Conference Notes 4-26-2012

Conference Notes 4-26-2012   ICEP Spring Symposium

Research Presentations

Dr. Phillips: Absorbable sutures are a lower cost method compared to non-absorbable sutures to repair wounds.   No difference in scar outcome, and similar complication rates.   Also easier on the patient.  No need for suture removal.

Dr. Cambride: Intubation during CPR (manual vs. automated).  Success rate and time to intubation was no different when compressions were or weren’t being done.  No difference between manual or automated compressions either.   So don’t stop compressions to intubate.

Dr. Hartman: Patient follow up requirements are carried out in widely different manners across the country.  Program Directors are generally dissatisfied with patient follow up learning methods.

Dr. Rifenburg: PE patients presenting with syncope are more likely to have a saddle embolus and less likely to have a small embolus than PE patients without syncope.  PE patients with syncope were more likely to have EKG changes.  PE patients with syncope were more likely to have RVH than non-syncope patients.


Investigation priorities in seizures: infection, mass, metabolic (electrolytes), toxins.   Dilutional hyponatremia can occur from not mixing formula correctly.  Genital ambiguity suggests congenital adrenal hyperplasia.  

Progressive causes of altered mental status: mass, meningitis, opioids, hypoglycemia.  All must be treated emergently.    Don’t give full  dose narcan to heroin addicts.   Beware of hypoglycemia.  It can mimic any neuro deficit.  If you can’t talk to someone, check their blood glucose. 

Anticholinergics      vs.  Sympathomimetics= Dry skin    vs.  diaphoresis

Pheochromocytoma can mimic sympathomimetic overdose.

Psoas abscess can cause limp.   If work up of febrile limping patient with leukocytosis is not fruitful, consider ct abd/pelvis to look for abscess.

Encephalitic patients should be treated with acyclovir.  Look for cold sores to suggest HSV encephalitis.   Pt’s can have seizures with HSV that appear like unusual behavior or agitation. 

Common cyanotic heart lestions: truncus, transposition, tricuspid atresia, tetrology of fallot, total anamolous return.   Tetrology is the one that can present with a patient 1-2 years old.    Failed hyperoxia test strongly favors cyanotic heart disease

Dr. Thompson      Toxicology: What’s New in the Street

 Sorry I missed this one, talking with old friends.

Dr. Allen   To DNR or CPR

1960 was the first description of modern CPR (ventilation,chest compressions, defibrillation).   1974 were first ACLS Guidelines.

22% overall rate of survival from CPR in ED’s across the country.  This is better than any other setting.  In general, survival is around 17% in all settings.

EP’s have reservations about CPR: overhyped, can cause suffering, costly, benefit is mostly extra days alive but not quality of life.

Slow CODE is not acceptable.    It is deception and could lead to survival with poor neurologic outcome.

APPLE   Shared Decision Making with Patient/Family at End of Life: Awareness , Prognosticate (make an estimate of short term outcome), Plan (basically figure out the patient’s goal and it is ok to give recommendation),  Lay the ground work, Empathize (sit down, be quiet and spend time listening, express regret, hopeful attitude)

NEXT Lectures

Dr. Kegg: Within 6 hours CT brain may have a high enough sensitivity to rule out SAH.

Dr. Mehan: Itralipid for local anesthetic toxicity acts as a lipid sink, metabolic substrate, or direct activation of CA channels.   Can also be used for beta blocker and CCB, TCA, Atypical antipsychotics and buproprion  Od’s.  Downsides: ARDS, pancreatitis, has compatibility issues with other meds.

Dr. Oh: You can use IVC/Ao ratio to evaluate dehydration in pediatric patients with diarrhea.  Serum bicarb over 15 is reasonable cut off for non-serious dehydration.  ETCO2>34 ruled out HCO3<15.  Check glucose because hypoglycemia is present about 10% of the time in pediatric patients with diarrhea.  Can give up to 60ml/kg bolus of saline for more severe dehydration.   

Dr. Pirotte: CDC and NIH say we should not due femoral lines (cat 1a recommendation) unless we have no other options.   They are more likely to cause infection.  Complications are worse, retroperitoneal hemorrhage, DVT, fistula, pseudoaneurysms.   Consider IO line in place of doing femoral line.

Dr. Rushforth:  Tranxemic Acid (TXA)will be more likely to be used in Trauma patients due to efficacy reports, no evidence of theoretical complications, inexpensive.   Most studies on this drug were done in under-developed countries where the baseline mortality may be higher to start with and critical care resources are less than in the US.  

Dr. Vogt: Scombroid most common around Florida and Hawaii.    Supportive care is the indicated treatment for all common fish toxins.  Ciguatera symptoms can persist for weeks to months.  Mannitol is still controversial as a treatment for ciguatera.  Alcohol can cause recurrence of ciguatera symptoms.  Be aware that fish flown in from other areas can cause various fish toxidromes.

Dr. Williamson:  Allergy to shellfish is due to shell proteins and not iodine .  Patients with shellfish allergy can receive radiology contrast.  Scombroid poisioning is due to bacterial overgrowth of improperly stored fish producing histidine.  The histidine is converted to histamine.  Pt’s will have flushing, rash, palpitations.   Treat with antihistamines.   Fugu is due to tetradotoxin that binds to sodium channels. Treat with supportive care and charcoal.