Flipping EM: Resuscitation

Welcome to the first edition of Flipping EM, our flipped classroom case-based learning conference activity! Each conference module we will post clinical cases for your consideration and each learner level (PGY1, 2, 3) will be asked to answer a question about the cases. In order to aid your response, links to journal articles will accompany each question. You will be responsible for reading the articles for your level’s assigned questions and developing an answer to the questions. During our scheduled conference time, we will break up into small groups of 6-9 residents (2-3 residents per level in each group) with a faculty facilitator. Each level of learner will discuss their question and corresponding articles and teach the rest of the small group what they learned with the other group members adding their thoughts and ideas. Below you will find the cases for this edition which focuses on Resuscitation. Please be prepared to discuss your articles and questions by conference on 7/28/16!

Case #1

62 M h/o HTN, DM, CAD s/p stent presents with 2 days of intermittent subjective fevers, cough productive of yellow sputum, and pleuritic chest pain. His daughter reports that he’s also been confused today occasionally saying things “that don’t make sense.” She’s very concerned as she hasn’t been able to get his fever down since this morning and he hasn’t been eating or drinking well. He last received 650 mg of acetaminophen 4 hours ago.

VS: BP: 95/65, HR: 110, R: 24, O2 Sat: 92% on RA, Temp: 39.3C

PGY 1: You suspect sepsis, would you apply the principles of EGDT to this patient?

• Trial of Early, Goal-Directed Resuscitation for Septic Shock

PGY 2: When is it optimal to administer antibiotics in this patient?

• Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. (requires library login)
• Association Between Timing of Antibiotic Administration and Mortality from Septic Shock in Patients Treated with a Quantitative Resuscitation Protocol

PGY 3: What options are available to assess this patient’s fluid responsiveness?

• Understanding cardiac output
• Optimization of Preload in Severe Sepsis and Septic Shock

Case #2

60 F h/o DM, HTN, MI s/p CABG BIBA in respiratory distress. Upon arrival to the ED, the patient is tachypneic, unable to speak full sentences, using accessory muscles. EMS has placed the patient on NRB and started a PIV.

VS: Temp: 98.9, HR: 128, BP: 80/50, RR: 40, O2 Sat: 85%.

PGY 1: You plan to intubate the patient, what strategies would you utilize to preoxygenate prior to intubation?

PGY 2: You successfully intubate the patient. The respiratory therapist asks what you would like for vent settings? How would you initiate and titrate your ventilator settings after intubating this patient?

PGY 3: The patient remains hypotensive despite fluid bolus. Discuss the use of vasopressors in shock and how would you manage this patient’s hypotension?

• Comparison of Dopamine and Norepinephrine in the Treatment of Shock

Feel free to utilize additional resources to support your responses and further the discussion of the topics raised in the cases! Please leave any questions or comments below. Thanks!