Conference Notes 3-2-2016

We had our first Wellness Retreat. 

I did not take notes at this retreat but a few key take home points:

1.  Andrea spoke about burn out in EM physicians.   Across the country, 70% of EM physicians have burn-out as measured by the validated Maslach assessment tool! Burn out includes 3 components: Loss of enthusiasm,  cynicism/depersonalization, and low sense of personal accomplishment.   We have a great career/calling but we have to be very aware of the toll our work can take on us. 

2.  Andrej introduced the Maslach burn-out survey.  All present at the retreat took the survey and were able to see their own level of burn-out.

3. We practiced yoga,focused breathing, and meditation with yogi Danny B.   These practices are all useful tools to maintain our mental health and compassion.  Danny taught us his Triad: Daily physical movement/breathing practice/meditation.  He recommended a practice of 5 minutes of each component daily to keep ourselves mentally healthy.  

Yogi Danny B   comment: 

Leo Tolstoy on practice and slow growth..........

“The greatest changes in the world are made slowly and gradually, not with eruptions

and revolutions. The same things happen in one’s spiritual life.”

“To be good at any activity requires practice: no matter how hard you try, you cannot do

naturally what you have not done repeatedly.”

“A person uses the wisdom of those who lived before him. The education of mankind

reminds me of the creation of the ancient pyramids, in that everyone who lives puts

another stone in the foundation.”

Hugs and high fives!!

ASANA (5min)

In general, move your body for 5min in a mindful way. Below is an example of what you

could do.

-establish your breath seated

-move into table top and find some movement of the spine, neck, hips

-down dog

-ragdoll

-standing-intention, breath

SUN SALUTE A

-raise your arms

-gentle back bend

-forward fold

-half way lift

-forward fold

-rise up to stand up with arms raised

-a breath of rest (arms at sides or at heart)

(do 3 times if you have the time)

SUN SALUTE B

-down dog

-lunge

-stand up to high crescent lunge

-open up to warrior 2

-extended side angle (tick tock your torso forward keeping side bodies long)

-reverse warrior (tick tock your torso backwards keeping side bodies long)

-table top or plank

-lower to belly or half way down

-cobra or upward facing dog (lift your torso up with your legs down, toes untucked)

-simple twist; standing, seated or on back

-bridge or wheel pose (a back bend)

-svasana for at least 30sec (laying flat on back, arms at sides, be the witness to the

energy you’ve created.)

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PRANAYAMA (5min)

Two essentials for pranayama: a stable (achala) spine and a still (sthira) but alert mind.

Find a tall, comfortable seat and an alert spine.

Shoulders comfortably pulled back to feel the chest expanded.

Don’t over exert.

Soften your skin.

Close your eyes. Gaze downward.

Set alarm for a 5min alert. DO NOT look at the timer!! Trust it is working.

The most simple breath is to simply BREATH. Take your breath off of auto-pilot, use

your ears and control the sound of the breath in and out so it sounds the same. Soft,

smooth, eased. Tension creates dis-ease. If the breath becomes “work”, stop. Take a

few normal breaths and start over. We don’t want to fight with the breath. We create

more harm than good.

More challenging “beginner” breath technique:

Samavrtti Pranayama (4 part equal breath)

Ideal ratio is equal. 1:1:1:1

If INHALE is 4 counts, HOLD breath at top for 4 counts, EXHALE for 4 counts, HOLD

breath out at bottom for 4 counts.

Don't stress yourself with holding breath out after exhale if this creates tension. It is

challenging. All of the air is out of you. Don’t panic. Find ease. This may take time to

build to. No problem. Your starting breath could be a 3 part breath, ratio 1:1:1. Example:

4 count inhale, 4 count hold at top, 4 count exhale, repeat.

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MEDITATION (5min)

Set alarm for a 5min alert. DO NOT look at the timer!! Trust it is working. With all your

might, stay seated with eyes closed and find as much ease as you can. Be the sky (all

of the thoughts), not the cloud (a thought). Try not to follow a single thread of thought,

be a witness to all that is happening. Don’t participate, just witness the subconscious tell

its story. The mind will race. This is normal!! Chatter will happen. Normal! Let the story

happen. Acknowledge it as being part of the process, but try to place it in your

periphery. This takes time and practice. There is NO such thing as "this isn't working".

It's working. Be there. Be present. Allow what comes to come and go. No judgement.

End your practice by acknowledging your efforts, loving yourself and smiling!

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"We either make ourselves miserable or we make ourselves strong. The amount

of work is the same." - Carlos Castenada

Yogi DannyB

Website:

www.yogidannyb.com

Email:

yogidannyb@gmail.com

Facebook: Yogi Danny B

Instagram: @yogidannyb

Twitter: @yogidannyb

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4. Kelly discussed key info regarding healthy eating.  She focused on the benefits of the Mediterranean Diet.  A short hand phrase to remember about eating is "Eat food, mostly plants, not too much." (Pollard)  Don't eat food-like substances (basically don't eat processed food that your great-grandmother would not recognize).   Don't drink your calories.  Don't eat food with more than 5 ingredients listed on the label.

5. Christine lead the group in a high intensity aerobic training session.  She used the website Fitness Blender that offers free aerobics videos.  The video-led exercise was challenging and many people had sore muscles over the next few days.

6. Natalie Htet led the residents thru a team building exercise.  Human interaction, strong working relationships and valued friendships are important aspects of long term health and resilience.

7. We shared a lunch consisting of Mediterranean diet components.  During lunch Andrej discussed the results and implications of the Maslach Burn-out survey.  Faculty and residents shared personal experiences with wellness practice.

Conference Notes 1-20-2016

Lee/Felder      Oral Boards

1.  33yo female had a seizure.   Patient is post-partum.  Vitals: HR=118, BP=95/60 otherwise normal.  Patient gave history of peri-partum hemorrhage followed by difficulty with breast feeding over the last 2-3 weeks.  Labs show sodium of 113 and potassium of 6.2.   Patient also had signs of UTI.   Concern was raised foradrenal insufficiency and stress dose steroids were given.  Diagnosis is Sheehan’s syndrome.

*Sheehan’s syndrome

Be alert for associated hypothyroidism due to lack of TSH.   Treatment for this case included Normal Saline if patient is no longer seizing.  Mark Pharm D comment: If patient is still seizing give hypertonic saline 30ml/hour. Goal is to raise the serum sodium level by 12 in 24 hours. 

Christine comment:  I like this idea from Emcrit http://emcrit.org/podcasts/hyponatremia/

Basically for the seizing hyponatremic patient, give 100 ml of hypertonic over 10-60 min, then re-evaulate. Should be ok for 50 kg or larger adult. And bonus for me, easy to remember.

Give hydrocortisone 100mg Q8 hours.

2.  10mo male noted by parent to have had a seizure in the crib.  Seizure lasted less than 5 minutes.  No Fever.  No one else is ill in the home.  No PMH.  On exam, the child is playful.  On further history, the babysitter noted that child had fallen out of car seat earlier on the day of ED visit.   A head CT and skeletal survey were ordered.  Imaging shows a skull fracture.   The skeletal survey shows a metaphyseal chip fracture and old rib fractures.

*Metaphyseal chip fracture

Diagnosis was seizure secondary to non-accidental head injury.  DCFS was notified and child was admitted to ICU.  This case illustrates the need to always be alert to the possibility of non-accidental trauma.

3. 68yo female transferred from the NH with ongoing seizure.    HR= 120,   BP=130/80,  Pulse OX=98%,   Dexi=25.  It was learned through discussion with NH that patient accidentally received long-acting insulin instead of lovenox.   Patient was given IV dextrose followed by D10NS drip to prevent further hypoglycemia.    

Be aware of adverse drug events in patients coming from a nursing home.

Check blood sugar in every patient who seizes and every patient who cannot speak normally with you. 

Elise comment: If a patient who is seizing does not respond to initial Ativan, you have to start thinking about more uncommon causes of seizures such as hyponatremia, INH toxicity, hypoglycemia, hypocalcemia. 

PharmD comment: When treating severe hyponatremia you can go up by 12 meq over 24 hours.

Harwood comment:  For Sheehan’s you need to test for and treat adrenal insufficiency and hypothyroidism.  For the boards, verbalize your assessment of the problem and your plan of management so the examiner can accurately evaluate your medical knowledge.   In my experience, the NH will never admit to a drug error.  If you suspect accidental insulin administration,  you can order an insulin level.  A high level will indicate exogenous insulin in the patient.

Den Ouden           The Force Awakens/Thoughts on Being an Emergency Physician

1.  We have an impossible job.    You have to accept the fact that you can’t meet all the demands placed on you.

2.  Patient satisfaction is a trickytask.  A UC Davis study showed a 26% higher mortality rate in the most satisfied patients.

The Cost of SatisfactionA National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality FREE

Joshua J. Fenton, MD, MPH; Anthony F. Jerant, MD; Klea D. Bertakis, MD, MPH; Peter Franks, MD

Arch Intern Med. 2012;172(5):405-411. doi:10.1001/archinternmed.2011.1662.

Text Size:

Background Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.

Methods We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.

Results Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).

Conclusion In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

3. What scares EM docs?  Lawsuits, Peds emergencies, big misses, difficult airways.

4. Make a human contact with patient and family. Shake their hand. Make eye contact.  Find out their fears.   A good emergency physician is like being a waiter.  You have to guide patients thru the system and keep them updated.

5. Repeat your plan of care multiple times to the patient.  Make a verbal contract with the patient.

6. Tell patients you want to make them feel better. Tell patients you will rule out anything emergent.  

7.  You have to do some “doctoring” that is reassuring the patient, review the “extensive” testing you did in the ED, express a caring nature to patients.

8. Everyone has bouncebacks.

9. Tools to screen for aortic dissection: HX of migratory pain and uncontrolled hypertension, bilateral blood pressure, CXR, d-dimer (imperfect test, you can’t document that you used it to screen for dissection), CTA.  CTPE will find dissections as well.

View fullsize

*Adam Bonder’s Reference: AHA Algorithm for working up Aortic Dissection

*Harwood’s Reference for using d-dimer for screening for aortic dissection.  This applies to low risk patients in the above algorithm

D-Dimer as a Test for Aortic Dissection: Relevant or Not?

Daniel J. Pallin, MD, MPH reviewing Asha SE and Miers JW Ann Emerg Med 2015 Mar 24.

A meta-analysis finds that a low D-dimer level excludes aortic dissection but only in low-risk patients, who might not be tested anyway.

Previous studies have shown that d-dimer levels tend to be high in the presence of aortic dissection and low in its absence. But is d-dimer testing sufficiently sensitive to contribute to clinical decision making? To find out, investigators conducted a meta-analysis to assess the negative predictive value of a normal d-dimer result among patients evaluated for aortic dissection. They analyzed the results according to pretest risk determined by an American Heart Association risk score. The score designates a patient as low risk if there are no high risk findings, which range from Marfan syndrome to new aortic insufficiency murmur, but, importantly, include chest, back, or abdominal pain of abrupt onset, severe intensity, and ripping or tearing quality. The pre-test probability (prevalence) of aortic dissection in low-risk patients is 6%.

In pooled analysis of data from four studies including 1557 patients, a d-dimer level <0.5 µg/mL had a sensitivity of 98% and a negative likelihood ratio of 0.05 to rule out aortic dissection. For non–low-risk patients, the authors concluded that d-dimer testing was not sufficiently sensitive to rule out aortic dissection and should not be used.

10.  Simple epinepherine drip for anaphylactic shock: Put 1 mg of cardiac epinepherine in 1 liter of NS.  Give 1 drop per second thru an antecubital IV.  You can titrate up as needed. You can do this with any pressor, 1 mg in 1 liter of saline gives you a 1mcg/ml solution.

11. Win your patients over. Make human contact with the patient and their families. Set the expectations of the ED visit.

Htet         Jeopardy

Boutoniere and swan neck deformities are seen with rheumatoid arthritis.

*boutoniere and swan neck deformities, mallet finger is also pictured.  Mallet finger is due to trauma.

*monteggia vs galeazzi fracture

*Kanavel’s cardinal signs

The incidence of appendicitis during pregnancy is the same as in non-pregnant patients.  The incidence of perforation during pregnancy is increased however.

Harwood comment: The location of the appendix does not change during pregnancy.  It is an urban myth that the appendix rotates up to the RUQ during pregnancy.

Rocky Mountain Spotted Fever is treated with doxycycline in adults and kids.  Even though we traditionally don’t use doxy for kids, RMSF has high enough mortality that doxy is recommended even for kids.  There was debate about the best antibiotic choice for a pregnant patient with RMSF.

CDC Reference:

The use of doxycycline to treat suspected RMSF in children is standard practice recommended by both CDC and the AAP Committee on Infectious Diseases. Use of antibiotics other than doxycycline increases the risk of patient death. Unlike older tetracyclines, the recommended dose and duration of medication needed to treat RMSF has not been shown to cause staining of permanent teeth, even when five courses are given before the age of eight. Healthcare providers should use doxycycline as the first-line treatment for suspected Rocky Mountain spotted fever in patients of all ages.

Other Treatments

In cases of life threatening allergies to doxycycline and in some pregnant patients for whom the clinical course of RMSF appears mild, chloramphenicol may be considered as an alternative antibiotic. Oral forumulations of chloramphenicol are not available in the United States, and use of this drug carries the potential for other adverse risks, such as aplastic anemia and Grey baby syndrome. Furthermore, the risk for fatal outcome is elevated in patients who are treated with chloramphenicol compared to those treated with doxycycline. Other antibiotics, including broad spectrum antibiotics are not effective against R. rickettsii, and the use of sulfa drugs may worsen infection.

Harwood comment: I would give a pregnant patient with RMSF an initial dose of IV erythromycin and consult ID and the CDC.   There is no great answer in this very difficult situation.

*Centor Criteria.   There was debate among faculty whether to perform a rapid strep test on the patients with 4 criteria or just treat them.

*Commotio cordis occurs when the pediatric chest is struck with a blunt object at just the wrong time during the QRS cycle to cause V-Fib.  It has to do with the potassium channel currents.

Button battery ingestions are high stakes situations.   If the button battery is in the esophagus it needs to be removed emergently.  If it is in any other area of the GI tract, it probably can be watched to see if it passes.   On xray you can identify if the object is a battery by looking for a circumferential crimp (double ring or Halo sign). 

*Button battery on xray vs. coin on xray.   Note the button battery has a double ring or Halo sign.

*Elise reference on the management of button battery ingestion

Kadar       Critical CareM&M

Consider using a lower dose of sedation and a higher dose of paralytic when intubating the unstable patient.  For example 10mg of etomidate and 1.5 mg/kg of succinylcholine.   Harwood comment: I would never go past 2mg/kg of succinylcholine.  Mark our PharmD said high doses (>2mg/kg) of succinylcholine can cause bradyarrythmias.   Very high doses of rocuronium can cause tachyarrythmias.

Harwood comment: Consider using ketamine and topical lidocaine for an awake intubation/sedated intubation in the unstable patient.   It is preferred to intubate in the ED versus other areas of the hospital.   We have more resources at hand in the ED.

*Delayed Sequence Intubation

*Awake intubation.   Rachel made the point that you could safely use both nebulized lidocaine and atomized lidocaine to anesthetize the throat.    If you don’t have atomized lidocaine, you can use nebulized lidocaine and viscous lidocaine.

*3-3-2 rule

Cirone          Physical Restraints in the ED

Restraint must be considered a last resort in the setting of the patient being at risk of harming themselves or others.

It is wrong to use physical restraints to prevent a patient from leaving the ED, punish them, or maintain an orderly environment.  

Within 1 hour of initiating any physical restraint, the physician must evaluate the patient with a face-to-face clinical exam and document it on the correct form or in the medical record using an appropriate template.

Physical restraint has risk of aspiration, injury, and death for the patient.   It also puts medical staff at risk of injury. 

Conference Notes 1-13-2016

Katiyar      Toxicology Rapid Review 2016

The toxic level of acetaminophen is 150mg/dl. It is important to know the units mg/dl because different labs use different units.  Just think MD for mg/dl

Elevated liver enzymes usually first develop 18 hours after acetaminophen overdose.

The typical metabolic picture of aspirin overdose is metabolic acidosis and respiratory alkalosis.

Urinary alkalinization is effective for aspirin and phenobarbital overdoses.  Urinary alkalinization traps the drug in the urine and it gets excreted.

Dolobid (an old NSAID) can give a false positive drug screen for aspirin.

*mnemonics for organophosphate poisoning signs

The treatment of seizures due to INH overdose is pyridoxine. Pyridoxine improves the production of GABA.  INH causes an anion gap acidosis.

*anion gap acidosis

Valproic acid overdose can cause CNS depression, miosis, prolonged QT, electrolyte abnormalities, and elevated ammonia level.  Treat with airway control, give L-carnitine, consider hemodialysis.   Indications for dialysis are respiratory depression,  metabolic acidosis and high valproic acid levels.

When looking at ethanol and toxic alcohols,  the more carbons that are present in the molecular structure the more inebriating the alcohol.  Isopropyl has 3 carbons so it makes you more inebriated than ethanol which has 2 carbons.   The less carbons present in the molecule, the more toxic the substance is.  Methanol has one carbon so it is more toxic than ethanol.   Ethylene glycol has two carbons but the glycol moiety makes it renal toxic.

*anion gap calculation

*osmolalgap calculationIt is ok to round 2.8 to 3 and 4.6 to 5 when taking the test to make the calculation easier.

*ciguatera poisoning

Jimson weed has anticholinergic effects.

Iron poisoning:  The most common iron preparations such as ferrous sulfate have 20% elemental iron.  If the patient ingests 20mg/kg of elemental iron they have risk of toxicity.   So for test-taking the number to remember for iron toxicity is 20.  20% elemental iron is most common in pills, and 20mg/kg is a dangerous ingestion.   A concerning serum iron level is above 350mcg/dl.     If the child is not vomiting by 6 hours after ingestion, significant toxicity is unlikely.    Treat iron toxicity with whole bowel irrigation, supportive care, IV fluids, deferoximine.  If liver toxicity is identified transfer to a transplant center.   Deferoximine changes urine to vin rose wine color.

Girzadas     PD Update

1.     Please speak with the MAR whenever admitting a patient to inpatient medicine or OBS.

2.     When collecting a specimen of any kind, bring a patient label in with you to the room before you obtain the specimen.  Check the label against the patient’s wristband. Initial/time/date the label.

3.     Please complete the ACGME survey ASAP.

4.     Please sign up for you 6 month eval

5.     If interested in a global health experience in Tanzania this coming fall, please speak with me.

6.     Wellness issues:  Be alert to your own and your fellow residents’ mental and physical health.

7.     Avoid excessive caffeine use.

8.     Adderal has significant arrythmogenic risk and should never be used off-label for alertness when working nights or taking tests.  It should only be used under the supervision of a physician experienced with it’s use for FDA indicated diagnoses.

Lambert           Ultrasound Guided Procedures

When doing an ultrasound guided central line be sure you can fully compress the vessel prior to puncturing the skin with the needle.  If you are able to compress the vessel, that rules out a clot in the vessel you are planning to place the line.

Elise Hart comment:  To make sure your probe is lined up properly (right to left) with the screen, put some gel on the probe and touch the right side with your finger and then touch the left side of the probe with your finger and make sure that you are seeing the corresponding image on the right and left side of the screen as you touch the probe.

When doing an IJ place the left side of the probe into the angle of the SCM and the clavicle.  Keep the probe perpendicular to the surface of the neck.  Angle the needle at about 30-45 degrees from the neck.

Mike prefers the long axis view of the vessel when doing an ultrasound-guided peripheral line.  Mike will identify the vessel and the course it is taking in the arm. He then has the nurse cannulate the vein. He feels that if he can identify the course of the vessel, the nurse can cannulate the vessel no problem with a longer needle.  The reason the nurse can’t cannulate the vessel without ultrasound is usually that they don’t know which direction the vessel is going.  The longitudinal view of a vessel is the best way to identify the direction the vessel is taking proximally. 

*Cellulitis with cobblestoning on ultrasound

*Abscess on ultrasound

Harwood comment:  If a patient says the abscess is draining some already, still take a look with the ultrasound.  You will be surprised that there is still significant abscess collection that requires I&D despite some drainage of fluid.

Mike discussed the technique of placing a femoral nerve block.   He identifies the femoral nerve lateral to the femoral artery with ultrasound and slowly injects bupivacaine without epi around the nerve.

Mike discussed axillary nerve block technique.

When doing pericardiocentesis find the area of greatest fluid and direct the needle right into the fluid from the closest point of entry.    If you can identify a significant volume of anterior pericardial fluid there is no lung interposed between skin and pericardial space.  No need to use the subxyphoid approach if you are using ultrasound and can identify  significant fluid.

*Ultrasound-guided pericardiocentesis

When doing thoracentesis, you can use ultrasound to identify the location of the fluid.  Also, using a linear probe you can identify the rib level that the diaphragm moves up to with expiration and make sure you are placing the needle above the maximal upward movement of the diaphragm.

Lambert/Chan/Frazer/Burns and other Team Ultrasound Members

Vascular Access Lab

Conference Notes 1-6-2016

Barounis        Hypoxemic  Respiratory Failure

Peak pressure is calculated on resistance and flow.

Plateau pressure is calculated on tidal volume and compliance.  There is no flow in the measurement of plateau pressure.   You get a plateau pressure when the ventilations are paused.

If peak and plateau pressures are both high then you have a compliance problem.

Compliance is affected by water, pus, air, or blood in the lung, or fat compressing the lung.

If the peak pressure is high and the plateau pressure is normal then there is a resistance/flow problem.  Think mucous plug or kinked ET tube or bronchospasm or right mainstem intubation.

Lungs are very sensitive to high plateau pressures.   As noted above, plateau pressure is affected by tidal volume.    High Tidal volumes have been found to cause ARDS.

Obesity can affect lung compliance.  It is important to put the patient in reverse trandelenburg (feet down, head up) to displace the stomach off the diaphragm.

Dave made the point: Use Low Tidal Volumes in All Patients

For most male patients a TV of 500 is a reasonable starting point.  In most women a TV of 400 is a reasonable starting point.  You have to give a slightly higher respiratory rate around 16 when using these lower tidal volumes.   Start with 5 of PEEP but you can go up to 10 or 12 if patient is still hypoxic.   Of course, asthmatic patients will need lower ventilation rates.

Don’t give a lot of fluids to patients with ARDS.  They will third space fluid into their lungs.   Dave wants to keep his ARDS patients as dry as possible.  In fact intensivists are using a lot of Lasix in ARDS patients to keep them as dry as possible.

Inhaled nitrous oxide can be useful to improve VQ mismatching.  Nitrous oxide improves the measurements of lung function but it has not been shown to improve mortality.

For refractory hypoxemia, prone positioning works to improve survival.

Finally ECMO can be life saving in a select group of severe ARDS patients.

Hart /Chan   Oral Boards

Case 1.  59 yo female with abdominal pain. Vitals normal except BP of 102/52. Labs are normal except an elevated lactate.  Repeat exam shows persistent pain and diffuse abdominal tenderness.  Upright Chext X-ray shows free air.

*Free air on Chest X-ray

Upright Chest X-ray is 80% sensitive for free air.   Give IV antibiotics, pain medication, fluids, and get patient to the OR.

Elise comment: Check an EKG on elder patients with abdominal pain.  AMI can present with abdominal pain.

Harwood comment:  Upper GI perforations will present early with severe pain.   Lower GI perforations from a perforated diverticulum will present in a delayed fashion with less severe pain and significant amount of free air.  The CT findings will seem inconsistent with the patient’s clinical presentation.

Case 2. 21 mo male refusing to walk.  Vitals and Dexi are normal.  Xrays show a Toddler’s Fracture

*Toddler’s fracture.  These are not associated with child abuse.

Case 3.  69 yo male with an episode of near syncope. Vitals are normal. Dexi is normal.   EKG shows markedly peaked T-waves.

*Hyperkalemic EKG note the Tall Narrow T waves. P waves are still present and QRS is still narrow.

*Hyperkalemic EKG changes

Patient had potassium of 6.7.  He had signs of renal failure.

*Treatment of Hyperkalemia

Elise comment: In a male with new renal failure, use ultrasound or place a foley to identify acute urinary retention.

Katiyar        Billing and Coding

Doctors are now almost universally evaluated by the RVU system.   If your group generates more RVU’s, you have more money to hire physicians and make capital investments such as purchasing an ultrasound machine.  If you are a low RVU generator you will be at risk to be fired.

There are two ways RVU’s are factored into physician compensation.  1. Pure RVU reimbursement.    2. As a factor in a bonus system above the guaranteed base salary.

*RVU’s per EM Code

Remember “Fortuntenate”   4-2-10-8.    4HPI factors,  2History Items,  10 ROS items,  8 physical exam items are required for a level 5 EM code.

Use the EM caveat for patients who cannot communicate effectively with you.  For kids under age 6 most faculty felt it is reasonable to use the caveat for age.   Our coder felt that age was problematic sometimes as an EM caveat.  She said to get as much history from the parent as possible. Language barrier is not a factor that can be used to invoke the EM Caveat.  You have a responsibility to get an appropriate translator.   Our coder suggested that using clinical acuity as the EM Caveat is probably the best factor you can use.

Risk management issues:

1.     Document “no FB” in all lacerations.   Harwood comment: I document that I asked the patient if they feel any foreign body or if they are concerned there is a foreign body. I document that I looked for a foreign body.  I document that the patient declined an x-ray.

2.     Document “tendon intact” for all lacerations

3.     Document pregnancy status in all female abdominal pain patients

4.     Document re-evaluations and status of patients

5.     Document time and content of conversations with PMD and Consultants

If you want the PICU attending to see a patient in the PED, put in a consult order for the PICU attending.

If you are sending images to another physician regarding patient care, be sure you have patient and family consent.  Also use Perfect Serve to send the image.  It is HIPPA compliant and time stamped.

Look at your all your xrays.  The radiologist can miss stuff because they don’t know the clinical picture.

Nejak     ED Crowding

ED Crowding is when the number of patients in the ED put such a strain on resources that ED care for patients is hampered or limited.

One thing we can do to improve patient throughput is to order antibiotics as soon as we know we are going to give them. 

Elective surgeries at the beginning of the week have been identified as an important factor in ED crowding.  Some are advocating 24/7 work culture for all areas of the hospital not just the ER and ICU’s.  The OR’s could go 24/7 to smooth out the weeks’ workflow.

Consequences of Crowding: Increased LOS, increased LWBS, increased ambulance diversion, increased medical malpractice claims (by a factor of 5 if the patient waits more than 30 minutes to be seen)

Fixing crowding requires an enormous effort on all departments in the hospital.  However, fixing our crowding problem will result in better patient outcomes.

Walchuk     Study Guide Pediatrics

*Bacterial Pathogens by age

*Physiologic vs Pathologic Jaundice

Strep pneumo is the most common bacterial cause of otitis media in children.

Strep throat is very uncommon in kids <3years of age.

*Potts Puffy Tumor

A single CT has a 1:2000 risk in young children for causing a fatal cancer sometime later in life.   A single CT has a 1:5000 lifetime risk of causing a fatal cancer in older children.

*Neonatal acne is most common around week #3.

*Erythema toxicum    Erythema toxicum neonatorum[1] (also known as erythema toxicum,,[1] urticaria neonatorum and toxic erythema of the newborn[1]) is a common rash in neonates.[2]:139[3] It appears in up to half of newborns carried to term, usually between day 2–5 after birth; it does not occur outside the neonatal period.

Erythema toxicum is characterized by blotchy red spots on the skin[4] with overlying white or yellow papules or pustules.[5] These lesions may be few or numerous. The eruption typically resolves within first two weeks of life, and frequently individual lesions will appear and disappear within minutes or hours. It is a benign condition thought to cause no discomfort to the baby.   (Wikipedia)

*Kawasaki’s Disease

0.3mg/kg po of decadron is equally effective as 0.6mg/kg of decadron for croup.  So use the lower dose.

Alexander/Ohl/Einstein      Discharge Pilot Project

We are trying to improve ED throughput. Optimize discharge process. Improve patient understanding and satisfaction.

Main interventions: Click Discharge Home but not Dr. Done.  Print up DC instructions, work note, prescriptions.   MD and RN go together to discharge patient.    After discharge click Dr. Done in the computer.

There was good discussion about this proposed pilot plan. It will begin on Monday 1-11-2016

Conference Notes 12-23-2015

Happy Holidays!  

Lovell       Study Guide     Peds 3

Congenital adrenal hyperplasia:  These kids need dextrose, saline, and hydrocortisone.

Dextrose dosing:  %Dextrosex ml/kg should always equal 50

Adult D50: 50% dextrose X 1ml/kg=50

Child D25:  25% dextrose X 2ml/kg

Neonate/Infant: D10: 10% dextrose X 5ml/k=50

CAH occurs when the adrenal glands do not produce enough cortisol and aldosterone hormones, and instead produce too much of the male-like hormones, androgens.

The overproduction of male-like hormones can affect a baby before it is born. Girls with CAH may have an enlarged clitoris at birth, and may develop masculine features as they grow, such as deepening of the voice, facial hair, and failure to menstruate or abnormal periods at puberty. Girls with severe CAH may be mistaken for boys at birth. Boys with CAH are born with normal genitals, but may soon become muscular, develop pubic hair, an enlarged penis and a deepening of the voice sometimes as early as two to three years of age. The testicles of boys with untreated CAH cannot function well and may not make sperm normally.

Children’s growth also may be affected. Their long bones have growth plates at the ends. These plates allow for growth and eventually “close” when normal adult height is reached. High levels of androgens may cause rapid early growth. However, if these high levels of male-like hormones continue, the growth plates may “close-up” too early resulting in a very short adult.

In its most severe form, called salt-wasting CAH, a life-threatening adrenal crisis can occur if the disorder is not treated quickly. An adrenal crisis can cause dehydration, shock, and death within 14 days of birth. Other forms include Simple Virilizing CAH and milder forms.   (Texas Department of Health Reference)

*Torus Fracture

*Kerion needs 8 weeks of oral griseofulvin.  Don’t I&D this!

*Red Flags for Syncope in Kids.  We also discussed the minimal work up in the ED for syncope is listening for a murmur, check a glucose, and get an EKG.

*Eczema Herpeticum.  This is a complication of eczema.  If you see vesicles where the patient normally has eczema then treat with anti-viral and admit.  These kids usually look somewhat ill.

*Crash and Burn mnemonic for Kawasaki’s(Thanks to John Meyers)

The leading cause of death in sickle cell disease is infection.  Sickle Cell patients have functional asplenia.  Consult with hematology for kids with fever and sickle cell disease.  Get a blood culture and give ceftriaxone.  Some kids with sickle cell disease and fever can go home on a case by case basis if well appearing and OK’d by Hematology.

For sickle cell pain crises don’t give a lot of IVF.  Over-aggressive IV fluids can increase the risk of acute chest syndrome.  If kids can drink then let them just drink.  Elise was OK with maintenance fluids but felt that boluses were not indicated.  In a similar fashion don’t give O2 unless the patient is hypoxic.

*MEmnemonic for Salter Harris Fractures

Christine made the point that on a recent EMRap podcast, there is a growing sense that Salter 1 injuries generally do very well and don’t necessarily need a post mold.  Elise felt that it depended on the level of pain and mechanism of injury.  Harwood made the point that Salter 5 fractures are a serious problem for kids.  You don’t want to miss these injuries.  Salter 5 injuries will look on xray like the growth plate is compressed or absent in comparison to the other side.  Kids with Salter 5 fractures will have arrested limb growth and will have assymetric limb lengths making it difficult to walk or use their arms

For hemophiliacs get Factor 8 into them as soon as possible.  Give the Factor before diagnostic studies.  For head injury give 50u/kg to attain 100% activity.   For hemarthrosis give 25u/kg to attain 50% activity.

*Toddler’s Fracture is a spiral fracture of the distal tibia in a toddler.  It is not a fracture of abuse. 

Bonder     M&M

I will not include details of the case to maintain confidentiality.  I will only give the teaching points.

Steroids have never shown any functional improvement in patients with spinal cord injury.  Since 2013 steroids are no longer recommended for spinal cord injury.

Surgery is still indicated for spinal cord injury if there is a possibility of decompression o the cord or stabilization of spine.

It is important to re-evaluate all patients in the ED.  Assess them carefully if they have any new complaints.   Document your re-evaluations in the chart.

Be cautious of cognitive biases that alter your thinking about the patient.  Our normal human responses to patients’ behavior can sometimes cause us to not evaluate them optimally.

McDowell    Thrombolytics in Sub-massive PE

Case: 30yo male with PE.  Patient has enlarged RV on echo.  BP is 110 systolic.  HR is 112.  BNP and Troponin are both elevated.  EKG has signs of right heart strain.

*Definition of Sub-massive PE.  Massive PE has hypotension, shock, or arrest.

*Daniels Score for EKG findings of right heart strain in the setting of PE.

Ekos Catheter is a catheter that goes into the pulmonary artery.  It gives off sound waves that weaken fibrin strands of clot and the catheter also gives intra-arterial thrombolytic in a smaller dose than intravenous thrombolytic.

Back to the case, we discussed the management of the initial patient.  Elise, Erik, and Harwood made the point that there is no consensus on how to manage this patient.  The benefit of thrombolytic treatment is that it prevents post-PE pulmonary hypertension.  This seems to be more important in younger patients who are more active, need towork and have longer lives ahead of them.  However whether you choose heparin, LMWH, TPA, or Ekos catheter  it is on a case by case basis.  Erik felt that for sub-massive PE he would lean toward TPA if the bleeding risk was low.  He would definitely give TPA for massive PE regardless of the bleed risk.  

*Management of PE

Alexander          Pediatric TraumaSafety Lecture

*Children are not just small adults.  It’s worth reading this slide.

We discussed a proposed Pediatric Trauma Protocol with defined roles for EM/PICU/Surgery responders at the Trauma Resuscitation.

There seemed to be consensus that there should be the same number of people responding to Pediatric Trauma Codes every time.  That number of responders should be capable of a maximal response for severe trauma cases.  The team captain can dismiss responders rapidly if the patient is not severely traumatized.   Also there was consensus that assigned roles and assigned locations around the bed were good ideas.

*Trauma Team Assignments

Iannitelli     M&M

I will not include details of the case to maintain confidentiality.  I will only give the teaching points.

Comfort measure for a terminally ill patient who is DNR:  2mg of morphine Q 1 hr PRN dyspnea/tachypnea/respiratory rate >24.

If a patient has a public guardian, call the public guardian to find out about the patient’s medical problems and their DNR wishes. 

Make a copy of the DNR/POLST form and affix it to the patient’s bed.

If you are admitting a patient for Hospice, call the physician who will be writing the admit orders to be sure there will be no confusion about DNR status.

West comment: If you have an elder family member who has specific DNR wishes, have the DNR form on every entrance to the home and on the wall above their bed.

Samir Patel comments:  I always give the family a clear picture of what the patient’s life will be expected to be like for the next six months.  The most common response of families to a patient who will not be independent is to “just make the patient comfortable and do heroic interventions”.

A Healthcare Power of Attorney can overturn a DNR form.

Munoz      Safety Lecture   Medication Errors

Medication errors are the most common type of safety events.

In the ED we have time pressure, multiple patients, patients are strangers, we use high-risk mediations and deal with high risk populations (elderly, pediatrics, pregnancy, comorbidities), and we have multiple distractions and interruptions.   We work in the almost perfect ecosystem for error. 

*Phases of Medication Dispensing

*Errors in Medication Dispensing

Most medication errors occur in the prescribing stage: wrong medication, wrong dosing, lack of knowledge about medication.

Avoid trailing 0’s when writing drug dosing.  It can result in over-dosage.

Conference Notes 12-16-2015

Burt/Paquette      Oral Boards

Case 1.    Patient had carbon monoxide poisoning with an ischemic appearing EKG.  Patient has criteria for hyperbaric treatment.

* Criteria for Hyperbaric Therapy for CO poisoning (#4 from bottom)

Case 2.  68yo male developed V-fib in the setting of  hypokalemia and pneumonia. 

*V fib

Patient was defibrillated to sinus rhythm but remained unresponsive.  Consequently patient needed to receive therapeutic hypothermia.

Elise made the point that the appropriate order of response to V-fib is Ciculation, Airway, Breathing. Circulation first with CPR and defibrillation.  After you address circulation then move to airway with an LMA if needed and then breathing.

Case 3.  24 year old female with foot pain.  Patient twisted her foot while dancing.

 Xray shows pseudo-jones fracture

*Jones vs Pseudo Jones fracture

*Jones vs Pseudo Jones fracture

Shannon Staley MD   ACMC Pediatric EM Faculty       Why Kids are not Small Adults

 Case 1.  22mo with head injury. No loss of consciousness but more fussy since injury.   Child has a frontal hematoma.   Should you scan or not?   It is estimated that around 5000 cases of cancer  may result from the 4 milliion CT scans done on kids per year.   The Choosing Wisely Campaign promotes doing less head CT’s in children for head injury.    Shannon advised using the PCARN guidelines to help make decisions on head-injured children.

*PCARNHead Injury Rule

*PCARN Head Injury Rule    A reasonable observation period is 6 hours from time of injury.

*TEN-4 Bruising Rule.   If you identify any of these types of bruises in an injured child, you need to investigate the injury a bit further to figure out if there was non-accidental trauma.

Case 2.  10 month old male with cough, congestion, wheezing in the winter time.  Diagnosis is bronchiolitis.   The go-to treatment for bronchiolitis is suctioning.   If there is overt wheezing , you can try  4 puffs with an albuterol mdi with a spacer and mask.  If the child improves,  home use is worth a try.  

In hypoxic patients, hi flow O2 is a good option. 

Which kids end up in the PICU?   Children under age 2 with history of low birth weight kids (<5 lbs)  and current RR>70.  Low birth weight kids are more prone to delayed lung development.   For full term kids admit all under 3 months of age for risk of apnea. 

Don’t get CXR on kids with bronchiolitis unless you suspect pneumonia for some reason.  

Give supplemental O2 for Pulse Ox <90%

No need to send PCR testing for RSV.  Testing does not change management.

Case 3. 7.5-week infant with fever to 101.2.     Child looks ok.   WBC is 11.  UA shows signs of UTI.   6.5% of UTI’s at this age will have bacteremia.  2.8% of  febrile neonates with uti will have serious neurologic complications such as meningitis or require intubation.    We had an animated debate about how much of a work up these kids need to have.  Many faculty wanted to do a limited septic work up in such a child with no LP.   However, everyone agreed that 2.8% rate of serious neurologic complications is concerning and makes you think twice that maybe doing an LP is more indicated than we thought.  

Case 4.    Shannon discussed complications of septic joints.  The main point was that septic joint patients can get severely septic and possible die or loose a limb more rapidly than you would expect.  If you suspect septic joint and there will be a delay to joint aspiration for several hours, she recommends giving IV antibiotics to cover MRSA and MSSA. 

Regan/Kennedy/Holland/Cartalano/Omi          Thoracic Trauma

 200,000 Americans die every year from trauma.   50,000 of those are from thoracic trauma.   1/3 of deaths due to thoracic trauma occur prior to arrival to hospital.   Another 1/3 of these deaths occur in the first 1-3 hours after arrival to hospital.  The main causes of early death are aortic injury, cardiac injury/pericardial tamponade, and airway obstruction/aspiration.

Fractures of ribs 1-3 suggest hi energy injury.  Lower rib fractures suggest lung and diaphragm injuries.   Diaphragm can move as high as the 4th intercostal space on expiration.

*Cardiac Box

The most common area of aortic injury is at the take off from heart.  This location of injury is always fatal.   The most common area of survivable aortic injury is just distal to the left subclavian artery because the aorta is tethered there. 

Unfortunately, I was called out for a large portion of this excellent lecture, so the notes are missing a lot of info.  

Harwood Reference:     Blunt Cardiac Injury, Screening for
Published 2012
Citation: J Trauma. 73(5):S301-S306, November 2012

Level 1
An admission electrocardiogram (ECG) should be performed on all
patients in whom BCI is suspected (no change).

Level 2
If the admission ECG reveals a new abnormality (arrhythmia, ST changes,
ischemia, heart block, and unexplained ST changes), the patient should
be admitted for continuous ECG monitoring. For patients with
preexisting abnormalities, comparison should be made to a previous ECG
to determine need for monitoring (updated).
In patients with a normal ECG result and normal troponin I level, BCI
is ruled out. The optimal timing of these measurements, however, has
yet to be determined. Conversely, patients with normal ECG results but
elevated troponin I level should be admitted to a monitored setting
(new).
For patients with hemodynamic instability or persistent new arrhythmia,
an echocardiogram should be obtained. If an optimal transthoracic
echocardiogram cannot be performed, the patient should have a
transesophageal echocardiogram (updated).
The presence of a sternal fracture alone does not predict the presence
of BCI and thus should not prompt monitoring in the setting of normal
ECG result and troponin I level (moved from Level 3).
Creatinine phosphokinase with isoenzyme analysis should not be
performed because it is not useful in predicting which patients have or
will have complications related to BCI (modified and moved from Level
3).
Nuclear medicine studies add little when compared with echocardiography
and should not be routinely performed (no change).

Level 3
Elderly patients with known cardiac disease, unstable patients, and
those with an abnormal admission ECG result can safely undergo surgery
provided that they are appropriately monitored. Consideration should be
given to placement of a pulmonary artery catheter in such cases (no
change).
Troponin I should be measured routinely for patients with suspected
BCI; if elevated, patients should be admitted to a monitored setting
and troponin I should be followed up serially, although the optimal
timing is unknown (new).
Cardiac computed tomography (CT) or magnetic resonance imaging (MRI)
can be used to help differentiate acute myocardial infarction (AMI)
 from BCI in trauma patients with abnormal ECG result, cardiac enzymes,
and/or abnormal echo to determine need for cardiac catheterization
and/or anticoagulation (new).

Pulmonary contusions are treated based on age and severity of contusion.  Dr. Cartalano advised ICU observation, aggressive pain control,  judicious IV fluids, bipap and intubation if needed.  The pulmonary contusion will be at it’s worst on day 3.  If the patient is in distress on day 1 they likely will need intubation to survive day 3. 

Flail chest requires 3 or more consecutive ribs with segmental fractures.  It is problematic mostly for the underlying pulmonary contusion.  Treat the pulmonary contusion as noted above.  There is debate among Traumatologists about the utility of internal fixation of the fractured ribs causing flail chest.

If intubating for thoracic trauma use a lung protective strategy of low tidal volume of 6-8 ml/kg,  and PEEP titrated to maintain oxygenation.

*Lung Protective Strategy

*Needle decompression of tension pneumothorax.  Trauma surgeons also said that if you can’t find a 3-inch catheter, just put in a chest tube if you suspect a tension pneumothorax.

Definition of massive hemothorax is 1500ml of blood into the chest tube initially or 200ml of blood output per hour for 4 hours.  Patients meeting this criteria should go to the OR.

We had a robust discussion on ED Thoracotomy.  Trauma faculty felt that if you are an emergency physician in an ED with no thoracic surgery back up, don’t ever do a thoracotomy.  Even if you can fix the problem with thoracotomy, you need some one to definitively treat the surgical problem.  If these patients get transferred with open chests they won’t survive.  If you have Trauma or Thoracic surgery back-up where you are working then consider following an algorithm such as the one below.

*Decision to Perform ED Thoracotomy

Tekwani/Watts     Research in Residency

Reasons to do research: Confidence builder, opportunities to travel and present your work, networking, career builder.

5 keys to a successful resident project: Start early, brainstorm multiple clinical questions that are interesting to you,  evaluate your ideas using FINER criteria (see below),   find a friend to collaborate on projects with,  create and follow a timeline. Pick an appropriate journal for publication.

Feasible

Interesting to you and the EM community

Novel: Based on literature search

Ethical

Relevant: Does it pass the “so what ?“ test

“Easy” IRB studies are “hands off” studies: chart reviews, education research, meta- analysis, etc.

“Difficult” IRB studies involve potential harm or cost to patients, RCT’s, studies on critically ill patients.

IRB approval not required: QI studies, Case reports, Image submission.

Conference Notes 12-9-2015

Sherman   Joint Pediatric and EM Conference           ENT Emergencies       

Case 1. We discussed a case of a 1.5-year-old child who had stridor after eating some food.    Inspiratory stridor indicates an upper airway obstruction.  With inspiratory stridor, CXR is not indicated.  Dr. Sherman recommended also not placing an IV in the ER in such a child.  He recommended keeping the child calm and getting the child to the OR ASAP.   The management of upper airway foreign body is best performed by ENT and Anesthesia in the OR.

*The pediatric airway is more anterior and superior than the adult airway.   The epiglottis is more floppy.   The occiput is larger.   The vocal cords are higher in a child than an adult.  Based on these differences a straight blade is usually thought to be a better choice than a curved blade to intubate in children.  Dr. Sherman felt whatever blade you are most comfortable with is optimal.  There is also the option of the pediatric glidescope.

If you have to intubate in the ER use a sedative (Ketamine) to keep respirations spontaneous.  Avoid positive pressure ventilation if possible as it may move a FB to a more problematic location.

Case 2.  We discussed periorbital/orbital cellulitis. 

*Orbital Cellulitis

*Chandler Classification of Orbital Infections.  Classes 2-5 require ENT/Ophthomology Consultation

*Pictures of Chandler Classes 1-4.

Case 3.   We discussed neutropenic patients with mucormycosis.   The inferior nasal turbinate is the most common site of findings indicating mucormycosis.   CT is not sensitive or specific for invasive fungal sinus disease.

Case 4.   We discussed a teenage patient who had persistent headache.   There was no improvement of a course of 2-3 weeks despite oral antibiotics.  CT showed mass in the ethmoid sinus and sphenoid sinus.  Patient had chronic allergic fungal sinusitis.

*Chronic allergic fungal sinusitis.  This is usually due to aspergillis.  Patients usually improve with oral steroids and surgery.  They do well in general.

Case 5.    Potts Puffy Tumor is more common in patients that have had prior frontal skull surgery.   We saw six cases at ACMC this year.   One ID specialist feels the increased incidence is due to vaccines selecting out more invasive bacteria in the nose.

*Potts Puffy Tumor

*Potts Puffy Tumor CT

Case 6.  Nasopharyngeal Angio Fibroma is a disease of boys.  They can’t breath thru their nose and have epistaxis.

*Juvenile Nasalpharyngeal Angio Fibroma

Juvenile Nasalpharyngeal Angio FibromaCT

Jamieson/Marynowski        Oral Boards

Case 1.  Adult with drooling and stridor and difficulty breathing.  Diagnosis was adult epiglottitis.   Patient could not be intubated and required cricothyrotomy.   Patient also required IV antibiotics.    Fiberoptic nasal intubation is the preferred approach for intubation in the patient with epiglottitis.

Case 2.   52 yo male hit in the face with a falling tree limb. Patient has left eye pain.  Exam was consistent with retrobulbar hematoma with orbital compartment syndrome  (Elevated intra-occular pressure, loss of vision, and non-reactive pupil) requiring lateral canthotomy.

*Retrobulbar hematoma

*Retrobulbar Hematoma with Orbital Compartment Syndrome

*Lateral canthotomy.  If IOP is above 40 following cutting the superior tendon, the next step is to cut the inferior tendon. 

Steve immobilized the patient’s C-spine appropriately.   He consulted ophthomology and obtained serial IOP measurements.  

Adjunctive therapy for retrobulbar hematoma with orbital compartment syndrome is osmotic therapy with mannitol and carbonic anhydrase inhibitor in addition to lateral canthotomy.

Case 3.  43 yo male injured his right upper extremity when he fell from step stool at work.   Patient has forearm deformity and a small laceration of the distal forearm.   Xrays show a Galeazzi Fracture/DLX.   With laceration you have to consider open fracture and give antibiotics.  Galeazzi fractures need surgical reduction and internal fixation.

*Galeazzi FX/DLX

 Town Hall Meeting

We discussed a number of issues affecting our residents.

ENTWorkshop

The workshop featured multiple stations covering common ENT topics such as epistaxis treatment, FB removal, and peritonsilar abscess management, and much more.

Conference Notes 12-2-2015

Much Thanks to Erin Frazer for Providing Lunch today for the Residents!!   If any attending or graduate would like to purchase a lunch for the residents on any conference Wednesday please contact Rose or the Chiefs. 

Meyers/Htet           STEMI Conference

Case 1. We discussed the management of out of patients who have V-Fib Arrest out of hospital.   EKG on arrival to the hospital shows STEMI.  CurrentLevel 1 Recommendations are  to proceed with urgent Cath Lab activation and therapeutic hypothermia for these patients.  

Now what do you do if the EKG is non-specific?  It has been shown that 31% of patients who are post –arrest and have a non-specific EKG have a culprit coronary occlusion on coronary angiography.   A non-randomized, retrospective analysis of post-arrest patients who go to the cath lab shows they have better survival with good neurologic outcome than patients who did not go to cath lab.  Cardiology comment: This is retrospective data and likely represents selection bias.

*Algorithm for post-arrest patients.   We focused on the risk stratification factors in the central portion of the algorithm.  Most faculty present felt these were reasonable markers of poor prognosis.   Harwood felt that patients with ESRD can sometimes be resuscitated by lowering the potassium level.  He also felt that drug overdose victims could sometimes be saved with ECMO.

Paul Silverman comments:  Even though 31% of patients have a culprit lesion there is no data to demonstrate that coronary angioplasty improves mortality in post-arrest patients.  We are developing a cardiogenic shock protocol for patients who may benefit from a support device in clinical situations such as a drug overdose.   A recent study showed that balloon pumps don’t improve mortality.   We still use them but there is no proven mortality benefit.

The problem with cathingpost-arrest patients is that we can open the artery and stent the artery but these patients don’t recover their brain function and they still die.

If a patient has an arrest, wakes up and has chest pain and a nSTEMI on EKG they may not benefit from emergent cath.   All cardiologists agreed that if a patient had recurrent V-Tach or V-Fib following arrest and they had neurologic function, they would take the patient to the cath lab.   Please talk to the interventional cardiologist and discuss these cases prior to activating a CODE STEMI.  Cooling is very important for all unconscious patients after arrest.

Erik Kulsad comment:  I agree with Dr. Silverman.  It is very ill-advised to base therapy on non-randomized retrospective data.  It is quite common that when these topics are re-examined with a prospective randomized trial the exact opposite results are found.

Case 2.   Patient with chest pain and evolving EKG with signs of posterior MI. Posterior EKG shows STEMI.   Most commonly (85%) posterior MI is due to an RCA lesion.  15% of posterior MI’s are due to a left circumflex occlusion.   Patient had V-Tach and needed to be cardioverted.

*Posterior MI

Be sure to repeat EKG’s in the ED when chest pain is continuing or worsening.  ST changes are dynamic and STEMI can develop over time.   If the patient is going to the cath lab be sure to pre-emptively place the Zoll pads on the patient to be prepared for V-Tach or V-Fib.

Paul Silverman Comment:  In most cases, I would take the patient to the cath lab based solely on the anterior EKG showing posterior STEMI.  If the posterior EKG shows ST elevation that is added confirmatory data but a suspicious anterior EKG is enough to cath the patient.  The only caveat would be maybe to give some nitrates and see if the patient’s pain and ST changes improve. If they do, this could be anterior ischemia/angina rather than posterior MI.

Case 3.   We discussed the difficult decision of taking patients with multiple co-morbidities to the cath lab.  The Cardiology Faculty felt that poor renal function, anti-coagulation, DM, age, cancer all portend a poor outcome including possible renal failure due to contrast administration for the patient.   Cardiology felt it would be totally fine to speak with the interventionalist on call and discuss these complicated cases prior to activating the CODE STEMI.  

Girzadas            M&M

Take home points:

•       Respect Asthma (Common, Deadly, Deceiving).  Patients can present with  typical wheezing and dyspnea, altered mental status, or only cough.

•       Be cautious with non-selective beta blockers (labetalol, propranolol, sotalol, carvedilol, and topical timolol)  These drugs have B-2 blocking effects and can cause fatal bronchospasm in asthmatics.  Topical ophthalmic beta blockers have caused fatal asthma attacks.     Even selective beta-blockers can have an adverse effect on FEV1 in asthmatics.

*Effect of Beta Blocker in Asthma

•       Optimize your communication with patients and their families.  Be sure to discuss your plan for the patient’s care with their family. 

•       Think about your clinical thinking. Beware of  “What You See Is All There Is”  (WYSIATI).  Our system 1 thinking works to make a coherent story out of limited and poor information.  Use your critical thinking (System 2) to calibrate youSystem 1.   To read more about this concept a great book is “Thinking Fast and Thinking Slow”

•       LMA is a bridge device that should be used in a failed intubation scenario to obtain a temporary airway.  You can then intubate thru the LMA or perform cricothyrotomy while you are bagging the patient through the LMA.

•       If you are going to perform cricothyrotomy, don’t over-delay the start of the procedure.  It is a common pitfall to start the procedure too late.

Navarrete         Triage

Reasons for triage:  Prioritize incoming patients, helps with appropriate bed assignment, and provides demographic data.

*ESI Triage system.   The more severe the presentation, the lower the number. 

*ESI Triage System Resources and non-Resources.  The resources in this chart are used to differentiate levels 3-5.

Theresa used the ESI algorithm to work through multiple triage case studies.

Cirone        HIV

HIV is a single stranded RNA that is enveloped.  The virus has a spherical shape.

In 1982 the virus was named HIV.

Mangabies and Chimpanzee’s are the animal reservoirs of the virus.

HIV1 makes up 95% ofHIV cases world-wide.   HIV2 is more prominent in West Africa.  HIV2 accounts for 5% of HIV cases and is more indolent than HIV1.

 AIDS= HIV infection plus CD4 count of 200 or less, CD4T <15%, or an AIDs defining illness.

*AIDS defining illnesses

*CD4 and Disease

The expected period of seroconversion after sexual assault is about 8 weeks.  If a patient has a negative HIV test 8 weeks after sexual assault, they are negative.

The most common presenting symptom of acute HIV exposure is sore throat (mono-type clinical picture)

Michael then discussed his research that he will be presenting at the national CDC Academic Assembly.  He found that ED patients are receptive to HIV testing.  HIV testing does not interfere with ED flow.  They were able to identify patients with HIV infections in the acute phase and also patients with AIDS.

Felder     OB/Gyne

Treatment for chlamydia infection during pregnancy is Azithromycin.

Fetus at 2-8 weeks:  Organogenesis, radiation is teratogenic

Fetus at 8-15 weeks:  Radiation can affect neurologic development

*Radiation exposure from various tests during pregnancy.

*HELLP Syndrome.   Consider this diagnosis in every pregnant patient with RUQ pain after 20 weeks gestation.

*Treatment of ecclampsia

Get a pelvic ultrasound in patients with abdominal pain or vaginal bleeding and a beta-hcg below 1500.   The ultrasound may show an ovarian mass, free pelvic or intra-abdominal fluid.  These ultrasound finding can help diagnose ectopic pregnancy.  If the ultrasound is unremarkable with no IUP then you will need to do serial b-hcg’s and advise the patient about the possibility of ectopic pregnancy.

*Management of Amniotic Fluid Embolism

*Kleihauer Betke Test

* Kleihauer Betke Test Interpretation

Conference Notes 11-25-2015

Shorter version of Conference Notes this week.       Happy Thanksgiving!

Bonder/Gupta     Oral Boards

Case 1.  Pregnant woman presents with abdominal pain.  Patient was worked up with ultrasound and MRI.  Diagnosis was appendicitis.    The WBC count is less useful in pregnant patients due to baseline leukocytosis of pregnancy.

Case 2.  48 yo male with severe back pain and hypotension.   Patient has been taking ibuprofen, norco, and valium for pain without relief.   Patient has history of fever.   Physical exam demonstrated murmur. Diagnosis was spinal osteomyelitis/diskitis secondary to endocarditis.   Management was getting blood cultures, MRI of spine, echocardiogram and treating with IV antibiotics and consulting ID and Neurosurgery.  Harwood comment: Vancomycin and Gentamycin is the recommended empiric combination therapy for native valve endocarditis.

Case 3. 61 yo female with shortness of breath.   Patienthad normal CXR and markedly elevated d-dimer.  CTPE showed sub-massive PE.  Patient wastreated with heparin.

*Daniel Score >8 predicts worse outcome for PE.  More recent study by Shopp, Kline et al.  Says HR>100, S1Q3T3, Complete RBBB, Invert T waves V1-4, ST Elevation in AVR, and Afib are all independent predictors of increased risk of shock and death.

Harwood comment: No need to give O2 to a patient with normal pulse ox.  When you are at ABEM General get the highest-level test.  Just get an MRI if you need it.  ABEM General has every resource.

Paik        M&M  and Asthma Management

John presented 3 cases.  I am not describing the specific cases to maintain confidentiality.

Asthma is very prevalent  affecting greater than 17milion Americans.   There were 1144 reported  in-hospital deaths 2006-2008.

*Risk Factors for Death from Asthma

Management to Avoid Intubation

IV Magnesium

Bipap

Next management tool is Epi IM or Terbutaline Sub Q

Heliox can be used to improve air movement thru bronchioles.

Ketamine can be used for sedation and it also has bronchodilator effects

All the above maneuvers do not have good data supporting their use but all are inexpensive and pretty benign so all are still reasonable moves for severe asthma.

There was a discussion about how to manage a pH <7  secondary to respiratory acidosis in the intubated asthmatic.  Careful increases in minute ventilation with an eye on plateau pressures was the first management move of most attendings present.  Most would not use IV bicarb to alter pH.   THAM would be an option in this situation to manage the pH in addition to increasing the minute ventilation.   Bolus THAM 250ml then give another 250 ml as a drip over 1-2 hours. You have to be sure the patient is making urine so they can clear the THAM.  Hyperkalemia and hypoglycemia are side effects of THAM.

ACMC ED Handoff Protocol

Quiet Environment with limited interruptions

Both faculty and residents sign out together

We follow an SBAR-type format

A record of the handoff is entered in the electronic medical record

We do bed-side handoff for critical care patients

Carlson              Opioids

Opioids are semi-synthetic or synthetic drugs altered from the parent opiate.

Synthetic opioids like fentanyl and methadone and tramadol will not show up on standard drug screens.  They are too dissimilar  of a molecule from morphine for the screen to pick it up.

If a patient is altered, look for and remove their fentanyl patches.  They can be hard to see and forgotten by the patient or nursing home staff.  Andrea had a patient recently who was found to have 5 fentanyl patches.   Fentanyl patches have 10mg of fentanyl total in the patch!   When you remove a fentanyl patch, do not just throw it out.  Put it in a sharps container.

*Opiate Toxidrome :  CNS depression, miosis, bradypnea, decreased bowel sounds

*Non-cardiogenic pulmonary edema is more common in patients who receive naloxone.  Naloxone may increase respiratory drive but not airway tone and patients may develop edema.

46 persons are believed to die every day from prescription drug overdoses.  There are more deaths from prescription drug overdoses than heroin and cocaine overdoses combined.

*Opioid Schedules

* Mu1 receptors cause euphoria,  Mu2 receptors cause respiratory depression,

Kappa 2 receptors cause dysphoria

Andrea suggested observing heroin overdose patients for 4 hours in the ED.  If they choose to sign out AMA, be sure you carefully document decisional capacity.

McDowell      Ketamine for ETOH Withdrawl

Standard protocol is lorazepam first line incrementally increasing.  If lorazepam at or above 6-8 mg IVP is ineffective then next give phenobarb 10mg/kg over 30 minutes.  If the patient is still having severe withdrawl, start a lorazepam infusion 5 mg/hr and titrate up to 30mg/hr.   Suggested as next line treatment is ketamine 0.25mg/kg/hr.

Nejak        Altered Mental Status

*AEIOU  Tips mnemonic

Some stuff you could miss with AEIOU TIPS,  thyroid storm, myxedema coma, adrenal crisis, CO2 narcosis, TTP, CO toxicity, toxic alcohols, ASA overdose, non-accidental trauma, non-convulsant status epilepticus, neuroloptic malignant syndrome, serotonin syndrome. 

Dan Nejak’s recommendation is to use EMR technology to help improve your differential.   He has an altered mental status template built into his documentation files that he can pull up in a chart.

Harwood comment: Vital signs can help you a great deal.  Bradycardia and hypothermia suggest myxedema coma.  ABG’s are a great way to gain rapid critical info on altered mental status patients. 

Christine Kulstad comment:  Beware of cognitive bias in the undifferentiated patient.   Give yourself a cognitive stop and give it some concerted thought.

Holland       ENT Infections

Otitis externa: Treat with pain control and Floxin drops or cortisporin otic suspension.  A wick may be necessary in the ear canal to get the antibiotic into the canal.  Beware malignant otitis externa due to pseudomonas.  MOE is more common in diabetics and immunocompromised patients.  Treat with intravenous anti-pseudomonal penicillin and aminoglycoside.  Also pay close attention to glucose control.

HIV can present with a mono-like pharyngitis.

*Centor Criteria for strep throat

There was a discussion about the management of peritonsillar abscess.  The majority of faculty felt that routine CT was not indicated for all peritonsillar abscesses.   If the patient has palpable fluctuance or ultrasound-identified abscess then attempt to drain the abscess in the ED with a needle.  If you cannot identify a drainable abscess or are unsuccessful draining the abscess, the patient may have peritonsillar cellulitis.  Peritonsillar cellulitis can be treated with IV antibiotics and IV steroids.  Some patients who do not have stridor or drooling can be discharged home with close ENT follow-up.  Dr. Regan noted that we did recently see in the ED a patient with peri-tonsillar abscess that required emergent intubation in the ED.  The larynx was very edematous when visualized with glidescope.  So you have to be a little cautious with who you manage as an outpatient.

Ludwig’s angina has edema of upper neck and floor of mouth.  Patients may have displacement of tongue.  Late signs are drooling and stridor.  With proper antibiotics edema may take up to 1 week to resolve.

Conference Notes 11-18-2015

Garrett-Hauser/Richard JamesChaplain         Religion and Medicine

We discussed the challenges of discussing and respecting religion with patients and their families.  The background for this discussion was based on the article: Religion, Spirituality, and the Intensive Care Unit.  The Sound of Silence.   Balboni, et al. JAMA Intern Med. 2015

Exerpt of Article Review: the authors explore the re-

ligious and/or spiritual thematic content of goals-of-care con-

versations between health care professionals and surrogates

of critically ill patients. Although religion was important to

77.6% of the surrogates, only 16.1% of the conferences in-

cluded any reference to religion or spirituality. Furthermore,

when they did occur, these conversations were initiated by sur-

rogates 65.0% of the time. A health care professional raised

spiritual concepts (eg, spiritual histories) only 14 times (5.6%),

and only 2 of the conferences (0.8%) were attended by a chap-

lain. When surrogates raised spiritual concepts, health care pro-

fessionals’ most common response was to change the subject

to the medical realities at hand. Although empathic re-

sponses were the next most common response, health care pro-

fessionals, in general, “rarely directly addressed surrogate’s

spiritual or religious language.” Only 2 health care profession-

als responded by exploring the patient’s or surrogate’s spiri-

tuality. Notably, for conversations that included religious and/or

spiritual content, various themes were identified, with miracles

being one of several spiritual themes that intersected with medical care

the authors highlight, indicate the crucial need for greater integra-

tion of chaplaincy into ICU care

4,6

and for spiritual care education for health care professionals,

5

including how to integrate

a basic exploration of religious and/or spiritual values into

health care communication.

Our patients and families who face serious illness typi-

cally find themselves in spiritual isolation in the medical set-

ting; their medical caregivers do not hear the spiritual rever-

berations of illness on their well-being and medical decisions.

As with the lonely, falling tree, the reverberations are unde-

niably there. The question remains whether we who care for

dying persons and their families will learn how to be present and listen.

Every spiritual discussion with patients/families is contextual.  You have to make an effort to “know thy patient” and “know thy self”.    Understanding the patient and your self will help you dialogue about religion.   You should try to rise above specific religious boundaries and get to a level of general spirituality.  A key is to make your interaction with the patient an experience of benevolent intent toward them.

You can actually express benevolent intent in a pretty short period of time in the ED.  As a non-medical example, you can tell even when you interact with a cashier for a even just aminute whether or not they are acknowledging and respecting you as a person.

Recognize when patients and families use their religion in unproductive ways.

An example would be a patient refusing surgery for a gangrenous leg and saying God will heal this leg.  You may need to consult a chaplain to help with this type of situation.

A good starter question to discuss spirituality with patients/families would be,

“Is there a particular faith perspective that you use to cope with life’s challenges?”

Harwood comment:  If someone expresses that faith is an important part of his or her coping strategy, I would consult pastoral care to help with the case.   Chaplain Richard James agreed.   The key is to show respect for a person’s faith.

Bamman         Traumatic Hand and Wrist Injuries

*Brief Hand Neuro Exam.

*Ever Briefer Neuro Exam.  All 3 nerves in one movement.

*Fight Bite Injury.   This is a high risk injury.  Give IV antibiotics such as Unasyn or Clindamycin/Cipro if PCN allergic.   GetX-rays to evaluate for fracture and foreign body.  Examine the wound through the full range of motion to identify any tendon injury.  Consult Hand Surgery. 

We had a discussion about nail trephination.  Girzadas suggested doing a digital block or at least discussing options for pain control or making the patient aware of possible pain prior to the procedure.  All the other attendings strongly disagreed and felt no digital block was necessary.   They felt just warning the patient that they may feel a momentary pain was adequate.

Mark discussed finger tip injuries.  All attendings agreed that if the nail is fully intact, don’t remove the nail to go searching for a nail bed laceration.  Only remove the nail to repair the nail bed if the nail has already been partially avulsed or disrupted.

*Thumb Fractures   There are two syllables in Bennet and the Bennet’s Fracture has two fracture pieces.  Rolando has three syllables and has three or more fracture pieces.

*Lunate and Peri-lunate Dislocations.  These need Hand Consultation while the patient is in the ED.  

*Scapho-Lunate Dissociation

*Colle’s Fracture

*High Pressure Injection Injury is a surgical emergency.

Williamson        Study Guide     GI

CT is not indicated for uncomplicated pancreatitis. 

Pancreatitis is considered severe when there is pulmonary dysfunction.

The most common causes of pancreatitis in order from most to least common:   Gallstones, alcohol, idiopathic, hypertriglyceridemia, scorpion bite.

*Ranson Criteria

*Epiploic appendigitis  is due to torsion or inflammation of an epiploic appendage.

Most common cause of SBO is adhesions.

*Olgilvie Syndrome seen most commonly in elderly patients who are ill, have had trauma or surgery.   It usually resolves with NG drainage alone.

*We discussed TXA for Upper GI Bleeding.  A quick literature review found a  Meta-Analysis showing some evidence of  lower mortality in patients who received TXA. 

The most common cause of bacterial diarrhea in patients diagnosed in the ED is Campylobacter.  Faculty all agreed that probiotics or yogurt with active cultures is a useful management tool for patients with diarrhea.

Elise comment:   Pepto-Bismol can turn a patient’s tongue black and can turn their stool black.

Staph Aureus Gastroenteritis:  Mayonaise/potato salad is a common buzz word in questions,  onset occurs within a couple of hours, patients have mostly vomiting,  it is self-limited.  Resolves in a few hours.

*Crohn’s vs Ulcerative Colitis

Most common cause of cancer of biliary tree is cholangio (gall bladder) carcinoma. 

Alexander        EKG Workshop

Ari led the residents thru multiple clinical scenarios of tachycardia with EKG stimuli. 

Elise comment: Regular rhythms (both supraventricular and ventricular)are more easily converted than irregular rhythms so initially use 100J for these regular rhythms.   Irregular rhythms are more difficult to convert so use 200J inititally.

Pharmacist comment: Procainamide is favored over amiodarone for converting stable V-Tach.

Ari discussed a case of SVT in a patient  who was on digoxin and a beta blocker.  The patient was given adenosine and then developed an idioventricular rhythm for a short time before she converted to sinus.  It was pretty terrifying for a few minutes. This may be a risk in patients on other cardiac meds.

Katiyar/Bonaguro   QI     Sepsis

Please pay close attention to the Sepsis Guidelines.    Document the suspected source of infection.    You need to perform/document a repeat physical exam after the patient receives their initial 30 ml fluid boluses.

*Surviving Sepsis Guidelines

*Sepsis Definitions

To document your repeat exam you need to note the following:

Vital signs, heart exam, lung exam, cap refill, peripheral pulse and skin exam.

In our Cerner system if you type in ..sepsis it will pull up a simple templated note that will draw in the vital signs and then you just need to fill in the physical exam.

Abhi and Sheila comments:  Think of sepsis similar to belly pain where you want to get a repeat exam documented in the chart.

The clock does not start toward time targets until there is documentation of  a suspected or confirmed infection in the chart or an elevated lactate is identified.

Conference Notes 11-11-2015

Nejak        Adrenal Crisis and Thyroid Storm

Adrenal Crisis is a life-threatening exacerbation of adrenal insufficiency.  The most common cause worldwide is TB.  The most common cause in the western hemisphere is autoimmune. HIV is another common cause.   The most common cause of secondary adrenal insufficiency is withdrawal of steroid therapy (both oral and inhaled steroids).  Also be aware of post-partum adrenal insufficiency (Sheehan’s syndrome) and post-head trauma adrenal insufficiency.

Adrenal crisis can present with hypotension, altered mental status, abdominal tenderness, hyponatremia/hyperkalemia, hypoglycemia, fever, and hyperpigmentation (hyperpigmentation only with primary adrenal insufficiency).   These are all signs that can be easily attributable to other diseases.  So it is a difficult diagnosis to make.

Treat adrenal crisis with D5.9NS and hydrocortisone 100mg IV bolus Q 6 hours for first 24 hours.  Use pressors as needed.

Thyroid Storm presents as hyperthermia, tachycardia, and altered mental status.

*Diagnostic Scoring for thyroid storm.  There was a discussion that this scoring system may have difficulty differentiating sepsis and thyroid storm.

*Treatment of thyroid storm.  Dan recommended: IV fluids, cooling, PTU followed Iodine, esmolol drip, steroids, and cholestyramine.  Cholestyramine interrupts enterohepatic circulation of thyroid hormone.

Parker          Pearls from Podcasts

Braden played an excerpt of “This American Life” podcast describing a haunting of a house.  This description was reported in a 1921 case report in the Journal of Ophthalmology.   The experiences  (strange sounds, visions, tactile sensations)the family had were due to CO toxicity in the house.

CO toxicity can present with headache, nausea, and a myriad of other nonspecific symptoms.   You have to have a high index of suspicion for CO toxicity especially in the cold weather months when people are using their furnaces. A CO level over 9% is indicative of CO poisoning. Use to the finger probe device to check the level.  It is accurate and painless.   Treatment is O2 and consider hyperbaric O2.    Andrea comment:  Headache is usually present with CO poisoning.  In the winter ask the patient if other people in the house are also having headaches. CO toxicity will affect everyone in the house.

SMARTEM Podcaston who needs LP to identify SubArachnoid Hemorrhage.

CT negative/LP positive SAH are aneurysmal and amenable to neurosurgical intervention.  The problem is identifying these patients.

*SubArachnoid Hemorrhage

Using CTA to screen for aneurysmal hemorrhage are problematic because 3% of the population have asymptomatic aneurysms that don’t require intervention. 

Doing an LP with every bad headache is also problematic.  It is estimated you will have to do  about 1500 LP’s to identify 1 patient who has a negative CT and a SAH due to aneurysm that is amenable to clipping.

Only 20% of SAH have sentinel bleeds.  If the sentinel bleed is missed the patient’s subsequent morbidity and mortality is 45%.  If the diagnosis is made at the tiem of the sentinel bleed,  the patient’s  morbidity and mortality is marginally better at 33%.

CT is very sensitive (99%) for picking up SAH within 6 hours of headache onset.   After 6 hours the sensitivity drops to 86% .  The other factor is that patients who present after 6 hours from the onset of headache have half the risk of SAH compared to patients who present within 6 hours of onset of headache.

Basically a negative CT within 6 hours of onset of headache effectively rules out SAH.   If the patient presents after 6 hours of onset of headache and the CT is negative, look for high risk features that would increase a patient’s risk and use shared decision making with the patient  to decide whether to do the LP.

Elise comment: Be careful.  This can be a tricky diagnosis.  If you are worried do an LP.   Harwood comment:  Be alert for the thunderclap headache.  If the patient reports that the headache became maximal within one hour after onset, that is considered a thunderclap headache.  There are a lot of urban legends about LP’s and patients in general will choose not to have an LP.  If you want to work the patient up further and they are refusing LP you can skip to CTA.  There is however a risk of finding asymptomatic aneurysms as noted earlier.   Girzadas comment: I recall a patient with a severe headache who had a negative CT and LP but still had a really bad headache. We next did a CTA and found an intracranial carotid dissection.  Be aware that this diagnosis is also lurking out there.  If the patient looks bad and the ED work up is negative use your tools to keep looking (neuro consult, CTA, MRA, etc.)

*Carotid dissection

Munoz     Pediatric Rashes

*Roseola   Fever usually starts after fever goes down.  Kid is usually happy.  Can be associated with febrile seizures.

* Pityriasis Rosea   Thought to be due to virus.  Can be mildly pruritic.  Has a larger herald patch.  Can last 2-3 months.

*Chicken Pox   Pruritic vesicles in various stages of evolution.

*Measles

*Scarlet fever    Due to GABS. More common under 10 years old.  Sandpaper feel to the rash.

*Pastia Lines of Scarlet fever and Sandpaper texture

*Rocky Mountain Spotted Fever

*Erythema Chronicum Migrans Rash of Lyme Disease

Urumov/Navarette     Oral Boards

Case 1.  39 yo male with history of HIV presents with altered mental status. Exam shows evidence of Kaposi’s sarcoma on the skin.  LP studies are positive for india ink and cryptococcal antigen.  Treatment is active rewarming, IV anti-fungal therapy (Amphoterecin B and flucytosine).  In immunocompromised patients always do a CT prior to LP to identify an potential mass lesions.  The cryptococcal antigen study is more sensitive than an india ink test.  You need to do that test on all HIV patients with altered mental status who you tap.

Elise comment: You have to know to do CT/LP and crypto antigen studies in HIV patients who have headache or have altered mental status.  Prior to LP, do CT with and without contrast to look for ring enhancing lesions.  If the patient has Cryptococcus and their opening pressure is high you need to remove fluid to lower ICP.  Harwood comment: You can fill your LP tubes to take off fluid.   No one knew the exact amount of fluid to take off but most felt thatif you took off 20-40 ml that should help a lot.

“CSF pressures should be reduced by therapeutic CSF removal when the opening pressure exceeds 250 mm H2 O. Following removal of CSF, the closing pressure should be less than 200 mm H2 O or at least 50% of the elevated opening pressure.  Medscape Reference”

Case 2.  68 yo female with headache and vomiting.  Patient became ill whe she attended a movie with her husband.   On exam patient is found to have one eye with a poorly reactive pupil and elevated intraocular pressure.  The diagnosis is acute angle closure glaucoma.

*Angle closure glaucoma

*Angle closure glaucoma treatment

Case3.   14 month old child who abruptly started coughing while playing.  No fever or URI symptoms.   CXR shows coin in esophagus.

*Coin in the esophagus (at the clavicles, george washington facing forward).   To be honest, I could not find a picture of a coin in the trachea (coin sideways, overlaying trachea).  It must be pretty rare.  The coin size must not fit thru the chords readily.  Tracheal foreign bodies probably have to be generally smaller than a coin.

ENT usually removes a FB lodged in upper esophagus and airway.  GI usually removes FB’s lodged in the lower esophagus.

Kristen Dibenedetto     Labeling Specimens

Bring the lpatient labels into the patient room prior to obtaining the sample or doing the procedure. Verify that the label matches the patient.  Ask the patient their name, then look at their wrist band.  Check that their name, birthdate, and medical record number all match the labels you have in your hand.  

Be sure you put your initials, date, and time on the label at the bedside. 

Lastly when you put the specimens in the specimen bag at the bedside say out loud the last three numbers of the MR number and match them to the patient’s wrist band at the bedside.

We wrapped up with a robust discussion about the difficulties with patient labels in the ED.

Tekwani       Study Guide   GI

Acute cholangitis: Fever/Pain/Jaundice=Charcot’s Triad.   Add in hypotension and altered mental status and that=Reynold’s Pentad.    Most common causative organisms are ecoli and other gram negatives.

Spontaneous bacterial peritonitis is identified by ascites fluid showing WBC>1000 or polys >250.  Enterobacter is the most common causative organism.   Treat with Rocephin or Zosyn.

*Acetaminophen metabolism pathway.  Acetaminophen overdose is the most common cause of liver failure in the US.

*Amebic Liver Abscess

Amebic liver abscess is caused by entamoeba histolytica.  E histolytica exists in 2 forms. The cyst stage is the infective form, and the trophozoite stage causes invasive disease. People who chronically carry E histolytica shed cysts in their feces; these cysts are transmitted primarily by food and water contamination. Rare cases of transmission via oral and anal sex or direct colonic inoculation through colonic irrigation devices have occurred. Cysts are resistant to gastric acid, but the wall is broken down by trypsin in the small intestine. Trophozoites are released and colonize the cecum. To initiate symptomatic infection, E histolytica trophozoites present in the lumen must adhere to the underlying mucosa and penetrate the mucosal layer.

Liver involvement occurs following invasion of E histolytica into mesenteric venules. Amebae then enter the portal circulation and travel to the liver where they typically form large abscesses.

The right lobe of the liver is more commonly affected than the left lobe. This has been attributed to the fact that the right lobe portal laminar blood flow is supplied predominantly by the superior mesenteric vein, whereas the left lobe portal blood flow is supplied by the splenic vein.   Medscape Reference.

*Hepatitis B Serology:  HBS AG is on the surface of the virus.   HBS AB is the antibody to HBS AG.    HBC AG is in the core of the virus.  HBCAB is the antibody to the core.  HBE AG is the degredation of the core and only seen in acute infection.   Anti-HBC IGM is also only seen in acute infection.

Irritable Bowel Syndrome pain is relieved by defecation.

Large bowel obstruction is most commonly caused by malignancy.

Most common cause of massive lower GI bleeding is diverticulosis.

For the diagnosis of pancreatitis, amylase and lipase have similar sensitivities but lipase is more specific.  So most clinicians order a lipase and pass on the amylase.

Toxic megacolon is more common in ulcerative colitis.  Ulcerative colitis almost always involves the rectum.  Crohn’s disease more commonly has peri-anal involvement.

Hart     Safety Lecture

We discussed issues with safe disposal of sharps.

If you identify that a sharps bin is full and needs to be replaced, call EVS at 41-5958 and they will come and replace the bin.

Do not try to force sharps into a full sharps bin.  Call for a replacement bin or carry your sharps carefully to another bin.   We discussed the possibility of having a large sharps bin on wheels that we could move to where a procedure is performed in case there is not an easily available, not completely full sharps container.

Don’t recap needles.  If you do recap a needle, use a one-handed technique.

To more easily dispose of a guide wire, you can coil up a central line guide wire with the rubber band that you used for the ultrasound probe cover.   Christine comment: Alternatively you can use the plastic guidewire sheath to replace the wire.

Conference Notes 11-4-2015

Barounis     Septic Shock

Early intervention in the ED affects the trajectory of sepsis illness throughout the hospital course.

The mortality rate of septic shock is still @20%.  Death from sepsis is due to multi-organ dysfunction syndrome.  Early intervention can prevent the development of multi-organ dysfunction syndrome.

There has been no single clinical intervention that has been shown to improve mortality from sepsis.  However, sepsis mortality has decreased over the last decade.   This is likely due to earlier diagnosis and more attentive care of sepsis patients.

SIRS criteria are insensitive for identifying all sepsis patients. There is no definitive biomarker to identify sepsis.  Clinical evaluation and judgment are the best tools to identify sepsis.

Encephalopathy=acute brain failure.   It is a sign of sepsis.

Other signs indicate sepsis: Hypotension, tachycardia, oliguria, acute brain failure, poor peripheral perfusion, acidosis, and respiratory distress.

The management of hypotension is an emergency.

In all large RCT’s on sepsis the average volume of fluid that a septic patient received was 4 liters.  Most septic patients will likely need somewhere close to that volume over the first day or so.

Dave showed an echo in which the LV was hyper-contractile with the walls of the LV “kissing” in systole.  If the walls of the LV are touching in systole, the patient is likely hypovolemic or severely vasodilated.

You have to trend lactates every 4 hours in septic patients.

Chloride (normal saline) is a renal toxin and has been shown to increase the incidence of AKI in septic patients. Dave prefers LR because it is safe and more physiologic.  LR has potassium in it but it is still OK in patients with hyperkalemia.  

Dave made the point that in a recent study, healthy volunteers receiving 2 liters of NS had a transient decrease in their GFR.  Elise comment: I am not so worried about NS in a patient who needs 1-2 liters.  If a patient needs 3 or 4 or 5 liters you need to be giving LR. 

Dave’s first-line pressor is norepinephrine.   If a second pressor is needed he uses vasopressin.  If you have not corrected hypotension with these two pressors you need to take cognitive stop and say to yourself,  “What the heck is going on?” 

Motzny Study GuideEMS

 Unfortunately I missed the majority of this excellent lecture.

Bioweapons

View fullsize

Acute Radiation Sickness.   Most commonly noted indicator of poor prognosis is low total lymphocyte count on CBC.

Set up your cammand center for a HAZMAT response up-wind and up-hill.

The most common barrier to an effective disaster response is problems with communication.

Nejak   Oxygen Delivery

Dan did an awesome job discussing and demonstrating various oygen delivery devices available in the ED.

April Kennedy/Felder/Urumov     Dental Procedure Lab

Much Thanks to April Kennedy DDS for leading an outstanding dental procedure lab!

Conference Notes 10-28-2015

Htet/Meyers   STEMI Conference

Case 1.  Patient with chest pain.

*Initial EKG

Cardiologist comments: It is unusual to have isolated V1 and V2 ST elevation without ST elevation in the other precordial leads.  If the ST elevation in V1 And V2 is related to proximal LAD occlusion it should also affect the other leads.  EKG also shows IRBB and RV strain.  It is also unusual for a STEMI to be bradycardic if it is not an inferior STEMI.

It was learned that patient had history of chronic aortic dissection and prior PE.  Patient was taken to the cath lab and a Type A aortic dissection was identified.

There was discussion of the risk of double dye load for CTA followed by coronary angiogram.  Dr. Silverman said that even if you take the patient to cath first without CT chest, the patient would still get about the same dye load for an aortic root shot followed by evaluation of the coronary arteries.   An alternative approach could be TEE for a patient with an elevated creatinine.

Dr. Silverman noted that pain from aortic dissection is more abrupt then that for AMI.

There was a discussion about the use of d-dimer to evaluate for aortic dissection.  Cardiology faculty was relatively  pro d-dimer for this indication.  EM faculty was more cautious about d-dimer in this setting.   Harwood and Elise felt d-dimer will miss about 5% of aortic dissections. Al-Kaled stated that if an elisa d-dimer is negative the patient does not have a dissection.  Drs. Harwood, C. Kulstad and Lovell almost had dissections of their own in response to this statement.  They felt the data shows that D-dimer can miss intramural hematomas/dissections.  Clearly this issue is controversial.

IRAD data on Aortic dissection shows that “classic” history and physical findings are not commonly present.

Elise comments and data: To be "low risk", you need a score of zero, meaning none of these features.  The patients I'm considering dissection in are usually patients who have abrupt, ripping, tearing pain, and therefore will not be "low risk".  Lower end of likelihood ratio 96%.  As Harwood said, not a disease to accept a 4% miss rate, and with the additional issue of low specificity, I'm not a fan of using d-dimer for diagnosing aortic dissection.

*Aortic Dissection Decision Rule

Cardiology comment: If patient has a pericardial effusion on echo in the setting of chest pain think aortic dissection.

Consensus by cardiology: Do a CTA if you consider aortic dissection.

Case 2.  Chest pain in a patient with recent stroke.

EKG

If you see a heart rate of 150 consider A-flutter.   If you see an RSR pattern in addition to a heart rate of 150 that makes A-flutter even more likely.  

CXR shows very prominent right pulmonary artery.  Bedside US showed dilated RV.  CTPE done and showed PE.

2.Massive vs. Sub-Massive PE

EKOS catheter was placed in pulmonary artery and TPA was given over 12 hours.

* EKOS catheter

*Ekos Catheter

Cindy Chan Follow Up Comment: Cards in PE management: The cardiologists have expressed willingness to assist with management of sub-massive and massive PEs, as many of them are credentialed to use the EKOS catheter.

- "On hours" 7a-7p: can call the on-call interventionalist for MASSIVE or SUB-MASSIVE PEs, as either they may be credentialed or should be able to get a partner who is help with this

- "OFF hours" 7p-7a: can call the on-call interventionalist for MASSIVE PEs to see if they are credentialed to assist; if not, then continue with our "traditional" course of management. SUB-MASSIVE PEs should be able to wait until the morning, when cards can be contacted if needed.

Iannitelli/Katiyar    Oral Boards

Unfortunately I missed this excellent lecture.

PharmD Lecture      Push Dose Pressors

Phenylepherine is the only drug at ACMC approved for bolus therapy.   It is a pure alpha agonist with rapid onset and short half life.

Avoid phenylephrine in patients who are bradycardic.  You could possibly cause worse reflex bradycardia.

ACMC Recommendation: 0.5-1ml (50-100mcg) of phenylephrine every 2-5 minutes.  Can be used in the peri-intubation period and peri-code period. 

Christine comment: Dopamine is universally available and is likely safer in an emergent situation.  You and your nurses are less likely to make a dosing mistake with dopamine than with phenylephrine.  The fail-safe way of giving emergent pressors is to just start a dopamine drip.

Mike Kennedy: Epinepherine could be used as a push dose pressor as well.  PharmD response is that there is no data on using epi as a push dose pressor.  It is not approved by our P&T Committee for push dose pressor use. 

Elise comment: I don’t use push dose pressors.  If I am resuscitating the patient in the peri-intubation period I will start a drip ofnorepi.  The only time I use epi in a push dose situation is for anaphylaxis.

There was a discussion of what the ultimate aim of push dose pressors.  You are just increasing BP transiently and not treating the underlying problem.  On the other hand, there is a growing chorus in the EM world about using push dose pressors in the peri-intubation period for very unstable patients ie. “Resuscitation before intubation”.  The patient oriented outcomes for this treatment will need to be studied further.

Urumov/Girzadas    Recruiting Season Update

A. Patel     Study Guide

Unfortunately I missed this excellent presentation.

Conference Notes 10-21-2015

Remke/E. Kulstad     Oral Boards

Case 1.  30yo male fell into the sand and surf while body surfing.  Patient has neck pain and paralysis of extremities.  Patient has decreased rectal tone and priapism.   C-spine x-ray shows compression fracture of C5 with bilateral facet dislocation.  Because patient had a C5 fracture and shallow respirations, he was intubated.   The patient developed hypotension and bradycardia due to neurogenic shock. Neurogenic shock  was treated with IV fluids and pressors.   Steroids are no longer indicated for spinal cord injury.  The patient was kept in C-spine immobilization.  Neurosurgery was consulted.

C5 Fracture and likely bilateral facet dislocation

Case 2. 12 yo male with left hand pain after having a stingray barb impaled into the dorsum of the left hand.   X-rays show no bony involvement.   Hot water therapy was initiated which greatly relieved pain.  The toxin of a stingray barb is exquisitely heat sensitive.  Hot water will significantly diminish pain.  The barb was then removed with trimming the end off and traction.

*Stingray Barb

Case 3. 22yo female passed out on the beach.  Temp=41.5C,  HR=136.    The patient had been playing volleyball and running on the beach in hot weather.  On exam, patient was confused and lethargic.  Skin is warm and dry.  (Three keys to heat stroke diagnosis: Temp >41, dry skin, mental status changes) Rapid cooling was initiated. Goal of cooling is 39C.  CPK was 9000 indicating rhabdomyolysis.  Aggressive hydration was initiated to treat rhabdomyolysis.   Avoid antipyretics in heat stroke because both liver and kidney are considered injured and may be very sensitive to acetaminophen and ibuprofen. 

Elise comments: A pulmonary function assessment (NIF) can be useful to assess respiratory strength in a c-spine injured patients.  

Look for any source of hemorrhagic shock in a trauma patient before you attribute hypotension to neurogenic shock. 

Treat slimy beach envenomation’s (jelly fish) with vinegar.   Treat sharp/pointy envenomation’s (stingray barbs) with hot water.   It’s actually not that simple but for test taking purposes it is pretty good rule of thumb.

Chan    Study Guide          Genitourinary Emergencies

2015 CDC Chlamydia Treatment Guidelines

2015 CDC Gonorrhea Treatment Guidelines

Before placing a foley in a patient with suspected urethral trauma, perform a retrograde urethrogram if you see blood at the meatus, a scrotal hematoma, or high riding prostate.   If you see none of these signs, gently try to place a foley.   If a foley is placed successfully, it acts as a stent  for the injury and should remain in place.

Pregnant women with asymptomatic bacteruria should be treated.  Asymptomatic bacteruria increases a pregnant woman’s risk of pyelonephritis.  Pregnant women with bacterial vaginosis either symptomatic or asymptomatic should be treated.

Testicular torsion has 96% salvagability in the first 6 hours.   

Detorsion attempts should turn the affected teste medial to lateral (opening the book).  Get the patient to surgery within 6 hours from onset of pain.

Opening the Book.  Medial to lateral detorsion attempt

*Ultrasound of torsed teste on right.  Left teste has normal flow.

90% of kidney stones smaller than 5mm will pass within 4 weeks.

5. *Kidney stones most commonly get lodged at these 3 locations: Ureteropelvic junction,  mid-ureter at pelvic brim,  and at the ureterovesicular junction.

Elise comment:  There are some downsides to Flomax in the elderly.  It can cause postural hypotension.   The newest interpretation of the data is that Flomax is most helpful in larger, upper tract stones.  Flomax is less efficacious for small stones far down in the ureter. 

Andrej Reference:

Quote from EM:RAP summary: December 2014:
Vincendeau, S et al. Tamsulosin hydrochloride vs placebo for management of distal ureteral stones: a multicentric, randomized, double-blind trial. Arch Intern Med. 2010 Dec 13;170(22):2021-7. PMID: 21149761.

This is probably the best study available: multicenter placebo controlled, randomized and double-blinded. They found no difference in expulsion rate (77% versus 71%) and no difference in the days to expulsion. They concluded that there was no benefit for small distal stones less than 7mm.
 

6. *Phimosis vs Paraphimosis    Para=Around,   so a paraphimosis means the foreskin is retracted around the penile shaft.  Paraphimosis needs to be reduced emergently.  Options include: manual compression and reduction, osmotic agents, traction with forceps, puncture techniques, and dorsal slit procedure.

Parker     M&M

Case left out to protect confidential information.  Take home lessons will be discussed.

If a central line is in a questionable location on CXR, you can use the “bubble test” to verify that the line is in a vessel that communicates with the RA.   To do this you rapidly inject saline while visualizing the RV on ultrasound.  If the line communicates with the RA, you will see turbulence in the RA with rapid injection of saline into the line. 

7.  *US of RA showing turbulence in the RA with rapid injection of 10 ml of saline.

You can also use ultrasound to visualize the guide wire in the IJ, RA, or RV prior to dilating your access tract.  To improve your visualization of the wire, use your finger to compress the vessel near the US probe.  You should be able to see the wire move on US. 

Elise comment: In all lines no matter how well they went, for patient safety, I recommend visualizing the wire in the IJ with ultrasound prior to dilating the vessel. 

Braden also discussed a technique of placing the angiocath in the central line kit over the wire without dilating the tract.  Then hooking up plain IV tubing or the wire holder in the central line kit to the angio cath to see if blood tracks up the tubing more than a few centimeters.  If it does you likely have entered an artery. 

You can use an ABG to detect the location of your line.  You need to draw an ABG from both the line and the radial artery and compare them.  This method can be problematic if you inconclusive results or you get some venous blood on the radial stick.

If you do inadvertently place a catheter in the carotid artery, don’t pull it out.  Call vascular for their consultation.  Pulling the line without surgical control can cause large hematomas, CNS events, and airway issues.

If you puncture the carotid artery with the needle but don’t dilate or place a catheter in the vessel, you can just pull out the needle and hold pressure for 15 minutes.  Needle puncture of the carotid is less problematic than dilating and canulating the vessel.

Ophthalmology Lab

Thank you to the Chiefs and Faculty for this outstanding workshop!

Conference Notes 10-14-2015

Special thanks to guest scribe Dr. Elise Lovell!

Conference Notes 10.14.2015

8 am:  Oral Boards:  Harwood vs. Paik

Case 1:  20 month female with abdominal pain/vomiting.   Lead poisoning:  Look for neuro sx, GI sx, hematology.  May show up as radio-opaque flakes on KUB.  CBC with basophilic stippling.  Lead levels useful.  Need to notify Health Department, call Tox Consult, remove from source, assess other kids.  Treatment Dimercaprol (BAL) IM, followed by Ca Na2EDTA.

Case 2:  20 yo male unstable Transmediastinal GSW. Need Echo, CT Chest, potentially bronch/esophagus.  Codeà ED thoracotomy; Shock/>1500 Chest Tube output immediately or 200 cc/hour for 3 hoursà OR; Stableà workup.

Case 3:  30 day female, ALTE:  Pertussis.  Reason for apneas in neonate:  bronchiolitis (RSV or influenza), pertussis.  May have 6 weeks of cough.  Treat with macrolide, exposures to be treated as well.   Diagnosis with PCR.  Admit if apnea, seizure, pneumonia, age <4months, respiratory distress, poor feeding.  Immunize!

9 am:  Radiology-Head CT West and Ede:

Use systematic approach:  “Blood Can Be Very Bad” = blood, cisterns, brain, ventricles, bone

Bleeds:

Epidural hematoma, lentiform, does not cross suture lines.  Usually arterial (middle meningeal classic).  May have lucid interval then decompensate.

Subdural hematoma, crescent shape, does cross suture lines, usually venous, may be indolent, with non focal neuro exam.

Subarachnoid hemorrhage; Hunt and Hess classification, 75-80% aneursymal, CT excellent sensitivity within first 6 hours then drops off.

Intracranial hemorrhage, hypertensive -> basal ganglia.  

Ischemic CVA:  often negative CT in first hours of presentation.  Look for hypoattenuation/sulcal effacement, blurring of basal ganglia in MCA infarcation, dense MCA sign (clot in MCA), insular ribbon sign-hypodensity and swelling of insular cortex.

Infections:  in meningitis CT before LP if AMS, focal neuro deficit, seizure, concern for mass (malignancy, papilledema).   Viral encephalitis CT usually normal initially, think about temporal changes for herpes.

Herniation:  6 types.  

9:30 am:  Syncope Lee:

Is it really syncope, or is it seizure , vertigo, etc?

Is it isolated primary syncope or is there an underlying cause (secondary syncope-cardiovascular, neurology, medication related)?  Be more worried if no prodrome symptoms (drop attack), or if exertional syncope.

History and physical, including PMH,  are key to identifying the cause.

In the young, think about dysrhythmia, seizure, pregnancy, blood sugar/electrolyte/volume status, bleeding/anemia.

Hypertrophic cardiomyopathy (LVH + Q waves)

Brugada (incomplete RBBB + downsloping ST segment)

WPW (delta wave + short PR)

Arrhythmogenic Right Ventricular Dysplasia (epsilon wave-upright wave, looks like an Osborn wave in a normothermic patient)

Who can go home?  Low risk factors:  primary syncope without concerning historical factors, age <50, no h/o CV disease, normal exam, normal ECG

San Francisco Syncope rule:  H/O CHF, Hct<30%, abnormal ECG, SOB, SBP < 90.  Careful-initial sensitivity of high 90s hasn’t held up well in other studies, but need to apply in correct population...a patient with a SAH would be low risk by this rule.

Rose syncope rule adds BNP,  low O2 sat, in order to increase sensitivity.

None of the many rules are terrific....

CT extremely low yield-don’t do it unless high suspicion for CNS etiology, or if on anticoagulants, or if unwitnessed and old.

Can’t miss diagnoses?  PE, SAH, Aortic dissection, AAA, ectopic pregnancy.

10:00 am:  Toxicology Carlson:  Aspirin toxicity

Shows up in variety of products (arthritis meds, IBD meds)-beware of combination products and brand names such as BenGay, Peptobismol, Alkaseltzer!

Enteric preps unpredictable absorption.

Low Volume of Distribution (good for dialysis) and high protein binding (bad for dialysis but can affect this by changing pH). 

Pathophysiology/Clinical presentation:  Key ABG:  respiratory alkalosis + metabolic (lactic) acidosis.  Will see hyperventilationàstimulates resp. center in medulla.  Also stimulates vomiting center, causing GI loss of potassium.  Uncouples oxidative phosphylationà metabolic acidosis and fever.  Hypo or hyperglycemia.  Relative CNS glucopeniaàadds to AMS.  Direct ototoxinà tinnitus.

Single OD: 

Mild: Tinnitus, N/V, hyperventilation hyperpyrexia

Intermediate:  Agitation, dehydration, acid/base problems, non-cardiogenic CHF

Before they die:  Lethargy/coma, hyperthermia, cerebral edema, seizure, oliguria, hypotension.  A death from salicylate poisoning is a CNS death-watch their mental status!

Much less predictable symptoms with chronic OD, associated with delay in diagnosis, have higher CNS burder, more common in elderly, greater morbidity at lower levels.

Intubation-Keep Respiratory Rate High!!  Avoid iatrogenic acidosis.

Treatment: 

Charcoal-absorbs aspirin very well.  Skip it if > one hour or if already symptomatic.  Multiple dose no longer recommended.

IV Bicarb/urine alkalinization for ion trapping (bound vs unbound salicylate).  Need to be sure to supplement potassium!!  Body will resorb potassium if low, and waste HCl, so urine will stay acidotic unless potassium replaced.  Follow urine pH, not ABG. Goal of urine pH > 7.5.

Dialysis!!  If AMS, ARDS/CHF, failing standard therapy, pH , 7.20, level >90 mg/dl.  In chronic, symptoms trump level.

11:00 am:  ENT/Epistaxis:  Alexander

Assess if blood thinner use/predispositions for severe bleeding.  Consider CBC, coags.  Anterior= more common.  Posterior=more serious. 

Anterior:  Kiesselbach’s plexus, often secondary to mucosal dryness, conservative measures to manage

Posterior:  look at back of throat, often elderly patients with inherited or acquired coagulopathy.  More challenging to control.

Treatment:  ENT box!  Get afrin, viscous lidocaine.  Ask patient to blow nose, expel clots, in order to help vasoconstrictors to work.  Direct pressure with fingers or 2 tongue depressors taped together for 10-15 minutes.  Good lighting-use nasal speculum.  If no anterior source visualized, consider posterior bleed.  Use Frazier catheter as needed.  Consider silver nitrate cautery if you see specific source of bleeding, cauterize around the bleeding site.  Be prudent-can cause septal perforation.  Thrombogenic gels and foams can help.  Tranexamic acid (antifibrinolytic) can be used as topical application of injectable form. 

Packing:  Rapid Rhino balloon-soak balloon in water for 30 seconds before insertion.  Blow up with air.  Insert parallel to floor of nose.  Alternative preformed sponge-Merocel.  Consider coating with bacitracin ointment.  Wet with saline AFTER insertion.  For posterior pack, consider parenteral analgesics.  Inflate posterior balloon first, then anterior balloon.  Use minimal inflation necessary to control bleeding-can cause nasal necrosis!

Ant/Post balloon packing:

Antibiotics (Keflex) to help prevent sinusitis/toxic shock syndrome.

Admit if posterior packing required (airway obstruction, apnea, hypoxia, syncope/cardiac dysrhythmia possible).

Failed management-call ENT, may need embolization.  Also “greater palatine foramen block” with 2 cc of lido + epi.  Dr. Sherman hasn’t done it, so beware...

11:30 am:  Pulmonary SG:  Lovell

Primary spontaneous pneumothorax-if stable, consider treating with aspiration +/- Heimlich valve catheter, regardless of size of PTX.  They usually don't need chest tubes!

Tuberculosis

•Primary infection (usually asymptomatic, infrequently pneumonitis)

•Latent (+PPD, Ghon complex on CXR reflecting healed primary)

•Immunocompetentà5% risk of progressing to active disease within 2 years, 10% lifetime risk

•Reactivation-fever, night sweats, hemoptysis, weight loss

HIV-most common cause of pneumonia is Streptococcus pneumoniae.  Pneumonia in HIV associated with high rate of bacteremia.  Pleural effusions are common.  Think about TB with CD4 counts 250-500 (not just seen in low CD4 counts).  If pneumothorax, think PCP.

High risk factors for lung CA:  male, smoking, age > 40, no lower resp. infection symptoms.  If abnormal CXR or high risk factors or active bleeding, needs CT + bronch.

Pleural effusions:  transudate vs exudate

Exudate if:

•Pleural fluid /serum protein > 0.5 or

•Pleuralfluid /serum LDH > 0.6 or

•Pleural LDH > 2/3 upper limit serum LDH

Asthma and pregnancy:  Beware of CO2 retention!  During exacerbation, normal alkalosis of pregnancy is aggravated, leading to decreased placental blood flow.  Hypoxemia is usually more severe in fetus than in mother.

•PaO2 < 70 = severe hypoxemia

•PaCo2 > 35 = respiratory failure

•B2 agonists, inhaled and oral steroids all safe

Bronchitis

•GOLD:  Chronic:  treat COPD exacerbations with antibiotics if increased SOB with increased sputum volume/sputum purulence, or intubated

• ACCP:  For acute bronchitis, the routine use of antibiotics is not justified

Lung Transplant Pearls:

•Usually receiving tacrolimus (over cyclosporin) and mycophenolate mofetil (over azathioprine) and prednisone.

•Lots of drug toxicity and drug interactions-renal insufficiency (tacro and cyclo)

•Fever, cough, sputum, CP, FEV1 decline = rejection or infection.  Isolate.  Bronch.

•Most frequent cause of death long termà bronchiolitis obliterans (wheezing, tx antirejection agents)

Conference Notes 10-7-2015

Jeziorkowski        Eye Emergencies

Stye vs Chalazion

Indications for Ophtho Repair of lacerations: Involvement of lid margin,  laceration anywhere near the medial canthus, laceration of inner surface of the lid, Ptosis, horizontal laceration with fat exposed

*Dacryocystitis Dacryocystitis is treated with oral augmentin and topical erythromycin.

Neonatal conjunctivitis within 2-5 days of birth consider gonorrhea.    Within 5-14 days of birth consider Chlamydia.   Both infections require oral and topical antibiotics. 

*HSV Keratitis   This is a potentially vision-loss infection.   Consult with Ophtho while the patient is in the ED. 

*Herpes Zoster Keratitis.   Look for Hutchinson’s sign, which is a zoster lesion on the tip of the nose.  Huthinson’s sign is a marker of corneal involvement by the herpes zoster virus.

When evaluating kids with eyelid swelling it is usually not orbital cellulitis.  Bug bites, pre-septal cellulitis, and allergic reactions are much more common.   If the child has normal eye movement, normal pupillary function, may have a sensation of pruritus, appears non-toxic with no fever, treat it as pre-septal cellulitis.  Give the patient oral antibiotics and discharge home.   If you have concern for orbital cellulitis: the child has fever, sicker looking kid, the child has eye pain, no pruritus, limited eye movement, start IV antibiotics and don’t get a CT on day 1.  Obtain a CT only if the patient is not improving on IV antibiotics.  Early CT  will rarely will change management.

Subconjunctival hemorrhages are generally benign.  Ask the patient  about coughing, sneezing, anticoagulant use.   Tekwani comment:  If you have a 360 degree subconjunctival hemorrhage you may want to evaluate for globe rupture.  Consider a CT of the orbit if there is a history of trauma.

*Retrobulbar Hematoma with vision loss and non-reactive pupil should be treated with lateral canthotomy.

*Hyphema   Keep head elevated.  Avoid NSAID's.  Consult Ophtho.

*Central Retinal Artery Occlusion.  Treat with eye massage, anterior chamber paracentesis by Ophthalmology, having patient breathe in a paper bag, and possibly hyperbaric therapy.

*Acute angle closure glaucoma.  Treat with mannitol, alpha agonist, beta-blocker, pilocarpine, and a carbonic anhydrous inhibitor. Consult Ophthalmology while patient is in ED

Navarrete     Review of DKA

Typical presentation is polyuria, polydipsia, and polyphagia.   Patients commonly will have nausea, vomiting, abdominal pain and body aches.

DKA is a problem of too little insulin.  Hyperglycemia is the symptom, not the problem.   HHS and DKA are on a spectrum.  HHS patients have a little bit of insulin to limit ketosis but not hyperglycemia.  HHS is less common and has higher mortality.

Cerebral edema occurs in <1% of DKA cases.  Cerebral edema is more common in kids and patients who present with more severe acidosis.  Avoid over-aggressive fluids.  Avoid insulin bolus and bicarb drips.   No one is sure of the cause.  Attending consensus was to be cautious with IV fluids in kids.   If you think the patient has cerebral edema, treat with hypertonic saline5 ml/kg over 10 minutes. 

When giving fluids follow the DKA protocol.  You need to be measured with your fluid resuscitation.  Adults can handle an initial first liter of saline then start your hourly rate.  Kids at most should receive an initial 10ml/kg bolus.  If the pediatric DKA patient is not in shock don’t give a bolus.   Just start an hourly rate per protocol. 

Don’t bolus insulin.  Start a drip at 0.1u/kg.   Follow the protocol from there. Bolus insulin increases the risk of cerebral edema.

VBG’s are adequate for DKA testing.  pH, bicarb and lactate are very consistent between VBG and ABG.

ETOH intoxication blocks hepatic metabolism of  glucagon and can result in hypoglycemia in the diabetic.   For the same reason,  glucagon won’t work to correct hypoglycemia in the intoxicated patient.

Lambert    Ultrasound ofthe Abdomen

*Gallstones with shadowing

*WES (wall echo shadow) Sign

Measure the gallbladder wall thickness at the anterior wall of the gallbladder.  The upper limit of normal gallbladder wall thickness is 3-4mm

The upper limit of normal for gallbladder size is 4cm in the AP diameter and 10 cm in the longitudinal diameter.

*Hydronephrosis Grades 1-4

When scanning the abdominal aorta start in the epigastrium.  You will need to hold steady pressure with the probe to displace bowel.  Aim the probe slightly inferiorly to image in the plane of the aorta.  Keep the indicator on the probe pointed to the patient’s right side.   You have to scan the proximal, middle and distal aorta.  Most aneurysms are infra-renal.    Mike suggested also scanning the iliac arteries in older patients (over age 80) to look for iliac artery aneuryms. 

*AAA.  

Lambert and Team Ultrasound     Ultrasound Lab

Conference Notes 9-16-2015

Williamson/Parker     Oral Boards

Case 1.  50 yo male with respiratory distress.  HR=100 BP=140/80RR=34T=98.7   Patient became SOB at subway station.   Exam reveals copious oral secretions. Patient also vomited and had abdominal cramping. EMS notes that other persons in the subway have similar symptoms.

*Cholinergic Toxidrome

Diagnosis is cholinergic toxidrome due to Sarin (organophosphate gas).   Treatment is high dose atropine until respiratory secretions have improved significantly, intubation,  and 2PAM.  Consult poison control.   Patient needs to be decontaminated. Staff needs to use PPI to prevent secondary exposure to toxin.  Patient’s clothing can off–let toxin for 30 minutes.  Sarin is colorless and odorless.

Elise comment: I saw a patient die of organophosphate poisoning in Africa.  It was horrible. The patient basically drowned in his own secretions because we did not have enough atropine.    Andrea comment: Initial dosing of atropine is 2-6 mg and go up from there until secretions are dried up.   There are stockpiles of atropine around the city and country.   The poison center has access to these stockpiles.  You have to get 2PAM into the patient as soon as possible to prevent irreversible aging of the acetylcholinesterase.

Case 2. 16 yo male with a headache for the last 10 days.  Vitals are normal.   Patient notes a weird feeling and paresthesias from waist down.  Legs have spasms occasionally.  Bedside ultrasound shows urinary retention.  MRI of the spine shows transverse myelitis. 

*transverse myelitis

Diagnosis is transverse myelitis due to multiple sclerosis.  Treatment is IV steroids.  Patient required foley catheter drainage of urine.   Transverse myelitis is an inflammation of the spinal cord.

In most cases a sensory level is documented, most commonly in the mid-thoracic region in adults or the cervical region in children. Pain in the back, extremities, or abdomen is also common while paresthesias (e.g., tingling, numbness, burning sensations) are typical in adults. Sexual dysfunction is also the result of sensory and autonomic involvement. Increased urinary urgency, bowel or bladder incontinence, difficulty or inability to void, and incomplete evacuation of bowel or constipation are other characteristic autonomic symptoms. Spasticity and fatigue are other symptoms common to transverse myelitis. Additionally, depression is often documented in TM patients and must be treated to prevent devastating consequences.  (Transverse Myelitis Association)

Case 3.  47 yo male presents with right foot pain for one week.  Vitals normal except for heart rate of 102.   Patient states that the pain began after a heavy board fell on his foot.   X-rays show lis franc injury.

*Lis Franc injury

Treatment requires ORIF and non-weightbearing for 6 weeks.   Harwood comment: this is a pretty severe lis franc injury.  Lis franc injuries usually involve the first and second metatarsals.  This xray shows all the metatarsals dislocated. 

Levato     Community Acquired Cellulitis

For uncomplicated cellulitis with no abscess use either cefazolin or clindamycin.   Elise raised concerns about the level of clindamycin resistance at our institution.   Harwood added that he would prefer to give Bactrim if you suspect MRSA.  

Levato’s Bottom line:  use more ancef and less vanco.  Patients without comorbiditities who have straightforward cellulitis with no fluctuance have a strep cellulitis. 

*Algorithm for soft tissue infections (Thanks Elise)

Remke      M & M

In order to respect the confidentiality of M&M, I am not going to give case details of M &M’s.  I will just present the take home points.

Be sure you have ordered a type and screen on pregnant patients who are bleeding.  If they deteriorate  and need transfusion, waiting for the type and screen can cause delay or necessitate the use of O negative blood.

Quantify vaginal bleeding based on whether it is more or less than a normal period.

On pelvic exam, if there is clot or tissue in the os, remove it.  Removing tissue and clot from the os can help the uterus to contract and lessen bleeding.

*Liklihood of Ectopic Pregnancy

In the setting of pregnancy, consult OB service for heavy bleeding, open cervical os, and positive beta hcg with no iup seen on ultrasound. 

Things to tell patients:

25% of pregnancies have bleeding

If a viable fetus is seen on ultrasound the risk of miscarriage is less than 10%.

Miscarriage is more likely with heavy bleeding, bleeding lasting a week or more, and if pain is associated with bleeding.

Emergency Physician Cognitive Issues:

Pay attention to subtle vital sign changes

Double check that the labs you need are ordered like type and screen.

Listen to your nurses when they raise a concern.

Get help from consultants when you are faced with a difficult situation.

Kelly Williamson comment: RH negative Patients who have a subchorionic hemorrhage on ultrasound but are not bleeding into the vagina do not need rhogam

Ortiz-Romero     Imaging the Pediatric Acute Abdomen

On ultrasound, a normal appendix is smaller than 6mm, compressible and has no surrounding free fluid.  Appendicitis is larger than 6mm, non compressible and hyper-vascular.  There will be point tenderness over the appendix with appendicitis.  Unfortunately 70% of the time the appendix is not visualized with ultrasound.

If you have an Alvarado score less than 5 and have an ultrasound with no inflammatory changes without visualization of the appendix, that clinical scenario has a negative predictive value of 99% for appendicitis!

Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

Blitman NM1, Anwar M, Brady KB, Taragin BH, Freeman K.

Author information

• 11 Department of Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY 10461.

Abstract

OBJECTIVE:

The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure.

MATERIALS AND METHODS:

We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports.

RESULTS:

Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%.

CONCLUSION:

Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.

When using CT for appendicitis, you need some peritoneal fat to identify the appendix.  So, very thin kids will be difficult to visualize the appendix on CT because they lack peritoneal fat.   However if there are no secondary signs of inflammation in the area of the appendix, that also makes appendicitis unlikely even if the appendix is not visualized.   To limit radiation exposure, you only need to do a pelvis CT.  Give IV and rectal contrast if the patient can tolerate them.   The cutoff for a normal appendix on CT is 7mm.

MRI can also be used to diagnose appendicitis. We are currently testing a MRI protocol for appendicitis.   The patient first gets scored on the pediatric appendicitis score.  If the score is 2 or more they are eligible for MRI testing.

Ultrasound is the first line test for identifying intussusception. 

Girzadas      ACGME Resident Survey Results

C Kulstad/Lovell    Preventing Diagnostic Error     Cognitive Bias

Misdiagnosis is the most common medical mistake and is a leading cause of malpractice claims. 

“Everyone is a human first and a novice or expert second”

There are 2types of causes for diagnostic error.  There are systems error and cognitive error.

*System and Cognitive Error

Error is more common when: uncertainty is high, the patient is unfamiliar to the physician, and the disease has an atypical presentation.   Cognitive error is a risk in high-pressure environments with many distractions. (the ER).

Nurses when acting as the wingman to the physician also need to be aware of their biases.  The nurse has the potential bias the physician either towards or away the right diagnosis.  If a nurse is biased against some aspect of the patient it can affect how the whole team approaches the patient. 

System 1 and System 2 Thinking.  To be a good EM Clinicianyou have to be able to switch back and forth between both systems.  Experienced clinicians have better developed system 1’s.  They have the experience to know when to switch into system 2 thinking.

*System 1 and System 2

Heuristics use pattern recognitions or mental shortcuts to solve problems.   Bias impacts heuristics a great deal.   This is a problem because ER docs use heuristics all the time in an environment that is prone to bias the heuristics.

Croskerry Six Biases:

1.     Over attachment to a particular diagnosis.  Anchoring on a specific feature too early and failing to adjust.

2.     Inheriting someone else’s thinking.  Following the cognitive path initiated by another provider.  This bias makes sign out a dangerous time.

3.     Failure to consider alternatives.  Tendency to stop looking once something is identified.

4.     Errors in estimation of prevalence.  Diagnoses that readily come to mind may be used more frequently.

5.     Bias related to patient characteristics or context.  Basically the physician has a personal perception about the patient and approaches the patient based on that concept of the patient.

6.     Errors associated with the clinician’s personality.  Over/under confidence is one example.   We need to have the appropriate level of both confidence and humility.

Tactics to overcome bias:

Cognitive debiasing:  Consider alternatives. Use metacognition or think about how you are thinking about a patient. 

Structured handovers:

Checklists :  Checklists help us to think of options we did not initially consider

QV&V: Qualify the source, validate the information, and verify the information.  Basically check that the info you are basing your decision on is correct and valid.

STEP Thinking: Story, Testing, Evaluate, and Plan

EMR Enhancements

Conference Notes 8-5-2015

E. Kulstad         Research Update

ACMC EM is #1 in the world in enrolling patients with intra-cerebral hemeorrhage  and hypertension into the ATACH 2 Trial!  Please continue to enroll these patients in the study.

The Macy Catheter can be used to give almost any medication rectally.   You can give up to about 500ml of water or pedialyte per hour rectally. This may be a therapeutic bridge option in the person who has a difficult IV access.

C. Kulstad       Study Guide Cardiology

There is no mortality benefit to routinely taking non-STEMI, ACS patients to the cath lab.   Thus, the patient with chest pain and bumped troponins and a non-STEMI EKG gets equal benefit from medical management as they would from going to the cath lab.

The absolute mortality risk reduction of ASA in ACS is 4%.  This data is derived from the 1988 ISIS study that showed ASA brought mortality down from 13% to 9%.  The absolute mortality reduction from heparin and LMWH in non-STEMI ACS is 0%.   The data for heparin and LMWH in STEMI is not known.  There is no Cochrane review on this topic.  We don’t really know the mortality benefit, if any, for heparin in STEMI.

POISE-2 study showed that you should hold ASA prior to abdominal surgery.  There is no increase in mortality if you hold ASA prior to abdominal surgery in patients with prior MI.  If you give ASA prior to surgery there is an increase in bleeding.  Elise comment: Most surgeons should not have a problem limiting surgical bleeding due to a patient’s ASA use.

*Electrical alternans is a poorly sensitive and reasonably specific finding of pericardial effusion.

Stress echo is a moderately sensitive (80%) and specific (80%) test for coronary stenosis.   It however is not a good test to identify risk for major adverse coronary events (MACE)

A murmur at the right 2nd intercostal space is consistent with aortic stenosis.  These patients can present with chest pain, dyspnea and exertional syncope.   It is a murmur that is easy to miss.  The prevalence of aortic stenosis in the elderly is 3% (pretty high prevalence).  There is now a new option of transcatheter aortic valve implantation that allows for valve replacement therapy without thoracotomy.

*Indications for temporary and permanent pacemaker

Hi dose NTG has shown mortality benefit in CHF.   We probably under dose IV NTG.   One strategy to get a higher dose of NTG into a patient is to use sublingual spray.  Each spray gives 400micro grams per spray.  You can give a spray every few minutes in the hypertensive, pulmonary edema patient.

Tobacco cessation is the single most profound risk reduction strategy in patients with CAD.

Pericarditis pain is worse lying down.  Patients can also have pain with swallowing.

Burns/C. Kulstad      Oral boards

Case 1.  24 yo male presents with agitation and hyper-adrenergic toxidrome. Patient had to be restrained by EMS personel and was fighting against restraints.   His troponin and AST are elevated.   His CK is markedly elevated.  Urine tox screen is positive for cocaine.  Patient management of cocaine overdose required relatively high dose IV benzo’s for agitation and hyperadrenergic vital signs. Treatment for cocaine toxicity is benzodiazepines as your  first/second/third line.  Patient also required  IV fluids for rhabdomyolysis.  A bicarb drip for cocaine-induced rhabdomyolysis is controversial.  Cooling measures were also indicated to manage hyperthermia. Avoid beta-blockers in cocaine toxicity.  You can get unopposed alpha effects.

Case 2.  28 yo female with left shoulder pain.

*Image

Diagnosis was AC joint separation.   Treatment is sling, pain control, and non-emergent orthopedic referral.  You have a two-week time frame to surgically repair an AC separation.   AC joint separation is the most common shoulder injury in athletes. High-grade separations require surgical repair.

Xray findings of AC separation: The acromion is not level with the lateral clavicle.

*AC separation Xray

Case 3.  20 month old female brought in for crying.

*Monitor strip

Exam shows enlarged liver.   Patient has cool extremities.

Diagnosis was SVT.  Treatment was IV adenosine 0.1mg/kg initial dose.  The rhythm slowed temporarily but then returned to SVT.  Second adenosine dose was 0.2mg/kg, which also did not convert the patient.  Child appeared more clammy/shocky so the next move was synchronized electrical cardioversion.  Patient was given intransal fentanyl prior to cardioversion.  Initial shock was 0.5j/kg.  Patient converted with first attempt at cardioversion.   If first attempt fails you can go to 1j/kg.

Remke    Pediatric SVT

Case 1.  7 day old with a heart rate of 300.   BP 75/47.   Afebrile.   Patient had been feeding well.  Lungs were clear.  Color was good.  Rythm Strip showed SVT.  Child was treated by peds cardiology in the ED with propranolol and rate was controlled.

 *3 Types of SVT

To diagnose SVT  in pediatric patients, the heart rate should be great than 220 in an infant and >180 in a child.   There should be no P waves on EKG.  The rhythm should be very regular with no variability.  Sinus rhythm has more variability than SVT.   Notching of the T wave suggests sinus rhythm with the P wave buried in the T wave. 

*Sinus Tach vs. SVT

*Pediatric SVT Management Algorithm

Vagal maneuvers include: ICE to the face, Valsalva maneuver, and rectal stimulation with a thermometer.

For known WPW use procainamide instead of adenosine.  Elise comment: For orthodromic narrow complex SVT it is ok to use adenosine even if it turns out to be WPW.  It is the AHA recommendation. 

Avoid verapamil in infants and children.  It is contraindicated in patients under 1 year of age because it can result in V-Fib and hypotension.   It can be used as a second or third line therapy for SVT in teenagers.

After cardioversion, admit infants and discharge older kids/teenagers after a 2-4 hour period of observation.  If you identify WPW discuss with cardiology about admission for ablation.

Ede      Low Risk Chest Pain

Chest pain patients are considered low risk if the probability of major adverse cardiac events is 1-2%.

Patient’s response to GI cocktail or NSAID or NTG is not reliable for ruling in/out ACS.

Women may have more atypical symptoms.

*HEART Score        Patients who are low risk by HEART score and have 2 negative troponins 3 hours apart have a less than 1% risk of MACE  (major adverse cardiac events)  in 6 weeks.

*Heart Score Decision Making

Hart        Tachyarrhythmias

*Tachycardia Algorithm.   I would only add that procainamide can also be used and is probably preferred for wide complex irregular tachyarrythmias (WPW).

If you have IJ central line access, you can use a lower dose of adenosine because of a faster transit time to the heart.  Braden Parker noted that 3mg of adenosine worked quite well in a patient with SVT that he treated through an IJ line. 

Adenosine causes a sense of doom or chest pain in patients.  You should give some sedation prior to administering adenosine.

*WPW Syndrome

Avoid AV nodal blocking agents (betablockers, calcium channel blockers)  in antidromic (wide complex) tachycardias.  Blocking the AV node in antidromic tachycardia can result in death.

Aflutter usually has a rate right around 150.

*Atrial Fibrillation and Atrial Flutter

Calcium Channel Blockers have been shown to be superior to beta-blockers for Afib.

*Junctional Tachycardia can be hard to diagnosis.  Consider digoxin toxicity when you see Junctional Tachycardia.

*Diagnosing V-Tach

*Girzadas note: Another Approach to Diagnosing V-Tach on ecgpedia.org. I have always struggled with differentiating VT and SVT with Aberrancy.  This seems like a simple way to do it.  In lead II if the initial upstroke or downstroke of the QRS takes more than a box it is likely VT.  A caution, It is not validated yet. 

First line treatment for Stable Ventricular Tachycardia is Procainamide.   Second line is Amiodarone.

*Torsades      Treat with Magnesium or Overdrive Pacing

Parker         PodCast Pearls  for Codes

Traumatic Arrest is usually due to one of a few things: exsanguination,  pericardial tamponade, or tension pneumothorax.    Based on that, is there any reason to do CPR for traumatic arrest?  CPR can also hinder other activities/procedures being performed on a trauma patient. CPR can increase the risk of blood exposure to the resuscitationist.

Mnemonic for PEA in the Trauma patient:  HOTT=  Hypovolemia, Oxygenation, Tamponade and Tension Pneumothorax.

C Kulstad and Girzadas comments:  We are uncomfortable dropping CPR completely from trauma resuscitation.  We think there is medical-legal risk to that.  Possibly a more middle of the road approach would be to prioritize life saving procedures.  If CPR is hindering other life saving procedures such as gaining IV access, relieving tamponade,  or relieving tension pneumothorax stop CPR for as short a time as possible and perform the procedure and re-start CPR as soon as possible.

PEA Management:  Use ultrasound to identify causes.  If the QRS in PEA is wide think metabolic causes like hyperkalemia, TCA overdose, infarction.  If the QRS is narrow think obstructive causes such as tamponade, tension pneumo, or PE.

Jamieson        Parasites

A parasite lives at the expense of the host.

The CDC Lists 5 Parasitic Infections we should know.

Chaga’s disease: Caused by protozoan Trypanosomi Cruzi.  Acutely, patients have fever and malaise.  They can also acutely have eyelid swelling, myopericarditis, and meningitis.  Chronically patients can have CHF or megaesophogus.   You need to get the treatment drugs from the CDC.

*Eyelid edema from acute Chaga’s Disease

Cystercercosis:  You get the worm from eating infected pork. Neurocystercercosis can result in seizures.   When the infection is in the muscle if feels like bumps.   Treat with albendazole, anti-seizure meds, steroids, and surgery.

*Nueorcystercercosis

Toxocariasis: Caused by ingestion of cat or dog feces. Acutely the patient will get a hepatitis or pneumonitis.  The pneumonitis can look like asthma.  Kids can also get unilateral visual impairment from fundal involvement.

Toxoplasmosis: Caused by ingesting cat feces.   Infection can be spread vertically from mom to infant.  Congenital toxoplasmosis can cause spontaneous abortion, fetal death, and fetal neuro deficits. Immunocompetent adult patients can have a mono-like syndrome.  Immunocompromised adult patients can get encephalitis.  

Trichomoniasis:  Most common non-viral STD.  Can be asymptomatic for months.  Women have vaginal symptoms.  75% of men are asymptomatic.  Can result in pregnant women having premature rupture of membranes and preterm delivery.

Conference Notes 7-29-2015

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Paquette      Study Guide     Special Patients

Black tar heroin mixed with lemon juice may harbor fungus that when injected can result in fungal chorioretinitis.

50% of elderly patients hospitalized after a fall die within a year.   Falls represent a sentinel event and are not a normal part of aging.

*Trench Foot is stratum corneum breakdown due to continuous water exposure.  This is commonly seen in homeless persons forced to wear wet shoes and socks for prolonged time periods. Treatment is dry socks and dry shoes.

Treat maggots with ethyl chloride.  The topical Freezing Spray (ethyl chloride spray) works well to kill maggots.   A recent study showed that a yankaur suction device works well to remove maggots.

To optimally visualize the airway in obese patients, use RAMP positioning.  The goal is to line up the external auditory meatus with the sternal notch. 

*RAMP positioning

Cotton fever is due to a gram negative rod that exists on cotton balls. This gram negative rod can get into heroin when the cotton is used as a filter.   The fever is due to an exotoxin from the gram negative rod and is self-limited.  No treatment other than antipyretics is indicated for cotton fever.  However, this provides little help because it will be hard to differentiate cotton fever from sepsis when the patient first presents to the ED.

The right heart valves are more prone to endocarditis than left side heart valves.  Injection cocaine use is more likely to cause endocarditis than injection heroin use because cocaine has a shorter half life resulting in more injections and cocaine causes direct damage to the valves.

Obese patients tend to have EKG’s with low voltage and inferior t-wave flattening/inversions.  These changes are thought to be due to increased chest wall thickness and possible shift of the normal axis.

Trauma patients over age 50 account for 30% of Trauma deaths.  Trauma patients of advanced age have less physiologic reserve to withstand severe injury. 

Subdural hematoma is more common in elderly patients.

*Subdural vs. Epidural Hematomas

In patients over 80 years of age, chest pain is not the most common symptom of AMI.  Dyspnea and weakness are more common presenting complaints.

Downs syndrome patients have chronic atlanotaxial instability

*Atlanto-axial Instability

“Parents have brought a child with Down’s Syndrome ‘walking funny’ to an emergency department for evaluation,” Dr. Bull recalled. “And then the ED would X-ray the child’s hips and say nothing is wrong. But they were not aware of the importance of evaluating the cervical spine.”

The neurologic manifestations of symptomatic AAI include easy fatiguability, difficulties in walking, abnormal gait, neck pain, limited neck mobility, torticollis (head tilt), incoordination and clumsiness, sensory deficits, spasticity, hyperreflexia...and (other spinal cord) signs and symptoms. Such signs and symptoms often remain relatively stable for months or years; occasionally they progress, rarely even to paraplegia, hemiplegia, quadriplegia, or death. Trauma rarely causes the initial appearance or the progression of these symptoms. Nearly all of the individuals who have experienced catastrophic injury to the spinal cord had weeks to years of preceding, less severe neurologic abnormalities..."

During intubation of a Down’s patient, Great care must be taken to maintain the

neck in a neutral position. This may be accomplished

by placement of a soft collar after induction of anes-

thesia to avoid extreme neck flexion, extension, and

rotation. Leaving the collar in place may also serve as

a valuable reminder to all caring for the patient dur-

ing the perioperative and postoperative period that

cervical instability may exist

*Autonomic Dysreflexia can be seen in spinal cord injured patients who have a uti, constipation, pressure ulcer or constricting clothing below the spinal cord level of their injury.  The patients don't feel discomfort from these problems but develop HTN, flushing, sweating, and headache. 

Asokan     Interpreting the Chest Xray

We are responsible for everything on the X-ray, not just the aspects that we are interested in.  Be sure to look at the neck, axillae, and abdominal areas of a CXR.

Pathologic densities in the lung show up as a white density signifying abnormal fluid.

*Normal CXR

If you see an abnormality, look for a second or third less obvious abnormality.  Your eyes get stuck on the most obvious abnormality.

Consolidation is when the alveolar space is filled with inflammatory exudate.  Consolidations have air bronchograms.

Consolidation with air bronchograms

*Upright film shows a pleural effusion with a curved upper meniscus.

When looking for pneumothorax, look between the ribs for the pleural line.

*Pneumothorax. Note the pleural line between the ribs on the right.

*CHF Findings

*More views of peribronchial cuffing

*Small Bowel Obstruction

*Coffee Bean Sign of Volvulus

Jamieson     M&M

Life Lesson #1:  Don’t use dermabond around the eye.   If you need to disolve glue on an eyelid or your finger gets glued to the skin,  use erythromycin ointment.   It doesn’t break glue down immediately but it will over a relatively short time.

Life Lesson #2:  In order to figure out  what is going on with non-verbal nursing home patients, it may require a call to the nursing home.   Steve described the case of a nonverbal nursing home patient who otherwise was well appearing. He called the nursing home and learned that the patient was normally quite talkative. He proceeded to CT scan the patient and identified an intra-cerebral hemorrhage.

Life Lesson #3: Beware the back hallway bias.  This anchoring bias can cause you to downplay a patient’s acuity and symptoms.   Just because a patient is in the hallway and not in a critical care room doesn’t mean they can’t have a critical illness.

Life Lesson #4: Intubating obese trauma patients can be risky.  Expect O2 desaturation to occur more quickly than expected.  Be sure you have maximized your  pre-oxygenation.  Place the patient in RAMP position.  Use high flow continuous nasal oxygenation during the pre-oxygenation and intubation periods.  Have video laryngoscopy ready as either your first device or back up device.  Have an LMA ready to use as a rescue device.   Be sure to check that your oxygen source is working properly.  You can use ketamine as an induction agent to perform delayed sequence intubation; you can preoxygenate and evaluate the airway prior to neuromuscular blocking.

Htet/Meyers/Faculty       Orthopedic Exam Lab

Conference Notes 7-22-2015

A special Thank you to Christine Kulstad for her help with the Conference Notes this Week!

Lovell/Htet        Oral Boards

Critical Actions Case 1:  Septic Shock from Capnocytophaga canimorsus/dog bite

--Identify Sepsis

--Rapid IVF, early broad spectrum antibiotics including dog bite coverage

--Elicit history of dog bite

--Reassessment

--ICU admission

(also consider Xray, irrigation of wound, consider tetanus update, rabies)

Teaching points:  Capnocytophaga canimorsus

--fastidious GNR identified in 1976, likes to eat iron

--normal oral flora of kitties and doggies

--Risk groups:  asplenic, alcoholics, beta thal, smokers (high iron), immunosuppression

--Alcoholics have high blood iron + immune comp.

--WORST OUTCOMES in asplenics:  high iron + decreased phagocytosis; high M/M!!

--Symptoms usually within several days

--Fever, V/D, malaise, abdominal pain, myalgia, confusion, dyspnea, headaches, rashes

--Special culture media

--Tx:   Dogmentin!  so use IV Unasyn, also susceptible to third gen. Cephalosporins

Critical Actions Case 2:  Submassive to Massive PE

--Recognize risk for PE (travel)

--Diagnose PE

--Risk stratify (Echo, BNP, Trop)

--Recognize decompensation and need for thrombolytics

--Assess contraindications to tPA

--ICU admission, Intensivist consultation

Teaching points:   Submassive/Massive PE

--Submassive:Normal BP but RV dysfxn (Echo or BNP) or myocardial necrosis (Trop)

--Massive: Low BP for 15 minutes or code or resp. failure or need for pressors

--Thrombolytics for massive, case by case for submassive

--r-tPA dose 100 mg IV over 2 hours

--Code dose, 50 mg bolus (maybe + 50 mg)

--start IV Heparin when PTT < 2X nml

--Lytics in PE:  2% ICH risk, 6% major bleed/transfusion

Critical Actions Case 3:  Jellyfish envenomation

--Identify as Jellyfish envenomation

--Irrigate 

--Consider vinegar, hot water

--Monitor for systemic sx, allergic sx

--Treat with benadryl, consider steroids, analgesics

Teaching points: Jellyfish Envenomation

--Mechanism-tentacles with venom containing nematocysts

--Symptoms--Itch, swell, burn, tingling/numbness.  Severe with N/V, HA, weak, dizzy, SOB

--Treatment-irrigate with NS or sea water (fresh water makes worse), remove possible remaining nematocysts by shaving skin or scraping skin

--Use benadryl, consider steroids, give analgesics

--vinegar-prevent further nematocyst firing, hot water to breakdown venom-some controversy over effectiveness

Levato     Pharmacy Update

Community-acquired but complicated UTI- E coli, Klebsiella, Proteus most likely. We have been using ceftriaxone for this but it is a broad spectrum antibiotic that is causing c diff in our hospital. Cefazolin found to be 89% sensitivity in E coli, 90% in Klebsiella, 100% Proteus. So new guidelines are to use cefazolin for these patients. CAUTION- not appropriate for nursing home patients. OK for pyleonephritis.

Ketaneh  (Class of 2014)  Starting out as a New Attending

Looking for a job: Take some pressure off- its just your first job, you can change it later. He interviewed all over and recommends it. Prospective employers will usually pay for your interview expenses so don’t shy away from multiple interviews. It helps to see a lot of practice environments too, see where you fit in.  Use the faculty resources here (they know somebody everywhere).

You will have a lot more money- try to live like a resident and save for a while. Student loans will come due, 401k should be funded. Need to find your work-life balance- how many shifts due you want to work to pay for your lifestyle.

Starting a new job- get familiar with the EMR before your first real shift. Will save you tons of time and pain before your first shift.

Have your charting macros prepared before you start.

Know where you are going to look stuff up.

Be super nice and respectful to everyone.

Get your charting done so you stay off the medical records radar. 

Get to know the culture of your workplace: protocols, antibiotic choices, sedative choices.

Nick told a scary story of how he ordered a fentanyl drip and the pharmacists and nurses were not familiar with using fentanyl as sedation and dosing errors were made.

At most ED’s you at times will be working alone with a couple of nurses.

Be very clear when communicating with nurses, they will do exactly whatever you say.

An important part of our job is charting and billing.  It’s just a fact of life.  Your income and job security depend on it.

*Ups and downs.   You have to be able bounce back from the downs as an ER doc and temper/be humble with the Ups

There are other jobs out there.  You can change jobs.   It is important to protect your reputation so people think well of you and you keep the door open to other opportunities.

Be smart with your money.   It is OK to rent for awhile until you have a clear idea of your monthly income.  Then live below your means so you are funding your retirement properly.

As a resident and attending, going the extra mile will not go unnoticed.

Get your paper work done. 

Favorite FOAM websites:  lifeinthefastlane.com, aliem.com, emcrit.com

The goal for an ED doc in the community is to not be ultra cutting edge and not be practicing medicine from 20 years ago.  You want to be somewhere in the middle and up to date. 

Regan       Seizures

*Causes of Seizures

Generalized Seizures: Affects both Cerebral Hemispheres. There is loss of consciousness.

*Seizure Types

Partial Seizures include: Simple in which conscious is maintained and Complex in which consciousness is altered.

Initial questions to ask the patient:  Do you have a seizure disorder?     Is there anything that would have lowered you seizure threshold?  (sleep deprivation, fever, etoh use, missed medication, stress)

EKG can be a quick initial test to pick up electrolyte abnormalities causing seizure.

*Medications for seizure management

Elise comment: In the Peds ED there is frequently the availability to get an EEG rapidly for a child with a new onset seizure.  This rapid turn around of an EEG can be very helpful to neurology to make good management decisions for the patient.

Case 1.  Etoh withdrawl seizures can be treated with Ativan first line and Phenobarbitol second line for persistant  seizures despite Ativan.    Christine comment: You can push the upper dosage range of Ativan in the ETOH withdrawal patient. Their GABA receptors are down regulated.   Elise comment: If your Ativan is not working in any type of patient, start thinking about underlying causes such as hypoglycemia, hyponatremia, INH poisoning, intracranial hemorrhage.

20mg/kg loading dose works for Phenytoin, fosphenytoin, Phenobarbital, Valproic Acid, and Keppra.  Basically 20mg/kg works for all commonly used epileptics other than Ativan.

Check the patient’s tongue for lacerations and hematoma.  Serious tongue injuries  could pose an airway obstruction issue.

Neuro exam in infants

Look for:

Balled fists with thumbs tucked in, this is an upper motor neuron sign (Babinski sign in infants)

Altered/increased tone

Abnormal Reflexes

Eye deviation

Elise comment: Midazolam IM is a very rapid acting anti-seizure medication that is useful in kids.   Eye deviation is an important finding in kids to identify a seizure.

30-50% of patients with pseudo seizures also have epileptic seizures.  This makes diagnosis and management possible psuedoseizures very difficult. 

Carlson                      Antidotes

*Antidotes

Isopropyl alcohol ingestion is not an indication for fomepizole.  It is metabolized to acetone.

Lead has 3 potential antidotes: BAL,  EDTA, and Succimer.   Peanut allergy is an absolute contraindication to BAL therapy.

Gyromitra mushrooms look like a brain and can cause seizures.  The antidote is pyridoxine (also the INH antidote/INH also causes refractory seizures).

*Gyromitra mushroom

Sodium Bicarbonate is an antidote for TCA poisoning.  The sodium overcomes Na Channel blockade.  The Bicarbonate decreases free TCA.   Andrea prefers bolus dosing with 1-2 ampules while closely observing the patient and the monitor.

Calcium channel overdose can cause bradycardia, hypotension, and hyperglycemia.  The antidote is the “perfusion salad”: calcium chloride, glucagon, intralipid, atropine, and insulin euglycemic therapy.

Deadly nightshade contains bella donna toxin.  Bella donna can be thought of as a Benadryl overdose.  Both cause an anticholinergic toxdrome.  The antidote for anticholinergic toxidromes is physostigmine.   Physostigmine should not be used in undifferentiated coma or in mixed overdoses.  However, it is safe in pure anticholinergic toxidromes.  

*Deadly nightshade berries

*Deadly nightshade leaves  (note the little “ears” small leaves around the big leaf)

Paint stripper that contains methylene chloride if ingested will be metabolized to CO.  Methylene chloride gets metabolized by liver to CO and can cause CO toxicity.    Antidote is hyperbaric oxygen. 

Statistically the most common cause of CO toxicity in the summer is indoor grilling or using a grill on a screened-in porch. 

*Hyperbaric indications for CO Toxicity

Causes of cardiac glycoside poisoning: digoxin, oleander, foxglove, Lilly of the valley, and the practice of toad licking.   Antidote is FAB fragments

West      Fever in Kids

Rectal temperature measurement is most accurate.   The temperature that determines a fever is 38C.

*Fever algorithm for kids </= to 3 months

For febrile kids (with immunizations up to date) over 3 months of age with no source on physical exam the next best diagnostic study is to check the urine.

Brain damage is not a complication of fever due to infection.

Faculty comment: Parents frequently under-dose Tylenol and Ibuprofen.  Check the dosing parents are giving to kids if the antipyretic is not bringing down the fever.

Harwood comment:  You may not need to do an LP on febrile kids age 30-60 days old if they have the following:

Well appearing child

Normal urine

Normal ANC

Normal Procalcitonin

This decision rule has not been validated. 

Elise comment: Right now there is a grey zone (based on age of infant) of whether there is a need to do an LP.  There is reasonable practice variation in non-toxic appearing, febrile kids age 30 days to 60 days.   Most faculty have a cut-off at 6 weeks, but up to 8 weeks is reasonable.  Ill appearing kids at any age require LP.

Fever Algorithm for ages Newborn to 36months

Bonder     Patient Satisfaction

Patient satisfaction rates are a factor in medicare reimbursement.

Research has shown that patient satisfaction measurements are biased and don’t correlate with clinical quality metrics.   Also, mortality rates tend to be higher in hospitals with high patient satisfaction levels.

Safety net hospitals and teaching hospitals regularly perform more poorly on patient satisfaction measurements.   There are geographic variabilities as well with California and East Coast hospitals usually scoring lower than other regions.

*Kaiser 4 Habits Model from Kaiser Health

Elise comment: Patient satisfaction measurements are not based on your clinical care or diagnostic accuracy.  They are based on how you communicate with the patient.

Christine comment: At the completion of the ED visit, take the time to explain to the patient what the tests showed and how they ruled out dangerous diagnoses.

*Patient Satisfaction Measures