Conference Notes 10-4-2011
ROHIT GUPTA CLINICAL DECISION RULES
CDR’s should be clearly defined and address a clinically important outcome.
CDR needs to be Validated in a population different than the Derivation population. The San Fran Syncope Rule did well in the derivation population but failed in the validation population.
A CDR then needs an Impact Analysis
Hieracrchy of rules: Level 4 needs further eval. Level 3 and 2 show increasing validity. Level 1 CDR’s have been well validated and widely used.
The Pneumonia Severity Index CDR was reviewed. This is a Level 1 CDR and can be used in our clinical practice.
The Glascow-Blatchford Bleeding Score for Upper GI Bleed was reviewed. Score based on BUN,HGB,SBP, and a few other random factors. This is a level 1 CDR also. This rule can guide decisions on who can be discharged and who needs endoscopy. Rohit advised that this CDR can be used in our own practice.
The PERC rule actually has not been well validated so far.
Harwood suggested MedEquations as an app for the iPhone for easy access to CDR’s. Rohit also suggested MDCalc.com.
DAN GROMIS and DR. OMI CURBSIDE CONSULT TRAUMA ISSUES
Use your judgment on ACLS care and ACLS meds during trauma resuscitations.
End Tidal Co2 is less valuable in Trauma resuscitation because most of the time the patient is profoundly hypovolemic.
The lethal triad: hypothermia/acidotic/coagulopathic.
New research ongoing with cooling animals to 18C to see if that improves outcome. Human trials are planned.
ECMO can be used but you have to be set up for it. Requires heparinization. Data is lacking on efficacy.
Minimal Trauma Work UP for the Patient with no Vitals: Blunt Trauma: Airway/ chest tubes bilat/central catheter fluid infusion/FAST scan. Penetrating Thoracic Trauma: consider thoracotomy
Who gets ED Thoracotomy? Penetrating torso trauma. The only thing likely to be fixed is Pericardial Tamponade. If patient has lost vitals for more than 10-15 minutes or pt is asystole ED Thoracotomy is unlikely to provide benefit.
If patient has brain injury and they have been resuscitated with stable vitals consider Organ Donation. Determination of brain death takes about 24 hours so patient’s circulation needs to be maintained for that time period.
CHINTAN MISTRY EMTALA
Anyone presenting to an ED must be provided with a timely medical screening exam to assess for an emergency medical condition.
If an emergency medical condition exists, the patient needs to be stabilized so they are unlikely to deteriorate prior to transfer. If patient is in labor the infant and placenta need to be delivered.
If a patient presents to an outpt clinic at the hospital, EMTALA is triggered if the patient feels they have an emergent condition.
Who does the screening? At ACMC it is an attending EP.
What is does screening consist of? No one is totally sure. Basically, do the right thing for the patient in the ED.
For legal purposes a discharge is a transfer.
For Trauma you have to accept from anywhere in the country. Pt’s outside US have no claim to EMTALA.
EMTALA fines are not covered by malpractice insurance. Hospitals can lose Medicare funding.
DAN NELSON and CINDY CHAN ORAL BOARDS
Case 1: Ovarian Torsion. U/S may show cysts and decreased blood flow to ovary.
Case2: Montaggia Fracture. Check for compartment syndrome. Consult Ortho for ORIF in adults. Kids can sometimes be tx’d with closed reduction.
Case3: DKA/NSTEMI Treat with IV fluids, insulin, and potassium. NSTEMI required asa, plavix, lovenox. Treatment. No benefit to immediate cath.
JOE MASLAR RADIATION INJURY
Radiation is the transfer of energy. Wavelength effects properties and energy content. Smaller wavelength has more energy.
Gamma rays can penetrate concrete and lead. Xrays are less damaging and easier to shield.
Ionizing particles Alpha and Beta. Because it is a charged particle it cannot penetrate skin/clothing. It is only an issue if you ingest the particle. Radon is a particle that emits radiation.
When energy from waves or particles hit atoms it ionizes the atoms.
Seiverts are the most important unit of measure for physicians because it measures the dose a patient received. 1 Seivert=1Gray=100Rads. 1Miligray=100 milirads
Avoid radiation exposure with time, distance, and shielding.
Ionizing radiation effects DNA. DNA most susceptible during mitosis. Radiation can also injure lysosomes and mitochondria.
Most sensitive cells are blood forming cells, reproductive organs, digestive organs, and vascular system.
Cell damage and organ dysfunction lead to radiation sickness.
Radiation induced malformations in fetuses does not pass on to the next generation. If the fetus survives it probably did not suffer catastrophic damage to the DNA blueprint.
Radiation sickness requires large dose of radiation from an external source, penetrating radition, short time, whole body exposure.
If a patient has neuro symptoms they are going to die. The nervous system is most resistant to radiation.
Three Radiation Syndromes: Hematologic, GI, CNS. They are on a continuum of increasing radiation dose. Anorexia/nausea/vomiting is the basic prodrome for all 3 syndromes. Time to onset can be an indication of severity of radiation exposure. If they are vomiting a lot at one hour they are at risk of dying.
24 hour lymphocyte count is the best marker for outcome. (Board alert) Rate of decline of lymphocytes is also used.
Risk to health care workers from radiation exposed patients is very low. If possible removed patients clothing and wash them off with water and soap. Do not delay care due to radioactive contamination of the patient.