Five hundred twenty five thousand six hundred minutes…any of you who are RENT (The Musical)fans out there can take it from here… We celebrate the major events and additions to the VTCEM family that occurred this year!
Peds Corner Peds Rescue Seizure Medications – Courtesy of Dr. Uherick and PharmD Kelly Mcallister Midazolam INH – On the inpatient side, providers tend to lean towards using inhaled midazolam. It is easier to administer than PR diazepam. Dosing for Midazolam INH is 0.2 mg/kg (Max 10 mg) split between the nares. There is a new commercial product made specific for intra-nasal administration, however, insurance companies are not covering it. Our inpatient Peds pharmacist has only had it successfully covered by insurance once. The pharmacists are sending patients home after educating them on how to draw up meds and use an atomizer. Diazepam PR – If a patient is already on Diastat PR (Diazepam PR), then sometimes inpatient providers will not switch them over because the patient is already used to it and has had success. The dose for Diastat PR is based on age and weight. Using the parenteral formulation (5 mg/mL): 0.5 mg/kg/dose, followed by 0.25 mg/kg/dose in 10 mins, prn (Max 20 mg dose). Rectal gel formulation: 2-5 years: 0.5 mg/kg PR; 6-11 years: 0.3 mg/kg PR; >= 12 years/adolescents: 0.2 mg/kg Clonazepam ODT – Clonazepam ODT is interesting and specific to certain kids. It is not actually sublingual like one would think. It is just a rapidly dissolving oral tablet (like Zofran ODT) that has the same pharmacokinetics as a regular tablet. Kids just don’t have to swallow it. Onset is close to 40 minutes, so it will not really help with an acute seizure. Our providers tend to use it more for those patients who have cluster seizures. If a kid presents with a respiratory infection and tends to seize often with those symptoms, pediatric providers will often start them on Clonazepam ODT for 3-4 days while they are symptomatic and then discontinue after symptom resolution. There are several different dosage forms: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg.
-Oct 20: Joint WM/EMS Fellowship Scenario: 2p-8p(Residents welcome to join) –Nov 4: Fellowship Journal Club (virtual with WM Fellowships nationwide)-Nov 7-8: Mountain Shepherd Survival School (ask Dr. Justin Gardner at jgardner4028@gmail.com for more details) WM PearlsCourtesy of Dr. Lareau: Accidental hypothermia can be a huge problem in cold weather for patient populations who cannot get out of the cold weather or people who are outdoors and get stuck there (think exhaustion, trauma, slips and falls, or intoxication). Patients who become really cold often appear dead, however, there have been some very impressive case reports of heroic efforts to re-warm seemingly dead people with normal neurological recoveries. One is a case of Anna Bågenholm, a Swedish ortho resident, who survived a body temperature of 56.7F after a 9 hour resuscitation effort involving cardiac bypass.
Rescuers working frantically to save Anna Bagenholm from a hole in the ice of a mountain stream.
Another case in which a patient was pulseless for at least 70 minutes after hypothermic arrest without CPR also had a full neuro recovery after resuscitation was initiated. So remember you are not dead until you are warm and dead!
Rosh Tests: Foundations I – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm, Unit 3 – GI III
Conference-Conference this week on Thursday will start at 7:30a with Multi-disciplinary Critical Care Case Conference followed by the VTCEM Residency Program Business Retreat. -Below is a general idea of how the Business Retreat may go. Please note that the location and timing has not been officially confirmed and may be subject to change. More information to come early this week.
8:30-9:30a Transition to Lancerlot Sports Complex, 1110 Vinyard Road, Vinton, VA 24179
-Each House should designate one person who will submit the Dear Doc Mystery Case answers to Dr. Perkins.
General Program
-Please read the following from the Program Director regarding Conference, Recruiting, Program Evaluations, New Faculty Orientation, New Shift Evaluations:
Courtesy of Dr. Uherick – A reminder of how our Pediatric Sepsis process works:
There is a trigger built in EPIC so when a pediatric patient is tachycardic or hypotensive and has a concern for infection, the nurses are prompted to answer a few more questions about abnormalities in mental status, perfusion, skin findings and risk factors.
If one of those is concerning, the nurse is asked to initiate a “sepsis huddle.” A huddle has the attending go to the beside to make a clinical judgement on if a sepsis alert should be called.
If a pediatric sepsis alert is decided upon, MEDCOM will send it out the overhead alert. Doing this prioritizes resources to that patient such as nursing support and pharmacy prioritization.
Unlike the adult alert, it does not start a bed identification process.
There is a pediatric sepsis orderset to use for these patients. Currently the orderset does not cover infants under 60 days, but we have an optimization in to add that which should be available soon.
Fellowship News
Wilderness Medicine:
WM Calendar
Sept 10 at 6p Wilderness Medicine Journal club: Topic and location to be announced
Sept 14-27 is the VTCSOM Student WM elective rotation. Residents are welcome to participate and help teach. Please email StephLareau@gmail.com if interested.
Sept 19 or 20th 1-6p: The Advanced Wilderness Life Support course (AWLS) in Roanoke, VA will mostly be virtual this year. There will be an in-person component on . Resident cost: $250
Sept 21: Swift Water Safety Course/ Drowning Journal Club (all day)
Sept 24-25 Backpacking Trip (need volunteers to help with surprise scenarios)
-Courtesy of our Wilderness Medicine Fellow, Dr. Justin Gardner, below is the fourth in a weekly series of WM Pearls about snakebites and snakes in Virginia.
-ED Management:
Mark the leading edge of erythema/tenderness/swelling as well as limb circumference above and below the envenomation for future comparison. This should be repeated every 15-30 min until local tissue effects stabilize.
Wound infections occur in only up to 3% of pitviper bites. Routine prophylactic antibiotics are not recommended.
Opioids are preferred for pain control.
Obtain baseline labs on patient arrival: CBC, BMP, LFT, INR, PT/PTT, Fibrinogen, D-Dimer, Urinalysis, CPK. Labs are repeated every 4-6 hours.
If severe abdominal pain or altered mental status develop, obtain CT imaging to assess for hemorrhage.
Early surgery is contraindicated. Excision not routinely performed. However, necrotic tissue and hemorrhagic blisters may benefit from debridement 3-5 days after the bite.
Venom leads to superficial edema and subcutaneous inflammation, rather than in sub-fascial spaces. In rare cases where venom is deposited in subfascial spaces, antivenom can prevent and treat compartment syndrome. Fasciotomy is rarely indicated – favoring antivenom administration.
If true clinical compartment syndrome develops, with objective measurement of compartment pressures, consult to surgical services is indicated.
In critically ill patients, supportive measures and antivenom are mainstays of treatment. Antivenom is the definitive treatment. If hypotension persists despite IV fluids and antivenom, then vasopressors are recommended.
Neurotoxic symptoms seen in bites from the Mohave rattlesnake can be profound. Antivenom has relatively poor efficacy in reversing the pre-synaptic neurotoxicity seen in these envenomations. Patients with paralytic features should be intubated early.
Blood transfusions may maintain a normal Hgb/Hct, but will not reverse the coagulopathy. Antivenom should be given and considered the mainstay of therapy. Transfusions given only in life-threatening bleeding or anemia refractory to antivenom.
-EMC Thoracic F1 – Unit 04-Pulm I, Unit 05-Pulm II
-Rosh Tests: Foundations I – F1 – Unit 04- Pulm I, Unit 05- Pulm II, Unit 17- ID
-Please let Christie Neal know if you did not receive your EM coach or Rosh assignments. Make sure you have logged into Rosh and EM coach and check to see your email/info is correct.
Conference
-You are required to attend the upcoming 8th Annual Fall EM Conference virtually on Thursday 9/10 that will start at 8a. There will be special alumni panel for residents from 12-1 PM. -Christie Neal will send out the Zoom link later this week.
