Grand Rounds: Stop the Bleeding!!!

Our awesome Stu Douglas did a fantastic job of bringing together the evidence, the lack of evidence, and evidence of the future together into a practical rounds on reversal strategies for anticoagulation and anti-platelet agents.

Consider using the StuDoug Approach (TM) when you see a patient who just won’t stop bleeding.

stop-the-bleeding-png

Download a copy of this click here!

If you are an emergency medicine, elective resident, medical student or otherwise rotating through our program in Kingston and would like to contribute to QEmerg.org please get in touch with Eve or Kristin at (epurdy at qmed.ca)!

Summer Series: Lumbar Puncture, Suturing, and Pediatric Resuscitation

Last week’s summer series was an excellent session on lumbar punctures, suturing, and pediatric resuscitation.

Lumbar Puncture and Suturing

Dr. Eric Mutter and Dr. Karen Graham walked us through how to perform a lumbar puncture, both with and without ultrasound guided landmarking prior to the procedure – an especially useful skill in those patients whose anatomy or body habitus makes external landmarking more difficult. Dr. Sharleen Hoffe led a parallel session on suturing – reminding us of the basic principles of wound management and showing us some spiffy new techniques. It turns out that pigs feet are excellent models to practice skin and tendon repairs! Check out the infographic below for a summary of some important tidbits or click here to download the pdf: LP & Suturing.

Summer series LP:suture

For a more in depth look at extensor tendon repair, Sharleen directs us to this acep article.

Pediatric Resuscitation

We spent the afternoon in the SIM lab working through a series of pediatric resuscitation cases with Sharleen and Tim. This topic is a scary one for many of us and I found it very helpful to go over a few potential pediatric patients. Some take home points from the day were as follows:

  1. Use the broselow tape! Yell out the colour and estimated weight so that everyone is on the same page. If the child looks heavy for their age, increase the medication doses but keep the equipment sizes the same.
  2. Sepsis response is age related! Kids will often get hypocalcemic + hypoglycemic so watch out for those. In general, treat septic shock with norepinephrine if there is no response to 2 boluses of fluid. (Epinephrine is suggested instead of norepi in cases of “cold shock”)
  3. Remember to initiate CPR in the bradycardic kid with a pulse <60bpm.
  4. Intubation should be a last resort in asthmatics – just like in our adult population!
  5. Treat DKA with judicious fluids + skip the insulin bolus – we want to avoid cerebral edema if we can!
  6. Delegate math/dose calculations. You will have too many other things to think about running a resuscitation.
  7. Refer to the Canadian Pediatric Society Guidelines for a great overview of the most up to date expert recommendations.

Summer Series: Optho 101 and Procedural Sedation

Two weeks ago now (sorry for the delay), we had a great morning session from Dr. Rob Brison – let’s call it Rob’s optho 101. He started out at Hotel Dieu with some slit lamp tricks and tips – did you know that it takes 5-10 minutes for corneal abrasions to uptake fluorescein fully? Put it in early and complete the rest of your eye exam before using the cobalt blue setting. Remember to use it with all elderly patients with conjunctivitis – you may be surprised with what you find. We discussed conjunctivitis – allergic (bilateral, papillary pattern), viral (uni/bilateral, follicular pattern), and bacterial (purulent discharge, unilateral); and many other common eye complaints that we see in the ED. Take home points: (1) always use fluorescein (2) call optho when unsure or to arrange close follow up when concerned.

Check out this article by Rob published in 1993 on the utility of antibiotics in corneal abrasions.

 

Procedural Sedation

After lunch Dr. Caley Flynn and Dr. Eric Mutter (under the watchful eye of Dr. Jaelyn Caudle) taught us a thing or two about procedural sedation. See the infographic below for a crude summary, or click here : Procedural Sedation for a pdf to download.

Summer series PS

The discussion was rich and interactive. We worked through several examples of the ETCO2 tracings that we use to monitor our sedations in the ED – it’s definitely not as simple as it seems! For more practice, try out a few cases on capnography.com.

Additionally, two drugs that were not included in the infographic, but were discussed at rounds were ketofol (ketamine + propofol) and dexmedetomidine (Precedex). Ketofol is theoretically meant to be a combination that allows the use of a lower dose of each drug individually, therefore decreasing the incidence of adverse effects of both. Practice seemed to vary with few using the 1:1 combination, opting instead for a good dose of ketamine followed by a titrating dose of propofol as needed. For some further reading on this topic, check out David and Shipp 2011 and Andolfatto et al. 2012. Dexmedetomidine, on the other hand, is an EXPENSIVE alpha-2 agonist that provides “cooperative sedation” (analgesia + sedation + anxiolysis) and is widely used in the ICU. Caley and Eric predict that it may soon become more common in the ED, so stay tuned!

 

 

Summer Series: Central Lines and Trauma

In this week’s edition of the summer series we learned about central lines and trauma. Though these sessions were on the same day, don’t forget that the central line is not a resuscitative line…unless it’s a cordis.

Central Lines

In the morning Bruder and the senior residents introduced us to a number of different central lines and we had the chance to practice seeing the anatomy in real-time. Though one of our first year residents claimed the largest IJ in the crowd, I was pleasantly surprised at my ability to expand my IJ.

Central lines are really best learned in the sim laboratory and we are fortunate to have a curriculum in central line placement as second year residents. This session allowed for the sharing of some more practical tips and tricks, similar to these central-line tips and tricks from Haney Mallemat.

Trauma

In the afternoon Tim and Chris led us through high fidelity simulation of four difficult trauma cases. The lessons learned ranged from Simulationa discussion of cyanide toxicity (covered by Shar in a previous rounds here) to difficult airways to neuroprotective intubation. Towards the end of the day we were thirsty to learn more and one resident asked where we might learn more about trauma. We have compiled a list of some trauma learning resources.

Text books: Chris and Tim both recommended that textbooks are a great place to start to develop a framework for trauma management. Rosen’s/Tintanalli’s are a good start but there are a ton more in our resident library. Make sure to check them out.

Trauma Guidelines: The Eastern Association for the Surgery of Trauma provides comprehensive guidelines for the management of most trauma related injuries that you can access here. Unbeknownst to most of us, there is also a Western Trauma Association and publish a number of helpful algorithms. It seems these two groups might benefit from joining forces…

Journals: Keeping up to date on trauma literature means surveying the literature. The Journal of Trauma and Acute Care Surgery and Trauma are starting points.

Online Resources: Below are a number of websites that we have found helpful when reading about trauma. IVLine (for the very basics), The Crashing Patient (a rather comprehensive overview of everything trauma),  Life in the Fast Lane (a large number of trauma related posts), The Trauma Professional’s Blog (case discussions, pearls, tips and tricks).

Just in Time Resources: We learned in this session that everyone should have easy and ready access to a paediatric app such as pedistat or PalmEM to help mitigate the stress of medication doses and equipment size in paediatric trauma.

Please comment below if you have additional resources about learning about central lines or trauma! Look forward to seeing you for the next session!

Summer Series: Deliberate practice, airways, and chest tubes

Round two of the summer series was led by the dynamic duo of Bob McGraw and Carly Hagel. They spent the day teaching us a very deliberate approach to airway and they also employed an impressively engineered model to practice chest tube placement. Perhaps the most important lesson of the day, DON’T CLAMP THE CHEST TUBE.

The 7 P’s of Intubation

Dr. McGraw highlighted the importance of an unchanged routine in preparing for airway management to free up cognitive space. One thing we did not directly discuss but we might consider implementing into practice in our next intubations is a checklist to ensure that we have not forgotten any of the important equipment or mental steps.

We repeated our setup dozens of times throughout the morning with direct and immediate feedback. This deliberate practice is one step in the movement towards expertise. Here is a reminder infographic on the 7 P’s of intubation that we practiced on Thursday. For more information about how to “Own the Airway” check out these links on Life in the Fast Lane.

summer-series-airway

To download a pdf of this infographic click here.

As Dr. McGraw pointed out, positioning is an often overlooked, critical aspect of the successful intubation. Though an article from the anesthesia and critical care world, this is an interesting review of some (low quality) literature discussing Back Up, Head Up positioning for intubation in a population of high risk patients that may be similar to those we see in the ED. Food for thought at the least!

Chest Tubes

The pretty nifty simulated model for chest tube insertion was a great way to practice the technical skill, outlined by this NEJM article and videos. The skill was easy when compared to the discussion of how chest tubes work and how to trouble shoot when things go wrong. We got deep into a discussion respiratory physiology. There were many take aways but the main was:

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

Clamping the chest tube is one way to make the patient much worse. Clamping the tube can cause a tension pneumothorax, making a bad situation for the patient much, much worse. When you are trouble shooting, get back to the basics. Take a deep breath, slow down and remember the circuit, even draw it if you have to!

Please share any resources you have found helpful or comment on your approaches to deliberate practice, airways or chest tubes!