Conference Notes 12-18-2012

Conference Notes 12-18-2012

Last Conference until  1-8-2013.  You can use that time to donate to our EM Foundation to benefit resident education/development.  Thanks and Happy Holidays!

Albanis   Ophtho Emergencies

Three key questions: Vision Loss?   Pain in the eye?  Previous Surgery?    Any previous hx of eye surgery puts pt at higher risk for endophthalmitis  or globe rupture.   Both can occur years after eye surgery.  The risk is probably highest following glaucoma surgery.

Visual acuity is the most important thing you evaluate about the eye.   VA is prognostic.  Better VA’s are more likely to do better than patients with worse VA’s for a similar process.

Barounis question: How do you get lids open with a swollen eye?  Albanis and Harwood comments: You need lid retractors or use bent paperclips to retract lids.   Check for 4 basic things: Is the globe grossly intact?   Does the pupil react?   Is there a hyphema?  Is there a 360degree sub conjunctival hemorrhage?  If these 4 are OK then you can move on, there is unlikely to be a severe eye injury.  If any are abnormal you should consult/image.

Case 1: Amaurosis Fugax: painless monocular vision loss, due to an embolism to the retinal artery or a branch thereof.

Stye is an acute staph infection.  Treat with warm compresses/lid scrubs/optional oral antibiotics if you have concerns about a preseptal cellulitis developing.  For styes that are really pointing resist the temptation to incise it with a needle. The ophthalmologists sit on these using warm soaks/lid cleansing/possible abx for 4 weeks prior to surgical treatment.  Concerns about surgery are that it can cause scarring or affect the mebomiun glands.  Chalazion is basically treated the same as stye.

Eyelid lacerations:  ER docs stay away from repairs near the medial canthus, and probably don’t repair lacs that involve lid margins.   Both are high risk for complications.  The general opthomologists don’t even repair lacs around the medial canthus; they refer to oculo-plastics.

Great test to identify myasthenia gravis in a kid with ptosis: Place an ice pack for a couple of minutes on the ptotic eyelid.  When you take the ice pack off and sit the patient up, if they have MG, the ptosis will temporarily resolve.

Subconjunctival hemorrhage in the setting of non-trauma is virtually always benign even if it is 360 degrees.    In the setting of trauma, a 270-360 degree subconjunctival hemorrhage is suspicious for a globe rupture.  If there is any second finding (vision loss/hyphema/altered pupil/etc)in association with this severe subconj hemorrhage, patient will likely go to surgery.   CT can help in this situation.

Barounis/Chastain    STEMI Conference

CASE 1: Posterior MI: Diagnosis is difficult because no specific leads represent this area.   You need posterior leads to verify the infarct (post leads are specific but not sensitive).   ST segment depression V1-3.  Prominent R wave V1-3.  Posterior MI frequently co-exists with acute inferior or lateral MI.  The vessel commonly involved in an isolated posterior MI is the circumflex.   If you are uncertain whether patient has an AMI, stat 2D Echo can help identify wall motion abnormality.   Harwood comment:  this patient had an isolated circ lesion causing isolated posterior mi.   Pt partially reperfused his vessel with his own TPA accounting for his improved 2nd EKG and temporized his clinical status until he was taken to the cath lab.

Case 2:  75 yo male with chest pain and new LBBB.  Harwood comment: pt has new LBBB and new first degree AV block putting him at risk for complete AV block.    Comment from care coordinator: If you document new LBBB on the first EKG in the chart, that case goes into the STEMI care bundle.  If you don’t feel the patient has a STEMI you need to document why the patient is not going to cath lab.    The STEMI Care bundles don’t factor in Sgarbossa criteria.    Proposed management for suspected ACS with presumed new LBBB: if unstable or CHF go to cath lab.  If stable with Sgarbossa criteria present, go to cath lab.  If Stable with no sgarbossa criteria present get stat echo.  Simplified Sgarbossa criteria are concordant st elevation >1mm or concordant st depression V1-3 >1mm,   1 positive Sgarbossa criterion is 95% specific but not sensitive.   The discordant ST elevation of 5+mm anteriorly has been taken out because of a relatively low likelihood ratio.

Case 3: Pt had a right coronary artery lesion.  He had waxing and waning perfusion resulting in intermittent accelerated idioventricular  reperfusion rhythm.  

Barouinis/Chastian/Harwood  Flash Mob Journal Club     

Article discussing oxygen toxicity due to post arrest resuscitation.

Background: Therapuetic hypothermia post-arrest is thought to prevent reperfusion oxidative injury.  Patients have some brain edema post arrest.  High oxygen exposure to the brain  during resuscitation is thought to increase oxidative injury by the production of excess free radicals.

Methods: 173 patients treated with therapeutic hypothermia.    Retrospectively the investigators identified the highest PAO2 recorded for each patient in the first 24 hours post arrest.   They correlated this PaO2 measurement with survival and  functional neuro outcome.    All patients were in the target therapeutic temperature range.

Outcome: Survivors had lower PaO2 compared with nonsurvivors.   Higher PaO2 associated with worse neuro outcome.   Cut off seems to be a PaO2 of220.   Above that level patients did progressively worse with higher PaO2 level.

Potential confounders:  High PaO2 could be just a surrogate marker for a sicker patient or poorer quality of the resuscitation.   The resuscitation team may have had to resuscitate the patient more aggressively and were hesitant to dial down the O2 or the resuscitation team may be subpar and were not watching the oxygenation level closely to optimize patient care.

What to do: The emergency physician may want to closely watch oxygenation and avoid hyper-oxygenation in the post arrest patient.  Consider  starting your vent settings for the post arrest patient at 50% FIO2.   Harwood comment: think of oxygen as a medication and there is a correct dose of oxygen for the post-arrest patient.  Giving boat loads of oxygen after resuscitation and damaging a patient’s brain is analogous to giving too much tobramycin and bagging a patient’s kidneys.    

Animated discussion started by Sola’s question and response lead by Harwood and Brian Febbo about supplemental oxygen in other types of patients.    No benefit of supplemental oxygen above 96% room air sat for  sickle cell patients.   Cochrane review shows harm to providing supplemental oxygen to acute MI patients with room air sats over 96%.

Badillo   Chest U/S

Ultrasonographic A lines are naturally occurring artifact lines or air lines.  They are horizontal on the screen and are stacked on each other.    B lines are bad lines and are signs of interstitial edema.  They are vertical  and extend down to bottom of screen.  3 or more B lines are consider pathologic.  The more you see the more specific the finding.

Parasternal long view:  Kinesis assessment by looking at whether the mitral valve anterior leaflet hits the septum and do the walls of the LV almost come in contact in systole.

Case1:  CHF patient with poor kinesis on echo and B line comet tails that signify pulmonary edema.

Case 2: US is better than supine CXR for identifying pneumothorax.  Use the linear probe in midclavicular line in area of 2nd intercostals space.   Look for sliding pleura between rib shadows.  There may be small B lines(also called minor B lines, comet tails, Z lines)  that don’t go all the way down to the base of the screen and are normal artifact as opposed to the abnormal B-lines that signify CHF.    There is an M-mode view that can also identify pneumothorax.  Patients with a pneumothorax have a “barcode” type appearance.

Big RV with bowing of septal wall toward LV raises concerns for PE.

Practical Scanning with the Residents.

Applicant Review