Conference Notes 5-24-2017

Putman/Ohl    Oral Boards

Case 1.  50 yo male with fatigue and low grade fever.  Patient has a petechial rash/skin bruising. Labs show anemia and low platelets. Peripheral smear shows shistocytes. Bun/Creatinine was elevated.   Patient has mental status change as well. Diagnosis is TTP.

 Classic Pentad for TTP.  However, the Triad of anemia, thrombocytopenia, and neurologic symptoms without fever and renal dysfunction is more common than the Pentad.

Classic Pentad for TTP.  However, the Triad of anemia, thrombocytopenia, and neurologic symptoms without fever and renal dysfunction is more common than the Pentad.

Treatment of TTP includes Plasma Exchange (PEX), andIV steroids.   TTP is due to ADAMTS13not cleaving VWF and platelets. Because of this ADAMTS13 dysfunction, the patient gets long VWF and marked platelet aggregation.   When considering TTP, check the level of ADAMTS13 activity.   Do not transfuse platelets unless there is life-threatening bleeding.  More platelets can cause larger platelet aggregates.  Get plasma exchange done as rapidly as possible.

Elise and Harwood comment: Avoid doing an LP and central line in non-compressible sites when the platelet count drops below 50,000.  

 

Case 2.  36 yo male presents with dental pain, fever, and brawny edema of the submandibular area.

*Ludwig's Angina is the diagnosis.  Treat with broad spectrum antibiotics and consult for ENT surgical evaluation.   Be prepared for difficult intubation.

Case 3.   35 yo female bit by her cat.  Treatment includes prophylactic antibiotics to cover pasturella multocida.  Augmentin is the usual choice for patients who are not PCN allergic. For PCN allergic patients, bactrim + Clindamycin or doxycycline + clindamycin or cipro + clindamycin are options.   Update tetanus status. Cat bites are low risk for rabies.  Check an xray for fracture or foreign body.

*Tip of the Cap:  Bristol Schmitz was nominated for an MVP Award*

Lovell/Williamson      Spiritual Wellness & Mindfulness

Resilience is foundational to wellness.   

One simple thing you can do to develop wellness is at the end of each day think of 3 good things that you experienced that day.

Spiritual Wellness includes: Nurturing your deliberate actions.  Having the ability to reset your attitude or thinking.  Finding purpose and meaning in your work.  Employing mindfulness, meditation, and or religion to reach spiritual wellness.

Mindfulness is a tool to improve our spiritual wellness.   Mindfulness is paying attention to the moment with purpose, and not passing judgment on the moment or the thoughts we have at that moment. This can include meditation or conscious breathing or just presence in the moment.  This is the opposite of multi-tasking. It is focused mono-tasking.  

Victor Frankl made the point that mindfulness helps us learn about the space between a stimulus we experience and our response to that stimulus. We can control that space and positively impact our behavior.

You can start to meditate by doing it 10 minutes a day for 10 days in a row.  "Head Space" is a website developed by a buddhist monk that can help you meditate.   Research has shown that Meditation develops your anterior cingulate cortex.

Tekwani       Study Guide  

WASH regimen for anal fissures: Warm water (sitz baths), Analgesia, Stool softeners, and High fiber.

With exposure to hepatitis B infection patient will develop anti-HBS and anti-HBC.   With vaccination, the patient will only have anti-HBS and not anti-HBC.  Editorial comment: For test purposes maybe remember C stands for Close Contact with source person. Kinda weak mnemonic but the best I could come up with.

 Amebic abscess is usually single and has a rim of edematous tissue.  Amebic abscess is treated with metronidazole.  Patients with amebic liver abscess may have an associated right side pleural effusion.

Amebic abscess is usually single and has a rim of edematous tissue.  Amebic abscess is treated with metronidazole.  Patients with amebic liver abscess may have an associated right side pleural effusion.

Strangulated hernias will have abdominal and or systemic signs due to impaired blood supply to the affected bowel.  Patients will have fever, tachycardia, and peritonitis. Don't reduce suspected strangulated hernias in the ED.  You may perforate the bowel. Consult surgery and start antibiotics.   Hernias with no fever, no peritonitis, and no systemic symptoms can have an attempt at reduction in the ED. 

 Cecal volvulus seen in young patients,  usually has dilated bowel in left upper quadrant on test questions.  Also look for dilated  small bowe l loops associated with cecal volvulus.   Sigmoid volvulus seen in elder patients, usually has dilated bowel in right upper quadrant and has dilated  large bowel  most prominantly. 

Cecal volvulus seen in young patients,  usually has dilated bowel in left upper quadrant on test questions.  Also look for dilated small bowel loops associated with cecal volvulus.   Sigmoid volvulus seen in elder patients, usually has dilated bowel in right upper quadrant and has dilated large bowel most prominantly. 

Dawson        Pediatric Airway Emergencies

Failure to manage the airway is the leading cause of preventable deaths in children.

The Pediatric airway is narrowest at the subglottic cricoid ring. The pediatric larynx is more superior in the neck compared to adults. The infant tongue is larger than the adult tongue.

 Dr. Dawson rarely uses an uncuffed ET tube. As a general rule cuffed ET tubes are preferred for most pediatric patients.

Dr. Dawson rarely uses an uncuffed ET tube. As a general rule cuffed ET tubes are preferred for most pediatric patients.

Lemierre's syndrome (or Lemierre's disease, also known as postanginal shock including sepsis and human necrobacillosis) refers to infectious thrombophlebitis of the internal jugular vein.[1] It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.

Lemierre's syndrome occurs most often when a bacterial (e.g., Fusobacterium necrophorum) throat infection progresses to the formation of a peritonsillar abscess. Deep in the abscess, anaerobic bacteria can flourish. When the abscess wall ruptures internally, the drainage carrying bacteria seeps through the soft tissue and infects the nearby structures. Spread of infection to the nearby internal jugular vein provides a gateway for the spread of bacteria through the bloodstream. The inflammation surrounding the vein and compression of the vein may lead to blood clot formation. Pieces of the potentially infected clot can break off and travel through the right heart into the lungs as emboli, blocking branches of the pulmonary artery that carry blood with little oxygen from the right side of the heart to the lungs.

Sepsis following a throat infection was described by Schottmuller in 1918.[2] However, it was André Lemierre, in 1936, who published a series of 20 cases where throat infections were followed by identified anaerobic sepsis, of whom 18 patients died.  Wikipedia reference.