As I was putting
together my slides for the ACEP 2017 Conference, I saw a tweet pop up. It was
by Dr. Amal Mattu (@amalmattu) advertising about The Crashing PatientConference in Baltimore in October 2017. It was the very same month I was going
to Washington DC for my one month of clinical rotation at George Washington
University Hospital. I was super-excited! It became a top priority to register
myself for the conference. I was dreaming of meeting my Emergency Medicine
gurus in person and this was an excellent opportunity, which I could hardly
lose.
The Crashing
Patient Conference is an annual one da conference which has many short lectures
with ‘to the point’ pearls. This year’s theme was resuscitation and risk
management. There were different lectures encompassing critical care,
resuscitation, shock, cardiology, endocrine emergencies, orthopaedics,
paediatrics, urology, burns and most importantly medico-legal.
I will summarize
the pearls here from each session. Dr. Mike Winters reviewed critical care
quickies with an interesting case that he had encountered.
1)
Before intubating the
patient, preoxygenate with 40-60L/min by
NRBM
2)
RSI drugs: remember TBW for
etomidate and IBW for ketamine (Obese patients were found to be dosed
inappropriately)
3)
ED ventilator settings matter,
especially if there is increased length of stay in ED!
4)
Deep sedation is known to
increase mortality. Target lighter level of sedation. Opioids (Fentanyl) are
first line!
Dr. Khoujah talked about delirium,
which is misdiagnosed most of the time.
1)
In patients with suspected
delirium, pay attention to “attention”.
2)
Use modified Richmond Agitation
and Sedation Scale to screen delirium.
3)
Delirium = predisposing
condition + precipitating insult; treat the underlying cause
4)
Change the environment ie allow
relatives to be besides the patient, put a date time and location on wall
facing the patient, try to minimize physical restraints.
5)
Most importantly, prevent
delirium before you have to treat it!
Dr. Manning discussed on ventilator
settings in severe asthmatics.
1)
Stick to the basic asthma
medications
2)
Maintain permissive hypercapnia
by balancing acidosis and auto-PEEP
3)
Indication for intubation:
cardiac arrest, exhaustion, agitation, silent chest and severe hypoxia
4)
Lower the respiratory rate,
allow patient time to breathe. Reduce I:E ratio to 1:4.
5)
Increase tidal volume to
8-10ml/kg, lower the PEEP and increase the flow rate 80L/min and gradually
taper FiO2.
6)
Trouble shooting :
a)Post-intubation hypotension- disconnect from vent, let them exhale then check
for pneumo. b) Post-intubation hypoxia- do the above and check the tube c)
post-intubation arrest- ACLS, go easy on bagging, needle the chest
7)
When in doubt, disconnect and
let the air out!
Dr. Bontempo discussed about deep
neck space infection and things to remember.
1)
The most common etiology of
deep neck space infection is odontogenic; specifically infections of lower 2nd
and 3rd molars.
2)
One should be worried if voice
change, shortness of breath, neck pain, DM, CRP >100
3)
Anticipate a difficult airway,
start broad spectrum abx, drain the pus out.
Dr. Dubbs discussed about the law
suits faced due to missed diagnosis of cancer in ED. She suggested:
1)
Always have a high index of
suspicion- prolonged symptoms, weight loss, B symptoms, voice change, stool
change, anorectal lesions, post-menopausal bleeding
2)
Watch out for the fine printed
reports- incidental findings, abnormal cell counts, etc.
3)
Discuss with the patient
4)
Document your discussion and
have a great QA process
Dr. Bond (@Docbond007) talked about
spinal epidural abscess and posterior shoulder dislocation.
1)
The incidence of epidural
abscess has increased in past 2 decades, keep a high suspicion for patients
presenting with spine pain.
2)
In patients with spine pain
without any neuro deficit, but with fever, risk factors, then check CRP/ESR; if
elevated get an MRI spine.
3)
Get X-ray axillary view in
suspected posterior shoulder dislocation. Ensure humeral head is in glenoid
cavity.
Dr. Lu discussed the complications of
myocarditis. It can be deadly in kids. Hence
1)
Always be wary of subtle signs
2)
Consider myocarditis if
dyspnoea, chest discomfort and antecedent viral illness.
3)
Consider myocarditis if
persistent unexplained tachycardia.
In the section on ‘Salt, sugar and
sex’, Dr. Willis summarized that
1)
Persistently hypoglycemic-
think adrenal insufficiency
2)
Hypoglycemia +hypotension –
Adrenal insufficiency until proven otherwise
3)
If there is any suspicion give
empiric steroids. (Hydrocortisone 100mg iv, Dexamethasone 5mg iv,
fludrocortisone 0.1mg iv
During the conference, Dr. Mattu kept
the audience engaged by his fun quiz. He was kind to gift me the signed copy of
the second edition of ‘Avoiding common errors in Emergency Department’ which I
will treasure the most.
Although it was a long day, but due to
short engaging presentations in a TEDx like format, it was very fun filled,
motivational and interesting conference. A definite must go!
Nikhil N. Tambe - @nikhil16marM.B.B.S., ECFMG (USA)
Emergency Medicine Resident
Masters in Emergency Medicine (GWU)
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai
Lifesupporters Institute of Health Sciences, Mumbai
