Conference Notes 7-19-2017

Girzadas/Marshalla     Oral Boards

Case 1.  29 you female extricated from an MVC.  Patient is 35 weeks pregnant. Patient has abdominal pain and vaginal bleeding.  She is hypotensive.  Fast exam reveals no intra-abdominal bleeding. Pelvis is stable.  Diagnosis is traumatic placental abruption.  Management: With C-spine precautions, tilt patient to left side to displace uterus off the vena cava.  Replace volume loss with crytalloid and blood products.   Initiate massive transfusion protocol.  Monitor the fetus.  Patient needs to go for emergent c-section. 

Abruption can cause DIC which may necessitate FFP, Platelet, and or Cryopreciptate transfusion.  Consensus among the faculty was that TXA would also be indicated in this case.

U/S is insensitive for diagnosing placental abruption.  Fetal monitoring is more sensitive.  Have a low threshold in pregnant women with a viable pregnancy who suffer a fall, mvc, or other trauma to send the patient to L&D for monitoring.   The placenta is inelastic.  With trauma or deceleration the uterus will deform and the placenta won't causing a shear stress that results in abruption.

The initial symptoms of abruption can be mild or overlooked.  The standard fetal monitoring period is 4 hours.  If the monitor shows infrequent contractions and normal fetal heart rate, the patient can be discharged after 4 hours.  If the patient has more frequent contractions or a worrisome fetal heart tracing the patient will be kept for a long period of time.

 

Case 2.  31 yo man with palpitations.  Initial EKG shows fast, irregular rhythm with varying QRS intervals.

 Elise comment: Know this EKG.  Irregular, wide and narrow, fast.  The answer for this EKGis always procainamide if stable, synchronized cardioversion if unstable.

Elise comment: Know this EKG.  Irregular, wide and narrow, fast.  The answer for this EKGis always procainamide if stable, synchronized cardioversion if unstable.

Patient then became unstable with hypotension and altered mental status.  EKG now shows:

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WPW with AFIB has degenerated to a wide complex, very fast tachycardia.  With the patient being unstable, immediate synchronized cardioversion is indicated.

EKG after cardioversion shows WPW syndrome with clear delta waves.

Patient was admitted to cardiology service for catheter ablation.

Case 3. 6 yo child with injury and gross deformity of left elbow after a fall from bike.  Xrays show displaced supracondylar fracture (Gartland 3)

Keys to management include careful neuro-vascular exam of injured extremity.  The most commonly injured nerve with supracondylar fractures is the median nerve.  A pure motor branch of the median nerve that is commonly injured is the anterior interosseus nerve.  This nerve is tested by seeing if the patient can perform the OK sign.

Supracondylar fractures have high risk for vascular (brachial artery) injury, nerve (median and radial) injury, compartment syndrome, and chronic boney deformity (cubitus varus).  Untreated, compartment syndrome can result in volkmann's ischemic contracture.

Non-displaced supracondylar fractures with intact NV status can be splinted and dc'd home with close Orthopedic follow up after consultation with Orthopedic Specialist.  Class 2 fractures with an intact posterior cortex will be treated on a case by case basis per Orthopedic surgery.  Some may be able to be discharged, some may need to have ORIF and admission.  All Class 3 fractures are going to the OR. If the patient has a good pulse and warm fingers there is no need for emergent manipulation of the fracture in the ED.  If the pulse is diminished and the fingers are warm, have cap refill, and/or have a good pulse ox wave form then again there is no need for emergent ED manipulation of the fracture.  This patient can be managed in the OR.  If the pulse is diminished and the fingers are cool or have poor cap refill or have poor pulse ox waveform and there will be a delay to going to the OR then after discussion with the Orthopedic Specialist, the emergency physician may need to attempt reduction of the fracture prior to the patient going to the OR.

 

Williamson      Study Guide      GI Emergencies

 American College of Gastroenterology Guideline for Diarrhea Management 2016

American College of Gastroenterology Guideline for Diarrhea Management 2016

Treat traveler's diarrhea with cipro or azithromycin.  Traveler's Diarrhea has high enough risk of bacterial pathogen to warrant antibiotics.  Below are recommendations by the American College of Gastroenterology

Viruses are the most common cause of diarrhea. Campylobacter is the most common bacterial cause of diarrhea presenting to the ED.  

Most common cause of food poisoning is staph gastroenteritis.

Glucagon showed no benefit over placebo for treatment of esophageal food impaction.

 Crohn's and Ulcerative Colitis

Crohn's and Ulcerative Colitis

 Crohn's and Ulcerative Colitis

Crohn's and Ulcerative Colitis

Ogilvie's syndrome can be treated with neostigmine.  Alternative treatment is colonoscopic decompression.

Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P<0.001). The median time to response was 4 minutes (range, 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine.  (NEJM 1999 341:137)

Anthony Gallaway Equality Illinois    LGBTQ Ally Development Training

Gender identity does not define Sexual Orientation and Sexual Orientation does not define gender identity.  

Sex assigned at birth does not define gender identity or gender expression or sexual orientation.  

As a physician, sometimes it is medically necessary to delve into a patient's gender status.  If there is some uncertainty on the physician's part about a patient's gender (biologic, identity, expression),  one suggested strategy is to introduce yourself and say these are my pronouns (she, her, her's, or he, him, his). You can then ask the patient, "what are your pronouns?"    If indicated to appropriately treat the patient, you can ask, "What gender were you assigned at birth?"    If medically necessary, you can ask further, "Do you have sexual relations with males or females or both?" If a genital exam needs to be performed, be sure to fully inform the patient what will be done as part of the exam.   Throughout all this history and physical process, it is most important to be supportive and caring. Demonstrating that you are an ally will help the patient the most.  Only delve into these questions if it is important to care for the patient medically.  If the answers to these questions are not directly relevant to the patient's care, don't ask them. 

Intention is everything.  If you make some mistakes while being well-intentioned and caring it is OK.

To re-emphasize, as a clinician you don't always need to know the patient's sexual assignment at birth or their gender status.  So you definitely don't always need to ask those questions.

LGBTQ patients have fear or discomfort with medical care because they don't know if the medical providers are going to be supportive or judgmental/disapproving of them.

A person can take Truvada with use of a condom to prevent HIV infection. This is called PREP (pre-exposure prophylaxis).

It means so much to LGBTQ patients to express a supportive and welcoming attitude.  Ask, "How can we help you today?"  Use your smile and your warmth when you ask this.

Ohl     Sedation and Paralytics

Sean discussed the sedation medications and neuromuscular blockers used for Rapid Sequence Intubation.

Sean then discussed the key points to rapid sequence intubation. 

Wing       EICU Process for Patients Awaiting a MSDU Bed

Elisa discussed the new process for initiating EICU coverage for patients boarding in the ED while waiting for step-down beds.