Conference Notes 10-31-2018

Twanow M&M

No case details just take home points.

Top 10 Lessons in residency:

10. If you want to be fast in the ED, focus on dispo’s. Make your dispo’s prior to seeing new patients.

9. Be kind to yourself. We have a hard job. Beating yourself up after a less than optimal case is not productive and can be self-destructive.

8. If you feel like something is wrong with a patient, listen to your gut instincts and work them up or re-evaluate them.

7. If your patient is not responding to therapy, you may be missing something. There may be another diagnosis that has not been identified.

6. Stay late for the right things (education, critical patient care) but know when to call it a day. It’s good to put in the effort to learn and care for patients. On the other hand you have to recognize when you are fatigued and not able to be the best for yourself and your patients.

5. Don’t send unstable patients to the CT scanner.

4. You will be in uncomfortable clinical situations at times but know who your backup is.

3. Some patients can be challenging to get along with, but beware, these challenging patients can still be sick with serious disease.

2. Our patients are our responsibility. This includes new patients, signed out patients, difficult patients, all of them.

  1. Be sure to take care of your colleagues. We all need each other to do this job.

Carlson Salicylate Toxicology

Many OTC products contain salicylate. Oil of wintergreen (methylsalicylate) has very high levels of salicylate.

Get serial serum levels of salicylate when managing salicylate overdose patients.

Salicyate causes neurostimulation resulting in tinnitus and increased respiratory rate and vomiting. It increases capillary permeability and can cause pulmonary edema. It uncouples oxidative phosphorylation and will result in lactic acidosis.

Snip20181031_3.png

Andrea made the point that if a salicylate toxic patient becomes lethargic or somnolent you’ve got big problems. Lethargy is a sign of brain dsyfunction, which is the main cause of deaths from salicylate.

Chronic salicylate toxicity is more lethal than acute poisoning. Chronic poisoning has high brain tissue levels despite modest blood levels.

 Beware of brain symptoms such as lethargy and somnolence. Andrea made the point that salicylate-toxic patients most often die from a CNS death.

Beware of brain symptoms such as lethargy and somnolence. Andrea made the point that salicylate-toxic patients most often die from a CNS death.

 Guidelines for hemodialysis in salicylate overdose. (EXTRIP Guidelines)

Guidelines for hemodialysis in salicylate overdose. (EXTRIP Guidelines)

Activated charcoal if given very early, before symptoms develop, binds salicylate very well. If a patient is symptomatic it is likely too late to benefit from activated charcoal.

Treat non-cardiogenic pulmonary edema with peep. You can try BiPap. You can intubate but it is dangerous because of the acidosis. It is difficult for a ventilator to keep up with the patient’s minute ventilation. If you have to intubate, use larger tidal volumes (around 8ml/kg) and high respiratory rate (40). If you can avoid using a neuromuscular blocker that would be optimal. Give 2 amps of bicarb prior to intubation to help manage the acidosis and possibly avoid a peri-intubation arrest.

Urinary Alkalinization: Put 3 amps of bicarb in a 1L bag of D5W and run at 250ml/hr. Add 20-40 meq of potassium to each liter. Shoot for a urine ph >7.5.

Carlson/Pastore Oral Boards

Case 1. 46yo female presents with suicide attempt. Patient is unresponsive. Pupils are pinpoint. Patient responded to narcan. Further history identified that patient ingested Zohydro (extended release hydrocodone). As ED course progressed, patient became re-sedated requiring re-dosing of narcan and starting a narcan drip.

Methadone, fentanyl, tramadol and buprenorphine will not show up positive on drug screen.

Synthetic opioids, such as dextromethorphan, fentanyl, meperidine, methadone, propoxyphene, and tramadol, show little or no cross-reactivity in opiate immunoassays. Urine immunoassays specific for meperidine, methadone, and propoxyphene are available. Given the increasing importance of buprenorphine as maintenance therapy for opioid dependency, it is worth noting that the combination of high potency and low cross-reactivity means that buprenorphine will generally not be detected by opiate immunoassays. Immunoassays for specific detection of buprenorphine have therefore been developed. (Goldfrank’s Toxicology)

Case 2. 19yo female presents with nausea/vomiting and abdominal pain. Patient is pregnant. U/S of pelvis shown below.

 Patients with molar pregnancy may have larger uterus and may have very high beta-hcg.

Patients with molar pregnancy may have larger uterus and may have very high beta-hcg.


Patients with molar pregnancy are at risk for trophblastic malignancy and need follow up. There is also risk of ovarian torsion.

Symptoms include vaginal bleeding in the first or second trimester (75% to 95% of cases) and hyperemesis (26%). Gestational trophoblastic disease, or molar pregnancies that persist into the second trimester, are associated with pre-eclampsia. When pregnancy-induced hypertension is seen before 24 weeks of gestation, consider the possibility of a molar pregnancy. The uterus is excessive in size for gestational age and shows a placenta with many lucent areas interspersed with brighter areas on US study. Because not all molar pregnancies are found on US, all tissue extracted from the uterus on suction curettage or during pelvic examination should be sent for histologic examination. If trophoblastic disease is suspected because of abnormally high β-hCG levels, a uterine size either larger or smaller than expected, and US findings suggestive of the diagnosis, obtain obstetric consultation. Treatment is by suction curettage in the hospital setting because of risk of hemorrhage. β-hCG levels that fail to decrease after evaluation are evidence of persistent or invasive disease necessitating chemotherapy. Metastasis to lung, liver, and brain may occur, but the prognosis for most patients is very good. (Tintinalli 8th ed.)

A molar pregnancy is caused by an abnormally fertilized egg. Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from the father, the other from the mother.

In a complete molar pregnancy, an empty egg is fertilized by one or two sperm, and all of the genetic material is from the father. In this situation, the chromosomes from the mother's egg are lost or inactivated and the father's chromosomes are duplicated.

In a partial or incomplete molar pregnancy, the mother's chromosomes remain but the father provides two sets of chromosomes. As a result, the embryo has 69 chromosomes instead of 46. This most often occurs when two sperm fertilize an egg, resulting in an extra copy of the father's genetic material. (Mayo Clinic online)

Case 3. 25 yo male presents with “allergic reaction” for 2 weeks. Vitals normal. Patient has pruritic rash.

 Rash c/w scabies

Rash c/w scabies

 Typical locations of scabies rash

Typical locations of scabies rash

A single application of 5% permethrin cream is curative for children older than 2 months. The cream may be applied to the face and scalp and needs to be left for 8 hours. Permethrin has been found to have a 97.8% cure rate with one application.10 Permethrin may cause burning and stinging as well as exacerbation of itching, although it is generally very well tolerated and has low potential for toxicity.11 The long incubation period makes treating the entire family advisable. Bedding and clothing should be laundered in hot water and dried using the hot cycle. Clothing and other materials that cannot be laundered should be removed and stored for several days to a week to avoid reinfestation.13 (Pediatric Emergency Medicine)

 From Pediatric Emergency Medicine 5th Ed

From Pediatric Emergency Medicine 5th Ed

Lovell Recruiting Season Update

Berklehammer Inflammatory Bowel Disease

Snip20181031_7.png
 Toxic megacolon can be seen with either ulcerative colitis or crohn’s disease. Bowel is >6cm in diameter. There is loss of haustra.

Toxic megacolon can be seen with either ulcerative colitis or crohn’s disease. Bowel is >6cm in diameter. There is loss of haustra.

 Crohn’s disease patients can get a stricture at the terminal ileum resulting in bowel obstruction.

Crohn’s disease patients can get a stricture at the terminal ileum resulting in bowel obstruction.

 Pyoderma gangrenosum (PG) is an inflammatory condition of all ages but is most common among 20- to 50-year-old females. Lesions can be located anywhere (most commonly on the lower extremities) and begin as a papulopustule surrounded by erythema. This pustule erodes to form a necrotic ulcer. Similar satellite pustules and ulcers form around the original lesion and eventually coalesce into a large ulcer. The surrounding border is “rolled,” due to the convex elevation, and has a violaceous hue. The ulcers are exquisitely tender to movement and palpation. On the extremities, the ulcers can rapidly involve muscles and tendons. Ostomy sites are a common location and make care very difficult.  Half of cases are idiopathic; the other half are associated with inflammatory bowel disease, hematologic diseases (leukemia, myelodysplasia, monoclonal gammopathy), and the arthritides. Since diagnosis is based on examination, dermatopathology, and exclusion of other causes, it is difficult to confirm. (Atlas of Emergency Medicine)

Pyoderma gangrenosum (PG) is an inflammatory condition of all ages but is most common among 20- to 50-year-old females. Lesions can be located anywhere (most commonly on the lower extremities) and begin as a papulopustule surrounded by erythema. This pustule erodes to form a necrotic ulcer. Similar satellite pustules and ulcers form around the original lesion and eventually coalesce into a large ulcer. The surrounding border is “rolled,” due to the convex elevation, and has a violaceous hue. The ulcers are exquisitely tender to movement and palpation. On the extremities, the ulcers can rapidly involve muscles and tendons. Ostomy sites are a common location and make care very difficult.

Half of cases are idiopathic; the other half are associated with inflammatory bowel disease, hematologic diseases (leukemia, myelodysplasia, monoclonal gammopathy), and the arthritides. Since diagnosis is based on examination, dermatopathology, and exclusion of other causes, it is difficult to confirm. (Atlas of Emergency Medicine)

In patients who have crohn’s disease, be very cautious of complaints of back pain or buttock pain. Patient’s with crohn’s can get deep tissue abscesses from fistulas that directly spread to back or buttock musculature.