Episode 75 – Mass Casualty Incidents

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We cover Free Open Access Medical Education (FOAM) on mass casualty incidents, an unfortunate reality in the current United States climate (and elsewhere).  There is a must read (truly, emergency providers really should read this) in EP Monthly by Dr.Kevin Menes, How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History”. He details his process in running the Emergency Department that evening. Some of our favorite pearls

  • Plan ahead and rehearse. This means both mass casualty drills and mental rehearsal. We do this with many things in emergency medicine (thinking about how we would handle rare and critical procedures or disease processes.
  • Prepare once you have the heads up to help mitigate system induced bottlenecks.  When a mass casualty incident is expected, call for help. This means, extra staff to transport patients and techs and nurses. This also may mean calling in all trauma surgeons, anesthesiologists, and emergency providers. Additionally, bring all stretchers and wheelchairs to the ambulance bay. Consider calling for items in bulk. For example, all vials of paralytic, all chest tube trays from central supply, or large quantities of blood products.
  • Triage – according to the textbook the most senior person should be doing this. In Vegas, Dr.Menes discusses how he was needed in the and turned triage over to a senior nurse who had been assisting him in the process to that point.

We cover pearls from other great resources include a post on the St. Emlyn’s blog, “Mass Casualty Incidents: Lessons from the AAST” and a free EBMedicine article on ballistic injuries. We recommend this article by Dr. Kellerman on the reasons for the lack of firearm research in the United States.

We cover core content on triage and ED treatment pearls using Rosen’s Emergency Medicine Chapter 192 and Tintinalli Chapter 5 as guides

 

Rosh Review Emergency Board Review Questions

A massive explosion occurred at a nearby automotive plant injuring hundreds of employees. You are called to help as part of the disaster team. You are assigned to work on scene triaging patients according to the Simple Triage and Rapid Treatment (START) protocol. Your first victim is found unconscious with significant head and facial trauma. The patient has no spontaneous respirations. What is the most appropriate next step?

A, Assign the patient a black tag

B. Intubate the patient with an endotracheal tube

C. Oxygenate the patient with a bag-valve mask

D. Reposition the patient’s airway

Answer

You should reposition the patient’s airway. In mass casualty situations, emergency personnel often use the Simple Triage and Rapid Treatment (START) technique that allows for rapid assessment of patient’s respirations, perfusion and mental status (RPM). Anyone that is able to walk is asked to move away from the incident site and is assigned a green tag (walking wounded). At this point emergency personnel then quickly assesses the remaining patient’s respirations, pulse and mental status, in order to assign red (immediate), yellow (delayed) or black (deceased) tags. The first step is to assess the patient’s respirations. If they have no spontaneous respirations, you make one attempt to reposition the airway. If there is no improvement, they are assigned a black tag. If they are breathing greater then 30 breaths/minute, they are assigned a red tag. If respirations are less than 30 breaths/minute, then you assess the patient’s perfusion. If their radial pulse is absent or their capillary refill is over 2 seconds, they are given a red tag. If the have a radial pulse or capillary refill less than 2 seconds, you assess their mental status. If they are able to follow commands they are assigned a yellow tag. If they cannot follow commands, they are assigned a red tag.

ACEP – H. Pylori, Zika, and Tox

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We bring you pearl from the American College of Emergency Physicians (ACEP) 2017 Scientific Assembly.

Pearls on H. Pylori from: It’s Alimentary – Poo-Pourri of Conditions From the Mouth to Rectum – Dr. Adebayo, Dr. Batra, Dr. Bavokek

References :

  1. Rosen’s 9th ed
  2. Meltzer et al. Ann Emerg Med. 2015 Aug;66(2):131-9.
  3. Meltzer et al. West J Emerg Med. 2013 May; 14(3): 278–282.

Emerging Infections: Zika and Its Friends – Dr. Joan Noelker

High Yield Toxicology – Dr Erickson, Dr Traub, Dr. Perrone

The Cutting Edge – PEs, Ultrasound, Pus, and more.

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In this episode, we summarize recent literature we feel is high yield, important, or frequently discussed in emergency medicine. As always, we encourage you to read the papers and not FOAM it alone.

Antibiotics and abscesses – Daum et al

FAST in hemodynamically stable patients –  Holmes et al

Haloperidol in gastroparesis – Roldan et al and Ramirez et al

Ignoring PERC – Buchanan et al

Steroids in non-asthma/COPD lower respiratory tract infections – Hay et alENDAO – Caputo et al

Gender pay gap persists in academic EM (and it’s not due to hours, rank, or roles) – Madsen et al

#dasSMACC – Airway Ultrasound, Critical Care, and Dunning-Kruger

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We are in Berlin for #dasSMACC and have lots of pearls to share from the speakers at this amazing conference.  Talks will be released for free on the SMACC podcast over the next year, but this podcast holds some pearls that we thought couldn’t wait.

Overall trope of the conference….

dasSMACC

for more on the Dunning-Kruger effect check out this post

Drs. Jacob Avila and Ben Smith on Airway Ultrasound

Check out this 7-minute video on ETT placement confirmation using ultrasound

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Dr. James Rippey on Point of Care Ultrasound Incidental Findings

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Dr. Jack Iwashyna on Persistent Critical Care

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FOAMcastini – Medical Texting

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We interrupt our normal core content to cover an important topic highlighted in JAMA’s recent article, “Medical Texting and Protected Health Information. What is permitted?

Protected Health Information

Other pearls:

  • Live tweeting is dangerous (exposes dates, potentially identifiable events)
  • If in doubt, leave it out

Reference:

Department of Health and Human Services. “Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.” November 16, 2015

Suviving Sepsis Campaign Guidelines 2017

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The new Surviving Sepsis Campaign Guidelines are out in Critical Care Medicine.  The biggest change is the change in the definition of sepsis, which now uses the language of Sepsis 3.0, introduced in 2016. Other significant changes include dropping protocolized care (ex: early goal directed therapy), and recommending against combination antibiotic therapy (double coverage) for a single pathogen [1,2].

Bonus discussion on new validation study of qSOFA

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References:

  1. Opal SM, Rubenfeld GD, Poll T Van Der, Vincent J, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2016;315(8):801–10.
  2. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med [Internet] 2017;1.
  3. Keh D, Trips E, Marx G, et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial. JAMA. 2016;316(17):1775-1785.
  4. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis. Jama [Internet] 2016;315(8):762.
  5. Freund Y, LeMachatti N, Krastinova E.Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients W.ith Suspected Infection Presenting to the Emergency Department. JAMA. 2017;317(3):267-268.

Roundup: Favorite Literature of 2016

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Article highlights of 2016

Sepsis 3.0

Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

  • This iteration of sepsis discarded systemic inflammatory response syndrome (SIRS), noting it’s poor discriminatory ability.  Further, these authors sought to define sepsis as a dysregulated response to infection, not just a normal response to infection (i.e. fever and tachycardia are normal responses to infection and therefore are, alone, not evidence of sepsis).

Sepsis 3.0

The quick SOFA score (qSOFA) also came out in hopes it “provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes.”  It is not part of the sepsis definition  but may help in identifying those that will die or have a 3 day ICU stay.  Studies looking at the performance of qSOFA applied retrospectively to data sets have not been promising [1,2].

Back Up Head Elevated Intubation

Khandelwal et al. Head-elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesthesia and Analgesia. Apr 2016.

back up head elevated intubation

Ketorolac Dose

Motov, S, Yasavolian, M, Likourezos, A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department. .Ann Emerg Med. 2016 Dec 16.

ketorolac

Pulmonary Embolism in Syncope 

Prandoni et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope.   N Engl J Med 2016; 375:1524-1531. This trial is probably one of the most over-reacted to trials of 2016.  News outlets, both by lay media and for health professionals overstated the claims of this trial.

image

What the trial actually did…

PESIT

Out of Hospital Cardiac Arrest Prognostication

Jabre et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation.   Intern Med. 2016 Dec 6;165(11):770-778

OHCA

ALTE (Apparent Life Threatening Event) is out, replaced with a new definition and classification, BRUE (Brief Resolved Unexplained Event).

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. 2016

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References:

  1. Churpek MM, Snyder A, Han X et al. qSOFA, SIRS, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the ICU. Am J Respir Crit Care Med. 2016. [article]
  2. Brabrand M, Havshøj U, Graham CA. Validation of the qSOFA score for identification of septic patients: A retrospective study. European Journal of Internal Medicine. 36:e35-e36. 2016. [article]

Vaccine Side Effects and Placebos

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We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPNOW and discuss high yield or cutting edge lectures each day.

Dr. Matthew DeLaney – 21st Century Snake Oil (Placebos)

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SGEM http://thesgem.com/2013/03/sgem26-honey-honey/

Dr. Al Sachetti – Immunization Reactions in the Emergency Department

check out the WHO fact sheets

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Dr. Corey Slovis – Atrial Fibrillation

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References:

  1. Llor C, Moragas A, Bayona C. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ (Clinical research ed.). 347:f5762. 2013. [pubmed]
  2.  Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922
  3. Dobson R. Cough medicines’ effect is mainly placebo. BMJ. 2006 Jan 7; 332(7532): 8. PMCID: PMC1325161
  4. Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; PMID:22869830
  5. Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Annals of emergency medicine. 64(5):526-532.e1. 2014. [pubmed]
  6. Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. The Cochrane database of systematic reviews. 2015. [pubmed]
  7. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 68(1):1-9.e1. 2016. [pubmed]
  8.  Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. [pubmed]
  9. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 4:CD007400. 2016. [pubmed]
  10. Silberban. Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why.

The Transgender Patient + more from ACEP

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We are in Las Vegas at ACEP 2016 and discuss high yield or cutting edge lectures each day.

Dr. Anne Daul – Emergency Care of the Transgender Patient

Most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients [1].  Many members of the LGBTQ community may have delays in medical care including 21% of transgender patients in a Canadian survey[2].  Also, according to a 2010 task force, 19% of transgender patients report being denied care in some way [3].

@FOAMpodcast
@FOAMpodcast

Here is a video from SMACC Dublin from Thom O’Neill on caring for LGBT youth

Check out these FOAM resources from EPMonthly and Mayo.

Dr. David Callaway – Active Shooter

2% of active shooter events take place in the health care setting.

Plan of Action in Active Shooter Scenario: AVOID DENY DEFEND TREAT

  • Avoid – stay away from the shooter.
  • Deny – deny them access to you or the area. Lock doors, block pathways, turn off the lights, make it more difficult for them.
  • Defend -.if necessary, defend yourself.
  • Treat – once you are safe, and the scene is safe, treat and care for your patients.

Dr. Kevin Klaur – Lawsuits

Documentation and discharge instructions repeatedly come up in lawsuits.

  • Documentation: If you document after the fact, particularly if there was a bad outcome – be straightforward that you are documenting after the fact. Do not document as though you do now know the outcome
  • Discharge – lawsuits often come up because discharge instructions or documentation were not sufficient. Klauer argues that it is not sufficient to state “patient improved, discharged home.” He urges us to document a repeat exam or show HOW they are improved.

Dr. Klauer also gave some general pearls on lawsuits – high numbers for orthopedics/missed fractures and administration of RhoGham.  An additional pearl he gave was for cauda equina.

  • These patients often have small post void residuals because it’s a neurogenic problem, not a mechanical obstruction.  Thus, if a patient has other features and has a post void residual of 100 cc, it’s not necessarily not cauda equina.

 

One ACEP16 lecturer talked about magnesium use in alcohol withdrawal – probably not ready for prime time, Cochrane agrees  [4].

References:

  1. Moll J, Krieger P, Moreno-Walton L. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 21(5):608-11. 2014. [pubmed]
  2. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine. 63(6):713-20.e1. 2014. [pubmed]
  3. Grant JM, Mottet LA, Tanis JD et al. National Transgender Discrimination Survey Report on health and health care Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force.  October 2010
  4. Tejani SM. Magnesium for the prevention or treatment of alcohol withdrawal syndrome in adults. June 2013