Conference Notes 8-7-2012
Grippo/Lovell Oral Boards
Case 1: Central Cord Syndrome: Treat with application of cervical collar, ct the cspine for evaluation for fracture. Recognize weakness in upper extremities. MRI to evaluate the spinal cord. Steroids for this injury is controversial. Consult neurosurgery. ICU admit. Identify urinary retention. Central cord is the most common incomplete spinal cord injury. Classic case is old person/hyperextension injury/arms weaker than legs. Check for pain and temp perception in suspected cord injuries.
Case 2: Cardiogenic Shock: Patient with Hypotension and hypoperfusion with AMI. Treat with BIPAP or intubation. Diagnose STEMI. Support hemodynamics with inotrope and pressor (dobutamine/dopamine). Cardiovert unstable VT. Get to the cath lab. These patients look very sick and may have altered mental status.
Case 3: Nasal Foreign Body: Treat with parent giving forceful breath into patient’s mouth. Works 50% of the time with non-sharp edged objects. Multiple other techniques are available to remove the FB (suction, fogarty catheter). Button batteries in nose can cause necrosis.
Harwood comment: Best approach to the steroid issue is discuss that it is controversial and then either give or not give. Probably better to intubate the patient so they can be more safely managed in the cath lab.
BINGISSER Geriatric EM
Dr. Bingisser is a practicing EP in Switzerland. ED’s in Switzerland also have crowding issues.
Seniors take taxis to the ER because it is cheaper than an ambulance. The Rolling Stones took along a geriatrician on their last European tour.
Problems managing elderly patients: poor communication/atypical presentations/broad spectrum of illness/complex interaction of social/medical problems/non-specific complaints/subtle vital sign changes to serious illness.
Triage in the elderly is difficult for the above reasons. Elderly patients are commonly undertriaged. Vital sign abnormalities were commonly unrecognized. Also high risk situations are frequently unrecognized.
Localized weakness: 75% were strokes 25% were stroke mimics. Genralized weakness complaints turned out to include diagnoses from all ICD9 code chapters.
Non-specific complaints: 1 year mortality for elderly patients with nonspecific complaints in Dr. Bingisser’s study was 13.5%. 30 day mortality was 6.4%. In 1210 patients, they made over 300 different diagnoses! Uti was most common cause and over 50% of those also had sepsis. 50% of ED diagnoses for non-specific complaints were incorrect. 6 predictors for serious outcomes of elderly patients with nonspecific symptoms are elevated BUN, low sodium, elevated CRP, history of exhaustion, clinician gestault, chf.
I missed this lecture giving Dr. Bingisser a tour of our ER, sorry. But, I did hear,” don’t bolus insulin or Dr. V. will hurt you”.
Roy Peds Vignettes
Case 1: Lethargic 6 month Infant, ddx includes CNS/tox/sepsis/metabolic/trauma/hypoglycemia/inborn errors/intussusception. Toxic encephalopathy can include hypertensive encephalopathy in kids due to post-strep glomerulonphritis. MCAD is a substrate dependent inborn error of metabolism that presents as hypoglycemia when a child doesn’t eat as regularly as normal due to an illness or sleeping longer. Unexplained neuro symptoms in an infant, you should think GI process. Think shigella in a febrile infant with diarrhea and seizure. Classic case of intussusceptions is lethargic kid in second half of first year of life. KUB in intussusceptions may show paucity of gas on right side. Intussusception used to be uncommon in kids under 4 months. However, now with rota virus vaccine it is possible under 4 months. Dr. Roy has seen 5 cases in the last two years in kids under 4 months. If the child has not had a rota virus vaccine, it is unlikely to get intussusceptions under 4 months of age. HUS is another cause of lethargy and seizures in an infant. Think HUS in a kid with gastro that got better then gets sick again 1-2 days later. Check a CBC in a gastro kid who has had a course of illness of 4-5 days to look for low platelets or hemolysis/anemia. CBC findings will precede bun/cr changes. Dr. Roy makes a point about the change in color in kids with intussusceptions or HUS. Kids can also get HUS from pneumococcus.
Unexplained respiratory symptoms in an infant think: Heart-CHF (check the liver for swelling). Myocarditis clues are marked tachycardia, tachypnea, murmur. GERD. Upper airway obstruction such as laryngo-tracheomalacia/sub-glottic stenosis/croup is unlikely in a young infant
Xrays are not necessary in most asthmatics or most simple croupers. Epiglotitis doesn’t bark like a seal. They usually have muffled voice and are drooling because swallowing is painful.
Nausea/vomit/abdominal pain without fever or diarrhea is DKA until proven otherwise.
Fever for 5 days is Kawasaki’s until proven otherwise.
Puffy eyes and puffy hands in kids is a renal problem until proven otherwise.
Do a CBC in a limping kid to eval for leukemia. 1 out of 7 kids with new onset leukemia presents with musculoskeletal pain. Don’t believe the parents’ story of trauma.
Case 2/3: 3 week old infants with vomiting. Think pyloric stenosis. Olive mass in ruq is uncommon. If child has low sodium and high potassium think congenital adrenal hyperplasia. Look for hyperpigmented scrotal skin in kids suspected of congenital adrenal hyperplasia.
Sickle rules: fever warrants admission. Get a retic count to r/o aplastic crisis. Respiratory or chest complaints require a CXR for acute chest syndrome. Check spleen for sequestration crisis. Most of the sequestration crises at ACMC over the last decade have been kids over the age of 10.
Grippo ACLS Update
Switch out your persons doing compressions every 2 minutes. Avoid over-bagging.
Defib with 200J biphasic.
1mg epi or 40u of vasopressin
Amiodarone 300mg IV
PEA: consider causes like pneumothorax, hyperkalemia
Bradycardia: Atropine 0.5mg to 3mg max. Transcutaneous pacing. If you can’t capture with TCP,try epi drip or dopamine drip. Last line is transvenous pacing.
Wide Complex Tachycardia: If unstable with pulse cardiovert. If no pulse defibrillate.
Narrow complex tachycardia: SVT/AFIB with RVR/AFutter/MAT
Wide and Irregular: WPW with AFIB, AFIB with BBB
Harwood comment: Use your right hand to help differentiate RBBB and VT. In RBBB second rabbit ear should be taller like your right hand with the 3rd finger taller than the index finger. If the first rabbit ear is taller, it is more likely to be V-tach.