EM:RAP and Pharm of VTE (June 2019)
AIR: https://www.aliemu.com/courses/pharmacology-of-venous-thromboembolism/
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/emrap2019june/heatstroke/
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?
6 comments
As a big emrap fan, i have to be honest and say this wasn’t the most compelling month in my opinion…but that said, some of the highlights for me:
a.) FOOSH. Loved learning about the pain with resisted supination. I will be documenting that in addition to snuffbox tenderness. A great example of how we need to put more specific timelines on follow up (eg see ortho in 1 week).
b.) Precedex. I look forward to discussing this with our ED pharmacists. It is widely used in our ICUs and I have used it a bunch on my rotations upstairs, but I have yet to use it in the ED. If we begin to develop an ICU boarding problem, this seems like a great option. I also didn’t realize it’s potential for calming the pt who is fighting bipap as a potential to avert intubation.
c.) PART/AIRWAYS2. At BMC we are lucky to be fed pts by BEMS and medflight, both of which are highly skilled at intubation. As we go into the community, we may be interfacing with EMS agencies that haven’t made this huge training commitment, and in those instances the option of intubation seems likely to be a loss. Even in the urban setting of highly trained medics, it seems the advantages may be less than I thought.
d.) abx stewardship. I think the real gem here was the statistic of NNH of 4-20. That is a pretty powerful stat to keep in mind (and to share with our patients when we are not prescribing).
1) Three things learned….
As mentioned by Andy M, I also appreciated the pointer on including pain on resistant supination for evaluation of wrist injury for possible scaphoid fracture.
It was great to learn that about cost-analysis data supporting progressing to MRI in the ED as cheaper than casting and referring patient with possible scaphoid fx for outpatient follow up (cost of immediate MRI $526 vs total cost $1200 for casting / follow up / serial XR).
Last but not least, very helpful review of management of heat stroke. Sweaty skin does not exclude the diagnosis of heat stroke, cool these patients to a core temp of 101-102 (NOT to normal 98.6), APAP does not help, intubate with Roc (with expectation of hyperkalemia and rhabdo), and don’t turn to pressors when they arrive with SBPs in 80s (treatment is cooling them down, pressors may worsen their course).
2) Changes to my practice
Will certainly consider all three points above on shift in the clinically appropriate scenarios. Also, will be more watch for SGLT-2 inhibitors on my DM2 patients. Another important change will be to strongly consider using precedex for post-intubation sedation as I am seeing it used widely and frequently in our MICU. The guidance on no bolus and how to titrate to HR was very helpful. I hope to also try this with the patient who is not tolerating BiPAP in the ED.
3) “too bleeding edge”
I didn’t think there were any points discussed that were definitively out not applicable to BMC practice. I think going straight to MRI after wrist injuries concerning for scaphoid fx would be difficult most shifts in our ED 2/2 patient volume, but perhaps on some occasions may be feasible. Also, I think holding back on initiating pressors for a hyperthermic patient with profound hypothermia would be challenging because sepsis or tox overdose would also be on the Ddx and might benefit from the pressure support, but that challenge would not be specific to BMC!
1) 3 things I learned this month:
– Great tips on how to manage heat stroke, and good reminder to keep an eye out for it (especially in the summer). Check a temp on altered patients ASAP. Evaporative cooling (ice baths if avail), NOT wet sheets. Benzo’s help w/shivering. Tylenol/NSAIDS etc are useless and may harm. Cool to 101-102 not 98. If you need to intubate, use Roc. Lots of fluids, avoid pressors.
– Scaphoid fx. Not just FOOSH, but any trauma w/wrist pain. Check for scaphoid tenderness and pain w/resistance to supination. If XR is negative and Pt has these findings, splint and prompt ortho f/up (1 week max), vs MRI in the ED (difficult to do at BMC). CT is only 83% sensitive, so not helpful.
– Child abuse: I’d never heard of the TEN 4 FACES rule for bruises on children before listening to this. Also taking care not to ask leading questions when taking a history from parents of children with falls/injuries. Spiral fx in toddlers can be normal if they’re running around and get their foot stuck/trip. Bucket-handle fx are a/w abuse.
2) Changes to my practice:
– Undress all babies/toddlers. High suspicion for abuse in babies with bruising, especially if TEN 4 FACES rule applies.
– Loved the idea of precedex for pts boarding in the ED on BiPAP to avoid intubation
– Keep a higher index of suspicion for euglycemic DKA, especially if Pt is on one of the SGLT-2 inhibitors
3) Too “bleeding edge”
– I laughed at the thought of getting a wrist MRI in the (BMC) ED for suspected scaphoid fx vs splinting w/ortho follow-up, however they made a good argument with the fact that it’s less than half the cost.
– I’ve never seen a patient come in with an LMA vs ETT from EMS. But based on the PART trial, seems like something our EMS colleagues should look into.
– Good luck taking your time to insert the chest tube in our trauma room, and pulling it out if you hit resistance to reinsert it. But Kenji’s point is really valid – once you’re in the pleural space, the emergency is done, and you should be able to take an extra minute or two to ensure you have good placement without jabbing the tube through the lung, etc, and secure it properly.
3 things that I learned:
The “Cardiology Corner: ACEP Clinical Policy on NSTEMI” episode really helped cement some of the basics:
1. I was reassured by the emphasis placed on the HEART score. My attendings and senior residents have been emphasizing the application of the HEART score from day one. Reading about how the American College of Emergency Physicians supports discharging patients after negative serial troponins along with a low HEART score helps me better understand how my practice compares to the practice of other EM physicians around the country.
2. I also enjoyed learning about the implications of further testing. I learned that sending patients for more provocative testing when that patient has a likelihood of ACS less than 2% increases the chances of a false positive and puts the patients at risk of harm. I will now feel more comfortable discharging by low HEART score patients since I know that they will not benefit from further testing.
3. The June intro focused on hernias. I will now make sure to consider richter hernias (protusion of one wall of the bladder) on my differential.
Areas of my practice I will change:
After listening to the medical legal briefs from this month I will make sure that all of my discharge summaries have are time and action specific.
No applicable to BMC.
This month for the Critical Care Mailbag, the team focused on the use of dexmetetomidine in the ED. They discussed how it’s still possible to assess the patient while on etomodate, how it serves as both sedation and analgesia, how it doesn’t affect the respiratory drive and is delirium spearing. Unfortunately we currently don’t have access to dex in the BMC ED. I hope this will change as we have more conversations with our critical care colleagues around our critically ill patients that are often in the ED for an extended period of time due to a lack of available beds.
Three things I learned and changes I would implement:
1. Extremes of heat are far more likely to be due to exposure than from an alternative medical diagnosis, and even if rarely caused by a medical problem (like hyperthyroidism), it is never wrong to start treatment with cooling regardless of cause. Particularly the idea that rate of cooling is directly related to mortality has reinforced that getting an accurate core temp and then quickly cooling takes priority to nearly any other intervention in the ER.
2. I especially appreciated the recognition of the things that cause delays in diagnosis. I think specific to BMC, we are so sepsis-focused that if someone feels hot, the first priorities we have are getting a BP and starting an IV for that “crucial” fluid bolus. I would change my practice to have core temperatures and exposure take priority to obtaining an IV, however, I truly think that they can be done simultaneously in trauma 1.
3. Some our routine thoughts for fevers/hypotension treatment don’t hold here. For example, it seems obvious that tylenol/NSAIDs are not helpful in this scenario, but less obviously, the idea that patient’s are not in a vasodilatory state and that refractory shock (after perhaps 2L) should continue to fluid resuscitated rather than jumping to pressors (which inhibit the ability to shed heat and may increase risk of dysrhythmias) is very important.
Too cutting edge/Not applicable to BMC:
– I think concurrent intoxication is something that wasn’t as thoroughly covered. However, I think take home would be that benzos are also highly appropriate for these patients for many reasons, including seizure prophylaxis and possible cocaine/meth coingestion, in addition to cooling. Listening to the podcast and hearing about runners and the elderly was a little different from our intoxicated/found down hyperthermic patients and I think we need to think a bit more broadly in these patients, particularly how they highlighted the metabolic derrangements (rhabdo/hyperK/hypoNa)
As a separate aside of not applicable to BMC, I completely agree with Lauri’s point. I cannot imagine getting a wrist MRI at BMC, but it would be great if we could have better access to the MRI because particularly in this case, this is likely a 3min exam rather than some of the involved 30-60min MRIs we are normally ordering. Additionally, I’ve never used precedex in the ER but having had multiple ICU boarders this week, and several that were very hard to sedate, I really wish we could start placing patient on this right alongside the propofol, with a slow concominant upward titration, however, I think this will take substantial pharmacy/nursing initiative and may be a long time coming
1) I had never heard of a lumbar hernia before; sounds very rare and yet another reminder that there is so much to know! Like Lauri, I found the “TEN 4 FACES” mnemonic to be really helpful. To be fair, I’ve already forgotten what some of it stands for, but at least I have something to look up now if I have a concern about certain bruising. I also learned that the onset times for lidocaine and bupivacaine are actually similar, so the risks of systemic toxicity of bupivacaine are probably not warranted.
2) I will seriously consider doing purse string sutures in future chest tubes. To be honest, I had never really thought about when the chest tubes are removed down the line, and this seems like a reasonable and humane thing to do for patients.
3) I think that dexmetetomidine is not ready for rollout in the BMC ED quite yet. We have more appropriate agents for initial sedation with which nursing is comfortable. Although we do frequently have boarders, I think that more education is needed and policy would have to be developed for people to be comfortable doing this. I also agree with those above who think that routine MRI for MSK injuries is not realistic. The MRI scanners are booked all day with outpatient studies, so realistically we’d only get these scans overnight if at all.