Conference Notes 6-5-2012

Conference Notes 6-5-2012


Droperidol and haldol can prolong the QT interval and precipitate torsades.   Check an EKG prior to giving either drug.

Treat dystonic reaction with benztropine (cogentin) and Benadryl.

Harwood comment: sometimes Benadryl doesn’t work in that case give cogentin and a few for home to prevent recurrence.

Low potency antipsychotics have more sedation and hypotension and anticholinergic symptoms

High potency antipsychotics have more dystonia and tardive dyskinesia.

Harwood comment: It’s ridiculous that there is a question about low potency  anti-psych drugs because they aren’t used anymore.

Harwood comment: Most people with panic attacks will not have a persistent resting tachycardia.  If pt is persistently tachycardic, check thyroid studies and consider other diagnoses.

3% of patients with steroid psychosis commit suicide.

Conversion disorder:  symptom that is a change or loss of function. Recent stressor, symptom not explained by any organic disease.  Labelle indifference.

Harwood comment:  Consult appropriate specialist to eval patient prior to making diagnosis of conversion disorder and discharging patient.

Munchhausen by proxy: caregiver fabricates illness in those who are in their care.   Form of child abuse.

SADPERSONS: mnemonic for suicidal risk.  Sex, age, depression/hopelessness, previous, excessive etoh, rational thinking loss, separated, organized attempt, no social support, stated future attempt.   Hopelessness, loss of rational thinking, stated future attempt all get 2 points and are higher risk than the other factors which get 1 point each.

TCA overdose: look for wide QRS and tall R wave in AVR on EKG.

Effexor (venlafaxine) has sodium channel blocking effects and will have similar EKG findings to TCA’s.

Discussion on neuroleptic malignant syndrome among attending: cool patient, use benzos, consult tox/neuro, give dantrolene.   


Patient with purple urine in foley bag.   Urine culture was positive for proteus and e coli.  Both organisms susceptible to cipro.

Purple urine bag syndrome: tryptophan metabolized to indole.  Liver converts indole to indoxyl sulfate.  Bacteria convert indoxyl sulfate to indirubin and indigo.   Usually in asymptomatic patients with chronic foley catheters.  Constipation predisposes to more uptake of tryptophan so more likely to have purple urine.   Multiple gram neg organisms can cause this.   Treatment is change out the catheter and burine bag and treat uti.  You can use the usual urine antibiotics.

Child with blue urine is likely to be due to food coloring or familial hypercalcemia.  Check a calcium level.


75 YO male, multiple chronic illnesses, hx of cholangitis. Presents febrile and tachy with green biliary drainage.    Antibiotics started.

Cholangitis: bile stasis that develops infection.   High rate of sepsis.  Stones can act as a nidus for infection.   Treatment is biliary drainage and antibiotics.

Charcot’s triad; fever, pain, jaundice.  Reynold’s pentad is the addition of hypotension and altered mental status.

80% will respond to antibiotics.  20% require emergent decompression of biliary blockage.

Patient deteriorated in ER.  Developed an urticarial rash.   Pt was treated successfully for anaphylaxis.  It was later learned pt has a pcn allergy.

Anaphylaxis criteria  there are three: 1. Acute onset of skin and respiratory or low bp effects. Or  2.  Any 2 of skin, gi, respiratory, bp  effects after allergen. or 3. Low bp after exposure to known allergen.

Treat with epinephrine 0.01mg/kg    in thigh.

Biphasic reactions are possible up to 72 hours out.   Patients should be observed for 4-6 hours in ER.

Pt had antibiotics changed, went for ERCP and eventually was dischared from hospital.

Dr. Riccardi discussed the importance of being alert to anchor bias.  Just because the patient is triaged to a lower acuity area of the ED does not preclude they may have a serious, or emergent illness or injury.   Elderly are more prone to under-triage.

Dr. Riccardi also discussed confirmation bias.  The EP is suspicious of a certain diagnosis and uses data collected to confirm this bias.   The EP tends to discount non-confirmatory data or not pursue data that would lead to another diagnosis.

Beyesian reasoning may help fight confirmation bias.  Does my test results raise or lower my pretest probability?

C. Kulstad comment: Be alert for under-triaged nursing home patients in the hallway.

Joan Coghlan  comment: Ask yourself, if I saw this patient in the Critical Care room would I do the same thing?   Frequent ED users also require extra vigilance.


 Case 1.   Pregnant patient with adominal pain.  Distended bladder.  Incarcerated uterus. Rarely  uterus can’t come out of the pelvis at about 10-12 weeks and will block bladder drainage.   

Case2.  Lower extremity compartment syndrome.     Severe calf pain.  Use Stryker to measure compartment pressure.   Normal pressure is 0-5.   Admit for pressure over 20.  Surgery for pressure over 40 or within 20 of diastolic blood pressure.

Case3. Optic Neuritis due to Multiple Sclerosis.  Treatment with IV Solumedrol.  Fundus will be normal.  Pt will have an afferent papillary defect.   Pts may have eye pain.

Joan Coghlan comment: Pain out of proportion should make you think either ischemia, compartment syndrome, phlegmasia, tendon rupture.     Know the likely disease entities at various  gestational ages.  Ectopic at 6-8 weeks, uterine entrapment at 10-12 weeks,  second trimester is appy or cholecystectomy, third trimester is abruption and previa.


Resilience: the ability to bounce back and endure adversity during residency.

Not resilient resident:

Resilient resident:

Hero’s Journey: Described in 1949 by Joseph Kimble.  Start with known (home field) and travel to unknown world (call to adventure), work thru challenges and temptations, reach an abyss (doubt of success), revelation, transformation, atonement, success and return to the known (home field).

Nutrition, aerobic exercise, sleep lead to healthy living but do not guarantee resilience.

Lessons from Athletics: How you think about failure whether it is permanent of fleeting is a part of resilience.  2nd category is locus of control.  If a person takes more internal control of their performance and not blame external factors they are more likely to be resilient.  3rd category is a sense of hope/optimism/higher purpose.

You have to dispute negative thoughts.  Either do it yourself or have a mentor to help you do that.

Decatastrophize problems.    Consider worst case scenario, consider best case scenario, and settle on most likely scenario.

Lessons from the military: NAVY SEAL’s are considered the most resilient people on the planet.  Optimism, perseverance, responsibility, integrity, support each other during training, self-efficacy (they believe they control their destiny), earned.

Comprehensive Soldier Fitness: Family, physical, social, emotional, and spiritual facets.  Military doesn’t have time to wait because currently there are more military deaths from suicide than from combat.

Marty Seligman: Formula for resilience or positive thinking: Content with the past, happy in the present, hopeful for the future.   Dr. Seligman runs the Comprehensive Soldier Fitness program.

Not much data to support specific resilience training.   3 factors do have some support: positive thinking, positive affect, positive coping.   2 other factors also important: realism and behavior control.

Positive coping, support from family/resident class, positive climate in Unit/program, Belongingness in Community/hospital.    Physical fitness is not a link to resilience.

Lessons from Medical field: SMART program at Mayo: Attention wanders to threats/pleasure/novelty.  Spend a lot of brain power in the past and future.   We should switch to the present moment.   Gotta override the limbic system.  Gotta train the mind to quiet the limbic center.   Focus on the current moment.  Interpret life with more flexibility, gratitude, compassion, forgiveness, and higher meaning.