Conference Notes 3-7-2018

For additional ultrasound education, you can find our monthly "Ultrasound Case Series" on the Christ EM website under the "Residents" tab: http://www.christem.com/ultrasound-case-series

Herron/Tran     Oral Boards

Case 1. Pregnant patient presents with seizures and hypertension.  Dexi was normal.  Patient was treated with IV magnesium, BP management and emergent delivery of baby.   Patient also had criteria for HELLP.

Snip20180307_3.png

Harwood comment: The keys to managing this case are IV magnesium and emergent c-section.

 Medications for treating hypertension in pre-eclampsia and eclampsia. Tintinalli 8th ed.

Medications for treating hypertension in pre-eclampsia and eclampsia. Tintinalli 8th ed.

Case 2.  60yo female presents with bi-temporal headache. ESR is 100.  Diagnosis was temporal arteritis.

Snip20180307_4.png

Treatment was initiating po steroids 60mg/day and arranging for temporal artery biopsy

Case 3. 15 yo male in cardiac arrest after being struck in the chest with a hockey puck.

 Patient is pulseless with polymorphic VT

Patient is pulseless with polymorphic VT

Patient was treated with IV epinepherine, defibrillation, and magnesium.  Patient had ROSC.  Therapuetic hypothermia was initiated. Diagnosis was commotio cordis.

 Mechanism of comotio cordis   (Life in the Fast Lane)

Mechanism of comotio cordis   (Life in the Fast Lane)

Dr. Lovell comment: Post-arrest you have to be disciplined about keeping the patients O2 sat at 94% (avoid hyperoxia), checking the post ROSC EKG for STEMI, and keeping BP over 90 systolic.  Target therapeutic hypothermia to a temperature of 36C.  Look for alternative cause of arrest such as sepsis.

Sklar     Study Guide        Infectious Disease

Patients with HIV/AIDS who present with pneumonia treat for PJP with Bactrim and also cover CAP. If patient is hypoxic give steroids.

 Stages of Lyme Disease

Stages of Lyme Disease

 Erythema chronicum migrans rash of Lyme disease

Erythema chronicum migrans rash of Lyme disease

Rabies wound care: Provide proper wound care, including tetanus prophylaxis, wound cleansing with soap and water and (if available) a dilute solution of povidone-iodine (1 mL povidone-iodine in 9 mL of water or normal saline), antibiotics (if indicated) to prevent bacterial infection (see chapter 46, Puncture Wounds and Bites), and rabies prophylaxis as indicated.17

 Rabies post-expoosure treatment recommendations

Rabies post-expoosure treatment recommendations

 There was a discussion about which patients should receive post-exposure prophylaxis for rabies.   A pre-verbal child or an older child or adult who for some reason may be obtunded or not be able to express that they were bitten who were in a room with a bat should receive  post-exposure prophylaxis.  Older children and adults with normal cognitive function will likely be able to accurately tell if they were bitten or not based on this picture.  Harwood also discussed a theory that it may be possible to contract rabies without a bite if you are in cave or lab or other area where many bats are living. Bats may be able to exhale the rabies virus into the air.  This theory is controversial.   Picture courtesy of Dr. Lovell.

There was a discussion about which patients should receive post-exposure prophylaxis for rabies.   A pre-verbal child or an older child or adult who for some reason may be obtunded or not be able to express that they were bitten who were in a room with a bat should receive  post-exposure prophylaxis.  Older children and adults with normal cognitive function will likely be able to accurately tell if they were bitten or not based on this picture.

Harwood also discussed a theory that it may be possible to contract rabies without a bite if you are in cave or lab or other area where many bats are living. Bats may be able to exhale the rabies virus into the air.  This theory is controversial. 

Picture courtesy of Dr. Lovell.

Gonococcal arthritis is the most common form of septic arthritis in adolescent and young adults.   The clinical picture of gonococcal arthritis is migratory arthritis, pustular rash and tenosynovitis.  Treatment is IV or IM ceftriaxone 1gram Q day initially.

 Pustule from disseminated gonorrhea

Pustule from disseminated gonorrhea

 Rocky Mountain Spotted Fever Rash

Rocky Mountain Spotted Fever Rash

 Rocky Mountain Spotted Fever Rash

Rocky Mountain Spotted Fever Rash

Treatment of RMSF for adults is doxycycline, 100 milligrams PO twice a day; for children under 45 kg with permanent teeth, treatment is doxycycline, 2.2 milligrams/kg twice a day. Doxycycline does not cause staining of permanent teeth.   (Text and pictures from Tintinalli)

 

 Grey membrane from diphtheria. Complications include myocarditis and neuritis potentially leading to diaphragmatic paralysis and death from respiratory failure. Diagnosis is confirmed by isolation of  C. diphtheria  by cultures of a nasopharyngeal swab. Treatment includes antitoxin and antibiotics ( erythromycin  or penicillin G) and respiratory support as needed. Tintinalli 8th ed.

Grey membrane from diphtheria. Complications include myocarditis and neuritis potentially leading to diaphragmatic paralysis and death from respiratory failure. Diagnosis is confirmed by isolation of C. diphtheria by cultures of a nasopharyngeal swab. Treatment includes antitoxin and antibiotics (erythromycin or penicillin G) and respiratory support as needed. Tintinalli 8th ed.

Yersinia enterocolitica infections are due to contaminated pork.  It can cause RLQ abdominal pain and diarrhea that is sometimes bloody in children and young adults. Yersinia has a preference for lymphoid tissue so will go to the area around appendix.  Diagnose yersinia with specific stool culture.   Yersinia enterocolitica infections are usually self limited but if there are systemic signs, treat with ceftriaxone or fluoroquinalones

Girzadas    Study Guide     Neurology

I gave this lecture so didn't take any notes.

However,  we did have one interesting discussion about initial stroke care.  We will discuss this further in Journal Club next week but a new strategy for more severe strokes has been published recently.  It employs the VAN score to more rapidly evaluate strokes with a risk for large vessel occlusion amenable to stent retriever endovascular therapy.  Thanks to Mitch Lorenz for the VAN references below.

 The VAN screening assessment. To be VAN positive you need to have weakness of one arm PLUS any   one   of the Visual, Aphasia, or Neglect signs. If the patient has no arm weakness, they are VAN negative.  If they have arm weakness but no other finding listed on the screening tool,  they are VAN negative.

The VAN screening assessment. To be VAN positive you need to have weakness of one arm PLUS any one of the Visual, Aphasia, or Neglect signs. If the patient has no arm weakness, they are VAN negative.  If they have arm weakness but no other finding listed on the screening tool,  they are VAN negative.

 VAN positive patients get CT and CTA right at the beginning of their ED visit.  The controversy is whether this goes against the new 2018 AHA guidelines which advise not delaying TPA to get CTA done. It appears that the VAN protocol gets TPA infused and endovascular therapy started more quickly anyway. We may be moving to this model of care.

VAN positive patients get CT and CTA right at the beginning of their ED visit.  The controversy is whether this goes against the new 2018 AHA guidelines which advise not delaying TPA to get CTA done. It appears that the VAN protocol gets TPA infused and endovascular therapy started more quickly anyway. We may be moving to this model of care.

Tekwani     Airway Lecture

Case 1.   If a patient has their jaw wired shut and you need to intubate, call Ortho, the OR,  or hospital maintenance personnel  to get wire cutters to snip jaw wires.  If an airway is suspected to be difficult, one strategy would be to sedate the patient with ketamine to see if you can visualize the airway prior to giving rocuronium.

Case 2.  Dr. Barounis comment: In the patient with peri-intubation hypotension, perform intubation with no paralysis and minimal or no sedation.  Just use good topicalization with atomized and topical lidocaine. It is a strategy to avoid CV collapse.  You avoid taking away the patient's  inspiratory drive that provides venous return.  Also look for blood loss, pericardial tamponade, and PE or MI as a cause for hypotension.

Case 3.  If there is a bloody airway, be prepared for failure of VL due to blood obscuring camera.  Have direct laryngoscopy ready to go.

Case 4. Pearl: If patient has chronic torticollis, assess neck movement prior to paralysis to make sure that patient does not have shortening of neck muscles that will make positioning difficult. You don't want to find that out after you paralyze the patient.

Case 5. Lubricate the ET tube to help it pass over the arytenoid cartilage.  Suction the airway prior to placing the tube. Make sure you have the glidescope in the velecula to give yourself some room to intubate.  If you have the glidescope blade lifting the valecula from the posterior side it makes intubation more difficult because you don't have enough room to place the tube.

Hormese             Changes to Adult DKA Guidelines

Identifying DKA:  Ph<7.3, bicarb<18, or anion gap.  Consider euglycemic DKA if glucose less than 250 but patient still has acidosis or gap.

LR preferred resuscitation fluid for DKA.  LR bolus up to 2 liters initially  followed by 150ml/hr.

If K<3.3 hold insulin until K is corrected with IV potassium.  If K<5.3 add 40meq K/liter to IV fluids.

Bicarb not indicated unless pH<7.0

Insulin drip 0.1u/kg/hr.   You want to aim for decreasing glucose by 75 md/dl/hr.   Titrate insulin for this ballpark rate of decrease.

You can transition to subQ insulin if the patient can tolerate PO, blood sugar drops below 250, acidosis has resolved, and gap has closed.

For additional ultrasound education, you can find our monthly "Ultrasound Case Series" on the Christ EM website under the "Residents" tab: http://www.christem.com/ultrasound-case-series