Conference Notes 1-3-2017

Harwood/Einstein    Oral Boards

Case 1. 18yo patient with multiple blunt trauma: Patient required airway protection for GCS<8.  Patient had diminished breath sounds on the right and required a chest tube and autotransfusion for hemothorax.  Patient had severe splenic and renal injuries that required crystalloid and blood products for stabilization prior to laparotomy.  And just to make it a bit more complicated, the patient had an epidural hematoma requiring neurosurgery.  The patient was able to be stabilized enough to get CT's done on the way to the OR.

 Epidural hematoma

Epidural hematoma

 3 Common types of extra-axial brain bleeds.&nbsp; The Epidural hematoma has the convex side toward the mid-line as opposed to the subdural hematoma that follows the contour of the brain and is concave toward the midline. The reasons it is important are that Epidural hematomas usually need rapid surgery to decompress the brain, and if decompressed have a better prognosis than subdural hematomas.

3 Common types of extra-axial brain bleeds.  The Epidural hematoma has the convex side toward the mid-line as opposed to the subdural hematoma that follows the contour of the brain and is concave toward the midline. The reasons it is important are that Epidural hematomas usually need rapid surgery to decompress the brain, and if decompressed have a better prognosis than subdural hematomas.

 Management Algorithm for Splenic Injuries.&nbsp; Hemodynamically unstable patients get a laparotomy.

Management Algorithm for Splenic Injuries.  Hemodynamically unstable patients get a laparotomy.

 

Case 2. 80 yo male with syncope due to PE

 Pt's presenting EKG showed S1Q3T3 which is seen with pulmonary disease. Classically it is associated with PE but it is not specific for&nbsp; PE.&nbsp; It is a sign of right heart strain and can be seen with bronchospasm, pneumothorax, pulmonary HTN, and PE.

Pt's presenting EKG showed S1Q3T3 which is seen with pulmonary disease. Classically it is associated with PE but it is not specific for  PE.  It is a sign of right heart strain and can be seen with bronchospasm, pneumothorax, pulmonary HTN, and PE.

 The patient also had a Westermark sign.&nbsp; If you are not thinking about this sign, it can be easily overlooked.

The patient also had a Westermark sign.  If you are not thinking about this sign, it can be easily overlooked.

Case 3.

 Patient presented with ankle injury.&nbsp; On exam, pt also had proximal fibular tenderness which is the key to identifying a Maisonneuve fracture.

Patient presented with ankle injury.  On exam, pt also had proximal fibular tenderness which is the key to identifying a Maisonneuve fracture.

Katiyar      Toxicology of Moth Repellents

 Treatment of Camphor toxicity is supportive care with the addition of benzodiazepines for seizures.

Treatment of Camphor toxicity is supportive care with the addition of benzodiazepines for seizures.

 Treat with supportive care in general. If hemolysis is severe,&nbsp; transfuse as necessary.&nbsp; Treat methemoglobinemia with methylene blue.&nbsp; Boards tip: If you are given a pulse ox around 85% think methemoglobinemia. Methemoglobinemia affects the way the pulse ox reads the lightwaves and causes it to read usually around 85%.

Treat with supportive care in general. If hemolysis is severe,  transfuse as necessary.  Treat methemoglobinemia with methylene blue.  Boards tip: If you are given a pulse ox around 85% think methemoglobinemia. Methemoglobinemia affects the way the pulse ox reads the lightwaves and causes it to read usually around 85%.

Cirone            HIV and Related Infections

HIV1 makes up 95% of the HIV cases world-wide.  HIV2 is more common in West Africa and has a slower course of illness.

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Most common cause of pneumonia in an HIV + patient is the same as regular community acquired pneumonia. (strep pneumo, h.influenza)  Staph and pseudomonas  are more common etiologies of pneumonia in HIV patients than the general population. Elise comment: be aware of the risk of TB in HIV patients. It is much higher than in the general population.

You can estimate a patient's CD4 count by looking at their absolute lymphocyte count.  If it is less than 1000 you can expect a low CD4 count (<200).

HIV is commonly co-transmitted with syphillis.  Any pathogen that can cause an ulceration or skin breakdown will increase a patient's risk of HIV transmission.

 

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Molluscum infection on the face should raise concern for HIV infection.  The more molluscum lesions on the face the lower the CD4 count.

 

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Oral hairy leukoplakia looks like candida but you can't scrape it off and it is a sign of HIV.   Elise comment: It is always on the side of the tongue.

If an HIV patient presents with fever and altered mental status get a contrast CT scan of the head to look for ring enhancing lesions.

Barounis           Sepsis

Sepsis is a dysregulated response to an infection.

Sepsis mortality has decreased since 2001.  This is because of early identification of sepsis rather than any specific treatment. No treatment/medication has been shown by itself to decrease mortality in sepsis. 

How do we better identify sepsis patients early on?  Beyond fever and WBC count, Dave suggests looking at patients' respiratory rate and mental status as early bedside indicators that can trigger a consideration of sepsis.  Another marker is a drop in platelets.

Septic shock is MAP<65 and Lactate >2 after initial resuscitation.

Hi Flow nasal cannula is an effective way to provide supplemental oxygen.  Dave always starts at 50L/min.  It even provides a small amount of PEEP.  We have been using it in kids for awhile but it is becoming more commonly used in adults. Dave loves this modality.

Practice Changer     LR has 1% lower mortality than NS for ICU-level septic patients.  Bottom line: Use LR for your septic patients. 1% mortality benefit was also seen in ED patients.  LR is safe and may even be preferred in hyperkalemic patients.    Harwood comment: You can't give a PRBC transfusion with LR so if you have to transfuse, you need to change to NS.

Editor note: If you are going to hydrate a patient who has hyperkalemia, consider giving LR instead of NS.  Dave agreed with this. The pH of LR is higher than NS and tends to move K into the cell. 

Dave made the point of being very thoughtful about IV fluids when managing sepsis. Recent literature shows that overly-aggressive fluids increases sepsis mortality.  My take home points were to switch to LR, and not order maintenance fluids after initial boluses for sepsis patients.  Dave is very wary about maintenance fluids because 125ml/hr adds up to 3L per day and tends to overhydrate patients. Give fluids in targeted doses and not as long term maintenance.

Dave made the point that any patient with septic shock from a UTI needs imaging of their kidneys to evaluate for an obstructed kidney. 

Another urine-related point, if a urine culture shows staph aureus it is due to staph bacteremia. For unclear reasons, staph bacteremia ends up infecting the urine.

The GI literature says that patients with cholangitis should have ERCP within 48 hours.   Dave feels better shortening this 48 hour period to as soon as possible.  If a patient presents at night they may be able to wait until the morning unless they are deteriorating.

Okubanjo               M&M

Editor's note: We will only be discussing take home points to protect the anonymity of the cases.

You can reverse heparin with protamine.  Protamine will also work partially with lovenox.  Reverse NOAC's with FEIBA.

 You an reverse heparin with protamine.&nbsp; Protamine will also work partially with lovenox.&nbsp; Reverse NOAC's with FEIBA.

You an reverse heparin with protamine.  Protamine will also work partially with lovenox.  Reverse NOAC's with FEIBA.

Harwood comment: If a patient is complaining of shoulder pain, think of something irritating the diaphragm like blood.

Review the details of the CBC including neutrophil count and lymphocyte count and platelets to avoid missing subtle abnormalities.  Editor note: If you see toxic granulocytes on the differential be very wary of badness.

Be sure to get a pregnancy test on female patients of child-bearing age with abdominal pain or back pain. 

 Hyperdense artery syndrome of basilar artery.  Hyperdense basilar artery (the basilar artery equivalent of the  hyperdense MCA sign) , present in ~65% 9  A high index of suspicion is needed in the correct clinical setting as the diagnosis can easily be missed (often only present on 1 or 2 slices); additionally it is well recognized that acute clots are of lower attenuation than chronic clots 5-6  Patients with acute occlusion of the  basilar artery  will present with sudden and dramatic neurological impairment, the exact characteristics of which will depend on the site of occlusion:  sudden death/loss of consciousness   top of the basilar syndrome   visual and oculomotor deficits  behavioural abnormalities  somnolence, hallucinations and dream-like behaviour  motor dysfunction is often absent  proximal and mid portions of the basilar artery (pons) can result in patients being 'locked in' 7-8  complete loss of movement (quadriparesis and lower cranial dysfunction)  preserved consciousness  preserved ocular movements (often only vertical gaze) 8  Radiopaedia Reference

Hyperdense artery syndrome of basilar artery.

Hyperdense basilar artery (the basilar artery equivalent of the hyperdense MCA sign), present in ~65% 9

A high index of suspicion is needed in the correct clinical setting as the diagnosis can easily be missed (often only present on 1 or 2 slices); additionally it is well recognized that acute clots are of lower attenuation than chronic clots 5-6

Patients with acute occlusion of the basilar artery will present with sudden and dramatic neurological impairment, the exact characteristics of which will depend on the site of occlusion:

sudden death/loss of consciousness

top of the basilar syndrome

visual and oculomotor deficits

behavioural abnormalities

somnolence, hallucinations and dream-like behaviour

motor dysfunction is often absent

proximal and mid portions of the basilar artery (pons) can result in patients being 'locked in' 7-8

complete loss of movement (quadriparesis and lower cranial dysfunction)

preserved consciousness

preserved ocular movements (often only vertical gaze) 8

Radiopaedia Reference

 This is similar to the above mentioned hyperdense basilar artery sign.

This is similar to the above mentioned hyperdense basilar artery sign.