Conference Notes 12-12-2018

Regan/Twanow Oral Boards

Case 1. 65 yo male presents with difficulty breathing. The patient is tachycardic and tachypneic. Patient has history of COPD. Patient has had worsening cough over last few days. Patient also had left sided chest pain. Patient has valid DNR/DNI order. CXR shows a left sided pneumothorax. Patient was treated with a chest tube and standard therapy for COPD.

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COPD is the most common risk factor for pneumothorax. Usually pneumothoraces in COPDr’s are due to apical blebs that rupture. Dr. Lovell comment: Be cautious not to diagnose an intact bleb as a pneumothorax. You could inadvertently place a chest tube into an intact bleb and cause a pneumothorax. You may need a CT to differentiate pneumothorax from a bleb.

Case 2. 32 yo female with hip and pelvic pain due to an MVC. Patient is tachycardic and hypotensive.

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Patient had an open book pelvic fracture. Pelvic binder applied. Crystalloid infused and Massive transfusion protocol activated. Transfuse in a 1:1:1 ratio of prbcs, platelets, and plasma. Pelvic ring fractures have the highest risk of hemorrhage. After intra-abdominal hemorrhage has been ruled out, IR should be utilized to stabilize patients with hemorrhage from pelvic fracture. IR stops arterial hemorrhage related to pelvic fracture but not venous hemorrhage.

Case 3. 43yo male presents with bleeding gums and oral pain. Patient is febrile.

Vincent angina is a polymicrobial infection, typically limited to the gingiva, and characterized by foul breath, cervical lymphadenopathy, and fever. In immunocompromised individuals, it may extend to include a necrotic gray pseudomembrane on the pharynx. (Current Diagnosis and Treatment Emergency Medicine)

Vincent angina is a polymicrobial infection, typically limited to the gingiva, and characterized by foul breath, cervical lymphadenopathy, and fever. In immunocompromised individuals, it may extend to include a necrotic gray pseudomembrane on the pharynx. (Current Diagnosis and Treatment Emergency Medicine)

Treat with Augmentin,clindamycin or doxycycline and chlorhexidine rinses.

Chastain Study Guide Endocrine Emergencies

Hypokalemia is the most dangerous electrolyte abnormality when treating DKA. Start repleting K with a K < 5.3. If K<3.5, don’t give insulin until you have started KCL infusion.

Anti-seizure medications, steroids, neuroleptics, ASA, betablockers, and calcium channel blockers can all affect glycemic control.

When treating DKA in kids, if they become altered, think cerebral edema. If iatrogenic hypoglycemia has been ruled out, start mannitol even prior to CT.

Patients with adrenal crisis will have hypotension, hypoglycemia, hyponatremia/hyperkalemia, weakness and diarrhea.

Patients with adrenal crisis will have hypotension, hypoglycemia, hyponatremia/hyperkalemia, weakness and diarrhea.

When choosing a steroid to administer for adrenal insufficiency, hydrocortisone has equal glucocorticoid and mineralocorticoid activity. Hydrocortisone is the steroid drug of choice for cases of adrenal crisis or insufficiency because it provides both glucocorticoid and mineralocorticoid effects. IV hydrocortisone (100-milligram minimum bolus) can be administered. (Titinalli 9th ed.)

Dexamethasone is the only steroid that does not interfere with the cortisol assay or cosyntropin test.

Thyrotoxicosis is a hypercoaguable state. So have your guard up for PE in patients with thyrotoxicosis and hypoxia.

Overview of therapy for thyroid storm. (Tintinalli 9th ed.)

Overview of therapy for thyroid storm. (Tintinalli 9th ed.)

Jones First Trimester Vaginal Bleeding

To optimize patient safety, consider every female ED patient pregnant until proven otherwise.

Next approach every pregnant ED patient as if they have an ectopic pregnancy until proven otherwise.

The most common site of ectopic pregnancy is the ampulla. Ectopic pregnancy is the leading cuase of first trimester maternal death.

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Emergency physicians should be extremely cautious about ordering methotrexate to treat ectopic pregnancy. You need to have very careful consultation with OB-Gyne consultant prior to administration. It may be preferable to defer entirely to OB-Gyne specialist. Harwood comment: The failure rate of methotrexate is 14% with rupture. In the setting of a pelvic ultrasound showing no IUP, the new ACOG Guideline recommends not diagnosing ectopic pregnancy until the level of quantitative beta-hcg is above 3000.

Emergency physicians should be extremely cautious about ordering methotrexate to treat ectopic pregnancy. You need to have very careful consultation with OB-Gyne consultant prior to administration. It may be preferable to defer entirely to OB-Gyne specialist. Harwood comment: The failure rate of methotrexate is 14% with rupture. In the setting of a pelvic ultrasound showing no IUP, the new ACOG Guideline recommends not diagnosing ectopic pregnancy until the level of quantitative beta-hcg is above 3000.

Definitions

Spontaneous abortion: Estimated 20% of pregnancies terminate in abortion. One-half occur before 8 weeks’ gestation and one-fourth before 16 weeks’ gestation. Many go unnoticed and unrecognized. This is a common cause for visit to the emergency department.

Complete abortion: Fetal demise and all products of conception are spontaneously expulsed.

Missed abortion: Fetal demise and failed expulsion of the products of conception from the uterus, with a closed cervix. If the condition lasts longer than 4-6 weeks, the patient is increased risk for infection and DIC.

Incomplete abortion: Incomplete expulsion of the products of conception. There is retained products of conception. The cervix is open.

Threatened abortion: Gestation has not reached the stage of viability (< 20 weeks). Patient may have pelvic pain and some vaginal bleeding, or any of the above symptoms. US may show a gestational sac and evidence of fetal cardiac activity. (Current Diagnosis and Treatment, Pediatric EM)

Harwood comment: There is no real role for 50microgram dosing of RH negative pregnant patients in the ED with vaginal bleeding or trauma. Give all RH negative patients with an indication for rhogam 300 micrograms.

Kentor Anaphylaxis in the ED

Unfortunately I missed a large portion of this outstanding lecture.

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Is there such a thing as biphasic anaphylaxis?
This was a retrospective review of 83 patients at a single center with severe anaphylaxis, requiring ICU admission. Of these, 99% received antihistamines, 90% steroids, and just 80% epinephrine. One patient out of 83 (1.2%) had probable biphasic allergic reaction, and this was merely skin changes, not life-threatening and not anaphylactic, according to the study definition. Of the 3 possible and 1 probable biphasic allergic reactions, they occurred at an average of 14 hours from the initial reaction. This study had some issues. The most important is that of patients with severe anaphylaxis, 20% didn’t receive the most important therapy - epinephrine. So, even with suboptimal treatment, the incidence of biphasic allergic reaction within 72 hours was very low and the single probable reaction was mild. Another issue is the retrospective nature was limited in determining what was and was not an allergic reaction, such as rash or hypotension for other reason, such as sepsis. My take home point is that true biphasic anaphylactic reaction is rare or non-existent. Most patients simply need to be observed a few hours to ensure they don’t have persistent anaphylaxis, especially those with ingestion of a food as the cause of the reaction.

Another Spoonful
The Skeptics Guide to EM did an in-depth, outstanding summary of biphasic anaphylaxis. Their bottom line: “Prolonged observation is likely unnecessary,” once symptoms resolve in the ED. Don’t miss this post.

Source
Low Incidence of Biphasic Allergic Reactions in Patients Admitted to Intensive Care after Anaphylaxis. Anesthesiology. 2018 Nov 5. doi:

(Journal Feed 12-6-2018)

Lorenz/Shroff Christmas Cases

Indications for emergent esophageal FB removal are complete obstruction, battery in the esophagus, and sharp object in esophagus.

The initial fluid rate used for burn resuscitation has been updated by the American Burn Association to reflect concerns about over-resuscitation when using the traditional Parkland formula. The current consensus guidelines state that fluid resuscitation should begin at 2 ml of lactated Ringer’s x patient’s body weight in kg x % TBSA for second- and third-degree burns. The calculated fluid volume is initiated in the following manner: one-half of the total fluid is provided in the first 8 hours after the burn injury (for example, a 100-kg man with 80% TBSA burns requires 2 × 80 × 100 = 16,000 mL in 24 hours). One-half of that volume (8,000 mL) should be provided in the first 8 hours, so the patient should be started at a rate of 1000 mL/hr. The remaining one-half of the total fluid is administered during the subsequent 16 hours. (ATLS 10th edition)

ATLS manual 10th edition

ATLS manual 10th edition

Calculating burn area based on rule of 9’s. ATLS manual 10th edition

Calculating burn area based on rule of 9’s. ATLS manual 10th edition

Putman ENT Emergencies

Mumps

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VIRAL PAROTITIS (MUMPS)

Viral parotitis is an acute infection of the parotid glands, characterized by unilateral or bilateral parotid swelling. It is most often caused by the paramyxovirus and may be caused less commonly by influenza, parainfluenza, coxsackie viruses, echoviruses, lymphocytic choriomeningitis virus, and even human immunodeficiency virus.25 It is most common in children under the age of 15 years old, but since November 2014, clusters of mumps have been reported in adult members of professional hockey teams. The virus is spread by airborne droplets, incubates in the upper respiratory tract for 2 to 3 weeks, and then spreads systemically. Vaccine protection is not 100%, and outbreaks occur in settings of close contact, such as schools, colleges, sports teams, and camps.26

After a period of incubation, one third of patients experience a prodrome of fever, malaise, headache, myalgias, arthralgias, and anorexia during a 3- to 5-day period of viremia.25 The classic salivary gland swelling then follows. Unilateral swelling is typically followed by bilateral parotid involvement. The gland is tense and painful, but erythema and warmth are notably absent. Stensen's duct may be inflamed, but no pus can be expressed.25

Diagnosis is clinical and treatment is supportive. Salivary gland swelling typically lasts from 1 to 5 days. The patient is contagious for 9 days after the onset of parotid swelling, and children with mumps should be excluded from school or day care for this interval.

Mumps is usually benign in children but can be severe in adults. Unilateral orchitis affects 20% to 30% of males (with a predisposition of ≥8 years of age), whereas oophoritis affects only 5% of females. Other complications of the mumps virus include mastitis, pancreatitis, aseptic meningitis, sensorineural hearing loss, myocarditis, polyarthritis, hemolytic anemia, and thrombocytopenia.25 Immunocompetent patients with isolated viral parotitis or orchitis can be managed as outpatients. Admit patients with systemic complications.(Tintinalli 8th ed)

Peritonsillar abscess drainage

Some tips: the carotid is posterior-lateral to the tonsil, so keep your needle directed posteriorly and medial to the molars.

The cavitary U/S probe can be very helpful to localize the abscess.

Using an 18 gauge 3 cm spinal needle is useful because compared to a standard 18g needle, the longer needle keeps the syringe at or distal to the patient’s teeth. This improves visibility of the peritonsillar area, gives an increased range of movement, and has more utility in the setting of trismus. You have to use an 18g needle to be able to aspirate pus. Smaller needles may not be able to aspirate pus.

You can get good exposure by having the patient use a laryngoscope or lighted disposable vaginal speculum to hold down their own tongue.

Trim the needle cap and place it over the needle to act as a depth gauge (  Figure 175-5   A ). The needle should project only 1 cm from the distal end of the needle cap. Alternatively, apply a piece of tape onto the needle to mark a point 1 cm from the tip of the needle (  Figure 175-5   B ). The guard (cap or tape) serves as a marker for the maximum allowable depth to insert the needle during the procedure.  Limiting of the depth of insertion of the needle will prevent injury to the carotid artery that is located approximately 1.5 to 2 cm posterior and lateral to the tonsil.

Trim the needle cap and place it over the needle to act as a depth gauge (Figure 175-5A). The needle should project only 1 cm from the distal end of the needle cap. Alternatively, apply a piece of tape onto the needle to mark a point 1 cm from the tip of the needle (Figure 175-5B). The guard (cap or tape) serves as a marker for the maximum allowable depth to insert the needle during the procedure. Limiting of the depth of insertion of the needle will prevent injury to the carotid artery that is located approximately 1.5 to 2 cm posterior and lateral to the tonsil.