Case 1 . 18yo female presented with strange behavior (grimacing, not speaking). Patient had history of depression, pituitary adenoma, and pseudoseizures. Patient was on multiple meds: Soma, Effexor, Parlodel and Norco. Patient was agitated, hypertensive, tachycardic and febrile.
Diagnosis: Serotonin syndrome
*Clinical Characteristics of Serotonin Syndrome. There is no objective diagnostic test. There are 3 diagnostic criteria
*Hunter Criteria for Serotonin Syndrome. Andrea said that this was the most up to date and accurate diagnostic criteria.
Treatment for Serotonin Syndrome is stopping all serotonergic medications and giving cyproheptadine.
*Serotonin Syndrome vs Neuroleptic Malignant Syndrome. If you see the term “lead pipe rigidity” on the boards, that is NMS. Treat NMS with bromocriptine.
Core temperature is the most important vital sign to correct in the setting of overdose. Andrea said the fastest way to cool a hyperthermic patient is to pack them in ice. Girzadas comment: We had amazing success with packing a patient in ice and using a high powered fan blowing air over the ice/patient.
Staley Approaching the Febrile Infant
Fever is defined as 100.4F or 38C. Also beware of hypothermia (<36.5) in infants as a marker of infection. If the parents take the temp by axillary or ear methods, don’t add or subtract anything to the reported number. In the infant under 60 days old, even reported fevers at home that are not substantiated in the ED need to be strongly considered for work up.
Around 10% of infants under three months of age with fever have serious bacterial illness (SBI). Physical exam in these infants is not able to distinguish kids with/without SBI.
Hi Flow O2 in septic infants is useful to prevent intubation.
If you can’t get an IV in 2-3 sticks go right to IO. IO has actually been shown to be less painful than multiple IV sticks.
If the child is less than 28 days old and they have fever, they get a full sepsis work up including LP. Give ampicillin and cefotaxime and admit. Give vancomycin and acyclovir if child appears critically ill.
If the child is 29-60 days old with fever, all get CBC, blood cultures and urinalysis/urine culture. If the CBC, urine, vitals are all OK, you can consider discharging the patient without antibiotics. If you decide to give antibiotics for any reason you have to do an LP. If you identify a UTI in infants this age and you decide to give antibiotics you still need to do an LP prior to giving antibiotics.
In infants older than 60 days, say 2-4 months old, with fever 39.5 or above, there is about a 6% risk of serious bacterial illness and you need to consider doing CBC, blood culture and UA/urine culture.
Tips for LP success in infants: Use EMLA prior to giving lidocaine. Use a pacifier dipped in sweetese. Sugar on a pacifier has been shown to be a very effective pain reducer in infants. Using a firm surface under the child (chest compression board covered in a blanket) this board keeps them from sinking into the mattress and it may line up landmarks better. Advancing your needle with the stylet removed after you have gotten past the skin helps you identify CSF more readily. If you get any flow of CSF, don’t try to adjust the needle to get better flow. Needle adjustments increase the risk of a bloody tap or moving the needle out of the CSF containing space.
Nejak Managing Shoulder Dystocia
The infant’s shoulder gets hung up on the pubic bone. You need to calm mother and try to limit contractions/pushing. Call OB for help.
Step 1. Put mom in extreme lithotomy position and apply suprapubic pressure to move the shoulder under the pubic bone.
Step 2Try turning the infant’s shoulder in the vaginal canal
Step 3. Deliver the posterior arm to free up some space
Step 4. Get mom/infant to OR.
*Management of Shoulder Dystocia
West Bedside Ultrasound for Shock
Evaluate the Pump: Evaluate the Heart for pericardial effusion/tamponade, contractility, abnormally large RV
Evaluate the Tank: Evaluate the IVC for flattening/collapse, do a FAST exam, and check the lungs for CHF or pneumothorax.
Evaluate the Pipes: Check for AAA, check for DVT.
DeStefani Brain MRI for Dummies
The DWI and ADC sequences of an MRI imaging set will identify acute strokes.
The DWI sequence will show all strokes acute and chronic.
ADC sequence differentiates acute vs chronic stroke.
Acute stroke region will be Bright on DWI and Dark on ADC MRI sequences.
Holland EMS VooDoo
There is no evidence to demonstrate benefit of routine use of long spinal immobilization boards.
There is no evidence to demonstrate benefit of routine use of cervical collars.
We as the EM community should advocate for a more rational and evidence based use of long boards and C-collars.
Suggested Indications for long boards: Transferring patients to an EMS cart or ED cart. After that, get the patient off the board.
Suggested Indications for Cervical Collars: Positive NEXUS criteria, high risk mechanism, or known cervical spine fracture.
Kennedy Intro to Ventilator Management
Always start with Assist Control
Lung Protective Strategy: RR=18, TV 6ml/kg, FIO2 100%, PEEP 5.
Obstructive Strategy (Asthma/COPD): RR=10, I:E Ratio should be 1:5, TV 6 ml /kg. FIO2 50%. Let pCO2 ride high. Watch for autopeep.
*Managing Problems with the Intubated Patient
Hart/Regan Ortho Cases
Boxer’s Fracture. Requires ulnar gutter splint. Elise comment: For all splinted patients, be sure to document that you re-evaluated the patient after splinting and splint was applied correctly and N/V status intact.
Tibial Plateau Fracture. High energy trauma in young patients. Plateau failure in older patients. Patients will have significant pain and won’t be able to bear weight. Management is commonly surgical.
*Tibial Plateau fracture types. There can be either or both depression and fracture fragments.