Neuro 01: Treatment of Status Epilepticus

This is a 12 minute review of the treatment of status epilepticus in the Emergency Department. I’m still playing with the format so feel free to tell me what you like and what you don’t like, what works and what doesn’t. Do you feel that this actually teaches you something?

When we work together in the department, we can now discuss the treatment of status and you can teach me a thing or two!

Here’s a link to the PDF I made during the video.

Inservice in the Breakroom: New ACLS Guidelines – Part 1

The American Heart Association released the 2010 Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) earlier this month. We can look at the different guidelines in subsequent posts, but this month, we’ll review the Executive Summary. The summary stresses the changes from prior recommendations.

The most evident change is the stress put on high-quality chest compressions started early. Survival is best improved by (1) calling EMS early, (2) early chest compressions and (3) early defib.

Recognizing that most lay people are unwilling or unable to provide mouth-to-mouth is part of it, but more importantly starting chest compressions FIRST is shown to improve surival. So now they are flipping the primary survey from A-B-C to C-A-B, putting “C” (chest compressions) first. Instead of “look, listen and feel” for ventilation, positioning the airway and providing two rescue breaths and then giving compressions, now start with 30 chest compressions and give breaths afterward (it should only take about 18 seconds).

“Hands-only CPR” (no ventilation) can be explained to untrained people over the phone, even. That’s right, no more mouth-to-mouth on gross vomit-encrusted bearded guys. Unless you’re into that. In fact, don’t even waste time looking for a pulse. If you insist, don’t waste no more than 10 seconds checking.

They even changed the v-fib/v-tach diagram into a circle which stresses the importance of early, quality CPR.

Here’s a summary of a few other things that changed:
– we should be using waveform capnography to measure exhaled CO2. Countless other studies have showed that ETCO2 is an earlier predictor of ventilatory failure than pulse oximetry. We don’t have this.
– Paramedics should be doing pre-hospital 12-lead EKG’s and informing the receiving hospital of the results. Any ST-elevations should prompt activation of the cath lab. Chicago may be getting this, according to Louie.
– Ambulances should take stroke patients to stroke centers and admitted to stroke units. We got these, but are they all being brought here?
– Cardiac care doesn’t end with restoration of spontaneous circulation (ROSC), but they’ve introduced new post-arrest algorithms. These are team-based approaches meant to optimize perfusion, early catheterization, post-arrest hypothermia and monitoring for organ failure.
– In PEA, no atropine
– In asystole, no transcutaneous pacing
– They also briefly mentioned family presence in resuscitations. Go Sarah!

They also include changes to first aid administered by lay people. They
– shouldn’t be giving aspirin
– shouldn’t be giving epinephrine (apparently people do this in some places)
– shouldn’t be giving oxygen (doesn’t help that much anyway)
– shouldn’t be applying tourniquets (though it has been helpful in Iraq and Afghanistan)
– should be using pressure immobilizer for poisonous and non-poisonous snake bites. They’re addressing snake bites?!
– Electrolyte solution PO hydration for dehydration

Okay next time – part 3 – the ethical consideration. Feel free to comment below.

Inservice in the Break Room: Therapeutic Hypothermia

On the topic of critical care, I thought we could bring up the idea of therapeutic hypothermia after cardiac arrest. We’re talking about a patient who comes in with v-fib or v-tach arrest (for less than 25-30 minutes) and is shocked, their rhythm is restored but they’re still not getting up. What to do?

Cooling the patient down to 32-34 C (metric system?!) has been shown to improve neurologic outcome by decreasing free radicals, cell death, calcium shifts and mitochondrial damage.

How to do it? Ice packs or cooled IV fluids, that’s about what we can do in the ER. The ICU may have some fancier devices, maybe be good to ask them what they do.

Watch out for

  • dysrhthmias (usually not too significant),
  • hyperglycemia (as insulin release is inhibited – also not usually too significant)
  • hyperkalemia
  • infection
  • seizures
  • hemorrhage

Basically, should we be putting IV bags in the fridge? What do you guys think? Have you seen an instance when we could have done this?

Inservice in the Break Room

I’m going to try to resuscitate this blog to try to get some nursing-doctor educational-conversational action here. It is absolutely impossible to get all the nurses together for an in-service, and I always thought it was a futile task to gather those who are around with the overhead page “in-service in the break room” while you guys are working clinically.

So let’s do it all online. Yes, Norine, that means you’ll have to turn on your computer.

Are there any particular topics or articles you’d like discussed? Let me know. Let Tes know.

Please share your comments below.

Inservice In The Break Room: Pressors

What do you do when presented with a hypotensive patient resistant to IV fluids? Maybe throw some steroids at ’em but more likely you start dopamine. This is our go-to drug of choice as a pressor. However recent literature has shown it to be falling out of favor (ie, septic shock). So what should we use? Norepinephrine and phenylephrine.

Why do we use dopamine? Speaking from a doctor’s perspective, it’s familiarity. We know how to use it. However it may have more arryhthmogenic effects (in cardiogenic shock). There are drugs which are just as effective and probably more so… shouldn’t we get learn to use something new… or in this case, something old…?

* NOREPINEPHRINE 1 MICROgrams/min IV and titrate as high as 30 MICROgrams/min

Yes, some of you may remember this little fellow by his other name, “leave-em-dead,” but that’s a bit of a misnomer. I believe that name arose from the fact that if you were reaching for this drug, the patient wasn’t doing so well.

Goals of early goal directed therapy in sepsis requires quick restoration of perfusion to tissues. When fluids don’t cut it, vasopressors are needed to increase cardiac output and oxygenation. Norepi may be a more potent vasopressor than dopamine.

Hopefully this should go in through a central line, but what if you don’t got one? Well anesthesiologists commonly push pressors through a peripheral IV. GASP! Yes, a peripheral. Phenylephrine works well for this. This is called “push dose pressors.”

* PHENYLEPHRINE 50 MICROgrams IV push (with flush)

You should hopefully see an improvement in blood pressure in a minute or two, and it only lasts about 5 minutes.

So next time we have a code together and I ask for “push dose phenylephrine” don’t look at me funny. Instead

  1. grab a vial of phenylephrine (10 mg in 1 mL) and
  2. inject it into a 100 mL bag of saline
  3. now you have 100 mcg/mL.
  4. Put some in a 3 cc syringe.
  5. To give a 50 mcg dose, give 1/2 a cc.

What do you think?

REFERENCES:

* De Backer D, et al (SOAP II Investigators) Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. March 4, 2010; 362(9): 779-89.
* EM-RAP: May 2010, Scott Weingard, MD and Mel Herbert, MD.

Med Student Shadowing – Think Out Loud


Being a hospital associated with a medical school, we’re bound to have students interested in emergency medicine — even M1’s. Some of them may want to hang out with us in the ER to get a feel of what it’s like.

I know what you’re thinking: They don’t know enough of anything to be helpful. I don’t have time to spend explaining everything to them: like “what does CHF stands for?” and “why did you give them motrin instead of ibuprofen?” I can’t even go to the bathroom without them following me. If I can make a couple of sharp turns and duck into the juice room, maybe I can lose the student. Or maybe I’ll have them look something up in Rosens, that’ll get them out of my hair for an hour or two.

However, there is a way to make shadowing informative for the student, enjoyable for the patient and create minimal time disruption to you.

First, ask the patient if it’s okay to have a student in the room. Introduce the student as an observer, and ask the patient and family if it’s okay if he or she hangs out in the room. More importantly let the patient know you’ll be thinking out loud to help the student understand your thought processes. Tell them you may use medical jargon, and if they (the patient) doesn’t understand they should feel free to ask questions.

Then go through the patient evaluation, but THINK OUT LOUD. Let the student know what you’re thinking and why you’re doing things. “I’m asking these questions to rule out a PE, remember patients who are truck drivers are at increased risk for thromboembolism… what? Oh, that’s a blood clot.” “I’m hearing crackles at this left base, possibly signifying a pneumonia.” “Now we’ll order an EKG to check for cardiac causes.”

Patient’s love this because it gives them a rare peek into how we doctor’s think. It’s a glimpse into something interesting to them. Plus many patients are more than willing to help a student learn. It feels good to be part of the education process. The student also gets a glimpse into how we think, rather than just chasing us around and wondering “why did he ask about cocaine use?” or “what does that swollen leg mean?”

One Minute Teaching in the ER

We (doctors) are notoriously bad teachers, relying on pimping, lectures and just overloading the learners with information. Good teachers actively engage the learner, provide specific and immediate feedback (especially positive feedback), limit the content and are willing to admit ignorance. Adult learners prefer to learn concepts (not facts) and need to apply them quickly for them to sink in. Their main goal is summed up in the phrase “what’s in it for me?”

This one-minute teaching technique tries to take these things into account. Plus it’s really easy and fast to do, even on a busy shift.

0. Business as usual.

Let the resident/student present the patient, they usually will stop after their physical exam and wait for you to give them the assessment and plan.

1. Get a commitment.

Make them commit to either a diagnosis or treatment plan. It’s okay to be wrong, but without putting their money down on something, they really won’t learn as much. For example, ask “what do you think is going on?” “Uh, maybe it’s GERD?” Even if they come up with a good differential and plan, you can still have them commit to some hypothetical situation, “what would you do if this patient was hypotensive? 80? 3 months old?” etc.

2. Ask for supporting evidence.

Find out why they think what they think. Let them follow their reasoning through especially if they’re wrong. “I think it’s GERD because he’s too young to have cardiac chest pain.”

3. Teach general rules.

Give them just ONE clinical pearl, not a whole lecture. They won’t remember a whole lecture and we don’t have time for a whole lecture. “Remember to always consider PE, especially in patients who have cancer, a broken arm and just drove from Miami.”

4. Reinforce what the learner did well.

This is the part that seemed hoakey to all of us, but they kept reinforcing how important it is to give specific and immediate feedback on what the learner did right before you tell ’em what they did wrong. Typically in medicine, no insults/arguments is to be interpreted as a compliment. That or a general “hey, good job.” You need to be more specific, such as “you elicited all the risk factors for PE very well…”

5. Correct Mistakes.

Now you can tell them what to do better next time (in a nice way). “…but you always have to consider PE. If you don’t consider it, you will certainly miss it.”

6. Further Study.

This is where we either point the resident/student to a source for further study (after the shift) or if they ask us something we don’t know, we can tell them we’ll look it up and get back to them. If you ask them to look something up, it helps to ask them later on what they learned.

safe med practice: administration of IVPB meds

during the staff meeting, the question was raised on safe practice–
some staffs were asking- re: how much flush is needed after IVPB meds/antibiotics was infused per heplock so patients receive 95-100% of their IVPB meds. ( that means, no other fluids are infusing per heplock except the antibiotics)— remember– they’re concerned that there should be antibiotics remaining in the tubing that the patient is not getting
—is it safe to say that tubing must be flushed with 10, 20 or 30cc ??? or should all antibiotics be piggybacked with 0.9NS bag… then how much??? 50cc? 100cc??

Please share if you’ve done any lit review on this…

I’ve done some literature review, and found one study that examined the administration of IV meds via soluset or continu-flow solution set. It’s posted in the breakroom— any comments….