Conference Notes 5-10-2017

Munoz   M&M

Pay attention to vital signs in kids.  Pediatric patients can look OK despite significantly abnormal vital signs.  Vital sign abnormalities, especially tachycardia above age-appropriate values may be the only early clue to serious illness.

Early IV antibiotics and IV fluids are as critical in kids as in adults for treating sepsis.

Be cautious of pediatric patients who have a return visit to the ED for the same illness. They may warrant a more detailed evaluation.   The average emergency physician during their career will send home 44 patients who will die within 7 days.

Risk factors for death in discharged patients: abnormal vitals especially tachycardia, failure to recognize worsening of chronic illness, atypical presentations of disease, patients with psychiatric illness or substance abuse. If a patient has one or more of these risk factors, consider further evaluation or a period of observation prior to discharge.

 Another interesting 2017 study discussing deaths in discharged medicare patients.  Higher admission rates are associated with less deaths.  ED discharge diagnoses such as altered mental status, dyspnea, and malaise, were the highest risk for death after discharge.  BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j239 (Published 01 February 2017) Cite this as: BMJ 2017;356:j239

Another interesting 2017 study discussing deaths in discharged medicare patients.  Higher admission rates are associated with less deaths.  ED discharge diagnoses such as altered mental status, dyspnea, and malaise, were the highest risk for death after discharge.

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j239 (Published 01 February 2017) Cite this as: BMJ 2017;356:j239

Elise comment:  Once you make the determination that a patient is ill and needs time-critical interventions,  you need to physically look at the clock and set definite time constraints on your team to get things done.  If you don't hit those time marks you need to stop all other activity and re-focus the entire team on the patient you are concerned about.

Patients who are boarding in the ED for prolonged periods of time can have significant changes in their condition.  Try to at least lay eyes on these long term sign out patients at least once during your shift. 

Submassive PE is defined by RV dysfunction or elevated troponin

Massive PE is defined by hypotension <90 mm HG lasting more than 15 minutes or requiring inotropic support, shock, profound bradycardia, or cardiac arrest

*Management of submassive and massive PE

Katiyar     Toxicology

The intrinsic and extrinsic coagulation pathways converge at Factor 10

 Excerpt from DeSancho TM, Pastores SM The Liver and Coagulation:   The liver is the primary site of synthesis of most of the clotting factors and the proteins involved in the fibrinolytic system. These include all the vitamin K-dependent coagulation proteins (factors II, VII, IX, X, protein C, protein S and protein Z), as well as factor V, XIII, fibrinogen, antithrombin α2-PI and plasminogen. The notable exceptions are von Willebrand factor (VWF),tPA, thrombomodulin, TPFI and uPA. The VWF, tPA, throm-bomodulin and TFPI are synthesized in endothelial cells, while uPA is expressed by endothelial cells, macrophages, renal epi-thelial cells and some tumour cells [4].

Vitamin K, a fat-soluble vitamin, is required to achieve proper levels of procoagulant factors (II, VII, IX and X) and anticoagulant factors (proteins C, S and Z). These factors require vitamin K as a cofactor for post-ribosomal modification to render them physiologically active.

Warfarin blocks Vitamin K reductase and affects the factors 2,7,9,10, and proteins C,S, Z

Warfarin side effects include blue toe syndrome, skin necrosis, hair loss, and urticaria in addition to bleeding problems.

*Warfarin Blue Toe Syndrome is a rare complication of warfarin.  If is thought to be due to cholesterol emboli released from bleeding within an arterial plaque.  If you stop the warfarin, the toes will remain blue but the pain will improve.  After stopping warfarin, changethe patient to a 10a inhibitor for anticoagulation. Consider other sources of thromboembolism such as an aortic aneurysm.

 

*Foods that have a high level of vitamin K.  Abhi discussed a case in which an elderly patient was not eating any vegetables because she lost her dentures and had an increasing INR because her dietary vitamin K intake had significantly decreased.

If a child ingests rat poison (super-warfarin) you don't need baseline labs on initial presentation.  Kids need coagulation labs 24-48 hours after ingestion. If at that time INR is prolonged or child has bruising/bleeding you would initiate vitamin K therapy.  Life threatening hemorrhage in this situation may require FEIBA for management.

 

*Factor 10a and 11a Inhibitors

Reversal of 10a and 11a inhibitors is accomplished by administering FEIBA.

Altman/Katiyar/Williamson        Medico-Legal Small Group Workshop

Chan/DeWeert     Oral Boards

Case 1.  67 yo female with abdominal pain.  Patient has history of Atrial fibrillation. She is not on warfarin or 10a inhibitor.  On exam pt has diffuse abdominal tenderness. Stool is heme positive. Lactate is 4.6.  Diagnosis is mesenteric ischemia due to an embolism to the SMA confirmed.   Diagnosis made by CTA showing occluded SMA.  Treatment is IV fluids, IV morphine, IV heparin, and IV antibiotics.  Emergent consult to Vascular Surgery and IR.

Which consultant provides definitive treatment (Vascular surgery, GI, or IR) will have to be determined on a case by case basis.  The clinical situation will determine which consultant can bring the most applicable skill set to the patient's care.  Some of the residents discussed cases where the GI consultant scoped the patient prior to surgery to determine the extent of necrosis. Depending on the type and extent of the vessel occlusion and how much the bowel is affected will determine whether Vascular Surgery or IR treats the patient.

 

Case 2. 33yo male with right ankle and foot pain after a fall.  Xrays show a calcaneus fracture.  Examine the spine and entire lower extremity for associated injuries in a patients with a calcaneus fracture.  Initial management is splinting, elevation, non-weight bearing with crutches or walker, pain management and orthopedic consultation.  Many patients with calcaneal fractures can be discharge home with outpatient follow up.  However, there are risks of compartment syndrome of the foot, fracture blisters, and associated injuries of the lower extremities, spine, pelvis and abdomen in patients with calcaneal fractures. .

Case 3.  54yo male with epigastric pain.  He is tachycardic.  Finger stick blood sugar is >600.  Labs are consistent with DKA (anion gap, metabolic acidosis, ketonuria). Patient has an elevated troponin but no STEMI on EKG.  Diagnosis is DKA with NSTEMI.  Treat with IV fluids, IV insulin, potassium, po asa, and IV heparin.

 Dave Barounis taught me to focus on the anion gap and urinary ketones.&nbsp; If both are present in the setting of hyperglycemia, you have DKA.

Dave Barounis taught me to focus on the anion gap and urinary ketones.  If both are present in the setting of hyperglycemia, you have DKA.

Okubanjo      Safety Lecture

I missed this excellent lecture

Chiefs    Ortho Cases

I missed this excellent lecture