Conference Notes 9-27-2017

Barounis     Ventilator Management

You will use Assist control/Volume control ventilator mode 99.9% of the time in the ED. There is rarely a need to use another mode in the acutely ill ED patient. 

5 Steps to setting the vent

1. Select Assist Control/Volume Control

2. Tidal volume.  Set your tidal volume to keep plateau pressure at or below 30.  Higher pressures cause lung injury. Low tidal volumes are lung protective.  Number Needed to Treat using low tidal volumes to save 1 life is 11!  Start at 6 ml/kg.  Distilling this down to a real basic guideline for ER docs is give 500 ml for guys and 400ml for women.  You can adjust up and down +/- 50ml if the patient is particularly tall or short.

3. Pick your RR.  If the patient has bronchospasm, you need to use a low rate (10 breaths/min) to give the patient more expiatory time so you are not causing breath stacking.  So, for asthma 10 breaths/min,  for hypoxia or to protect airway 20 breaths/min, and for severe metabolic acidosis 30 breaths/min.   Logan Traylor comment: For respiratory acidosis due to asthma or COPD, patients still need a low rate to avoid breath stacking. As the clinician, you will need to accept some respiratory acidosis.    Dave agreed and added furtehr comment: There is some data that patients who are acidotic after cardiac arrest may do better with a higher PCO2 level and an acidotic ph than ventilating them rapidly and lowering the PCO2 and causing cerebral vasoconstriction. 

4. Set PEEP.  You want to keep the driving pressure (plateau pressure-peep) less than 15.   Start with a peep at 8 for the average overweight ED patient.  After 20 minutes, do an inspiratory hold and figure out the driving pressure and increase the peep as needed to lower the driving pressure to 15 or less.

5. Set the FIO2.  Base your FIO2 on the O2 sat.  Try to keep the O2 sat around 95%.  Avoid hyperoxia and hypoxia.

 

If peak pressure is high and plateau pressure is OK then you have a resistance problem.  Resistance issues include: patient biting the tube, mucous plug, blood in the ET tube, tension pneumothorax, and asthma.

Nand   The 2 Midnight Rule

Patient who are inpatients for more than 2 midnights after admission are presumed to be appropriate for Medicare Part A payments.  Our documentation needs to reflect the necessity of that admission.

The clock starts when the patient begins to receive care in the ED. If the patient is in the ED at midnight, that counts as the first midnight.

One exception is a patient placed on a ventilator.  They can all be made inpatients even if they will stay less than 2 midnights.

Keeping patients for social or safety reasons who have no other medical issues should in general be OBS stays.  If the patient has some concurrent medical issue they may be appropriate for admission.

Patients with symptom-based diagnoses (chest pain, abdominal pain) should be OBS.  If you think patient will go home the next day, make them an OBS.

Don't write" we will admit to OBS"  Medicare will not approve this type of explanation. We have to avoid using both the terms Admit and OBS in the same chart.  When both terms (Admit, OBS) are used in the same chart Medicare uses that lack of clarity to decline payment.   Better to write "we will place patient in OBS for further evaluation"  or " we are admitting patient for management of pancreatitis"

If you need to change a bed request. 

1. Cancel the initial level of care order.  2. Cancel the initial bed request.  3. Place the new bed request.   If you don't do this in the correct order medicare will deny the admission.   

Mounica Donapudi comment: 1. Right click the level of care and click cancel d/c.  2. Rght click the the bed request and click reorder. 3. change the bed request order and sign.

Tran    Human Trafficing

Unfortunately I missed this excellent lecture.

Traylor   Admin Update

You need to write the sepsis re-eval (..sepsis macro) for any patient with a lactate over 4 or a MAP<65.    Give 30ml/kg of LR or saline.  3 liters should work for most patients.  You have to write the reassessment note within an hour after the IV fluid bolus.   If you have concerns about volume overload, document that concern and order >125ml/hr (126ml/hour is acceptable)

April Kennedy    Dental Emergencies

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How to describe teeth.

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Cross sectional anatomy of a tooth.

 Pulpitis is the most common cause of tooth pain.&nbsp; Treat with pain control and antibiotics.&nbsp; If there is an open area on the crown, it may help to place a covering on the tooth with Temrex. Patientswill need dental referral for extraction or root canal.

Pulpitis is the most common cause of tooth pain.  Treat with pain control and antibiotics.  If there is an open area on the crown, it may help to place a covering on the tooth with Temrex. Patientswill need dental referral for extraction or root canal.

 Patients will need tooth extraction as definitive management of pericoronitis. In the ED start them on antibiotics and pain meds and refer them to their dentist or an oral surgeon.

Patients will need tooth extraction as definitive management of pericoronitis. In the ED start them on antibiotics and pain meds and refer them to their dentist or an oral surgeon.

 Dry socket occurs when the blood clot that has developed in the socket since dental extraction becomes dislodged from the socket. This leaves the nerve exposed and is quite painful.&nbsp; Dry socket is more common in smokers, patients over age 25, patients with poor oral hygeine and patients who use straws to drink liquids.

Dry socket occurs when the blood clot that has developed in the socket since dental extraction becomes dislodged from the socket. This leaves the nerve exposed and is quite painful.  Dry socket is more common in smokers, patients over age 25, patients with poor oral hygeine and patients who use straws to drink liquids.

Academic Life in EM: Trick of the Trade: Extra-Oral Reduction Technique for Anterior Mandible Dislocation

  1. Place the patient in either sitting or supine position.
  2. The provider should stand in front of the patient.
  3. The provider places their thumb on the patient’s cheek, on the mandibular ramus and coronoid process of the dislocated mandible, and applies persistent pressure posteriorly (figure 3).
  4. The fingers are placed behind the angle of the mandible to stabilize the grip.
  5. At the same time on the opposite side, the provider places their fingers from the other hand on the angle of the mandible and pulls, applying anterior force (figure 4). Note that this maneuver causes further anterior dislocation of the ipsilateral TMJ, rotates the jaw, and facilitates contralateral TMJ reduction.
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Once one side of the dislocation is reduced, the other side will usually go back spontaneously. If that doesn’t work, repeating the same maneuver with minimal force will usually result in success. Also consider applying posterior force on both coronoid processes at the same time if the above strategy doesn’t work.

If a primary tooth (baby tooth) is avulsed do not replace it.  If a permanant tooth is avulsed, rinse the tooth with saline. Save the tooth in tooth saver liquid, the patients own saliva, or milk.  Replace the tooth and splint it in place.  Give doxycyline as antibiotic prophylaxis to adults. Update their tetanus shot.  Patient will need dental or oral surgery referral for a root canal.   Replacing the tooth actually supports the alveolar bone and optimizes the bone for eventual dental prosthetic if needed.  Dr. Kennedy advises replacement of the tooth up to 24 hours out.  You should advise patients that they will likely loose the tooth and need a prosthetic.

 You can cover Ellis fractures with Calcium hydroxide or Dermabond.

You can cover Ellis fractures with Calcium hydroxide or Dermabond.

 

Dental Lab