Conference Notes 12-5-2018

Barounis/Dodd/Ketterhagen Central Line Simulation Lab

Our awesome EM Intensivists taught us how to optimally place a central line. I can’t do justice to all the teaching they did but here are just a few fine points I picked up.

When putting your sterile gown on by yourself, Velcro the neck first before you put your arms through the sleeves.

The plastic adhesive strips in the sterile probe cover package can be used to tape the probe cord to the drape so the probe doesn’t fall off the patient.

Line up bevel of needle with the numbers on the barrel of the syringe so you know where the bevel is.

When you are locating the IJ in the neck, keeping the probe pointed at the floor instead of aiming it toward the neck will help keep the orientation of the IJ and IC more true.

Once you have punctured the skin, move the ultrasound probe with your needle so that you always have the tip in view and can visualize exactly where you enter the vessel.

When making the cut with a scapel put the blunt side of the scapel towards the wire.


Hawkins Case Presentation and Ortho Xrays

45 yo male presents with altered mental status. Patient was reported to be intoxicated and vomiting. In ED patient was found to have head laceration and rash. He was hypotensive and tachycardic.

Patient was in detox recently and was on multiple medications including antabuse.

DDX=disulfiram reaction, ETOH intoxication, serotonin syndrome, ICH, toxic ingestion, dehydration, sepsis, anaphylaxis.

Patient had improving blood pressure and rash with IV fluids. Mental status worsened with a GCS of 7-8. Patient is next intubated.

Disulfiram reactions can result in tachycardia, hypotension and cardiovascular collapse.

Other tha ETOH, disulfiram reactions can also be caused by chlorpropamide, flagyl and griseofulvin.

The duration of the disulfiram-alcohol reaction varies from 30 to 60 minutes in mild cases to several hours and is largely dependent on the amount of alcohol that needs to be metabolized. Due to vomiting and volume depletion, serum glucose, electrolytes, and kidney function should be evaluated. Since only small amounts of ethanol can precipitate a disulfiram–ethanol reaction, it may be useful to confirm the presence of ethanol with a blood concentration. Patients with cardiovascular instability should have an ECG. Symptomatic and supportive care is the mainstay of treatment. Most patients with hypotension respond to intravenous 0.9% sodium chloride. Refractory hypotension is rare, but if necessary, a vasopressor can be administered. A direct-acting adrenergic agonist such as norepinephrine should be used since disulfiram inhibits dopamine β-hydroxylase (DBH), an enzyme necessary for norepinephrine synthesis. As such, indirect vasopressors, such as dopamine, that require functioning norepinephrine synthesis may be less effective.

For further symptomatic care, antiemetics can be administered, and for cutaneous flushing, a histamine (H1) receptor antagonist, such as diphenhydramine, can be given.101 Most patients with a disulfiram–ethanol reaction have mild symptoms, are hemodynamically stable, and can be safely discharged following resolution of symptoms.

Fomepizole may halt the accumulation of acetaldehyde and thus cease severe disulfiram–ethanol reactions. Fomepizole, an inhibitor of alcohol dehydrogenase, may terminate the progression of the disulfiram reaction by blocking ethanol metabolism to acetaldehyde (Antidotes in Depth: A30). In a study of alcoholics, fomepizole decreased acetaldehyde concentrations and improved clinical symptoms in those expe­ri­enc­ing a disulfiram–ethanol reaction.59 A recent case series reported two patients who developed severe disulfiram–ethanol reactions with hypotension and tachycardia unresponsive to fluids who were treated successfully with a single dose of fomepizole.97 One patient improved clinically 90 minutes after administration of fomepizole and the other within 30 minutes. (Goldfrank’s Toxicologic Emergencies)



 This is an avulsion of the lateral capsule and is called a Segond fracture. It has a very high (>90%) association with a tear of the anterior cruciate ligament. (Atlas of Emergency Radiology)

This is an avulsion of the lateral capsule and is called a Segond fracture. It has a very high (>90%) association with a tear of the anterior cruciate ligament. (Atlas of Emergency Radiology)

Segond Fracture is associated with an ACL tear




Montaggia vs Galeazzi

 Both Monteggia and Galeazzi fracture-dislocations require emergent orthopedic consultation and are treated with immobilization in a long-arm splint (with elbow flexed at 90 degrees). The forearm is placed in a neutral position for a Monteggia fracture and supinated for a Galeazzi fracture. Treatment is usually surgical for both injuries, although children may be treated by reduction and casting. (The Atlas of Emergency Medicine)

Both Monteggia and Galeazzi fracture-dislocations require emergent orthopedic consultation and are treated with immobilization in a long-arm splint (with elbow flexed at 90 degrees). The forearm is placed in a neutral position for a Monteggia fracture and supinated for a Galeazzi fracture. Treatment is usually surgical for both injuries, although children may be treated by reduction and casting. (The Atlas of Emergency Medicine)


Katiyar Toxicologic Emergencies Hallucinogens

 Hallucinogenic compounds all have similar chemical structure.

Hallucinogenic compounds all have similar chemical structure.


Hallucinogenic botanicals include morning glory and Hawaiian baby woodrose.

Magic Mushrooms are a source of psilocybin.

Ayahuasca and the Yakee plant are plants in the amazon that contain the compound N,NDMT a potent short-acting hallucinogen.

Toad licking can cause hallucinogenic effect. (Colorado toad). Toad licking also can cause arrythmias.

in one species of toad, Bufo alvarius (Sonoran Desert toad or Colorado River toad).77 Although bufotenine has been classified as a Schedule I substance by the DEA for many years, 5-MeO-DMT was not scheduled until 2009.91 Like DMT, 5-MeO-DMT is rapidly metabolized by intestinal monoamine oxidase enzymes; oral ingestion of toad venom or skins would thus have limited potential as a route of recreational use.21 Methods for extracting and drying B. alvarius secretions for smoking and insufflation are available on the Internet. Death has resulted from wrongful use of Bufo secretions for purposes of aphrodisia.30,55 The toad venom glands also produce cardioactive steroids, called bufadienolides, which cause digoxinlike cardiac toxicity, and in some species, can secrete tetrodotoxin.87,139 (Goldfrank’s Toxicologic Emergencies)



Peyote and mescaline are other hallucinogens. Some cacti available on line contain peyote or mescaline.

Salvia is from the mint family and can be purchased on the internet or at a garden store. The leaves contain hallucinogens.

Nutmeg contains a hallucinogen.

Most hallucinogens affect the serotonin receptors. There may also be sympathomimetic effects.

Hallucinogens are not routinely identified on urine toxicology screens.

Treat hallucinogenic overdoses with benzodiazepines, cooling, and quiet environment.


Katiyar Toxicologic Emergencies Hypoglycemic Agents

Ackee fruit from Jamaica can cause hypoglycemia.

Sulfonylurea medications increase insulin secretion from pancreatic beta cells.

Metformin inhibits gluconeogenesis, enhances glucose transport into muscles. Decreases glucose being released from liver.


Mild changes in renal function or a new drug interaction can be causes of new onset hypoglycemia.

A single large injection of insulin is more dangerous than multiple smaller doses because a large dose creates a “depot effect”. The “depot effect” will result in prolonged release of insulin.


Insulinoma and sulfonylureas will result in elevated c-peptide levels. Synthetic insulin does not have c-peptide.


Treat sulfonylurea toxicity with glucose and food. Also start octreotide. Check the blood sugar Q1 hour. Keep for OBS or admit



Estoos/Kishi/Miner Trauma Lecture: Neck and Above


In the hypotensive trauma patient, consider hemorrhage as #1 cause. After hemorrhage, consider obstructive causes of shock (tamponade or tension pneumothorax).


When exposing the patient make sure you examine the whole body back and front looking for subtle injuries. At the same time consider environmental exposures such as acids, bioterrorism agents, or radioactive contamination. After fully exposing the patient, keep patient warm with blankets and heat to avoid hypothermia.

The GCS is a critical means of communicating the neurologic status of the patient between caregivers as well as a way to monitor the patient’ neurologic status.

 The GCS is an objective measurement of clinical status, correlates with outcome, is a reliable tool for interobserver measurements, and is effective for measuring patient recovery or response to treatment over time. However, the scale has several limitations. It measures behavioral responses, not the underlying pathophysiology. Patients with similar GCS scores may have dramatically different underlying structural injuries and require different clinical interventions (  Figure 257-2  ). It is not as useful as a single acute measure of severity as it is as a tool to measure disease progression over time. The GCS may additionally be affected by drugs,  alcohol , medications, paralytics, or ocular injuries. Finally, the scale lacks the granularity necessary to assess mTBI. (Tintinalli 8th edition)

The GCS is an objective measurement of clinical status, correlates with outcome, is a reliable tool for interobserver measurements, and is effective for measuring patient recovery or response to treatment over time. However, the scale has several limitations. It measures behavioral responses, not the underlying pathophysiology. Patients with similar GCS scores may have dramatically different underlying structural injuries and require different clinical interventions (Figure 257-2). It is not as useful as a single acute measure of severity as it is as a tool to measure disease progression over time. The GCS may additionally be affected by drugs, alcohol, medications, paralytics, or ocular injuries. Finally, the scale lacks the granularity necessary to assess mTBI. (Tintinalli 8th edition)


Key ED goal for head trauma management is to avoid hypotension and hypoxia. Elevate the head of the bed. Mannitol or hypertonic saline may be used to lower ICP. Avoid mannitol in patients with renal failure. Avoid hypertonic saline in patients with CHF.

Basilar skull fracture=temporal bone fracture.

 Subdural hematomas have significant underlying brain injury. The blood collection can cross suture lines. It is venous bleeding from bridging veins.

Subdural hematomas have significant underlying brain injury. The blood collection can cross suture lines. It is venous bleeding from bridging veins.


 Traumatic subarachnoid hemorrhage

Traumatic subarachnoid hemorrhage

Traumatic subarachnoid hemorrhages as opposed to aneurysmal subarachnoid hemorrhage are more peripherally located.


Epidural hematoma

 Epidural hemaoma

Epidural hemaoma

Traumatic intraparenchymal hemorrhages are often in frontal or temporal lobes.

DAI has a benign appearing CT head/MRI with a severely affected GCS/mental status exam. Some DAI patients will improve significantly within a year or so. Prognosis is difficult to predict.

Patients with head injury have 50% increased mortality with single episode of hypotension.

Do not use therapeutic hypothermia in traumatic head injury. Recent RCT showed no benefit and trauma surgeons emphasized that hypothermia increases traumatic bleeding.

When intubating patients with significant head injury and you don’t have to do a crash or life-saving emergent intubation, be very careful to avoid any desaturation or hypotension during the intubation.

Unfortunately I missed a significant portion of this outstanding lecture.

























































































































































Conference Notes 11-28-2018

Lorenz/Shroff STEMI Conference

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Be very cautious giving IV beta blockers to patients with decreased cardiac function. Patients with diminished cardiac function can deteriorate with IV beta blockers. Determining a patient’s cardiac function can be challenging in the acute setting. Consider checking a bedside echo prior to giving a rate control agent. Start with a low dose and re-evaluate closely. During the discussion of this clinical situation, the Cardiologist at the meeting voiced a contrarian view and felt this was an overly cautious approach and that most patients can tolerate reasonable doses of rate control agents.

Tekwani comment: Get an ABG or VBG early on to see the lactate. It may clue you in to a hypoperfused state or cardiogenic shock. Harwood comment: A VBG also gets you a rapid potassium level.


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Cardiology comments: We try to avoid cath in patients with coronary artery dissection because cath can propagate the dissection. Most patients are treated with anticoagulation. I f a patient has a new right bundle branch block and left anterior fasicular block, be concerned for a proximal LAD occlusion and need for a pacemaker. Post-partum patients who develop coronary artery dissection should be counselled to not have further pregnancies. Cardiac surgery can be helpful at times to manage SCAD. There was consensus among the cardiologists that managing coronary artery dissections is very treacherous and cardiac cath is not a slam dunk. If you have a post-partum patient presenting to the ED with a STEMI you should activate the cath lab but discuss with the cardiologist the possibility of SCAD.

If you have concerns for ACS get repeat EKG’s every 10 minutes or so to try to pick up a STEMI. Inferior STEMI’s can initially have subtle inferior ST elevation, so be alert to ST depression in leads 1 and AVL which can be more eye catching. If Lead 3 is elevated more than Lead 2 or AVF it suggests right coronary involvement. Avoid Nitro in a patient with a normal BP and concern for right coronary infarct.

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Felder/Tran Oral Boards

Case 1. 19yo female with chest pain for 2 days. Patient is tachycardic. Patient had been forcefully vomiting in the days prior to presentation.

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Diagnosis was Boerhaave’s syndrome. Patient required IV antibiotics and Thoracic surgery consultation.

Case 2. 11 yo male with behavior changes. Vitals are normal. Patient had recent sore throat with incomplete antibiotic therapy. Patient recently moved from Saudi Arabia. Patient had choreiform movements and emotional lability. Diagnosis was Sydenham’s Chorea and Acute Rheumatic Fever. Treatment is 500mg of PCN BID chronically.

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 Sydenham chorea, which is due to an autoimmune insult to the basal ganglia, 11  occurs in 10% to 15% of patients and may be the only manifestation of ARF; involuntary choreiform movements and facial grimacing are exacerbated by stress and disappear with sleep. Mild cases may present with restlessness and clumsiness. The motor movements may be unilateral. Symptoms are often preceded by behavioral disturbances including emotional lability, personality changes, anxiety, and poor school performance. Some patients may have “Sydenham speech” that is characterized by bursts of dysarthric speech. The time to development of chorea (1–6 months) is longer than for arthritis or carditis: streptococcal antibodies may be decreasing or undetectable at presentation. Physical findings of chorea include irregular contractions of the hands when squeezing the examiner’s finger (milkmaid’s grip), spooning and pronation of the hands when the arms are extended, and wormian movements of the tongue upon protrusion. Alterations in handwriting may be noted. The duration of chorea varies, but it is a self-limited process. Recurrence has been reported in 20% to 60% of patients and usually occurs within 2 years of initial presentation. 11  Sixty-three to 94% of patients with Sydenham chorea will also have cardiac involvement. 11  (Tintinalli 8th edition)

Sydenham chorea, which is due to an autoimmune insult to the basal ganglia,11 occurs in 10% to 15% of patients and may be the only manifestation of ARF; involuntary choreiform movements and facial grimacing are exacerbated by stress and disappear with sleep. Mild cases may present with restlessness and clumsiness. The motor movements may be unilateral. Symptoms are often preceded by behavioral disturbances including emotional lability, personality changes, anxiety, and poor school performance. Some patients may have “Sydenham speech” that is characterized by bursts of dysarthric speech. The time to development of chorea (1–6 months) is longer than for arthritis or carditis: streptococcal antibodies may be decreasing or undetectable at presentation. Physical findings of chorea include irregular contractions of the hands when squeezing the examiner’s finger (milkmaid’s grip), spooning and pronation of the hands when the arms are extended, and wormian movements of the tongue upon protrusion. Alterations in handwriting may be noted. The duration of chorea varies, but it is a self-limited process. Recurrence has been reported in 20% to 60% of patients and usually occurs within 2 years of initial presentation.11 Sixty-three to 94% of patients with Sydenham chorea will also have cardiac involvement.11 (Tintinalli 8th edition)


Case 3. 64 yo female with facial weakness. Patient has DM and HTN. Exam also identified vesicles on the external ear and ear canal.

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RAMSEY HUNT SYNDROME (HERPES ZOSTER OTICUS)

Ramsey Hunt syndrome is a herpes zoster infection of the geniculate ganglion. Signs and symptoms include unilateral facial nerve palsy, severe pain, and a vesicular eruption on the face. Ramsey Hunt syndrome may be indistinguishable from Bell's palsy if paralysis precedes the vesicular eruption. Cranial nerve VIII may also be involved with associated vertigo, nausea, and hearing loss. As opposed to classic Bell's palsy, when active herpes zoster is suspected, treatment is with both steroids (prednisone 1 milligram/kg per day PO for 7 days) and antivirals (famciclovir 500 mg PO three times a day for 7 days or valacyclovir 1 gram PO three times a day for 7 days).5 (Tintinalli 8th edition)


Tekwani Difficult Airway Conference

3 indications to Intubate: Protect airway, Can’t oxygenate or ventilate, Anticipated clinical course.

 The LEMON mnemonic is a well accepted algorithm for the initial evaluation of the airway and predicting a difficult airway.  It is not 100% sensitive for identifying a difficult airway.

The LEMON mnemonic is a well accepted algorithm for the initial evaluation of the airway and predicting a difficult airway. It is not 100% sensitive for identifying a difficult airway.

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 Thenar Grip Technique for bag-valve-mask

Thenar Grip Technique for bag-valve-mask


If you foresee a difficult airway, call for help. Ask Anesthesia or the MICU Intensivist to come down to back you up.
If you have a failed airway where basically you can’t intubate, place a LMA and proceed to cricothyrotomy.

Pre-oxygenate with NRB mask with O2 at “flush rate” for at least 3 minutes or use BIPAP. Preoxygenate the patient sitting up if possible to optimize pulmonary function. Also use apneic oxygenation at 15L NC in addition to your NRB or BIPAP.

Dr. Patel comment: You can use HI FLOW nasal cannula O2 for apneic oxygenation.

When intubating, start bagging the patient as soon as their O2 sat drops to the 95% range.

Case 1. If an asthmatic has a PCO2 of 42 or higher you need to be thinking they are fatiguing. You need to escalate care and be prepared for intubation.

After intubating an asthmatic patient set your vent to a Tidal volume of 6 ml/kg. Set ventilation rate at 12. Set O2 sat at 100% initially then titrate down to 40% quickly if possible. Set Peep at 0-5. I:E 1:5. High inspiratory flow rate 80-100 liter per minute. You will have to tolerate an elevated PCO2 so you don’t run into breath stacking, elevated peak and plateau pressures, or barotrauma.

Case 2.

ACE-I are the #1 cause of angioedema. Calcium channel blockers are the #2 cause of angioedema.

When giving ketamine for induction of a patient with a presumed difficult airway give 2mg/kg but give it slowly over a few minutes. If you give this dose rapidly, you can cause apnea.


Carlson Toxicology Case Conference: Antidotes

Antidote=Anything that improves survival from a toxin.

 When calculating the Osmoles for a boards question you can simplify the equation by rounding 18 to 20, 2.8 to 3 and 4.6 to 5. You will get close enough to the right calculation.

When calculating the Osmoles for a boards question you can simplify the equation by rounding 18 to 20, 2.8 to 3 and 4.6 to 5. You will get close enough to the right calculation.


Ethylene glycol and methanol will increase the anion gap. The antidote for ethylene glycol poisoning is fomepizole.

The antidotes for severe lead poisoning are BAL and EDTA. Oral succimer can also be used for mild cases or if you can’t use BAL due to peanut allergy. Editor note: mnemonic for BAL-EDTA is LED. BAL ends with L and EDTA starts with ED.

The antidote for Gyromitra mushroom poisoning is B6 (pyridoxine). Patients can seize from Gyromitra poisoning. B6 is also used for seizures due to INH poisoning.

The antidote for TCA cardiac toxicity is NA-Bicarb.

 If you see this EKG in the setting of an overdose, think TCA and give a trial of NABicarb. If it works, it will narrow the QRS complex and narrow the terminal R wave of AVR. A Wide R wave in AVR and wide QRS complexes generally are clues on the EKG to a TCA overdose.

If you see this EKG in the setting of an overdose, think TCA and give a trial of NABicarb. If it works, it will narrow the QRS complex and narrow the terminal R wave of AVR. A Wide R wave in AVR and wide QRS complexes generally are clues on the EKG to a TCA overdose.


The antidote for calcium channel blocker overdose is Insulin at 0.5 U/kg bolus followed by 0.5U/kg/hr drip. You can also give calcium gluconate. Calcium gluconate is preferred over Calcium chloride due to less risk of soft tissue damage if the calcium extravasates from the vein.

Jimsonweed has anticholinergic effects. The treatment is benzodiazepines. A direct antidote is physostigmine if needed.

Antidotes for sulfonylurea overdose are glucose and octreotide. Glucagon may help if there is some glycogen stores remaining.

Oleander, foxglove, and lily of the valley are all botanical glycosides and the antidote for them is digibind (FAB fragments). You can also try atropine.

The antidote for hydrofluoric acid burn is calcium gluconate. The fluoride burns through tissue and binds calcium. You can give calcium gluconate by making a gel with surgilube, or give subQ injections with a TB syringe or for severe burns give intra-arterial calcium gluconate.

Methylene blue is the antidote for methemoglobinemia. Dapsone can cause methemoglobinemia.

The antidote for organophosphate poisoning is atropine and 2-PAM. The atropine reverses the muscarinic symptoms, specifically it dries secretions. 2PAM re-activates the acetylcholinesterase to stop the nicotinic effects.

The antidote for iron toxicity is deferoxamine. Side note by Dr. Carlson: The antibiotic omnicef is chemically similar to deferoxamine and can give small kids “brick red” poop. This can be concerning for parents.

The antidote for carbon monoxide is hyperbaric oxygen.

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Conference 11-21-2018

Katiyar Billing and Coding

Unfortunately I missed this outstanding lecture.

Williamson/Florek Oral Boards

Case 1. 45 yo male presents with fever and shortness of breath. Patient is tachycardic. Patient has history of type 2 diabetes. Exam demonstrates scrotal swelling, erythema, and crepitence. The patient required IV antibiotics (Vanco/Zosyn/Flagyl) and emergent surgical debridement.

Dr. Williamson made the point that diabetics with fournier’s gangrene may have sensory neuropathy that diminishes pain perception and may not be aware of an early perineal infection.

FOURNIER'S GANGRENE

Fournier's gangrene is a polymicrobial, synergistic, infective necrotizing fasciitis of the perineal, genital, or perianal anatomy. This process typically begins as a benign infection or simple abscess that quickly becomes virulent, especially in an immunocompromised host, and results in microthrombosis of the small subcutaneous vessels, leading to the development of gangrene of the overlying skin.

Patients with diabetes and alcohol abuse are disproportionately affected with Fournier's gangrene.6 Mortality rates have varied from 3% to 67%,7 but contemporary estimates range from 20% to 40%.8,9,10,11,12,13 Age over 60 and complications during treatment are the most important predictors of death.12,13

In advanced Fournier's gangrene, the local signs and symptoms are usually dramatic, with marked pain and swelling. Crepitus and ecchymosis of the inflamed tissues are common features. Prompt recognition of Fournier's gangrene in its early stages may prevent extensive tissue loss that accompanies delayed diagnosis or treatment. Treat with aggressive fluid resuscitation, gram-positive, gram-negative, and anaerobic antibiotic coverage (see also chapter 151, "Sepsis"). Recommended agents include piperacillin-tazobactam, 3.375 to 4.5 grams IV every 6 hours, or imipenem, 1 gram IV every 24 hours, or meropenem, 500 milligrams to 1 gram IV every 8 hours, plus vancomycin.7,8,9 Urgent urologic consultation is required for wide surgical debridement.7 The addition of clindamycin, 600 to 900 milligrams IV every 8 hours, or metronidazole, 1 gram IV, then 500 milligrams IV every 8 hours, to the antimicrobial regimen may be of benefit.7 Hyperbaric oxygen therapy in the pre- and postoperative setting is a treatment option but does not improve mortality.14 Admission to the intensive care unit postoperatively is typically required.7 (Tintinalli 8th edition)

Case 2. 2 yo female patient presents with decreased level of consciousness. Patient is hypotensive and tachycardic. The patient took some of mom’s medications. X-rays show radio-opaque pills.

 Radio-opaque iron tablets in the stomach.  The preferred method of GI decontamination is whole bowel irrigation (WBI). 6   Dr. Wilimson made the point to not do whole bowel irrigation in patients who have GI bleeding or signs of shock.  Activated charcoal does not adsorb iron. WBI with polyethylene glycol electrolyte lavage solution (PEG-ELS) should be initiated if pills are seen on abdominal radiographs. PEG-ELS is given by nasogastric tube at a rate of 25 mL/kg/h in small children and 1 to 2 L/h in adolescents and adults. The end point of therapy is a clear rectal effluent. It is also useful to obtain an abdominal radiograph after completion of WBI to confirm the absence of pills. Active GI bleeding, ileus, and bowel obstruction are contraindications to WBI. 6  (Pediatric EM 4th Edition)

Radio-opaque iron tablets in the stomach.

The preferred method of GI decontamination is whole bowel irrigation (WBI).6

Dr. Wilimson made the point to not do whole bowel irrigation in patients who have GI bleeding or signs of shock.

Activated charcoal does not adsorb iron. WBI with polyethylene glycol electrolyte lavage solution (PEG-ELS) should be initiated if pills are seen on abdominal radiographs. PEG-ELS is given by nasogastric tube at a rate of 25 mL/kg/h in small children and 1 to 2 L/h in adolescents and adults. The end point of therapy is a clear rectal effluent. It is also useful to obtain an abdominal radiograph after completion of WBI to confirm the absence of pills. Active GI bleeding, ileus, and bowel obstruction are contraindications to WBI.6 (Pediatric EM 4th Edition)

Either a 50mg/kg ingestion of iron or a serum iron level of 500 are indicators of severe toxicity.

Even moderately poisoned children require meticulous supportive care to ensure a positive outcome. For patients in shock, large volumes of intravenous fluids and sodium bicarbonate are required to maintain fluid, electrolyte, and acid–base status.

Editor’s note: Dr. Carlson disagreed with the use of sodium bicarbonate. She felt sodium bicarb was not indicated for standard management of iron toxicity.

Chelation with intravenous deferoxamine is used for significant iron ingestions. Indications are the presence of significant symptoms or signs of iron poisoning, a serum iron concentration greater than 500 μg/dL, or metabolic acidosis.

Deferoxamine should be administered at a rate of 15 mg/kg/h. Administration of intravenous deferoxamine to patients with intravascular volume deficits risks nephrotoxicity. It is important to provide a bolus of crystalloid before initiating the deferoxamine infusion. The duration of chelation therapy is variable; there are no reliable end points.7 Serum iron determinations during the course of iron poisoning do not reflect clinical toxicity, and they are often unreliable during deferoxamine therapy.

Using a return of urine color to normal is not recommended as an end point for chelation therapy. It has never been validated, and pigmentation of urine (vin rose urine) is concentration and pH dependent. The most useful criterion for continued chelation is the presence of a metabolic acidosis despite satisfactory perfusion. This indicates the presence of non–transferrin-bound iron in the plasma. Deferoxamine is rarely required beyond the initial 24 hours after iron ingestion.

Hypotension is a potential side effect of intravenous deferoxamine therapy if it is given too rapidly. In a dog model, hypotension has been observed at infusion rates of 100 mg/kg/h. It is not reported at the usually recommended rate in humans, 15 mg/kg/h. Delayed pulmonary toxicity with symptoms resembling those of acute respiratory distress syndrome has been reported in patients who received prolonged chelation (>24 hours).8

Renal failure can be seen in ill hypovolemic patients. For patients undergoing chronic therapy, visual and hearing deficits, and Yersinia infections have been reported. (Pediatric EM 4th Edition)

Dr. Carlson comment: the TIBC level does not have a role in determining iron toxicity.

Case 3. 38 yo male with right arm pain. Patient fell from ladder and injured right arm. Patient has a laceration in area of injury. Xrays showed the injury below.

 Galeazzi Fracture, fracture of the distal radius with radial-ulnar dislocation. This injury requires surgical management.

Galeazzi Fracture, fracture of the distal radius with radial-ulnar dislocation. This injury requires surgical management.

Menon Global Health in New Zealand

It’s a big decision to go to New Zealand to do locums. You have to weigh the upsides and downsides for you and your family.

Downsides to going: You will make less money (@$100,000) and the cost of living is higher. Taxes are 30% in New Zealand and you also get taxed again in the US for whatever you make over $100,000. You obviously need to move far away. You will be placed in a rural environment because that is where they need the docs. You have to commit for at least a year.

Reasons to do this: You get to do something really cool. You get significant time off (6 weeks paid, 10 days paid holiday). You get to practice your craft in a different environment. You get to experience a different healthcare system and a different way of life.

The work: EM is a relatively young specialty in NZ. Because of that, consultants like anesthetists and pediatricians frequently get involved in your cases. NZ has a national formulary so medications are affordible for patients. Malpractice risk is quite low. No night shifts for attendings! There are no respiratory therapists. Hemodialysis is rare. The pain control culture is very different. Patients want very little pain medication. There is much less imaging than in the US. Getting a CT is kind of a big deal.

Hawkins/Pastore Global Health in Dominican Republic

Top 3 causes of death in Dominican Republic: Ischemic heart disease, stroke, road injury.

Our residents and faculty took part in this global Health experience through a faith-based clinic and surgery center (Institute for Latin American Concern) affiliated with Creighton Medical School and Advocate.

Visiting health professionals taking part in this global health experience live with local families near the clinic.

Drs. Hawkins and Pastore took back the awesome experience of living and practicing medicine in another country and a gratitude for what we have here in the US.

Ahmad Determinining Capacity and Leaving AMA

AMA myths debunked: Insurance does cover AMA dispo’s. You can give prescriptions to patients signing out AMA.

You as the physician can explore with the patient what factors are pushing them toward leaving AMA. Sometimes you may be able to address their concerns so they can stay.

AMA discussions do not need to be confrontational. You will be better served if you can be supportive and collaborative with the patient. Maybe think about it as managing/optimizing the AMA process instead of having a conflict with the patient.

Patients who have decisional capacity can not be kept against their will unless they are suicidal, homicidal, or psychotic.

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To proceed with an against-medical-advice discharge, assess the patient's capacity, with special attention to barriers limiting capacity. Alcohol use and psychiatric diagnoses are not absolute barriers to discharge against medical advice, with the exception of suicidal and homicidal patients. Document the patient's behavior that clearly demonstrates there was no impairment of capacity by intoxication or mental illness. Educate the patient about the risks associated with refusing to complete evaluation and/or treatment. Discuss the patient's reasons for leaving, because these often present opportunities for negotiation and convincing the patient to continue care.9 Use plain language and avoid medical terms. Given the medical-legal and patient risks of against-medical-advice discharge, make a substantial effort to convince the patient to remain but do not resort to threats. Incorrect statements such as "insurance will not pay for this visit if you leave against medical advice" may further damage the patient–provider relationship and discourage the patient from returning.26,27 Model documentation of an against-medical-advice discharge should contain the following elements21,28:

  • Documentation of capacity (ideally with examples and examination clearly noted)

  • Discussion of the risks reviewed with the patient including what diagnoses were being considered

  • Explicit documentation in the chart that the patient was leaving against medical advice and what treatments, procedures, and courses of actions were refused by the patient

  • Offers made of alternative treatments or courses of action

  • Efforts to involve family, friends, or clergy in the decision

  • Explanation of any potentially problematic entries in the chart such as nursing notes or abnormal laboratory values—for example, if the patient has an elevated serum alcohol level, document that the patient is clinically sober and has capacity, if true

  • Patient's signature on the against-medical-advice form, and if patient refuses to sign, document that fact

  • Documentation of treatment and follow-up provided

  • Documentation that the patient was told he or she is welcome to return at any time

While the most important part of documenting an against-medical-advice discharge is the discussion with the patient addressing the items above, having the patient sign an actual against-medical-advice form may help provide further liability protection in three ways: "1) it may terminate the providers legal duty to treat a patient; 2) creation of the affirmative defense of 'assumption of risk'; and 3) the creation of a record of evidence of the patient's refusal of care."29

When a patient leaves against medical advice, reasonable treatment should be provided as appropriate for the patient's medical condition and concordant with the patient's wishes. For example, provide antibiotics for infection, aspirin for chest pain, or stabilization for fractures. Tell the patient to return at any time. Provide a listing of resources for close follow-up and instruct the patient on signs and symptoms to prompt a return visit to the ED should the patient change his or her mind.9,21 (Tintinalli 8th edition)

Example of documentation describing patient’s decision making to sign out AMA: “It is my medical opinion that the patient appears to currently have capacity to refuse care. He is alert, able to reason through the information I am providing him and seems to understand the serious risks of refusing care up to and including death. He is able to communicate his refusal to me and does not appear to be actively suicidal or have worsening depression influencing his decision making capacity.”

Delbar Pancreatitis and Biliary Tract Disease

The level of lipase elevation does not correlate with severity of pancreatitis. CT imaging is not required for most cases of pancreatitis.

Treat pancreatitis with aggressive LR administration. Give 1-2 liters as a bolus then continue with a rate of 150-200ml/hour.

Patients generally need a total of 2.5 to 4 L of fluid over the first 12 to 24 hours.19,22 The specific rate of fluid delivery depends on the patient’s clinical status. In the situation of renal or heart failure, deliver fluid more slowly to prevent complications such as volume overload, pulmonary edema, and abdominal compartment syndrome. Crystalloids are the resuscitation fluids of choice. Normal saline in large volumes may cause a nongap hyperchloremic acidosis and can worsen pancreatitis, possibly by activating trypsinogen and making acinar cells more susceptible to injury.19,39 A single randomized study showed a decreased incidence of systemic inflammatory response syndrome in patients who received lactated Ringer’s instead of 0.9% normal saline.39 Regardless of which fluid is selected, monitor vital signs and urine output for response to hydration. (Tintinalli 8th edition)

Mild pancreatitis does not have organ dysfunction. If a patient has SIRS or organ dysfunction they have moderate or severe pancreatitis. The three most common organ dysfunctions associated with pancreatitis are renal, cardiovascular, and pulmonary.

Sonographic Murphy’s sign is 97% specific. So if the patient has tenderness with the probe over a gallbladder with stones, they have cholecystitis.

Choledocolithiasis and Cholangitis both need GI and Gen Surg on consult. Patients with cholangitis also need IR to get source control by placing a percutaneous drain.

Abughnaim Healthcare Disparities

Health Disparities= Higher burden of illness for a specific group

Healthcare Disparity= Difference in access to care and quality of healthcare between groups.

Social determinants of health include many things outside of the healthcare system such as housing, income, racism, pollution, social and family support, the legal system, etc.

Consider the social differential diagnosis for different complaints. Lack of access, need to provide childcare, poverty, side effects of medications, can’t miss work, need to serve as a care giver to another person, prison, and homelessness are just some examples.

 Some social determinants of health

Some social determinants of health

ED Care Managers can work through the social differential and figure out how to support a patient to improve their overall health and be able to be compliant with the treatment plan. Care Managers can arrange disposition from the ED to a SNF. They can arrange financial assistance. They can set up follow up appointments.

















Conference Notes 11-14-2018

Logan M&M

No case details, just the take home points.

If you have to intubate a patient who has pulmonary hypertension or RV failure consider using push dose pressors to optimize BP prior to intubation and do an awake intubation with ketamine instead of RSI.

If a trauma patient says, “ Don’t let me die!” that usually portends badness. Be aggressive in managing these patients.

Be disciplined when doing your secondary survey. Even examine the patient’s mouth. You have to be very careful not to miss other injuries.

Always have a back-up plan when intubating a patient. Have all the tools you need to perform both your primary plan and your back up plan ready to go at the bedside.

Remember that narcan can cause your patient to vomit.

NALOXONE (NARCAN)

Naloxone is a pure opioid antagonist that works by competitively inhibiting narcotics at the opioid receptor. Intravenous administration reverses the respiratory depressive effects of opioids within 1 to 2 minutes. Its clinical duration of effect is approximately 20 to 30 minutes. Long-acting narcotics may cause resedation. The opioids and their metabolites are active longer than the reversal agent. Carefully monitor a patient receiving naloxone for resedation and respiratory depression. The drug can be delivered via multiple routes (i.e., endotracheally, intramuscularly, intravenously, subcutaneously, and sublingually). The administration of 1 to 2 mg intravenously in adults and 0.1 mg/kg in children will reverse most respiratory arrest situations. Administer additional doses every 2 to 3 minutes to a total of 10 mg. Actively seek another etiology of the sedation and respiratory depression, other than narcotics, if the respiratory depression is not reversed after 10 mg of naloxone. Use caution as naloxone can result in opioid withdrawal in those with physical dependence or intoxicated with narcotics.

Small aliquots of 40 µg titrated to effect may be delivered in a situation where the patient is slightly oversedated and rapid full reversal of the narcotic is not desired. Mix 0.4 mg of naloxone with 9 mL of normal saline to produce a concentration of 40 µg/mL. Administer 1 to 2 mL aliquots every 1 to 3 minutes to alleviate respiratory depression yet maintain the narcotic analgesic effect. (Reichman’s Emergency Medicine Procedures)

Don’t be afraid to call for help or back up. Being over-confident and getting in over your head can be problematic.

Be sure to talk with EMS when they drop off the patient in the ED. They can have critical info to give you that will make a difference in your managment.

For pediatric lacerations: LET applied with tegaderm works better than LET applied with gauze. Intra-nasal versed works well for sedation. Child life specialists can be very helpful to distract pediatric patients during laceration repair.

Lovell Procedural Sedation

 For procedural sedation, we are usually shooting for moderate sedation. Sometimes we need to go to deep sedation for more painful procedures. Ketamine is in a different category altogether which is dissociative sedation. The patient retains blood pressure and airway reflexes with ketamine.

For procedural sedation, we are usually shooting for moderate sedation. Sometimes we need to go to deep sedation for more painful procedures. Ketamine is in a different category altogether which is dissociative sedation. The patient retains blood pressure and airway reflexes with ketamine.

Moderate sedation is characterized by a depressed level of consciousness and a slower but purposeful motor response to simple verbal or tactile stimuli. Moderate sedation most closely matches the formerly used term "conscious sedation." Patients at this level generally have their eyes closed and respond slowly to verbal commands. Moderate sedation can be used for procedures in which detailed patient cooperation is not necessary, and muscular relaxation with diminished pain reaction is desired. During moderate sedation, the patient is usually able to maintain a patent airway with adequate respirations.9 Depending on the agent, the incidence of hypoxia and/or hypoventilation during moderate sedation is 10% to 30%.10,11,12 Procedures performed using moderate sedation include reduction of dislocated joints, thoracostomy tube insertion, and synchronized cardioversion. Agents used for moderate sedation in adults include propofol, etomidate, ketamine, methohexital, and the combination of fentanyl and midazolam.

Dissociative sedation is a type of moderate sedation. Dissociation is a state in which the cortical centers are prevented from receiving sensory stimuli, but cardiopulmonary activity and responses are preserved. Ketamine is the agent most commonly used for dissociative sedation.13

Deep sedation is characterized by a profoundly depressed level of consciousness, with a purposeful motor response elicited only after repeated or painful stimuli. Deep sedation may be required with procedures that are painful and require muscular relaxation with minimal patient reaction. The risk of losing airway patency or developing hypoxia or hypoventilation is greater with deep sedation than with moderate or minimal sedation.10,14,15 Examples of ED procedures sometimes requiring deep sedation are reducing fracture dislocations, open fracture reductions, and burn wound care. Deep sedation generally is achieved in the ED with the same agents as moderate sedation, but with larger or more frequent doses. (Tintinalli 8th edition)

Remember that propofol and etomidate do not provide analgesia. Propofol tends to have associated hypotension. Etomidate can stimulate vomiting. Etomidate can also cause myoclonus. Etomidate is associated with adrenal suppression but this is not a significant concern for brief procedural sedation.

Procedural sedation has low risk of aspiration. ACEP guidelines say NPO status has no relevance to procedural sedation.

FASTING STATE

There is no primary evidence that the risk of aspiration during procedural sedation is increased with recent oral intake.24,25,26 Current guidelines regarding the safe fasting period prior to procedural sedation were developed by expert consensus,27 and the American Society of Anesthesiologists guidelines for fasting prior to general anesthesia are of limited relevance to the risk of aspiration with ED procedural sedation.25 Thus recent food intake is not a contraindication.27 If the risk of aspiration is concerning, waiting 3 hours after the last oral intake before performing procedural sedation is associated with a low risk of aspiration, regardless of the level of sedation.27 (Tintinalli 8th edition)

Critical Questions and Recommendations

Question 1: In patients undergoing procedural sedation and analgesia in the ED, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

Level B recommendations: Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduced risk of emesis or aspiration when administering procedural sedation and analgesia. (ACEP Guideline)

 Complications are primarily determined by the interaction of the depth  of sedation and the patient's current medical condition. A common tool  for assessing the patient's underlying medical condition is the American  Society of Anesthesiologists' physical status classification system. 16   The risk of a significant complication from ED procedural sedation and  analgesia in American Society of Anesthesiologists class I (healthy  normal patient) and II (patient with mild systemic disease) is low,  usually less than 5%. 1 , 5 , 6 , 7 , 8   The risk of an adverse procedural sedation and analgesia event is  correspondingly higher in patients with an American Society of  Anesthesiologists class of III (patient with severe systemic disease) or  IV (severe systemic disease that is a constant threat to life). 17 , 18   (Tintinalli 8th edition)

Complications are primarily determined by the interaction of the depth of sedation and the patient's current medical condition. A common tool for assessing the patient's underlying medical condition is the American Society of Anesthesiologists' physical status classification system.16 The risk of a significant complication from ED procedural sedation and analgesia in American Society of Anesthesiologists class I (healthy normal patient) and II (patient with mild systemic disease) is low, usually less than 5%.1,5,6,7,8 The risk of an adverse procedural sedation and analgesia event is correspondingly higher in patients with an American Society of Anesthesiologists class of III (patient with severe systemic disease) or IV (severe systemic disease that is a constant threat to life).17,18 (Tintinalli 8th edition)

 If you get over these doses, toxicity will manifest as either CNS symptoms/signs or Cardiovascular toxicity. Treat toxicity with benzos for seizures, ACLS medications for shock, and intralipid.

If you get over these doses, toxicity will manifest as either CNS symptoms/signs or Cardiovascular toxicity. Treat toxicity with benzos for seizures, ACLS medications for shock, and intralipid.

EM Faculty Sedation Workshop

Putman/DenOuden Sedation Debrief

Do a formal Time-Out with every sedation. Use the time-out to go over your mental checklist assuring you have everything you need (suction, ambu bag, capnometry, medications, reversal agents, rescue devices, etc).

Whatever sedation agent you choose, be prepared for the possible side effects and complications known for that medication.

After sedation is complete and the patient is awake, inform the patient of how the sedation went and whether there were any difficulties such as apnea or need for assisted ventilations or hypotension.

 Patient can go home following procedural sedation if they score a 9. Basically, normal mental status, normal vitals, can walk, talk, and cough.

Patient can go home following procedural sedation if they score a 9. Basically, normal mental status, normal vitals, can walk, talk, and cough.







Conference Notes 11-7-2018

Wing M&M

No case details, just a few take home points.

If a patient has signs of cardiac strain from PE or has other high risk factors (PESI score), consider admitting patient to the ICU or Step-down rather than the floor.

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 The reported sensitivity and specificity of CT in demonstrating right heart dysfunction are around 81% and 47% respectively 5.  Described features include:  abnormal position of the  interventricular septum  1 flattening of the interventricular septum paradoxical interventricular septal bowing, i.e. towards the  left ventricle   right ventricular enlargement ( right ventricle  bigger than the left ventricle)   pulmonary trunk  enlargement (bigger than the aorta)  features of right heart failure: inferior vena caval contrast reflux, 1 dilated azygous venous system, dilated hepatic veins +/- with contrast reflux

The reported sensitivity and specificity of CT in demonstrating right heart dysfunction are around 81% and 47% respectively 5.

Described features include:

abnormal position of the interventricular septum 1 flattening of the interventricular septum paradoxical interventricular septal bowing, i.e. towards the left ventricle

right ventricular enlargement (right ventricle bigger than the left ventricle)

pulmonary trunk enlargement (bigger than the aorta)

features of right heart failure: inferior vena caval contrast reflux, 1 dilated azygous venous system, dilated hepatic veins +/- with contrast reflux

 D sign of LV

D sign of LV

 McConnell’s sign

McConnell’s sign

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All the above indicators should prompt consideration of admission to a higher level of care (Step down or ICU)

Putman HEENT Study Guide

 Don’t try to close lacerations near the medial canthus on either the upper or lower eyelids. There can be an injury to the tear duct. Consult Ophthalmology.

Don’t try to close lacerations near the medial canthus on either the upper or lower eyelids. There can be an injury to the tear duct. Consult Ophthalmology.

 TRAUMATIC IRITIS  Patients with posttraumatic iritis usually present 1 to 2 days after blunt trauma to the eye, complaining of photophobia, pain, and tearing. They often have marked blepharospasm and perilimbal injection (ciliary flush). Test for pain on accommodation by having the patient first look across the room at a distant object and then quickly focus on the examiner’s finger held several inches away. If near gaze causes pain, there is a high probability of iritis. The pupil may be large or small. Posttraumatic miosis develops secondary to spasm of the pupillary sphincter muscle, whereas posttraumatic mydriasis results when sphincter fibers are ruptured. Slit lamp examination will usually reveal cells in the anterior chamber, the hallmark of iritis.  Treat with a long-acting topical cycloplegic, such as 5% homatropine, four times a day for 1 week, oral anti-inflammatory medication, and dark sunglasses to decrease pain. Symptoms may persist for up to 1 week. Although ocular steroids decrease inflammation, prescribe them only after consultation with the ophthalmologist who will see the patient in follow-up.

TRAUMATIC IRITIS

Patients with posttraumatic iritis usually present 1 to 2 days after blunt trauma to the eye, complaining of photophobia, pain, and tearing. They often have marked blepharospasm and perilimbal injection (ciliary flush). Test for pain on accommodation by having the patient first look across the room at a distant object and then quickly focus on the examiner’s finger held several inches away. If near gaze causes pain, there is a high probability of iritis. The pupil may be large or small. Posttraumatic miosis develops secondary to spasm of the pupillary sphincter muscle, whereas posttraumatic mydriasis results when sphincter fibers are ruptured. Slit lamp examination will usually reveal cells in the anterior chamber, the hallmark of iritis.

Treat with a long-acting topical cycloplegic, such as 5% homatropine, four times a day for 1 week, oral anti-inflammatory medication, and dark sunglasses to decrease pain. Symptoms may persist for up to 1 week. Although ocular steroids decrease inflammation, prescribe them only after consultation with the ophthalmologist who will see the patient in follow-up.

We commonly associate HSV keratitis with a dendritic pattern on the cornea

 HSV keratitis on the surface of the cornea

HSV keratitis on the surface of the cornea

If HSV involves the deeper layers of the cornea, you can also see a disciform HSV keratitis.

 Disciform HSV keratitis

Disciform HSV keratitis

 Malignant otitis externa can be seen in diabetic patients. The most common complication is paralysis of the 7th cranial nerve.

Malignant otitis externa can be seen in diabetic patients. The most common complication is paralysis of the 7th cranial nerve.

Walchuk/Robinson Oral Boards

Case 1. 61yo female brought in by EMS with “stroke” symptoms. Dexi=155. Patient is altered and has slurred speech. Last time patient was normal is unclear. On further history, patient states she has been dizzy for a week. Patient is on phenytoin for seizures. Her phenytoin level is markedly elevated to 63. Treatment of phenytoin toxicity is supportive. Very severe toxicity may benefit from dialysis.

Phenytoin has a long and erratic absorption phase after oral overdose, so the decision to discharge or medically clear a patient for psychiatric evaluation cannot be based on one serum level. After acute ingestions, serum level should be measured every few hours. Patients with serious complications after an oral ingestion (seizures, coma, altered mental status, or significant ataxia) should be admitted for further evaluation and treatment. Those with mild symptoms should be observed in the ED and discharged once their levels of phenytoin are declining and they are clinically well. Mental health or psychiatric evaluation should be obtained, as indicated, in cases of intentional overdose. (Tintinalli 8th edition)

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Case 2. 61 yo male brought in by EMS after a motorcycle crash. It was low speed accident and patient struck his head on the other vehicle. Patient has bilateral hand weakness. CT head and CT cervical spine show no acute abnormalities. MRI of the cervical spine shows:

 Central Cord Syndrome is the most common spinal cord syndrome. It is seen most commonly in elderly patients with hyper-extension cervical spine injuries.

Central Cord Syndrome is the most common spinal cord syndrome. It is seen most commonly in elderly patients with hyper-extension cervical spine injuries.

 Signs of Central Cord Syndrome

Signs of Central Cord Syndrome

The patient required C-spine stabilization and Neurosurgery consultation. Steroids are no longer recommended for central cord syndrome.

Case 3. 18yo male with right wrist injury from playing football.

 Distal Radial-Ulnar Joint (DRUJ) dislocation should be suspected with any widening of the space between the distal radius and ulna. The lateral view shows to distal ulna displaced posterior to the radius.

Distal Radial-Ulnar Joint (DRUJ) dislocation should be suspected with any widening of the space between the distal radius and ulna. The lateral view shows to distal ulna displaced posterior to the radius.

Treatment is closed reduction, splinting the wrist, and orthopedic follow up. In some cases surgery is required.

Davis/Shroff/Friend ED BounceBacks

No case details, just a few take home points.

3 cases were presented. Each patient returned to the ED with a change in clinical picture. If the patient has an unclear diagnosis (belly pain, vague neurologic symptoms, back pain) and you are discharging them home, be sure to give clear discharge instructions describing signs/symptoms that should prompt return to the ED.

Dr. Williamson comment: These cases demonstrate the importance of communication with the patient. You want the patient to feel totally comfortable about returning to the ED for further evaluation.

Dr. Ryan comment: I tell the patient, “if your pain is getting worse, or you get a fever, or some new problem develops, that should not be happening. If it does happen, that is a sign that something is wrong and you need to come back to the ER.” Also give patients a time frame on when they should be feeling better. If they are not feeling better by then, they need to return for further evaluation.

Ebeledike/Johns Safety Lecture Choosing In-Patient Level of Care

Choosing the appropriate level of inpatient care for a specific patient (Floor, Telemetry, Step Down, or ICU) can be challenging.

Examples of diagnoses suitable for telemetry: Stable NSTEMI, syncope presumed to be cardiac, arrhythmia/heart blocks, pacemaker or ICD problem.

Examples of Patients suitable for Step-Down: Patient on a single pressor, chronically ventilated patients, patients requiring a high level of nursing care, and patients with significant risk of deterioration.

In general, if you are concerned that a patient may deteriorate or decompensate, strongly consider placing them in Step-Down rather than the floor.

If the patient is critically ill put them in the ICU.

Dennis Ryan comment: Consult with the ICU attending to collaborate on whether a patient belongs in Step-Down or the ICU to better determine level of care.

Editor’s comment: Suggested simplified algorithm. Stable patients go to the floor/med-tele/telemetry. If you are worried the patient may deteriorate consider Step-down. Critically ill patients go to ICU.

Lorenz/Shroff Visual Diagnosis

The Chiefs presented multiple clinical pictures for pattern recognition. This outstanding presentation moved too fast for me to capture.

Conference Notes 10-31-2018

Twanow M&M

No case details just take home points.

Top 10 Lessons in residency:

10. If you want to be fast in the ED, focus on dispo’s. Make your dispo’s prior to seeing new patients.

9. Be kind to yourself. We have a hard job. Beating yourself up after a less than optimal case is not productive and can be self-destructive.

8. If you feel like something is wrong with a patient, listen to your gut instincts and work them up or re-evaluate them.

7. If your patient is not responding to therapy, you may be missing something. There may be another diagnosis that has not been identified.

6. Stay late for the right things (education, critical patient care) but know when to call it a day. It’s good to put in the effort to learn and care for patients. On the other hand you have to recognize when you are fatigued and not able to be the best for yourself and your patients.

5. Don’t send unstable patients to the CT scanner.

4. You will be in uncomfortable clinical situations at times but know who your backup is.

3. Some patients can be challenging to get along with, but beware, these challenging patients can still be sick with serious disease.

2. Our patients are our responsibility. This includes new patients, signed out patients, difficult patients, all of them.

  1. Be sure to take care of your colleagues. We all need each other to do this job.

Carlson Salicylate Toxicology

Many OTC products contain salicylate. Oil of wintergreen (methylsalicylate) has very high levels of salicylate.

Get serial serum levels of salicylate when managing salicylate overdose patients.

Salicyate causes neurostimulation resulting in tinnitus and increased respiratory rate and vomiting. It increases capillary permeability and can cause pulmonary edema. It uncouples oxidative phosphorylation and will result in lactic acidosis.

Snip20181031_3.png

Andrea made the point that if a salicylate toxic patient becomes lethargic or somnolent you’ve got big problems. Lethargy is a sign of brain dsyfunction, which is the main cause of deaths from salicylate.

Chronic salicylate toxicity is more lethal than acute poisoning. Chronic poisoning has high brain tissue levels despite modest blood levels.

 Beware of brain symptoms such as lethargy and somnolence. Andrea made the point that salicylate-toxic patients most often die from a CNS death.

Beware of brain symptoms such as lethargy and somnolence. Andrea made the point that salicylate-toxic patients most often die from a CNS death.

 Guidelines for hemodialysis in salicylate overdose. (EXTRIP Guidelines)

Guidelines for hemodialysis in salicylate overdose. (EXTRIP Guidelines)

Activated charcoal if given very early, before symptoms develop, binds salicylate very well. If a patient is symptomatic it is likely too late to benefit from activated charcoal.

Treat non-cardiogenic pulmonary edema with peep. You can try BiPap. You can intubate but it is dangerous because of the acidosis. It is difficult for a ventilator to keep up with the patient’s minute ventilation. If you have to intubate, use larger tidal volumes (around 8ml/kg) and high respiratory rate (40). If you can avoid using a neuromuscular blocker that would be optimal. Give 2 amps of bicarb prior to intubation to help manage the acidosis and possibly avoid a peri-intubation arrest.

Urinary Alkalinization: Put 3 amps of bicarb in a 1L bag of D5W and run at 250ml/hr. Add 20-40 meq of potassium to each liter. Shoot for a urine ph >7.5.

Carlson/Pastore Oral Boards

Case 1. 46yo female presents with suicide attempt. Patient is unresponsive. Pupils are pinpoint. Patient responded to narcan. Further history identified that patient ingested Zohydro (extended release hydrocodone). As ED course progressed, patient became re-sedated requiring re-dosing of narcan and starting a narcan drip.

Methadone, fentanyl, tramadol and buprenorphine will not show up positive on drug screen.

Synthetic opioids, such as dextromethorphan, fentanyl, meperidine, methadone, propoxyphene, and tramadol, show little or no cross-reactivity in opiate immunoassays. Urine immunoassays specific for meperidine, methadone, and propoxyphene are available. Given the increasing importance of buprenorphine as maintenance therapy for opioid dependency, it is worth noting that the combination of high potency and low cross-reactivity means that buprenorphine will generally not be detected by opiate immunoassays. Immunoassays for specific detection of buprenorphine have therefore been developed. (Goldfrank’s Toxicology)

Case 2. 19yo female presents with nausea/vomiting and abdominal pain. Patient is pregnant. U/S of pelvis shown below.

 Patients with molar pregnancy may have larger uterus and may have very high beta-hcg.

Patients with molar pregnancy may have larger uterus and may have very high beta-hcg.


Patients with molar pregnancy are at risk for trophblastic malignancy and need follow up. There is also risk of ovarian torsion.

Symptoms include vaginal bleeding in the first or second trimester (75% to 95% of cases) and hyperemesis (26%). Gestational trophoblastic disease, or molar pregnancies that persist into the second trimester, are associated with pre-eclampsia. When pregnancy-induced hypertension is seen before 24 weeks of gestation, consider the possibility of a molar pregnancy. The uterus is excessive in size for gestational age and shows a placenta with many lucent areas interspersed with brighter areas on US study. Because not all molar pregnancies are found on US, all tissue extracted from the uterus on suction curettage or during pelvic examination should be sent for histologic examination. If trophoblastic disease is suspected because of abnormally high β-hCG levels, a uterine size either larger or smaller than expected, and US findings suggestive of the diagnosis, obtain obstetric consultation. Treatment is by suction curettage in the hospital setting because of risk of hemorrhage. β-hCG levels that fail to decrease after evaluation are evidence of persistent or invasive disease necessitating chemotherapy. Metastasis to lung, liver, and brain may occur, but the prognosis for most patients is very good. (Tintinalli 8th ed.)

A molar pregnancy is caused by an abnormally fertilized egg. Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from the father, the other from the mother.

In a complete molar pregnancy, an empty egg is fertilized by one or two sperm, and all of the genetic material is from the father. In this situation, the chromosomes from the mother's egg are lost or inactivated and the father's chromosomes are duplicated.

In a partial or incomplete molar pregnancy, the mother's chromosomes remain but the father provides two sets of chromosomes. As a result, the embryo has 69 chromosomes instead of 46. This most often occurs when two sperm fertilize an egg, resulting in an extra copy of the father's genetic material. (Mayo Clinic online)

Case 3. 25 yo male presents with “allergic reaction” for 2 weeks. Vitals normal. Patient has pruritic rash.

 Rash c/w scabies

Rash c/w scabies

 Typical locations of scabies rash

Typical locations of scabies rash

A single application of 5% permethrin cream is curative for children older than 2 months. The cream may be applied to the face and scalp and needs to be left for 8 hours. Permethrin has been found to have a 97.8% cure rate with one application.10 Permethrin may cause burning and stinging as well as exacerbation of itching, although it is generally very well tolerated and has low potential for toxicity.11 The long incubation period makes treating the entire family advisable. Bedding and clothing should be laundered in hot water and dried using the hot cycle. Clothing and other materials that cannot be laundered should be removed and stored for several days to a week to avoid reinfestation.13 (Pediatric Emergency Medicine)

 From Pediatric Emergency Medicine 5th Ed

From Pediatric Emergency Medicine 5th Ed

Lovell Recruiting Season Update

Berklehammer Inflammatory Bowel Disease

Snip20181031_7.png
 Toxic megacolon can be seen with either ulcerative colitis or crohn’s disease. Bowel is >6cm in diameter. There is loss of haustra.

Toxic megacolon can be seen with either ulcerative colitis or crohn’s disease. Bowel is >6cm in diameter. There is loss of haustra.

 Crohn’s disease patients can get a stricture at the terminal ileum resulting in bowel obstruction.

Crohn’s disease patients can get a stricture at the terminal ileum resulting in bowel obstruction.

 Pyoderma gangrenosum (PG) is an inflammatory condition of all ages but is most common among 20- to 50-year-old females. Lesions can be located anywhere (most commonly on the lower extremities) and begin as a papulopustule surrounded by erythema. This pustule erodes to form a necrotic ulcer. Similar satellite pustules and ulcers form around the original lesion and eventually coalesce into a large ulcer. The surrounding border is “rolled,” due to the convex elevation, and has a violaceous hue. The ulcers are exquisitely tender to movement and palpation. On the extremities, the ulcers can rapidly involve muscles and tendons. Ostomy sites are a common location and make care very difficult.  Half of cases are idiopathic; the other half are associated with inflammatory bowel disease, hematologic diseases (leukemia, myelodysplasia, monoclonal gammopathy), and the arthritides. Since diagnosis is based on examination, dermatopathology, and exclusion of other causes, it is difficult to confirm. (Atlas of Emergency Medicine)

Pyoderma gangrenosum (PG) is an inflammatory condition of all ages but is most common among 20- to 50-year-old females. Lesions can be located anywhere (most commonly on the lower extremities) and begin as a papulopustule surrounded by erythema. This pustule erodes to form a necrotic ulcer. Similar satellite pustules and ulcers form around the original lesion and eventually coalesce into a large ulcer. The surrounding border is “rolled,” due to the convex elevation, and has a violaceous hue. The ulcers are exquisitely tender to movement and palpation. On the extremities, the ulcers can rapidly involve muscles and tendons. Ostomy sites are a common location and make care very difficult.

Half of cases are idiopathic; the other half are associated with inflammatory bowel disease, hematologic diseases (leukemia, myelodysplasia, monoclonal gammopathy), and the arthritides. Since diagnosis is based on examination, dermatopathology, and exclusion of other causes, it is difficult to confirm. (Atlas of Emergency Medicine)

In patients who have crohn’s disease, be very cautious of complaints of back pain or buttock pain. Patient’s with crohn’s can get deep tissue abscesses from fistulas that directly spread to back or buttock musculature.


















Conference Notes 10-10-2018

Paquette/Friend Oral Boards

Case 1. 45 yo female with left knee injury while doing yoga.

 Lateral tibial plateau fracture

Lateral tibial plateau fracture

Tibial plateau fractures can be difficult to diagnose. Soft tissue injuries associated with tibial plateau fractures may influence outcomes. Anterior cruciate ligament and medial collateral ligament injuries are associated with lateral plateau fractures, whereas posterior cruciate and lateral collateral ligament injuries occur with medial plateau fractures. A Segond's fracture (see below) is pathognomonic for an anterior cruciate ligament injury, and it is important recognize and treat the ligament injury, rather than just the plateau fracture.12 Potential complications of tibial plateau fractures include popliteal artery injury with high-energy displaced fractures, the development of deep venous thrombosis, and osteoarthritis. (Tintinalli 8th ed)

 Segond Fracture

Segond Fracture



Case 2. Pregnant female patient presents with abdominal pain and syncope.

 Fast exam shows free fluid in Morrison’s pouch.  In the setting of early pregnancy with abdominal pain this finding is highly suggestive of ruptured ectopic pregnancy.

Fast exam shows free fluid in Morrison’s pouch. In the setting of early pregnancy with abdominal pain this finding is highly suggestive of ruptured ectopic pregnancy.

Patient was diagnosed with ruptured ectopic pregnancy and was taken to the OR.

Case 3. 40yo male presents with altered mental status and hypotension. EKG is shown below.

 3rd degree heart block

3rd degree heart block

Patient ingested a toxic dose of digoxin.

Digoxin poisoning can induce nearly every form of dysrhythmia or conduction disturbance. Classic ECG findings include supraventricular tachydysrhythmias (atrial flutter or fibrillation) combined with variable AV nodal blockade resulting in slow ventricular rates (Figure 59-1). Bidirectional ventricular tachycardia is nearly pathognomonic for serious digoxin toxicity. Additional ECG findings include sinus bradycardia, ventricular bigeminy, and ventricular fibrillation. (Tintinalli 8th ed)

 Bidirectional ventricular tachycardia which is highly specific for digoxin toxicity

Bidirectional ventricular tachycardia which is highly specific for digoxin toxicity

Chinwala M&M

To protect the anonymity of the case, I will only give some take home points.

Be sure to re-eval sign-out patients who are altered or intoxicated.

If you initiate a treatment, be sure you re-evaluate the patient in a timely fashion to assess how the treatment is working and how the patient is doing.

Lorenz/Shroff Toxicology Escape Room

Anion Gap calculation= “ABC” NA-(Bicarb +Chloride)

Osmolar Gap calculation streamlined= 2NA + BUN/3 +Glucose/20 + ETOH/5 (ETOH is actually 4.6 and the way to remember this is 4 6packs in a case of beer.)

ASA, Lithium, Toxic Alcohols (ALT)= things you can dialyze.

 TCA Overdose EKG. Wide terminal R wave in AVR and wide QRS complex in all leads. Treat with IV bicarb.

TCA Overdose EKG. Wide terminal R wave in AVR and wide QRS complex in all leads. Treat with IV bicarb.

 Ricin is a protein that inhibits ribosomes. It is used as a bioterrorism agent. It is dervied from the castor plant.

Ricin is a protein that inhibits ribosomes. It is used as a bioterrorism agent. It is dervied from the castor plant.

 Foxglove is a botanical cardiac glycoside. Basically it can cause digoxin toxicity. Treat with FAB fragments.

Foxglove is a botanical cardiac glycoside. Basically it can cause digoxin toxicity. Treat with FAB fragments.

 Amanita phylloides is the most toxic mushroom. Dr. Carlson noted the “death cup” at the base of the mushroom.

Amanita phylloides is the most toxic mushroom. Dr. Carlson noted the “death cup” at the base of the mushroom.

Dr. Carlson recommended using IV NAC for all patients with acetaminophen toxicity for practical reasons. Pregnant patients need IV NAC to get better fetal treatment.

Dr. Lovell comment: Critical Factoid for figuring out how many grams are in a given volume of solution. %=grams/deciliter. So 0.9% NS has 0.9 grams of saline in a deciliter and by extrapolation, 9 grams of saline in a liter of fluid.

Conference Notes 10-3-2018

Girzadas/Chinwala Oral Boards

Case 1. 55yo male presents bradycardic and hypotensive after beta blocker overdose.

 Tintinalli algorithm for different modalities to treat beta blocker overdose.

Tintinalli algorithm for different modalities to treat beta blocker overdose.


Case2. 7 yo male with GSW to the right thigh. Patient is hypotensive and tachycardic. Patient was resuscitated with IV crystalloid and IV PRBC transfusions. Patient had abnormal ABI and soft signs of vascular injury. Patient had CTA showing vascular injury an patient was taken to the OR.

Snip20181003_5.png
 Tintinalli algorithm for management of penetrating vascular trauma.

Tintinalli algorithm for management of penetrating vascular trauma.


Case 3. 4yo male who had non-fatal drowning.


 If normal O2 sat, normal mental status, normal lung exam after 4-6 hours patient can go home.

If normal O2 sat, normal mental status, normal lung exam after 4-6 hours patient can go home.

Pecha Kucha

Robinson Foley Catheters

The most frequent complication of urethral catheterization is infection. Foleys are the #1 cause of nosocomial infections so use them judiciously.

Patients are colonized within about a week of an indwelling foley catheter. So diagnose UTI only in symptomatic patients and/or with positive culture results.

Dr. Lovell comment: If the nurse can’t place the foley, the emergency physician needs to attempt placement of foley prior to consulting GU.

Florek Tracheostomy Problems in the ED

Risk of tracheo-innominate fistula is highest at 7-14 days after surgery.

Lubricate the Shiley prior to placing it in the tracheostomy site.

You can attempt to oxygenate patients with a mask over the patient’s mouth or over the trach site.

Some patients are neck breathers and can’t exchange air through the mouth (laryngectomy, laryngeal mass)

Most common cause of tracheostomy bleeding is mucosal irritation. Worst cause is tracheoinnominate fistula.

 To control TI fistula first overinflate the shiley balloon to tamponade the bleeding. If that is ineffective you can insert your finger in the tracheostomy site and compress against the sternum

To control TI fistula first overinflate the shiley balloon to tamponade the bleeding. If that is ineffective you can insert your finger in the tracheostomy site and compress against the sternum

Tracheoinnominate fistulas are quite rare, occurring in less than 2% of cases, but they carry a mortality rate of 25% to 50%.9 They may present as the classic “exsanguinating bleed” but often present with a less impressive sentinel bleed. Any bleeding of more than a few milliliters of blood should raise concern for a possible fistula of the innominate artery. Prompt critical resuscitation measures and emergent consultation with a Vascular Surgeon and Otolaryngologic Surgeon is required. Definitive management is surgical. Techniques for temporarily controlling bleeding from the innominate artery include local digital pressure, hyperinflation of the tracheostomy tube cuff, and traction on the tracheostomy tube. An alternative method is to deflate the tracheostomy tube cuff, reposition the cuff at the bleeding site, and then reinflate or hyperinflate the cuff. When bleeding occurs, the tracheostomy tube should not be removed until the airway is secured by another means from above (orally or nasally). (EM Procedures Reference)


Erbach Dialysis Access Complications
50% of dialysis catheters develop an infection within 6 months.

AV grafts have 10% rate of infection, and AV fistulas have a 5% rate of infection

Bleeding from dialysis graft, treat with direct pressure or quickclot gauze. Consult with Vascular Surgery. Below are some other suggestions from Tintinalli.

Snip20181005_1.png


Friend G-tubes

If G-tube is clogged, first try with flushing with warm water. If that won’t work, your can try cola.

If a g-tube site is less than 4 weeks old don’t replace the tube and just consult GI. In the first 4 weeks, the site is not fully mature and replacing the tube could end up in the wrong place. After 4 weeks we need to get the tube replaced as soon as possible to avoid closure of g-tube site.

Don’t replace J-tubes.

 Gastrograffen in SubQ

Gastrograffen in SubQ

 Intraperitoneal gastrograffen

Intraperitoneal gastrograffen

Lorenz Insulin Pumps

Insulin pumps give a basal rate of insulin and bolus dosing when a patient eats. Patients can also have long term glucose monitors for multiple days in the skin that communicate directly with the insulin pump or an apple watch.

Patients who have pumps who are hypoglycemic, treat first with glucose then second disconnect the pump.

You can see a patient’s bolus history by reviewing their pump data.

Chinwala VP Shunts

Obstruction is more common in the first year after placement. Proximal obstruction is due to choroid plexus and distal obstruction is due to thrombosis.

Staley The Febrile Neonate

Temp of 38C at home or in the ED is considered positive for fever in the infant.

In neonates with fever, the risk for serious bacterial infection is about 13%.

The clinical appearance of a neonate does not predict serious bacterial illness. You will need to rely on tests to identify serious bacterial illness in this age group.

For patients 0-28 days of age with a fever of 38C or higher, do full septic workup. Get a CXR only for patients with respiratory symptoms such as cough or increased work of breathing. Get a NP swab to screen for RSV. Give ABX within 1 hour for these very young children. (Amp and Cefotaxime) add Vanco if the infant is critically ill or mom was treated for Group B strep.

If LFT’s are elevated, get HSV serology and start IV Acyclovir. Elevated LFT’s are a sign of HSV infection.

For patients aged 29-60 days with fever, get a CBC, blood culture, UA and urine culture. Urine studies are the highest yield tests. Again, limit CXR’s to patients with respiratory symptoms. Get a Procal, CRP and viral testing. If biomarkers are negative don’t do LP in this age group. If you don’t do LP, discharge without antibiotics. If biomarkers (WBC, Procal, CRP) are elevated, do an LP and start antibiotics. If UA is positive get a blood culture (bacteremia 10%) and consider LP (meningitis 1/200). If you do an LP and decide to treat with antibiotics, give ceftriaxone. Any discharged patient needs arranged close follow up.

Infants less than 60 days who are fussy at home and have temps close to febrile (close to 38C) should be observed in ED for a couple of hours and have temp rechecked. Consider getting a CBC, blood culture, UA, and urine culture in these borderline kids.

In infants under 60 days, a temp >/=40C indicates a 40% risk of serious bacterial illness.

Tips for doing LP’s in infants: put the CPR compression board under the patient to keep the patient from sinking into the bed. After you insert the LP needle through the skin, you can remove the stylet and advance the needle without the stylet so that you can identify CSF as soon as you enter the CSF space.

Insert the LP needle between the L4 and L5 spinous processes in the intervertebral space in the midline of the back, and direct the needle toward the umbilicus. This interspace is easily located because it lies in line between the iliac crests. Introduce the needle with the bevel of the needle up. Insert the needle until the characteristic "pop" identifies introduction into the subarachnoid space. An alternative method is to remove the stylet from the needle49 after the needle pierces the skin. Advance the needle, without the stylet, incrementally until CSF flows. Occasionally rotating the lumbar needle clockwise or counterclockwise up to 360 degrees may help improve flow if the bevel of the needle is sideways. When removing the lumbar needle, replace the stylet. (Tintinalli 8th ed)

Barounis PE and Pulmonary Embolism Response Team

From Dr. Barounis: Here are some takeaways from today's lecture, please share with other residents. I included a lot of the literature that I had obtained for the lecture so feel free to review yourself and see if you come up with different takeaways.

Imaging:

CT scans, not V/Q's for sick people please!

Massive PE:

1. Massive PE is life-threatening and immediate thrombolysis is recommended by all major societies. At ACMC surgical embolectomy can be considered if immediately available as an alternative in candidates for surgery, or when thrombolysis has been attempted and unsuccessful.

DOSE 10mg bolus, followed by 90mg over 2 hours. Consider MOPETT dosing in high bleeding risk patients (see below).

2. Hold heparin when starting tPA as there appears to be no benefit with likely a higher likelihood of bleeding.

3. Obtain a fibrinogen level prior to beginning thrombolysis (same time you are getting PT/INR/PTT). If fibrinogen is dropping consider stopping tPA, hold heparin.

4. Try high flow nasal cannula, and avoid intubation when possible prior to thrombolysis given high propensity for cardiac arrest during intubation. If diagnosis is uncertain, will require clinician judgement. Most patients die from shock, RV failure >>> hypoxemia

5. CALL 40-0702 for help This will activate the PE response team

6. Start pressors early, probably can avoid volume loading altogether. (RV perfused by MAP, not DBP)



Submassive PE:

1. Thrombolysis is indicated to reduce risk of Hemodynamic decompensation and development of respiratory failure, in the select cohort of patients at high risk of deterioration (prognostic features below)

2. The data on ultrasound-assisted thrombolysis has not been consistently shown to improve long-term outcomes, see the ULTIMA trial/ SEATTLE II trial (included below) based on RV/LV ratio @ 3 and 6 months. It did show reduce RV/LV ratio at 24 hours. ULTIMA is the only RCT comparing EKOS to heparin. The PEITHO trial also showed no reduction in PH, or death at 24 month f/u in patients who received tenecteplase vs. placebo. IT APPEARS THERE IS SHORT TERM BENEFIT, but LONG TERM patients own fibrinolytic system appears to do the job.

3. Ultrasound assisted thrombolysis has not shown improvement in clot resolution over plain catheter directed thrombolysis in the only RCT comparing the two (see below, engelberger). Each ekos catheter is around $1,100.

4. Lower dose tPA appears safe and equally effective, and is appealing in patients with submassive PE to avoid hemorrhagic complications. Currently this is done using CDT with ekos at ACMC, and future studies may prove that lower dose controlled thrombolysis will be equally efficacious?? MOPETT dosing tPA for submassive PE with high risk features, or even stable massive PE

5. Poor prognostic features: tachycardia, tachypnea, hypoxemia, lactic acidosis (>2), PESI SCORE, BOVA SCORE, poor cardiopulmonary reserve.

6. Patients with concomitant DVT and PE have higher inpatient mortality than PE alone.


PERT TEAM:

Call 40-0702; please obtain the labs provided in order set (top righ thand side of PERT DOCUMENT included below).

Best,

Dave

 Proposed Management Algorithm for Massive and Sub-massive PE

Proposed Management Algorithm for Massive and Sub-massive PE






Conference Notes 9-19-2018

Hart/Nakitende U/S Monopoly

Snip20180919_1.png
 You can measure the width of the pericardial fluid to grade the severity of a pericardial effusion. More than a centimeter (10mm) is significant.

You can measure the width of the pericardial fluid to grade the severity of a pericardial effusion. More than a centimeter (10mm) is significant.

An echo finding suggestive of tamponade is incomplete filling of RV in diastole. The RV wall will be scalloped.

 Large pericardial effusion with incomplete filling/scalloping of RV suggestive of tamponade

Large pericardial effusion with incomplete filling/scalloping of RV suggestive of tamponade

When using echo to differentiate acute PE vs chronic pulmonary hypertension, the RV wall in acute PE will be thin while the RV wall in chronic pulmonary hypertension will be hypertrophied.

 D-sign showing PE. Elevated pressure in the RV flattens the LV septal wall making the LV look like the letter D on a parasternal short view.

D-sign showing PE. Elevated pressure in the RV flattens the LV septal wall making the LV look like the letter D on a parasternal short view.



 McConnell sign. The apex of the RV contracts OK despite overall RV hypokinesis. This is a specific sign of PE.

McConnell sign. The apex of the RV contracts OK despite overall RV hypokinesis. This is a specific sign of PE.

Snip20180919_7.png

Bartgen/Erbach Oral Boards

Case 1. 75yo female with fever, cough, and wheezing. O2 sat 92%. CXR shows pneumonia. Patient has SIRS. IV fluids and IV antibiotics started. Patient deteriorated late in her ED course with worsening weakness. Son noted that patient has had weakness at the end of each day for weeks now. Patient was diagnosed with Myasthenic crisis precipitated by pneumonia/sepsis. Treatment with plasmaphoresis was arranged. IVIG and steroids are also indicated. Airway needed to be managed due to expected course of illness with worsening weakness.

Dr. Bartgen made the following points about nueromuscular blocking agents in the setting of myasthenic crisis. I used a Tintinalli reference to encapsulate his comments:

The most significant ED complication of myasthenia gravis is respiratory failure, which is usually precipitated by infection, surgery, or the rapid tapering of immunosuppressive drugs. Although intubation should be considered in patients with a low forced vital capacity or in the presence of abnormal blood gas analysis, this decision is made primarily on clinical grounds. Patients may have increased sensitivity to nondepolarizing agents based on their concurrent use of acetylcholinesterase inhibitors. Additionally, they can have either resistance or prolonged duration from depolarizing agents. Because of the increased sensitivity of myasthenia gravis patients to neuromuscular junction inhibitors and an unpredictable reaction to succinylcholine in particular, avoid the administration of depolarizing or nondepolarizing paralytic agents in preparation for intubation.27 Patients with myasthenia are extremely sensitive to these agents, and the paralytic effects can be expected to persist at least two to three times longer than in normal patients. Consider using short-acting agents such as fentanyl or propofol in smaller doses, as it is important to avoid further respiratory depression. Sugammadex may be used to reverse rocuronium if necessary.28 If paralytic agents are absolutely necessary, consider using one with a shorter half-life, such as etomidate, at one-half the dose of these agents, although this recommendation is anecdotal. (Tintinalli 8th ed.)

Case 2. 70yo female with cough, shortness of breath and O2 sat of 85%. Patient was cleaning bathroom with a mix of clorox bleach and lime-away. The combo of these cleaning supplies caused strong fumes that overcame the patient. Mixing bleach with either an acid or ammonia can cause the release of chlorine or chloramine gas. The patient was treated with intubation. Steroids should be given to intubated patients with lung injury due to chlorine gas.

Case 3. 90yo female presents with scalp rash for about 6 weeks. The rash had a boggy consistency. Diagnosis was a kerion which is more common in pediatric patients and the elderly.

 Kerion, treat with griseofulvin or fluconazole. Kerion causes hair loss which can help differentiate it from other scalp lesions.

Kerion, treat with griseofulvin or fluconazole. Kerion causes hair loss which can help differentiate it from other scalp lesions.

Tinea capitis (scalp) presents as a pruritic, erythematous, scaly plaque. This may develop into a delayed-type hypersensitivity reaction, where the initial erythematous, scaly plaque becomes boggy with inflamed, purulent nodules and plaques (kerion). The hair follicle is frequently destroyed by the inflammatory process in a kerion, leading to a scarring alopecia. Systemic antifungals are required to treat tinea capitis infections. Due to the long-term treatment requirement and associated side effects, referral to a dermatologist is recommended. (Tintinalli 8th ed.)

Dr. Napier comment: Consider checking LFT’s as a baseline prior to starting griseofulvin.

Ginsburg Endovascular Treatment of PE

RV/LV ratio 0.9 or greater is a sign of RV strain on CTPE study.

 Massive PE patients are candidates for systemic TPA. Sub-massive PE patients are candidates for catheter directed thrombolysis. Patients with a low risk of bleeding who have RV dysfunction and elevated troponin are probably the most likely to benefit from catheter direct thrombolysis in the submassive group.

Massive PE patients are candidates for systemic TPA. Sub-massive PE patients are candidates for catheter directed thrombolysis. Patients with a low risk of bleeding who have RV dysfunction and elevated troponin are probably the most likely to benefit from catheter direct thrombolysis in the submassive group.

 High risk PESI scores warrant consideration of ICU admit.

High risk PESI scores warrant consideration of ICU admit.

Risk of ICH with systemic TPA is 3%. Risk of ICH on heparin is 0.3%

50% of patients with massive PE have a contraindication to TPA.

 This slide just gives an idea of the total incidence of PE and PE deaths in the US.  As a comparison  MVC’s account for 30-40,000 deaths/year and drug overdoses account for approximately 80,000 deaths/year.

This slide just gives an idea of the total incidence of PE and PE deaths in the US. As a comparison MVC’s account for 30-40,000 deaths/year and drug overdoses account for approximately 80,000 deaths/year.

Schroeder Management of DKA

Snip20180919_12.png

Type 1 DM has a genetic component but it is not all genetic. Only 40% of identical twins will have Type 1 DM.

Snip20180919_14.png

DKA patients are more dehydrated than they look because they are losing intracellular water with glucose in the urine rather than water and sodium in the stool.

Expect DKA patients to be potassium depleted. Begin replacing potassium very early in the management of DKA.

Younger kids, those with limited access to care, and low BMI kids are more likely to present in DKA and are more likely to have a delay in diagnosis.

If a patient has an insulin pump and presents in DKA, turn off the pump and treat with IV insulin. It is better to have complete control of the insulin the patient is receiving.

There is no indication to give an initial bolus of insulin. Just start a continuous drip drip after first priming the line with insulin. The IV tubing adheres the initial insulin and if you don’t first prime the line with insulin, it can take hours before the patient starts receiving insulin because the infusion is getting absorbed by the IV tubing.

10ml/kg bolus is probably fine and safe as your initial fluid administration. Use LR to avoid hyperchloremic acidosis associated with NS.

PECARN IV Fluid in DKA Study (NEJM 2018)

Critical Results:

  • 1,389 distinct episodes of DKA were evaluated in 1,255 patients, but only 1361 episodes of DKA were included in the primary analysis. 132 children had a second episode of DKA and underwent randomization as well.

  • There were a total of 48 episodes (3.5%) resulting in a GCS <14 with 22 episodes (1.6%) requiring hyperosmolar therapy for cerebral edema, and 12 episodes (0.9%) of clinically apparent brain injury.

  • There were no statistically significant differences in the percentage of episodes among the 4 groups where the GSC decreased to less than 14, the magnitude of decline or duration GCS remained less than 14

  • Incidence of a GCS decline <14 & clinically apparent brain injury was actually lower in fast rehydration groups (21 vs 27 & 4 vs 8 episodes respectively), but both were not statistically significant

  • Memory assessed by forward and backward digit-span scoring did not significantly differ between the 4 groups

  • Hyperchloremic acidosis was more common among patient receiving 0.9% NaCl vs 0.45% NaCl and more common in patients receiving fluid at a rapid rate vs slow rate

 DKA Protocol for ACMC/Hope Children’s Hospital

DKA Protocol for ACMC/Hope Children’s Hospital

Tekwani Medical Student Rotation Review





Conference Notes 9-5-2018

Lorenz       Important Recent EM Papers

HEART Score was validated on 2440 patients in the Netherlands.

Snip20180905_1.png

Procamio Study  June 2016

Procainamide works better than Amiodarone for stable v-tach with less adverse events.

Revert Study August 2015

Initially attempt to treat SVT with postural modification to valsalva maneuver. Put head of bed at 40 degrees and have patient blow in syringe for 15 seconds. Then lay patient flat and raise legs.  Then sit them back up.

 Try this modified valsalva maneuver to terminate SVT. It works 25% of the time.

Try this modified valsalva maneuver to terminate SVT. It works 25% of the time.

Dr. Lovell comment: If patient has alot of anxiety about adenosine, consider propofol to sedate patient.

Aromatherapy vs Zofran Study      August 2018

Olfactory distraction works for nausea. For patients who don't have an IV and have nausea, Inhaled isopropyl alcohol from an alcohol wipe works as well or better than zofran.   Consider this for a patient with nausea. Patients get relief for 30-60minutes.

Haldol for Gastroparesis    Acad Emerg Med 2017

5mg IM was very effective for gastroparesis symptoms.

Dr. Lovell comment: Haldol treats both pain and nausea.  Watch for QT prolongation

Treating Hypokalemia with Low-dose insulin

In patients with CKD/ESRD,  5u of insulin works just as well as 10u of insulin with much less hypoglycemia.

Flomax for Kidney Stones 2018

For stones in the distal ureter, 4-7mm, flomax worked better, faster, with less painful passage of stone. Number needed to treat is high though.  Avoid flomax in patients with risk factors for CAD.

BICAR-ICU Study

Bicarb for anion gap acidosis in the ICU did not lessen mortality or organ failure but it did decreased the need for dialysis.

Dr. Lovell: This study is a game changer for acidotic patients.  Most of these patients with anion gap acidosis had sepsis.

PEITHO   Systemic TPA for PE

Normotensive PE patients with RV strain on echo who got TPA and heparin did not have improved mortality compared to heparin alone. TPA patients did have greater adverse bleeding outcomes.

Procedure Lab

 

 

Conference Notes 9-12-2018

This Week’s Conference was our City-Wide Windy City EM Conference hosted at ACMC and organized by Dr. Andrea Carlson. It was a tremendous event! These notes capture just a small portion of the great info presented.

Regan Disaster Medicine and Emergency Preparedness

EMTALA is not relaxed during disasters or mass shootings. All persons who present to your ED need to be evaluated and stabilized.

Because of the chaos around a mass shooting and the fact that police respond before EMS, victims will come to your ED by cars, pickups, and uber. Victims also don’t just go to the Level 1 hospital. In Vegas, most people went to the Level 2 hospital because it was the closest and many people took an uber.

Hospitals need to be able to surge hundreds of patients to respond to a mass casualty event.

Rate limiting hospital personnel will be your anesthesiologists, intensivists, and pediatric surgeons. It is very difficult to have enough of these specialists available during mass casualty events.

Hospitals have run out of supplies like ventilators and chest tubes in mass shooting events.

Emergency physicians are the best prepared physicians to provide care in these mass shooting events. We have a key role to play in the response to mass casualty events.

Sharp Wilderness Medicine: Desert Endurance Racing

The emergency physician’s home environment is in the ED. We know how to manage emergencies in the ED. Moving out into the wilderness takes us out of our normal environment to care for patients.

If you are the emergency physician in an austere environment, if you can, you need to plan carefully for what you will need when you go out to that environment. The main concerns for persons in the desert are hyperthermia, dehydration, and exercise induced hyponatremia.

It can be difficult to differentiate dehydration from hyponatremia in the field.

Athletes need 500cc of fluid, 500mg of sodium, and 500cal per hour in the desert. It’s kinda the 500/500/500 rule in the desert. Like the 1/1/1 rule for massive transfusion.

Athletes in the desert, if they get hypoglycemic can actually have hypothermia in the heat. This is postulated to be due to the need for glucose to generate body heat.

Champus Sports & Event Medicine

Communication and Incident Command preparations are critical for large sporting events like a marathon.

The Marathon is a pre-planned disaster. Planners know that there will be a 2%-10% illness rate depending on weather. You also have to make sure the city’s EMS and police can function during the marathon so that you can get patients to the hospital who need that level of care.

The life-threatening diagnoses that planners have to be prepared for are cardiac arrest, hyponatremia and heat stroke.

The marathon planners have all the light posts numbered, they have observers on the course. They have a communication system to keep the whole system coordinated.

Mass sporting event planning can improve the overall resilience of the EMS system in a city and improve the city’s ability to respond to disasters.

McCombs EM in the Military Settings

All patients presenting to forward medical stations are searched for ordinance.

IED’s were devised by the Taliban to maim but not kill the initial soldier. So when the rescuing team came to extract the injured soldier a second more devastating bomb would trigger and kill the responders.

Nelson Addiction Medicine

Unfortunately I missed this outstanding lecture

Hawkins/Chan/Checkett/Mikkilineni Global Health Panel Discussion

If you want to pursue global health in your career, fellowship is probably the most efficient way to jump start that pathway. Fellowship allows you to more quickly build your global health skill set, get critical mentorship and develop a professional network.

If you don’t do a fellowship, the pathway forward the panelists all suggested was to network with people in the field. Go to a meeting and reach out to speakers. Follow up with an email to those networking contacts. Identifying where to invest your time with a global health organization is best informed by people you know or have made a contact with.

Senior Residents Around the City Memorable Moments in the ED

editor’s note: Each Senior Resident told a wonderful, memorable story that occurred in the ED. Some were funny, some were touching, some were clinically great diagnoses, and some challenged us to be mindful of our biases when caring for patients. The notes for this section only take one general point from each story.

When providing bag valve mask ventilation and you are not able to acheive adequate oxygenation try using a Peep Valve. It will recruit alveoli and may improve the O2 sat.

Sometimes giving people a kind gesture is all you can do in the face of an untreatable, life-threatening illness. That kind gesture can mean the world to the patient and their family.

Basics like bagging, cpr, intubation, hemorrhage control will save lives, even neonates. Focus on the basics and it will serve you well.

Cultural awareness can help de-escalate tense situations. Understanding the root cause of a patient’s fears and anxiety can lead to the best approach to caring for that patient.

An insect in the ear canal can be very very uncomfortable. Trust the patient if they say a bug is in their ear. Kill the bug with viscous lidocaine, then remove the bug with an alligator forcep.

Sometimes when we have a difficult case in the ED it may seem a downer at the time but a more useful perspective is to view it as a power boost/opportunity to improve our practice.

We belong. Our work as emergency physicians is vitally important. We are a team and we all care for each other.

Conference Notes 8-22-2018

STEMI Conference

If a patient has the clinical picture of ACS with anterior ST depression you can activate the the Cath lab for suspected posterior MI.  The cardiologists present did not feel it was a requirement to have ST elevation on the the posterior EKG to activate the cath lab for suspected posterior MI.   Anterior horizontal ST depression can be enough with the right clinical picture. There is not a lot of data regarding the sensitivity and specificity of the posterior EKG.   The cardiologists felt the posterior EKG is very specific but the sensitivity is not known and may be too low.

 Posterior MI

Posterior MI

 Posterior EKG showing ST elevation in posterior leads V7-9. The criteria of 0.5mm of ST elevation is not necessary to activate the cath lab.

Posterior EKG showing ST elevation in posterior leads V7-9. The criteria of 0.5mm of ST elevation is not necessary to activate the cath lab.

New Left Bundle Branch Block in the setting of chest pain is very controversial.  A new LBBB when compared to an EKG from a year ago may not be an MI.  A new LBBB when compared to an EKG from a week ago is a different story and more concerning. 

New LBBB from MI will arise from an LAD occlusion.  With LAD occlusion, you should have echo findings of anterior wall motion abnormality to go along with the EKG findings.  Wall motion abnormalities will help identify AMI in the setting of LBBB.  The cardiologists felt that an AMI causing a new LBBB will cause the patient to be ill appearing. It is a relatively large infarct. 

There was consensus that a new LBBB is not very specific for AMI.  Sgarbossa criteria are specific but insensitive. Cardiologists want to be called on cases with concern for AMI in the setting of new LBBB.

 You need 3 points to diagnose AMI

You need 3 points to diagnose AMI

 Decision rule using Sgarbossa criteria and ST/S ratio to diagnose AMI in the setting of LBBB

Decision rule using Sgarbossa criteria and ST/S ratio to diagnose AMI in the setting of LBBB

 An example of how to calculate the ST/S ratio

An example of how to calculate the ST/S ratio

Patients who have had a valve replacement and are sub-therapeutic on their INR can embolize to the coronary arteries causing AMI.  We think of embolic phenomena going to the brain most commonly.  The cardiologists have noted that emboli can also cause AMI.

Steroids are arthrogenic and can increase the risk of AMI.

Ryan/Hawkins     Oral Boards

Case 1. Patient presents unresponsive. EMS gave him narcan with no response.   In the ED the patient was intubated.  His blood sugar was normal.   Further history by EMS revealed the patient ingested GHB.  GHB overdoses frequently result in intubation and the patient later wakes up and self-extubates or can be extubated relatively quickly. 

γ-Hydroxybutyrate (GHB) is an endogenous molecule as well as a drug. GHB was originally used as an IV anesthetic, primarily in several European countries. In recent years, it has been marketed as a drug for body builders to improve body mass and reduce fat, as well as for use as a hypnotic, antidepressant, anxiolytic, and cholesterol-lowering drug.16 GHB has been found in drug-facilitated sexual assaults.17 Sodium oxybate (the sodium salt of GHB) is currently approved only for use within a highly regulated setting for the treatment of narcolepsy.18 In some European countries, GHB or sodium oxybate is used as a treatment for alcohol dependence and withdrawal.19 GHB can be formulated as a clear liquid or in solid form as a capsule, tablet, or white powder. GHB has many vernacular names, including "liquid ecstasy," "Georgia Home Boy," "G," and "Grievous Bodily Harm."

GHB has a steep dose–response curve with a narrow therapeutic ratio; doses of 10 milligrams/kg result in short-term amnesia, doses of 20 to 30 milligrams/kg result in sedation and drowsiness, and doses exceeding 50 milligrams/kg result in seizure, coma, respiratory depression, and cardiac depression.22 Bradycardia, hypothermia, and either miosis or mydriasis can occur.20 During recovery, the patients often wake up surprisingly quickly as opposed to the more prolonged awakening phase seen after an overdose with other sedatives. Despite co-ingestants being commonly encountered, most patients fully regain consciousness within 6 hours. The co-ingestion of ethanol can worsen hypoxia and possibly result in a longer elimination half-life of GHB.23

Treatment is largely supportive.20 Intubation is generally unnecessary, even in patients with severely depressed consciousness (Glasgow Coma Scale score ≤8) because patients are usually able to protect their airway and maintain ventilation.24 Once the patient is awake and alert, assuming no co-ingestants or secondary complications such as aspiration, the patient can be medically discharged or transferred.  (Tintinalli 8th ed.)

Dr. Carlson comment: You can never be faulted for intubating these patients to protect their airway.

Case2.  Patient was at a party and injured his shoulder.

 Luxatio erecta, inferior shoulder dislocation

Luxatio erecta, inferior shoulder dislocation

 Clinical appearance of luxatio erecta

Clinical appearance of luxatio erecta

 Reduction technique for luxatio erecta.&nbsp; Harwood recommends gently walking the arm back down to the patient's side while maintaining traction-counter traction.

Reduction technique for luxatio erecta.  Harwood recommends gently walking the arm back down to the patient's side while maintaining traction-counter traction.

 

Case 3. Pregnant woman presents seizing.  Patient was treated with IV magnesium and IV lorazepam.  Seizure was terminated.  A magnesium drip was started.  OB was consulted for urgent delivery of the baby.

  Management of eclampsia includes treatment of seizures, treatment of hypertension, and emergent obstetric consultation to facilitate urgent delivery of the fetus . Tintinalli 8th ed.

Management of eclampsia includes treatment of seizures, treatment of hypertension, and emergent obstetric consultation to facilitate urgent delivery of the fetus. Tintinalli 8th ed.

Bartgen     Study Guide      Heme-Onc

Leukemia buzz words: Problem of bone and blood, so back pain, fever, hematologic abnormalities, hepatosplenomegaly  are the buzz words.

Platelet transfusion thresholds for thrombocytopenia: ICH and surgery is 100K, GI or other serious bleeding is 50K, LP is 50K, asymptomatic is 20K, Central Line is  20K.  

Management of Rhabdomyolysis:  Once the patient is in the ED, continue aggressive IV rehydration for the next 24 to 72 hours. One method is rapid correction of the fluid deficit with IV crystalloids followed by infusion of 2.5 mL/kg/h, with the goal of maintaining a minimum urine output of 2 mL/kg/h.11 Another method is a goal of 200 to 300 mL of urine output each hour.12

No prospective controlled studies have demonstrated benefit from alkalinization of the urine with sodium bicarbonate or forced diuresis with mannitol or loop diuretics.12,13,14 Bicarbonate is widely recommended but without an evidence base. If bicarbonate is given, maintain an isotonic solution and avoid metabolic alkalosis or hypokalemia.12 Mannitol may be harmful because it may cause osmotic diuresis in hypovolemic patients. 

Hypocalcemia observed early in rhabdomyolysis usually requires no treatment. Calcium should be given only to treat hyperkalemia-induced cardiotoxicity or profound signs and symptoms of hypocalcemia. If hypercalcemia is symptomatic, continue saline diuresis. Treat hyperphosphatemia with oral phosphate binders when serum levels are >7 milligrams/dL. Treat hypophosphatemia when the serum level is <1 milligram/dL. Hyperkalemia, which is usually most severe in the first 12 to 36 hours after muscle injury, can be significant and prolonged. Traditional insulin and glucose therapy, although recommended, may not be as effective in rhabdomyolysis-induced hyperkalemia. The use of ion-exchange resins (e.g., sodium polystyrene sulfonate) is effective. Dialysis may be needed (see chapter 17, Fluids and Electrolytes).

Avoid prostaglandin inhibitors such as nonsteroidal anti–inflammatory drugs because of their vasoconstrictive effects on the kidney. Finally, treat the underlying cause.   (Tintinalli 8th edition)

Harwood comment: CPK less than 1000 I don't worry about rhabdo.  CPK  2-10,000 most can be treated with oral hydration.   >10,000 CPK usually will need IV hydration/OBS.  

A late complication of rhabdo is DIC.

Factor 8 replacement for Hemophilia is basically: 50u/kg for head injury and 25u/kg for all other injuries/bleeding.  1 unit/kg of factor 8 will raise factor activity 2%. 50u/kg will get factor activity up to 100%.   25u/kg will get factor activity up to 50%.   Give the factor 8 prior to CT for head injury. 

 

 Treat VWD with desmopressin, VWF concentrates, or Cryoprecipitate. (Tintinalli 8th ed.)

Treat VWD with desmopressin, VWF concentrates, or Cryoprecipitate. (Tintinalli 8th ed.)

 Check ADAMTS13 levels when considering TTP. Treatment for TTP is plasmapheresis which is life saving. Consulting Hematology will expedite plasmapheresis.

Check ADAMTS13 levels when considering TTP. Treatment for TTP is plasmapheresis which is life saving. Consulting Hematology will expedite plasmapheresis.

Ahmad/Bernard/Destefani/Einstein/Nakitende/Regan                        Job Search Panel

Plan that it will take several months to get a permanent license in any state.

There are pros and cons to job searching early and late in EM-3 year.  Sometimes it's better to lock in the job early.  On the other hand, sometimes good jobs open up later in the year.

If you are doing independent contracting as part of your work-mix you need to hire a professional accountant manage your taxes/finances.

Don't be hesitant to ask and negotiate for more $ or time once you are offered the job. Everything is negotiable.

During the interview, no question is off the table.

You can probably create a individualized job for yourself anywhere if you plan it out carefully, have the right skill set, describe it well, list the metrics to measure your performance, and present yourself in excellent fashion to the employer.

 

 

 

There was tons more of great advice that I could not encapsulate in these notes.

Florek                Seizures

It is not necessary or recommended to give IV anticonvulsant medications during the course of an uncomplicated seizure, although the practitioner should be ready to administer these medications if seizures do not terminate. Most seizures will self-resolve within 5 minutes. Any unnecessary sedation at this point will complicate the evaluation and result in a prolonged decrease in level of consciousness.7 Seizures that fail to abate after 5 minutes are considered status epilepticus and require more aggressive medical interventions (Tintinalli 8th ed.)

 Chart from Tintinalli 8th ed.

Chart from Tintinalli 8th ed.

5 Causes of Seizures: 1. Abnormal Vitals(hypoxia, hypotension, hypertension)/Hypoglycemia, 2. Toxic-Metabolic (electrolyte abnormalities, ETOH withdrawal), 3. Infectious, 4. Structural, 5. seizure-like activity.

In nonconvulsive status epilepticus, the patient is comatose or has fluctuating abnormal mental status or confusion, but no overt seizure activity is present. The diagnosis is challenging and is typically made by EEG. Findings suggestive of nonconvulsive status epilepticus include a prolonged postictal period after a generalized seizure; subtle motor signs such as twitching, blinking, and eye deviation; fluctuating alterations in mental status; or unexplained stupor and confusion.25 (Tintinalli 8th ed)

To screen for pseudoseizure you can flush the eye with saline. This can frequently disrupt a pseudoseizure.

Dr. Williamson comment: Consider CT scan of the head for first-time seizures.   Instructions for patients with first-time seizure should include no driving or swimming, or dangerous work until cleared by neurologist.  Also if you have another seizure, you need to return to the ED.

 

 

 

 

 

 

 

 

 

 

 

 

 

Conference 8-15-2018

Ahmad      Difficult Conversations

Before you start a difficult conversation with a patient, have a plan. 

SPIKES:   Set an expectation,  Perception, Inform, Knowledge, Empathy, Summary.

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Lovell comment:  The times of delivering bad news are incredibly important to our patients and their families.  We need to work on this skill to provide compassionate care to our patients.

Empathy is a critical virtue to being able to give bad news to a patient or family in a compassionate fashion.

Beware of traps:  Bias,  Ancillary staff perceptions of the patient,  Fatigue. 

Expect the unexpected:  Families may have intense emotional reactions, or indifference, or anger.

Know your audience.  Deliver your news with consideration of the patient's or family's healthcare literacy, culture, and their sensitivities.

When telling a family that a loved one died, use the words dead or died.  Don't use passed away.   To soften the blow,  use compassionate phrases right after you use the word dead or died.  "I am so sorry for your loss"  "You have my deepest condolences"   "You did everything you could"  

Delivering Bad News Workshop

Small group discussions of ED specific scenarios that required the emergency physician to deliver bad news.

Gerity       Endovascular Treatment of Stroke

 Modified Rankin Score

Modified Rankin Score

MRI Cerebral Blood Volume and Blood Flow measurements can be used to predict the degree of ischemia of brain tissue .

 CBF correlated with degree of ischemia

CBF correlated with degree of ischemia

 VAN Positive is Defined by unilateral arm weakness plus yes to any of the following:&nbsp; visual disturbance, aphasia, or neglect.&nbsp; If a patient is VAN positive, they need CTA of the head and neck in addition to CT head.

VAN Positive is Defined by unilateral arm weakness plus yes to any of the following:  visual disturbance, aphasia, or neglect.  If a patient is VAN positive, they need CTA of the head and neck in addition to CT head.

Lovell     2018 ACGME Resident Survey

Dr. Lovell reviewed this year's ACGME Resident Survey.

Humphrey     Bites/Stings/Envenomations   Wilderness Medicine

The risk of infection from a dog bite is @5%.  Prophylax with Augmentin ("dogmentin")    Dog bites are at risk of capncytophagia infection.

Tigers kill more humans than any other mammal except humans. Tigers have killed over a million people over the course of history.

Domestic cat bites have a higher risk of infection than dogs.  Pasturella multocida infection is a risk of cat bites.  Treat with Augmentin.

The black widow spider usually only bites defensively.  The bite of a black widow spider is painless but within hours patients can develop muscle cramps, diaphoresis, and hypertension. 

Cleansing of the bite site is reasonable. Pain and muscle spasms can generally be controlled with liberal doses of opioids and benzodiazepines.22 Although IV calcium has been advocated to relieve symptoms, a retrospective review of patients with Latrodectus envenomation indicated that this treatment is ineffective.22 For severe envenomations, admission may be required for continued analgesia. The most effective therapies for severe envenomation are parenteral opioids and Latrodectus antivenom.

Administration of Latrodectus antivenom often causes rapid resolution of symptoms and can significantly shorten the course of illness. Even in severely symptomatic cases of Latrodectus envenomation, patients can often be discharged from the ED after a short observation period when antivenom is administered. Successful treatment of latrodectism with antivenom has been described even with administration 90 hours after envenomation.23 Antivenin Latrodectus mactans is not contraindicated in pregnancy. (Tintinalli 8th ed)

Brown recluse spider bites cause a necrotic skin lesion.  Less commonly patients can develop coagulopathy and thrombocytopenia.

Patients with systemic symptoms following a bite warrant hospitalization. Various treatments have been advocated for brown recluse spider bites, including antihistamines, antivenom, colchicine, dapsone, hyperbaric oxygen, surgical excision, steroids, and topical nitroglycerin. None of these therapies have clear benefit, and most wounds from the brown recluse are self-limiting and heal without any medical intervention.  (Tintinalli 8th ed.)

 Brown Recluse Bites are over-diagnosed and this decision rule helps avoid misdiagnosing another illness as a Brown Recluse bite.

Brown Recluse Bites are over-diagnosed and this decision rule helps avoid misdiagnosing another illness as a Brown Recluse bite.

Bark Scorpion sting  There is antivenon for scorpion bites.

New antivenin for crotalid bites has been developed called Anavip. The Anavip structure has 2 FAB fragments bound together.  There is slower renal clearance of this molecule and longer activity in blood stream. This results in less late term recurrance of coagulopathy from venom.

 

 

 

 

 

Conference Notes 8-8-2018

Editor's note: A Big Thank you to Mitch Lorenz and Anita Shroff for writing the majority of the Conference Notes this week!

Drs. Marek, Muhammad, Schroeder, Mishra, Kemp, Akhter

Joint EM/PEDs   Expert Panel on Asthma

PASS score- use the cumulative score to guide appropriate management and disposition

 PASS Score &nbsp; Can also be found in MD Calc App

PASS Score   Can also be found in MD Calc App

 A score of 3 or higher is severe asthma.

A score of 3 or higher is severe asthma.

Albuterol dosing- when should we use continuous vs unit nebs?

-continuous nebs have lower admit rates and no difference in adverse events when compared to intermittent nebs (Carmago CA, Cochrane Database 2003)

-Schroeder comment: from a practical standpoint in the ED, it is difficult to do q15-20min reassessments, so it is often beneficial for the patient to start an hour long neb

-Muhammad comment: try to reassess them 15-20 min after the END of the albuterol treatment for it to take full effect

Ipratropium

-giving 2-3 doses in the initial dosing of asthma reduces the amount of total albuterol needed and the total length of stay, and had lower hospitalization rates

Steroids- who should receive steroids?

-Schroeder comment: anyone who gets an hour long neb gets steroids

 

Which patients need a CXR?

-routine CXR is NOT recommended

-it is recommended if the patient has  persistence  of any of the following: severe symptoms, significant hypoxemia, marked asymmetry on lung exam

-cxr is is infrequently associated with change of management  (Ann Emerg Med 2018)

-Kemp (PICU) comment: if patient is admitted to the PICU, they will get a CXR to assess for pneumomediastinum or pneumothorax. This info is critical when using higher nasal cannula flow rates, higher bipap or ventilator peak flow rates, or higher peep.

Who should receive antibiotics?

-NHLBI guidelines recommend not routinely giving antibiotics

Carlson/Lorenz        Oral Boards

1. Rocky Mountain Spotted Fever - treat tick borne diseases with doxy, think about these in anyone who has been camping, most prevalent outside of the Rocky mountains

 The rash of&nbsp; Rocky Mountain Spotted Fever starts on the ankles and wrists and moves toward the trunk.&nbsp; Fever precedes the rash by a few days.

The rash of  Rocky Mountain Spotted Fever starts on the ankles and wrists and moves toward the trunk.  Fever precedes the rash by a few days.

 

Dr. Lovell comment - check labs before a LP especially when you're not sure whats going on to make sure platelets/coags are normal

Rickettsia rickettsia, the causative organism of Rocky Mountain spotted fever (RMSF), is transmitted by the bite of an infected tick. Fever, headache, rigors, abdominal pain, myalgias, and malaise occur 2 to 14 days after inoculation. Three to five days after the onset of symptoms, the rash begins with erythematous, blanching macules on the distal extremities (wrists and ankles). This is followed by centripetal spread to the trunk and to the palms and soles. The lesions evolve into papules and petechia. Without treatment, RMSF has a 25% mortality; delayed diagnosis and delayed antimicrobial treatment results in 3% to 4% mortality. (Atlas of EM reference)

2. Heat Stroke - 2 types, diagnositic criteria > 40C, AMS.

-elderly more commonly not diaphoretic

-young/athletes more likely  to be diaphoretic

-treat w/ ice water immersion or evaporative cooling and benzos to control shivering

-antipyretics are normally ineffective

 Tintinalli 8th edition

Tintinalli 8th edition

The cardinal features of heat stroke are hyperthermia (>40°C [>104°F]) and altered mental status. Although patients presenting with classic (nonexertional) heat stroke may exhibit anhidrosis, the absence of sweat is not considered a diagnostic criterion because sweat is present in over half of patients with heat stroke.15

The CNS is particularly vulnerable in heat stroke. The cerebellum is highly sensitive to heat, and ataxia can be an early neurologic finding. Virtually any neurologic abnormality may be present in heat stroke, including irritability, confusion, bizarre behavior, combativeness, hallucinations, plantar responses, decorticate and decerebrate posturing, hemiplegia, status epilepticus, and coma. Seizures are quite common, especially during cooling. Neurologic injury is a function of the maximum temperature reached and the duration of exposure.15

The distinction between exertional and classic (nonexertional) heat stroke is not clinically important, because immediate cooling and support of organ system function is the therapeutic goal for both. A delay in cooling increases the mortality rate.    (Tintinalli 8th ed)

 

3. intranasal foreign body - button battery

-do not attempt to irrigate out a button battery as it may cause it to leak its corrosive contents

-if it does not come right out, consult ENT

A button battery lodged in the ear can result in tympanic membrane perforation or destruction, necrosis of the epidermis of the external auditory canal, hearing impairment, destruction of ossicles, and facial nerve paralysis.25 Intranasal button batteries can produce chondritis, nasal septal perforation, and superficial burns of the nasal mucosa.35

A child with a button battery in his nose or external auditory canal should be immediately referred to an otolaryngologist for its removal. If its instillation was recent, for example, less than 1 to 2 hours, the emergency physician may consider an attempt of removal.   (Tintinalli 8th edition)

Carlson     Toxicology

Unfortunately I missed this outstanding lecture.

Kishi   Safety Lecture

Unfortunately I missed this outstanding lecture.

Hormese     New Medication Therapies for EM Applications

Angiotensin II is indicated for patients who are in shock despite high-dose norepinephrine.   Patients started on Angiotensin II need prophylactic heparin and SCD's because this medication increases patients' risk for DVT/PE

Patients with low risk DVT and PE can be discharged home on xarelto or eliquis.  Use modified Hestia criteria to decide who can go home.  Patients need PCP follow up and are reliable to follow up.  The first month of treatment with xarelto will be free of charge.  After the first month, the patient will need to pay for the medication through insurance or cash.

 Hestia Criteria. If you answer yes to any of these questions, the patient cannot be treated at home.&nbsp; Tintinalli also notes that an extensive DVT should be treated in the hospital.

Hestia Criteria. If you answer yes to any of these questions, the patient cannot be treated at home.  Tintinalli also notes that an extensive DVT should be treated in the hospital.

 

Quick Pharmacy Factoids:

Ciprodex not covered by insurance.

Prednisolone ODT not covered by insurance

Zofran liquid not covered by insurance

Please list the ingredients and the volume of each ingredient of magic mouthwash on your script.  Pharmacies are calling our pharmacists with many questions about our magic mouthwash prescriptions.

Lovell                Town Hall Meeting

Conference Notes 8-1-2018

Lorenz        M&M

No Case Details, Just some take home points.

When you are wrong, admit it and move on.

“Any fool can try to defend his or her mistakes—and most fools do—but it raises one above the herd and gives one a feeling of nobility and exultation to admit one’s mistakes.”
Dale Carnegie, How to Win Friends & Influence People

The secondary survey is critical in trauma to avoid missing more subtle injuries beyond that identified on the primary survey.

Paraphimosis: A retracted foreskin will block lymphatic drainage from the distal penis. As arterial inflow continues, lack of lymphatic drainage will cause a progressive edema of the penis distal to the retracted foreskin. As the foreskin continues to swell the phimotic ring becomes progressively tighter, and if not reduced, will eventually obstruct venous outflow. The distal penis will become painful and hyperemic. The edema will progress to ultimately obstruct arterial inflow resulting in penile ischemia, necrosis, and gangrene. This series of events, from retraction of the foreskin to arterial inflow obstruction, can occur over a few hours to 1 to 2 days. To relieve the obstruction, the phimotic ring must be advanced (reduced) over the glans of the penis. (Procedures in EM reference)  This diagnosis can be confused with other GU complaints or overlooked. Be cautious not to miss this diagnosis.

Respect the risks of placing a central line.  To verify placement of the line in the IJ, you can ultrasound the the IJ in the longitudinal plane.  With the wire still within the vessel, angle the probe into the thorax and you can see the IJ widen into the right atrium. If you can visualize the wire in this area you know you are good.  Alternatively, after pulling the wire, you can inject 10 ml of saline rapidly through the line and have an ultrasound probe on the heart to see turbulence in the right atrium and ventricle.

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Kalnins     NeuroRadiology

 

 Dense MCA sign

Dense MCA sign

A dense MCA sign corresponds to a significant acute clot in the proximal cerebral vasculature. Patients with this radiographic finding may benefit from neurointerventional procedures to aid in clot lysis or mechanical clot removal in order to reperfuse ischemic brain tissue.  If you see this sign, consider consulting interventional neuro-radiology emergently.

 

 Note the assymetry of the insular cortex from right to left.&nbsp; Dr. Kalnins emphasized the importance of the insular ribbon sign in identifying early stroke.

Note the assymetry of the insular cortex from right to left.  Dr. Kalnins emphasized the importance of the insular ribbon sign in identifying early stroke.

Dr. Kalnins recommended the website http://www.radiologyassistant.nl   as a great resource to learn about radiology of all types.  editors note: I googled it briefly and it looks outstanding. 

Dr. Kalnins discussed cutting edge use of CT technology (perfusion, blood flow, cerebral blood volume, mean transit time studies)  to identify early stroke.

Hawkins      Interpreting CXR's

Unfortunately I missed this outstanding presentation.

Chiefs/EM Faculty      Orthopedic Lab

 

 

 

 

Conference Notes 7-25-2018

Lovell     Trauma Study Guide

Perimortem cesarean delivery should be performed only when the gestational age is greater than 24 weeks.

Some find that an incision from the umbilicus to the public symphysis is large enough to accomplish fetal delivery. The uterine incision should be vertical as well.

Perimortem cesarean delivery might actually improve maternal circulation and is better performed early rather than too late. There have been reports of maternal survival after perimortem cesarean delivery, even when the mother has been in cardiac arrest. Theoretically, delivery of the fetus can help restore maternal circulation and remove pressure from the inferior vena cava.  The primary goal is improvement of maternal, not fetal, resuscitation.

The procedure is ideally performed within 4 to 5 minutes of the loss of maternal circulation. Survival of the mother and the fetus is unlikely if the procedure is performed too late and is virtually futile if performed after 20 minutes of maternal cardiac arrest.

Handlebar injury in kids and adults:  look for pancreatic injury (CT, labs)

Seatbelt sign:  look for intra-abdominal trauma, especially small bowel injury. 

CT may be normal or nonspecific in both pancreatic and small bowel injury, so if persistent pain/tenderness, observe in hospital even with negative CT.

 SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) associated with pediatrics due to hyper-flexibility of spine, and in elderly secondary to spondylosis.  Refers to spinal cord injury with negative plain xrays and/or CT.  Currently an ambiguous term, as majority of SCIWORA has abnormal MRI imaging.  Important entity that can present with transient or delayed neurologic symptoms; do careful history, exam.

 Those hypermobile kids can also tear off the renal pedicle in blunt trauma, especially MVC, so a lower threshold of hematuria is used to prompt CT imaging.  For kids, if >50 RBCs/HPF in blunt trauma and hemodynamically stable get a CT abdomen.

Harwood comment:  Handlebar injuries are also associated with duodenal hematoma.  Vertical falls are also associated with renal pedicle injuries.

Cochrane Review September 2017: Lewis SR, et al. 

Hypothermia (body temperature cooling) for people with an injury to the brain

Review question

What is the effect of mild hypothermia (body temperature cooling) following a brain injury on whether a person dies, has a poor outcome, or gets a type of severe chest infection (pneumonia)?

Background

Hypothermia has been used for many years to treat people who have had a severe brain injury. This involves cooling the head or the whole body to a temperature below normal body temperature. We aimed to assess whether people treated with hypothermia after a brain injury are less likely to die or have a poor outcome (which we defined as death, coma or severe disability) and whether using hypothermia might increase the risk of a severe chest infection called pneumonia.

Study characteristics

We included 37 studies with 3110 participants. In each trial, patients were randomly divided into two groups: one group remained at normal body temperature of 36.5 to 38 °C, and the other group was cooled to a maximum of 35 °C for at least 12 hours.

Key results

We did not combine results of these studies to assess whether hypothermia improves patient outcome. This was because the results had large differences which we could not explain. We identified some differences in the ways in which the studies were carried out and the participants that study authors had recruited, but we did not assess whether this could explain the differences in results. We did not have enough good quality evidence that was sufficiently similar to be confident that treating people who have had a severe brain injury with hypothermia will reduce the incidence of death or severe disability, or increase the incidence of pneumonia.

Quality of evidence

Many of the studies were not well reported and we were unable to assess whether differences between the quality of the studies may also have affected our results. We used the GRADE approach to judge the quality of evidence. We judged the evidence for death or severe disability to be very low quality, and the evidence for pneumonia to be low quality.

Authors' conclusions: 

Despite a large number studies, there remains no high-quality evidence that hypothermia is beneficial in the treatment of people with TBI. Further research, which is methodologically robust, is required in this field to establish the effect of hypothermia for people with TBI.

Although the appropriate length of time to observe a child with a concussion in the emergency department for worsening signs and symptoms has not been definitively established, the PECARN authors recommend a 4- to 6-hour observation period; the likelihood of missing a delayed clinically important traumatic brain injury during this time seems to be rare. Inpatient observation, unless the family is not able to observe the patient at home and follow appropriate instructions, is generally not necessary.

Harwood comment:  Rule of thumb for return to play following concussions is: 1 week out of sport for first concussion.  1 month out of sport for second concussion. 1 year out of sport for third concussion.

 

 Chance Fracture

Chance Fracture

A Chance fracture is a flexion-distraction injury, associated with MVC and flexion over a lap-belt (seatbelt).  There is complete disruption through the vertebral body and associated structures in a horizontal plane.  They are commonly misdiagnosed as compression fractures.   There is a high rate of associated intraabdominal injuries.  As the disruption is in the horizontal plane, sagittal CT images are more sensitive than axial CT for diagnosis

 

   Burst fractures    are associated with  motor vehicle crashes,   as well as falls from height. &nbsp; Burst fractures are inherently unstable due to the potential for the retropulsion of bone fragments into the spinal canal secondary to disruption of the posterior column; about half of patients with this injury will have  neuro deficits. &nbsp; For this reason, additional imaging should be performed if there is clinical suspicion for a burst fracture, and neurosurgery consultation is required.

Burst fractures are associated with motor vehicle crashes, as well as falls from height.  Burst fractures are inherently unstable due to the potential for the retropulsion of bone fragments into the spinal canal secondary to disruption of the posterior column; about half of patients with this injury will have neuro deficits.  For this reason, additional imaging should be performed if there is clinical suspicion for a burst fracture, and neurosurgery consultation is required.

  A “no-zone” approach to all penetrating neck trauma, with stability and presence/absence of hard findings informing the decision of CTA or surgery (hard signs indicate surgery, soft signs indicate CTA)&nbsp; has gained favor compared to a zoned approach, with comparable outcomes.&nbsp; Two other reasons to adopt no-zone:&nbsp; injuries may&nbsp; cross zones, and no-zone approach leads to fewer unnecessary neck explorations.

A “no-zone” approach to all penetrating neck trauma, with stability and presence/absence of hard findings informing the decision of CTA or surgery (hard signs indicate surgery, soft signs indicate CTA)  has gained favor compared to a zoned approach, with comparable outcomes.  Two other reasons to adopt no-zone:  injuries may  cross zones, and no-zone approach leads to fewer unnecessary neck explorations.

Lovell/Logan    Oral Boards

Case 1. 78 yo male bleeding from tracheostomy site.  Patient had tracheostomy placed within the last 2 weeks.

 Use hyperinflation of trach tube balloon initially to compress the innominate artery. If that is ineffective, use your finger to hold pressure.&nbsp; Third maneuver is apply traction to the tracheostomy tube to compress the vessel.

Use hyperinflation of trach tube balloon initially to compress the innominate artery. If that is ineffective, use your finger to hold pressure.  Third maneuver is apply traction to the tracheostomy tube to compress the vessel.

Any bleeding of more than a few milliliters of blood should raise concern for a possible fistula of the innominate artery. Prompt critical resuscitation measures and emergent consultation with a Vascular Surgeon and Otolaryngologic Surgeon is required. Definitive management is surgical. Techniques for temporarily controlling bleeding from the innominate artery include local digital pressure, hyperinflation of the tracheostomy tube cuff, and traction on the tracheostomy tube. An alternative method is to deflate the tracheostomy tube cuff, reposition the cuff at the bleeding site, and then reinflate or hyperinflate the cuff. When bleeding occurs, the tracheostomy tube should not be removed until the airway is secured by another means from above (orally or nasally).

Peak incidence is 1-2 weeks after tracheostomy surgery. 75% within 4 weeks post-op. Emergently consult thoracic surgery to take the patient to OR.

Case 2. 55yo female with weakness. HR=130. Other vitals OK.  Started chemotherapy for non-hodgkins lymphoma 3 days ago.

 

 If you consider tumor lysis syndrome be sure to order phosphate and uric acid levels in addition to your usual CBC, CMP.

If you consider tumor lysis syndrome be sure to order phosphate and uric acid levels in addition to your usual CBC, CMP.

Treat tumor lysis syndrome with IV fluids, Hyperkalemia management, Rasburicase for elevated uric acid, phosphate binders, and dialysis if needed. 

Case 3. 8 month old male who won't stop crying.  Vitals all OK except for HR=110.  Patient appears fussy. Physical exam demonstrates a hair tourniquet on the toe.

 Hair Tourniquet

Hair Tourniquet

Two standard approaches to salvage the compromised digit are to either unwind the hair or thread if possible or, otherwise, make a midline longitudinal incision along the extensor surface of the toe to cut the hair or thread.42 To cut the hair, it will often be necessary to split the fibers of the extensor ligament, but avoid transecting the fibers. The multiple strands of hair or thread are then removed using fine forceps without teeth. The toe often retains the initial appearance, making the physician uncertain whether all of the strands have been removed or cut. A novel but unvalidated method is to apply hair-dissolving compounds.43 Hair-thread tourniquet syndrome can cause deep cutaneous lacerations that result in tendon lacerations requiring operative repair.44 Hair-thread tourniquet syndrome is not the result of intentional injury and does not warrant reporting as suspected child abuse.   (Tintinalli 8th Ed)

Faculty comments:  Nair seems to work pretty well. It takes about 15 minutes to dissolve the hair fiber.  Otherwise a small incision on the lateral aspect of the digit down to bone will cut the fibers.

 Incision to cut hair tourniquet

Incision to cut hair tourniquet

 

Hawkins       EKG's

Have a system to approaching EKG's the same way each time.

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 V-tach.&nbsp;&nbsp; Harwood comment you know this is V-tach based on NorthWest axis (down in I and AVF) and QRS &gt;140 ms.&nbsp;

V-tach.   Harwood comment you know this is V-tach based on NorthWest axis (down in I and AVF) and QRS >140 ms. 

Williamson    AICD/Pacers

Unfortunately I missed a large portion of this outstanding lecture.

1/3 of patients with AICD shock will have troponin elevation. 

For a single shock, check a troponin, check lytes,  get an EKG. If patient is asymptomatic and has normal vitals and labs are consistent with prior levels, the patient can possibly can go home after discussion with cardiologist. 

If patient gets shocked twice they need a higher level of caution because either they are getting multiple appropriate shocks or the device is malfunctioning.  Consult Cardiology and likely admit.

If a patient gets 3 or more shocks that is considered electrical storm and the patient needs emergent cardiology consultation, antiarrythmic therapy, anxiolytic, and ICU admission.

 JAMA 2006 reference.

JAMA 2006 reference.

Lovell    How to Give an Effective Lecture

Be the content expert. Make sure you know your topic.

Be enthusiastic about the topic you are speaking about. Enthusiasm shows and is important for gaining your audience's attention.

Work on your public speaking skills: Most important is to practice your presentation beforehand.     During the presentation, leave the podium and engage the audience.   

Get Creative.  When developing your presentation, think about how to make the content more engaging or interactive.

Pay attention to slide design. Don't put too much info on slide. Big picture/few words.  Make your slides visually appealing. Don't use slides as a crutch.

 

 

Conference Notes 7-11-2018

Cirone/Shroff       Oral Boards

Case 1. 20 yo female presents with fever, tachycardia, and hypotension.  Patient complains of right leg pain. Patient has necrotizing bullae on shin.  Patient was at beach/ocean yesterday and had a skin abrasion on her shin that got infected. 

 Vibrio cellulitis

Vibrio cellulitis

Patient was treated for septic shock with IV fluids, IV antibiotics and norepinephrine.

Vibrio is gram negative bacteria seen in coastal waters. Vibrio can cause blistering cellulitis. Almost always occurs at site of prior wound.  The infection can progress to necrotizing fasciitis.  Tintinalli says: Treat with 4th generation cephalosporin combined with doxycycline.  There is synergy with combining a 4th generation cephalosporin with doxycycline. If the patient develops necrotizing fasciitis they need emergent surgical debridement.

Dr. Lovell comment: For boards, bad infections associated with water are Vibrio for salt water and Aeromonas for fresh water.  Make sure you treat with a 4th generation cephalosporin plus doxy  or flouroquinalone.

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Case 2. 25 yo male presents with altered mental status.  Patient was bit by a snake the day prior in the everglades.

 Red on yellow Kill a fellow (coral snake).&nbsp; Red on black venom lack.

Red on yellow Kill a fellow (coral snake).  Red on black venom lack.

Patient was treated with 3-5 vials of antivenin.  If there is a definite coral snake bite, the patient should receive antivenin.  If a patient has neuro symptoms, admit to ICU.  Obtain a NIF to identify early respiratory weakness.

Case 3. 19yo male presents with foot pain due to injury playing basketball. 

 Jones fracture is also known as a Zone 2 fracture of the 5th metatarsal.

Jones fracture is also known as a Zone 2 fracture of the 5th metatarsal.

Jones fractures have poor blood supply and have risk of malunion.  Treat with post mold, non-weight bearing, and orthopedic referral.

Treatment and Follow-Up

Patients with nondisplaced Jones fractures should be non–weight bearing in a cast for 6 to 8 weeks. Complications of a Jones fracture treated nonoperatively include bony nonunion, which may later require intramedullary screw fixation. Shock wave therapy has also been reported for treatment of nonunion.17 Some orthopedic surgeons are advocating for early surgical correction, especially in athletes, so posterior splinting and outpatient referral to an orthopedic surgeon are appropriate initial treatment.18 Nondisplaced avulsion fractures of the tuberosity, also known as a pseudo-Jones fracture, can be treated with a walking cast and pain control with weight bearing as tolerated. (Tintinalli 8th edition)

Burns      Ultrasound Physics

Acoustic Impedance is due to the difference between tissue characteristics.  If there is a large difference in impedance of two tissues the ultrasound image will be reflected or refracted and will limit the image.    This is the problem with air and bone.  Because air and bone impedance are so different from water, tissue, and blood, the ultrasound image is very negatively impacted by the air or bone.

 Water, blood, and tissue all have similar impedances ranging from 1.48 to 1.7.&nbsp; Bone and air on the other hand have very different impedances from water, blood, and tissue. When bone or air is present in an ultrasound image, it will cause much reflection and refraction of sound waves degrading the image in the far field.

Water, blood, and tissue all have similar impedances ranging from 1.48 to 1.7.  Bone and air on the other hand have very different impedances from water, blood, and tissue. When bone or air is present in an ultrasound image, it will cause much reflection and refraction of sound waves degrading the image in the far field.

 Gallstones are an example of a large difference of impedance between bile and stone.&nbsp; Distal to the bile/stone interface is only shadowing.

Gallstones are an example of a large difference of impedance between bile and stone.  Distal to the bile/stone interface is only shadowing.

Gain adjusts the strength of returning echos (brightness).  You want to have uniform brightness in both the near and far fields.

Higher frequency probes give better resolution.  Lower frequency probes give you better tissue penetration.  To image deeper structures, you may need to sacrifice some resolution to have deeper penetration of the sound waves.

Lambert        Emergency Echocardiography

Mike's tip for imaging the subcostal view of the heart is to start in the right sucbcostal region and image the liver then rotate the probe to point at the left shoulder and you should be able to image the heart.  Use the greatest depth to get this image.  It's a long way from the RUQ to the top of the heart with this imaging window. So you need the greatest depth to see the heart from this window.   Mike says the best subcostal images use the liver as a window to the heart. This is the best view to see pericardial fluid because you are looking at the base of the heart where dependant fluid would be.

 Echo Windows: A. Parasternal long. B. Parasternal short.&nbsp; C.&nbsp; Apical.&nbsp;&nbsp; D. Subcostal.

Echo Windows: A. Parasternal long. B. Parasternal short.  C.  Apical.   D. Subcostal.

 Subcostal view of a large pericardial effusion

Subcostal view of a large pericardial effusion

 Large RV on Parasternal short axis view due to PE.&nbsp; Patient also has a "D sign" in which the large RV deforms the LV into a D shape.

Large RV on Parasternal short axis view due to PE.  Patient also has a "D sign" in which the large RV deforms the LV into a D shape.

Lambert        Ultrasound in Trauma

FAST is basically a search for blood in the pericardium, thorax, or peritoneum.

 E-FAST adds lung windows to the traditional FAST to look for pneumothorax.

E-FAST adds lung windows to the traditional FAST to look for pneumothorax.

 RUQ view on FAST showing blood in Morrison's pouch and blood in the right chest cavity.

RUQ view on FAST showing blood in Morrison's pouch and blood in the right chest cavity.

 Looking for sliding of pleural line is critical to identify pneumothorax.&nbsp; With pneumothorax, the pleural line does not slide.

Looking for sliding of pleural line is critical to identify pneumothorax.  With pneumothorax, the pleural line does not slide.

Lambert and Team Ultrasound       Ultrasound Lab

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Conference Notes 6-6-2018

Tekwani        Medical Student Rotation Overview

Lovell      The Resident as Educator

2 Easy to use bedside teaching techniques:

1. 1 minute Preceptor: Get a commitment (get the student to commit to what they think is going on) , probe for supporting evidence (ask them how they reached that conclusion), teach a general principle, reinforce what was done well, correct mistakes (do this as kindly as possible), and identify next learning steps (suggest a topic to read further on).

2. SPIT=Serious,  Probable,  Interesting, and Treatable.   Have the student suggest 1-2 diagnoses for each of these categories that would fit the patient's presentation. This method is a quick way to build a broader DDX with a student learner.

Give feedback in as positive a fashion as possible.  Tell them at the beginning of your feedback:  "I am giving you some feedback now"

Remember, you are always "role modeling" to students

Send students to all codes and to interesting cases, rashes, or other significant physical findings.

Twanow       Myocarditis and Pericarditis

Myocarditis is most commonly a clinical diagnosis.  The diagnostic gold standard for myocarditis is endomyocardial biopsy which is rarely done.

Causes of myocarditis include viral infections, mycotic infections, RMSF, Chagas, Toxins, and medications.

Myocarditis can present as new onset heart failure, new murmur, new bundle branch block or heart block. Myocarditis can also present as persistent tachycardia, pericarditis with heart failure, arrythmias following uri, and unexplained heart failure.

Diagnose myocarditis with troponin, BNP, CXR and EKG. Echo is also important to make the diagnosis.  Inpatients can get Cardiovascular MRI which can also help to diagnose myocarditis.

In the ED, provide supportive care if needed with with pressors, anti-arrythmics, pacer, and anticoagulation.  Avoid NSAID's.  Cards may consider IVIG, ECMO, LVAD and other modalities.

Pericarditis can be caused by viral infections, TB, fungal, and parasitic infections.  Lupus, RA, and scleroderma can cause pericarditis. Neoplastic processes, post-MI, uremia, and radiation can all cause pericarditis.

Pericarditis classically has pain that is improved when sitting up.

 Pericarditis EKG. There is diffuse ST elevation and PR depression.&nbsp; AVR has the opposite changes with ST depression and PR elevation.&nbsp; If you see localized ST depression in the inferior, anterior, or lateral leads that&nbsp; is not c/w pericarditis and needs to be strongly considered for STEMI criteria.

Pericarditis EKG. There is diffuse ST elevation and PR depression.  AVR has the opposite changes with ST depression and PR elevation.  If you see localized ST depression in the inferior, anterior, or lateral leads that  is not c/w pericarditis and needs to be strongly considered for STEMI criteria.

 Life in the Fast Lane reference

Life in the Fast Lane reference

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Dr. Lovell comment: Treat with ASA and Colchicine.  ASA has benefits over giving NSAID's.

 

(Tintinalli reference 8th ed.) Treatment of pericarditis depends on the cause.34 Most patients with idiopathic or presumed viral pericarditis have a benign course lasting 1 to 2 weeks. Symptoms respond well to nonsteroidal anti-inflammatory agents administered for 7 days to 3 weeks. Ibuprofen, 300 to 800 milligrams orally every 6 to 8 hours, may be preferred because of fewer side effects, limited impact on coronary artery blood flow, and large dose range. Colchicine, 0.5 milligram orally twice a day, may be a beneficial adjuvant and may prevent recurrent episodes.35,36 Hospitalization is not necessary in most cases, unless there is associated myocarditis, and follow-up or repeat echocardiography is not needed unless symptoms fail to resolve or reappear or new symptoms are noted.37 Indicators of a poor prognosis include temperature >38°C (100.4°F), subacute onset over weeks, immunosuppression, history of oral anticoagulant use, associated myocarditis (elevated cardiac biomarkers, symptoms of CHF), and a large pericardial effusion (an echo-free space >20 mm).38 In general, patients with these risk factors or with an enlarged cardiac silhouette on chest radiograph should be admitted for echocardiography to assess the extent of the effusion and degree of hemodynamic compromise and cardiac dysfunction.

Logan        Safety Lecture    New Stroke Pathway

Unfortunately I missed this excellent lecture but the new pathway is listed here.

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Chastain/Felder/Paquette       Efficiency Panel

The panel discussed many excellent tips on being an efficient emergency physician in our ED. I was only able to capture a few of them.

When you have multiple patients who are waiting to be seen, one way to prioritize them is: 1. Time dependent complaints like chest pain and stroke should be seen first, 2. Patients with abnormal vitals next 3. Then quick complaints that can be dispo'd quickly 4. While you are seeing those patients, put in lab and imaging orders on the lower acuity  patients with complaints like abdominal pain or weakness.

Maintain excellent communication with the nursing staff regarding your plan and discuss any roadblocks the nurses are facing.

If you are going to be delayed to see a new patient, ask the patient's nurse to go into the room and inform the patient you are delayed because of a critical patient.  When you finally get to that patient, apologize to them and explain why you were delayed.

Keep you communication brief with admitting and consulting physicians.

Utilize the care managers to help set up patient follow up and specialist appointments.  Care managers can help patients with limited healthcare access. The Care managers are stationed in the old telemetry room in the hallway to radiology.  You can leave them a message on their voicemail or slip a note under their door at night.  They will address the issue when they start their shift in the morning.

Ask a patient what their fears are, and/or what their hopes or expectations are for this ED visit.

Tran      Radiology Lecture

Unfortunately I missed this outstanding lecture.

Florek/Lorenz/Pastore/Robinson/Wing         Trauma Lecture

Unfortunately I missed this outstanding lecture.

 

 

 

 

Conference Notes 5-9-2018

Almeida/Eastvold/Tomasello     EKG's

 You only need 1 lead of concordant ST elevation/depression with bundle branch block to diagnose STEMI

You only need 1 lead of concordant ST elevation/depression with bundle branch block to diagnose STEMI

 Posterior MI

Posterior MI

 A straightened ST segment is indicative of ischemia/evolving STEMI

A straightened ST segment is indicative of ischemia/evolving STEMI

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If you don't have an old EKG, make an old EKG by getting serial EKG's.

 DeWinter's T waves anterolaterally&nbsp; STEMI equivilent

DeWinter's T waves anterolaterally  STEMI equivilent

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Know your epinepherine dosing for anaphylaxis

For Adults   0.3mg-0.5mg 1:1000 IM repeat as necessary.   For anaphylactic shock 0.1mg 1:10,000 IV slow

Chest pain that radiates to both arms is highly specific for cardiac chest pain. Chest pain that radiates to left arm is non-spcific for cardiac chest pain.  Chest pain that radiates to right arm is more specific for cardiac pain than for left arm pain.

 

 

Conference Notes 5-23-2018

McKean/Logan   Oral Boards

Case 1. 10 month old child drank gasoline.  Child had respiratory distress and bilateral pulmonary infiltrates.  Patient was intubated to treat aspiration of gasoline.

 CXR of bilateral pulmonary infiltrates due to hydrocarbon aspiration

CXR of bilateral pulmonary infiltrates due to hydrocarbon aspiration

In addition to pneumonitis, patients with hydrocarbon ingestions can develop CNS depression, seizures, and arrhythmia.  Catecholamines, antibiotics, and steroids should be avoided.

"Treat hypotension with aggressive fluid resuscitation. Avoid administration of catecholamines such as dopamine, norepinephrine, and epinephrine. Catecholamines may cause dysrhythmias, especially after exposure to halogenated hydrocarbons and aromatic hydrocarbons. Hydrocarbon-induced dysrhythmias are generally seen shortly after the exposure, especially with inhalational use. Continuous cardiac monitoring should be initiated, and an ECG should be obtained. For hydrocarbon-induced ventricular dysrhythmias, class IA (procainamide) or class III (amiodarone, bretylium, and sotalol) antiarrhythmics should be avoided because of the risk of QT-interval prolongation.18 Propranolol, esmolol, and lidocaine have been reported to treat these ventricular dysrhythmias successfully.10,18,39

There is no benefit to gastric lavage because risks of aspiration far outweigh any theoretical benefits.40 Activated charcoal does not adsorb hydrocarbons well and poses a risk for vomiting and aspiration, so charcoal is not recommended either. I  (Tintinalli reference)

Case 2. 29 yo female with syncope. Upreg is negative.

 Patient had run of stable V-tach in ED treated with Amiodarone

Patient had run of stable V-tach in ED treated with Amiodarone

Arrythmogenic RV Cardiomyopathy

 Epsilon Wave specific for arrythmogenic right ventricular cardiomyopathy.

Epsilon Wave specific for arrythmogenic right ventricular cardiomyopathy.

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Case 3. 74 yo male with knee pain. Patient fell at Wrigley field. On exam patient cannot extend the knee against gravity. 

 Quadricep tendon rupture with low riding patella on the right

Quadricep tendon rupture with low riding patella on the right

Patient needs orthopedic consult for surgrical repair.

Kishi  5- Slide Follow Up

Treatment for Acute Flash Hypertensive Pulmonary Edema also known as Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

 Nitro sprays followed by Nitro drip at 100mcg/min

Start patient on bipap

Limit diuretic use as these patients are frequently hypovolemic.  If you think the patient is hypervolemic, cautious IV lasix may be indicated.

Dennis Ryan comment:  sublingual sprays give 400micrograms per dose.  This is a good way to give big doses of nitro early on. 

Miner    5 Slide Follow Up

Microangiopathic hemolytic anemia, one of the cardinal features of hemolytic-uremic syndrome, may be profound with a hemoglobin level between 5 and 9 grams/dL. A peripheral smear demonstrates schistocytes, helmet cells, and burr cells. The Coombs test is negative. The platelet count is <150 000/mm3. The WBC count may be elevated.

Hyponatremia and hyperkalemia develop as a result of metabolic acidosis from renal failure, and hyperbilirubinemia results from acute hemolysis.   (Tintinalli reference)

Aytpical HUS is differentiated from HUS by the fact that it is not caused by toxin producing ecoli.

 Treat atypical HUS with plasma exchange and eculizumab (Soliris).&nbsp;

Treat atypical HUS with plasma exchange and eculizumab (Soliris). 

Jones    5 Slide Follow Up

Bedside echo is key to the evaluation of acute chest pain and hypotension.

If you see cardiac tamponade on bedside echo, think aortic dissection.

 Aortic Dissection Detection Risk Score is one tool to consider when evaluating chest pain. You can check out the decision guideline in MD Calc.&nbsp; (editor's note) It has not been fully validated but it I think it helps organize my clinical thinking about dissection.

Aortic Dissection Detection Risk Score is one tool to consider when evaluating chest pain. You can check out the decision guideline in MD Calc.  (editor's note) It has not been fully validated but it I think it helps organize my clinical thinking about dissection.

 

Johns       5 Slide Follow Up

 Consider headache "red flags"

Consider headache "red flags"