with low health literacy can be difficult. I also had a surprising number of patients who got angry with me for not being paternalist with them. They didn’t want the burden of decision and they shouted things like “You’re the doctor, why don’t you know what we should do?” They questioned my competence if it seemed like I could trust a patient to make a decision that they thought should require years of experience.
Three things I learned from this podcast:
1. During the NIHSS, patients should receive credit as though they could complete a requested task if they cannot complete said task because of global weakness. Furthermore, the NIHSS does a poor job evaluating necrologic deficits related to dizziness or spatial perception.
2. Giant Cell Arteritis (GCA) should be on the differential diagnosis for any patients > 60 y/o (and possibly as young as 50 y/o) with sudden visual loss, or transient visual loss or diplopia over the preceding month. If they have vision loss, start IV high-dose steroids. If they have transient visual loss or diplopia, they should still be started on PO steroids until outpatient, urgent follow-up with Ophtho. Up to 25% of patients with GCA will have no associated symptoms and there presenting symptom will be vision loss. Steroids will not affect biopsy results within the expected timeframe for the biopsy.
3. There is a sputum sample PCR-based test for TB that can offer results on presence of TB in sputum and drug resistance patterns in approximately 2 hours. This is an alternative to sending a Quantiferon Gold, and has become the stardard practice at some hospitals. The benefit is the speed with which results become available. Also, in patients with a working diagnosis of PNA but for whom TB remains on the DDx, FQ (i.e. levaquin) should be avoided as this medication has an essential role in the treatment of drug-resistant TB.
Areas of personal practice I might change in response to this podcast:
1. For Post-ROSC temperature management, I will likely change how I express temperature goals to reflect evidence that 36 degrees Celsius is as good as 33 degrees Celsius but maintaining a core temperature of 36 C is more difficult in practice. I will likely indicate a goal of 36 C and explicit comment that going below that as low as 33 is ok prn.
2. I will likely consider and treat empirically for GCA more often that I have thus far, and will speak more confidently to our Ophtho colleagues when needed to come to the ED to evaluate patients without any associated symptoms but at risk for GCA
3. I will try to use NS for hydrodissection instead of my anesthetic when doing US guided nerve blocks.
4. I have learned that patients with SR Bupoprion overdose categorically should be admitted for observation.
5. I may try to use the shared decision making tool for CP published by the Mayo Clinic as a supporting resource when caring for patients in our ED.
“Bleeding Edge” Appraisal:
I don’t believe any of the content in this episode of EMRAP would be not applicable to practice at BMC because of lack of evidence. I think any decisions not to employ the content of this particular session would be more reflective of individual provider comfort.
1. Very happy to finally get familiar with the literature that proved 36C is equivalent to 33C for post-arrest cooling. It is far easier to cool patients to 36C without needing to use the Artic Sun, and from working in the CCU, there is far far less shivering when at 36C. Finally I learned that if the patient has a post-arrest STEMI, then they should begin cooling as they go to the cath lab, which makes sense but I haven’t actually done yet.
2. In terms of the Bupropion OD segment, I’m unsurprised another tox overdose is treated with benzodiazepines. Luckily it seems to hold in most any agitated AMS patient, benzodiazepines are a good first line measure. And similar to TCAs, if any QRS widening, give bicarb.
3. Massive hemoptysis is a super scary presentation, and it was great to have Weingart break down his approach. Unlike in massive GIB, the differentiation that this is not a bleeding death but rather an airway death is an important distinction, however, this is made much more complicated by the fact that the blood is coming from the lung so an ETT can actually worsen things because it eliminates the patient’s ability to clear their airway. So I would definitely change my practice in this scenario to delay intubation as long as the patient is satting well and not altered. They also mentioned the idea of using a meconium aspirator to provide a suction port in line in the ETT after intubation which would be excellent in this scenario as a typical ETT suction would likely get clogged off. Finally, I wouldn’t have thought to give steroids but this may be helpful in the case of diffuse alveolar hemmorhage, whereas a bronch would better address focal bleeding.
Too bleeding edge for BMC:
– I think shared decision making with patients about chest pain is very difficult at BMC because of the lower health literacy. I feel like most patient would opt for admission as it is difficult to explain the risk of a workup may outweigh the risk of sending the patient home. Beyond this, this is a long conversation that during a busy shift is far easier to just admit to obs. I would appreciate a concerted effort from the hospital to have a premade script that a non-physician could discuss with the patient to allow them to make a decision, however, I bet that that strategy also invites litigation as counselling may have to come from a physician to provide sufficient detail.
– It would be amazing if we could get PCR TB tests in the ED, that would be such a faster way to stratify patients. I’m curious as to the cost-benefit of this test vs having patients have to stay in a negative pressure room for serial induced sputums and cultures/AFB smears that take much longer to result.