By: Tom Gill, MD
Disseminated intravascular coagulation (DIC)
-Causes: Many…infection, inflammation, malignancy, toxins, liver dysfunction
-Microvascular thrombus most common
-Work up: Platelets, INR, D-dimer, fibrinogen, PTT
-Treatment: Cryoglobulin (if low fibrinogen), FFP (if bleeding), other products as needed
-Small vessel occlusion
-Bleeding and clotting risk
-Importance? 90% Mortality without treatment!
-Work up: Cr, CBC, check peripheral smear, ADAMTS13 test, consult hematology/oncology
-Treatment: ICU, central line, plasma exchange, FFP, +/- prednisone
Heparin induced thrombocytopenia/thrombosis (HIT)
-Risk of bleeding and clotting (small/large, venous/arterial)
-Importance? 30-50% develop thrombus, Mortality 30%
-Typically 5-10 days after heparin exposure
-Drop in platelets to less than 150,000 or by more than 50%
-PF-4 antibody (high sensitivity, screening)
-Serotonin release assay (high specificity, confirmatory)
-Treatment: STOP heparin, START other anticoagulant (argatroban or fondaparinux)
-Presents with pancytopenia or leukocytosis
-Review CBC with differential: increased concern in all uniform or blasts reported
-Send DIC Panel, Consult Hematology/Oncology, Request peripheral flow cytometry
-Sludging of the microcirculation which occurs with elevated WBC
-Importance? Increased mortality with this finding in early AML
-Pathophysiology: thrombi, local hypoxia, endothelial damage, bleeding
-Symptoms: Bleeding, stroke, deafness, ataxia, confusion, blurred vision, vertigo, nystagmus, headache
-Send serum viscosity, avoid transfusions, treat underlying disease
Idiopathic thrombocytopenia purpura (ITP)
-Treatment: Dexamethasone, IVIG, may need aminocaproic acid if significant mucosal bleeding
- Read the scene, find an ally
- Appropriate setting is key, understand the relationships you are walking into
- Frequent updates are important, and can set the stage for future discussions. Match body language. Be concise, be clear, ditch the medical jargon.
- Oftentimes in the ED giving a prognosis is harder than informing of death.
- Frequently our job is to set the ICU team up for success
- Under promise, with hope to over deliver. Be honest with realistic chances.
- Let parents know they didn’t do anything wrong. Release them from guilt.
- Be honest with prognosis. Explain the process and what comes next.
How do you handle giving bad news for a patient who is actively coding? Do you bring families in the room?
- This can go very well or very poorly. Bring the family in at the right time. Think about avoiding teenagers in the room. What parts of the patient’s body can the family touch without getting in the way?
- Being on hospice doesn’t preclude someone from being full code.
- It can be very difficult for families to envision what being perimortem looks like.
- The primary outcome that we can influence by having the family in the room is how the family feels when leaving the room.
How, as the provider, do you return to the rest of your shift after dealing with a code?
- Rely on your peers. Talking out your cases is one of the best things you can do. When you are outside of work, be 100% outside of work. This is hard, but remembering that you have done your best can be incredibly helpful.
- Life changes fast. Trying to bury feelings about end of life won’t help you. Let yourself feel pain and experience grief.
- It is okay to cry, it is okay to remember those cases.
- Having social work and pastoral care available is incredibly helpful. Pastoral care has a longitudinal relationship with families through the grieving process.
- Listen to the family. Envision what they are saying, on paper. Try to see the words they are saying, orally, on paper. This may allow you to focus on the details.
- Mnemonics for giving bad news are good, but ultimately you have to read the room.
- This is as high stakes as anything we do.
- Algorithms are helpful, but the most important thing is a human connection.
- Sit every time. The tone is what the family remembers.
- HICS – applying ICS to hospital setting: www.hicscenter.org
- On the intranet home page, click on Disaster Management to see more BMC-specific info
- Have your own personal disaster plan:
- Have your important phone numbers handy, if you are to lose your cell phone
- Do you have an emergency kit at home?
- Paper map of your area
- Backup supply of medications
- Flashlights, batteries
- Pet food
- For more info: ready.gov/kit
- Do you have secure storage for all your important documents and professional credentials?
- Think in twos:
- Sick or not sick:
- What are the vitals?
- What do you see when you walk into the room?
- Work of Breathing
- Pattern of Breathing
- Mental Status
- Upper or Lower
- Obstructive or Non-Obstructive
- Sick or not sick:
- Context is Key!
- The hardest thing about a cricothyrotomy is the decision to act.
- All pacemakers should have alphanumeric codes visible on XR
- Pacers can be: Paced, Sensed, or Respond to Sensing
- Sensing and pacing atria, inhibits pacemaker if sensing a native beat
- Ventricular demand pacing
- AV sequential pacing
- Used for AV block with normal SA node
- Magnet Mode: Asynchronous pacing, either AOO or VOO
- RV paced rhythms will resemble LBBB
- CanadiEM Approach to Paced EKG:
- Great quick review, check it out
- Three type of pacemaker failure:
- Failure to pace – pacemaker doesn’t trigger the myocardium to depolarize
- Failure to capture – pacemaker impose is unable to depolarize myocardial tissue
- Failure to sense – pacemaker works despite native beats
- Pacemaker syndrome:
- Suboptimal AV Synchrony
- Ultimately caused by increased atrial pressures
- Presentation: Fullness in the head/neck, cannon A waves
- Pacemaker Induced Tachycardia:
- Sort of like AVNRT, can still happen even if you have no native SA/AV function (1/3 of these patients have preserved retrograde conduction)
- Know where your magnet is!
- Be ready to transfer if you don’t have EP in your facility.
Resident Author: Tom Gill, MD
Resident Editor: Jeffrey Rixe, MD