Trauma

#FOAMed Digest No. 8: Thank You Sir, May I Have Another?

In the spirit of demonstrating how FOAM resources can reinforce resident curriculum, I thought for this installment of #FOAMed digest we would do something a little different and highlight FOAM resources that build on the topics and discussions from conference last week.  For those of you who didn't make it, the conference run down from last week:

             GI core content: esophagus and stomach
             Trauma Case Conference: Traumatic cardiac arrest in the blunt trauma patient 
                                                           Traumatic cerebrovascular injury
             Key papers in critical care
             Navigating the politics of innovation
                .... and a little on cognitive overload

For those of you who want to solidify and expand your knowledge,  you need not wait for tommorrow's review.  Here are some FOAM resources to help you do just that:

Disorders of the esophagus and stomach: Medical school taught you to memorize buzzwords and basics of management for disorders of the esophagus and stomach, but the FOAM world can expand
on this background and sometimes teach you to think critically about management decisions.  Here are some good FOAM resources on the Upper GI bleed:
              Who can I send home?  An oldie but goodie - a review from our own journal club on risk stratification for patients presenting with a GI bleed.
               Here is a critical review by EM Lyceum of upper GI bleed management including PPIs, octreotide in variceal bleeds, and conclusions from the good old NG lavage.  Some of things we do are really not that evidence-based.

Dr. Wessman's review of key article in critical care touched on GI also, recommending that we all read  this article published in NEJM, and reset our transfusion goal to 7 in the absence of massive hemorrhage.

And here is a link to the Scott Weingart video on Blakemore placement shown in conference. 

Traumatic Arrest:  Let's see if we can learn about things being done a little differently ... and prehospital -  Listen to this emcrit podcast  on management of a patient in traumatic arrest with Irish Road Racing doctor and RAGE team member, John Hinds.  Be sure to read the commentary, because there is an excellent discussion/debate bringing up important considerations for management of traumatic arrest.

Traumatic arrest patients usually do not need meds to facilitate intubation, but as an aside last week one of our trauma colleagues brought up whether we should be using ketamine instead of etomidate
Photo credit: http://inkrose98.deviantart.com/art/Car-Crash-2-254652116
when intubating trauma patients (especially hypotensive ones) in our ED.   I highly recommend this critical review posted last week by the SGEM about ketamine's undeserved bad reputation.  You might just make it your go-to in your next trauma patient even if you suspect intracranial pathology.


What blood products should we be giving to our patients?  A recent body of research from the THOR consortium (Traumatic Hemostasis and Oxygenation Research which includes St. Louis Children's Hospital PICU attending Phil Spinella), suggests whole blood.  Here is a link to the THOR website and articles of interest published by the consortium.

Last week during conference we asked the FOAMed world via twitter for input on CPR in traumatic arrest.  The response was largely negative.  Steve Carroll of @embasic mentioned potential use of REBOA.  For those of you unfamiliar with this device here is a description of the procedure and current evidence regarding its use from the Hennepin County site HQMeded.  If you are still interested, here is  an amazing story recounted on emcrit of prehospital REBOA use for a pelvic fracture. 

And finally... if you still have not watched Cliff Reid's talk on Making Things Happen on leading a resuscitation, do it now.  You will not regret it.

Traumatic vertebral artery injury: If you need a basic review of the talk given by our surgery colleagues, you can read the East Guidelines on Blunt Cerebrovascular Injury.  If you are wondering about the data on the sensitivity of CTA for detection of blunt cerebrovascular injury, you can listen to a podcast by the SGEM here.  Finally, our own blog took on the subject of whether vascular imaging is mandated in the presence of a cervical seatbelt sign, read what we had to say here 

Navigating the politics of innovation: When I think about what I like about FOAMed, it is that it is a a bottom --> up innovation.  As we learned from Dr. Andrew Knight's talk last week, one of the barriers to dissemination of innovation is top-down decision making with the expectation of bottom-up use.  This is important when thinking about how to effect culture change, but also useful when thinking about managing patient expectations.  I think two good reads on how to talk to patients regarding management decisions are this article in Wired about David Newman and the NNT as a method for data translation, and the "Ed in the ED" blog as a discussion forum on difficult patient conversations.

Wild Style, the epitome of quick-thinking-calm-under-pressure
... and a little on Cognitive Overload : I highly recommend this lecture from Air Force pararescuer Mike Lauria on enhancing cognition and critical decision making in acute care that was shared on the emcrit blog.   Take a Deep Breath.


Enjoy,
Maia Dorsett (@maiadorsett), PGY-3

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.
EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  





Oldie But Goodie:

This post isn’t actually that old, but it’s about older patients, so we’re gonna count it. On the heels of Dr. Galante’s lecture from last month, Ken Milne at the Skeptics’ Guide to Emergency Medicine takes on Chris Carpenter’s systematic review of ED tool to predict fall risk ingeriatric patients from this months Annals.
This is a can’t-miss episode, as it is the initial installment of the “Hot Off The Press” series. You can watch in real-time as the FOAMed and published-journal worlds start to merge. Each episode of this series will feature a critical analysis and interview with an author of a paper just published in Annals or CJEM. The audience (i.e., everyone) will have a chance to respond with their own post-publication peer review via social media outlets. The top responses will be featured in a future publication in each journal. Knowledge translation and crowdsourced feedback at the speed of social media!

F(FN)OAMed:

If you’re going to pick one podcast to listen to religiously, that podcast should probably be EM:RAP. This month, be sure to check out the segment on IV contrast myths.
Take-home points: Iodine is not an allergen. Seafood allergy does not increase risk of anaphylaxis to IV contrast any more than any other given allergy, although previous reaction to IV contrast or past history of atopy does increase risk. And most notably – premedication with steroids has not been shown to decrease the number of severe reactions.

The Gunner Files:

1. Check out Scott Weingart’s interview with Dr. John Hinds regarding his approach to the patient with blunt traumatic arrest.
In Dr. Hinds’ shop, before they do anything else they: 1) intubate, 2) perform bilateral finger thoracostamies, 3) place a pelvic binder, 4) reduce any gross long-bone deformities, 5) start uncrossmatched transfusion. Only then do they start a formalized assessment. Really interesting stuff.

2. Similar to the R&R from the Fastlane mentioned above, Ryan Radecki’s EM Lit of Note blog is another excellent version of a curated primary literature review. Here is his critical appraisal summary of a systematic review and meta-analysis comparing trauma “pan scan” with more selective imaging.

3. The most recent installment of the EM BASIC podcast is your panic-free look at what we know about Ebola – screening, clinical signs & symptoms, diagnosis, isolation, and treatment.

4. The ultimate skeptic, Rory Spiegel of EM Nerd, turns his nihilistic eye towards the cash cow of cardiac interventionalists everywhere – PCI. Turns out, there’s not a lot of evidence to support its use outside the realm of emergent intervention for STEMI.

5. In the most recent podcast on Emergency Medicine Cases, an EM sports medicine specialist and an orthopedic surgeon help you to avoid falling prey to the “Commonly Missed (Uncommon) Orthopedic Injuries.” Want to know how not to miss a DRUJ? Lisfranc? Perilunate? Tune in.


Never stop learning,


C. Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.
(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.


Never stop learning,

Sam Smith, PGY-3

#FOAMed Digest No. 1: Total Eclipse of the Heart

Welcome to the very first edition of the WUEMR FOAMed Digest! The Social Media Committee hopes with this segment to parse out from the overwhelming FOAMed universe a few of the most high-yield pieces of highest relevance to the general EM trainee. We hope to deliver this in an easily digestible format that you can realistically work through over a week – even if you’re stuck in an ICU.

Each post will contain several sections:

1. Three Stars: Three of the best-of-the-best from the FOAMed world published in the past week or so.

2. Oldie But Goodie: The FOAMed universe has been around long enough that there’s already a good number of very well-done and highly informative blog posts and podcasts.

3. Free (For Now) Open Access Med Ed: F(FN)OAMed for short. There are some great resources out there that are not free to the vast majority of EM practitioners but, due to your EMRA membership being graciously covered via the residency and MoCEP, you have access to them. Most notably, your EMRA membership allows you subscription to the EM:RAP podcast and the EB Medicine resources – EM Practice, EM Critical Care, etc. You should take advantage of this opportunity while you can, and this section will help you do so. (Contact your friendly local Social Media Committee member if you need help setting up your access.)

4. The Gunner Files: The Social Media Committee recognizes that, with this being Wash U and all, some of you will always be overachieving. So we’ll include a few extra selections for those of you that have a more insatiable FOAMed appetite.

Without further ado, let’s kick the tires and light the fires.
This week, “Total Eclipse of the Heart,” will focus on care of various cardiac conditions.

Three Stars:

1. Ever heard of Wellens’ Syndrome? If you have any hope of passing your boards one day, you should. Not mention that whole “you shouldn’t miss a critical EKG finding that portends certain doom” thing. Never fear, Salim Reazie, author of the excellent R.E.B.E.L.-EM blog, has you covered
(Don’t miss the links list at the bottom that highlights posts from other top-notch FOAMed resources!)

2. Syncope is one of those presenting complaints that really must be approached in a systematic manner. The grandmaster of EM EKG interpretation, Amal Mattu, reviews the differential while highlighting the characteristic EKG findings of a can’t-miss diagnosis.

3. Okay, so DKA isn’t exactly a “cardiac” condition – but the worst-case-scenario is still hemodynamic collapse, right? It counts. The EBM gurus over at Anand Swaminathan’s blog EMLyceum give you the latest & greatest when it comes to evidence-based care of DKA.

Oldie But Goodie:

So you’ve achieved the nigh-impossible – achieved sustained ROSC in an OHCA patient. Now what? The reigning American Idol of EM Critical Care, Scott Weingart, tells you what in an excellent two-part interview with one of the lead authors of the TTM trial, Stephen Bernard.

F(FN)OAM:

Worst-case scenario #137: Running ACLS on a patient brought in with PEA arrest. As CPR continues, the staff looks to you. “Uhhhhhh…more Epi?” Like all things resus, you need a systematic approach. The smart dudes over at EM:RAP, along with EM cardiology expert Amal Mattu, review a newly published paper that will help you do just that in the August 2014 edition.
PubMed link to the paper itself here.
(Once again, contact the Social Media Committee if you need helping subscribing to EM:RAP.)

The Gunner Files:

1. Excellent review article from the journal Emergency Medicine Australasia covering that bane of the overnight Deuce shift. No, not vaginal discharge – dental pain.

2. EMLyceum deals in pearls once again when addressing ocular emergencies.

3. Ryan Radecki over at EMLitofNote looks at a very interesting paper just published in JAMA regarding the use of pulse oximetry and dispo of bronchiolitis patients
(And as always, be sure to read the original paper for yourself!)

4. My FOAMed man-crush, Rory Spiegel of EMNerd, tackles the C-spine injury algorithm debate.

5. The Aussies over at St. Elmyn’s get you straightened out when dealing with the breathless patient in the ED. Incredibly high-yield for new ‘terns, but useful for docs of all ages.

Now get to FOAMing! 
As always, comments/concerns/criticisms are appreciated!



C. Sam Smith, PGY-3