Conference Notes 9-13-2011

GROMIS   ASOKEN   Use of Contrast for imaging studies

Most abdominal studies can be done without contrast.

Rectal contrast can save you time when doing a abdominal study.  Downsides are pt discomfort,  and pt having release of contrast from rectum. 

If the pt has some abdominal fat ct without contrast should be fine because the fat will outline the organs.

IV contrast is critical to opacify blood vessels example pe and aortic dissection. IV helps with inflammatory changes.   Looking for mets/tumor is aided by iv contrast. 

Oral contrast is much less likely to cause allergy compared with iv contrast.  IV contrast is iodine based so more allergic potential. Probably not a true allergy but more likely an idiosyncratic reaction.  

IV contrast is unpredictable in relation to causing an allergic reaction.  Patients with any type of allergy may be at increased risk.   Seafood allergy doesn't specifically mean a pt will be allergic to iodine based contrast.

GFR less than 30 is high risk for iv contrast.   GFR between 30 and 60 needs a risk/benefit analysis between radiologist and EM Doc.

IV or PO  hydration is the key to preventing increase in creatinine due to contrast. 

You probably don't need contrast for ct abd/pelvis for appy, obstruction, diverticulitis.

HINTON   CT ABD/PELVIS

Fat stranding is important marker of inflammation

Appendicitis shows an appendix greater than 6mm in width and associated inflammatory changes.   Start looking for the appendix at the cecum. 

U/S is better than CT for picking up gallstones.   Ct is better than U/S for identifying inflammatory changes around gallblader. 

Portal venous gas extends out to periphery of liver and is a poor prognostic marker.

Feces in the small bowel is a sign of bowel obstruction. 

SAWLANI   MANAGEMENT OF UTI

Who needs a urine culture?  If you decide to give antibiotics to a child up to 24 months for fever without clear source get a urine culture. 

Get urine for ua and culture by catheter or suprapubic tap. 

Risk factors for uti are fever equal/more than 39 and greater than 1 day of fever. Uncircumcised male is higher risk.  White girls and nonblack males are higher risk. 

If a ubag specimen urinalysis or dipstick is neg you are done. If it is positive you got to do a cath specimen.

A uti is diagnosed by a positive ua and culture of at least 50,000 cfu's. 

Uti and fever in kids under age 2 is considered pyelonephritis. 

ABX treatment for pyelo is omnicef.  it is covered by public aid as well. 

Febrile infants with first uti should get an ultrasound of urinary tract.  No VCUG unless u/s is abnormal.

Recurrent uti gets a VCUG.    Prophylaxis is not indicated.

HINTON AND CARLSON   ORAL BOARDS

Case 1 Methylene Chloride and Methanol.  Treat with oxygen and fomepizole. Consult hyperbaric chamber.  Always ask for co-oximetry.

Case 2 Pneumonia with adrenal crisis.   Give iv fluids, hydrocortisone, treat hypoglycemia, abx for pneumonia

Case 3  Measles.  Isolate patient, get confirmatory testing, arrange treatment of at risk contact (vaccinate or immunoglobulin), report case to health department.  Measles has cough/coryza/conjunctivits, rash moves head to toe, look for koplik's spots. 

WATTS   VAGINAL BLEEDING

menorrhagia  too much bleeding or too long or too frequent

metorrhagia   is off cycle

menormetorhagia is both of the above

4 stars on chicago flag is for chicago fire, fort dearborn, columbian exposition, century of progress exposition

Polycystic ovarian syndrome: high estrogen, low progesterone, endometrial hyperplasia.   Obesity, hirsuitism, anovulatory.

Over 35 with abnormal vaginal bleeding is cancer until proven otherwise.   They need follow up for u/s and biopsy. 

IV estrogen can help decrease bleeding in 5 hours in the unstable patient who then needs hysterectomy or embolization

PO estrogen  for stable vaginal bleeders.    3 tabs/day of orthocyclin for 7 days.   After that patients will have a heavy period.  The estrogen stabilizes the endometrium.      In young, non smoking pts not at risk for dvt/pe.  Patients over 35 are at some risk of cancer so probably don't give ocp's.