Conference Notes June 7

Kettaneh/Destefani    Oral Boards

1. 65 yo male with severe vomiting. Initial vitals normal except for tachycardia.

Boerhaave's syndrome can have findings of minimal mediastinal air such as this CXR or large pleural effusion and even pneumothorax as discussed in this case.  Esophogus usually ruptures at the left, posterior aspect. Thus you should look to the left side of the thorax for air and fluid on CXR.

Boerhaave's syndrome can have findings of minimal mediastinal air such as this CXR or large pleural effusion and even pneumothorax as discussed in this case.  Esophogus usually ruptures at the left, posterior aspect. Thus you should look to the left side of the thorax for air and fluid on CXR.

Treatment was thoracic surgical consultation, IV fluid resuscitation, broad spectrum IV antibiotics, and chest tube to drain large pleural effusion.

2. 54 yo female with URI symptoms and headache for 5 days. Vitals are normal except for mild increased respiratory rate and fever.  Diagnosis was meningitis. Give steroids before or at the time of antibiotics. IV steroids have shown the most treatment effect for meningitis due to Strep pneumo.  Strep pneumonia is the most common bacterial cause of meningitis in adults.  Give vancomycin and ceftriaxone.  Consider ampicillin for listeria in patients over age 50.  Consider acyclovir for herpes encephalitis.    Nick and Andrea made the same comment: Strep meningitis may present with mild symptoms initially. So you have to keep your guard up. 

Graph showing the incidence of different etiologic agents of meningitis base on age. Strep pneumo is predominant after for patients 19yo and up. Listeria is increased at less than 1 month and over age 60. 

Graph showing the incidence of different etiologic agents of meningitis base on age. Strep pneumo is predominant after for patients 19yo and up. Listeria is increased at less than 1 month and over age 60. 

 

3. 5 yo male with URI symptoms for 5 days. Vitals are normal.  Patient has had fever during the last 5 days.

Patient had clinical findings consistent with Kawasaki's disease

Patient had clinical findings consistent with Kawasaki's disease

Diagnostic criteria for Kawasakis Disease.  It is also called muco-cutaneous lymph node syndrome.  This term is a brain hack to remember the criteria for diagnosis.

Diagnostic criteria for Kawasakis Disease.  It is also called muco-cutaneous lymph node syndrome.  This term is a brain hack to remember the criteria for diagnosis.

ESR and CRP are usually elevated in the setting of Kawasaki's.  Treatment is po ASA and IVIG.

Carlson      Toxicology Axioms for the EM Graduate

Toxicologic Mimics

Iron toxicity, ASA, and toxic alcohol poisoning can mimic DKA

CO, arsenic, and digoxin toxicity can mimic food poisoning

CO poisoning can mimic SAH hemorrhage

Salicylate overdose can mimic meningitis

Cyanide, CCB's and ASA overdoses can mimic sepsis

Toxidromes

Toxidromes

CCB's, Beta blockers, Organophosphates, botanical cardiac glycosides, flourides, clonidine, sodium channel blocking drugs, INH and gyromitra will all need very large doses of antidote.  Carfentanyl also requires very high doses of naloxone. Most protocols for treating carfentanyl overdoses recommend early intubation to avoid using up stockpiles of narcan.  

 

Gastric lavage is rarely necessary to manage an overdose.  Charcoal administration is also very infrequently required to manage an overdose. If you have any concerns about vomiting or aspiration, you can feel OK about not giving charcoal. 

Get serial levels of salicylate, vlaproate, lithium, tegretol, and theophylline if you have concerns that any of these substances could have be taken in overdose.

Even if you aren't sure of the overdosed medication, many time you can still treat effectively. This is because most of toxicology is supportive care: protect the airway, treat hypotension, cool the hyperthermic patient, correct acid/base abnormalities, prevent renal injury, dialyze as needed, and protect against self-harm.

Williamson      "So you got a Subpoena"

This lecture is not about medical malpractice but rather about subpoenas physicians receiveto testify as a medical professional.

If you receive a subpeona for medical records, refer the request to risk management.

3 types of cases you may be asked to testify: civil, criminal, DCFS.   For civil cases provide testimony on the substance of treatment, the patient's medical condition, and their prognosis.   For criminal cases, you may be asked to provide medical testimony regarding a crime.  DCFS may subpoena you to testify regarding your clinical findings about a child who may have suffered abuse or neglect.

Always contact risk management when you get a subpoena.  Check with your hospital whether they provide legal counsel for treating physician testimony that is not medical malpractice related. Most hospitals do not offer legal counsel for non-malpractice issues.  However, if they do, take advantage of it. It is always helpful to have a lawyer advising you.

The scheduled time on the subpoena is not accurate.  You need to contact the law office to find out the real time.  There is usually some flexibility regarding the date and time of your testimony that you can negotiate with the lawyer.  For depositions, you can ask for a location that is convenient for you.

For depositions for civil suits you should ask to be paid.   Most faculty say they ask for somewhere between $300-500 per hour.   You will be paid at the time of deposition.  When calculating your time, include your travel time.

AMG suggested fee schedule for depositions, testimony, and record review.

AMG suggested fee schedule for depositions, testimony, and record review.

There was a discussion about whether it is reasonable to review the chart prior to going to a deposition or trial.  Most faculty said they would ask for the chart through risk management and not go into the patient's medical record on their own. 

Wear a suit to the deposition or trial.  You are being judge on your appearance and statements. Many depositions are recorded on video.

Always review the transcript of your testimony.  Don't waive your right to review the transcript of your testimony.

When giving a deposition always tell the truth.  Your answer has to be right, correct, and accurate. Do not answer hypothetical questions.

Elise comment: You have to be like a rock during a deposition, emotionless.   The lawyers are trying to get you to react.  Don't take the bait.  Always, answer calmly sticking to the direct facts that are documented on the medical record.  If they are asking questions of the case beyond the medical record, you can say repeatedly "I have no independent recollection"

Dennis comment: Cautiously give as focused and as limited an answer that you can give to each question.

If you get served a subpoena for medical malpractice, contact risk management immediately and don't discuss with anyone else.

Logan    5 Slide Follow Up   20+ week Peripartum Emergencies

Peripartum Cardiomyopathy   Diagnose with echo.  Treat with nitorglycerine, diuretics, inotropes, and heparin.

Thromboembolic disease   5 times greater risk during pregnancy and 60 times the risk for 3 months after pregnancy .  Treat with heparin which does not cross the placenta.

Pre-Ecclampsia and HELLP   Diagnose with a straight-cath Protein/Creatinine ratio.   Treat with magnesium, BP control, and delivery.

Placental Abruption   Diagnose with fetal monitoring.  U/S is not sensitive for placental abruption.

Hawkins    5 Slide Follow Up    Calcium Channel Blocker Overdose

Management(Life in the Fast Lane Reference)

  • early intubation and ventilation when life-threatening toxicity is anticipated
  • Early invasive blood pressure monitoring if evolving hypotension and shock; initiate therapies below

Specific treatment (support cardiovascular system)

  • Fluid resuscitation (up to 20 mL/kg crystalloid)
  • Calcium
    • can be a useful temporising measure to increase HR and BP
    •  options
      • 10% calcium gluconate 60mL IV (0.6-1.0 mL/kg in children)
      • 10% calcium chloride 20mL IV (0.2 mL/kg in children) [must be given via CENTRAL VENOUS ACCESS – it burns!]
    • repeat boluses can be given up to 3 times
    • consider calcium infusion to keep serum calcium >2.0 mEq/L
  • Atropine: 0.6mg every 2 min up to 1.8 mg (often ineffective)
  • High dose insulin – euglycaemic therapy (HIET)
    • see below
  • Vasoactive infusions
    • titrate catecholamines to effect (inotropy and chronotropy); options include dopamine, adrenaline and/ or noradrenaline
    • if vasoplegic, consider noradrenaline and vasopressin. Consider methylene blue if refractory (to decrease cGMP formation, scavenge nitric oxide, and inhibit nitric oxide synthesis leading to vasoconstriction).
  • Sodium bicarbonate
    • consider in severe metabolic acidosis
    • 50-100 mEq sodium bicarbonate (0.5-1.0 mEq/kg in children)
  • Cardiac pacing
    • electrical capture may be difficult to achieve and may not improve overall perfusion
    • use ventricular pacing to bypass AV blockade, typical with rates not in excess of 60/min
  • Intralipid
    • consider in refractory cases, as calcium channel blockers lipid soluble agents
  • Circulatory support devices
    • consider in refractory cases
    • VA ECMO or cardiac bypass is preferred to intra-aortic balloon counterpulsation (useful if poor inotropy, will not correct refractory vasoplegia)

High-dose insulin euglycaemic therapy (HIET)

  • The place of HIET in the step-wise approach to managing cardiovascular toxicity has evolved
  • Formerly considered a last ditich measure, early is use is increasingly advocated. This is important as the beneficial effects of HIET are not immediate

 

Elise and Harwood both made the point of avoiding charcoal in any patient with altered mental status or risk of seizure, vomiting, or needing intubation.

Elise and Harwood both made the point of avoiding charcoal in any patient with altered mental status or risk of seizure, vomiting, or needing intubation.

Recommended high-dose insulin euglycaemic therapy protocol based on the clinical experience of the Western Australian Toxicology Service, published case reports, reviews and animal studies (from Nickson and Little, 2009)

Schmitz      Administrative Update

Regan/Hart   Visual Diagnosis

Cannon ball metastases are associated with renal cell carcinoma and choriocarcinoma.  Less commonly prostate cancer, synovial sarcoma, and endometrial cancer.

Cannon ball metastases are associated with renal cell carcinoma and choriocarcinoma.  Less commonly prostate cancer, synovial sarcoma, and endometrial cancer.

Diffuse ST depression with ST elevation in AVR is consistent with Left Main coronary Artery occlusion.    

Diffuse ST depression with ST elevation in AVR is consistent with Left Main coronary Artery occlusion.

 

 

Glioblastoma classically has butterfly appearance on CT.  See image below as well.  

Glioblastoma classically has butterfly appearance on CT.  See image below as well.  

Glioblastoma

Glioblastoma