Another Outstanding Week in Conference! but first an important word from our sponsor:
SAVE THE DATE for the ACMC EM Foundation Golf Outing
What: Emergency Medicine Golf Outing – October 1, 2013
Time: Immediately Following the Emergency Medicine Conference
Cost: $150/golfer (includes golf, dinner & drinks)
Purpose: To raise awareness for the Emergency Medicine Endowment which provides funding for residents to further their education
Contact: Jason Keene, Director of Development 708-684-2012 or firstname.lastname@example.org
*Proceeds will benefit the Emergency Medicine Endowment
*Electronic Invitation to follow
Lotsa pics in these notes if you don't see them scroll to the bottom and click "read in browser"
Coghlan Study Guide ENT
Most common source of bleeding in posterior nose bleeds is the sphenopalatine artery.
Compications of posterior nasal packs: eustacian tube dysfunction, nasopulmonary reflex causing apnea/bradycardia/hypoxia/bronchoconstriction/cardiac arrest, necrosis of the columella.
Best nerve block for complex ear laceration is the auriculotemporal block.
Diabetic with signs of otitis externa: Consider malignant OE due to pseudomonas. These patients are ill-appearing, diabetic, febrile, elderly and have granulation tissue in their external ear canal.
OE with TM perforation: Use Floxin because it is the only topical antibiotic approved by FDA for use with an open middle ear. If cost is an issue, use Cortisporin otic suspension as an alternative .
Tooth avulsion: never re-implant primary teeth. Adult tooth that is avulsed hold by crown, irrigate with saline and re-implant in the socket ASAP. Beyond 2 hours the chance of success of re-mplantation is quite low. Best transport mediums for an avulsed tooth is Hank’s solution. Saliva, milk, saline are 2nd, 3rd, 4th best..
ANUG (acute necrotizing gingivitis) : Due to oral anaerobes, pt’s have “punched out inter-dental lesions of the gingival”. Treat with antibiotics that cover anaerobes.
Lemierres syndrome: Infectious thrombophelbitis of the IJ due to a parapharyngeal space infection. Pt’s can get septic pulmonary emboli.
Diagram of Lemierre's Syndrome
Aphthous stomatitis: Cellular immune mediated response. Treat with pain medication and steroids.
Pt gets hit in the mouth with a baseball. Pt has dental injury. Dental mobility but not displacement is called subluxation. Dental mobility and displacement=luxation. There can be intrusive, extrusive, posterior and anterior luxations
For burns, don’t use silvadene above the clavicles as it can permanaently alter the color of facial skin.
There was a discussion about complications from OM. Harwood comment: This is a bogus question. It is extremely rare for a patient to develop meningitis from otitis media. If the infection gets severe, the TM ruptures before they get meningitis. Joan’s humorous response: Well Tintinalli says you’re wrong.
We discussed parotitis and parotid gland/other salivary gland abscess due to a stone in the salivary duct. Joan’s comment: It is analogous to pyelonephritis complicated by an obstructing ureteral stone. You gotta get that stone out of the duct. Although the textbooks say you can milk the stone out of the duct, it can be rather difficult to remove and ENT may need to surgically extract the obstructing stone. Treat with anti-MRSA antibiotics but the infection won’t resolve until you remove the obstructing stone.
Sickle cell patient with spontaneous hyphema and elevated IOP: Avoid carbonic anhydrase inhibitors because they can cause sickling of RBC’s.
Recurrent jaw dislocation should raise suspicion for ehler-danlos syndrome or marfan’s syndrome. Most mandiblar dislocations are anterior.
Adult epiglottitis: Most common organisms are strep and staph but 25% are still hemophilus. Think about this diagnosis in the patient with severe symptoms but a relatively benign appearing pharynx. They may also have anterior laryngeal tenderness. Girzadas comment: Every patient I see with a sore throat has severe symptoms and anterior neck pain so those symptoms I feel are nonspecific. Joan felt that most patients with severe symptoms have pharyngeal findings to go along with the symptoms. If they don’t, then get a soft tissue neck xray and look for epiglotitis. If you make this diagnosis, put patient in the ICU because there is some chance of airway obstruction.
Xray of Epiglotitis with Thumb print sign and Valecula not extending to hyoid bone
Herrmann/Kettaneh STEMI Conference
Case 1: Elderly female with previous CABG and current chest pain and non-diagnostic EKG with non-specific interventricular conduction delay. Pt had a ph of 7.01, cxr showed CHF and she was tubed. Pt was admitted to the ICU and was cathed the next day. Pt ended up having an ostial vein graft 99% occlusion. All cardiologists agreed the management was appropriate. They felt pt did not meet criteria to go to the cath lab emergently from the ED. They all agreed that vein grafts don’t recanulate once occluded, they only get worse. So this patient never had a complete occlusion of the vein graft. New 2013 guidelines state: Pt with ischemic chest pain and LBBB and a sgarbossa score of 3 or higher may indicate AMI. Low sgarbossa score however, does not rule out AMI. Dr. Al-Khaled comment: Low pH greatly increases risks related to angiogram/plasty. She may have died if she went to cath.
Case 2. 78yo male with chest pain, jaw pain for 2-3 days. No hx of CAD. EKG shows LBBB. Pt became bradycardic down to 30 transiently in ED. Labs show Trop of 15. 2nd EKG shows no evolution, still with LBBB. On cath pt had 100% occlusion of mid-RCA. Silverman Comment: The LBBB had nothing to do with his acute RCA occlusion. It is a confounding factor. Harwood comment: first EKG has a 1st degree heart block. Al-Kaled: If pt has typical ischemic chest pain with BBB (old or new) they go to the cath lab. Robust discussion about LBBB with chest pain. If patient has Typical ischemic pain and LBBB you should activate the cath lab. Trevedi comment: Acute MI causing LBBB should make patient pretty sick. LBBB and first degree AV block puts patient at risk for 3rd degree block and should have standby transcutaneous pacing available.
2012 JACC study by Neeland: Low incidence of LBBB and AMI. No culprit lesion on cath. Early PCI not helpful. If you have sgarbossa score of 3 or higher increases the chance of AMI. Other markers are ongoing chest pain and elevated troponin. Echo showing wall motion abnormality is also helpful.
Algorithm: Chest pain and LBBB>> if unstable go to cath>> sgarbossa score>If 3 go to cath>>get echo looking for wall motion abnormalities. Siverman comment: Echo looking for wall motion abnormality is the most useful modality to help figure out this situation. Elise comment: You have to look at the patient like the LBBB isn’t there. LBBB shouldn’t sway you either way for or against cath. Look at the patient, if they have typical pain, if they look at all sick, or have abnormal contractility on bedside echo activate cath.
Case 3. 31yo male with chest pain. EKG with Infero-Lateral ST elevation with no reciprocal changes. Silverman: This is either pericarditis or big wrap-around LAD infarct. Bedside echo looking for wall motion abnormality would be very helpful in this situation. Second ekg looked a little worse. Code STEMI called. Bedside U/S showed subtle anterior wall motion abnormality. Dr. Silverman comment: don’t delay cath for the echo. Cath showed wrap-around LAD lesion and trop peaked at 45. Silverman comment: I am seeing more and more young persons in their 30’s who have stemi’s. Don’t let age dissuade you from going to Cath Lab. Harwood comment: Young people don’t have collateral flow and are at higher risk of large/serious infarct secondary to vessel occlusion from plaque rupture than older patients who are more likely to have some collateral flow.
Algorithm for STEMI vs. Pericarditis
If EKG shows any st depression, st segments are convex up, or ST elevation in lead III > lead II then call a Code STEMI. If none of the above, then if pt has multiple PR depression and history fits it may be more likely to be pericarditis. Dia comment: If ST elevation in lead III> lead II in setting of STEMI more likely to be RCA. If ST elevation in lead II> lead III it is more likely to be circumflex. Silverman comment: Don’t hang your hat on the height of ST elevation in leads III vs. II to decide between pericarditis and AMI. These leads are highly variable and he has seen many cases that don’t follow the rules.
Chiefs/Faculty ENT Workshop