Shorter version of Conference Notes this week. Happy Thanksgiving!
Bonder/Gupta Oral Boards
Case 1. Pregnant woman presents with abdominal pain. Patient was worked up with ultrasound and MRI. Diagnosis was appendicitis. The WBC count is less useful in pregnant patients due to baseline leukocytosis of pregnancy.
Case 2. 48 yo male with severe back pain and hypotension. Patient has been taking ibuprofen, norco, and valium for pain without relief. Patient has history of fever. Physical exam demonstrated murmur. Diagnosis was spinal osteomyelitis/diskitis secondary to endocarditis. Management was getting blood cultures, MRI of spine, echocardiogram and treating with IV antibiotics and consulting ID and Neurosurgery. Harwood comment: Vancomycin and Gentamycin is the recommended empiric combination therapy for native valve endocarditis.
Case 3. 61 yo female with shortness of breath. Patienthad normal CXR and markedly elevated d-dimer. CTPE showed sub-massive PE. Patient wastreated with heparin.
*Daniel Score >8 predicts worse outcome for PE. More recent study by Shopp, Kline et al. Says HR>100, S1Q3T3, Complete RBBB, Invert T waves V1-4, ST Elevation in AVR, and Afib are all independent predictors of increased risk of shock and death.
Harwood comment: No need to give O2 to a patient with normal pulse ox. When you are at ABEM General get the highest-level test. Just get an MRI if you need it. ABEM General has every resource.
Paik M&M and Asthma Management
John presented 3 cases. I am not describing the specific cases to maintain confidentiality.
Asthma is very prevalent affecting greater than 17milion Americans. There were 1144 reported in-hospital deaths 2006-2008.
*Risk Factors for Death from Asthma
Management to Avoid Intubation
Next management tool is Epi IM or Terbutaline Sub Q
Heliox can be used to improve air movement thru bronchioles.
Ketamine can be used for sedation and it also has bronchodilator effects
All the above maneuvers do not have good data supporting their use but all are inexpensive and pretty benign so all are still reasonable moves for severe asthma.
There was a discussion about how to manage a pH <7 secondary to respiratory acidosis in the intubated asthmatic. Careful increases in minute ventilation with an eye on plateau pressures was the first management move of most attendings present. Most would not use IV bicarb to alter pH. THAM would be an option in this situation to manage the pH in addition to increasing the minute ventilation. Bolus THAM 250ml then give another 250 ml as a drip over 1-2 hours. You have to be sure the patient is making urine so they can clear the THAM. Hyperkalemia and hypoglycemia are side effects of THAM.
ACMC ED Handoff Protocol
Quiet Environment with limited interruptions
Both faculty and residents sign out together
We follow an SBAR-type format
A record of the handoff is entered in the electronic medical record
We do bed-side handoff for critical care patients
Opioids are semi-synthetic or synthetic drugs altered from the parent opiate.
Synthetic opioids like fentanyl and methadone and tramadol will not show up on standard drug screens. They are too dissimilar of a molecule from morphine for the screen to pick it up.
If a patient is altered, look for and remove their fentanyl patches. They can be hard to see and forgotten by the patient or nursing home staff. Andrea had a patient recently who was found to have 5 fentanyl patches. Fentanyl patches have 10mg of fentanyl total in the patch! When you remove a fentanyl patch, do not just throw it out. Put it in a sharps container.
*Opiate Toxidrome : CNS depression, miosis, bradypnea, decreased bowel sounds
*Non-cardiogenic pulmonary edema is more common in patients who receive naloxone. Naloxone may increase respiratory drive but not airway tone and patients may develop edema.
46 persons are believed to die every day from prescription drug overdoses. There are more deaths from prescription drug overdoses than heroin and cocaine overdoses combined.
* Mu1 receptors cause euphoria, Mu2 receptors cause respiratory depression,
Kappa 2 receptors cause dysphoria
Andrea suggested observing heroin overdose patients for 4 hours in the ED. If they choose to sign out AMA, be sure you carefully document decisional capacity.
McDowell Ketamine for ETOH Withdrawl
Standard protocol is lorazepam first line incrementally increasing. If lorazepam at or above 6-8 mg IVP is ineffective then next give phenobarb 10mg/kg over 30 minutes. If the patient is still having severe withdrawl, start a lorazepam infusion 5 mg/hr and titrate up to 30mg/hr. Suggested as next line treatment is ketamine 0.25mg/kg/hr.
Nejak Altered Mental Status
*AEIOU Tips mnemonic
Some stuff you could miss with AEIOU TIPS, thyroid storm, myxedema coma, adrenal crisis, CO2 narcosis, TTP, CO toxicity, toxic alcohols, ASA overdose, non-accidental trauma, non-convulsant status epilepticus, neuroloptic malignant syndrome, serotonin syndrome.
Dan Nejak’s recommendation is to use EMR technology to help improve your differential. He has an altered mental status template built into his documentation files that he can pull up in a chart.
Harwood comment: Vital signs can help you a great deal. Bradycardia and hypothermia suggest myxedema coma. ABG’s are a great way to gain rapid critical info on altered mental status patients.
Christine Kulstad comment: Beware of cognitive bias in the undifferentiated patient. Give yourself a cognitive stop and give it some concerted thought.
Holland ENT Infections
Otitis externa: Treat with pain control and Floxin drops or cortisporin otic suspension. A wick may be necessary in the ear canal to get the antibiotic into the canal. Beware malignant otitis externa due to pseudomonas. MOE is more common in diabetics and immunocompromised patients. Treat with intravenous anti-pseudomonal penicillin and aminoglycoside. Also pay close attention to glucose control.
HIV can present with a mono-like pharyngitis.
*Centor Criteria for strep throat
There was a discussion about the management of peritonsillar abscess. The majority of faculty felt that routine CT was not indicated for all peritonsillar abscesses. If the patient has palpable fluctuance or ultrasound-identified abscess then attempt to drain the abscess in the ED with a needle. If you cannot identify a drainable abscess or are unsuccessful draining the abscess, the patient may have peritonsillar cellulitis. Peritonsillar cellulitis can be treated with IV antibiotics and IV steroids. Some patients who do not have stridor or drooling can be discharged home with close ENT follow-up. Dr. Regan noted that we did recently see in the ED a patient with peri-tonsillar abscess that required emergent intubation in the ED. The larynx was very edematous when visualized with glidescope. So you have to be a little cautious with who you manage as an outpatient.
Ludwig’s angina has edema of upper neck and floor of mouth. Patients may have displacement of tongue. Late signs are drooling and stridor. With proper antibiotics edema may take up to 1 week to resolve.