EM:RAP and Neurology (May 2019)
AIR: https://www.aliemu.com/courses/neuro2019/
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/emrap2019may/incidental
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?
7 comments
1. Please list three things you learned from this podcast that you were not aware of before.
This month I learned a lot about honey!
I could not have imagined that using honey would be important in so many scenarios. The most surprising fact was the importance of honey in delaying time to perforation for button batteries lodged in the esophagus. Who would have thought that honey neutralizes the alkali from the battery???
It’s comforting to know that my grandmothers recommendation of eating honey when I have a soar throat is also supported by the literature. As I’m getting older, I’ll make sure to continue to consume honey since it also has anti-inflammatory and anti-thrombotic properties!
Moving past honey, this month I realized that term “synthetic cannabinoid” is a misnomer. These drugs often have nothing to do with marijuana and can have a variety of presentations. After listening to the podcast I now understanding the importance of focusing more on the possible downstream consequences (metabolic acidosis, agitation, etc.) and less on what drug they took exactly.
Finally, in the section on “Febrile Illnesses in Returned Travelers” I was reminded of the treatment options for patients with malaria. Regardless of the type of malaria lumefantrine/artemether is the medication of choice!
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
This month’s introduction really forced me to think about my discharge summary’s and what information I’m providing my patients on their way out of the ED. My discharges always provided return instructions, follow-up information but often don’t have step by step instructions on how to take the medication I’m prescribing; I usually talk about with the patient as I’m giving the hard copy of the prescription. From now on I hope to be more thorough by not only talking about it with my patient but also detailing the steps to taking the medication in my discharge summary.
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 would love to talk more about the hemodynamically protective and the hemodynamically neutral intubations with our attendings. Is this something they would do/have done at BMC? How would they approach those scenarios?
1. The way they presented fever in a returning traveler was very helpful and organized. Beyond learning that framework, I also had never heard of Artemisinin combination therapy for malaria, which seems excellent compared to older therapies. Also learned that 10 ml honey hourly after button battery ingestion can save the esophagus, which is great. And the hemodynamically neutral intubation is something I’d like to use in the future as well.
2. I will definitely incorporate what I learned into my future practice, such as using honey and ACT as mentioned above. I will also make sure to take extra time when discussing incidental findings with patients AND their family members. Having a loss of communication here is highly detrimental and the case discussed really puts that point home.
3. While I’m interested in Scott Weingart’s intubation methods, he clearly states this is an evidence free zone and I think knowing that is important. Some of what he does is highly anecdotal, but in theory how he describes his HD neutral intubation makes a lot of sense to me. Perhaps not quite ready for prime time, but I think it’s a cool start.
1. Honey is amazing and we should probably be putting it on our MRSA cellulitis patients. It’s also probably way cheaper and safer than most of our antibiotics. Watch out for status epilepticus in flu patients. Ketamine is great for synthetic mj becaues reducing agitation reduces the patient’s temp. Sedate and get an EKG. Hemodynamically neutral intubation (bad pulmonary hypertension, aortic stenosis) – the goal is to decrease venous return. Use topical lidocaine and low dose ketamine and intubate the spontaneously breathing patient who is now anesthetized.
2. I’m going to use honey more on my kids and maybe even my patients if pharmacy can give it to me. As I approach second year I’m going to think more about how to help stabilize patient’s hemodynamically before intubation, and maybe even encourage awake intubation. I’m also going to freak out a little less when patients who recently traveled to a tropical area return with a fever. Unless they were pregnant in a zika area. Or they are the unlucky 1% with hemorrhagic dengue.
3. Well, probably this HD neutral intubation idea. Also probably lathering honey on patients. But I’d love to see some of this at BMC.
Like you guys, I was amazed by the piece on honey. This fall I had a kid at Good Sam who we had to fly out for endoscopy, and some honey would have been great to have for that kid!
The active shooter piece, although stressful to listen to, brings up some important points. We work in an ED with many entrances, and their point about locking down the units that cannot be evacuated has me a bit concerned. I don’t know that our ED could effectively be locked down. They also bring up the notion of bleeding control, which at first I thought seemed kinda ridiculous (it’s a hospital), but then I thought about what might happen if an event occurred up in Ophtho clinic, in a situation where proceed-out teams could not safely get there.
As always, I loved the rural medicine segment and this month was one of the more interesting ones with tetanus! Although it’s possible or likely I will never see this, I appreciated their very aggressive perspective on clinical deterioration and early intubation. The picture that I had in my mind was of a slower-onset syndrome, but this clinical vignette showed the importance of being ready for rapid airway decline.
Like Ted, I also enjoyed the febrile returning traveler, as this is a topic that has given me anxiety in the past. Historically I have just clicked on every ID-related test I can find, but this narrowed it down to the big ones of malaria and dengue, of which malaria is the major treatable one.
1. I found Amal Mattu’s review of the 4th Universal Definitions of MI to be helpful. I have heard him talk about needing more than 1 mm of ST elevation in the early precordial leads to diagnose STEMI, but it’s good to know that it’s now in the consensus guidelines. Vaccination is becoming an ever-more contenious issue, so anything that makes it less open to critique or refusal is great. I learned that egg allergy is no longer a contraindication for the flu vaccine, so that should help to encourage people to get vaccinated. I learned many other things from this month’s episode, but the third one that I will list is from the tetanus case. This is something that we prophylax against all the time, but I don’t think I’ve really been taught (or ever stopped to think) about how that would actually present or how the case would play out and what management decisions would need to be made.
2. I will definitely be more cognizant about how I’m doing my discharge instructions. It is very telling that most people throw them away and/or don’t really understand what they say. Every time we discharge a patient, we’re probably just checking a box or following a process more than truly bringing closure to the encounter and clearly delineating the treatment plan and next steps. The segment on incidental findings was particularly moving and poignant. I will be making sure to make more prominent notes about incident findings in discharge paperwork and in my charts/handoffs for admitted patients.
3. One thing that may not quite be ready for prime time (at least at BMC) is the honey for button battery ingestion. I think that to go against long-standing practice (NPO status, etc.) where multiple specialties are/will be invovled (GI, anesthesia, surgery), there need to be multiple conversations to make sure that everyone is on the same page.
1. Three things learned…
(1) The segment of vaccinations, and the associated adverse effects of vaccinations was extremely helpful. I am glad to know there are such detailed but user-friendly resources available from the WHO. Some great tidbits included learning that up to 20% of adults will have severe site pain after receiving TDap, that fevers are common after tetanus vaccines in kids – but that while ~13% of kids may have a fever < 101 F in the first 24 hours, only about 0.1% will have a fever greater than 104 F in that time frame. MMR vaccines are associated with encephalitis in about 1 of every million patients vaccinated, as opposed to 1 of every 1000 patients with measles who will develop encephalitis. Up to 5% of kids getting a varicella vaccine will develop a small, localized outbreak of vesicular lesions which can be contagious. (2) I learned about the recently published guidelines recommending 10 mL of honey every 10 minutes for up to 6 doses for children who have ingested button batteries. (3) Finally, I learned that for patients with suspected malaria and shock in presentation, we should call the CDC to have IV artesunate flown to the nearest airport!
2. All the above points will hopefully be areas of change to my practice if the clinical scenarios arise! The most likely to be used in the near future will be offering guidance to parents on symptoms of adverse reactions after childhood vaccines.
3. I think the description of hemodynamically neutral intubation with viscous lidocaine and ketamine for awake intubation followed by placing a patient on pressure support ventilation at 0/0 feels potentially to "bleeding edge" for usual practice at BMC. I have found that even on discussion of half-dose sedatives and increased doses of paralytics for hypotensive patients undergoing RSI there has been variable reception by faculty on that practice. Perhaps with some very specific scenarios it could be discussed, but I think for most patients who are hypotensive and need emergent intubation practices of volume resuscitation and pressors hanging and ready are much more likely to be the strategies employed at this time.
Three things I learned and how they will change my practice:
1. Incidental findings are an incredibly difficult topic in our ER. I think this stems from two things common to our population, health literacy and availability of PCP follow up. It is uncomfortable during your discharge conversation to say “hey we found this thing that is probably nothing but could be cancer, follow up with your PCP, they may want to get a CT scan in a year”. It is difficult to find the words to explain this in the very brief amount of time we have to counsel patients. The podcast gave a better structure to categorize the type of finding so that our discharge instructions are more succinct and appropriate to the clinical scenario. I wish BMC had a scripted template for these three categories of incidental findings (probably nothing, unsure, definitely concerning) to help us provide to patients.
2. I have personally never seen an awake intubation performed although I had an awake laryngoscopy on me in conference. As I am new to the trauma/airway resident role, I am anxious about having a hypotensive patient with a tenuous airway that might benefit from this approach. I’ve used 4% lidocaine frequently for flexible rhinnolaryngoscopy, and patients tolerate it extremely well. I hope this is something I get to attempt at BMC prior to ending residency, but this might fall into the “bleeding edge” at BMC.
3. The rural medicine segment was a good reminder that our “life saving tetanus” actually is life saving on a larger scale. I’m surprised we don’t encounter tetanus more frequently, and it’s probably the result of our liberal dosing of tdap (which is why I see the push for Hep A vaccination as well).
Too bleeding edge for BMC:
Can’t imagine honey being used in button battery ingestion, but we also have the benefit of 24hr ENT/GI for retrieval. Also, I’m somewhat concerned that I don’t know of an active shooter policy at BMC, and particularly am unsure of what we are expected to do aside from call on public safety. However, I think we are lucky at BMC that public safety is <30sec away.