Conference Notes 5-9-2018

Almeida/Eastvold/Tomasello     EKG's

You only need 1 lead of concordant ST elevation/depression with bundle branch block to diagnose STEMI

Posterior MI

A straightened ST segment is indicative of ischemia/evolving STEMI

If you don't have an old EKG, make an old EKG by getting serial EKG's.

DeWinter's T waves anterolaterally  STEMI equivilent

Know your epinepherine dosing for anaphylaxis

For Adults   0.3mg-0.5mg 1:1000 IM repeat as necessary.   For anaphylactic shock 0.1mg 1:10,000 IV slow

Chest pain that radiates to both arms is highly specific for cardiac chest pain. Chest pain that radiates to left arm is non-spcific for cardiac chest pain.  Chest pain that radiates to right arm is more specific for cardiac pain than for left arm pain.

Conference Notes 5-23-2018

McKean/Logan   Oral Boards

Case 1. 10 month old child drank gasoline.  Child had respiratory distress and bilateral pulmonary infiltrates.  Patient was intubated to treat aspiration of gasoline.

CXR of bilateral pulmonary infiltrates due to hydrocarbon aspiration

In addition to pneumonitis, patients with hydrocarbon ingestions can develop CNS depression, seizures, and arrhythmia.  Catecholamines, antibiotics, and steroids should be avoided.

"Treat hypotension with aggressive fluid resuscitation. Avoid administration of catecholamines such as dopamine, norepinephrine, and epinephrine. Catecholamines may cause dysrhythmias, especially after exposure to halogenated hydrocarbons and aromatic hydrocarbons. Hydrocarbon-induced dysrhythmias are generally seen shortly after the exposure, especially with inhalational use. Continuous cardiac monitoring should be initiated, and an ECG should be obtained. For hydrocarbon-induced ventricular dysrhythmias, class IA (procainamide) or class III (amiodarone, bretylium, and sotalol) antiarrhythmics should be avoided because of the risk of QT-interval prolongation.18 Propranolol, esmolol, and lidocaine have been reported to treat these ventricular dysrhythmias successfully.10,18,39

There is no benefit to gastric lavage because risks of aspiration far outweigh any theoretical benefits.40 Activated charcoal does not adsorb hydrocarbons well and poses a risk for vomiting and aspiration, so charcoal is not recommended either. I  (Tintinalli reference)

Case 2. 29 yo female with syncope. Upreg is negative.

Patient had run of stable V-tach in ED treated with Amiodarone

Arrythmogenic RV Cardiomyopathy

Epsilon Wave specific for arrythmogenic right ventricular cardiomyopathy.

Case 3. 74 yo male with knee pain. Patient fell at Wrigley field. On exam patient cannot extend the knee against gravity. 

Quadricep tendon rupture with low riding patella on the right

Patient needs orthopedic consult for surgrical repair.

Kishi  5- Slide Follow Up

Treatment for Acute Flash Hypertensive Pulmonary Edema also known as Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

 Nitro sprays followed by Nitro drip at 100mcg/min

Start patient on bipap

Limit diuretic use as these patients are frequently hypovolemic.  If you think the patient is hypervolemic, cautious IV lasix may be indicated.

Dennis Ryan comment:  sublingual sprays give 400micrograms per dose.  This is a good way to give big doses of nitro early on. 

Miner    5 Slide Follow Up

Microangiopathic hemolytic anemia, one of the cardinal features of hemolytic-uremic syndrome, may be profound with a hemoglobin level between 5 and 9 grams/dL. A peripheral smear demonstrates schistocytes, helmet cells, and burr cells. The Coombs test is negative. The platelet count is <150 000/mm3. The WBC count may be elevated.

Hyponatremia and hyperkalemia develop as a result of metabolic acidosis from renal failure, and hyperbilirubinemia results from acute hemolysis.   (Tintinalli reference)

Aytpical HUS is differentiated from HUS by the fact that it is not caused by toxin producing ecoli.

Treat atypical HUS with plasma exchange and eculizumab (Soliris). 

Jones    5 Slide Follow Up

Bedside echo is key to the evaluation of acute chest pain and hypotension.

If you see cardiac tamponade on bedside echo, think aortic dissection.

Aortic Dissection Detection Risk Score is one tool to consider when evaluating chest pain. You can check out the decision guideline in MD Calc.  (editor's note) It has not been fully validated but it I think it helps organize my clinical thinking about dissection.

Johns       5 Slide Follow Up

Consider headache "red flags"

Conference Notes 4-25-2018

Velamati/Lorenz       Oral Boards

Case 1.  3 yo male presents with bloody diarrhea.  Patient has abdominal pain and dark urine. Multiple family members had diarrhea after eating at a BBQ. Patient has elevated blood pressure to 118/80. On exam patient has some extremity edema, abdominal tenderness,  and a palpable liver edge. Labs c/w hemolysis, and abnormal renal function tests.

Diagnosis is HUS. HUS presents about  3-7 days after ingestion of contaminated food. 

Shiga-toxin HUS usually does not need plasmaphoresis.

Harwood comment: Atypical HUS can be treated with monoclonal antibody eculizmab.

Detailed graphic differentiating TTP, atypical HUS, and Shiga-Toxin HUS

Case2. 30 yo female with right leg pain and inability to walk. Vitals are normal. Patient was playing soccer when she felt her leg buckle. Since then she can not bear weight on right leg.  Patient has a history of lupus and steroid use.  On exam, right knee has large effusion and patient cannot extend right knee against gravity. Neurovascular status intact distal right lower extremity.

Left image is normal position of patella.  Right image is a superiorly displaced patella due to rupture of patellar tendon.

Diagnosis is patellar tendon rupture.  Management is knee immobilizer and crutches and orthopedic consultation for operative repair.

Case 3. 12 yo male presents with confusion and difficulty walking.  Accucheck is 59.  Vitals are significant for hypotension.  Patient was given D25 rapidly. Skin is bronze colored. Labs showed hyponatremia and hyperkalemia.

Diagnosis was adrenal insufficiency.  Patient was treated with IV hydrocortisone.  CT head was negative.  Vitals improved with IV fluids and IV hydrocortisone.  For severe hyponatremia and neurologic signs, treat with hypertonic saline.   Consult endocrinology.

Yapo       Non-Accidental Trauma

Bruising on ears or neck in a child under age 4 is concerning for abuse.

Slate grey macules (Mongolian spots) are not signs of abuse.

Only about 12% of abusive abdominal injures will have abdominal bruising. Intra-abdominal organs are more susceptible to injury due to pediatric anatomic differences from adults (less abdominal wall musculature, more pliable ribs, horizontal diaphragm).  Abusive injury to the abdomen has higher mortality than non-abusive injuries.  Abdominal injuries present 3.5 days after trauma.  Symptoms will be vague.  Non-abuse related falls do not usually cause intra-abdominal injury.

The duodenum is susceptible to abusive trauma because it has both fixed and mobile portions. 

The liver is the most common solid abdominal organ injured from abuse.

Pediatrics 2009 LInberg: If AST or ALT is >80 you have to consider intra-abdominal injury.  The liklihood ratio for AST or ALT>80 for identifying intra-abdominal injury is 4.3. Draw this lab in patients under 5 years of age in whom you are screening for non-accidental trauma.  If ALT or AST is over 80 get abdominal imaging. Draw ALT and AST if a patient has fracture, head injury or other injury raising suspicion for abuse.

Skeletal survey is manadatory in age <2.  Case by case basis for skeletal survey in ages 2-5.  No utility of skeletal survey in children over age 5.

Scan an infant's head for any alteration in mental status, any sign of abuse in a child less than 6 months of age, and any child with suspicion for shaken baby syndrome.   Dr. Yappo said that you should strongly consider getting a CT head in a child less than 6 months with any evidence of abusive injury even if there is no sign of head injury. 

Mullen  5 slide Follow Up

If a patient is unresponsive after a seizure, consider sub-clinical status epilepticus. If you have a suspicion of sub-clinical status epilepticus you should get an EEG to assess for ongoing seizures.

Management of Status Epilepticus. If you have to intubate, consider succinylcholine rather than rocuronium to keep the time of neuromuscular blockade as brief as possible. You don't want to obscure seizure activity with neuromuscular blockade.

Ebeledike    5 Slide Follow Up

Male patient with groin pain.  Dr. Ebeledike discussed hernias.

Adlington    Care of Sexual Assault Patients

If sexual assault occurred within 7 days of ED presentation we have to offer evidence collection, date rate drug testing,  STI testing, emergency contraception, and HIV prophylaxis. 

If sexual assault occurred more than 7 days prior, evaluation is done on a case by case basis.

There is a macro in our FirstNet power chart in the medical decision making section (**sexual assault) that covers all the areas of required documentation.

Legal Definition of penetration: Any contact between the the labia even if minimal/superficial is considered penetration.

New concept (at least for me)  avoid the word "alleged"in your documentation.  It may convey a negative connotation to the patient's history.  We had a discussion about the challenges of avoiding this term in documenting the H&P and diagnosis.  (editor's note) It may be challenging in certain circumstances to find an acceptable alternative term.  The presenter said she would send us suggested coding alternatives.

New concept (at least for me) In pre-pubescent children, do not interview them about what happened.  That interview needs to occur with the state's attorney and with a trained forensic interviewer.

Any age person can consent to an exam and evidence collection after sexual assault or abuse.  Don't do an exam or collect evidence if patient refuses or is resisting exam.  If you have to use force or sedation to do an exam, don't do it.

SANE trained nurses can do the entire evidence collection and exam independently.   ED nurse without SANE training cannot do the genital or anal exam. The physician will need to perform this portion of the exam.   Everyone in the room during evidence collection must have gown, hair covering, shoe covers, and a mask in order to keep examiners/care givers DNA from getting into specimens.

On the forensic documentation form you have to write "no injury identified" in each picture section of any area you examined.  If nothing is written in a section of the forensic documentation, the court assumes no exam of that area was performed.

In prepubescent female children the swabs for evidence collection are obtained by lightly touching superficially the mucosal area between the labia.

Hawkins    EKG's

Dr. Hawkins reviewed multiple EKG's in a very interactive fashion.  I was unable to encapsulate this lecture in these notes. 

Chinwala      Safety Lecture

Med Tele and Tele have the same nursing ratios for patient care.  They have the same monitors.   Patients with a cardiac problem (nstemi, cardiac syncope, arrythmia, new-onset CHF) who require monitoring should go to tele.   Patients with a medical problem (sepsis, PE, hyperkalemia, CVA, etoh withdrawal, recurrent CHF) who require monitoring should go to med-tele.

Dr. Chinwala also discussed how we triage patients for CT scanning.

Pastore      Safety Lecture

Dr. Pastore discussed the CODE 15 process for behavioral health emergencies.

Twanow       Safety Lecture

Dr. Twanow discussed active shooter scenarios.

29% of hospital shootings occurred in the ED. 23% of hospital shootings were due to a shooter who took away the security guard's gun.

Active shooter scenarios occur in about 15 minutes and frequently end before police arrive.

Basic plan: Alert those around you.    Then RUN>>>>Hide>>>>Fight in that order.

The 4 A's of an Active Shooter situation: Accept that a life threatening active shooter situation is occurring, Assess what you should do, Act for your own and others safety, Alert law enforcement. (editors note: Accept is probably the most important factor.  The others will come naturally after that.)

Shroff   ICEP Presentation

Dr. Shroff gave a preview of her upcoming ICEP Spring Symposium presentation.

Conference Notes 4-18-2018

Denk/Traylor      STEMI Conference

Case 1.   Following resuscitated cardiac arrest, if a patient has  hypertension, it may be indicative of impending cardiogenic shock.  The post-arrest patient maybe vasoconstricting to compensate for poor cardiac output.

Case 2.  If a patient has focal ST depression associated with ST elevation in other leads, you can't call it pericarditis.

Steps to distinguish pericarditis from STEMI:

Is there ST depression in a lead other than AVR or V1? This is a STEMI

Is there convex up or horizontal ST elevation? This is a STEMI

Is there ST elevation greater in III than II? This is a STEMI

Now look for PR depression in multiple leads… this suggests pericarditis (especially if there is a friction rub!)

From Life in the Fast Lane

A Right sided EKG looks for STEMI on right side. If the patient has right sided ST elevation this increases the probablility of RV dysfunction.  If the patient has RV dysfunction they potentially will be very preload sensitive to nitroglycerin.  Thus, in this setting of right sided ST elevation, nitro can cause hypotension.

Bedside echo can be useful in difficult cases where you are not sure if there is a STEMI. If you see wall motion abnormality or poor squeeze you know you have a STEMI.

Case 3.   If you see ST depression in AVL you really gotta look for ST segment elevation in the Inferior leads. The ST depression in AVL may be more eye catching than subtle ST elevation inferiorly.

There is also a thing called Jone's sign which is a straight ST segment which suggests evolving STEMI. Jone's sign will occur prior to full-fledged ST elevation.

Straightening of the ST segment suggestive of STEMI

Case 4. When you see an EKG showing STEMI but the coronaries are clean, and the patient has a low EF, the patient has Takotsubo's.

Takotsubo's is more common in women.  If a patient gets it once, they are at higher risk to get it again. 

Characteristic apical balloning of left ventricle similar to octopus trap in Japan.  Takotsubo's is Japanese for octopus trap.

Menon/Twanow     Oral Boards

Case 1. 50yo male with chest pain s/p mvc. Heart rate 120, BP=160/120. Patient has signs of abrasions to left chest. Patient has left abdominal tenderness.  FAST is negative. CTA shows aortic injury.

Extreme example of CXR showing widened mediastinum and multiple classic findings of blunt aortic injury.

CTA shows in aortic injury

You want to bring down pulse and BP to manage the shear force on aortic wall. Give esmolol and a vasodilator such as nicardipine or nitroprusside. 

Case 2. 21yo male with right shoulder pain.   Patient injured right shoulder playing rugby. Vitals are OK.

Posterior shoulder dislocation. Y view on right shows humeral head posterior to scapula and Y.

With posterior dislocation, humeral head looks like golf ball on a tee.  With anterior dislocation, humeral head looks like a golf club head.

Posterior dislocations are classically associated with seizures or electrical shock/lightning strike.

Case 3. 7yo with rash and joint pain. Vitals all OK.  Rash on lower extremities c/w HSP

HSP rash

HSP is the most common vasculitis in childhood.  It is an IGA vasculitis. Patients are at risk for intussusception, renal disease (nephritis), and joint pain.  Management is supportive.  Steroids can be given to treat severe pain but in general steroids are not indicated. Steroids are not useful for renal disease and they do not shorten course of illness.

Burns/Denk    Using Echo to Calculate Cardiac Output and Rescue Echo

Cardiac Output=Stroke volume X heart rate

U/S calculation of stroke volume= Pi (LVOT diameter/2)squared X VTI

Stroke volume is measured with U/S  by using parasternal long view. Left Ventricular Outflow Tract (LVOT) diameter is measure the width of LV outflow tract when valve leaflets are open. Measure the width just proximal to aortic valve leaflets.  The computer on the machine squares this measurement to come up with the stroke volume.  Normal width will be around 2cm.

VTI is calculated by ultrasound machine when using the Apical 5 chamber view.

LVOT diameter normal is 2.   VTI normal is 15-20.  Normal CO=4-6

editor' s note: This was an outstanding, highly technical discussion of calculating cardiac output with U/S.  I had difficulty encapsulating the discussion in these notes. That is based on my own unfamiliarity with the procedure and the math. 

Rescue Echo looks for causes of hypotension

Rescue echo utilizes parasternal, subcostal, and apical views.

The critical Rescue Echo diagnoses: LV dysfunction, RV dysfunction, severe valvular dysfunction, systolic anterior motion abnormalities SAM, cardiac tamponade, and hypovolemia.

Katiyar   Billing and Coding

Critical care billing gives 6.33 RVU's for first 30 minutes.  That's more than a level 5 chart which is 4.9 RVU's. 

Critical care requires risk of life threatening deterioration requiring the highest level of physician attention.

The critical charge covers 30-74 minutes of critical care.  You cannot include the time you spent performing procedures such as intubation and central line.

Critical care billing requires that the attending physician is giving direct attention to the patient either at the bedside or reviewing diagnostic studies, discussing with consultants and family members, or documenting.  The total time does not need to be continuous.  You can hit 30-74 minutes of critical care time by caring for a patient intermittently.  The time you count towards critical care just has to be focused entirely on that patient and not include procedure time.

You need to document the time you spent and how you spent it.  You have to document the risk of deterioration if the patient was not treated. It is beneficial to document all the re-evals you performed on the patient. It is beneficial to document the timeline of when you evaluated, re-evaluated, consulted, reviewed diagnostics, and had discussions, etc.

Conference Notes 3-7-2018

For additional ultrasound education, you can find our monthly "Ultrasound Case Series" on the Christ EM website under the "Residents" tab: http://www.christem.com/ultrasound-case-series

Herron/Tran     Oral Boards

Case 1. Pregnant patient presents with seizures and hypertension.  Dexi was normal.  Patient was treated with IV magnesium, BP management and emergent delivery of baby.   Patient also had criteria for HELLP.

Harwood comment: The keys to managing this case are IV magnesium and emergent c-section.

Medications for treating hypertension in pre-eclampsia and eclampsia. Tintinalli 8th ed.

Case 2.  60yo female presents with bi-temporal headache. ESR is 100.  Diagnosis was temporal arteritis.

Treatment was initiating po steroids 60mg/day and arranging for temporal artery biopsy

Case 3. 15 yo male in cardiac arrest after being struck in the chest with a hockey puck.

Patient is pulseless with polymorphic VT

Patient was treated with IV epinepherine, defibrillation, and magnesium.  Patient had ROSC.  Therapuetic hypothermia was initiated. Diagnosis was commotio cordis.

Mechanism of comotio cordis   (Life in the Fast Lane)

Dr. Lovell comment: Post-arrest you have to be disciplined about keeping the patients O2 sat at 94% (avoid hyperoxia), checking the post ROSC EKG for STEMI, and keeping BP over 90 systolic.  Target therapeutic hypothermia to a temperature of 36C.  Look for alternative cause of arrest such as sepsis.

Sklar     Study Guide        Infectious Disease

Patients with HIV/AIDS who present with pneumonia treat for PJP with Bactrim and also cover CAP. If patient is hypoxic give steroids.

Stages of Lyme Disease

Erythema chronicum migrans rash of Lyme disease

Rabies wound care: Provide proper wound care, including tetanus prophylaxis, wound cleansing with soap and water and (if available) a dilute solution of povidone-iodine (1 mL povidone-iodine in 9 mL of water or normal saline), antibiotics (if indicated) to prevent bacterial infection (see chapter 46, Puncture Wounds and Bites), and rabies prophylaxis as indicated.17

Rabies post-expoosure treatment recommendations

There was a discussion about which patients should receive post-exposure prophylaxis for rabies.   A pre-verbal child or an older child or adult who for some reason may be obtunded or not be able to express that they were bitten who were in a room with a bat should receive  post-exposure prophylaxis.  Older children and adults with normal cognitive function will likely be able to accurately tell if they were bitten or not based on this picture.

Harwood also discussed a theory that it may be possible to contract rabies without a bite if you are in cave or lab or other area where many bats are living. Bats may be able to exhale the rabies virus into the air.  This theory is controversial. 

Picture courtesy of Dr. Lovell.

Gonococcal arthritis is the most common form of septic arthritis in adolescent and young adults.   The clinical picture of gonococcal arthritis is migratory arthritis, pustular rash and tenosynovitis.  Treatment is IV or IM ceftriaxone 1gram Q day initially.

Pustule from disseminated gonorrhea

Rocky Mountain Spotted Fever Rash

Rocky Mountain Spotted Fever Rash

Treatment of RMSF for adults is doxycycline, 100 milligrams PO twice a day; for children under 45 kg with permanent teeth, treatment is doxycycline, 2.2 milligrams/kg twice a day. Doxycycline does not cause staining of permanent teeth.   (Text and pictures from Tintinalli)

Grey membrane from diphtheria. Complications include myocarditis and neuritis potentially leading to diaphragmatic paralysis and death from respiratory failure. Diagnosis is confirmed by isolation of C. diphtheria by cultures of a nasopharyngeal swab. Treatment includes antitoxin and antibiotics (erythromycin or penicillin G) and respiratory support as needed. Tintinalli 8th ed.

Yersinia enterocolitica infections are due to contaminated pork.  It can cause RLQ abdominal pain and diarrhea that is sometimes bloody in children and young adults. Yersinia has a preference for lymphoid tissue so will go to the area around appendix.  Diagnose yersinia with specific stool culture.   Yersinia enterocolitica infections are usually self limited but if there are systemic signs, treat with ceftriaxone or fluoroquinalones

Girzadas    Study Guide     Neurology

I gave this lecture so didn't take any notes.

However,  we did have one interesting discussion about initial stroke care.  We will discuss this further in Journal Club next week but a new strategy for more severe strokes has been published recently.  It employs the VAN score to more rapidly evaluate strokes with a risk for large vessel occlusion amenable to stent retriever endovascular therapy.  Thanks to Mitch Lorenz for the VAN references below.

The VAN screening assessment. To be VAN positive you need to have weakness of one arm PLUS any one of the Visual, Aphasia, or Neglect signs. If the patient has no arm weakness, they are VAN negative.  If they have arm weakness but no other finding listed on the screening tool,  they are VAN negative.

VAN positive patients get CT and CTA right at the beginning of their ED visit.  The controversy is whether this goes against the new 2018 AHA guidelines which advise not delaying TPA to get CTA done. It appears that the VAN protocol gets TPA infused and endovascular therapy started more quickly anyway. We may be moving to this model of care.

Tekwani     Airway Lecture

Case 1.   If a patient has their jaw wired shut and you need to intubate, call Ortho, the OR,  or hospital maintenance personnel  to get wire cutters to snip jaw wires.  If an airway is suspected to be difficult, one strategy would be to sedate the patient with ketamine to see if you can visualize the airway prior to giving rocuronium.

Case 2.  Dr. Barounis comment: In the patient with peri-intubation hypotension, perform intubation with no paralysis and minimal or no sedation.  Just use good topicalization with atomized and topical lidocaine. It is a strategy to avoid CV collapse.  You avoid taking away the patient's  inspiratory drive that provides venous return.  Also look for blood loss, pericardial tamponade, and PE or MI as a cause for hypotension.

Case 3.  If there is a bloody airway, be prepared for failure of VL due to blood obscuring camera.  Have direct laryngoscopy ready to go.

Case 4. Pearl: If patient has chronic torticollis, assess neck movement prior to paralysis to make sure that patient does not have shortening of neck muscles that will make positioning difficult. You don't want to find that out after you paralyze the patient.

Case 5. Lubricate the ET tube to help it pass over the arytenoid cartilage.  Suction the airway prior to placing the tube. Make sure you have the glidescope in the velecula to give yourself some room to intubate.  If you have the glidescope blade lifting the valecula from the posterior side it makes intubation more difficult because you don't have enough room to place the tube.

Hormese             Changes to Adult DKA Guidelines

Identifying DKA:  Ph<7.3, bicarb<18, or anion gap.  Consider euglycemic DKA if glucose less than 250 but patient still has acidosis or gap.

LR preferred resuscitation fluid for DKA.  LR bolus up to 2 liters initially  followed by 150ml/hr.

If K<3.3 hold insulin until K is corrected with IV potassium.  If K<5.3 add 40meq K/liter to IV fluids.

Bicarb not indicated unless pH<7.0

Insulin drip 0.1u/kg/hr.   You want to aim for decreasing glucose by 75 md/dl/hr.   Titrate insulin for this ballpark rate of decrease.

You can transition to subQ insulin if the patient can tolerate PO, blood sugar drops below 250, acidosis has resolved, and gap has closed.

For additional ultrasound education, you can find our monthly "Ultrasound Case Series" on the Christ EM website under the "Residents" tab: http://www.christem.com/ultrasound-case-series

Conference Notes 2-14-2018

Tekwani/Pastore    Oral Boards

Case 1.  28 yo female with right eye pain.  Patient's child shot a nerf dart into patient's right eye the day before.

Traumatic Iritis with peri-limbal conjunctival injection.  Be sure to evaluate for globe rupture, hyphema, and corneal injury.  Always doucment visual acuity.  Treat with cycloplegic drop.  Discuss with ophthalmology about topical steroids.  Some increased risk of glaucoma long term.

Case 2. 14 yo male with right knee pain for 2 weeks.

Patients with Osgood Shlatter's disease will have pain and swelling over tibial tubercle. Xrays may show apophysitis and widening of physis of tibial tubercle

Osgood-Shlatter disease is a traction apophysitis. The disease is self-limited. Treatment is NSAID's, ice and continued activity if pain can be controlled.

Case 3.   Patient presents with a few days of fever and seizure. Patient is not immunized.

Koplik's spots with measles

Measles rash.  Rash is preceded by fever and koplik's spots.  Patient's with measles have T-cell suppression and can develop pneumonia and encephalitis.

It is critical to isolate patients with measles. The disease is highly contagious.

Harwood comment: 100,000 patients per year die from measles world-wide. It is a serious disease.

CDC Website snapshot of recent measles cases in US.

Usmani     Abdominal Compartment Syndrome

Normal abdominal compartment pressure is 5-7 mm/hg

When abdominal compartment pressure goes up the patient will develop worsening renal function and oliguria. 

Abdominal compartment syndrome is defined as an intra-abodminal pressure of 20 mm/hg or more with new organ dysfunction.

Abdominal Perfusion Pressure=MAP-Intra-abdominal pressure.  Goal abdominal perfusion pressure should be above 50.

Obesity and pregnancy predispose a patient to abdominal compartment syndrome.  This is because both obesity and pregnancy elevate the baseline intra-abdominal compartment pressure.

Other risk factors for abdominal compartment syndrome include: mechanical ventilation, sepsis, massive fluid resuscitation, liver dysfunction, laparoscopic surgery, SBO, and intra-abdominal infection.

Physical exam of abdomen is not accurate in detecting  intra-abdominal compartment syndrome.  You need to diagnose abdominal compartment syndrome by measuring bladder pressure.  This measurement is as sensitive as directly measuring the abdominal pressure with an intra-peritoneal probe.

Technique of measuring bladder pressure. Patient needs to be flat.

The kidney is the most sensitive organ affected by abdominal compartment syndrome.  Patients will have decreased urine output and and rising creatinine.  Pretty much every organ is adversely affected by abdominal compartment syndrome.

Mortality for abdominal compartment syndrome is 40%.  Earlier diagnosis and decompression improves mortality.

Positioning patient's head/back at 20 degrees or lower optimizes abdominal compartment pressure.  Positioning the head/back higher than 20 degrees increases abdominal compartment pressure.

Initially treat with NG tube, rectal tube, drain ascites if present, sedate and paralyze, avoid excessive fluid resuscitation, and position patient with head at or below 20 degrees.  Lasix drip has no effect on intra-abdominal compartment pressure.   Surgical decompression is the ultimate management of abdominal compartment syndrome.   

Lovell comment: patients with ascites that is causing abdominal compartment syndrome can be treated initially with paracentesis. Paracentesis may or may not be definitive in these patients. Some patients may still need laparotomy.

We had a discussion of which patients in the ED we should be alert for possible abdominal compartment syndrome.  The clinical picture is one of a critically ill patient, with worsening renal function, who has a lactic acidosis and low BP.  Patients with ascites and/or liver disease who have received large volume fluids are at increased risk.

Burns/Denk      Advanced Echo in the ED

TAPSE less than 1.7 indicates RV strain and suggests PE.  To measure TAPSE, one must obtain an apical four-chamber view of the heart and use M mode to measure the longitudinal displacement of the lateral tricuspid annulus during systole and diastole. M mode will generate a sine wave that can be measured from peak to trough. Measurements less than 17mm are considered positive, suggestive of right heart systolic dysfunction and are associated with a poor prognosis in patients with PE, particularly in those with tachycardia or hypotension.

The TAPSE, a simple echocardiographic parameter, may help stratify risk in normotensive APE patients and is superior to RV/LV in MDCT and echocardiography. Patients with TAPSE ≤ 15 mm should be admitted to an intensive care unit and closely monitored. In these patients, acute PE may lead to clinical deterioration with indications for fibrinolysis. Subjects with TAPSE ≥ 18 mm form a low-risk group with good prognosis and are candidates for a short hospital stay.  (Arch Med Sci 2016)

D Sign is seen on parasternal short axis view. An overloaded RV flattens the septum and makes the LV look like a D.  This can be seen both in acute PE and chronic pulmonary HTN.  This is a sign that may be easier to identify than TAPSE because it does not require m-mode measurements and can be identified by visualization alone.

There was a discussion of how to assess the RV pressure using echo.  Unfortunately I don't know how to encapsulate it adequately for these notes.   It starts with assessing the peak velocity of tricuspid regurgitation using an apical 4 view echo image. You then assess the variation of the IVC on a subxiphoid 4 chamber view while having the patient sniff.  These two assessments can lead to a calculation of RV pressure. 

Denk/Traylor           Board Review

NIF and FVC can be used to assess respiratory status in patients with myasthenic crisis.  Treat with myasthenic crisis with airway management if needed, IVIG, plasmaphoresis and steroids.

Low NIF and low FVC are indications for intubation in patients with myasthenic crisis.

6 Herniation Syndromes

Uncal herniation=blown pupil

Cerebellotonsillar herniation=pt is in extremis/dying

Subfalcine herniation=can't walk good/weak legs, bladder incontinence

Central herniation=forced downward gaze

Subcutaneous AICD/pacemakers in which the wires do not go transvenously but rather only in the subcutanous tissue were approved by the FDA back in 2012.  They are becoming more common and used in patients with difficult venous access.  The AICD/pacer device is placed in the left lateral chest wall. This patient's sternotomy procedure is separate and unrelated to the placement of the AICD/pacer.

Katiyar       Toxicology

Most common cause of death from organophophate poisoning is respiratory failure from bronchorhea.

Small puncture wounds from Black Widow spider Bite. Patients will have sharp pain after bite.  Patients can develop muscle cramps, hypertension, diaphoresis and anxiety. Patients can be treated with narcotics, benzos, BP management and consideration of antivenom. Update tetanus status. Patients can develop hypocalcemia but calcium administration has not been demonstrated to be effective in the management of black widow spider bites.

The only therapies with proven effectiveness are opioid analgesics and black widow spider antivenom. Antivenin Latrodectus mactans is an equine-derived antivenom based on immunoglobulin G.4,10,19,20 The proposed pharmacologic mechanism is binding of venom toxic constituents by the antivenom antibodies. A single vial (2.5 mL) generally provides adequate relief in human (adult or pediatric) poisoning cases.3–5,14,19,21 The Kaiser Permanente (KP) acquisition cost for one vial of Antivenin Latrodectus mactans was $27.71 in 2011. In the largest series reported to date of moderate to severe black widow spider envenomation (n = 163), patients treated with antivenom experienced a much shorter duration of symptoms and were less likely to be admitted to the hospital than those who did not receive antivenom.3 Relief of symptoms occurred within an average of 31 minutes of antivenom infusion.3 Administration of antivenom even late in the course of envenomation has been reported to be effective.21,22 In one reported case, antivenom was used effectively for the treatment of symptoms 90 hours after a black widow spider bite. (Permanente J 2011)

Black widow antivenom may be difficult to obtain.  You likely will need to contact poison control to obtain it.

Ciguatera Toxin causes strange neurologic symptoms.  The common buzz word for Boards is HOT/COLD sensory reversal.  Treatment is supportive.  Some references suggest mannitol improves symptoms.

Valproic acid toxicity causes prolonged QT interval and elevated ammonia level.  Treat with L-carnitine.

The mechanism is too complicated for me, but basically carnitine administration helps the cell detox valproic acid.

On the left is methemoglobinemia, chocolate blood.  For boards these patients will have a pulse ox of 85% due to the light wavelengths transmitted by the darker blood.  Treat with methylene blue.

Conference Notes 2-7-2018

Paquette/Shroff     Oral Boards

Case 1.  34yo female with fever.  UCG is positive. UA shows signs of UTI.  U/S shows SLIUP at 12 weeks.   Treatment was initiated with IV fluids and IV Ceftriaxone.   Pyelonephritis in the setting of pregnancy needs to be admitted.

Cse 2.  18 yo male brought in from school for feeling lightheaded with hypotension and bradycardia.  A few weeks ago, the patient developed a febrile illness with associated rash after going on a camping trip.

Erythema Chronicum Migrans Rash

EKG showing 3rd Degree Heart Block on ED presentation

Diagnosis is Lyme Carditis with 3rd Degree heart block.  Patient was admitted for monitoring and possible pacemeaker if needed. Patient was started on doxycycline.

Case 3.   33yo male with fever and cough.  Patient notes some hemoptysis.  He has had weight loss and night sweats.

CXR showing Left Upper Lobe Cavitary Infiltrate consistent with TB

Rapid HIV test was positive.  Treatment initiated with anti-viral medications, antibiotics for CAP and TB. Very important that patient was placed in isolation. Patient was a guard in a prison so state department of public health needs to be notified.

Ohl      M&M

I will only note the take-home points to protect the anonymity of the cases.

How we feel toward patients and their families can affect how we evaluate and manage a patient.  If the patient or family are demanding or we find them arrogant or annoying or histrionic we can at times not accurately assess and evaluate them. We have to be on guard for these situations, recognize our own internal responses to patients, and do our best to mitigate these biases.

It can be difficult to differentiate NMS from Serotonin Syndrome.  Rigid extremities or "lead pipe rigidity" are  the common catch phrases on boards to signal NMS.

When you are getting ready to intubate, have a plan for back up. Slow down when doing intubations and think through your plan before starting the procedure.   Have multiple options for back up. Assess the airway before you give medications. If you encounter difficulty and are contemplating doing a cric, remember LMA can act as a bridge device to provide oxygenation and ventilation until you can get the airway.  If you are headed toward a  cric in a difficult airway situation, don't wait too long.  Most commonly physicians wait too long to start the cric procedure.

Andrea comment:  If there is a study ordered/performed (CXR,EKG, Lab) on a patient, make sure you see it and review it.   Thinking anthropomorphically about diagnostic testing, the diagnostic studies are trying to avoid being seen.  The tests are trying to elude you or the disease is trying to hide the clue from you. They are hiding on the counter by the sims, or in the patient's file slot, or by the nurse's desk or in the patient's room or it was never done. You gotta find it to make the diagnosis.

Velamati     Pediatric  Resuscitation

In Pediatric Sepsis give 60ml/kg of fluids in 60 minutes using the pull/push method with a 30ml syringe.  Stop at every 20ml/kg infused and re-assess patient to decide if they need more fluids.

The most common rhythm in pediatric arrest is Asystole. PEA is next most common, and VT/VF is third most common.

Use the PediStat App or the Broslow tape to cognitively unload your brain during pediatric codes.

100-120 chest compressions per minute in pediatric patients.

Sites for IO access in pediatric patients.  The distal femur although not FDA approved is still a legit site for access especially in very small patients in which the tibia is very small.

The anatomic differences between the Pediatric and Adult airways.  The narrowest point in the pediatric airway is the cricoid ring as opposed to the adult airway in which the cords are the narrowest point.

Infants will desat to less than 90% in about 2 minutes after pre-oxygenation. Use passive oxygenation with continuous nasal cannula O2 to prolong the safe apnea time.

Most young children will have improved airway visualization with this type of positioning with elevation of the thorax to accommodate the larger occiput.

This also seems like a great positioning approach but is a bit more complicated to set up.

Ketamine is probably the go-to induction agent for most indications in pediatric patients.

"Code 21" is the Airway Code for pediatric intubations.  The PICU attending will respond to the "Code 21".  You can also have Anesthesia respond if you want. 

Felder/Naik/Schmitz      Admin Update

Dragon devices within First Net are not working currently.  This has gone up to the corporate level for a fix.  A work-around is to use the older Dragon App that is opened outside of FirstNet.

Please continue your outstanding documentation of Face to Face evaluations of patients requiring restraint.

There is a continuous focus on and concern to improve on how slotting is done in the ED.

We discussed other challenges experienced in the ED

Thanks to Nancy Burke and our Nursing Colleagues for providing new refrigerators in the charting rooms!

Stanek        Weight Discussions

Providers of health care have concerns about raising issues of body weight with their patients.  They are concerned about how patients will react to these conversations.

When bringing up the topic of body weight it is best to be patient oriented.

1. First engage the patient in a non-medical topic to develop rapport

2. Discuss the weight issue upon re-evaluation not on first contact with patient

3. Ask, Has your primary care doctor had any discussion with you about your weight

4. Your weight places you at increased risk of adverse health problems.

5. Did you know that blood pressure, diabetes, and cholesterol problems are affected by your weight.

6. Give some simple suggestions for healthy living.  Shop the perimeter of the store.  Start an exercise that you like, for example walking 30min per day.

Florek      Safety Lecture  Glycemic Control in the ED

Type 1 diabetics are more likely to develop DKA.   Type 1 diabetics who are spending prolonged time in the ED need to have their blood glucose monitored regularly and managed. 

Glucose over 500 will likely be managed with Insulin and OBS/Admit

Glucose over 200 start sliding scale insulin or 0.1 U/kg of insulin

All diabetics boarding in the ED should have low dose sliding scale insulin ordered to prevent development of DKA.

Shroff     Safety Lecture

It is important that patients are fully undressed and in a gown when the physician evaluates them.  If the patient is in a gown, physicians are less likely to miss an injury or other physical finding. 

Always have a chaperone when performing rectal, genital, breast exams.

Conference Notes 1-24-2018

Airway Day

Patel        Airway Emergencies

Airway Assessment. You need to consider 4 things. Will it be difficult to BVM. Will it be difficult to Intubate. Will it be difficult to place a LMA. Will it be difficult to Cric?

Mnemonics to help answer the four questions above.

One thing not listed in all of these is pregnancy which makes all of these more difficult due to physiologic changes.

The LEMON method of airway assessment.  Consider all these assessments when planning your approach to managing the airway.

3-3-2 rule

Mallampati Scoring

Mallampati is an imperfect marker of airway difficulty.  A Mallampati 1 is predictive of a Grade 1 laryngeal view. Higher Mallampati scores are non-specific for which Laryngeal view you will get. If you have a Mallampati 4 you can expect a Grade 4 Laryngeal view (difficult).

If a patient has a neck hematoma or neck mass do not give a paralytic. If you do give a paralytic, the patient will loose any musle tone in their neck and will occlude their airway emergently.  Instead use ketamine and topical anesthesia and then look with video laryngoscopy or nasal/oral fiberoptic device.

Apneic oxygenation.  15L O2 via nasal cannula or even better you can use high flow nasal cannula O2.   It has been shown to prolong the safe apnea time, raise the lowest O2 sat, and increase first pass success in ED patients.

When you are pre-oxygenating a patient keep them sitting up. It improves functional residual capacity.  Don't lay them down until after you give your induction medications.

DSI  (Delayed Sequence Intubation) basically is using ketamine 1mg/kg to calm the patient patient who is in too much distress to adequately pre-oxygenate.  Giving ketamine may relax them enough to effectively pre-oxygenate with BiPAP and also allow you to optimize them hemodynamically. When the patient is optimized with better oxygenation and BP, move forward to intubation either with or without paralytic based on expected difficulty.

Lovell      Airway Devices

Unfortunately I missed this outstanding lecture.

Airway Lab in the New ACMC Sim Center

Thanks to Liz Regan for the pictures!

Conference Notes 1-17-2018

Kernicki-Sklar      Study Guide Infectious Disease

Severe sepsis is defined when the patient has any sign of organ failure including elevated lactate, altered mental status, and elevated creatine among many signs.   Septic shock is a lactate >4 or a MAP<65 after 30ml/kg of fluids.  Start norepi if patient has shock.

Bed bug bites tend to be in a line.  They are intensely pruritic.  There is no infestation on the patient meaning the patient is not carrying bed bugs. You can not get bed bugs from touching the patient.  The bed bugs live on the mattress or other places in the house.

Occular syphillis can have red spots on iris.

Secondary syphilis rash can take many forms. If you see a rash on the palms or soles think syphilis.  Condyloma lata or syphilitc warts are extremely contagious.

Typical areas of scabies infection.  Patients with scabies, unlike bed bugs, do have a mite living in/on their skin and can transmit scabies by direct contact.  Treat with permethrin cream.

Strawberry Cervix of Trichomonas Infection

Anna spoke about the new recommendations for antibiotic prophylaxis to prevent endocarditis. The only procedure in the ED you may want to consider giving prophylaxis for is draining an intra-oral abscess in a patient with high risk of endocarditis (prosthetic valve, prior infective endocarditis, and patients with un-repaired congenital heart disease or congenital heart disease repaired with prosthetic material)

The diagnosis of necrotizing fasciitis may not be apparent upon first seeing the patient. Overlying cutaneous inflammation may resemble cellulitis. However, features that suggest involvement of deeper tissues include (1) severe pain that seems disproportional to the clinical findings; (2) failure to respond to initial antibiotic therapy; (3) the hard, wooden feel of the subcutaneous tissue, extending beyond the area of apparent skin involvement; (4)systemic toxicity, often with altered mental status; (5) edema or tenderness extending beyond the cutaneous erythema; (6)crepitus, indicating gas in the tissues; (7) bullous lesions; and 8) skin necrosis or ecchymoses.  (IDSA Guidlines 2014)

IDSA Antibiotic Recommendations for Necrotizing Fasciitis

Lambert       U/S  DVT

You need to use a high frequency linear probe to scan for DVT.

The main sign of DVT is non-compressibility of the vein. 

Common femoral vein that compresses normally

Transverse views of popliteal vein with DVT. Note that on the right side image even with compression the vein does not collapse.  The orientation of the vein in the popliteal fossa is always superficial to the popliteal artery.  Hence "Pop on Top"

Lambert     MSK  Ultrasound

95+% of Rotator Cuff Injuries affect the supraspinatus muscle. The supraspinatus muscle abducts the humeurs.  You can use ultrasound to identify suprasinatus tears.

U/S can identify hip effusions as seen above.

Ultrasound can be used to identify tendon ruptures

Lambert and Team Ultrasound     DVT & MSK U/S Workshop

Awesome U/S Workshop in our new Sim Lab.

Conference Notes 1-10-2018

Denk/Traylor     STEMI Conference

Case 1.  Patient with chest pain.  EKG showed elevation of AVR and diffuse ST depression.

2013 AHA Guidelines note that this is a STEMI equivilent.  It can be due to left main, LAD, or triple vessel disease.  Diffuse subendocardial ischemia from causes such as cardiac arrest or hypotension from blood loss, or sepsis can also cause this pattern.

You need to have this pattern recognition in your brain.  Jenny and Logan presented multiple cases that were variations on this pattern.  Not all patients went to the cath lab.  ST elevation in AVR is a marker of increased mortality in both STEMI's and NSTEMI's.   If you think the patient is having a STEMI with AVR elevation, (clear cut STEMI or patient is ill appearing or hypotensive or has acute heart failure) activate the cath lab.  If you identify AVR elevation with diffuse ST depression in a patient who has other suspected diagnoses such as sepsis or hemorrhage or the patient is stable appearing,  it was strongly recommended to emergently consult with interventional cardiology about cath lab activation.

Ahmed/Hawkins     Oral Boards

Case 1.  3 mo infant brought in by parents unresponsive with no vitals. They found child not breathing in the crib and they started CPR.  Resuscitation was continued in ED.  Patient found to have a monomorphic VT and was defibrillated to sinus rhythm. Resuscitation required PALS management.  Dosing for defibrillation is 2J/KG followed by 4J/KG if the first shock doesn't work..

Case 2.  19yo female with abdominal pain and vaginal bleeding.  Vitals showed tachycardia and hypotension.  B-hcg is elevated to 7500.  FAST Exam shows free fluid in Morrison's pouch. Diagnosis was ruptured ectopic pregnancy and patient went to OR. Ampulla of the Fallopian tube is the most common site of rupture.  Give RhoGam 50mcg to all RH negative women with a lost pregnancy in the first trimester.

In one study, only 10% of physicians were able to identify the presence of less than 400cc of free intraperitoneal fluid, suggesting that a positive FAST typically indicates a large amount of acute blood loss. The combination of positive FAST and positive pregnancy test should prompt an immediate call to OB-GYN to take the patient to the OR for a presumptive diagnosis of ruptured ectopic pregnancy. Bedside pelvic ultrasonography by emergency medicine physicians has led to improved time to diagnosis and should be performed whenever feasible. (CDEM Curriculum Reference)

Case 3.  49yo male with chest pain and diaphoresis 2 hours ago that resolved.  Patient has hx of IDDM and HTN.  EKG showed Wellen's syndrome.

Wellen's syndrome is associated with proximal LAD occlusion.

Wellens’ syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD).

Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next few days to weeks.

Due to the critical LAD stenosis, these patients usually require invasive therapy, do poorly with medical management and may suffer MI or cardiac arrest if inappropriately stress tested.

Patient had further chest pain in the ED and repeat EKG showed acute anterior STEMI. Patient was taken to the cath lab.

Lovell       Intellectual Wellness

First, An Overview of the other components of Wellness:

Social Wellness:    Human interaction builds our resilience

Spiritual Wellness:   We benefit from connecting to a belief system

Occupational Wellness:   Finding purpose and meaning in our work

Physical Wellness:    Get a doctor, sleep, eat well, exercise

Emotional Wellness:     Conflict managment, narrative medicine

Intellectual Wellness:   A commitment to life-long learning and skill acquisition.

Strategies for intellectual wellness: Read on ideas and topics outside of medicine.  Try to alter your patterns of every day life, travel, audit a class, Khan Academy, Ted Talks, documentaries, learn a language, learn music, play games like euchre, experience something you don't understand like opera.  You can take online college level courses with the website Coursera.

To enhance your intellectual wellness, start with a specific goal.  Define what success will look like upon reaching goal.  Set a timeline for meeting this goal. See if you can pair up with an accountability buddy.  Somebody to help you stay on track. Set out to achieve the goal.

Naik     ED Operations Update

Trushar discussed strategies for managing our boarding patients.

DeStefani      HINTS Exam

3 components of HINTS exam: Head Impulse,  Nystagmus, Test of Skew

Peripheral vertigo is a problem with the sensing organ, the vestibular apparatus.   Central vertigo is a problem with processing movement signals in the brain.

Use the HINTS exam if a patient has acute vestibular syndrome.  It is not helpful in patients with benign peripheral vertigo who have vertigo lasting less than a minute with change in position or halpike testing. Acute vestibular syndrome causes persisitent vertigo/dizziness lasting hours to days. 

To meet the clinical definition of AVS, total duration must exceed 24 hours of continuous dizziness. This excludes most disorders in which dizziness typically presents with transient episodes lasting seconds, minutes, or hours, such as benign paroxysmal positional vertigo (BPPV), cardiac arrhythmia, transient ischemic attack (TIA). Thus,these disorders rarely remain diagnostic considerations in AVS patients beyond the first few minutes or hours. Menière disease and vestibular migraine may be exceptions.  (Newman-Toker Reference)

Head Impulse: When you move the patients head to the midline, if the eyes lag behind the head movement, that indicates peripheral vertigo.

Nystagmus: Unidirectional (fast phase of nystagmus is the same whether looking to the left or right)  horizontal nystagmus is good and indicates peripheral disease.  Vertical or direction changing nystagmus indicate central vertigo.

Test of skew: Have the patient fixate on your nose and then alternately cover each of the patient's eyes.  If you see the uncovered eye adjust vertically that indicates a central cause.

Peripheral vertigo is identified by: eyes lag on head impulse, unidirectional horizontal nystagmus, and no skew.

There is a HINTS+ exam which adds hearing loss.  Hearing loss increases the liklihood of central cause of vertigo.

We had a discussion of whether this test can be used reliably by ED docs.  The studies that have looked at this test found a high percentage (@70%) of patients who had acute vestibular syndrome had a central cause.  That percentage is high enough for most people at this lecture to OBS or Admit all patients with acute vestibular syndrome for neuro evaluation.  Most people would be uncomfortable discharging home a patient based on HINTS testing.

Logan      Eye Emergencies

Ruptured globe with teardrop pupil

Iritis has redness most prominent around the limbus as opposed to conjunctivitis which has perilimbal sparing.  Iritis is associated with sarcoid, TB and inflammatory bowel disease as well as multiple other etiologies. 

Cirone mnemonic: Chlamydia is "clandestine" it takes longer to become evident on exam than GC.

Donapudi       Pulmonary HTN and Pulmonary Fibrosis

Idiopathic Pulmonary Fibrosis is irreversible, with a high mortality and morbidity.   Definitive treatment is a lung transplant.

Pulmonary HTN presents with very non-specific symptoms and signs.  Look for signs of right heart failure. Lung sounds may be normal.  EKG can show R side heart strain. CXR is nonspecific. LFT's may be elevated due to hepatic congestion. Pulmonary Function testing shows low lung volumes.

There are multiple categories of pulmonary HTN based on etiology.

In the ED get get all the usual cardiac labs and an echo. Correct hypoxia and hypercarbia. Use bipap if needed.  Avoid intubation if at all possible.  Intubation may result in very high PA pressures and cardiac arrest.  Be cautious with fluids.  Discuss with cardiology more specific management options.

We have a Pulmonary HTN Team at ACMC who can be paged for consultation on Pulmonary HTN patients.

Conference Notes 1-3-2017

Harwood/Einstein    Oral Boards

Case 1. 18yo patient with multiple blunt trauma: Patient required airway protection for GCS<8.  Patient had diminished breath sounds on the right and required a chest tube and autotransfusion for hemothorax.  Patient had severe splenic and renal injuries that required crystalloid and blood products for stabilization prior to laparotomy.  And just to make it a bit more complicated, the patient had an epidural hematoma requiring neurosurgery.  The patient was able to be stabilized enough to get CT's done on the way to the OR.

Epidural hematoma

3 Common types of extra-axial brain bleeds.  The Epidural hematoma has the convex side toward the mid-line as opposed to the subdural hematoma that follows the contour of the brain and is concave toward the midline. The reasons it is important are that Epidural hematomas usually need rapid surgery to decompress the brain, and if decompressed have a better prognosis than subdural hematomas.

Management Algorithm for Splenic Injuries.  Hemodynamically unstable patients get a laparotomy.

Case 2. 80 yo male with syncope due to PE

Pt's presenting EKG showed S1Q3T3 which is seen with pulmonary disease. Classically it is associated with PE but it is not specific for  PE.  It is a sign of right heart strain and can be seen with bronchospasm, pneumothorax, pulmonary HTN, and PE.

The patient also had a Westermark sign.  If you are not thinking about this sign, it can be easily overlooked.

Case 3.

Patient presented with ankle injury.  On exam, pt also had proximal fibular tenderness which is the key to identifying a Maisonneuve fracture.

Katiyar      Toxicology of Moth Repellents

Treatment of Camphor toxicity is supportive care with the addition of benzodiazepines for seizures.

Treat with supportive care in general. If hemolysis is severe,  transfuse as necessary.  Treat methemoglobinemia with methylene blue.  Boards tip: If you are given a pulse ox around 85% think methemoglobinemia. Methemoglobinemia affects the way the pulse ox reads the lightwaves and causes it to read usually around 85%.

Cirone            HIV and Related Infections

HIV1 makes up 95% of the HIV cases world-wide.  HIV2 is more common in West Africa and has a slower course of illness.

Most common cause of pneumonia in an HIV + patient is the same as regular community acquired pneumonia. (strep pneumo, h.influenza)  Staph and pseudomonas  are more common etiologies of pneumonia in HIV patients than the general population. Elise comment: be aware of the risk of TB in HIV patients. It is much higher than in the general population.

You can estimate a patient's CD4 count by looking at their absolute lymphocyte count.  If it is less than 1000 you can expect a low CD4 count (<200).

HIV is commonly co-transmitted with syphillis.  Any pathogen that can cause an ulceration or skin breakdown will increase a patient's risk of HIV transmission.

Molluscum infection on the face should raise concern for HIV infection.  The more molluscum lesions on the face the lower the CD4 count.

Oral hairy leukoplakia looks like candida but you can't scrape it off and it is a sign of HIV.   Elise comment: It is always on the side of the tongue.

If an HIV patient presents with fever and altered mental status get a contrast CT scan of the head to look for ring enhancing lesions.

Barounis           Sepsis

Sepsis is a dysregulated response to an infection.

Sepsis mortality has decreased since 2001.  This is because of early identification of sepsis rather than any specific treatment. No treatment/medication has been shown by itself to decrease mortality in sepsis. 

How do we better identify sepsis patients early on?  Beyond fever and WBC count, Dave suggests looking at patients' respiratory rate and mental status as early bedside indicators that can trigger a consideration of sepsis.  Another marker is a drop in platelets.

Septic shock is MAP<65 and Lactate >2 after initial resuscitation.

Hi Flow nasal cannula is an effective way to provide supplemental oxygen.  Dave always starts at 50L/min.  It even provides a small amount of PEEP.  We have been using it in kids for awhile but it is becoming more commonly used in adults. Dave loves this modality.

Practice Changer     LR has 1% lower mortality than NS for ICU-level septic patients.  Bottom line: Use LR for your septic patients. 1% mortality benefit was also seen in ED patients.  LR is safe and may even be preferred in hyperkalemic patients.    Harwood comment: You can't give a PRBC transfusion with LR so if you have to transfuse, you need to change to NS.

Editor note: If you are going to hydrate a patient who has hyperkalemia, consider giving LR instead of NS.  Dave agreed with this. The pH of LR is higher than NS and tends to move K into the cell. 

Dave made the point of being very thoughtful about IV fluids when managing sepsis. Recent literature shows that overly-aggressive fluids increases sepsis mortality.  My take home points were to switch to LR, and not order maintenance fluids after initial boluses for sepsis patients.  Dave is very wary about maintenance fluids because 125ml/hr adds up to 3L per day and tends to overhydrate patients. Give fluids in targeted doses and not as long term maintenance.

Dave made the point that any patient with septic shock from a UTI needs imaging of their kidneys to evaluate for an obstructed kidney. 

Another urine-related point, if a urine culture shows staph aureus it is due to staph bacteremia. For unclear reasons, staph bacteremia ends up infecting the urine.

The GI literature says that patients with cholangitis should have ERCP within 48 hours.   Dave feels better shortening this 48 hour period to as soon as possible.  If a patient presents at night they may be able to wait until the morning unless they are deteriorating.

Okubanjo               M&M

Editor's note: We will only be discussing take home points to protect the anonymity of the cases.

You can reverse heparin with protamine.  Protamine will also work partially with lovenox.  Reverse NOAC's with FEIBA.

You an reverse heparin with protamine.  Protamine will also work partially with lovenox.  Reverse NOAC's with FEIBA.

Harwood comment: If a patient is complaining of shoulder pain, think of something irritating the diaphragm like blood.

Review the details of the CBC including neutrophil count and lymphocyte count and platelets to avoid missing subtle abnormalities.  Editor note: If you see toxic granulocytes on the differential be very wary of badness.

Be sure to get a pregnancy test on female patients of child-bearing age with abdominal pain or back pain. 

Hyperdense artery syndrome of basilar artery.

Hyperdense basilar artery (the basilar artery equivalent of the hyperdense MCA sign), present in ~65% 9

A high index of suspicion is needed in the correct clinical setting as the diagnosis can easily be missed (often only present on 1 or 2 slices); additionally it is well recognized that acute clots are of lower attenuation than chronic clots 5-6

Patients with acute occlusion of the basilar artery will present with sudden and dramatic neurological impairment, the exact characteristics of which will depend on the site of occlusion:

sudden death/loss of consciousness

top of the basilar syndrome

visual and oculomotor deficits

behavioural abnormalities

somnolence, hallucinations and dream-like behaviour

motor dysfunction is often absent

proximal and mid portions of the basilar artery (pons) can result in patients being 'locked in' 7-8

complete loss of movement (quadriparesis and lower cranial dysfunction)

preserved consciousness

preserved ocular movements (often only vertical gaze) 8

Radiopaedia Reference

This is similar to the above mentioned hyperdense basilar artery sign.

Conference Notes 12-20-2017Dr.

Sunbulli       Respiratory Failure

Dr. Sunbulli discussed the 4 types of respiratory failure.

Tissue hypoxia occurs when the patient's O2 sat drops to less than 70%.  Keeping the O2 sat above 90% provides a margin of safety.

CPAP or BIPAP is used in the setting of sleep apnea to stent open the upper airway while the patient is sleeping.

Nasal mask vs Face mask for BIPAP is really determined by patient comfort and the presence of secretions that patient will need to clear by throat. If there are significant secretions, a nasal mask may be better than a face mask.

BiPAP has been shown to be effective for COPD exacerbations and Pulmonary edema.  Illnesses such as pneumonia that take longer to reverse are less optimal for BiPAP therapy.  It is probably better to intubate hypoxic patients with pneumonia because they will require multiple days of support.

If you are going to intubate a septic patient.  Give them IV fluids and minimize sedation prior to induction and intubation.  Sedation and positive pressure ventilation will unmask and exacerbate a borderline hypovolemic state and can result in CV collapse.

Basically if the patient has significantly altered mental status, has worsening acidosis, has a process causing respiratory failure that is not rapidly reversible, or the patient has significant secretions or emesis, BiPAP has a higher risk of failure and intubation may be indicated. Haven't seen the BAP-65 guideline before but seems simple and using MD Calc it gives you risk of mechanical ventilation.

Haven't seen this BAP-65 decision guideline before.  If a patient has a score of 3 or 4, 70% were intubated and 50% died.  Any patient with a score of 3 or 4 should be strongly considered for ICU admission.

Friend           Bowel Obstruction

Most common cause of SBO is adhesions.

With acute SBO, you can still have passage of stool or flatus for 24 hours

Closed loop bowel obstructions can be difficult to diagnoses and are at high risk of perforation.

Small Bowel Obstruction on X-Ray shows air fluid levels, dilated bowel in the central portion of the abdomen, and visible valvulae coniventes (lines that go completely across the bowel, stacked coins).

Gallstone Ileus: Repeated bouts of cholecystitis result in adhesion of the gallbladder to the small bowel (usually duodenum) with eventual fistula formation and passage of gallstones into the lumen. The most common site of entry by erosion is thought to be to the duodenum. Small stones presumably pass without incidence. However, large cholesterol stones can become impacted typically at the ileocaecal valve. As such, gallstone ileus is a mechanical small bowel obstruction. Ileus is a misnomer as the term ileus is usually used to describe a functional, rather than, mechanical obstruction.  (Radiopaedia reference)

You don't usually need IV antibiotics for small bowel obstruction management. The small bowel does not harbor significant levels of bacteria.  Do Treat pain.  Do Give IV fluids and NG drainage. Do consult surgery in the ED.

Nice pearl to help differentiate Cecal vs Sigmoid volvulus. Sigmoid volvulus will have large bowel dilatation.  Cecal volvulus will have small bowel dilitation.

There was consensus among faculty that CT Abd/Pelvis is the optimal initial imaging choice to diagnose bowel obstruction rather than plain x-rays.  Dennis Ryan advocated oral contrast in suspected bowel obstruction if the patient can tolerate it.

Girzadas comment: If you identify a bowel obstruction on imaging, you have to go back and examine the patient for a hernia especially if they do not have a history of prior surgery.

Twanow comment: If an infant has bilious emesis, they need an emergent upper GI study to evaluate for malrotation and midgut volvulus.

Pecha Kucha

Miner       Management of Constipation in the ED

I missed this outstanding Lecture

Tran       ED EKG Findings

Epsilon Wave is associated with arrythmogenic right ventricular dysplasia, a cause of sudden death in young patients.

Wellen's syndrome is associated with critical LAD stenosis

Johns   Targeted Temperature Management after Cardiac Arrest

2013 NEJM Study did not find benefit of 33 degrees C over 36 degrees C so the target temps in this chart are a bit low.  You can use a target temp of 36 degrees C. The rest of the chart is reasonable.

After cooling, need to re-warm slowly 0.25-0.5 degree C per hour. If you re-warm too fast it eliminates any benefit derived from cooling.  Need to avoid fever.

Cooling can increase risk of infection and bleeding.  Another side effect is hypokalemia and arrythmias.

Estoos     Evaluating the Patient with Altered Mental Status

mnemonic: He Stops for TIPS on Vowels

Detailed mnemonic, but it covers a lot of potential etiologies of altered mental status

Delbar    Sports Injuries

Depressed skull fractures should be covered with broad spectrum antibiotics.

Posterior shoulder dislocation with humeral head behind the scapula.

Delta pressure, the difference between systolic BP and compartment pressure, is a useful indicator of need for fasciotomy.

Schroeder     Study Guide  Pediatrics

Acute chest syndrome can be caused by fat emboli, infection, and thromboemboli.  If Infection is identified, the most likely organism to cause acute chest syndrome in sickle cell patients is a virus or mycoplasma pneumonia in kids under 9yo.  In kids older than 9yo chlamydia and mycoplasma are the most common organisms.

An algorithm to help with using lab testing to evaluate for Kawasaki's disease.

Practice Changer*   Bill made the point that in children with ankle injuries near the physis of the distal fibula with no sign of fracture on x-ray you can treat with an air cast rather than post mold.  There are studies showing that the outcomes of patients with suspected occult Salter 1 fractures are excellent without full post-mold splinting.  Similarly, isolated buckle fractures and possible occult Salter 1 injuries at the wrist can also be treated without a post-mold and use just a velcro splint.

Rule of 50 for administering dextrose to kids to treat hypoglycemia.  ML's/kg X dextrose concentration should always equal 50.

1ml/kg  of  D50  

2ml/kg of  D25    

5ml/kg of  D10  This is Bill's go-to for all kids if available. 

10ml/kg of D5

Klein's line can help identify slipped capital femoral epiphysis.

Forscheimer spots on palate from scarlet fever.  They are not specific for scarlet fever and can be seen in rubella and measles as well.

The rash of scarlet fever is like "sandpaper" or "goosebumps"  It may not always be erythematous.  Darker skinned patients may have bumps that are close to their skin color.

Be agressive in treating hypokalemia in DKA.  Consult with PICU Intensivist early on. Hypokalemia in DKA can be life-threatening due to large potasium deficit.

Sweiss      Neurocritical Care  of Intracerebral Hemorhage

Unfortunately I missed this outstanding presentation.

Conference Notes 12-13-2017B

Katiyar/Florek      Oral Boards

Case 1.  14 yo patient presents with 2 episodes of syncope on the day of her ED visit. The patient passed out while running in gym class. UCG is negative.  EKG showed prolonged QT interval. Patient has history of depression and takes amitriptyline and sertraline. While in ED patient develops torsades. 

QT interval 500ms or greater on EKG increases risk of Torsades.  Treat torsades with defibrillation and IV magnesium 2g IV ( this dose can be repeated Q15min once or twice if still reverting to torsades) Once the patient is in sinus rhythm, you can use overdrive pacing or IV isoproterenol to increase the heart rate to 110-120 and narrow the QT interval.  Next, correct hypokalemia and hypomagnesemia. You can give lidocaine or phenytoin as antiarrhythmics if needed beyond the other above measures.

Patient was treated with IV magnesium and defibrillation.  She returned to sinus rhythm.

Defibrillation dosing in pediatric patients is 2J/KG initially followed by 4J/KG on repeat attempts at defibrillation.

There was a discussion about the optimal anti-arrhythmic in the setting of prolonged QT.  The consensus was that you want to avoid Class 1A's like procainamide and Class 3's like amiodarone. They both can lengthen the QT innterval and cause torsades.  1B's like lidocaine are probably the safest choice.   

Vaughan-Williams Classification of Anti-Arrhythmics

Case 2. 41 yo male with finger pain. Patient was working with "rust remover" to clean bricks.  Patient was having pain due to hydroflouric acid exposure to hands. Treated with calcium gluconate gel.

Treat Hydroflouric acid burns with copious irrigation followed by applying a calcium gluconate gel made by mixing an amp of calcium gluconate with surgilube. Put that gel in a surgical glove and put it on the patient's hand.  If the patient is still having pain, calcium gluconate can be injected into the subQ tissues with a 27g needle. Finally, if needed, calcium gluconate can be given intra-arterially. Consult with an Toxicologist and/or an Intensivist when considering intra-arterial calcium gluconate.

Case 3. 42yo male with back pain for one month since bicycle accident.  Pain radiates down right leg. Pt notes some urinary incontinence.  Pt states his belly feels full.  On exam pt has diminished sensation and strength in right lower extremity. Patient had decreased rectal tone. Foley was placed to decompress the bladder.  MRI showed compression of bilateral S1 nerve roots. Diagnosis was cauda equina syndrome.  Patient was treated with emergent decompression surgery.

Clinical Picture of Cauda Equina Syndrome

Barounis/Jonas     Central Line Workshop

The finer points of central line placement were discussed in this outstanding simulation workshop.

Traylor        FirstNet Hacks Workshop

We were taught how to create our own order sets and dot-dot phrases.

Huu/Lorenz/Wing    Thoracic Trauma

If you can resuscitate a penetrating thoracic trauma patient with ED thoracotomy, you have 90% chance of the patient surviving neurologically intact.  Blunt trauma patients have low chance of survival from ED thoracotomy.  If they do survive <2% have intact neurologic function.

If penetrating thoracic trauma with some signs of life, do an ED thoracotomy.  If blunt trauma with no signs of life, don't do it.  Every other situation is a case by case decision.

Emergency Department Thoracotomy

Published 2015
Citation: J Trauma. 79(1):159–173, July 2015

When placing a chest tube for a patient with thoracic trauma, put in at least a 32F size tube or larger.

A really obvious CXR demonstrating aortic injury

In summary, we propose three important and evidence-based recommendations regarding blunt thoracic aortic injury (BTAI), which were formulated using the GRADE methodology. First, we strongly recommend CT of the chest with intravenous contrast for the identification of clinically significant BTAI. Second, we strongly recommend the use of endovascular repair in patients with BTAI who do not have contraindications to endovascular repair. Finally, we suggest the use of delayed repair in patients with BTAI and emphasize that effective blood pressure control with antihypertensive medication must be used in these cases.

Blunt Aortic Injury, Evaluation and Management of

Published 2015
Citation: J Trauma. 78(1):136-146, January 2015.

Editor's note: There were better outcomes with delayed repair of blunt thoracic aortic injury for patients who required further resuscitation and/or management other life threatening injuries. In the subset of patients without other life-threatening injuries, delayed repair resulted in higher rates of paraplegia and renal failure. 

Conference Notes 12-6-2017

Tekwani    Quarterly Difficult Airway Conference

3 Indications for Intubation

1. Protect airway 2. Failure to oxygenate or ventilate  3. Anticipated Clinical Course

Assessing for Difficult Laryngoscopy

These are the bedside tools to assess for difficult laryngoscopy

Difficult Bag-Valve-Mask mnemonic "ROMAN"

Radiation   Obesity/Obstruction/OSA   Mask seal/Mallampati/Male   Age older than 55     No teeth.  Any of these portend difficult bagging.

Difficult Airway Algorithm from Ron Walls Difficult Airway Course

Optimize your preoxygenation with a NRB hooked up to O2 open to flush rate (wide open, turn the dial on the wall oxygen device as far as it will go. This has been shown to provide more FIO2 than 30L/min) or use Bipap.  Also hook up passive oxygenation with 15L NC.  Keep the patient upright when preoxygenating.

Faculty Pearls

Consider increasing etomidate dosing for induction to 25mg for morbidly obese patients

For intracranial hemorrhage pre-treat patients with fentanyl 3 micrograms/kg given slowly a few minutes prior to giving your induction agent.

Avoid succinylcholine 72 hours to 6 months post stroke or other neuro injury. 

Thenar grip is superior to C3 or other bagging techniques.

When intubating children place some towels behind their torso to elevate the thorax to give more room for the larger occiput and to better line up the external ear canal to the sternal notch.

Intubating LMA is a key rescue device to have ready to go for difficult intubations. It can be used as a bridge to cricothyrotomy and/or provide 1 further attempt at intubation if you are able to effectively bag through the LMA.

Carlson      Critical Care Toxicology

Unfortunately I missed this outstanding presentation

Alex/Wigfield   Emergencies in Lung Transplant Patients

The survival of lung tansplant patients is 50% at 5 years.  The first year after transplant has the highest risk of death. If a patient survives the first year they have a 70% 5-year survival.

Lung transplant patients can suffer from gastroparesis due to vagal nerve injury, opioids and diabetes.

Lung transplant patients are immunocomprised. Beware of unusual and atypical presentations.  Infections can progress rapidly and be catastrophic.   Culture and image aggressively.  Start antibiotics rapidly. Always contact the Lung Transplant Service early in the ED course  708-684-9646 or even better use Perfect Serve to contact Dr. Alex.

Calcineurin inhibitors (cyclosporin, tacrolimas) can cause elevated ammonia levels.  So if a lung transplant patient is obtunded or comatose check an ammonia level.  These drugs can also cause PRES  (Posterior Reversible Encephalopathy Syndrome)

Diagnostic pathway to PRES

Bilateral posterior findings of PRES on MRI

Acute rejection occurs mostly in the first year after transplant.  The key findings are pulmonary symptoms (dyspnea, cough, abnormal CXR) and/or a drop in FEV1.  CXR's may show infiltrates or be clear.  You will likely need to treat for both rejection with IV steroids and infection with IV antibiotics.  Dr. Alex was more concerned that we treat possible infections with broad spectrum antibiotics.  The Transplant Service will order steroids later if needed.

Anti-rejection medications are prone to cause renal failure, encephalopthy, and serious infections. (Think Beans, Brain, Bugs)

If you are going to get a CT chest on a lung transplant patient do it without contrast unless you are looking for PE. You want to avoid any contrast insult to the kidneys if possible.

Patients on steroids can have perforated viscous without minimal abdominal symptoms.  Steroids can also make patients prone to bone fractures and AVN.

Conference Notes 11-29-2017

Einstein      M&M

Critical Causes of Chest Pain

Consider these causes of chest pain for every chest pain patient.  Utilizing bedside Echo for your chest pain patients can help you identify pericardial fluid/tamponade, RV strain from PE, LV wall motion abnormalities associated with ACS, and an enlarged aortic outflow tract from type A dissection.  Lung windows can identify pneumothorax and CHF. Subxiphoid views can help assess volume status in the proximal IVC.

Cognitive Biases

Being aware of potential cognitive biases may help you avoid them in your clinical thinking. 

When you are re-dosing pain meds, it may be helpful to consider "Why is this patient having so much pain? "  It may be the time to re-think your presumptive diagnosis.   It's OK to, on some level, trust your info sources but verify the info your are receiving whenever possible.  For example talk to family members of patients to get their perspective on what is going on.    "Trust but verify"

If you see mediastinal air in the setting of suspected Boerhaave's syndrome, get a chest CT with IV contrast.  If that is not diagnostic of boerhaave's then follow that up with a gastrograffen esophagram. Start broad spectrum antibiotics and consult thoracic surgery

Lorenz       Safety Lecture

You need to document a Face to Face evaluation when placing a patient in physical restraints.  A face to face evaluation needs to be documented with 1 hour of placing a patient in physical restraints and then again at 16 hours if the patient is still in restraints.  There is a ..facetoface template in FirstNet. The order for physical restraints needs to be renewed every 4 hours.  

Advocate-wide,  $40million dollars was not collected due to PTT, BNP, and urine toxicology tests.  Insurance companies are not reimbursing for these studies if not clearly documented why they were necessary.  If you order any of these 3 tests you need to document why the test was needed.

Logan/Schmitz    Administrative Updates

Patients cannot be admitted to the detox unit from the ED.  This is due to state regulations regarding the detox unit. 

The new charting room has the new wide monitors for all the computers.   All the computers in the new charting room have Dragon functionality.

Omari    COPD

12% of Americans have COPD.  It is a very expensive disease in human and financial terms.

25% of patients who smoke more than 15 years will develop COPD.

The severity of COPD is staged by spirometry.   If you cannot exhale 70% of your lung volume in 1 second you have COPD.  There are some experts who feel the 70% number should be varied based on age. Many persons over age 80 will not be able to hit the 70% number even though they never smoked.

3 cardinal signs of a COPD exacerbation are: acute dyspnea, increased sputum, and cough.   Dr. Omari asks his COPD patients how long it usually takes them to resolve their COPD exacerbations.  If it usually takes a few days then the patient likely will have a mild exacerbation.  If they say they were in the hospital for a week or in the ICU the last time, you can expect a severe exacerbation. 

Get the patient's O2 sat between 88-92%.  You don't want to get too much over 92% to avoid CO2 retention.   Watch out with continuous neb treatments.  Nebs are driven by 12L O2 per min. If the patient is on the neb mask for more than an hour even if the neb has finished they are getting 12L/min of O2 and may start having increased PCO2.

Albuterol/Atrovent combo nebs are thought to be superior to albuterol alone for COPD patients. It is OK and may be better, to repeat the atrovent dosing along with albuterol nebs multiple times for COPD patients.

Dr. Omari's recommendation: For severe COPD exacerbations (speech with effort, accessory muscle use, diminished air movement on lung auscultation) give 125mg of Solumderol rather than PO steroids.  After the initial 125mg dose of Solumedrol, he will then taper that down to 60mg IV Q6 hours.  When they are better he will then switch them to PO prednisone.  Harwood comment: If the patient is in the ED for more than 8-12 hours what is the second soumderol dose?   Omari response: give solumedrol 60mg Q6 hours. 

If a patient is coming to the ED for a COPD exacerbation, start an antibiotic.  Give azithromycin or moxifloxacin.  Azithromycin has an additional benefit of anti-inflammatory effects in addition to antimicrobial effect. For really sick patients, there is demonstrated mortality benefit for antibiotics for COPD patients going to the MICU. 

Bipap has been shown to prevent worsening of an exacerbation and decrease intubations for COPD.  BiPap=Good for severe COPD exacerbations. 

We discussed a ballpark cut-off PCO2 where BiPap won't work for elevated PCO2.   Dr. Omari said if the patient is responsive you can try BiPap up to somewhere around a PCO2 of 110-120.  Levels higher than that or if the patient is obtunded you have to intubate because bipap therapy will not likely be successful in those patients.

For milder exacerbations (only 2 of the three cardinal signs dyspnea/cough/increased sputum), if the patient responds quickly to treatment in the ED and they feel they are back to their baseline breathing you can consider discharging home if they can get/take antibiotics orally, take oral prednisone, use an mdi, and have follow up in the next few days.  If  you can't get all that in place, admit or OBS the patient

Bonaguro/Chan      Quality Updates

For Pediatric Sepsis Alerts, you need to call the alert overhead so nursing and PharmD's are aware that a Pediatric Sepsis Alert is in progress.  You need to have antibiotics started within an hour.  You need to have the fluid bolus administered within an hour.

If a child under  1 year of age has bilious emesis you gotta move fast to IV hydrate, consult surgery, and get an upper GI done to evaluate for malrotation with midgut volvulus.

Conference Notes 11-22-2017

Joint EM-Peds Conference on Complications of Sinusitis

Don't treat sinusitis unless the patient has fever 102+ with 3-4 days of green/yellow drainage  OR their symptoms have lasted more than 10 days or they have worsening symptoms after initially improving.

If a patient has headache, or mental status changes or forehead swelling associated with sinusitis. You need to suspect intracranial involvement such as pott's puffy tumor.   The diagnostic test of choice is a CT head with contrast.  A plain CT will miss significant diagnoses.  Harwood comment: You can order a CT head with thin cuts through the sinuses to optimize your view of the sinuses.

The cases presented with complications of sinustis described children with many days of sinusitis  symptoms with associated fever and headaches.   If kids have headache or mental status changes associated with fever and sinusitis get a contrast ct head with fine cuts through the sinuses.

Typical appearance of Pott's Puffy Tumor

Pott's puffy tumor with brain involvement.

Treat sinusitis with antibiotics and nasal steroids to attempt to prevent complications of sinusitis.  Dr. Collins made the point that 50% of sinusitis treatment is nasal hygiene with nasal steroids. Dr. Sherman also stated that saline nasal spray and clearing nose with blowing  is important as well.

If a child has swelling of the forehead, be very cautious chalking it up to a bug bite.  The children presented at this conference had bumps on the forehead diagnosed as bug bites that turned out to be pott's puffy tumor.

Dr. Collins comment: Strep anginosis is sub-type of strep viridans.  It is known to cause complications of sinusitis especially abscess. If you have a child with a positive blood culture or other culture for strep anginosis, you have to look very carefully for abscess including intracranial abscess.

Harwood comment:  If I see any meningeal involvement on a contrast ct with sinus disease, that patient is going to the ICU and needs ID, ENT and Neurosurgery consults.

Staley     Study Guide    Pediatrics

Most common causes of pneumonia in children with cystic fibrosis is staph aureus and H. flu.

If you are giving a prostaglandin infusion in a neonate to re-open the ductus be on guard for apnea.  Apnea and flushing are side effects of prostaglandin infusions.  If you have to transfer a patient receiving prostaglandins it is recommend to strongly consider intubation prior to transfer in case the child becomes apneic during transfer.

Shock or cyanosis in the first 2 weeks of life should raise the suspicion for congenital heart disease as the ductus is closing during this time period. 

Components of Tetrology of Fallot

Knee-Chest position to treat a Tet Spell.  Also give oxygen, IV hydrate, and give morphine 0.1 mg/kg.  By then you should be consulting Peds Cards or PICU.  But other strategies that can used are ketamine, phenylepherine, and esmolol.

Young infants with vomiting and or diarrhea have a high risk of hypoglycemia.  Check a dexi.  After initital boluses, give glucose containing maintenance fluids in kids.

 If a child under 1 yo has bilious emesis you need to work up that patient with an upper GI for suspected malrotation with midgut volvulus.   There may be an emerging role for ultrasound to screen for this disease process but you can't rely on ultrasound yet.  Harwood comment: If you can't get an upper GI done in a rapid fashion at your institution you need to transfer to a pediatric center. 

Classic "corkscrew sign"  of Midgut Volvulus on Upper GI

Shimanuki et al [8] evaluated the clockwise “whirlpool sign” by color Doppler ultrasound in diagnosing midgut volvulus. In 13 patients with surgically confirmed midgut volvulus, color Doppler ultrasound showed clockwise “whirlpool sign” in 12 patients and no “whirlpool sign” in one patient. The sensitivity, specificity, and positive predictive value of clockwise “whirlpool sign” for midgut volvulus were 92%, 100%, and 100%, respectively [8].

Clinical signs of NEC

When considering NEC, on xray look for portal gas and pneumatosis intestinalis.

Destefani      M&M

When dealing with a sick patient, be sure to communicate with the family clearly and prognosticate the possibility of death or poor outcome.  It is better to prepare the family for this possibility early on in the ED course.

When you have to give bad news, focus all your attention on that family.  You owe it to that family to not have distractions during that time. Speak to the family in a quiet place. Turn off your phone.  Wear your coat.  Know the patient's name and check with the family that they are here for that patient.  Give the family an appropriate amount of your time.  Shake everyone's hand.  Sit down, lean forward.   Have security officer nearby if you think there is a possible safety risk.  Make eye contact, speak slowly and clearly.  Use the word "died".  Allow a 10 second pause after breaking the bad news. Then express your sympathy and availability for the family should they have any questions.  Kelly Williamson comment: Reassure the family that they did everything right and they did the best they possibly could to care for the patient leading up to this event.    If you have to use a translator during bad news, be sure to contact the translator and prep them prior to walking in to meet the family.

Pick one case every shift that you felt didn't go as well as possible.  On your way home from the shift consider what went well and what didn't go well.  Think about what you would have done differently and how you would act differently the next time.

Katiyar       Billing and Coding  Medical Decision Making

Include in your medical decision making any medications the patient may be taking that are relative to this ED visit.  Also include the medications you used to treat the patient in the ED.

Document your Differential Diagnosis.

Document that you discussed the case with the patient and or the family. 

Document patient re-evals.  

Include your interpretation of prehospital ekgs and rhythm strips. 

In your medical decision making, include any guidelines such as PERC , Well's, PECARN, or Heart Score that you used to guide management.

In general terms, when document your MDM, describe the patient, describe what you did for the patient, describe what you ruled out, what is the most likley diagnosis, and describe your disposition of the patient.

www.Ritecode.com Jeffrey Restuccio, CPC, CPC-H jeff@ritecode.com

www.Ritecode.com Jeffrey Restuccio, CPC, CPC-H jeff@ritecode.com

Conference Notes 11-15-2017

Zelkovich      Radiology

Unfortunately I missed this excellent lecture

Walchuk      Pediatric Study Guide

Kawasaki's Disease

If you think a patient may have Kawasaki's Disease order a CRP or ESR. If the results are high, consider an ID consult or OBS stay.

Images associated with Kawasaki's disease

Fever work up

One reasonable approach to the febrile infant under 3 months.  Some more conservative docs would move the cut-off for full septic workup to 6 weeks.  

Brian Carlson       Financial Planning

An important way to protect your assets is with an auto liability umbrella policy.  You can get sued for major $'s due to auto accidents or injuries on your property. These types of policies are a cost-effective way to protect your assets. You definitely should purchase as much as you can.

Strategies to protect wealth from litigation are:

1. 401K/403B/Pensions.  These are off-limits to lawsuit damages.

2. Whole life insurance policies or Premanant Life Insurance policies.  These options can have additional tax benefits but they need to be structured properly to provide that benefit. These are to be considered only as long term asset protection strategies. These are off-limits to lawsuit damages.

3. Educational accounts (529 accounts), Not accessible to lawsuits.

4. Irrevocable trust.  Cannot be taken away in a lawsuit but you also cannot get at the money either.

5. Annuities are also a protected class of assets.  But annuities are high-cost and not a great vehicle for most doctors.

6. If you are married, put your house in "tenancy by the entirety" so it cannot be taken away in litigation.  This is inexpensive to do and it protects your house from loss due to medical malpractice or other lawsuits. If you are not married you cannot take advantage of this strategy. 

7. IRA's in the State of Illinois are protected from liability litigation.   If you move to another state it may not be protected, so you have to be very careful about where you put your money.

An important strategy for building wealth is to get $ into tax protected vehicles: Roth IRA's,  permanent life insurance, and educational investment funds (529) are some examples.

You need to get a private disability policy as soon as you can and as early in your career as possible.  This should take priority over life insurance.  This is because the younger you are the less expensive disability insurance is.  The cost goes up 8% every year that you wait.  This added cost is carried forward throughout your career.    Make sure your policy is specialty specific. "True own occupation" policies will pay the benefit if you can't practice EM even if you work and earn income doing physical exams or in another medical specialty.

Do not write prescriptions for yourself!  If you write a prescription for yourself, even if just for zofran or a Z-pack it will disqualify you from getting a disability policy!  The insurance companies see this as a red flag for dishonesty in your health history and risk for future self-prescribing for more serious medications like benzos or opioids.

Traylor     Environmental Emergencies

Capnocytophaga Canimorsus is a bacteria in the oral flora of dogs.  Patients who are asplenic (sickle cell disease patients, patients with prior splenectomies) are at risk for bacteremia and sepsis following dog bite from this organism.  Bacteremia and sepsis from this organism has a 30% fatality rate.

Capnocytophaga canimorsus has been implicated as a pathogenic agent in a variety of clinical conditions such as septicemia, purpura fulminans, peripheral gangrene, endocarditis, and meningitis following dog bites (116, 139, 158, 166, 178, 189). Although fulminant infections with Capnocytophaga canimorsus after a dog bite have been reported for immunocompetent patients (116), it appears that immunocompromised patients (e.g., those who have undergone splenectomy and those with liver disease, etc.) are most susceptible to this type of infection and its complications (139, 166, 178, 189). 

Abrahamian FM, Goldstein EJC. Microbiology of Animal Bite Wound Infections. Clinical Microbiology Reviews. 2011;24(2):231-246. doi:10.1128/CMR.00041-10.

These pictures demonstrate livedo racemosa from capnocytophaga canimorsus.  Editors note: Highest risk patients are those without a spleen, alcoholics, and other causes of immunocompromise.  Immunocompetent patients however also have gotten this infection.  Consider prophylaxis with Augmentin or Clindamycin for dog bites. 

Posterior shoulder dislocation

Y view shoulder x-ray showing the humeral head not in contact with the center of the Y and posterior to the scapula. 

Walsh PharmD   Lecture on Hypertensive Emergencies

Aortic emergencies: Shoot for dropping the systolic BP to 120 and HR to 60.  You want to lower the shear stress on aortic wall.  Reach for esmolol and nicardipine. Start esmolol first. 

Ischemic and Hemorrhagic stroke: For hemorrhagic stroke, get the systolic BP between 140-160.  For ischemic stroke patients receiving  TPA get the BP to less than 185/110.  For ischemic stroke patients not receiving  TPA, don't treat until BP is over 220.   Use nicardipine to control BP in stroke patients.  Labetalol can also be used but be very careful with labetalol. It is a non-selective beta-blocker and can cause severe asthma exacerbations in patients with asthma and cardiac collapse in patients with cardiomyopathies.

Pre-ecclampsia/Ecclampsia   Treat with magnesium and methyldopa or hydralazine.   Labetalol can be used but it can precipitate fetal distress.

Stimulant-induced (cocaine, Meth) HTN: Give benzos initially.  Benzo's usually will do the job.  if you need a second drug use nicardipine.    Avoid beta-blockers/labetalol in these situations because they can cause severe hypertension.

Conference Notes 11-8-2017

Barounis     Critical Care Tips

Tip #1   You can flush a central line with saline to verify the placement in a central vein.  Using bedside echo, if you see bubbles in right side of heart you know you are in the correct vessel. You can then start using the line right away and not wait for CXR.

Tip #2  Massive hemoptysis is life-threatening.   Patient's with large volume hemoptysis should go to the MICU. When intubating a patient with massive hemoptysis, b prepared and have 2 suction catheters ready to go.  Give TXA and if the patient is on anti-coagulation, give FEIBA.  You can try video laryngoscopy but blood likely will obscure your image of the airway so you have to be prepared to do direct laryngoscopy.  After the patient is intubated, you need to some way oxygenate the good lung and isolate the bleeding lung.  You can pass a fiber optic scope thru the ET tube and direct the tube to the non-bleeding side.  Dave also discussed a bronchial blocker device that can obstruct a bleeding bronchus. It takes some paractice to use this device reliably.

3. If you can't pass a suction catheter thru the ET tube you have to consider the patient may be biting the tube, there may be a mucous plug or clot, or the tube may have migrated to a supraglottic position.

4. 

Lobar or lung collapse on CXR will demonstrate increased density on affected side and mediastinal shift to affected side. Treat with suctioning, nebs, chest PT and bronchoscopy.

#5  Flow rate for a Cordis 333ml/min.  Other flow rates: 16g peripheral IV 220ml/min, 20g peripheral IV is 60 ml/min,   Triple lumen is 52ml/min.  Shorter, larger bore catheters deliver more volume than longer and smaller bore catheters. 

If a dialysis patient is critically ill or peri-arrest it is totally OK to infuse fluids and blood through the dialysis catheter until you can get another line.  Dave says, "It's OK."

#6 Dave gave the advice that when placing a blakemore tube for variceal bleeding introduce the tube through the nose rather than the mouth.  The balloon/tube looks too big for the nose but it will pass. Dave does not inflate the esophogeal tube in order to avoid esophogeal rupture. He says the gastric balloon usually takes care of the problem because the bleeding is usually by the GE junction.  He attaches a 1 liter bag of saline to the external portion of the tube and lets it hang over the bed rail to apply tension to the gastric balloon.

The Blakemore tube can tamponade bleeding and allow suctioning of blood in the stomach.  Dave advised using a 1 liter bag of saline as your counter weight to apply tension to the gastric balloon.  Editor's note: I have not done this but I think I would use a clamp to attach the saline bag to the esophageal inflation port because you likely will not be inflating that balloon anyway as per Dave's advice. 

#7 For neuro intubations use fentanyl and esmolol to smooth out BP and ICP elevations. Use gentle laryngoscopy to avoid ICP spikes.

Garett-Hauser      Ethics Potpourri

We had a discussion about prescribing opioids.  There were varying views among the attendees.  Everyone agreed that there has to be a balance between treating pain and avoiding opioid addiction.  The pendulum has swung to being more restrictive in opioid prescriptions based on the prevalence of opioid addiction and overdose deaths.

Euthanasia is legal in the Netherlands, Belgium, Columbia and Luxemburg.  Assisted suicide is legal in Switzerland, Germany, Japan, and Canada.  Assisted suicide is also legal in California, Washington, and Oregon Washington DC, Colorado, and Vermont.

Iceland has a policy to screen all pregnancies for Down's Syndrome. There is a 100% abortion rate for screened fetus' with this disease.  There was a discussion of the ethics of that national policy.

Next issue was the ethics of trying new un-tested therapies on patients with advanced cancer or other terminal disease. Again there was discussion weighing two sides. The first is the desire to offer patients hope and give them a last ditch treatment option. That was countered by the concern of giving false hope with untested, potentially dangerous and costly treatments.

There is a new technology being developed that uses artificial intelligence to analyze teenagers social media to screen for suicidal risk.   Cirone comment: Most teenagers have alternate Instagram profiles called "Finstas" that are more edgy than their public profiles. Their Finstas are kept secret from parents, teacher, and other adults.  Finstas are only shared among the teenagers.   We all agreed that teenagers/parents/teachers have a very difficult time dealing with social media issues.

Lovell/Williamson    Emotional Wellness

The emotionally well person is self-aware of their emotions and accepts some conflict in life as a positive thing.

Anger develops from the amygdala and is probably our most primitive emotion.  Chronic anger is maladaptive and can lead to coronary artery disease and other long term physical illnesses.

One tool to limit anger/confict is ARTS of communication

A=Ask the other person about their perspective  R=Respond with empathy  T=Tell your perspective.    S=Seek joint solutions.

Logan Traylor comment: If you sense that a statement/comment you made has upset someone, it can rapidly diffuse the situation by apologizing early.

Cirone comment: Acknowledge the other person's workload and identify ways to help them. 

Ahmed comment: Identify the patient's goals and fears that they bring to their ED visit and directly address those issues.  Empowering co-workers by asking for their input is a great way to diffuse conflict.

Narrative writing can be a useful tool deal with uncomfortable emotions such as disgust. Putting thoughts on paper can better define them and make them less threatening.

Sadness needs to be processed over time. There is no quick fix for sadness.

Depression is more common in residents than in age-matched controls. The same is true for physicians in general.  Warning signs/risk factors for depression include changes in behavior, relationship issues, and substance abuse.

The vast majority of states have a Physician Health Program to provide in-depth evaluation, treatment, and monitoring to care for physicians.

As doctors, we need to develop the skill to compassionately tell families that their loved one has died.  We also need to be able to deal with the stress that we experience ourselves when a patient dies.  Post-resuscitation debriefs can be an effective tool to help caregivers process patient deaths.

Reference from Dr. Lovell:  Hyperlink to Dr. Naomi Rosenburg's excellent and brief narrative medicine essay in the NYT on how to break bad news:

https://www.nytimes.com/2016/09/04/opinion/sunday/how-to-tell-a-mother-her-child-is-dead.html?_r=0

...and the September 2017 EMRAP piece on Post-Resuscitations Debriefing:

 https://www.emrap.org/episode/mildlyacidotic/annalsof 

Fear in moderation can be a productive way to motivate us to prepare and be cautious and provide the best possible care for our patients. For our patients, we need to acknowledge their fear and do our best to mitigate their fear.

Uncertainty goes hand in hand with fear. We need to learn to manage uncertainty.  One strategy that can be effective is , "we don't have time to hurry."  Meaning we need to take the time to carefully consider the risks and plan. 

Joy is the happiness and fulfillment that we feel from our work.  If you aren't feeling joy about your work you need to consider that you may be experiencing burnout.  Ways to find joy: focus on the patient-doctor relationship. Avoid negativity. Be engaged in your workplace and value and appreciate your co-workers.

Conference Notes 11-1-2017

Bartgen/DeWeert    Oral Boards

Pneumothorax re-expansion pulmonary edema

Large pneumothorax in a young person

RPE is a possibly life-threatening but relatively little known condition. Therefore its occurrence is often not recognized as a complication of chest drainage after pneumothorax. Signs and symptoms include dyspnea, tachypnea and low saturation levels usually within an hour after intercostal drainage.

Risk factors include younger age, larger pneumothorax or longer existing pneumothorax and maybe a swift drainage of large amounts (>1L) of fluids or air.

To prevent RPE it is advised to drain less than 1L  of air or fluids initially. The disease is often self-limiting and therapy is supportive.

Treat with supplemental O2 or bipap or intubation depending on the severity of pulmonary edema.  Editor's note: For larger pneumos that I drain going forward, I will watch the patient for 1-2 hours in the ED following chest tube placement.

Verhagen M, van Buijtenen JM, Geeraedts LMG. Reexpansion pulmonary edema after chest drainage for pneumothorax: A case report and literature overview. Respiratory Medicine Case Reports. 2015;14:10-12. doi:10.1016/j.rmcr.2014.10.002.

Carlson      Critical Care Toxicology

Capnography is superior to pulse-oximetry to identify early hypoventilation or airway obstruction.    If you only have a pulse-ox to monitor the patient, don't give supplemental oxygen. You basically want to identify oxygen desaturation as a marker for hypoventilation/respiratory depression and supplemental O2 will mask early oxygen desaturation. 

The most common toxicology causes for intubation are ETOH, Benzos, and sedative hypnotics.

Bipap is a problematic strategy for respiratory support in toxic patients due to altered mental status and risk of vomiting.  Andrea's bottom line: BiPap is a no-go for the poisoned patient except for non-cardiogenic pulmonary edema (eg. post heroin overdose patient).

If the patient has salicylate poisoning you have to be very careful to adequately ventilate the patient after intubation. You will need higher tidal volumes like around 10ml/kg and a rate around 30+.  This is very different from usual lung protective ventilatory strategy with tidal volume of 6ml/kg and rates around 15.

The peri intubation period in the Tox patient is very high risk. Be sure to have a well thought-out airway management plan and optimize the patients hemodynamics prior to starting intubation.

First choice vasopressor for Toxin-Induced Cardiogenic Shock (TICS) is epinepherine.  If that doesn't solve the problem you can add norepi BUT there is no mortality benefit shown for using a second pressor.  If the first pressor isn't working you may to start thinking about mechanical CV support like an Impella device or ECMO.

High dose insulin 1 unit/kg is the first line agent for hypotension for beta blocker or calcium channel blocker overdose.  Be sure to supplement glucose and potassium.  You usually don't need high doses of glucose to prevent hypoglycemia because blood sugar doesn't drop that much with insulin therapy in the setting beta blocker overdose.  Editorial advice: Check the sugar q 1 hour if you are using high dose insulin.

Hormese  Pharm D    Management of PE

Proposed Management Algortithm for PE

Elise comment: the alternate terminology for sub-massive PE is "intermediate risk" PE.

Treatment of massive PE with TPA showed improved mortality (10mg bolus and then 90mg over 2 hours)

Treatment of sub-massive PE with TPA in the PEITHO Trial 2014 did not show improved mortality.  When investigators combined mortality and hemodynamic instability as the outcome there was benefit.  The study demonstrated a 6% extra-cranial bleed rate and 2% intracranial bleed rate.

Thanks to Dr. Lovell for this reference.  Quote from article is: "The management of sub-massive PE continues to elude us."

Patients less than 65yo with sub-massive PE  do better with TPA than older patients.  Use low dose strategy 10mg bolus followed by 40mg over 2 hours.  Elise comment: there is no right answer for the management of sub- massive PE.  The body of data thus far does not show clear benefit.  Treatment for sub-massive PE is decided on a case by case basis.  In younger patients with worse PE's a better case can be made for it.  Harwood comment: Don't even consider TPA for sub-massive PE unless you have an abnormal echo AND an elevated troponin.  Definitely use low dose strategy and use it in only in patients under 65.  The bleed risk is significant. Use shared decision-making with patient/family/cardiologist/intensivist.

EKOS catheter directed thrombolysis can be considered for both massive and sub-massive PE's.  Here at Christ the Cardiologists are performing this procedure.  If you need an EKOS trained cardiologist call the STEMI Cardiologist on call and they will get the person who can do EKOS.

Cost to patient for TPA is $32,000.

There was a discussion about what to do for the unstable patient who has PE in the DDX but has not had a CT yet.  Everyone agreed that this was a tough decision to give TPA without a confirmatory test. Everyone agreed that bedside echo is the best test to help you in this situation.

HCAP Guidelines

The new HCAP guidelines for ACMC were reviewed.

Friend       Epinepherine dosing in place of an Epipen

We no longer have epipens in the ED.  Dr. Friend discussed our current strategy to administer epinepherine to our patients with anaphylaxis. To prevent dosing errors, Dr. Harwood suggested that in the epi kit there should be 1 vial of epinephrine and 3 insulin syringes.  When the kit is opened. All 3 syringes should be used to draw up 0.3 ml of epinephrine in each syringe.  That gives you 3 doses of 0.3mg of epinephrine to administer.  That way you can't inadvertently give too large of a dose.  Everyone agreed this was an excellent safety strategy. 

Give Epinephrine IM rather than SubQ.  There is more reliable absorption by the IM route. 

Florek    PE/DVT

Dr. Florek discussed the diagnostic strategy for 5 types of patients with suspected PE.

1. Well appearing. Low risk Well's and PERC negative----Done

2. Well appearing  Low risk Well's and PERC positive------Get a D-dimer (age-adjusted) If you are using age adjusted d-dimer you have to scan if pt exceeds the age adjusted limit by even 0.01.

3. Intermediate or High Risk on Well's-----Go straight to CTPE study

4. Peri-Arrest------Get CXR, EKG, bedside Echo.  If high suspicion for PE and dissection is felt to be unlikely then start heparin and consult for EKOS

5. PEA arrest------ Get history and perform bedside echo.  If suspicion for PE is high you can consider TPA 50mg IV bolus.

For pregnant patients use pregnancy adjusted d-dimer and if positive, your initial imaging should be venous dopplers of the legs.  Jeff Kline uses d-dimer cut-offs  of 0.75 in first trimester, 1.0 in second trimester, and 1.25 in third trimester.  He states in his article that if the pregnant patient has low-risk Well's score, no high-risk features, PERC neg, Venous dopplers negative, and d-dimer is under pregnancy-adjusted cut-offs no need to work up further. (Kline JEM 2015)

Conference Notes10-18-2017

Garrett-Hauser/Schmitz     Oral Boards

Case 1. 32 yo female with shortness of breath and abdominal pain. P=135, BP=235/125.   Patient has prior history of PE, HTN, and Cardiomyopathy.

CXR shows congestive changes and cardiomegaly.  Troponin is elevated. 

CT showed thoracic mass between the aorta and vena cava.  Diagnosis was extra-adrenal, intra-thoracic pheochromocytoma. 

Very Quick Literature search found one paper describing 34 cases of pheochromcytoma.  The above picture lists the number of patients with pheochromocytoma at each of the sites.  7 patients had extra-adrenal locations of their pheochromcytoma with 2 being intra-thoracic near aorta.  It looks like these tumors are going to be in the adrenals or by a major arterial structure.

There was an interesting discussion of how to manage the HTN and Tachycardia associated with pheochromcytoma in the ED.  The consensus was to use NTG or Nicardipine for HTN initially, and after BP was improved cautiously beta-block with esmolol or lopressor.  If a patient has CHF or Asthma/COPD you need to be very cautious about using a beta blocker.   Some faculty felt esomolol may be safer due to the fact it can be d/c'd rapidly if you have any unwanted effects.  It would be wise to consult Cardiology for assistance with these complicated patients.   All cases of pheochromocytoma need surgical consultation for removal of the tumor.

Case 2. 92 yo male brought in from NH for unwitnessed fall. Patient has history of dementia.  He is agitated and combative.  Vitals are normal. Patient has pain and deformity of shoulder.  

Image shows a superior shoulder dislocation. A superior shoulder dislocation is very uncommon.

After reduction with traction/counter traction, the shoulder pop's back up out of place. Superior shoulder dislocations usually severely damage the rotator cuff making any attempts at reduction unstable.  Surgery also is commonly not successful.  These patients usually develop a non-functional or severely limitedshoulder joint.

Case 3. 11yo child fell from bike and won't walk. Vitals are normal except HR=125.  Child is in pain.   Child has a porta-cath for prior treatment of leukemia. Patient has right hip pain with associated ecchymoses in right inguinal region. X-rays were negative.  CT of the pelvis showed an iliac artery injury. Vascular surgery was consulted for repair of the artery.  Iliac artery injuries can result from handlebar injury to the anterior pelvis/hip region.

PharmD     Acute Angle Closure Glaucoma

Clinical appearance of acute angle closure glaucoma

Increased intra-occular pressure develops when aqueous humor can't drain thru the angle.   Definitive management is laser iridotomy that drills a hole thru the iris to allow aqueous humor to drain.

mnemonic for causes of Acute Angle Closure Glaucoma: SAMS PA= Sulfa drugs, Anti's (anticholinergic/antihistamines/antiparkinson's drugs/antipsychotis/anticoagulants), MOAI's, Sympathomimetics, Parasympatholytics, Antiarrhythmics

ED Treatment: Timolol drops (fastest action), wait 3 minutes then give brimonidine (alpha-agonist), when IOP gets down to less than 40 you can give pilocarpine.  If IOP is above 40, give mannitol and acetazolamide.    Treat pain with narcotics. Treat nausea with ondansetron. Consult ophtho for iridotomy.

Burns      FAST and E-Fast Exam

EFAST exam or Extended Fast exam adds bilat lung windows to the standard FAST exam (RUQ, SUb Xiphoid, LUQ, Supra-pubic views) to check for pneumo/hemothorax.

RUQ view.    Fluid in Morrison's Pouch

LUQ FAST image showing fluid between kidney and spleen

When you are getting a subxiphoid view, ask the patient to bend their knees so that their feet are flat on the cart.  This will relax the abdomimal muscles and give you a better chance at a decent view of the heart.

Lung Views with EFAST using M-Mode.  Left side shows normal lung.  Right side shows pneumothorax.

Lambert     Gallbladder and Renal Ultrasound

Important landmarks to assure you are visualizing the gallbladder are the right portal vein and main lobar fissure.   For extra points, getting the right kidney in the image also helps assure that you have visualized the gall bladder.

A Q&A between Elise and Mike brought out an important point. In the longitudinal view of the GB (G) you commonly will see the IVC (V) and just behind the IVC, the right Renal Artery (Arrow)

Acute cholecystitis with stones and wall thickening

Team Ultrasound        Ultrasound Workshop