EM:RAP and Thyroid Disorders (April 2019)
AIR: https://www.aliemu.com/courses/thyroid-disorders/
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/emrap2019april/leftventricular
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?
8 comments
• Please list three things you learned from this podcast that you were not aware of before.
As an intern who has not had any experience with intubation I found the section on “Post-intubation Sedation and Analgesia” very helpful. I did not know the importance of using both sedation and analgesia after using a long-acting paralytic.
This segment also thought me the importance of starting norepinephrine rather than titrating down the sedation when my patient’s blood pressure starts to drop.
Finally the segment on Left Ventricular Assist Devices (LVADs) helped me understand how to approach these patients when they arrive to the ED. I learned that
1. The mean arterial pressure ( MAP goal between 70 and 90 mmHg) can be assesses by using a manual blood pressure cuff or arterial line.
2. A low mean arterial pressure in LVAD patients may be due hypovolemia, hemorrhagic shock and infection (always start by given a bolus of fluids)
3. If an LVAD patient truly has cardiac arrest, first start with the following before doing chest compressions:
a. Determine if the LVAD is working by auscultating the chest and listening for a hum
b. If there’s a hum assessing the MAP.
c. Asessing the RV and LV with US
d. Look for error messages on the controller to further assess the machine.
• Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
If the setting is appropriate, in the future I hope to give more PO antibiotics to my patients being admitted for pneumonia if they are able to take oral medications.
• 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?
During the “Post-intubation Sedation and Analgesia” segment the presenters explained that Dr. Weingart’s current site, it takes a long time to get a fentanyl drip. Because of this delay he gives 1mg of hydromorphone immediately after intubation.
I am under the impression, after rotating in our MICU, that starting a fentanyl drip on our intubated patients is more streamlined and isn’t as complicated as in other hospitals. Even though we could give 1mg of hydromorphone immediately after intubation I am under the impression that this practice isn’t necessary at BMC since there’s less of a delay to obtain fentanyl.
1. In the case where the patient was trapped in a machine, the speaker discusses considering doing a “tomahawk” intubation, which I had never heard of before. While this is an unfortunate and potentially offensive name (could easily refer to it as a “hammer” intubation or a “pick axe” intubation, which are both generally held in the same manner); it is an interesting idea to consider for patients who can’t lie flat.
The whole chapter on LVADs was pretty much new information for me, in terms of how to manage patients presenting with these devices, how to check if it’s working (and what I’m looking for for auscultation — the “Washing machine” sound), and how to check the blood pressure (must use a manual cough or arterial line). It’s comforting to know that I can’t mess anything up by fussing with the control panel, and what kind of information I’m looking for/can obtain from the panel. Also good to know it’s ok to shock patients and potentially deliver CPR if necessary.
I learned that new studies show that probiotics don’t really help with patients with diarrhea. All the same, I’ll probably still suggest it to well patients (with benign-appearing causes of diarrhea) as something to try — it may not necessarily help, but it can’t hurt, and gives patients an option of something to try for a bothersome but ultimately benign condition.
2. I’ve already started being more aggressive about post-intubation analgesics, which was Scott Weingart’s big rant this month. This week, I even convinced my attending at Good Sam to start fentanyl along with versed for post-intubation by quoting Weingart. It makes sense that it’s the humane thing to do!
From the pneumonia chapter (much like the cellulitis chapter from January 2019), recommends PO antibiotics over IV, even for inpatient, which I’ve also started to order. Also, I’m happy to no longer worry as much about HAP/HCAP in the ED setting (the new definition is only after 48 hours hospitalization, so the hospitalist should be making the diagnosis, not the ED doctor).
And not sure if this is changing practice — but I’m definitely more comfortable with caring for potential LVAD patients after this month’s review of them.
3. I’ve already gotten push back for trying to implement Weingart’s suggestion of adding pressors instead of turning off sedation/analgesia if the patient’s blood pressure gets low. While it makes sense to me, in terms of patient care, I think there is culturally a very high threshold for starting pressors in the ED (not just at BMC).
– Please list three things you learned from this podcast that you were not aware of before. I became much more aware of the important of treating a patient’s pain first before resorting to full sedation. In caustic ingestion it’s important to try and find out the pH of the solution, as anything within 2 points of 7 is less likely to cause significant injury. You can observe and PO challenge and usually a perforation will declare itself within 12 hours and then they can be scoped. The success rate for neonatal LP goes from 25%-95% if you sedate and use local anesthetic. If you get a head CTA within 6 hours of suspected SAH it is 100% specific and 100% sensitive. With LVADs you will not palpate a pulse. MAP goals of 70-90, but above 90 can be harmful. Don’t freak out if the alarm is going off, you cannot change the settings.
– Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
I will probably push more for my CTA head if there is suspected subarachnoid to ensure it is within 6 hours of onset. I will keep in mind that a lot of patient intubated with rocuronium are high risk of poor pain control and sedation. I never really recommended probiotics to patient with diarrhea, but now I definitely won’t. I’ll make sure to really cover my bases with incarcerated patients and make sure all of the follow up we need can be done, or else just admit the patients and finish all necessary testing.
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?
I think the stuff on in the field amputations may never apply to me, but it sounds really cool and I think it would be a really interesting opportunity, but a very rare opportunity, especially without EMS fellowship.
1. Please list three things you learned from this podcast that you were not aware of before.
1. In “community medicine rants” I thought it was interesting that high flow NC has the added effect of “dead space washout” and lowers CO2. Also interesting that only certain products have this effect.
2. Never seen an LVAD before and haven’t really read about them either so the section on LVADs were great. Briefly, keep MAPs 70-90, don’t worry about giving fluids up front. In terms of things that can go wrong with a machine- think about pump thrombosis, “suck down” of the LV wall, running out of batteries. Also don’t forget about the usual non-LVAD-related cardiac pathology. Also, they’re all anticoagulated so they can bleed bloody blood, but don’t be super aggressive about reversing anticoagulation because you can cause a pump thrombosis.
3. No probiotics for diarrhea? Well that’s no fun, but I didn’t really prescribe them or recommend them in pedi anyway. It’s usually just popsicle and DC.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
1. It’s good to know that intranasal versed works well for pedi seizures, seems like an excellent bridge while obtaining IV access.
3. What topics mentioned in this podcast is cdonsidered 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?
1. Re: diagnosing subarachnoid hemorrhage—On a busy day, I feel like it’s tough to meet someone within 6 hours of onset of their headache and get them to a CT scanner, particularly with our patient population and the volume we see in the ED. I’m also not sure how good we are at getting an accurate onset time for headache. I ask this question to patients and often don’t get an exact time. With that in mind, I feel like it’s hard to stop at non-con CT if your clinical suspicion is high enough, in which case I feel like it’s still worth pursuing an LP.
1. Please list three things you learned from this podcast that you were not aware of before.
-Pedi seizure: 0.2 mg/kg IN versed! Use IV formulation
-Caustic ingestion: pH 7 likely to cause injury. Asymptomatic observation for 6 hrs can likely d/c. If symptoms, admit for non-emergent scope, give IV PPI, monitor airway, serial abd exams for new peritonitis, CT for ?mediastinitis
-Staph colonization: 1/4 cup bleach in 20 gallons of water in bathtub. Splash solution over body in bath then shower it off, wash feet well to prevent bleach stains on carpets. Helps clear colonization!
-LP in neonates: can sedate with high glucose solution (25% infant dextrose solution) orally if under 6 weeks age. IN fentanyl if older.
-Everything about LVADs, especially that they are pro-anticoagulating by their mechanics
-Also the field entrapment story was WILD.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
-I’ve always tried to be aggressive with post-intubation analgesia. I find so often that it gets neglected, especially when working in community sites. The chapter on enforcing that will keep me pushing for it early.
-I will use CTA more when looking for aneurysms once a SAH is identified by LP. Also I get a lot of push back from radiology about ordering CTVs, but now feel emboldened to do so, cause if positive I can skip the MRV
3. 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?
-I agree with Elana. Adding pressors instead of removing sedation is maybe not going to fly at BMC. I feel like I’d definitely not be able to get that by the nurses and pharmacists all the time.
1.Non-intentional asymptomatic caustic ingestions can be observed, PO challenged and discharged. On the flip side, “gastritis” symptoms count and these patients likely warrant admission and a scope by GI
2.You can try LET solution on a cotton swab for epistaxis. Cool!
3.You only have a 6-hour window for using a non-con CT head to rule out SAH. After that, the blood density changes and sensitivity drops way down. Then you need to consider LP+/- CTA
1. I’m not intubating yet, but remembering to get analgesia and sedation on board quickly after intubating is something I’ll try to prioritize. I never considered how easy it probably is for this to get lost when you’re working on multitasking for a sick patient
1. The discussion of reversing anticoagulation to give TPA in stroke was interesting. I’m not sure how our stroke colleagues at BMC feel but to me, it seems like the evidence is just not there yet, and the potential (substantial) risks outweigh the benefits for now. Especially considering that some of these reversal agents are so new and we aren’t sure to what extent they interact with TPA, etc.
1. Three things learned… (1) A different practice approach for hypotension after intubation. I have certainly taken the approach of halving or turning off propofol after intubation when the patient is newly and significantly hypotensive. I appreciated learning a different approach where we add on a vosopressor earlier and really titrate propofol to a sedation goal less encumbered by blood pressure while titrating norepinephrine to a blood pressure goal. This makes physiologic sense to me, but is a definite departure from what I have seen and done before. (2) The review of current guidelines for the role of reversal of anticoagulation and tPA in suspected ischemic stroke was very helpful. I have not yet had a case where AC reversal was advocated for, but I could foresee such a case and am glad to have an understanding that their is simply not enough evidence to support that practice and that guidelines remain clear in advising against this. (3) Finally, I learned a valuable approach to caring for a hypotensive or arresting patient with a LVAD. Remember the same causes for hypotension we would think through in any patient, and then add driveline infection, pump thrombosis, “suck down” events to the DDx. Also, very helpful to learn the role of US in checking for pump thrombosis, how important it is to treat AF in patients with LVAD because of the loss of the atrial kick, and that its ok to both shock and perform CPR on patients with LVADs.
2. In addition to the learning points mentioned above, other areas where I anticipate a likely change to my practice after this month’s EM:RAP include: (1) feeling more comfortable sending a minimally symptomatic child with mild oral lesions after small and exploratory caustic ingestion home after ~4-6 hours observation and PO challenge in the ED, (2) reaching for intranasal versed in pediatric patients who are seizing but NOT using propofol as my go-to sedative if the child has been intubated for status epilepticus, and having informed conversations with parents of pediatric patients that probiotics may not actually be very helpful in kids presenting with diarrhea (though given overall safety I would likely still feel comfortable prescribing probiotics on discharge if parents felt very strongly).
3. There were not any sections of April’s EM:RAP that I thought were too “bleeding edge” for widespread practice or use at BMC. Returning to the point of not reducing propofol for post-intubation hypotension – I think that is a very logical and appropriate approach but anticipate it will take a lot of time before our culture shifts away from what is nearly an automatic response to low blood pressures on intubated and sedated patients.
Three things I learned and how they’ll impact my practice.
1. I’ve not had a patient with an LVAD, but luckily Dr. Stapleton helped arrange a sim case for just this purpose. Secondary signs of perfusion aside from pulse (ex. mental status, cap refill) are helpful, but the idea of a manual pressure with the first sound representing the MAP is crucial knowledge for treating these patients. Fluids should be the first line of treatment which is an easy enough place to start before calling the pump manufacturer and ultrasounding to try to determine the cause of the hypotension. Finally, I learned that GIB are a difficult problem for these patients as they require continuous anticoagulation while also concominantly destroying vWF mechanically, so they are at high risk for bleed with no easy reversal strategy. (pump thrombosis and embolism are significant risks so PCC is usually out of the question) Even products must be used cautiously as they are at high risk of needing products in the future during their eventual transplant and so care must be taken to prevent antibody development.
2. SImilar to reversing anticoagulation in LVADs, there was also discussion of reversing anticoagulation in order to administer TPA for acute ischemic stroke. This sounds crazy to me, which was the gist of the podcast. Reversing anticoagulation only to administer a lytic seems like far overestimating our ability to control the balance of bleeding and clotting. We already have a fairly even chance of inducing a bleed vs improvement by giving TPA, adding anticoagulation and reversal into that equation is far beyond evidence based medicine, and EMRAP seems to confirm that point.
3. The last topic I thought was very informative was the post intubation sedation piece. Notably, our hypotensive patients that barely make it through intubation pose a difficulty with sedation. I have used ketamine bolus for sedation several times now with excellent results. However, I have never started anyone on pressors to combat propofol but instead regularly have lowered the propofol with agitation resulting instead. This podcast helped reinforce the idea that we are partially responsible for their hypotension and shouldn’t be fearful to use pressors to combat the vasodilatory effects.
Not applicable to BMC or too cutting edge:
– As above, its definitely way too cutting edge to consider reversal in order to give TPA in patients’ with ischemic stroke on anticoagulation.
– Also, the idea of giving PO antibiotics as an inpatient for pneumonia is definitely not ready to happen at BMC, which is a shame because many of our patients come in largely for social reasons and not because IV treatment is necessarily warranted. Additionally, vancomycin is frequently used for pneumonia, yet we do not frequently MRSA swab patients to try to expedite discontinuing the vancomycin, and there is some evidence for this practice.