Conference Notes 7-3-2012
Chandra/Harwood Oral Boards
Case 1. Multiple Blunt Trauma with left hemothorax, splenic injury and epidural hematoma. Management required intubation, left chest tube, identify epidural hematoma/splenic injury. Pt needs to go to OR emergently.
Harwood comment: You can identify epidural hematoma (between dura and skull) by thinking high pressure causes bulging toward the midline. Low pressure subdural (between dura and arachnoid)does not cause a bulge toward the midline.
Case 2. Syncope due to PE/FX toe. Management requires identify CT, give heparin, reduce toe fx.
Harwood comment: S1Q3T3 on EKG and Westermark sign (unilateral oligemia due to clot) on CXR were present in this case.
Case3. Maisonneuve Fx. Identify fracture pattern, splint, urgent ortho consult. Surgery not required emergently but in a prompt fashion.
Asokan Emergency CXR Evaluation
If patient has hx of a fall, a radiologist looks for pneumothorax, pleural fluid, rib fx’s, or vascular injury.
If the trachea deviates toward a soft tissue density, the soft tissue density is likely not a mass but some scarring or buckling.
If a patient has a widened mediastinum due to a dissection, it is because of a mediastinal hematoma. The dissection itself does not cause a widened mediastinum.
Indications for surgery in aneurysm is 6cm in the thoracic aorta and 5cm in the abdominal aorta.
Superior mediastinal widening has a differential of 4T’s: thymoma, teratoma, thyroid, terrible lymphoma.
On lateral view: Posterior infiltrates are in either right or left lower lobe. Anterior infiltrates are in the RML or left lingula. On anterior view: RLL infiltrates should basically be on the diaphragm. RML infiltrate may obscure the right heart border. RUL infiltrate should be at apex.
Hemithorax with whiteout : if trachea deviates to side of white out consider collapse or pneumonectomy. If trachea deviates away consider hemothorax/mass/effusion.
CHASTAIN SIGN OUT
Transfer of information AND responsibility for the patient.
IPASS: illness severity, patient summary, action list, situation awareness, and synthesis.
It is important for the receiving team to ask questions about the case.
Signed out patients need to have a complete H and P note written by the leaving team.
WILLISON EKG
Osborne waves indicate hypothermia
WPW: accessory tract can lead to SVT’s of different types. Antidromic conduction has a wide QRS and requires procainamide or cardioversion.
V1 if RBBB pattern: Taller left rabbit ear suggests ventricular tachycardia.
If you find non-specific st changes in a anatomic distribution, get serial ekg’s to look for st elevation.
AVR with tall/wide terminal r wave think: TCA, or Benadryl or cocaine.
Cerebral T waves: huge deep inverted t waves due to acute intracranial hemorrhage.
Wellens: biphasic t wave in V3 suggests severe proximal LAD lesion. High risk for v-fib on treadmill.
Brugada: Saddleback t wave changes in septal leads. Associated with sudden death. Needs AICD.
WISE HEMOPTYSIS
Gas exchange impaired with >400ml of blood in alveolar space.
Mild hemoptysis without risk factors: CXR and outpt f/u
Causes: bronchitis, pneumonia, abscess, tb, lung carcinoma, pe, behcet, goodpastures, bronchiectasis, warfarin, crack lung, bioterrorism-agents . Top 3 in US: bronchitis, bronchiectasis, cancer, pneumonia. Tops in world: TB
Earlier bronchoscopy= higher yield. CT may be useful in massive hemoptysis. CT plus bronch identified source in 93% of patients.
Lateral decubitus position with bleeding lung on downside may protect the good lung. Selective mainstem intubation or double lumen ET tube may also be effective.
Consider FEIBA for the massive hemoptysis pt on warfarin or other anticoagulant.
Use an 8FR ETT when intubating to allow for bronchoscope.
Barounis comment: Dr. Hanif said you can pass a pediatric foley through the ET tube and pass the foley into right mainstem bronchus and inflate balloon to occlude right bronchus.
KULSTAD/TEKWANI/WATTS STATS
High specificity tests rule in disease. SPIN=specificity, positive results, rules in the diagnosis.
High sensitivity tests rule out disease. SNOUT=sensitivity, negative result, rules out the diagnosis.
Positive predictive values is highly dependent on prevalence rate of a disease. PPV can change despite no change in the sensitivity or specificity of a test based only on the different prevalances.
Bayes’ theorem: new info should be interpreted in light of what is already known. You need to consider the pre-test probability of disease. Can base on the literature or clinical gestault.
Positive Liklihood ratio: prob of + test in presence of dz/prob of + test in absence of disease. If LR is >1 the result is more likely to be positive in a pt with disease than without disease. The benchmark for A very good LR+ is 10. The benchmark for a very good LR- is 0.1.
Harwood Comment: Determining the pretest probability is key to determining an accurate post test probability.
Heart Score for Chest Pain:
|
History |
Highly suspicious |
2 |
|
Moderately suspicious |
1 |
|
|
Slightly suspicious |
0 |
|
|
|
||
|
ECG |
Significant ST-depression |
2 |
|
Non specific repolarisation disturbance |
1 |
|
|
Normal |
0 |
|
|
|
||
|
Age |
≥ 65 years |
2 |
|
45 – 65 years |
1 |
|
|
≤ 45 years |
0 |
|
|
|
||
|
Risk Factors |
≥ 3 risk factors or history of atherosclerotic disease |
2 |
|
1 or 2 risk factors |
1 |
|
|
No risk factors known |
0 |
|
|
|
||
|
Troponin |
≥ 3x normal limit |
2 |
|
1 – 3x normal limit |
1 |
|
|
≤ normal limit |
0 |
|
HEART Score |
Risk of MACE |
Proposed Policy |
|
0 - 3 |
0,9% |
Discharge |
|
4 - 6 |
12% |
STRESS |
|
7 - 10 |
65% |
ANGIO |
We then discussed 8 cases in small groups developing post test probabilities for strep testing, d-dimer, ct for appy, and dopplers for dvt.
JAKUBOWITZ CHF/ASTHMA
Observation status delivers equivalent clinical care to admission at a lower cost.
Asthma Protocol: Bread and butter asthma patient not better in 3 hours should go into this protocol. DC home with albuterol/oral steroids/inhaled steroids/asthma action plan/follow up.
CHF Protocol: Patients with new CHF, abnormal labs, unstable vitals, o2sat <90% are excluded.
Less than 10 patients last year were admitted into each of the CHF or Asthma Protocols.
Observation management may be more expensive for patient than inpatient management. However, some of these protocol patients may not meet criteria for admission.