Grand Rounds: September 17, 2015

jkms-24-1224-g001-l

Dr. Kristin Berona enlightens us with a great talk on the pitfalls and limitations of the FAST exam, Dr. Allison Sarff Luu gives us an amazing review on the management of anticoagulated patients with TBI, Dr. Angelica Loza-Gomez reviews a number of actual base station calls to LAC+USC, and get ready for another PIMP session where Drs. Michael Menchine and Sanjay Arora present the use of tPA in stroke and a low-cost method for converting SVT to NSR.

TTA FAST QA

Dr Kristin Berona enlightens us with a great talk on the pitfalls and limitations of the FAST exam. She reminds us that when looking in the cardiac window to always look in 2 views if there is any question of free-fluid, free-fluid that is only posterior to the LA is probably not an effusion, free-fluid that is only anterior and moves with the heart is probably a fat pad, one should see bowing of the atria and ventricles if cardiac tamponade is causing hemodynamic instability, and always take a second look if vital signs change. She also emphasizes that one should suspect a pleural effusion or hemothorax if there is a spine sign superior to the diaphragm in the RUQ. Finally, she would like to remind everyone to continue recording their FAST’s and to keep up the good work!

Management of Anticoagulated Patients With TBI

Dr. Allison Sarff Luu gives us an amazing review on the management of anticoagulated patients with TBI. Delayed post-traumatic bleeds for patients on warfarin is a rare occurance (1%). She presents a no fuss mnemonic to TBI she likes to call BRAINS (BP, Reverse coagulopathies, ABC, ICP control, NSG, Seizure ppx). Don’t forget to keep the MAP >80. Use PCC with vitamin K for anyone warfarin, anyone with liver failure, or anyone with an INR of >1.5. Use PCC for anyone on xarelta, eliquis, or pradaxa. Use platelets and DDAVP for anyone on aspirin, plavix, or dialysis with uremia. Use protamine for anyone on lovenox or heparin.  Phenytoin is the first line medication for post-traumatic seizure prophylaxis. Charateristics of a post-traumatic delayed bleed in a patient taking warfarin include age >60, varying INR’s, LOC, GLF, bleeding 6hr-1wk after the event, no NSG intervention during their ED course, and an initial GCS of 15. Discharge any patient >60 yo who is on warfarin after an initial negative CTH or any patient taking plavix. Observe any patient who is taking warfarin who has either a poor social structure, presents during an overnight shift, has significant trauma, has an initial GCS <15, or has an INR >4.95. Consider treating any patient who is taking xabans or dabigatran like a warfarin patient. Finally, don’t forget to look at your own scans even if they are read as negative and give explicit return precautions to all of your patients!

Base Station Radio Calls

Dr. Angelica Loza-Gomez reviews a number of actual base station calls to LAC+USC. Initial EKG door to balloon time should be less than 90 min for cath lab activation in the field. Activate code STEMI x97111 if the patient has an STE >1mm in 2 contiguous leads in the field. Follow EtCO2 after 10 and 20 min of CPR. EtCO2 at 10 mmHg or an abrupt rise in EtCO2 predicts ROSC or out of hospital survival. The base hospital doesn’t need to be contacted if the patient is apneic, in asystole, and has no neuro reflexes in addition to decapitation, massive crush injury, an injury with evisceration of heart, lung or brain, decomposition, incineration, extrication time >15 min without BLS prior, penetrating trauma, blunt trauma, rigor mortis, or lividity. If CPR is initiated, EMS may determine death if the patient has asystole after 20 min of CPR, the patient is >18 yo, no shockable rhythm at anytime, no ROSC at any time, and no hypothermia. Have the patient transported if ROSC is confirmed with an abrupt rise in EtCO2, or if the patient has persistent VT/VF after 3 shocks. Termination of in field resuscitation can be initiated if the physician deems it futile, the arrest was not witnessed by EMS, or if the patient had an unknown downtime.

PIMP Session: tPA and SVT

Get ready for another PIMP session where Drs. Michael Menchine and Sanjay Arora present the use of tPA in stroke and a low cost method for converting SVT to NSR. Tsivgoulis et al in Stroke looked at the incidence of administering tPA to stroke mimics and the risk of an ICH occurring in stroke mimics if tPA were given. Older studies like NNIDS and ECASS III showed a favorable outcome with tPA if given within < 3 hrs and < 4.5 hrs of symptom onset respectively, however, the practice remains controversial. This and other studies have demonstrated that you will give tPA to the wrong patient 5-15% of the time, and 0.5 to 1% of stroke mimics who are given tPA will suffer an ICH. Current ACEP 2015 IV tPA guidelines provide a level B recommendation for giving IV tPA < 4.5 hrs of symptom onset and a level C recommendation for shared decision-making when feasible. Appelboam et al in The Lancet demonstrated that patients with stable SVT who were placed supine and had their legs elevated immediately after Valsalva had a 3 time higher chance of conversion to NSR without adenosine when compared with standard Valsalva.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s