Conference Notes 7-5-2017

Lovell/Ohl      Oral Boards

Case 1. 35yo male fell off a boat and suffered a severe laceration to his mid thigh from a propeller injury. 

  • Patient has severe bleeding and a tourniquet is applied to the left thigh by EMS. 
  • Massive transfusion protocol initiated in ED. 
  • Patient also has signs of worsening hypoxia due to drowning.  Patient was then intubated. Patient was evaluated for other injuries. 
  • TXA was given for severe hemorrhage.
  • Patient went to the OR for femoral artery injury. 

Do not explore the wound locally. This patient has hard signs for arterial injury and is going to the OR.

In accordance with the ILCOR guidelines, patients should be referred to as drowning victims if they have suffered a suspected respiratory injury following submersion in a liquid medium, regardless of their clinical status, which may vary from essentially asymptomatic to severely ill at time of presentation. Additional descriptors such as whether there was a precipitating event that led to drowning or whether the drowning was witnessed may be used as necessary. The primary outcome of a drowning episode is either death or survival. Adopting this clinical nomenclature will allow future studies to better characterize, study, and risk stratify drowning victims.   EM Reports Vol 16 N. 32015.

 Hard and Soft signs of arterial vascular bleeding

Hard and Soft signs of arterial vascular bleeding

Case 2.  20 yo female with a headache for a few hours.  Normal Vital signs. Patient has nausea and left anterior neck and face pain as well.   Patient was on a roller coaster ride prior to the onset of this pain.   On exam patient has a horner's syndrome on the left side ipsilateral to where she is having pain.

 Horner's syndrome on the left.   Horner's caused by internal carotid artery dissection will have ptosis and miosis but not anhydrosis.  Anhydrosis is caused by sympathetic ganglia around the external carotid, not internal carotid. 

Horner's syndrome on the left.   Horner's caused by internal carotid artery dissection will have ptosis and miosis but not anhydrosis.  Anhydrosis is caused by sympathetic ganglia around the external carotid, not internal carotid. 

CTA of the neck shows that the diagnosis was internal carotid artery dissection. 

  • Treatment for extra-cranial dissections is usually anticoagulation. 

Case 3.  28 yo male with joint pain in bilateral wrists/hands and ankles. Patient has a temperature of 38 and otherwise normal vital signs. Patient has a few pustules on his hands and ankles.

 Pustule from disseminated ghonorrhea

Pustule from disseminated ghonorrhea

  • Treatment is parenteral ceftriaxone for a minimum of 7 days.   Treat chalmydia presumptively as well.   

Dissemenated ghonorrhea can present with one of two syndromes: 1. dermatitis-tenosynovitis or 2. oligo arthritis.  Get an RPR and HIV test on every patient.  It is tough to make this diagnosis so swab urethra/cervix. If you can get fluid from a pustule or a joint also culture and gram stain that fluid.

Schmitz    M&M  

No case specifics, just a couple of take home points.

Get a CT scan of the head in patients who are intoxicated and have suffered head trauma.   If the patient refuses the study you have to carefully balance the patient's decisional capacity with the risk of intracranial injury.  Err on the side of imaging and sedate if necessary to get the study done.  Observation in the ED in place of imaging can be problematic for many reasons so getting a scan is the more fail-safe approach.

Be aware of anchoring bias.  Patients triaged to the hallway can still have serious injuries.

Be cautious of your cognitive biases.  Cognitive bias can mislead us. 

 Be careful not to attribute a patient's behavior to some personality or character flaw rather than to their illness, pain, or injury. This bias is called the "Fundamental Attribution Bias"

Be careful not to attribute a patient's behavior to some personality or character flaw rather than to their illness, pain, or injury. This bias is called the "Fundamental Attribution Bias"

Chiefs      Codes (44, Sepsis, STEMI, Stroke)  in the ED

Approach all these rapid response codes in the ED the same way every time.  Assess the patient's airway.  Evaluate their breathing and circulation.  Do a rapid NIH stroke scale and expose them completely to look for other problems.    In short, ABCDE's, IV, O2, Monitor, Dexi, EKG on all these patients.

35% of patients with sepsis progress to septic shock.  So if you identify sepsis, call a CODE SEPSIS.  It will get you nursing and pharmacy help for the care of that patient.

 Our Goal is administering IV antibiotics within 1 hour of identifying sepsis.  If the patient has hypotension (systolic BP<90 or MAP<65) or a lactate of 4 or above they need 30ml/kg of IV crystalloid fluids.  If you have concerns that the patient cannot handle 30ml/kg of crystalloid you can alternately give 126ml/hr or higher of IV fluids and write a note in the chart discussing briefly why you felt 30ml/kg was unsafe for the patient. 

Our Goal is administering IV antibiotics within 1 hour of identifying sepsis.  If the patient has hypotension (systolic BP<90 or MAP<65) or a lactate of 4 or above they need 30ml/kg of IV crystalloid fluids.  If you have concerns that the patient cannot handle 30ml/kg of crystalloid you can alternately give 126ml/hr or higher of IV fluids and write a note in the chart discussing briefly why you felt 30ml/kg was unsafe for the patient. 

For CODE Strokes you need to do an NIH Stroke Scale.   Girzadas comment:  The NIH Stroke Scale is the new defacto EM Neuro Exam.  You need to do this on your patients with neurologic symptoms.

 NIH Stroke Scale

NIH Stroke Scale

 Absolute contraindications to TPA for Stroke.&nbsp; Take a close look on this chart at the factors regarding bleeding diathesis.&nbsp;

Absolute contraindications to TPA for Stroke.  Take a close look on this chart at the factors regarding bleeding diathesis. 

Traylor      Ventilator Management

Indications for intubation: 1. protect airway,  2. inadequate oxygenation and/or inadequate ventilation despite non-invasive O2 support, 3. Respiratory fatigue or anticipated respiratory failure.

 Ventilator Lung Protective Strategy &nbsp;

Ventilator Lung Protective Strategy  

 Obstructive Ventilation Strategy &nbsp; EMCRIT reference

Obstructive Ventilation Strategy   EMCRIT reference

Denk    Management of Shock

 4 types of shock.

4 types of shock.

Treat hypovolemic shock with volume (crystalloid or blood products)

Treat with distributive shock with volume and pressors

Treat obstructive shock with volume and concurrently a needle, chest tube, impella device, thoracotomy, or TPA.

Treat cardiogenic shock with dobutamine/norepinepherine and concurrently activate cath lab for PCI and or mechanical support device.