EM:RAP and Cutaneous (July 2019)
AIR: https://www.aliemu.com/courses/cutaneous2019/
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/emrap2019july/intimatepartner
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
3 things I learned:
• Intranasal midazolam may be helpful in a seizing child without IV access. We can use the IV formulation and use an atomizer to administer a dose of 0.2 mg/kg to 0.5 mg/kg.
• The longer a child is seizing the higher the likelihood the GABA receptors targeted by benzos will be internalized and digested by the cell. Because of that we need to administer benzos early and make sure we also tackle the new NMDA receptors that are synthesized on the cell surface. Being aware of this physiology helps me better understand how propofol/benzos affect the seizing patient and it’s also a reminder to use ketamine (1-2mg/kg) since it tackles the NMDA receptors.
• After listening to the Fascia Illiaca Block chapter and realizing that I must have intralipid readily available when using bupivacaine I asked around and realized that our intralipid is located in the Trauma 3 Pyxis. In case of emergency we need to ask the pharmacist to run over and grab it for us.
Areas of my practice that I will change after listening to this podcast:
I learned a lot from the chapter focused on Intimate Partner Violence. I took care of one patient as an intern and was really discouraged when she told me she would return to her partner. In discussing with the team we had made sure to not ask “ why don’t you just leave” . I really appreciate the tools that were made available during this chapter. I will make sure to communicate with more empathy by using “How can I help you get out of this situation” as suggested by the episode. I also made sure to look up the resources available to these patients and will make sure to print it out for them:
https://www.mass.gov/service-details/domestic-violence-programs
Practices mentioned in this podcast that I would consider to not be applicable to our practice setting here at BMC:
The rural medicine piece was a lot of fun but I am grateful that we have more resources available to us here at BMC. I wish the podcasters had a more extensive conversation about managing the lack of access to O2. Are there interventions we can do to still support these patients? Should I just focus on triaging my patients and identifying who should our resources be funneled to? If we are triaging, how do I make these decisions?
Having recently seen several DV patients in the trauma room, I’m unsurprised at the profound prevalence of this, and I bet it is even higher in our patient population. Things I learned:
1. We all know our frequent flyers, but I can’t say that I’ve often thought of DV as a possible root cause of their presentations. Many of these patients have known unstable social situations (i.e. homelessness, polysubstance abuse) which also leads them to be higher risk of DV. I think that having a more frank line of questioning as a physician rather than a canned nursing triage prompt may ellucidate more of these patients.
2. Strangulation is probably the most common and obvious manifestations of DV that we encounter. I feel that these patients are difficult because it is hard to know a dispo because the reality is that resources are fairly limited and patient’s offenders are often highly motivated to find them no matter where the patient winds up (so alternative family may not be the best dispo strategy). I didn’t realize the OR of fatal outcome is 10 when the presentation of DV is strangulation, and I would gladly hold these patients in the ER longer for a safer dispo, especially on overights when more eresources may be available in the morning.
3. I was unaware of the mandatory reporting laws around this issue. Per the podcast, what seems to hold is that only in the event of a deadly weapon being involved is this a mandatory reporting event. I still am unaware of the exact details of reporting specific to MA, and would probably fall back on SW and our public safety officers speaking with the patient to determine reporting.
I think there were several rather important parts of this month’s podcast.
Perhaps most interesting to me, I thought the new PECARN study continues to raise a lot of interest. Perhaps less so in the BMC adult ED, but in the community the ability to potentially bypass an LP has huge implications. I’m impressed by their 0 critical misses in the 0-28 day population, and look forward to more validation of this new tool. That said, obviously the “holy grail” will be no a tool that requires no bloodwork (they needed a pro cal and ANC), which even getting bloodwork in these little kids can be very challenging for community RNs who don’t see too many freshly-released little fetuses.
As always, I loved the community medicine piece. Not a whole lot of hardcore medical facts in that segment this month, but an important reminder that we have everything available to us, 24/7 at BMC. Can’t even imagine running out of oxygen…
The DV section, as Sean points out, was very important. I wasn’t aware of the huge mortality risk associated with strangulation, but will definitely be approaching that injury pattern with marked seriousness in the future. Actually had a pt last night who had a prior visit for strangulation and I sat down and talked with her about safety after listening to this segment.
The segment of fascia iliac block is an important one. That is a procedure I have been working on, and am now a bit embarrassed to say that I have never actually verified that the intralipid truly does live in the pixis in trauma 3, let alone consider bringing it to the bedside. Going forward, prior to any fascia iliaca block I will be strongly considering lidocaine, and if i go with bupivacaine i will verify the presence of the med and FYI pharmacy that I am going to do a high-risk procedure. In the US literature, this block is billed as incredibly safe (in fact, one piece even suggested a 0% complication rate when using US guidance), but Scott’s advice would speak strongly to the contrary.
Lights and sirens – concerning that Boston EMS responds and transports lights/sirens 100%…perhaps a bit higher than the 50%/5% that they recommend. Perhaps a good possibility for intervention on behalf of our EMS colleagues.
1) 3 new things I learned from this podcast:
– I knew that we should be putting the PEEP valve on our BVM’s, however I never really realized that without it, the patient is essentially just getting 21% FiO2, so I’ll definitely be checking my BVM’s more carefully before shift.
– Strangulation is associated with a 10-fold increased risk of death, and they likened it to a sentinel bleed in SAH.
– Trace ketones in a UA for neonates is NOT normal, and they should be worked up for a metabolic disorder. Also ammonia levels > 200 are concerning for metabolic disorder, and ammonia can stimulate a respiratory alkalosis. Sending a uric acid from the ED can be helpful for further workup upstairs.
2) Areas of practice I would change
– Ask any patient who I’m concerned for DV about strangulation.
– Do a little more research into dosing and availability of intralipid prior to performing a fascia iliaca (or any nerve block) using bupivacaine.
– Consider ketamine in pediatric status epilepticus if several doses of benzo’s aren’t working bc the longer a patient seizes, the more NMDA receptors they make.
3) Areas that are too “bleeding edge”
– The new pediatric fever clinical prediction rule (using UA, ANC and PCT), was well-done and the findings were exciting, however I’m not sure we’re going to get away with not doing an LP on a neonate < 28 days with a fever.
1) There were a number of cool pearls this month. I had never heard of tension mediastinum before, so in addition to having another thing to be terrified of, I now have a treatment strategy should I encounter it. Similarly, I had never heard of the “lipid rescue” website and it is reassuring to know that there’s a quickly-available resource should I ever find myself needing to give intralipid. A third thing is the the workup and management of suspected metabolic disorders in newborns. This is a category of disease in a patient population that is truly terrifying, so having concrete steps to approach things is great.
2) Based on the domestic violence segment, I will definitely make a better effort to interview patients alone when they are accompanied by an overbearing significant other. I have had a few patients who have given off all the red flags but whose partners insist upon staying in the room, after which the patients have followed suit. I’ll need to put some thought into how to get the significant other to leave to interview the patient in confidence.
3) I agree with Lauri – I think that there is too much momentum behind doing LPs in febrile neonates and that it’s probably going to take more research and discussion with our pediatric (pediatrician?) colleagues for people to feel comfortable not doing them.