Conference Notes 3-27-2019
Jurkovic Safety Lecture Trauma Bypass
These are the Criteria for a medical center to have a Level 1 Trauma designation.
Since 2016 CFD criteria for a patient meeting trauma criteria includes patients 55yo and older who fall from standing position and hit their head.
Bypass means that BLS and stable ALS patients get diverted unless the other hospitals are on bypass.
Patients that fall into these categories cannot be bypassed to another institution.
Bypass is a courtesy. BLS and stable ALS patients can still go to the waiting room. Cases that are exempt from bypass are Trauma, STEMI, CVA, full arrest, respiratory distress and those with unstable vital signs. These patients are still going to arrive in our ED whether or not we are on bypass.
In consultation with the House Supervisor, and the ED Lead Physician, it is the role of the ED Charge Nurse to activate bypass. All monitored beds in the hospital need to be occupied. Also any Internal Disaster would prompt a bypass decision.
On average, bypass diverts 1.7 patients/hour. The effect on ED patient volume is not that significant.
IDPH is investigating how hospitals are using bypass to see if an alternative system is possible.
Walchuk/Ebeledike Oral Boards
Case 1. 54 yo female patient presents after resuscitated cardiac arrest. Patient became nauseated at a restaurant and was found unresponsive in bathroom. Exam shows urticaria. Patient became hypotensive again in ED. Diagnosis was anaphylaxis and treatment initiated including epi drip.
Anapylaxis is IGE mediated.
If you have suspected allergic reaction and two systems are involved or the patient is hypotensive, diagnose anaphylaxis and give Epi. There is no contraindication to Epi in the setting of anaphylaxis.
Anaphylaxis treatments. First line therapy is EPI. Everything else second line to EPI. One additional pearl, if patient is on a beta blocker and has hypotension refractory to EPI, you can try glucagon 1mg IV Q 5 minutes.
Case 2. 15 yo female patient presents with knee injury while playing soccer.
Patient’s knee exam was as pictured. Xray confirmed lateral patellar dislocation.
Case 3. 28 yo female present with rash. Patient had EM rash.
Erythema multiforme. Common precipitating factors are infection, especially with Mycoplasma and herpes simplex virus; drugs, especially antibiotics and anticonvulsants; and malignancies. However, the cause is often unknown.3 Most likely, erythema multiforme is the result of a hypersensitivity reaction, with immunoglobulin and complement components demonstrated in the cutaneous microvasculature on immunofluorescent studies of skin biopsy specimens, circulating immune complexes found in the serum, and mononuclear cell infiltrate noted on histologic examination.3 (Tintinalli 8th edition)
Systemic steroids are commonly used for localized disease and provide symptomatic relief but are of unproven benefit in influencing the duration and outcome of erythema multiforme.7 Many authorities recommend a short, intensive steroid course of prednisone, 60 to 80 milligrams PO once a day, particularly in drug-related cases, with abrupt cessation in 3 to 5 days if no favorable response is noted. Systemic analgesic agents and antihistamines provide symptomatic relief. (Tintinall 8th edition)
Erythema multiforme (EM) is an acute inflammatory skin disease (Figure 249–1) with a broad range of severity, from a minimal, nuisance-level event to a severe multi-system illness. It is divided into two distinct sub-types, considering the extent of involvement, presence of epidermal detachment, and the development of mucous membranes lesions. Erythema multiforme minor, the less severe form of the illness, is a localized papular eruption of the skin, with an acral distribution and involving target lesions and/or raised, edematous papules. Erythema multiforme major is the more severe form of EM with multi-system involvement and widespread vesiculobullous lesions and erosions of the mucous membranes; specifically, EM major includes involvement of one or more mucous membrane areas and epidermal detachment less than 10% of total body surface area.
Some authorities include Stevens-Johnson syndrome (SJS) as a severe form of EM major while others consider it a less severe form of toxic epidermal necrolysis. Perhaps the most appropriate classification approach for the emergency physician is as follows: Stevens-Johnson syndrome noted with less than 10% of the body surface area with epidermal detachment; the “overlap” presentation of Stevens-Johnson syndrome and toxic epidermal necrolysis noted with 10% to 30% epidermal detachment; and toxic epidermal necrolysis noted with greater than 30% epidermal detachment.1 In either consideration, SJS is a serious dermatologic illness with significant, widespread skin involvement, more extensive epidermal detachment, and mucous membrane lesions. This taxonomic controversy has no meaning for the emergency physician; what is important for the emergency physician is the recognition of a significant, potentially life-threatening, multi-system dermatologic condition. (Tintinalli 8th edition)
Lambert Pelvic Ultrasound
Yolk sac is the first structure visible of an IUP at about 5-6 weeks. Fetal cardiac activity comes later at about 8.5 weeks.
Live IUP has to have gestational sac with fetal pole and cardiac activity in the uterus. The endometrial stripe needs to surround the gestational sac/fetal pole/heart.
IUP has a yolk sac and fetal pole without cardiac activity within the endometrial echo of the uterus.
If the pregnancy is not within the endometrial echo then the pregnancy is extrauterine (ectopic).
You should have Gyne consult formally on a patient in ED if the patient has abnormal vitals, significant pain, fluid in the pelvis or adnexal mass identified on ultrasound.
When US reveals an unequivocal IUP and no other abnormalities, ectopic pregnancy is effectively excluded unless the patient is at high risk for heterotopic pregnancy. An embryo with cardiac activity seen within the uterine cavity is referred to as a viable IUP. When an embryo without cardiac activity is visualized within the uterus, the diagnosis of fetal demise can be entertained, provided that the crown–rump length is at least 5 mm. Briefly, transvaginal scanning can usually visualize the early sonographic signs of pregnancy, the gestational sac, yolk sac, and fetal pole, at 4.5, 5.5, and 6.0 weeks, respectively. Visualization by transabdominal scanning can be done approximately 1 week later.
No further diagnostic testing is needed when sonographic findings confirm or are highly suggestive of ectopic pregnancy. An empty uterus with embryonic cardiac activity visualized outside the uterus is diagnostic of ectopic pregnancy. This is seen in <10% of ectopic pregnancies using transabdominal scanning, but in up to 25% of cases when the transvaginal approach is used. When a pelvic mass or free pelvic fluid is seen in conjunction with an empty uterus, ectopic pregnancy is considered highly likely (Figure 98-2). The combination of an echogenic adnexal mass with free fluid in the setting of an empty uterus confers a risk of ectopic pregnancy near 100%, whereas a large amount of free fluid alone has a 86% risk (Table 98-4). In addition to a living extrauterine pregnancy, an extrauterine gestational sac is highly predictive of ectopic pregnancy (Figure 98-3). Any adnexal mass (other than a simple cyst) seen with US also has high positive predictive value for the diagnosis of ectopic pregnancy.20,21 It has also been suggested that increased thickness of the endometrial stripe is predictive of ectopic pregnancy when no other diagnostic findings are noted on US. However, the wide overlap between endometrial stripe thickness in normal and ectopic pregnancy limits the usefulness of this observation.22 (Tintinalli 9th edition)
Lambert and Team Ultrasound Ultrasound Lab