Conference Notes 9-10-2013

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*EMF Golf outing October 8.  All faculty and Alumni welcome!

*Congratulations to Andrej Urumov for winning the International CPC Competition in Marseilles, France!

Jakubowicz/Carlson       Oral Boards

Case 1.   Rocky mountain spotted fever.  62 yo male with fever and headache for 2 days followed by new rash on distal extremities for the last 12-24 hours.  Critical actions: Recognize the rash, treat hypotension with fluids, start abx (doxycycline is first line, chloramphenicol  can be used for the doxy allergic patient and pregnant patients.  doxy is ok in kids)  , report the illness to health department and get confirmatory testing.   The frequency of diagnosis of RMSF  has tripled in the last 10 years but the mortality has dropped.  RMSF is also know as “tick typhus” because of it’s clinical similarities with typhus.  Infectious agent is ricketsia ricketsii.  Vectors are dog, wood, and lone star ticks.  Incidence increases with age.  Rash starts 2-6 days after onset of illness.  Labs show anemia, low platelets, low sodium, and ARF.  Test with ELISA.   Gore comment:  Can this look like TTP or meningitis?   Andrea: Yes, this is a difficult diagnosis but you have to look at the context of the presentation.



Case 2.   Phenobarbitol  overdose in a child.  Child presented with altered mental status, hypothermia, and hypoglycemia.   Mom was poisoning child.     Critical actions:  Intubate, treat hypoglycemia,  correct hypothermia, Multi-dose  charcoal, Alkalinize the urine, identify child abuse and contact child protective services.   Andrea comment: get an alcohol level as alcohol can  cause hypoglycemia and sedation as well.   On CXR, the patient had non-cardiogenic pulmonary edema.  Andrea gave the differential of toxin caused non-cardiogenic pulmonary edema :  Salicilates, opioids, phenobarb, ethclorvynol, calcium channel blockers were the ones I caught.

Case 3.  Spontaneous  pneumomediastinum in a teenager due to laughing while doing situps.       Critical actions:   Don’t do a CT chest.  Treat pain.   Don’t let patient fly on a plane or run in track meet until pneumomediastinum resolves.    Both can increase the volume of pneumomediastinum.   Boerhaave syndrome can have a similar CXR appearance to spontaneous pneumomediastinum but  is usually related to vomiting and this patient wasn’t vomiting.  Boerhaave’s is due to esophageal rupture and is a serious risk of mediastinitis.   Spontaneous pneumomediastinum is not a risk for mediastinitis.  Spinnaker sign:  Elevation of thymus due to pneumomediastinum.

Bad Pneumomediastinum                         


Spinnaker Sign




Knight      Facial Trauma

Case 1. 21 yo male in a high speed mvc.  Pt had a seizure in the field.  Pt also had serious facial trauma.   On arrival to ED pt was intubated using etomidate/rocuronium.  Cricothyrotomy tray was the planned back up maneuver if intubation failed.  Another option is intubation with ketamine sedation and topical anesthetic in oropharynx without neuromuscular blockers.   Don’t nasally intubate patients with severe facial trauma.  

LeFort  Fractures

Treatment for LeFort fxs: airway management, nasal packing, IV antibiotics, plan for surgical repair, ophthalmology evaluation.

Mandible fractures:  Order of frequency  body>angle>condyle.  Tongue blade test 95% sensitive/68% specific.   Check the ears for tm rupture/hemotympanum/ear canal injury.   Open fractures need IV pcn or clinda, admission and ORIF.   Closed fractures can be dc’d home on pain meds and soft diet.

Case 2. 38yo female assaulted by cousin.  Pt was punched in the head and bit in the nose.    Pt’s nose was largely amputated by bite.    Human bite wounds have 10% risk of infection.  Infections are polymicrobial with concern for eikenella corodens.    Pt required complex reconstruction including a forehead flap and cartilage graft from ribs.

Case 3. 40 yo male transferred to ACMC for multiple gsw’s to chest and face.  One gsw went through left orbit.   Orbital blowout fractures are more commonly caused by blunt trauma to orbital area.   Patients with orbital blowout fractures may have infraorbital anesthesia and diplopia on upward gaze.   Dispo home with instructions to not blow nose, smoke, or drink through straw.  Need follow up with plastics or max-face surgery.    Globe rupture:  Use bent paperclips to retract eyelids to see eye.  Patients may have irregular or tear shaped pupil.    Konicki Comment:  In an eye that is not obviously ruptured, you can do a very gentle U/S with a lot of gel.  If the probe just touches the gel, you wil get an image of the eyeball.   Girzadas comment: Have a low threshold for getting a CT for possible orbital fractures.  I have been impressed with how many orbital fractures I have found with relatively mild ecchymoses around orbit after blunt trauma.  Don’t “diss” the paperclips.  Bent paper clips are very effective in retracting swollen eyelids. 

Harwood comments: You can anesthetize the airway by injecting lido through cricothyroid membrane.  Knowing the different types of LeFort fractures is not that clinically relevant.  Most facial fractures are complex and don’t follow the strict classifications.

Levato      ACMC Recommended  Management of Infections

Uncomplicated UTI: Macrobid BID X 5 days,  Cephalexin TID X7 days,  last choice is Cipro X3 days.    Cipro should be avoided unless you can’t use the first two.   GFR cutoff for using macrobid is 50.     Harwood comment: You have to be careful with macrobid in the elderly with low GFR.   Definitely need to use cephalexin or cipro in patients with GFR less than 50.  

ACMC is really trying to not use Cipro for uncomplicated uti’s.    Bactrim is not a good choice for empiric treatment of uti.  Resistance to bactrim is around 31%.

Cipro has growing resistance from pseudomonas and e coli.  Both bacteria has 25-30% resistance to cipro.    Cipro and other quinolones  are associated with NAP-1 hyper-toxin producing C-diff strain.

Use cipro/flagyl combo only for the pcn allergic patients.

Question by Adam Wise: What do we use for nursing home patients with  pcn allergy who are diagnosed with UTI?    Answer:  Cipro or Gent.   Aztreonam also suffers from a lot of resistance from e coli.  Similar resistance pattern as cipro.   You have to pick on a 3 not great choices in this situation.   Gent probably has the best microbial coverage but you have to be aware of potential nephrotoxicity.

For intra-abdominal infections that are uncomplicated like simple diverticulitis give Ceftriaxone/flagyll.  If patient has a complicated intra-abdominal infection such as post-surgical, hospital acquired,  or abscess formation give Zosyn.  In the last 10 years, Cefoxitin has had less than 80% effectiveness against anaerobes.  That’s why we use it less often.  We have been using it less over the last few years so it’s effectiveness may have improved. Christine comment: She feels she has had surgery request cefoxitin being given for appendicitis.   Should I push back and recommend Ceftriaxone/flagyll?  Levato answer: Cefoxitin is ok for that situation. 

Harwood comment:  If you have a nursing home patient with ED diagnoses of both pneumonia and uti.  Just treat the pneumonia.  You will get decent coverage of most likely uti pathogens.  When you get urine culture back in 2 days you can narrow your antibiotic choice.

Diabetic lower extremity cellulitis limited to 2cm around ulcer : Treat strep and staph with Ancef.      For legit diabetic foot (foot is red/swollen/painful and at risk for amputation) give Vanco and Zosyn.    Interesting discussion about the common presentation we see which is diabetics with cellulitis involving a larger area of the lower leg but don’t have foot at risk for amputation.   Consensus was to consider the overall picture of the patient, level of blood sugar control, vascular status of affected leg, and rapidity of progression of infection when deciding between ancef and Vanco/Zosyn combination.

This Diabetic Foot would get Vanco/Zosyn based on our discussion


Two grading scales for diabetic foot


General rule at ACMC  for all infections is go to a beta lactam first and move to other classes for specific reasons.  One exception is macrobid for uncomplicated uti.

Herrmann question: Where do we find the ACMC recommendations for antibiotic treatment of infections.    Levato answer: We are working on an online bug and drug section on the ACMC website.

Zosyn, Unasyn, Imipenem, cefoxitin all have adequate anaerobic coverage and when using these, you do not need to add flagyl.

Febrile neutropenia: Cefipime or Imipenem.   Add vanco for HCAP, cultures  gram positive organisms,  suspect MRSA, line infection, neutropenic shock,or  pcn allergy.

C-Diff treatment: Treating with flagyl (500mg po TID) alone is only appropriate for mild first presentations  or first recurrances   (WBC<15K, Cr<1.5).   Anything else treat with oral vanco (125mg qid).    Severe C-Diff infections give 500mg Vanco enterally QID + IV Flagyll 500mg QID.

Katiyar     Study Guide   Ortho

Sorry I missed the majority of this excellent lecture.

Traumatic knee dislocation: This injury needs emergent ortho referral.   Popliteal artery and common peroneal nerve are at risk.    50% of  these dislocations spontaneously reduce prior to arrival to ED.  Do ABI, if <0.9 do arteriogram or CT angio.

Knee Dislocation

Harwood comment:  You can have an intimal injury of popliteal artery that clinical looks ok with nl pulses initially. I would not trust ABI’s to decide on doing a CT angio.  If the patient has a knee dislocation do a ct angio and admit.  Group discussion ensued,  One of our residents had a knee dislocation personally, had an angio and was discharged with a knee immobilizer.   All faculty present felt they would admit all knee dislocations.   We are talking knee dislocations, not patellar dislocations.

Tibial plateau fractures: Can be subtle.   Harwood and Girzadas comments:  these patients have a lot of pain, and have effusions.  Pay close attention to any depression or fracture lines through the lateral tibial plateau. 

Positive birefringent crystals is pseudogout (PP;positive=pseudo).  Negative birefringent crystals is gout (NG; negative=gout).


Fort         EKG Basics

Professor Chamberlain’s 10 rules of normal ekg

PR=120-200 ms

QRS should be less than 120

QRS should be up in I and II

Qrs and T’s should be concordant

All waves are negative in AVr

Normal R wave and S wave progression


St segments should be isoelectric except V2 and V3

No abnormal q waves.

T waves must be upright except avr


Weinckeback (progressive prolongation of pr interval)



Mobitz 2 Block



Accelerated ideoventricular rhythm: Rate 50-100, has fusion and capture beats.   Common Boards Question: In the setting of TPA reperfusion, what is the  management  for Accelerated Ideoventricular Rhythm?    Answer: Observation


Accelerated junctional rhythm :  Rate of 60-130.  Retrograde p waves can be present.    Harwood comments: When you see this rhythm, think  congenital problem, medication effect,  rheumatic fever, post surgery, anorexia, CHF, caffeine, isoproterenol, and brain injury. 








Brian covered the common myocardial infarct patterns.


Wellen’s syndrome:  Biphasic T wave inversions in the antero-septal leads.  Associated with critical stenosis of proximal LAD.



Left main coronary artery occlusion: Widespread horizontal ST depression, most prominent in leads I, II and V4-6.  (6 or more leads with ST depression)

  • ·  ST elevation in aVR ≥ 1mm
  • ·  ST elevation in aVR ≥ V1



This is considered a STEMI equivilent in the new ACC guidelines.  AVR ST elevation should be alittle more than ST elevation in V1.  In this EKG they are pretty close.  Bottom line if you see more than 6 leads of ST depression and AVR and V1 are elevated and the patient is having chest pain, call a STEMI or Speak with the cardiologist.

Patient Safety/Doctor Safety     Be Safe out there.   Be careful with Sharps.