Rank #1: How to master CPR
Little things can make a big difference when it comes to running a code. EMS director and CPR aficionado Bill Reed gives a primer on High Performance CPR.High Performance CPR core principles
- Rate = 110 (100-120).
- Metronome set at 110.
- Depth = 2.0-2.5 inches.
- Full recoil (no leaning).
- Focus on rate & depth.
- Listen for 15 second countdown warning of upcoming compressor switch.
- Change compressors at 2-minute intervals/cycles.
- Whenever possible, compressions performed from patient’s right side and new compressor comes in from the previous compressors right side. Opposite is true for left sided compressions.
- New compressor to “hover” over chest during rhythm check and/or defibrillation.
- No more than 5 second pauses for compressor change or rhythm checks.
- Immediately resume CPR after defibrillation (no pulse checks) or when rhythm check is complete.
- NRB or nasal cannula at max flow initially.
- BVM when available.
- Rate = 1 breath every 10 compressions (unsynchronized).
- Volume = no more than ½ ambu bag.
- ETI when feasible or if no ROSC by 6-8 minutes as resources allow.
- ETCO2 monitor connected as soon as feasible.
- ETI should be accomplished by a provider other than code lead.
- Hands off patient and/or airway device at 2-minute check.
- Attach as soon as possible.
- Standard pad placement.
- If witnessed VF while pads were in place for another reason, immediate charge and defibrillate. Otherwise, ensure CPR for at least 30 seconds before delivering any defibrillations.
- Pre-charge defibrillator 15 seconds prior to 2-minute checks.
- If non-shockable rhythm at 2-minute check, “dump” charge by pressing the decrease energy selection button.
- If shockable rhythm at 2-minute check, immediately defibrillate & resume CPR (no pulse checks).
- If VF on rhythm check at 6 minutes (third cycle), immediately defibrillate, then roll patient 30 degrees towards new compressor, attach new posterior pad slightly below and medial to the patients left scapula, roll patient back and resume CPR. Attach new anterior pad over left superior chest. Connect new AP pads to new monitor/defibrillator.
- At 8 and 10-minute checks (fourth & fifth cycles), pre-charge and defibrillate with new AP pads & monitor/defibrillator set at max joules.
- At 12-minute check (sixth cycle), pre-charge both defibrillators to max joules and defibrillate both “simultaneously” if patient is still in VF. One operator, two fingers.
- Changing to AP pads and/or double sequential defibrillation (DSD) is only for refractory VF.
- If VF converts with standard pad placement, AP pad placement, or DSD, use that pad placement and energy setting for recurrent VF defibrillations
- IO is faster than IV.
- IV can follow IO.
- Central venous access should be accomplished by a provider other than the code lead.
- Know your rhythm before giving drugs! That tachycardia might be SVT or something that might not take kindly to a bolus of epinephrine
- Goal is for 3 doses in first 10 minutes.
- Can give at 2,4, & 6-minute checks or whatever time interval is most easily accomplished.
- After 10 minutes, goal is for Epi every 5 minutes.
- Amiodarone (for VF)
- Goal is for 2 doses in first 10 minutes.
- 300mg first dose and 150mg second dose.
- Can give at 2 & 6-minute checks or whatever time interval is most easily accomplished.
- Confirm/ensure metronome use & appropriate CPR depth & rate.
- Confirm/ensure appropriate BVM or BV ET Tube rate and volume.
- Confirm/ensure ETCO2 connected and documented.
- Notify team of impending compressor change and rhythm check 15 seconds prior to the end of the 2-minute cycle.
- Confirm/ensure defibrillator is pre-charged.
- Interpret rhythm.
- Instruct defibrillator operator to deliver shock (or deliver shock if code lead is the operator) after confirming no team member is touching the patient.
- Confirm/ensure resumption of CPR and BVM after rhythm check and/or defibrillation.
- Request and confirm drug delivery at appropriately intervals.
- Confirm/ensure documentation of rhythm(s) and drug doses.
- Ensure all pauses are less than or equal to 5 seconds (use 5 sec verbal count down).
Rank #2: ZDoggMD
Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone.
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In this interview we cover a wide range of topics including
- How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist
- The Mind Illuminated
- The roots of anxiety
- Mental preparation before giving a talk
- ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement
- Nurse practitioners
A Smattering of Performance Improvement, Stress Management, and Wellness Episodes
- Finding the Joyin Your Job
- Performance Coach Jason Brooks
- Making Order Out of Chaos
- How to Not Freak Out
- When Consultants Give Bad Advice
- Beating Stress and the Hot Offload
- Mastering the Storm
My Favorite Zdogg Song
Rank #3: What you don't know about Wernicke's encephalopathy
Megan Spyres, toxicologist and emergency physician at LA County-USC, gives a primer on diagnosing and treating Wernicke's encephalopathy. The title of this post "What you don't know about Wernicke's encephalopathy" is more from my perspective than a commentary on what you, the listener, may know. After all, you might be a genius when it comes to this disease. For me, this has always been confusing and difficult to diagnose. So let's sharpen our clinical acumen and learn why neglecting thiamine can be a really bad thing. Special thanks to Dr. Anand Swaminathan for his journalistic excellence in putting together this interview.Pathophysiology
- secondary to thiamine deficiency (vitamin B1). Thiamine is a cofactor for pyruvate dehydrogenase. This enzyme is needed to take glucose from anaerobic glycolysis into the Krebs cycle (where we make the majority of our ATP)
- pyruvate dehydrogenase converts pyruvate (the end product of glucose metabolism in glycolysis) to acetyl co-A. Acetyl co-A is the entry point into the Krebs Cycle.
- if there is no thiamine, there is no Acetyl co-A... no Krebs Cycle... no ATP.
- The heart and brain get quite upset and function poorly when they don’t have ATP
- we only have a few weeks of thiamine reserves (best case scenario)
Cardiac: Wet beriberi
- high output heart failure. Fatigue SOB, peripheral edema
CNS: Wernicke's encephalopathy
- altered mental status/confusion/memory problems
- It would be nice, in a clinical sense, if patients presented with all elements of this triad, but the overwhelming majority do not (there may be just one or two)
- Wernicke's encephalopathy can progress to Korsakoff syndrome - an irreversible anterograde amnesia. May also include confabulation, apathy, lack of insight.
- In addition to the above findings, there may also be absent reflexes on physical exam
How common is Wernicke's encephalopathy?
- estimated to be present in 2% of the US population
Who is at risk?
- insufficient intake
- insufficient absorption
- enhanced elimination
Specific groups who are at risk for thiamine deficiency
- Chronic Alcoholics: poor nutrition, poor absorption
- Bariatric surgery, AIDS, malignancy, hyperemesis gravidarum
- Insufficient intake: eating disorders, prisoners, institutionalized elderly
- Enhanced elimination: patients on furosemide
Evaluating for Wernicke's encephalopathy
- It’s an easy disease to overlook. Consider in an alcoholic patients with multiple presentations with confusion
- Do a good neurologic exam. Don’t blow off persistent ataxia, especially when the intoxication has resolved to the point where the patient can be discharged
- In 1997, Caine et al suggested that the diagnosis could be made with two or more of the following:
- dietary deficiencies
- oculomotor abnormalities
- cerebellar dysfunction
- either an altered mental state or mild memory impairment
- give thiamine
- in the presence of ETOH, thiamine absorption is reduced by up to 50%. Don't think you will be able to rapidly correct this disease with PO treatment alone
- 100mg IV is good for prevention and might protect patients for at least a week. This dose is not, however, considered sufficient for treatment
- treat with 500mg IV thiamine three times daily for 2-3 days, then 250mg IV TID for 3-5 days
Does thiamine need to be given before glucose?
- a glucose load will increase thiamine requirements.
- historically, it has been thought that giving a load of glucose (or dextrose) might ‘push patients over the edge’ into encephalopathy. There’s no evidence that this occurs in patients who aren’t already overtly thiamine deficient.
Bottom Line: Wernickes encephalopathy is easy to treat but also easy to miss. When we miss it, our patients can suffer
Rank #4: Massive GI Bleed on Anticoagulants
Rob and Tom Deloughery discuss management of actively bleeding patients who have been prescribed anticoagulation medications.
Rank #5: Getting Sued
This is not an easy episode. It's not easy because a doctor gets named in a lawsuit, a patient has a bad outcome, and it openly discusses some of the systems failures we have in medicine. If that's enough to turn you off, close the page and go about your day. You'll probably be happier for it.
Still here? Well, here's what we've got... Cam Berg is arguably one of the brightest stars in emergency medicine (or all of medicine if you ask me.) Even that level of excellence, however, didn't stop Cam from being named in a lawsuit when a patient had a catastrophic outcome. This case involves a series of events that include: hypertension, IV hydralazine for asymptomatic hypertension, boarded patients, stroke, thrombolytics, brain bleeds, and the collateral effects of getting sued.
Rank #6: Cellulitis
Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?
The great cellulitis mimic: Stasis Dermatitis
- Similar in appearance to cellulitis
- Often bilateral (where cellulitis is usually unilateral)
- Risk factors include venous stasis, lymphedema
- Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation
- Many recommendations out there, many of them consensus, opinion or based on weak data
- Compression if the patient can tolerate it
- Wet dressings if there is crusting and exudative eczema
- Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
- If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)
Admit or go home?
- Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
- No validated decision instruments regarding admission or discharge
- 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
- Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
- Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
- A nice review of the admit or discharge cellulitis question can be found here
Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235
- 500 patients with cellulitis
- Treated cephalexin alone or cephalexin plus TMP/Sulfa
- No significant difference in outcome
Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080
- 150 patients with cellulitis
- Treated cephalexin alone or cephalexin plus TMP/Sulfa
- No significant difference in outcome
Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin
Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation. References
- Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
- Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
- Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
- Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
- Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
- Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
- Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
- Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
- Original Kings of County Analysis of Admit or Discharge Cellulitis
Rank #7: Alcohol, c-spines, and lots of pus
A day late and a dollar short, but here it is, the Ercast summer Journal Club. As per usual, boy genius Adam Rowh, MD is in the house to give his take on the medical literature. In this episode, we discuss
- Cervical spine clearance in the intoxicated patient (can you remove the collar if they have a negative CT?)
- Is there utility to giving antibiotics to patients with simple cutaneous abscess?
- Thrombolytics don't give long term benefit to patients with submissive pulmonary embolism
- Haloperidol is good for what ails you (if you have gastroparesis)
- Steroids for bronchitis
Also mentioned in this show
- Boneyard RPM IPA
- Follow us on Facebook. It's the new information portal for updates, questions, etc. If you want to contact me personally, use the contact link on this webstie
- Now on to the education....
Do patients with simple abscesses need antibiotics?
The answer for much of the antibiotic era has been no. I and D is sufficient treatment. But with the rise of MRSA, that thinking has been questioned. A paper by Talan in 2016 investigating TMP-Sulfa vs placebo for uncomplicated skin abscess suggested that TMP-Sulfa conferred a higher cure rate after I and D. Now comes a study of similar ilk but an additional treatment arm.
- Title: Daum, Robert S., et al. "A placebo-controlled trial of antibiotics for smaller skin abscesses." New England Journal of Medicine376.26 (2017): 2545-2555.PMID: 28657870
- The patients: 786 patients with abscesses 5 cm diameter or less.
- The treatment: After I and D placebo, patients received either placebo, clindamycin, or TMP-Sulfa
- Primary endpoint: Clinical cure. This includes improvement of the treated abscess but ALSO no new abscesses forming elsewhere (that will come into play later)
- The results: Compared to placebo, both clindamycin and TMP-Sulfa improved short-term outcome. Clinical cure was 83% clinda, 81% TMP-Sulfa, and 69% placebo. NNT of 8. There was not much difference between the different antibiotics, but big a difference compared to placebo
Looking under the hood (examining the details)
- Treatment effect was only when staph was the culprit. When there was no staph isolated, the outcome was not influenced by antibiotics
- Average surrounding erythema was over 2cm. This suggests that there was some cellulitis in these patients. Prior to this study, the common practice was to treat these patients with antibiotics. We recognize that it's not always easy to delineate between redness from the abscess itself and spreading cellulitis. Our point of contention, that these abscesses also had cellulitis, may be making a big deal out of a small thing (or it could be the most legitimate criticism of the paper).
- Treatment failure was mostly formation of new abscess and not worsening of the original abscess. While this is certainly a measurable effect, is it really a treatment failure? We argue that it is not. What's probably happening here is decolonization on some level. That is pure conjecture, of course, and it's certainly possible that there was autioinfection from the main abscess.
- Our bias: We don’t want to give extra antibiotics. Coming into this paper, we were looking for any faults in the study that could confirm an 'antibiotic stewardship' approach. If this was a paper showing even a small benefit for thrombolysis in the treatment of pulmonary embolism, we would look at in the exact opposite manner-where is the signal of benefit that says we might help patients.
- Will this change our management? Both Rob and Adam say it will not. We will continue to treat simple cutaneous abscesses (without surrounding erythema) with I and D alone. If the abscess is a recurrence or it is a patient with multiple abscesses, we will consider antibiotics.
C-spine clearance in the intoxicated patient
An intoxicated patient with moderate trauma has a pristine looking, completely normal, CT of the cervical spine. Do we need them to continue wearing their cervical collar until clinical sobriety? Enter our next study
- Title: Schreiber, Martin, et al. "Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey." (2017). PMID: 28723840
- The patients: About 10,000 moderate trauma patients, of who approx 3000 were TOX positive (alcohol, drugs, or both). The average injury severity score was 11 (moderate trauma).
- Intervention: CT cervical spine
- Primary outcomes: Incidence and type of cervical spine injuries, accuracy of CT scan, and the impact of TOX+ on the time to cervical spine clearance
- The results: In the TOX positive group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable cervical spine injuries missed by CT (NPV=100%). One patient in the Tox + but CT negative group had a central cord injury. When CT cervical spine was negative, TOX + led to longer immobilization vs sober patients (mean 8 hrs vs 2 hrs, p12hrs) in 25%.
- Author take home: CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization
This conclusion mirrors the EAST guidelines on cervical spine collar clearance in the obtunded adult blunt trauma patient:
In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. This conditional recommendation is based on very low-quality evidence but places a strong emphasis on the high negative predictive value of high quality CT imaging in excluding the critically important unstable C-spine injury.Haloperidol for Vomiting
The lament for droperidol's absence from our pharmacopeia continues unabated, yet there is another shining star: haloperidol. What's old is new when it comes to treating severe nausea and vomiting. Long recognized in the palliative care world as the cat's pajamas for management of nausea, haloperidol is finally getting the recognition it deserves.
The study: Ramirez, R., et al. "Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department." The American journal of emergency medicine (2017). PMID:28320545
The patients: Retrospective study of 52 patients with diabetic gastroparesis treated with 5mg IM haloperidol.
The comparator group: The SAME PATIENTS on ED visits when they didn’t get haloperidol! You can't get better matching characteristics than that.
The results: Using haloperidol in this group of patients decreased amount of opiates given and admissions but not ED or hospital length of stay. There were no complications seen in patients given haloperidolSystemic lytics don't work for intermediate risk PE
This has been a subject of much debate over the past decade and there has been signal that there may be a benefit in function outcome when thrombolytics are given to so-called intermediate risk pulmonary emboli- not hypotensive but right ventricular dysfunction and a positive biomarker. The biggest research article to date says lytics don't improve outcome.
The study: Konstantinides, Stavros V., et al. "Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism." Journal of the American College of Cardiology 69.12 (2017): 1536-1544. PMID:28335835
The patients: About 700 patients with intermediate risk PE given either Tenecteplase of placebo. Intermediate risk PE defined as RV dysfunction confirmed by echocardiography or spiral computed tomography of the chest. Myocardial injury confirmed by a positive troponin I or T test result.
The results: At 3 year follow up, there was no significant difference in mortality, functional limitations, pulmonary HTN, or RV dysfunction.
Our take home: When we first saw this paper, we were giddy because here was evidence that would show, once and for all, that lytics were an effective treatment for this cohort. The cold hard data says quite the opposite: lytics don’t make a difference in long term outcome. The best evidence we have to date suggests that there is no justification to give systemic thrombolysis to a stable patient with intermediate risk PE. Will catheter directed lysis prove any better, or are there certain high risk groups under the 'intermediate' umbrella who would benefit? Time will tell.
Prednisone for cough
The study: Hay, Alastair D., et al. "Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial." Jama 318.8 (2017): 721-730. PMID:28829884
The patients: 400 patients with cough for less than a month and at least 1 lower tract symptom like phlegm, chest pain, wheezing or SOB in the past day. Patients received either 40 mg of prednisolone or placebo daily for 5 days. The primary outcomes were duration of cough and mean severity of symptoms on days 2 to 4.
The results: Steroids did not make a difference
Our take home: WTF!? Of course steroids didn’t work! Only 6 percent of patients had wheezing and only a handful had crackles. Does a patient with an undifferentiated acute viral respiratory infection benefit from steroids? Apparently not. We tend to prescribe patients to these patients who DO have wheezing, but this supports our practice of not using them in patients who don't.
Rank #8: When can you shower after stitches?
- When is showering OK after stitches?
- What type of ointment should be placed on a laceration to promote healing?
- Is there an advantage to using antibiotic ointment over petroleum jelly on a non infected laceration?
- How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?
- What type suture to use for extensor tendon repair.
How long does one have to wait to take a shower after getting stitches?
- There is limited data addressing this question, but based on the data we do have, showering after 48 hours is probably OK.
- Even the NHS thinks so.
- It may be perfectly fine to shower even sooner, but there's no evidence that gives a time cutoff for optional showering.
- Note- showering does not mean submersion and it certainly doesn't mean getting in a hot tub. Second note- the intent of this podcast it for medical providers to understand the medical literature and differing opinions on this question, not direct medical advice to patients.
What should you use to dress a wound?
- Keep it moist. Don't let the wound dry. Lungs do the breathing, the wound needs to be smothered.
- Petroleum jelly is fine. Antibiotic ointment on a non infected wound does not confer extra benefit and may actually lead to worse outcomes (hypersensitivity)
- A 1995 study found that using antibiotic ointment on acutely sutured traumatic lacerations decreased the incidence of 'stitch abscess' but otherwise did not improve outcome for more severe infectious, such as cellulitis
- Non adherent dressing, absorptive dressing, then overwrap. Many dressings incorporate all three of these in one product
How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?
- Our interviewed expert says he repairs anything 25% or greater
- In Roberts and Hedges it says repair is optional if the laceration is less than 50% of the cross-sectional area of the tendon.
- A study that surveyed hand surgeons on flexor tendons found that some surgeons repair all of tendon lacerations, some only if they were more than 50% PMID: 7606610
- If you’re wondering if that injured tendon needs repair, if it’s a little divot, probably not. When you get into the 25-50% range, possibly. If in doubt, splint and refer.
- Many options
- Avoid Vicryl. It will break down too fast (2-3 weeks, not long enough for the tendon to heal)
- Nylon commonly used
- Our consultant prefers 4-0 Monocryl or PDS II. They will both dissolve but maintain tensile strength for a long enough the for the tendon to heal
Showering after laceration repair
- Hsieh, Pei-Yin, et al. "Postoperative showering for clean and clean-contaminated wounds: a prospective, randomized controlled trial." Annals of surgery 263.5 (2016): 931-936. PMID:26655923
- Toon, Clare D., et al. "Early versus delayed post‐operative bathing or showering to prevent wound complications." The Cochrane Library (2015). Full text link
- Harrison, Conrad, Cian Wade, and Sinclair Gore. "Postoperative washing of sutured wounds." Annals of Medicine and Surgery 11 (2016): 36-38. Full text link
Keeping the wound moist to promote healing
- Dyson, Mary, et al. "Comparison of the effects of moist and dry conditions on dermal repair." Journal of investigative dermatology 91.5 (1988): 434-439. Full text link
- Dire, Daniel J., et al. "Prospective Evaluation of Topical Antibiotics for Preventing Infections in Uncomplicated Soft‐tissue Wounds Repaired in the ED." Academic Emergency Medicine 2.1 (1995): 4-10. PMID: 7606610
Contact Dermatitis Offenders
Rank #9: Internal Medicine in the Emergency Department
Internist Neda Freyha sprinkles some IM in the ED - how to interpret TSH levels and why aspirin is no longer recommended for a-fib thromboprophylaxis.
Rank #10: Why Epi Might (and might not) Work in Cardiac Arrest
The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.
20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed. Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission.
Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate. Also, amongst the survivors, the neurologic outcome was worse.
Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful.
The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period. These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.
Rank #11: Should I give bicarbonate in DKA?
Should I give bicarbonate to DKA patients with severe acidemia? I've certainly been admonished for NOT doing it. The reason for withholding bicarb has been that I've heard that it doesn't help and may actually be a bad idea. I can't say the action (or inaction) was based on a deep understanding.
How could bicarb in DKA be a bad idea if even the American Diabetes Association (ADA) recommends we give a bicarb to DKA patients with pH under 6.9? The argument in favor of giving bicarb is that the more acidemic the patient, the higher the risk of circulatory collapse and cardiac arrest. Even though there is no evidence of benefit, the ADA gives a very specific set of steps to take in the low pH patient..
- Because severe acidosis may lead to numerous adverse vascular effects, it is recommended that adult patients with a pH less than 6.9 should receive bicarbonate. Specially 100 mmol sodium bicarbonate, two ampules, in 400 mL sterile water with 20 mEq KCL admitted at a rate of 200ml/hr for 2 hours until the venous pH is over 7. If the ph isn’t over 7 at that point, they say repeat the bicarb infusion every 2 hours until the ph is over 7.0
With that sort of exact guidance, you'd think there would be evidence to back it up, but here is the sentence that precedes the above recommendation.
- No prospective randomized studies concerning the use of bicarbonate in DKA with pH values
Rank #12: Pseudoseizures (PNES)
Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.
- PNES is a conversion disorder: an unconscious manifestation of psychological trauma.
- Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
- PNES is not ‘faking it’ or lying
- Patients with PNES may also have true epileptic seizures
- Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out
How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it?
- Seizures related to a specific stimulus (sound foods, body movement)
- Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
- Maintenance of consciousness and may have some of the below
- may guard the face with passive hand drop
- resist eyelid opening
- visual fixation on a mirror
- Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES. If they grimace, probably not an epileptic seizure.
- Purposeful movement
- Avoids injury
- May use convulsions as a way of harming staff
- Intermittently awake and vocal during the episode
- Convulsive frequency decreases, amplitude increases as seizure progresses
- No response to pain
- Allow passive eye opening
A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.
- Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
- Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
- Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
- Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
- Urinary incontinence, more common in epilepsy, but does happen in PNES.
- Post-ictal recovery period. Surely, this is the sine qua non of epilepsy. It is way way more common following generalized epileptic seizures but happens in around 15% of PNES.
- The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES
Walker’s take home points
- PNES patients aren’t ‘faking it’
- This is a real disorder, it's just not epilepsy
Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733
Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136
Rank #13: Conquering Night Shifts and Soft Tissue Ultrasound with Mike Mallin
Mike Mallin is a legend in emergency ultrasound but, by day, he's a regular guy and community ED doc. In this episode, Mike and Rob talk about
- making the change from an academic to community medicine job
- working in a place that sparks joy
- working locum tenens
- soft tissue ultrasound looking for abscess
- placing peripheral IV catheters under ultrasound guidacne
- how they approach night shifts (both single and stacks of shifts)
- patient handoffs
Soft tissue ultrasound
This is one of Mike Mallin's favorite exams, because no matter how good he thinks he is at guessing how much or if any pus is underneath the skin, he's often surprised when looking with ultrasound. A landmark study by Tayal in 2006 found that the introduction of soft tissue ultrasound into an ED evaluation for a skin and soft tissue infection changed management 56% of the time. Some patients who docs thought needed drainage didn’t and some that docs did not think needed drainage did.Pearls when looking for an abscess Compress with the probe: Pus can look a lot like surrounding tissue - especially nasty, thick MRSA pus. Sometimes the only way to see the pus pocket is to compress. What you're looking for is the swirl sign (sometimes called the 'squish sign') Use Color Doppler. Make sure that dark pocket of fluid you’re about to incise isn’t a AV fistula, or a random artery or vein. An 11 blade in a vascular structure is considered bad form. Look for Air: While looking at the infection, beware of air bubbles in the skin, they- along with fluid tracking on the fascial planes, can tip you off to gas forming bacteria. While that doesn’t always mean necrotizing fasciitis, it should get your attention. Unless there is already a hole in the skin for air to get in, these patients probably need a surgeon's hands on them.
Soft tissue air. Ultrasound from Joseph Minardi
Another example of necrotizing fasciitis on US from the EDE blog
Rob's Patient Handoff Macro This is a [ ] year old [ ] who presented to the emergency department with a chief complaint of [ ]. Patient care transferred from Dr. [ ] at [ ]. Presenting symptoms: [ ] Workup to this point: [ ] Pending studies: [ ] Plan at time of sign out: [ ] Study results: [ ] Patient reassessment: [ ] Plan: [ ]
Rank #14: The White Coat Investor
The White Coat Investor (AKA Jim Dahle, MD) talks debt, investing, philanthropy, investment philosophy, and investment strategies for different stages of your career.
Key Links from this episode
When Jim was an intern, he didn't know much about finance. His education started with this book
Books Jim recommends as foundational reading to understand personal finance
- The Only Investment Guide You'll Ever Need
- The Millionaire Next Door
- The Coffeehouse Investor
- The Four Pillars of Investing
White Coat Investor advice for a medical student
- Try to spend as little as possible. Every dollar you spend in medical school is going to be 3 dollars you pay back later
- This is they time you're expected to be poor. Be frugal
- Your specialty choice has a huge effect on your future financial life. Pick the one you will be able to work at the longest that makes you the happiest.
Advice to a young doctor
- The year that matters most in your financial life is your first year as an attending physician. That year sets habits.
- In med school and residency, have a plan in place for your first 12 attending paychecks.
- In the first few years after residency, live the lifestyle of a resident while earning like an attending. This can lead to rapid savings and loan repayment
- Embrace the habit of saving
- Calculate your annual savings rate/what you're putting toward retirement. Amount of annual savings divided by gross income. That number should be around 20%
- Look at your purchases from the point of view, "Will this make me happy?" The is the essence of budgeting: attaching your values to how you spend your money
- Each month, review where your money is going. Is that where you want it to be going? If it's not, make some changes.
- Don't buy on credit. Spending your money on payments is not what you want to be doing
- Most doctors want or need a good financial advisor
- The problem is that what we want is just to have a 'money guy' that takes care of all the money and we don't have to pay attention to it
- To make sure you're getting good advice at a fair price, you'll need at least a basic level of financial education (or at least get a second opinion)
- Be aware of the fees your advisor is charging. Expect at least 4 figure amounts
Starting residency. Buy or rent?
- Buy a home when you are in a stable professional and social situation
- there are high transit costs. It costs about 15% of the value of the home to make the 'round trip in and out of the home.About 5% to get in and 10 % to get out. If you're not there long enough for the home's appreciation to make up for that 15% loss, you're probably going to come out behind
- Homes appreciate about 3% per year
- If you're in a 3 year recency, changes are you won't break even
- White Coat Investor recommends most residents NOT buy a home and rent
New Attending. Buy or rent?
- There is a good chance you will change jobs in the first few years
- This is not the most stable professional time
- Make sure the job work for you before you buy a house
- Rent for the first 6-12 months
- You should still be living like a resident during this first year
- Buy a home when you are in a stable professional and social situation
The "Point of Enough"
- If you don't define it, it will always seem like a number that's twice what you have
- Take how much you spend in a year and multiply it by 25. When you have that in assets, you have reached finically independence.
Real estate investing
- Owning actual property is to the only way to do it. Other options include.....
- The easiest way is the REIT. Real Estate Investment Trust index fund.
- Syndicated real estate
Pay Down Debt vs Invest in the Market
- Doing either one will increase your net worth (unless the market tanks)
- Focus on what percentage of your income is going toward building wealth rather than what compartment that wealth building is going into
- Student loans have a few negative aspects: You can't deduct the interest when you're an attending; student loans tend to have high interest rates. Try to get rid of student loan debt within 2-5 years after residency
Jim's Ideas on Giving/Philanthropy
- Good for the soul
- Develops a stewardship mentality
- Giving money away sends a message to the subconscious that you have enough - you can give some away and still be OK
- It keeps you connected to the rest of the world
- It can make your portfolio more tax efficient
Rank #15: Haloperidol for Analgesia
One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.
In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17).
Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain.
A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects.
Haloperidol is an analgesic option for patients taking chronic opioids.
Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV, 5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose. If that doesn’t work, he uses analgesic dose ketamine.
For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum.
Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses. Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check.
- Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text link. PMID: 21412369
- Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link. PMID: 21029354
Droperidol for analgesia
- Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396. PMID: 20832967
- Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279
- Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073
Early studies on Haloperidol for analgesia
- Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741
- Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10.
- Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130.
Haloperidol for pain
- Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669
- Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode
- Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990
- Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034
Rank #16: Mind of an Addict
Our guest today is Joe Polish. Unlike most guests on this show, Joe is not involved in medicine- heis one of the best known marketing minds on the planet. He is the creator of the Genius Network which is the place high level entrepreneurs go to get their next big breakthrough with access to connection, contribution, and collaboration. Joe is also a best selling author and renown podcaster with I Love Marketing, genius network, Rich Cleanerand 10x Talk. But none of those things are why Joe is on the show today. Joe is also an addict, but deeper than that, he’s turning his experience with addiction into a force for change with Genius Recovery and Artists for Addicts.
In this episode
- Open Letter to Anyone Struggling with Addiction
- Joe's story of addiction and how he's dealt with it on the path to recovery
- The roots of addiction, why punishing addicts doesn't work and what we can do instead
- Sex addiction and connection
- The Craving Brain: Why addiction may not be a choice and what we need to understand about it
- How to bring more compassion and empathy to addicts and help them recover
- Gabor Mate:"Not why the addiction, but why the pain?"
- Be transformational, not transactional
Rank #17: Performance Coach Jason Brooks
Jason Brooks PhD is a performance coach helping health care providers, athletes, and other high level performers live better, work better, and be better. In this episode Jason gives his strategies and tactics on myriad topics including: three techniques for stress inoculation, improving test taking, the unseen costs of hiding ignorance, and what habits are common among high level performers.
- A look back at ERCast episode one on Rectal Foreign Bodies
- Jason's work with physicians through Phenomenal Docs
- You can't stop the waves but you can learn to surf - Jon Kabat Zinn
- Who consults a performance coach? Those who are stuck and want to become unstuck. Those who are excelling and want to excel at an even higher level. These forces can exist simultaneously in the same person
- What's easier to accomplish? Moving from a perception of low-level performance or getting to a higher level of excellence?
- Answering the question, "Why is this happening to me?"
- Start with Why by Simon Sinek Book TED Talk
- Having an internal yardstick to gauge how decisions align with your values
- Making time for periodic reflection
- The importance of adversity
- It's not what we do that causes burnout, it's losing sight of why we do it
- Common habits of top performers that transcend a particular career
- Humility is a common attribute in high level and respected performers driven to be the best I can be, but I don't have all the answers
- Expectations of a master physician to learners: make me better by contributing to my knowledge base, and I expect you let me know if you think I'm making a mistake
- Shedding the fear of exposing ignorance. What is the real cost of not exposing ignorance? Leaving knowledge on the table
- Three techniques for stress inoculation
- Practice through visualization
- Breathing techniques to trigger parasympathetic response and mitigate sympathetic fight/flight/flee
- Using a trigger word to de-escalate stress (mine is "level down")
- Improving test taking performance
- How an Olympic archer recalibrates after missing a shot
- Connect with Jason: Facebook, Twitter, email doctorjbro at gmail dot com
Rank #18: C Diff Treatment Changes
A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.
Mentioned in this episode
- ERcast 2.0launches May 1, 2018
- To sign up for the new site and 1 year of free CME, click here
- Essentials of Emergency Medicineis just around the corner. If you can't make it to Vegas, the digital live stream is pretty sweet.
New IDSA C Diff Guideline Treatment Recommendations
Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5)
- Vancomycin 125 mg PO QID for 10 days
- Fidaxomicin 200mg PO BID for 10 days
- Metronidazole 500mg TID PO for 10 days
Initial Episode, Severe (WBC >15k, creatinine >1.5)
- Vancomycin 125 mg PO QID for 10 days
- Fidaxomicin 200mg PO BID for 10 days
Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon)
- Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube.
- If ileus, consider adding rectal instillation of vancomycin.
- Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present
• Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR
• Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR
• Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode
- McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280
- Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597
- Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937
- New Evidence Favoring Vancomycin
- Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306
- Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326
CDC C. Diff Statistics
New York Times article on the association of the rise of new sweeteners and the rise of C. diff.
Rank #19: The Dying Asthmatic
Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy. Asthma is different than other causes of severe respiratory distress. And there are different forms of asthma as well.
Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case?
Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management.
In the rare cases of severe asthma with a ‘stone chest’ that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible. It’s the only way to safely provide the airway pressures you need.
Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration.
Failed attempts at intubation are especially risky in these patients. As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.
Rank #20: Emergency Complications of Cirrhosis
Britt Long, MD and Rob Orman, MD discuss emergency department management of patients with complications of cirrhosis.