Dump that stone up into the umbilicus. This is what it looks like, um, totally healed. So the top picture is where it's accessed, and the bottom picture is where they've taken the catheter out. Um, what you typically see in the emergency department are these kids come in before they've seen us, before their four-week follow-up, um, and the catheter has come out. So that's a surgical team consult for them to re-access the channel, um, when they're really fresh postoperatively, it's easy to put in, when you put in the catheter to go down the false tract, and you don't wanna do that. Um, The other thing you'll see is infection concerns. A lot of times the parents will just send us pictures and so we can manage that in the outpatient setting. Um, they also have stitch granulomas. This catheter is stitched in after surgery. Um, that's not an infection. The treatment for that is just to cut the stitch and then take the tube in place. So this is the alone. And then the other device that we use typically is the shape trapdoor. These are placed in interventional radiology annually. These can also be used for stricture management of the appendicostomy. These are not my favorite device. They come out a lot. Um, they leak a lot. Um, but it's better for kids that don't want to do the catheterization every day. Um, like, yeah, sensory issues or something like that. That's a picture of it, what it looks like in the patient. The other device we use is the mini button. It's very similar to the G tube. A lot of times you'll see this in the right lower quadrant, not in the upper lius. Um, and that's because that surgical procedure, procedure is a little bit different. They're not doing the secret ligation and pulling it up. Um, they're really just making the appendix a little stump and then sewing back to the abdominal wall. These are again great for kids that don't want a cath every day. Um. Sometimes they have some problems too. They can have a lot of granulation tissue. The tube comes out. The balloon deflates often and they're very expensive, and insurance is not very all for them. Um, the complications of the appendicostomy surgery or strictures the most common, that can be managed with a tape or a minis button or just putting the balloon catheter in and leaving it there for a week. Um, sometimes you'll get some prolapse of the appendiceal tissue and that can be managed with a skin level revision. Um, leaking is very common. So stool leaking out around the appendicostomy. That's usually when the kids are really constipated and then we need to do an adjustment of their flush solution. It could also be that the cecal ligation has broken down, especially if they've had it for a long time, and then they'll need a surgical revision for that, or you can place a new splint. So is that your due to like the if you're one of the Ace things in the right lower quadrant and that comes out so it's like almost like this it's not like, so it depends on how fresh it is. If it's within the 1st 4 weeks after surgery, then yeah, you wanna have them access that site. If it's just like. This kid has had this mini A for 2 years. That you, we usually manage that clinic cause it's not an emergency. We send them home with um emergency Foley catheters to access the site of the menis malfunctions while they're at home. And then we just get them into the clinic and replace that. But yeah, if it's greater than 4 weeks, then you guys are more than. Qualified to access that. Any other questions? Yeah, where did they transition into adulthood? That was the last one like here that I saw. Was it a 19 year old that run out of supplies and it's like, like full rectal supplies like his catheters, yeah, to access. I would give them our phone number and we were more than helpful to take care of that, um. There's not a great place to transition these kids into adulthood that have these devices. Like if they have a cheap tube, they don't place those at adult facilities. They have to come here. We also have some spina bifida adults that just come here to IR to get those placed, um. So not a great answer for you. We're looking for adult a good answer, yeah, just called colorectal. I know you kind of breezed over this, but like when, with enterocolitis, what are some, can you tell us like the key points, the rules, when to worry, when not to worry, what I have a whole section now as you can see is a lot. Um, so, so this is probably the most common thing that you see in the emergency department. Um, we really try to manage these kids at home with rectal irrigations when they get sick. Basically, if you have first-time disease and you call me and you're kind of sick, you're gonna get these 3 times a day. say for a week. Um, the most, what the symptoms include are vomiting, foul smelling diarrhea, rectal bleeding, decreased energy, fever, and abdominal distention. There is a let's talk about enterocolitis that has a QR code that leads to our rectal irrigation video. It's available in Spanish and English. Really helpful for families, I think, typically, they're not aggressive enough. And how much fluid they put in, how far they insert the catheter, and what size catheter they're using. Bigger is better. They've had a suction rectal biopsy, they can get an 18 correct catheter in. Um, so the treatment's usually rectal irrigation 3 times a day for 7 days. Um, we will do a phone triage, and if they have two moderate symptoms and a severe symptom, they're either coming into the clinic to be evaluated by us or they're coming to see you guys. So the studies, you're gonna get the tubu abdominal X-ray, some labs, the GIPCR for infection, and then you wanna do a rectal exam, especially if they're pretty close to surgery. Because they can have stricture that would cause them to have more obstructive-like symptoms, so enterocolitis. So, rectal exams on all colorectal patients. Pearl. Um, you're gonna do a PO challenge, and if they can do that and you get a good rectal irrigation, they're probably OK to go home. The admission criteria is dehydration, or oral intake, and lethargy. When they're inpatient, they're gonna get the rectal irrigation 3 times a day, um, IV fluids, and then Flagyl until your GIP scar comes back. If it's negative, um, then you would stop that. And then they're usually inpatient for 1 to 2 days, and then they go home on rectal irrigation for about 10 days. Did that answer your question? Yeah, OK. So for rectal exam, we want us to do a digital exam and see if we're feeling stricture, and we're not gonna interrupt any. So if they are 3 weeks, like if they're early, um, indirect or pull through, which is the surgical procedure to manage forper disease, if they're within their 3-week postoperative window, and you're calling these guys and they're doing the rectal exam and the, um, rectal irrigation. They're outside that window. And they've had like their first post-operative visit where like me or the surgeon has done their rectal exam and it's fine to do that. Um, Further questions? But if you're not comfortable with it, that it might be fun. I'm so weird, but it, it's like it does. They're so descended miserable and you do a good one and they're immediately like not descended and eating it's still so much better talk about. I love it. It is a really cathartic treatment. So anything else questions about peace arts. Yeah, OK. There's, there's so much of her focus on what we wanna talk about. We love you guys. Thanks for everything you do. We have a monthly meeting where we try to come up with protocols and standardizations. So if you think of a process that needs some help, definitely send it my way. You get your slides. You get all of this, and there's some great girls on there. Thank you so much for coming. That's amazing. We might have to if you guys come a couple of times a year. It's all. Well, there's like a lot of other diagnosis we can talk about. Yes. Thank you so much. Yeah, I know the CME too. That's how we track it. We'll take a 5 minute break and then Doctor Faulkner is gonna talk to us. He's from, uh, the Department of Emergency medicine about heat related, uh, I have. I. You said that it's activity and I, I have you guys don't well that's how we track. 000 I'm just. I don't like you, it's still really. You know it's a challenge, but I, uh, oh yeah, uh, originally, yeah, still lived here for a few years, yeah, I saw your profile. It's a, it's a good, good, great place, uh, great, uh, yeah, a lot. What did you, uh, do when you lived here? Uh, I was a neuroscience student at UU. I I I did neuroscience for a few years and my wife was, uh, she was a nursing student, so she worked, uh, at IMC downtown. Yeah, we, we just got back we had a fellow who years ago and she ended up doing our fellowship. OK, yeah, he's got it. So thanks guys appreciate it. Yeah, yeah, it's not like it takes so I was, yeah. I know. No, that's perfect. I was, that was our general surgery, OK, super, super interesting, interesting material, and I was about pediatric management, but some something I walker done. Oh well, I've seen a chronic, you know. Uh-huh, yeah, I guess they rarely, yes, yes, but maybe you see them have to uh, yeah, I'll sit you up there. I'll start, I'll start next month. So I saw you 6 ft too much to cover yeah this is great. I'm more than happy if you would like that I'm more than happy to do, uh, cold injuries that, uh, I, I, I really just wanted to be practical. you know you heard that song's by a personal, uh, uh, what's his first name? Oh, John, he's a singer he has a son 1020 others. Are you guys, he was born on the bike. Oh, what were they? Were they, were they, uh, I know on a bike. I, we got a handful of patients, yeah, yeah, yeah, if you're cannulating it's pretty bad, but you know, you think you did it anyway, yeah, no. Yeah, I'm not sure that's it's I. Yeah, obviously neurologically it's expensive. All right, well, maybe we'll get started since we're a little uh delayed. This is Doctor Mitchell Faulkner. He's a wilderness medicine fellow with the University of Utah Department of Emergency Medicine, um. I lived in Utah for a few years in San Antonio for residency and now back here as a couple of months ago. Thank you. Thank you for your introduction. It's very much a pleasure to be with y'all. Um, so I'm, I'm ER trained, uh, in the wilderness program. I drove back to Beach, uh, California, and then, uh, lived in, lived in Utah for a few years and, uh, trained. I've been in. for the last 7. Heat injury is something, um, unfortunately, I've gotten very accustomed to taking care of down there. Um, so my approach is I wanted this to be just practical bread and butter stuff that you can apply on ship without hopefully having to think too much. I just, um, talked to Park City EMS. So this is a, uh, adapted lecture from that. I took a lot. the simple path of this out because you guys already know that stuff and I, I put in just the practical pros I think it will help. That's my, that's my hope, OK. Uh, cold injuries, I think a different beast if you guys, uh, found, found benefit maybe in the future, I'm more than happy to come back and talk about cold. OK. So, uh, no disclosures, and I'm gonna start with a case. So, uh, you have a 4. A year old male coming in hot with, uh, by EMS. He's an ESI 1. he's altered, and he's got a temp of 106. So, if it, you, I would love for you all to chime in and for it to be sort of a, a give and take case, um, cause I think it's a lot more fun that way. So, super informal. Just tell me your thoughts, OK? So, Uh, that's your report, OK? You're on shift. You're busy. You're getting crushed like always, um, and that's your report. What do you, what are you guys thinking? Sure, yeah. What else are you thinking? You gotta cool him down somehow, yeah. I mean, where, I wanna know what was the circumstances. He's sick. It wasn't a fever. Parent's room at 100.6 or if he's got meningitis or it's just, yeah, really like, yeah, totally the context what's the and, and so we always do that, right? We're like, OK, well, it's the story like, OK, I got you, but you know, like I don't know, right, that's usually how it goes. I don't know. We'll see when they come in when they come in. I don't know. OK, uh, yeah, so, so things to think about, you know, just organization of your room, making sure you're kind of getting ready again. This is very like EM focused or, or shit. Um, now, if it's just you and you got this case and you're really worried, maybe I, you know, it's an ESI1 most hospitals, I have not worked at yours but have like a protocol in place to bring our team, bring X-ray, bring the chaplain, bring everyone, but this is probably one of those cases gets really sick. Consider getting your resources ready. Now, everything changes when it's multiple patients, right? So an MCI totally changes everything the way you process this case. Cause now you're doing battlefield medicine in an urban setting. Um, and, uh, the, and I'm gonna talk about this. This is very much what we had to deal with our ship down to San Antonio. Uh, but yeah, so that changes the way you approach it. It changes the way you triage and treat, and you kind of think, well, how am I gonna move through 6 of these similar cases. Um, so an MCI changes obviously a little bit, it changes how you approach this. So toxic appearing, pale and unresponsive. So back to this case, toxic appearing is pale and unresponsive. Uh, he's got a patent airway, uh, no stridor. His lungs are clear. Uh, no full chest, but he's ago agonally breathing. Um, pale, peripheral pulses are weak. What are you guys thinking now? Yeah, yeah, how are you gonna get access? How do you guys normally get access, but I, I'm asking, I'm genuinely asking what you, what, what your nurses are really good, really, really good. And if not an I, yeah, drill, yeah, for sure. OK, great. Uh, OK. Bad vitals. He's tachycardic. Uh, he's got, uh, he's hypotensive. Uh, he's got a respirations, and he's got a poor temposis, but he's actually hypothermic. Um, low GCS. Pupils are not, uh, res reactive, um, for any pulses, and, um, he's hot. So, you guys know this, you guys are very good at this. Again, this is an adapted, uh, you don't need this slide really adapted from, from EMS presentation, but like, you know, resuscitation before you're gonna take your airway, making sure you're optimizing your hemodynamics, uh. Uh, uh, before you, you know, you, you pass plastic on a patient that needs it. Um, cool. And rapid cooling, so rapid cooling, I agree that you should be addressing that. I'm gonna talk more, I'm gonna talk a lot more about that. Uh, and then, uh, you know, something that is, is intuitive in this setting, but often a lot more complex in the trenches is, you know, Why, why are they hypothermic? Like, it's really easy for us to sit and talk about differentials, and it's fun to do, right? We're a bunch of docs. We like talking about differentials. It becomes a lot more difficult, a lot more complex when you have a full board. Your mind is busy, and now this kiddo comes in, he's critically ill and he's hot, and you're like, oh, why is he hot? Um, but it's not enough to say they're hypothermic. It's, you have to go seeking for an underlying etiology. Uh, you know, we talked about that with the Afib RVR. We talked about that with DKA, like don't, it's not, that's not your stopping diagnosis. You need to keep going. So same thing with hypothermia. Uh, back to this case. So he was found, context, as you said, very important, essential to the story, um, and it really does, it really does guide what, how you're gonna approach this case. So he's in the back of the vehicle. The bystanders broke him out, breached the vehicle, got him out, um, extricated, and it was a quote, the EMS says, doc, it was a load and go. Um, that's all I know. Uh. So, rapid cooling and resuscitation management as next steps. So we're gonna talk about that. So there's two main types of cooling. Um, they're both very effective, and I'm gonna talk about one that I, I think, uh, is more effective and some things that you guys can do. as docs to facilitate this. Evaporative cooling, you're essentially wetting them down and you're moving air across their body, evaporative cooling. Um, it is super effective. So you can do that in the ED. You can wet them and fan them. Um, and you can fan them with like anything, um, and that it will, it will drop your temperature very quickly. I immersion therapy. Um, so, um, And I, I think I have a slice this more specific details, but, but, uh, you want 50% of their body underwater, cold water, ice water, and, um, if you can get 50% of their body underwater, you can drop their temperature by 3 degrees in about 15 minutes. So that's very rapid cooling, very rapid cool. Uh, And so, Again, uh, a little bit of an adaptation from a prior lecture in that just get them out of the heat, right? The EMS guys, get them out of the heat. Uh, and I, I, I'm telling EMS that they need to cool, start cooling in the field. So getting them out of the heat, getting them out of the, uh, bending agent, and then also getting them in the back of the rig and cooling them in the back of the rig. And there's different ways, um, there's different ways that this can be approached. I, I don't know if we have, I, I don't think that we have standardized EMS protocols for this right now. Um, um, I have been asked to help write some protocols for Park City, um, in Summit County, um, just so that we can have like a standardized approach for patients that are truly, uh, Uh, who are worried about heat stroke cause it doesn't matter. You don't wanna keep them in a hypothermic state for an extended period of time during transport, and then they get to you and then you start treatment. It should be treatment at, you know, at, uh, initial contact. So, I, I wanted to, I just think it's interesting. I wanted to take a second to tell you about personal experience I've had face to face with this. Um, this is, this is where I came from. This is our bay. Um, and, um, What's that? Oh, OK. Uh, yeah, so that's our bay. Um, our PD ED was just right here. We had a, a different bay for pes, um, but medicine trauma, and, um, when we have MCIs, they would all come in at once, obviously. This is, um, a real case that we had come into our hospital. Um, we're, we're a border, we, we're, we're the, uh, where I trained, it was the tertiary referral center, trauma center that covered, um, the border. So we, we took all of the, the bad stuff that came from South Texas and Mexico adjacent. And, um, so what will happen, unfortunately, you probably have seen this on the news, um, but what will happen is they'll bring them across the border in a truck. And then the driver will, uh, just hop out and leave, um, get paid, hop out and leave, and you have like family sitting in the back of the truck roasting. Um, uh, it's, it's, it's awful. Um, it's been pretty traumatizing for a lot of our, a lot of our docs that have to, have to be the receiving docks for these, for these cases, but they're always MCIs, um, and so I wanted to, you're probably not going to have that, right? You're probably, hopefully, you're not gonna see an MCI like this, um, but What would you do if you were getting an MCI, getting a report? I'll tell you what we did. This is what our preparation looks like. So we get, basically, we pull resources from the whole hospital. We get all the ice in the hospital. We get bins, and we put them down in the ER and we wait. And we have body bags, and we put patients in body bags and we dump ice in the body bags. So we cool them very quickly that way. Um, And these are things that you have. These are ice and body bags. You have this. You could do this now, right? Um, so this is what I would recommend on ship. If you have a kiddo that was truly hypothermic and you're altered and you're worried about heat stroke, we're gonna talk about diagnostic criteria. Get a body bag, get ice and dump it, make it, and, and cool them down. You do it quickly, and it costs you nothing. It costs you some ice. Um, don't anchor. So, yeah, again, we talked about the context, right? And that's true with, with all of the things that we do in the ER, uh, is, is anchoring can be really dangerous. Um, and last, just last night, I was like, I made this, and then I was reviewing it this morning and I was laughing over the fact that I anchored like real hard last night on an elderly woman in the ER that was altered and super sleepy, and I cannot figure out why. And I went through all the things that we're gonna talk about and could just like literally cannot figure out like why are you so sleepy. She did not fit other than she was sleepy. She didn't fit any of the other vital signs arrangements or physical exam findings for an opioid toxic drug, but I didn't narcan her. I did not narcan her. I was admitting her to medicine. They're like, did you give her a Narcan. It's like I thought about it. No, cause I don't think it's an opioid thing. She's not on any opioids. Anyway, long story short, I gave her Narcan, she's like fully awake. Uh, so I was like, I'm gonna send fentanyl. I already did her detox is negative. I wanna send a fentanyl, uh, fentanyl, uh, test as well. I don't know. I, I still like think that. Threw me off. But yes, don't anchor. Be open-minded. This kiddo is sick and deserves attention and, uh, your thought, right? OK, so let's talk about the differential. AE IOU tips for, uh, as a, as a framework which you guys have already reviewed. You guys already know. I will not like spend too much time, but I do wanna review it. How often are you reviewing AD IOU tips? Not many of us are, right, unless you're saying the board or something, but not many of us are reviewing this. I think it is a good I think it is good to check but we'll just stop through it real quick. Alcohol, uh, this, this, and this kiddo or any kiddo or any teenager that you have could be involved in any of these things. This kid is probably acidotic. These patients that come in with heat stroke are acidotic. They're very acidotic. They come in like around 769. They, they look terrible, um. Uh, it's a DKA, it's HHS, any altered patient, you should get a, a, a glucose, like standardize that in your practice, I think would be, would be good practice, um, you know, cause that's gonna change everything you do, right? You get this kid and that's what you see. Um, and the thing is too, and I tell EMS like, well, OK, what's Is it like, yeah, they're hypothermic, and yeah, it's probably heat stroke, but what caused that? Did they go down? Was it a medical cause the ideology that caused them to go down? Were they, you know, walking for a long time in the mountain and then they had diabetes it's totally controlled and they didn't eat a bar, and now they're like, now they're heat stroke because they were so altered, you know, um, adrenal crisis. If you Google sad adrenal glands, this is what you'll get. Uh, so I thought that was pretty awesome. Adrenal crisis, another tiology to consider. You know, um, thyroid storm, right? Hypothermic, um, and altered, potentially altered, uh, something to think about. Do you think it's a thyroid etiology, uh, Altered? Sure. OK. So, um, this is more in the wheel have more common bread and butter stuff and wilderness like wilderness medicine stuff. So, in events like, uh, you know, Out in Big Bend, we would do Big Bend Ultra Bike Patrol, stuff like that. We would see patients that would be like, um, acutely hyponatremic. They see this a lot in the Grand Canyon actually. A lot of patients, um, down at the, down at the bottom in the canyon will become hyponatremic. So they're drinking water, but they're losing electrolytes and so it'll cause electrolyte shifts and, uh, alterment status. Uh, OK. So, there's a kid stroke, right? That's our main topic. Are they septic? Is it an infectious cause? Is it meningitis, things like that. These are things that we need to consider. Um, do they respond to oxygen? Are you like me and you didn't do this like you should have? Um, And then, you know, they said a uremic, uh, pathology, you know, dialysis patients, etc. So, um, and don't forget about trauma. Don't forget about concomitant trauma, right? So these, these kiddos, these kiddos that are, that come in are adults, right? Whoever you're taking care of, they come in, they're altered, they're hypothermic. Did they fall? Is, is, do they have a head bleed uh on top of all of this? Those are both low threshold to scan these, these, these patients. Um, and then, uh, you know, NS, there, there's a lot of, there's a lot of reasons that you can give, and, and I'm an LR personally, I'm an LR guy like LR like plasma light, um, but, but MS in cases like this, right, you're, you're attacking a lot of different causes all at once. So if you're worried about, um, you know, you're worried about electrolyte arrangements, you're worried about hypo, uh, hypoglycemia, you need to get a volume, you're worried about a head bleed. You know, and that is a pretty safe, at least at our, at my old shop. NS is like a pretty good go to when you're undifferentiated still. Uh, but you'll have your own, you'll have your own culture and thoughts on that, I'm sure. Uh, and then it's, and then acute envenomations. So, Do a, and this is really my, my slide to just like hit on do a good exam, do a good head to toe exam, right? Um, because like if you saw two puncture wounds on their foot and then they went down and then they were hypothermic as a subsequent result, right? Like all this could happen in the summer, uh, that would change, that would change management actually, right? You would consider antivi or, uh, your, your envenomation pathways, um, your snake bite severity scores, etc. It takes you down a different path. While still treating what you're, what you're seeing uh immediately in front of you. OK. And then strokes, uh, seizures, syncope? OK. So, I'm gonna break down the heat injury spectrum pretty quickly. And really what I want you to know is it's either heat stroke or it's not. That's how you need to think as a doc. This is heat stroke or it's not. Cause heat stroke comes in. If it's not, it doesn't probably need to come in. You can probably go home. Um, OK. So, the minor, uh, yeah, moderate. So moderate is heat exhaustion, we'll talk about that, and then heat stroke. But, but again, really like the take-homes on this lecture is like ident identification of heat stroke specifically, and then what to do about it. So if it's a heat rash, this is like stuff your, your, your family members are gonna ask you if you, like my, I have, uh, my sister, my sister-in-law gets a heat rash and she's always asking me how to manage it. NSAIDs, uh, persistent heat rash, you can use steroids, um, like, but typically NSAIDs get out of the heat. I start to get out of the sun. Uh, heat edema. So you get, uh, leaky, uh, like increased capillary permeability, and they get edematous, um, a pollution of sweat ducts and edema, and it's really the same treatment, you know, get out of the heat. Uh, And then heat cramps is typically an electrolyte derangement, but not to the point where they're gonna need, typically, they're not gonna need uh They're usually not going to need any like intravenous therapy here. It's simply oral, oral electrolyte replacement, um. I thought this picture was uh funny, so I put it in. That was really the only reason that's there, but yeah, electrolyte imbalance during heat cramps. Um, I ran, uh, a Spartan a long time ago with, uh, our, our ER team, and there's this one spot like at mile 2, I think, or mile 3, and it was like, it was funny, but also it happened to me where everyone was cramping at this one jump. So like, you had to get over this wall and to jump, like everyone was cramping at that one spot. Uh, and I have, I was kind of laughing and it happened to me and I started cramping in my calf. Uh, but yeah, so they get cramps. It's really simple. These guys are gonna go home. You're gonna give them some, um, oral fluids and, and they don't need much. So, um, good. Heat syncope. OK. So, a little bit more concerning, they passed out. Now, do you need to do a trauma exam? Do you need to scan their head? Things like that, right? But aside from that, this is, this is essentially, uh, the same thing. They're getting vasodilatory pooling, uh, and it, it puts them at higher risk of like an orthostatic picture, they pass out. Um, uh, heat syncope still, if you get the story that they passed out, they're out in the heat, they passed out when they got up, it was a positional change. These are things that don't require you to do a whole lot other than your trauma evalve and just know that, you know, give them good education and repercussions, you know, they shouldn't be out in the heat that day, uh, any further. OK. And then fluids, you, you, you know, fluids is very, IV fluids is very reasonable for these patients. Heat exhaustion, uh, just another ridiculous picture here. Uh, and, OK, so heat exhaustion, I want you to, so heat exhaustion isn't really something that you need to identify clinically because it's not heat stroke. Again, heat stroke, not heat stroke, it's not heat stroke, but um this is sort of the point where compensatory mechanisms will start to break down if they're not, it's almost like a theoretical. So I think of heat stroke or a heat exhaustion as like a theoretical transition point between like benign and, and not. Um, this is where they will start to like decompensate. So their temp is under 104 diagnostically. And uh this is where you'll start to see some vital sign derangements. So they can be tachycardia, they can be weak, they can have passed out, um, they can be vomiting. They, they'll look, they'll look unwell. Um, these are patients that if they are not brought out of the heat, they will decompensate and go into heat stroke. Um, and now, um, They can develop renal failure, rhabdo, DIC. These are very rare under heat exhaustion, and I think probably most docs would just call it heatstroke if they're having significant organ damage at that point. But, um, I want you to just think about heat exhaustion, if, if you remember it at all. You, you really don't have to cause it's important, it's not clinically that important um for you in the ED, but it's the cliff, so they're gonna fall off this cliff and go into heat stroke. Um. OK, so And it's the same treatment. You wanna cool them down rapidly, um, evaporative cooling or immersion therapy. So let's talk about heat stroke, which is really what matters. It's bimodal in nature, so it's the, it's the elderly and the young are the most susceptible to, to this, this, um, severe heat injury. Um, OK. And, and it's important. So this is important. Identification of this is, is important because their morbidity and mortality is really high, OK? So up to 50 of these, these patients will die. Um, they're very sick. And anecdotally, I'll tell you, uh, the I've had, I've had a lot of heat stroke cases. I've had one heatstroke case that I think was OK neurologically. All of, all of my other heat stroke patients were either peri-arrest, uh, died during intubation, or died in ICU. They're very, very sick. Um, So what do you need diagnostically? You need a temperature, ideally a core temp. You should get a core temp. You should get a core temps and a good physical exam and history. Temp diagnostically greater than 104. And they're altered. That's your diagnostic criteria, OK? Um, So altered mental status, altered sensorium can be irritability, confusion. They go into this kind of uh toxic triad of seizures, coma, and death. And that is true. I can tell you anecdotally, I've, that's what I've seen. They'll they'll come in seizing. They'll come in posturing. Um, they look very, very sick. They're very comatose at arrival, um, get them out of heat, obviously. So we're gonna begin aggressive cooling, and you, you do, oh sorry. You do wanna remove their clothing. So strip them down, body bag and ice is my recommendation. If you don't, if you, if you can't just resource wise, you can't get those things, then um wet them down, get a fan or get a lid, like a rigid lid and start fanning them yourself, but like that should be a priority. Um. I, in, in, uh, at our hospital, we did do in uh invasive, uh, aggressive cooling. So we would do chest tube irrigation, we would do, um, bladder irrigation, things like that. Um, Those are Hail Marys. Honestly, you're, those are like real last-ditch efforts. I, I, I personally, I, I think having done all those things, I, I think I'm more into just body bag and ice camp now, uh, especially just being practical. Y'all are super busy and you have like, you know, 100 patients on your list, like doing chest tubes and all that stuff. One a patient that's probably already neurologically devastated doesn't. Probably doesn't make tons of sense. This, this is just my my two senses having experienced it. I think, I think cooling them in a, in a bag, uh, with ice, I think is, is just as effective. Um. It's not unreasonable to do those invasive measures. It's not unreasonable. It's just, it is very time-intensive and uh, you know, very invasive. So, OK. And then airway management, we talked about airway management already. That's obvious. You're gonna, you're gonna do that appropriately. Um, Your target temperature isn't normal. You're not gonna remember 102.2. Like no one's gonna remember that. But you, you just know that you don't have to get them down to normal thermia at, at like when you're, when you're just pulling them. You don't have to wait until they're like normal thermic. You're gonna start pulling them. You're gonna do your full ultra mental status workup, and they're gonna go to the ICU, right? Um, but if you're, if you're doing immersion therapy, they're gonna stay hypothermic. It takes time to get them down. Um, you can get them down pretty quick, but you're probably not gonna get them down to normal. Um, and a lot of it comes down to when I was reading about this, just trying to understand it a little bit better. A lot of it comes down to injury to the, um, hypothalamus and like, it's just like a set point regulation, um, it's basically damage to the brain that causes this, this offset set point. Um, it's more complicated than I understand and feel comfortable teaching, so I just left it out. Uh. OK. And then, um, So, you know, I left this in just cause I, I think it's, I think it's an interesting point. Like, our EMS agencies down in San Antonio and these places around the border is very, very hot. We have, they have like, uh, chest freezers with ice bags, and then they just, they just load all this on a cooler, and then they go to the patient, and they bring it and they cool in the field. Um, that's actually something I wanna implement out here. Um, and again, like how much of this are we seeing a lot less, I, uh, recognize, but when you see it, you see it and you're, you're worried. And, and there's different, there's different causes, right? It could be from a car. It's probably gonna be more likely something like that. Um, and, uh, OK, good. So we talked about this half-body. 3 degrees, 15 minutes. And then, um, if you're doing evaporative therapy, you're trying to get them down to basically a normal temp. Uh, These patients are at higher risk for dysrhythmias and arrest, so you want them on telemetric monitoring. Um, this is all things that you would do intuitively. You're not gonna put a patient that was heatstroke on the floor without telling, of course, you're gonna end up into the ICU. Of course, they're gonna be on telemetric monitoring, and of course, of course, you're gonna have close monitoring and their ICU level care. Um, Yeah, uh, high proportion, uh, you know, that's a big range, and I don't know actually what that, I don't know what to make that. I just, in my mind, I'd say half. Half of them are gonna develop cardiovascular collapse. They're gonna need vasoactivepressor support. So you're gonna put these patients on compressors. Um, and that's 100%, like, anecdotally, that's 100% what I've had to do. They all come in, they're, they have like iron respirations. They have essentially their GCS 3, their posturing, if, if anything, they're getting, uh, pressers, re uh fluids, pressers. They're getting tubed, um, they're dipped with body bags and mice, they're going to ICU. That's sort of like they go CT ICU sort of our, how it happened. Um, And we know that they're getting admitted. So on that admitting criteria like your disco, um, if, if it's not heat stroke, they weren't, uh, over 100, 100.4, and they're not altered. And you're, if you don't have any organ damage on your workup, then they, you can safely discharge these patients, OK, um, as long as you didn't find anything else in their workup that would require admission, but these, these patients, most of them will go home because it wasn't heat stroke, OK. So everything else is supportive care, right? Uh. And uh 104. I'm sorry, 104. OK, that's a good good question. Um, so I, I, we, we have a fair number of the heat exhaustion patients in the ER at the right time of year and especially these like all-time high school athletics, that's when we get a lot of them cross country races and stuff like that. But, um, I mean I, I've had a limited number of heat and stroke patients, um. When you get their temperature coming down, um, and they're not dead, how quickly do you see their mental status improve, or do you not a lot of the times when you're admitting them to the ICU and they're still pretty unresponsive. I, I'm just really good question. Yeah, all the heat stroke patients were all intubated. So, so I never had any, uh, they start to buck on the tube and so like. Yeah, and then we, so we will, we, we will notice, we, we will put them on like fentanyl drip or, or we'll put them on a, this is like what we saw, put them on a fentanyl infusion, leave off propofol for a while, see how they do. If they start waking up, they start bucking, we're like, oh good, like, and then that helps us communicate with the ICU. Yeah, they were actually agitated on the vent. Uh, we added propofol or whatever. Um, we added a second, uh, uh, infusion for sedation, but most of them didn't, unfortunately. And then thank you and then follow up for that, um, you know, among your differential diagnosis items, uh, and thinking of things that take extra effort from us as ER providers to do like a spinal tap, um, which, you know, isn't all that hard, especially if they're out of it or in an intubated sedated, but How often do you do that, and how much does the clarity of the story of this being an exposure problem, Have, uh, persuade you to not do a spinal tap and these patients. Yeah, yeah, if, if they were, if they were found down in the, in the city and we didn't know why and they were hypothermic and altered and we tubed them, we would do the tap, uh, for the ICU and we just send it and they were with people, they were well before it was witnessed and those ones, would you not if it was a really great story. Yeah, right, there's not really other reasons to do it diagnostically or therapeutically, right? Right, yeah, yeah, so exactly. So like the, the train, like the train, uh, the last MCI was a train, so it was like 50 people and like I think 20 of them died in the train, um, and a few of them came to us, like none of them got, none of them got LPs, no, no, we didn't. treat meningitis heard them any of them were like, yeah, they're out in the sun. They got roasted. There's nothing, there's nothing here to, to, you know, so that's like a pretty clear story. But yeah, I guess so if you're, if you're not sure and you think it may be, may have been, uh, an infectious etiology or you're concerned about an infectious etiology, then there, there is no reason not to just do the, do the tap, you can always just treat your in the icing. That's at least my thought. Um, but, but if the story is like if you're getting, you know, it's pretty much a heat, a heatstroke case and you feel pretty confident, you've gone through your differentials, so like heatstroke makes the most sense and I don't think you need to tackle, yeah, um. OK. And then, uh, Rapid cooling. So we talked about evaporative cooling. So if, if they're a heat exhaustion, just do evaporative cooling, you know, wet them down and put a fan on. If you, I don't know if you have fans in the ED or anything like that, but that would be a simple box fan is like literally what you looked into it the other day. And we, I don't think we have a fan. So maybe, maybe that's a couple of little ones. Yeah, we probably need to have one, get one of those $30 ones, yeah, yeah, exactly. So like that's something y'all's group can invest in as a box fan, just like a simple box. He exhaustion, turn on the box fan. Let them down and put on a box and just come back in 15 minutes, 20 minutes, half hour, see how they're doing, um, give you some fluids and, uh, you know, you can discharge those patients. So, um, I think that's all I had. Yeah, that's some sources, but, uh, yeah, what questions do you guys have or like anything you want that? Yeah, yeah, I, the first case you showed, uh, the kid had like a GCS of 5, I think, right? Uh, and, and you, I think you said to try to resuscitate them and cool them first, even though their GCS is 5. I'm just curious, like, How long are you going to do that before you're like this kid's GCS is 5. We've been doing this for 30 minutes. Let's tube him. Oh, YouTube him, yeah, YouTube him. You, I, I, you would do all the things in parallel. You'd be cooling him. You'd be tubing him. You'd be, yeah, all that stuff. But like get the IV fluids going, get ready before youtube them yeah, like, yeah, oh yeah, the way I would do it. Me personally, I'd have this kid come in. I get all my resources. I'd start resuscitating him. I'd say someone get a body bag, we can put him in so we can drop some ice on it. We can, we can intubate. We can do all those things, but let's start cooling in parallel. That's what I would do. But I think the message for EMS is bag while you Do this other stuff, yeah, you're getting called for medical direction. They need to get access. They can always bag a kid, right? I wouldn't want them messing around with too. Yeah, I got a respiration, so back on, yeah, exactly, like provide all the care you would normally do, but cool as well. Like it, it is hard, right? Like, so all, all of your codes are like, you know, as you guys are, as you guys already. Your code, your code is gonna start off a little busy, a little chaotic. You task saturate nursing staff. You kind of shout off all your stuff, and you're like, OK, I need to just like put my hands in my pockets, let everyone work cause I just gave everyone a ton of stuff to do. Let me just wait for a second and let you guys do your thing, and then, you know, but yeah, you can be like, hey, uh, let's like. Call the cafeteria and get ice down. We need a bucket of ice. We need a few buckets of ice. So let's call the cafeteria. Let's get some ice down here now, um, or wherever you, where, uh, I'll just call it cafeteria. You can call whoever you want to get ice, but, um, wherever you think you can get it, and just say, let's, let's start working on that. And again, if you have another means of like some, uh, immersion therapy, then do that. But A baggage. It's just like they already have them, yeah, I remember a long time ago I used to read like they talked about pulling like armpits is that still, yeah, so, um, I did read and I, I didn't include that here, um, actually, so doing palms and feet is kind of, uh, equally effi uh efficacious, um, so, and I think that Um, I'm trying, I'm, I'm really pulling on this one, but, but what I vaguely remember in doing a deeper dive on this was you don't need to do groin and axilla, you should do palms and feet if you're gonna, if you're gonna do that. Personally, I would just do evaporative cooling. That's what I would do. I would wet them and I would do evaporative cooling. But I think it's really it's really effective. It works well. And when I looked up our EMS protocols, we do have a heat and cold exposure protocol that you tested EMO protocols. Awesome. I mean, it's all ages and you know, obviously some crews can be really limited in what they have, but they do, the protocol says, you know, airway support, get an IV, get 20 per kilo. Um, then I want you to do aggressive cooling, unclothe the patient, use water spray, bands if you have them, um, ice packs to groin and this is not recommended for children and infants. And I don't know if they're worried about tissue necrosis. I don't know if they're worried about. Aggressive cooling should stop as shivering begins. And to watch for dysrhythmia. Yeah, I, I read, I read into that too. So, so they'll shiver and obviously you worry about like an uh exacerbating hypothermic state with, with, uh, with shivering. But I personally think that the bene if they're still hypothermic, the benefit is gonna outweigh the risk. At that case, I probably dump them. Cause then, then you may cause some, you may exacerbate a little bit of heat injury there, but if you're some, if you're immersing them, uh, you're going to continue to cool past that anyways. So that's what I personally would do. Yeah, if I was worried about heat stroke and they were shivering in the middle of my, my therapeutic interventions, I would, I would push on, yeah, I would push on. So if they're intubated by that point, would you paralyze them to stop shivering, yeah. Yeah, I would. I mean, you probably are paralyzed. Yeah, I would, I totally would, and it's, you know, very, very reasonable. Yeah, any other questions, good, good questions to ask? Yeah, yeah, I, I like the way you said resuscitate before intubate. Yeah, I feel like a lot of people wanna rush to get the endotracheal tube in, and that can cause more trouble sometimes. We've all had, I think we've all, we've all probably killed some plasty, right? Um, I'm no exception, so, and I think you, you learned the hard way, yeah, yeah. Thank you so much. I ask one more question. I know sometimes when you're like they're super cold and you warm up too fast, you can cause the arrhythmias. But if they're very hot, you cool them down. Is there an increased concern if you're cooling too quickly or anything to cause arrhythmias? I, I think, I think they're cooking their brain. And so, uh, your, your like time is brain tissue basically. So if I would say I would just aggressively cool, yeah, maybe, and, and it, but you could argue if they had dysrhythmias, it was probably an organ damage from the heat trauma, you know, not, not, not your, not your intervention. So if they are if they arrest on you, it's like you're doing literally everything you could and they just showed up falling off the cliff, you know, you just reset, you just, yeah, resuscitate them. Thank you. Yeah, that was nice. back in the spring when we have the cold water runoff for the cold. I, I've been at the back. I actually just had one, a cold one, a cold water runoff, did you like in the last month. were they late winter? No, actually they were allergic. Yeah, you so much. That's thank you so much. This is really great. um, so y'all are the people that all of us here now, you know, 2 to 3 years, yeah, we're good to go. Um, but yeah, yeah, so we're disaster curriculum residents it's a pleasure and, and, uh, yeah, if you guys want to talk about cold injuries, I can I I'll, I'll do a whole thing on I lecture on frostbite. I, I did a whole thing on frostbite, frostbite management. I got in the week and everyone, like, all, you know, it's very informal. Everyone's like giving me tons of crap for it and then we had a. It was right before that it was like 2 months ago that I like sent this very passive aggress to the whole department cause I got so much crap. Please reference Doctor Paul's frostbite lecture they just roasted me after that. They're like, oh yeah, uh, and the attendings in the back like out of San Antonio we got frostbite. I was like. Yeah, well, you never know. And then it happened and I was like yeah, yeah, no problem. Can I have yes, it's it's like. yogurt. It's not yogurt, right? It's way too fluffy, but it is good. I know. I was expecting yogurt. I'm not a lucky person. What does that mean? Why is it? I know I know I know. I don't like that texture. I'm a very I like it so much. I, I know, yeah, I am definitely autistic. We're probably all autistic. I own that. I like, yeah, I'm have to say if I would have been tested, yeah, go get things like um don't like to. like that. Yeah, no, I haven't. We haven't. That's why I said, yeah, they are. Can you rent? I mean, I guess it's like none of the jobs have rentals. Yeah, but what is your? I looked at ASL. There's like, do you want me to, how many do you need that. I theoretically we could get you 10, not mine. My, um, really good her husband actually she's like a 750 mile um yeah it'll be self-supported right you went right from here to here is like I have like. For now I don't know. OK. Oh, LDS, uh, LSC very different. So she's super cool. I just reach out one of them if they have ideas or I'm not sure. I mean it's just so it was insane. Like yeah yeah yeah yeah yeah we have so we have no chance but we can get you can get I think more like we actually have like a lot like we've been able to drive and fix it. How much are they magic. Oh gosh, yeah, that's a kid and just my, the most impressive. So they intubated to just calm him down. Well, it was. But it was just so crazy and like he couldn't he couldn't like do anything with it. He's biting did he like yeah yeah wow that's pretty nice it's amazing. It's like it's um yeah I mean my, my daughter was crazy when she fell the other week she's better but she definitely took a lot of meds here. I haven't been doing that already felt like the sweet gate backwards while we're in Colorado she like was like lost her mind screaming about or down did you give birth. Ativan. So yeah, probably should have said, uh, more Ativan and scan and they were really scared they were gonna. I think she got more. I think she got more and then, and then they gave her, they tried to see CT her and they like told her that. So now I'm like right now she's got brain cancer and then they work they work and then I got the CT, but she was crazy and so I was worried at one point they're gonna turn off but it's fantastic. It was like. I know she was out of her mind and she's 14 yeah, was negative. I never saw it, but yeah, I wonder if she had it's like the in there, you know, sexual I drink which is really good. They weren't thrilled with me or her. It was, it was at the moment it was pretty scary. It was also just frustrating. I just need, I know I don't get she's OK. She is she's I thought she was she's probably 3 years out. Yeah, yeah, it's a great learning to like just talk for two weeks, um, but I know like one shift that they can pick her up. I'm trying to, so I'm not sure like yeah it's like I think it's yeah I'll. OK, I'm gonna go to the, I have the thingy. OK, you have it already, yeah, with um, yeah, she's doing great. OK, great. I have 3 a.m. because they couldn't get an IV.
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