Conference Notes 11-15-2011

Conference Notes 11-15-2011


Altered mental status differentiates heat exhaustion from heat stroke.

Most effective way to cool patient is evaporative cooling.   Stop cooling once you have patient at 39 degrees.

Pricky heat: Sweat glands get blocked, histamine release, itchy rash.  Treat with antihistamines and talcum powder.

Acclimatization to heat: early onset of sweat production, increased plasma volume, decreased sweat electrolyte concentration, lower heart rate and increased stroke volume.

Most marathoners have a tropnin leak that is not prognostic of adverse outcome.  They can go home.

Dapsone may be effective in brown recluse spider bites.   Controversy about this.

Coral snake: red on yellow kill a fellow, red on black venom lack.  Elapid snake with neurotoxin venom.  Any bite gets antivenom for a coral snake.

Rattlesnakes: Crotalid snake,  triangular head, elliptical pupil, retractible fangs, pit anterior to eye.  Antivenom for spread(progression of localized symptoms)/bled (coagulopathy)/almost dead(abnormal vitals).

Antivenin is not contraindicated in pregnant patients.  It is not weight based.  Starting dose is 5 vials.  May need to redoes antivenin.

Spikey toxins use heat to deactivate toxins.   Slimey toxins use acetic acid.

Life threatening jelly fish are the box jelly fish and Portugese man-o-war.

Cold related EKG findings: Osborn waves, slow v-fib, bradycrdia,  t wave inversion, long pr and qt intervals,  afib,  muscle tremor artifact.

 Cerebral arterial gas embolus (CAGE).  Usually occurs within 10 min of surfacing. Vertigo, and altered mental  status are most common symptoms.   Recompression therapy is the only definitive treatment. Use saline to fill ET tube cuff when sending a patient to hyperbaric treatment.

Most common malady of scuba divers is ear squeeze (Barotitis).

Decompression sickness: Type 1  is joints/skin.             Type 2 is pulmonary, cv, neuro, vestibular.

Chillblain: inflammatory lesions of skin caused by long term intermittent exposure to damp, nonfreezing conditions.

Ophthalmia nodosa is a chronic ocular manifestation after exposure to tarantula spider hair


We covered the management of SVT, AFIB, WPW and Vtach, V-fib and Torsades.


Mesenteric ischemia: Think about this in htn, smoking, dm, afib, post-mi.  You usually have double or triple vessel disease to have ischemia.  Check lactate. Diagnose with CTA. Tx with surgery or embolectomy.

Venous mesenteric ischemia has insidious onset.   Think about It in portal htn, hypercoaguable state, malignancy.  Dx with iv contrast CT. Tx with heparin.

Ischemic colitis: Sudden onset Abdominal pain with passage of mostly blood clots  per rectum. Usually will have lateral abdominal  tenderness.  You don’t need angio for colonic ischemia.  Only need angio for small ball ischemia.

Cholesterol  emboli following  cardiac cath can also cause mesenteric ischemia.


For HPI you need 4 elements for a level  5.

For ROS you need 10 systems elevated for a level  5.

For PMH/SH/FH  you need 2 of 3 for a level  5.

Need 8 organ systems from physical exam for level 5.

Please make note of your medical decision making by noting test results, treatments and ekg/imaging interpretations.

Fortunate   (4-2-10-8) is the mnemonic for remembering what you need for  HPI-PMH/SH/FH-ROS-PE elements to get a level 5.


Get a  troponin on all new onset afib patients or any pt with afib and chest pain.

Important to start heparin or lovenox on all new afib patients in ER.

Consider d-dimer if  considering pe as cause of afib.   TSH should also be obtained in new afib patients.

Consider cardioversion for rhythm control for  young person with lone afib of less than 24 hours,  hemodynamically unstable afib,  patient with paroxysmal afib who is on Coumadin an comes in with afib.   

Any patient with rhythm conversion (chemical or electrical) requires warfarin for 4 weeks.


Rate control target is less than 110 beat per minute.

Ibutilide is best conversion drug.  Chemical cardioversion works better with afib less than 24 hours.

CHADS2 score.   (CHF 1, HTN 1, AGE >70 1, Diabetes 1 , Stroke or embolic phenomenon 2 )Less than 1 you don’t need warfarin and can use asa alone.  2 or more you need warfarin.  If score is 1 could be asa, plavix, dabagatrin, or warfarin based on physician judgment.

Ablation is 95% curative for a flutter.