A special Thank you to Christine Kulstad for her help with the Conference Notes this Week!

Lovell/Htet        Oral Boards

Critical Actions Case 1:  Septic Shock from Capnocytophaga canimorsus/dog bite

--Identify Sepsis

--Rapid IVF, early broad spectrum antibiotics including dog bite coverage

--Elicit history of dog bite

--Reassessment

--ICU admission

(also consider Xray, irrigation of wound, consider tetanus update, rabies)

Teaching points:  Capnocytophaga canimorsus

--fastidious GNR identified in 1976, likes to eat iron

--normal oral flora of kitties and doggies

--Risk groups:  asplenic, alcoholics, beta thal, smokers (high iron), immunosuppression

--Alcoholics have high blood iron + immune comp.

--WORST OUTCOMES in asplenics:  high iron + decreased phagocytosis; high M/M!!

--Symptoms usually within several days

--Fever, V/D, malaise, abdominal pain, myalgia, confusion, dyspnea, headaches, rashes

--Special culture media

--Tx:   Dogmentin!  so use IV Unasyn, also susceptible to third gen. Cephalosporins

Critical Actions Case 2:  Submassive to Massive PE

--Recognize risk for PE (travel)

--Diagnose PE

--Risk stratify (Echo, BNP, Trop)

--Recognize decompensation and need for thrombolytics

--Assess contraindications to tPA

--ICU admission, Intensivist consultation

Teaching points:   Submassive/Massive PE

--Submassive:Normal BP but RV dysfxn (Echo or BNP) or myocardial necrosis (Trop)

--Massive: Low BP for 15 minutes or code or resp. failure or need for pressors

--Thrombolytics for massive, case by case for submassive

--r-tPA dose 100 mg IV over 2 hours

--Code dose, 50 mg bolus (maybe + 50 mg)

--start IV Heparin when PTT < 2X nml

--Lytics in PE:  2% ICH risk, 6% major bleed/transfusion

Critical Actions Case 3:  Jellyfish envenomation

--Identify as Jellyfish envenomation

--Irrigate 

--Consider vinegar, hot water

--Monitor for systemic sx, allergic sx

--Treat with benadryl, consider steroids, analgesics

Teaching points: Jellyfish Envenomation

--Mechanism-tentacles with venom containing nematocysts

--Symptoms--Itch, swell, burn, tingling/numbness.  Severe with N/V, HA, weak, dizzy, SOB

--Treatment-irrigate with NS or sea water (fresh water makes worse), remove possible remaining nematocysts by shaving skin or scraping skin

--Use benadryl, consider steroids, give analgesics

--vinegar-prevent further nematocyst firing, hot water to breakdown venom-some controversy over effectiveness

Levato     Pharmacy Update

Community-acquired but complicated UTI- E coli, Klebsiella, Proteus most likely. We have been using ceftriaxone for this but it is a broad spectrum antibiotic that is causing c diff in our hospital. Cefazolin found to be 89% sensitivity in E coli, 90% in Klebsiella, 100% Proteus. So new guidelines are to use cefazolin for these patients. CAUTION- not appropriate for nursing home patients. OK for pyleonephritis.

Ketaneh  (Class of 2014)  Starting out as a New Attending

Looking for a job: Take some pressure off- its just your first job, you can change it later. He interviewed all over and recommends it. Prospective employers will usually pay for your interview expenses so don’t shy away from multiple interviews. It helps to see a lot of practice environments too, see where you fit in.  Use the faculty resources here (they know somebody everywhere).

You will have a lot more money- try to live like a resident and save for a while. Student loans will come due, 401k should be funded. Need to find your work-life balance- how many shifts due you want to work to pay for your lifestyle.

Starting a new job- get familiar with the EMR before your first real shift. Will save you tons of time and pain before your first shift.

Have your charting macros prepared before you start.

Know where you are going to look stuff up.

Be super nice and respectful to everyone.

Get your charting done so you stay off the medical records radar. 

Get to know the culture of your workplace: protocols, antibiotic choices, sedative choices.

Nick told a scary story of how he ordered a fentanyl drip and the pharmacists and nurses were not familiar with using fentanyl as sedation and dosing errors were made.

At most ED’s you at times will be working alone with a couple of nurses.

Be very clear when communicating with nurses, they will do exactly whatever you say.

An important part of our job is charting and billing.  It’s just a fact of life.  Your income and job security depend on it.

*Ups and downs.   You have to be able bounce back from the downs as an ER doc and temper/be humble with the Ups

There are other jobs out there.  You can change jobs.   It is important to protect your reputation so people think well of you and you keep the door open to other opportunities.

Be smart with your money.   It is OK to rent for awhile until you have a clear idea of your monthly income.  Then live below your means so you are funding your retirement properly.

As a resident and attending, going the extra mile will not go unnoticed.

Get your paper work done. 

Favorite FOAM websites:  lifeinthefastlane.com, aliem.com, emcrit.com

The goal for an ED doc in the community is to not be ultra cutting edge and not be practicing medicine from 20 years ago.  You want to be somewhere in the middle and up to date. 

Regan       Seizures

*Causes of Seizures

Generalized Seizures: Affects both Cerebral Hemispheres. There is loss of consciousness.

*Seizure Types

Partial Seizures include: Simple in which conscious is maintained and Complex in which consciousness is altered.

Initial questions to ask the patient:  Do you have a seizure disorder?     Is there anything that would have lowered you seizure threshold?  (sleep deprivation, fever, etoh use, missed medication, stress)

EKG can be a quick initial test to pick up electrolyte abnormalities causing seizure.

*Medications for seizure management

Elise comment: In the Peds ED there is frequently the availability to get an EEG rapidly for a child with a new onset seizure.  This rapid turn around of an EEG can be very helpful to neurology to make good management decisions for the patient.

Case 1.  Etoh withdrawl seizures can be treated with Ativan first line and Phenobarbitol second line for persistant  seizures despite Ativan.    Christine comment: You can push the upper dosage range of Ativan in the ETOH withdrawal patient. Their GABA receptors are down regulated.   Elise comment: If your Ativan is not working in any type of patient, start thinking about underlying causes such as hypoglycemia, hyponatremia, INH poisoning, intracranial hemorrhage.

20mg/kg loading dose works for Phenytoin, fosphenytoin, Phenobarbital, Valproic Acid, and Keppra.  Basically 20mg/kg works for all commonly used epileptics other than Ativan.

Check the patient’s tongue for lacerations and hematoma.  Serious tongue injuries  could pose an airway obstruction issue.

Neuro exam in infants

Look for:

Balled fists with thumbs tucked in, this is an upper motor neuron sign (Babinski sign in infants)

Altered/increased tone

Abnormal Reflexes

Eye deviation

Elise comment: Midazolam IM is a very rapid acting anti-seizure medication that is useful in kids.   Eye deviation is an important finding in kids to identify a seizure.

30-50% of patients with pseudo seizures also have epileptic seizures.  This makes diagnosis and management possible psuedoseizures very difficult. 

Carlson                      Antidotes

*Antidotes

Isopropyl alcohol ingestion is not an indication for fomepizole.  It is metabolized to acetone.

Lead has 3 potential antidotes: BAL,  EDTA, and Succimer.   Peanut allergy is an absolute contraindication to BAL therapy.

Gyromitra mushrooms look like a brain and can cause seizures.  The antidote is pyridoxine (also the INH antidote/INH also causes refractory seizures).

*Gyromitra mushroom

Sodium Bicarbonate is an antidote for TCA poisoning.  The sodium overcomes Na Channel blockade.  The Bicarbonate decreases free TCA.   Andrea prefers bolus dosing with 1-2 ampules while closely observing the patient and the monitor.

Calcium channel overdose can cause bradycardia, hypotension, and hyperglycemia.  The antidote is the “perfusion salad”: calcium chloride, glucagon, intralipid, atropine, and insulin euglycemic therapy.

Deadly nightshade contains bella donna toxin.  Bella donna can be thought of as a Benadryl overdose.  Both cause an anticholinergic toxdrome.  The antidote for anticholinergic toxidromes is physostigmine.   Physostigmine should not be used in undifferentiated coma or in mixed overdoses.  However, it is safe in pure anticholinergic toxidromes.  

*Deadly nightshade berries

*Deadly nightshade leaves  (note the little “ears” small leaves around the big leaf)

Paint stripper that contains methylene chloride if ingested will be metabolized to CO.  Methylene chloride gets metabolized by liver to CO and can cause CO toxicity.    Antidote is hyperbaric oxygen. 

Statistically the most common cause of CO toxicity in the summer is indoor grilling or using a grill on a screened-in porch. 

*Hyperbaric indications for CO Toxicity

Causes of cardiac glycoside poisoning: digoxin, oleander, foxglove, Lilly of the valley, and the practice of toad licking.   Antidote is FAB fragments

West      Fever in Kids

Rectal temperature measurement is most accurate.   The temperature that determines a fever is 38C.

*Fever algorithm for kids </= to 3 months

For febrile kids (with immunizations up to date) over 3 months of age with no source on physical exam the next best diagnostic study is to check the urine.

Brain damage is not a complication of fever due to infection.

Faculty comment: Parents frequently under-dose Tylenol and Ibuprofen.  Check the dosing parents are giving to kids if the antipyretic is not bringing down the fever.

Harwood comment:  You may not need to do an LP on febrile kids age 30-60 days old if they have the following:

Well appearing child

Normal urine

Normal ANC

Normal Procalcitonin

This decision rule has not been validated. 

Elise comment: Right now there is a grey zone (based on age of infant) of whether there is a need to do an LP.  There is reasonable practice variation in non-toxic appearing, febrile kids age 30 days to 60 days.   Most faculty have a cut-off at 6 weeks, but up to 8 weeks is reasonable.  Ill appearing kids at any age require LP.

Fever Algorithm for ages Newborn to 36months

Bonder     Patient Satisfaction

Patient satisfaction rates are a factor in medicare reimbursement.

Research has shown that patient satisfaction measurements are biased and don’t correlate with clinical quality metrics.   Also, mortality rates tend to be higher in hospitals with high patient satisfaction levels.

Safety net hospitals and teaching hospitals regularly perform more poorly on patient satisfaction measurements.   There are geographic variabilities as well with California and East Coast hospitals usually scoring lower than other regions.

*Kaiser 4 Habits Model from Kaiser Health

Elise comment: Patient satisfaction measurements are not based on your clinical care or diagnostic accuracy.  They are based on how you communicate with the patient.

Christine comment: At the completion of the ED visit, take the time to explain to the patient what the tests showed and how they ruled out dangerous diagnoses.

*Patient Satisfaction Measures