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.

HIV

I hope everybody had a restful and relaxful Labor Day. Today's POTD comes straight from the horses mouth, AKA our fearless admin leader REUBEN "I'M NOT THE GUY FROM CASH CAB " STRAYER.  

He posed a question to me. "Josh, I want to diagnose more people with HIV in our ER, how would I go about doing it???"

Well thankfully for Reuben, and all our new HIV positive folks, we as doctors can order the screening test in HMED. It used to be controlled by nursing, but now we have the power. FIRST, lets talk about how to order it.

-Go into PHYSICIAN tab --> CDS forms --> HIV testing (it's ~10th on the list, just below EBOLA screening). From there it's just a single button in the HIV testing page.

NOW lets talk about what the hell you're ordering. It comes up as "HIV AB, HIV 1/2, EIA, WITH RFLX". HUH???

So, what this means.

1. The first test that the blood is run through is a HIV 1/2 antibody test with ELISA (enzyme-linked immunosorbent assay, or EIA as in the order). This is a quick test, where they dilute the serum and apply it to a plate with HIV antigens attached. If it sticks, it's positive (it's more complicated than just PRESTO, but for our simple ER minds I'll leave it at that). Sensitivity AND Specificity of this assay are >99% according to multiple studies. However the RFLX at the end of the order means that if it's positive, they will reflexively do a western blot to confirm.

-The ELISA is ready fast, a few hours at the most.

2. Western Blot. That's the fancy thing with gel electrophoresis and stuff. Who cares. It's pretty good. They will run it only if the EIA is positive. And if you positive you positive dawg.

-This can take days. Patient needs to be given good follow-up and someone to follow up this blot.

Now go out there and diagnose some people with HIV!