POTD Tuesday. Tricky TrickY Tuesday

FIRST AND FOREMOST, GO BRONCOS!

Today's POTD is a shoutout to Dr. John "Fearless Leader" Marshall, as brought up at last weeks CQI.

ABDOMINAL EXAMS AND A COMMON PITFALL

There was a recent case of a PERFORATED VISCOUS (of course he presented with SOB, but that's another story). The XR was extremely clear. Of course it was missed. The patient had no abdominal TTP, no rebound/guarding/rigidity. Completely non surgical. The free air was missed because they weren't looking for it. (Even the radiologist only read this obvious free air as "possible free air")

HOW THE HELL WAS HE NON-TENDER!?!?!?!?!?!? THESE PATIENTS ABDOMEN'S SHOULD BE A BOARD THEY'RE SO RIGID

CHRONIC STEROIDS (*ominous sounds*)

• Patients on long term steroids (for asthma, auto-immune dz, etc...) can mask a surgical abdominal exam. They may have no tenderness, nothing.
• Again, patients on long term steroids may have a completely normal abdominal exam, even with having surgical pathology.

Don't believe me? While there may be no true RCT, or even a retrospective trial, there are case studies and anecdotal cases (such as the one above). The best one I found is linked right below.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391396/

From Medscape: "Remember that the presentation and the findings on clinical examination may be entirely inconclusive or unreliable in patients with significant immunosuppression (eg, severe diabetes, steroid use, posttransplant status, HIV infection)"

So Be DILIGENT. Have a HIGH-LEVEL OF SUSPICION.

And as Dr. Marshall would say, "Anoscope, Anoscope, Anoscope"

POTD MONDAY: ZEUS EM TWICE DAWG!!!

DUAL SEQUENTIAL DEFIBRILATION (aka the return of the CAPS AND COLORS!!!!) Also, thank you for participating, Antony "Not the guy from the 2nd Triumvirate" Mathew, week 1 of fantasy football is in the books! (Just jinxed myself)

Back to the topic at hand, What the hell is it?

• Placing 2 sets of defib pads on a patient
• Charging them both fully
• Hitting the Shock button at the same time. ZAP GOES THE WEASEL

HOW TO PLACE THE PADS

There are a few ways to place the pads, but the general idea is you want to blanket the chest with electricity

 

Consideration, Evidence, and when to Use (the meat of the article)

• Studies showed that the higher the amount of body fat, the lower the amount of electricity gets to the heart (in pigs)
• However, initial ROSC with VF arrest and single defib is fairly high (studies show various numbers, but it's decent)
• Series of case studies showing that after multiple rounds of CPR, multiple single shocks, and appropriate meds given, Dual Defib can increase the chances of ROSC.
• One study in an EP lab showed increased success of dual defib, but in a more controlled setting.
• Certain EMS systems, and hospitals are now including it in their ACLS protocol, either after FOUR OR FIVE normal shocks.

WHAT WILL I BE DOING????

• By the time you're considering doing this, the patient is pretty dead. They can't get dead-er. I've tried this a few times (never worked) but I think I'll keep using it. There are case studies out there with it working, and some pretty smart people swear to it anecdotally.
• As Einstein put it (probably about defibbing a patient 10 times during a code)
  • "The definition of INSANITY is doing the same thing over and over again, butexpecting different results"

POTD WEDNESDAY: DRUNK FUN!

Whatsup yall. A rainy Wednesday POTD comin at ya, fast and quick. Who's excited? Everybody. But you know what everybody isn't stoked about? Drunk trauma peeps. They stink. They can't give a good history. They literally stink. "SCAN EVERYTHING!" you may say, and you will never go wrong. Zap em with some good old fashioned radiology. If everything is fine, then what????

Can you clear that spine with a drunk traumatic patient with a negative CT spine? Well they still fail NEXUS criteria. Canadian is more EH.........maybe????

Thank god someone studied this. https://www.ncbi.nlm.nih.gov/pubmed/28723840

Basically they had a 3 year, prospective, multicenter trial, with appx 3000 drunkypants patients. Sensitivity of CT for any Cspine injury was 94%, specificity 99.5%, and NEGATIVE PREDICTIVE VALUE of 99.5%. HOT DAMN DIGGITY DAWG THATS SPECTACULAR.

EVEN BETTER, for clinically significant injuries, the NPV was 99.9%, and NO UNSTABLE CSPINE injuries were missed on initial CT.

Why does this matter? The study also showed that drunks stayed in collars 4X as long as sober peeps. It sucks. Try wearing a collar, even after a few brewskies.

Will this change your practice? Maybe? Will anybody listen to you if you want to clear these collars? Probably Not, but go ahead and show them this data, and then still be told no. But still, as always, research pushes forward telling us to just chillax people. Don't stress.