Conference Notes 12-14-2016 & 12-21-2016


Menon      Study Guide


*WPW   Orthodromic tachycardia goes down the AV node and back up the accessory pathway resulting in narrow complex tachycardia that can be treated with adenosine.  Antidromic tachycardia goes down the accessory pathway and back up the AV node giving a wide complex tachycardia that should be treated with procainamide.


*WPWIf you have Afib with wide complex RVR, that needs to be treated with procainamide or cardioversion.   Any drug that slows the AV node like adenosine or Cardizem can cause life threatening tachycardia in this clinical situation.


5ways to differentiate V-tach from SVT with Aberrancy

Age and History: Older patient with prior MI or CHF is more likely to have VT.


AV dissociation

Fusion beats

Capture beats



Harwood comment: If you have fusion beats or capture beats, you have V-Tach


*An interesting algorithm using AVR findings may be easy to use.


Elise comment: Icatibant for ACE-I angioedema is looking like it doesn’t work.  There is a large negative study coming out soon about this topic.  It takes a long time for the drug to work.  So it may have some utility for the intubated patient in the ICU to resolve the angioedema sooner but for emergent care in the ED it won’t help. 



*For V-fib that persists despite standard ACLS, you can consider double defibrillation with 2 defibrillators.  You shock with both at the same time.   If you do this, give esmolol as well.  There are some case reports that suggest esmolol and double defib can be useful for “electrical storm”

Little known point:  you can’t do synchronized double cardioversion because you can’t sync two machines together and you risk causing V-Fib.  You can only use two defibrillators in the setting of V-Fib.


*PEA Management   Narrow complex is more likely a mechanical problem.  Wide complex is more likely a metabolic problem.


Elise Reference: Amiodarone, Lidocaine, or Placebo in Out-of-Hospital  Cardiac Arrest  May 16, NEJM


Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory

ventricular fibrillation or pulseless ventricular tachycardia, but without proven

survival benefit.


In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine,

and saline placebo, along with standard care, in adults who had nontraumatic out-ofhospital

cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular

tachycardia after at least one shock, and vascular access. Paramedics enrolled patients at

10 North American sites. The primary outcome was survival to hospital discharge; the

secondary outcome was favorable neurologic function at discharge. The per-protocol

(primary analysis) population included all randomly assigned participants who met eligibility

criteria and received any dose of a trial drug and whose initial cardiac-arrest rhythm

of ventricular fibrillation or pulseless ventricular tachycardia was refractory to shock.


In the per-protocol population, 3026 patients were randomly assigned to amiodarone (974),

lidocaine (993), or placebo (1059); of those, 24.4%, 23.7%, and 21.0%, respectively, survived

to hospital discharge. The difference in survival rate for amiodarone versus placebo was 3.2

percentage points (95% confidence interval [CI], −0.4 to 7.0; P = 0.08); for lidocaine versus

placebo, 2.6 percentage points (95% CI, −1.0 to 6.3; P = 0.16); and for amiodarone versus

lidocaine, 0.7 percentage points (95% CI, −3.2 to 4.7; P = 0.70). Neurologic outcome at discharge

was similar in the three groups. There was heterogeneity of treatment effect with

respect to whether the arrest was witnessed (P = 0.05); active drugs were associated with a

survival rate that was significantly higher than the rate with placebo among patients with

bystander-witnessed arrest but not among those with unwitnessed arrest. More amiodarone

recipients required temporary cardiac pacing than did recipients of lidocaine or placebo.


Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival

or favorable neurologic outcome than the rate with placebo among patients with

out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or

pulseless ventricular tachycardia. 



Einstein     Diarrhea

Diarrhea can cause normal anion gap acidosis.

Stool cultures are only positive 2-5% of the time.   Get them for abdominal pain and fever, ill-appearing children, pregnant patients, and immunocompromised patients. 

Order a C-diff test in any recently hospitalized patient and any patient who recently was on antibiotics.

Treat with oral rehydration or IV fluids. 

Advise complex carbohydrates and lactobacillus-containing yogurt

Antibiotics for symptoms >5 Days and/or systemic symptoms, traveler’s diarrhea, bloody diarrhea, or immunocompromise.   Cipro or azithro are your main choices.


Elise comment:  If you do give antibiotics, make sure you get a stool culture.


Harwood comment:  As the duration of diarrhea increases, the risk of bacterial diarrhea goes up.   Don’t bother with fecal leukocytes.  It is not specific for bacterial causes.  Just get a culture if you are thinking of getting a stool sample.


Girzadas comment: Be alert for hypoglycemia in younger kids (<2yo) who have diarrhea or vomiting.   Hypoglycemic kids usually present cranky and crying.  


Regan    Reading a Thromboelastogram(TEG)


 A TEG measures the speed of clot formation and strength of a clot.  

Thrombin converts fibrinogen to fibrin. 



R time is time to first clot. 

Alpha angle identifies fibrinogen deficiency

Maximum amplitude measures clot stability and platelet activity.

LY 30 measures clot reduction after 30 min and thrombolysis activity.


*Abnoral TEG’s

Long R is due to coagulopathy from coagulation factor issues


*Therapy based on TEG

Increased R time give FFP

Decreased Angle give cryoprecipitate

Decreased MA give platelets and DDAVP



Cirone     M&M

I missed this excellent lecture


Bernard/Schmitz       Trauma Conference


I missed most of this excellent lecture but at the end there was spirited discussion between EM and Trauma faculty about the value of ED thoracotomies.  Basically there was agreement that ED thoracotomy is rarely indicated or life-saving.  The one trauma indication it may be useful for is an isolated stab wound to the heart with hemopericardium.   For the procedure to save a life, you need to have a surgeon rapidly available to take the patient to the OR.


Paquette/Nejak      Oral Boards

Case 1. 50yo male presents with altered mental status.   RR is low.  Patient has a right side dilated pupil and evidence of head trauma.  Patient was emergently intubated.  CT showed acute epidural hematoma.  Patient required emergent decompression.


Case 2. 25yo male presents with left hand pain.  Pain and tenderness is localized to 4th finger.  Patient was involved in a fight the night before.   X-rays shows Jersey finger.  Treatment is splinting with referral to hand or orthopedics for surgical repair.


Case 3.  6 yo patient brought in by parents for abdominal pain.  On exam, patient has palpable purpura on lower extremities.   Patient had marked abdominal tenderness. Plain x-ray of chest shows free air.  Diagnosis is HSP with intussusception with perforation.


HSP Rash.&nbsp; Papable purpura on the lower extremities.

HSP Rash.  Papable purpura on the lower extremities.

Katiyar       Methemoglobinemia

 Case: Infant male brought into ED for decreased PO intake and diarrhea. Child more lethargic than normal.   Child has lost weight.   Pulse Ox =85%.   Blood looks chocolate brown.   Diagnosis is methemoglobinemia.  


There are a lot of causes of methemogloginemia: well water, topical benzocaine (hurricane spray),  and other medications. Poppers (amyl nitrate) and Dapsone can cause methemoglobinemia.   There are congenital causes as well. 

Infants can have nitrite forming organisms causing diarrhea.  Infants have an immature reductase system and can’t handle the nitrites formed by infectious gut organisms.

In the developing world, insecticides are the most common cause of methemoglobinemia.

Treatment includes decontamination if applicable. 

Asymptomatic patients with level <30% will clear methemoglobin in 36 hours. 

Asymptomatic patients with a level >30% and symptomatic patients should get methylene blue.   Can’t give methylene blue if the patient has severe renal dysfunction.

Side effects of methylene blue include blue or green urine, chest pain, and hemolysis.  Patients treated with methylene blue need to be admitted due to risk of hemolysis.


 Katiyar     Billing for Critical Care


Critical care charts don’t have the typical level 5 chart requirements.  You just have to document the critical situation of the patient and your concern for potential decompensation. Then you have to document the time you spent in direct care of the patient (management, discussions, documentation, etc)  Critical care time does not include procedure time.


Be sure to document  all updates and re-evals that you perform on the patient. Document the info you obtained from review of old records.


Central lines, intubations, cardioversion, and A-lines can be billed separately from critical care.  The time you spend on procedures does not count toward critical care time.


If you care for a cardiac arrest patient who is brought to the ED and despite your efforts at resuscitation the patient does not get ROSC, you can’t bill critical care for that.


Residents cannot bill critical care.  The attending has to spend 30 minutes or more in direct patient care and document that care to bill for it.   Mid-level providers can bill critical care similar to an attending.


Critical care time frames are 30-74 minutes and then every 30-minute period beyond that initial time period.   Your time providing critical care does not need to be continuous. It can be the total of multiple 5-10 minute time frames.


Critical care billing is based on the midnight-to-midnight 24 hour day.  If the patient’s care crosses midnight, you can actually bill critical care for each day if you spent more than 30 minutes both before and after midnight.


Okubanjo          Healthcare Disparities

Women healthcare providers are increasing in numbers.  African American providers are still a very low percentage of the total providers.

Historically African-American Universities are very successful in placing graduates into medical school.

Minority physicians are more likely to choose primary care specialties, serve minority populations, and work in areas of manpower shortage.   Their patients are more likely to be low income and have less access to care.

A large factor in clinical uncertainty is the gap between a patient’s cultural or socio-economic background and the healthcare provider’s background.

Hueristics or quick decision-making tools we use in our minds to make rapid decisions in the ED can lead to stereotypes and then biases.   Bias is a negative evaluation of one group and it members relative to another.  When heuristics becomes based on stereotype or bias it can mislead the decision maker.


Bias can also negatively affect the doctor-patient relationship


Zakieh   Fluid Resuscitation in the Critically Ill Patient


In hypotensive patients, IV fluids won’t always solve the problem. Only 50% of hypotensive patients will have a positive response to IV fluids.   Both ventricles have to be on the ascending portion of the Starling curve to benefit from added fluids.


CVP measures RV pressure but is not an accurate measure of central volume or fluid responsiveness.  Again CVP is about 50% accurate in measuring central volume.



*Passive leg raising test is the gold standard test for fluid responsiveness.  It translates to a 300ml auto transfusion.  You can check vital signs in about 2 minutes to see if there is improvement.


Fluid boluses have transient effect.  Fluid leaks out of vascular system in about 60 minutes.


Excessive IV fluids increase mortality in the critically ill patient.


LR as a resuscitation fluid has lower incidence of acute kidney injury compared to normal saline.


We need to move the culture of resuscitation away from normal saline to using more LR.

Patients who receive several liters of saline are at risk for hyperchloremic metabolic acidosis, AKI, and increased mortality.