Conference Notes 12-13-2017B

Katiyar/Florek      Oral Boards

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

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

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

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

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

Vaughan-Williams Classification of Anti-Arrhythmics

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

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

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

Clinical Picture of Cauda Equina Syndrome

Barounis/Jonas     Central Line Workshop

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

Traylor        FirstNet Hacks Workshop

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

Huu/Lorenz/Wing    Thoracic Trauma

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

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

Emergency Department Thoracotomy

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

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

A really obvious CXR demonstrating aortic injury

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

Blunt Aortic Injury, Evaluation and Management of

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

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

Conference Notes 12-6-2017

Tekwani    Quarterly Difficult Airway Conference

3 Indications for Intubation

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

Assessing for Difficult Laryngoscopy

These are the bedside tools to assess for difficult laryngoscopy

Difficult Bag-Valve-Mask mnemonic "ROMAN"

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

Difficult Airway Algorithm from Ron Walls Difficult Airway Course

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

Faculty Pearls

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

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

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

Thenar grip is superior to C3 or other bagging techniques.

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

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

Carlson      Critical Care Toxicology

Unfortunately I missed this outstanding presentation

Alex/Wigfield   Emergencies in Lung Transplant Patients

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

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

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

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

Diagnostic pathway to PRES

Bilateral posterior findings of PRES on MRI

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

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

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

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

Conference Notes 11-29-2017

Einstein      M&M

Critical Causes of Chest Pain

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

Cognitive Biases

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

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

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

Lorenz       Safety Lecture

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

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

Logan/Schmitz    Administrative Updates

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

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

Omari    COPD

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

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

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

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

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

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

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

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

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

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

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

Bonaguro/Chan      Quality Updates

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

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

Conference Notes 11-22-2017

Joint EM-Peds Conference on Complications of Sinusitis

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

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

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

Typical appearance of Pott's Puffy Tumor

Pott's puffy tumor with brain involvement.

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

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

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

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

Staley     Study Guide    Pediatrics

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

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

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

Components of Tetrology of Fallot

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

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

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

Classic "corkscrew sign"  of Midgut Volvulus on Upper GI

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

Clinical signs of NEC

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

Destefani      M&M

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

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

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

Katiyar       Billing and Coding  Medical Decision Making

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

Document your Differential Diagnosis.

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

Document patient re-evals.  

Include your interpretation of prehospital ekgs and rhythm strips. 

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

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

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

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

Conference Notes 11-15-2017

Zelkovich      Radiology

Unfortunately I missed this excellent lecture

Walchuk      Pediatric Study Guide

Kawasaki's Disease

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

Images associated with Kawasaki's disease

Fever work up

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

Brian Carlson       Financial Planning

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

Strategies to protect wealth from litigation are:

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

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

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

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

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

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

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

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

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

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

Traylor     Environmental Emergencies

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

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

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

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

Posterior shoulder dislocation

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

Walsh PharmD   Lecture on Hypertensive Emergencies

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

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

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

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

Conference Notes 11-8-2017

Barounis     Critical Care Tips

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

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

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

4. 

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

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

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

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

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

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

Garett-Hauser      Ethics Potpourri

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

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

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

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

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

Lovell/Williamson    Emotional Wellness

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

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

One tool to limit anger/confict is ARTS of communication

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conference Notes 11-1-2017

Bartgen/DeWeert    Oral Boards

Pneumothorax re-expansion pulmonary edema

Large pneumothorax in a young person

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

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

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

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

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

Carlson      Critical Care Toxicology

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

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

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

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

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

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

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

Hormese  Pharm D    Management of PE

Proposed Management Algortithm for PE

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

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

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

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

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

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

Cost to patient for TPA is $32,000.

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

HCAP Guidelines

The new HCAP guidelines for ACMC were reviewed.

Friend       Epinepherine dosing in place of an Epipen

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

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

Florek    PE/DVT

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

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

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

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

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

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

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

Conference Notes10-18-2017

Garrett-Hauser/Schmitz     Oral Boards

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

CXR shows congestive changes and cardiomegaly.  Troponin is elevated. 

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

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

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

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

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

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

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

PharmD     Acute Angle Closure Glaucoma

Clinical appearance of acute angle closure glaucoma

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

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

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

Burns      FAST and E-Fast Exam

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

RUQ view.    Fluid in Morrison's Pouch

LUQ FAST image showing fluid between kidney and spleen

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

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

Lambert     Gallbladder and Renal Ultrasound

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

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

Acute cholecystitis with stones and wall thickening

Team Ultrasound        Ultrasound Workshop

Conference Notes 10-11-2017

Denk/Traylor   STEMI Confernce

Inferior Posterior MI with RV involvement. Note the ST elevation greater in Lead 3 than Lead 2.

Patient with an Inferior/Posterior/RV MI.  With hypotension.  Cardiology advised initial 1 liter of saline.  If that does not solve hypotension problem, next start a pressor.  No difference in outcomes between dopamine and norepi.  Dopamine has been shown to have more arrhythmia.  Harwood comment: If the patient is bradycardic, dopamine has more chronotropy and is preferred. because you will raise the heart rate. 

Editors comment: If the patient is not bradycardic, my reading of the below reference suggests that norepi may be the preferred choice.

New England JournalReference: The trial included 1679 patients with shock of all causes, of whom 858 were assigned to dopamine and 821 to norepinephrine. The baseline characteristics of the groups were similar. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock (P=0.03 for cardiogenic shock, P=0.19 for septic shock, and P=0.84 for hypovolemic shock, in Kaplan–Meier analyses).  De Backer N Engl J Med 2010; 362:779-789

Balloon pump therapyhas not shown a mortality benefit in cardiogenic shock but all the cardiologists present felt that ballon pumps are useful in supporting the patient in the short term.  They usually use it in patients with high pulmonary capillary wedge pressure or patients who need improved coronary flow.  

Editor's note:  This feeling generally corresponds to a brief lit search on this topic.  No overall mortality benefit but some patients did have hemodynamic improvement with balloon pump therapy.

Transvenous pacers are more easily placed in the cath lab than in the ED because of flouro.  Only place a transvenous pacer in the ED if the patient is unstable due to bradycardia or heart block. 

Factors making angioplasty more risky:  If a patient has prior CABG it makes angioplasty much more difficult. Patients who have had cardiac arrest prior to going to the cath lab have worse outcomes overall.  When in a difficult decision making situation regarding whether or not to take a patient to the cath lab, be sure to document the collaborative decision making that you had with the cardiologist.   Lovell comment: Your mantra should be "shared decision-making"

Polycythemia Vera can result in sluggish coronary flow and MI.

Regan    Disaster Planning

The new paradigm after the Columbine event is to extricate victims as soon as possible.  Most SWAT teams have tactical medics or doctors who go in with SWAT team to get shooting victims out as fast as possible and get them to medical care. This change has improved survival.

It is common for people to "freeze" and not react properly to a terrorist or mass shooting event.  There are clear reports of this happening during the 9-11 event.  First responders will need to give victims clear direction to get them to safety.

When EMS contacts the ED, key pieces of information include: are there pediatric patients involved, is there a HAZMAT component to this event, the number of victims, and the estimated time of arrival of patients to the ED.

If there is a disaster or terrorist or shooting event that affects our hospital a CODE TRIAGE will be called.   The Emergency Operations Center (EOC) will be in the Conference Center Auditorium. Hospital Administrative personnel will run the EOC.  We as ED physicians will provide triage and patient care.   In a disaster the goal of patient care is not to provide "standard of care", but rather "sufficient care."  Basically that means you provide basic stabilization care to patients, not definitive care.

"The term “altered standards” has not been defined, but generally is assumed to mean a shift to providing care and allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals."  AHRQ Publication No. 05-0043April 2005

In the event of a mass casualty incident, call the Medical Director of Disaster Medicine (Liz or Sean). 

We then will huddle with ED nursing and physcian staff to assign duties.

There is a disaster box in the back charting room.  It has written role cards for staff.   Doctors will assigned to Triage (1 physician and Charge nurse in the ambulance bay)  or to Treatment of patients. Both attendings and senior residents will be treating injured patients.   Junior residents will take on the role of moving our patients already in the ED out of the ED to make room for the injured patients.

Physicians report to the Charge MD who will be Sean, Liz or the most senior ED physician in the ED.

The Trauma Surgeons will be in the OR's.

Triage will occur in the ambulance bay.  Treating physicians in the ED will stabilize patients and identify which patients require the OR as soon as possible.

Use IO access preferentially in a disaster situation.  DO NOT spend the time to place a central line or ultrasound guided line.

Employ your Trauma skills to stabilize patients: assess/protect airway, use needle thoracostomy/chest tubes to treat pneumothorax and hemothorax, give blood, use TXA liberally,  control extremity bleeding with tourniquets, get patients to the OR.

Additional physicians who are called in should park in garages A,B, or C.  When you get to the hospital report to the ED Administrative Offices.

Do not self-dispatch to the hospital in the event of a mass casualty incident.  We don't want too many people here at one time.  Only come in if you have been contacted to come in.

EM1's      Pecha Kucha

Chinwala       Sleep for EM Physicians

Unfortunately I missed this excellent lecture

Jurkovic   Blessed

Heart warming lecture describing how senior residents have helped the interns learn and battle through adversity.

Pastore         Priapism

Basic management approach to low flow priapism

Blood gas findings indicating low flow (ischemic) priapism

Low flow priapism is compartment syndrome of the penis.   Give IV pain medication and perform a dorsal penile block.  Aspirate blood from the corpus cavernosum.  The blood will look like motor oil.  Irrigate with saline.  Inject phenylepherine .   After detumesence apply an elastic bandage on the penis.

For priapism associated with sickle cell disease consult hematology for an exchange transfusion.

Kentor    HINTS Exam

Used in patients with continuous vertigo for more than 24 hours. Is more reliable identifying a central cause of vertigo than MRI.

With rapid head turning, if eyes can stay on target then it may be central vertigo.    With regard to nystagmus if has direction changing nystagmus or vertigal nystagmus that suggests central cause.

Kishi    U/S Guided Forearm Nerve Blocks

Patrick described the procedure of using soft tissue ultrasound to identify and aid local injection around the median, radial, and ulnar nerves in the forearm .

Ohl     Subarachnoid Hemorrhage

CT is close to 100% sensitive in the first 6 hours.  Beyond 6 hours in the setting of a negative CT head, the next study would be LP.

Treat BP with Nicardipine.  Keep the patient's head elevated at 30 degrees.

Vasospasm is more common in younger patients, smokers, larger bleeds, and patients with HTN.

Conference Notes 9-27-2017

Barounis     Ventilator Management

You will use Assist control/Volume control ventilator mode 99.9% of the time in the ED. There is rarely a need to use another mode in the acutely ill ED patient. 

5 Steps to setting the vent

1. Select Assist Control/Volume Control

2. Tidal volume.  Set your tidal volume to keep plateau pressure at or below 30.  Higher pressures cause lung injury. Low tidal volumes are lung protective.  Number Needed to Treat using low tidal volumes to save 1 life is 11!  Start at 6 ml/kg.  Distilling this down to a real basic guideline for ER docs is give 500 ml for guys and 400ml for women.  You can adjust up and down +/- 50ml if the patient is particularly tall or short.

3. Pick your RR.  If the patient has bronchospasm, you need to use a low rate (10 breaths/min) to give the patient more expiatory time so you are not causing breath stacking.  So, for asthma 10 breaths/min,  for hypoxia or to protect airway 20 breaths/min, and for severe metabolic acidosis 30 breaths/min.   Logan Traylor comment: For respiratory acidosis due to asthma or COPD, patients still need a low rate to avoid breath stacking. As the clinician, you will need to accept some respiratory acidosis.    Dave agreed and added furtehr comment: There is some data that patients who are acidotic after cardiac arrest may do better with a higher PCO2 level and an acidotic ph than ventilating them rapidly and lowering the PCO2 and causing cerebral vasoconstriction. 

4. Set PEEP.  You want to keep the driving pressure (plateau pressure-peep) less than 15.   Start with a peep at 8 for the average overweight ED patient.  After 20 minutes, do an inspiratory hold and figure out the driving pressure and increase the peep as needed to lower the driving pressure to 15 or less.

5. Set the FIO2.  Base your FIO2 on the O2 sat.  Try to keep the O2 sat around 95%.  Avoid hyperoxia and hypoxia.

If peak pressure is high and plateau pressure is OK then you have a resistance problem.  Resistance issues include: patient biting the tube, mucous plug, blood in the ET tube, tension pneumothorax, and asthma.

Nand   The 2 Midnight Rule

Patient who are inpatients for more than 2 midnights after admission are presumed to be appropriate for Medicare Part A payments.  Our documentation needs to reflect the necessity of that admission.

The clock starts when the patient begins to receive care in the ED. If the patient is in the ED at midnight, that counts as the first midnight.

One exception is a patient placed on a ventilator.  They can all be made inpatients even if they will stay less than 2 midnights.

Keeping patients for social or safety reasons who have no other medical issues should in general be OBS stays.  If the patient has some concurrent medical issue they may be appropriate for admission.

Patients with symptom-based diagnoses (chest pain, abdominal pain) should be OBS.  If you think patient will go home the next day, make them an OBS.

Don't write" we will admit to OBS"  Medicare will not approve this type of explanation. We have to avoid using both the terms Admit and OBS in the same chart.  When both terms (Admit, OBS) are used in the same chart Medicare uses that lack of clarity to decline payment.   Better to write "we will place patient in OBS for further evaluation"  or " we are admitting patient for management of pancreatitis"

If you need to change a bed request. 

1. Cancel the initial level of care order.  2. Cancel the initial bed request.  3. Place the new bed request.   If you don't do this in the correct order medicare will deny the admission.   

Mounica Donapudi comment: 1. Right click the level of care and click cancel d/c.  2. Rght click the the bed request and click reorder. 3. change the bed request order and sign.

Tran    Human Trafficing

Unfortunately I missed this excellent lecture.

Traylor   Admin Update

You need to write the sepsis re-eval (..sepsis macro) for any patient with a lactate over 4 or a MAP<65.    Give 30ml/kg of LR or saline.  3 liters should work for most patients.  You have to write the reassessment note within an hour after the IV fluid bolus.   If you have concerns about volume overload, document that concern and order >125ml/hr (126ml/hour is acceptable). 

April Kennedy    Dental Emergencies

How to describe teeth.

Cross sectional anatomy of a tooth.

Pulpitis is the most common cause of tooth pain.  Treat with pain control and antibiotics.  If there is an open area on the crown, it may help to place a covering on the tooth with Temrex. Patientswill need dental referral for extraction or root canal.

Patients will need tooth extraction as definitive management of pericoronitis. In the ED start them on antibiotics and pain meds and refer them to their dentist or an oral surgeon.

Dry socket occurs when the blood clot that has developed in the socket since dental extraction becomes dislodged from the socket. This leaves the nerve exposed and is quite painful.  Dry socket is more common in smokers, patients over age 25, patients with poor oral hygeine and patients who use straws to drink liquids.

Academic Life in EM: Trick of the Trade: Extra-Oral Reduction Technique for Anterior Mandible Dislocation

1. Place the patient in either sitting or supine position.
2. The provider should stand in front of the patient.
3. The provider places their thumb on the patient’s cheek, on the mandibular ramus and coronoid process of the dislocated mandible, and applies persistent pressure posteriorly (figure 3).
4. The fingers are placed behind the angle of the mandible to stabilize the grip.
5. At the same time on the opposite side, the provider places their fingers from the other hand on the angle of the mandible and pulls, applying anterior force (figure 4). Note that this maneuver causes further anterior dislocation of the ipsilateral TMJ, rotates the jaw, and facilitates contralateral TMJ reduction.

Once one side of the dislocation is reduced, the other side will usually go back spontaneously. If that doesn’t work, repeating the same maneuver with minimal force will usually result in success. Also consider applying posterior force on both coronoid processes at the same time if the above strategy doesn’t work.

If a primary tooth (baby tooth) is avulsed do not replace it.  If a permanant tooth is avulsed, rinse the tooth with saline. Save the tooth in tooth saver liquid, the patients own saliva, or milk.  Replace the tooth and splint it in place.  Give doxycyline as antibiotic prophylaxis to adults. Update their tetanus shot.  Patient will need dental or oral surgery referral for a root canal.   Replacing the tooth actually supports the alveolar bone and optimizes the bone for eventual dental prosthetic if needed.  Dr. Kennedy advises replacement of the tooth up to 24 hours out.  You should advise patients that they will likely loose the tooth and need a prosthetic.

You can cover Ellis fractures with Calcium hydroxide or Dermabond.

Dental Lab

Conference Notes 9-6-2017

ACMC EM Conference Notes(filling in for Dr. G)

Editor's note:  Much Thanks to Dr. Lovell for writing these notes when I missed Conference on 9-6-2017.

8 am:  Oral Boards:  Dr. Williamson and Dr. Okubanjo

--Thyroid storm:  Consider in setting of hyperthyroidism, fever, AMS, sympathetic surge, and always look for precipitating event (eg infection, CNS, cardiac event).

Management:

• IVF + glucose
• acetaminophen (no NSAIDS or asprin -> displaces thyroxine from proteins)
• propranolol to dampen sympathetic surge, also blocks T4 to T3

• hydrocortisone or dexamethasone (shield from adrenal insufficiency + decrease peripheral conversion)
• Thionamides:  methimazole or propylthiouracil (block new production)
• after blockade by thionamide, wait at least 60 minutes then give sodium iodide or potassium iodide (SSKI) or Lugol’s iodine to block thyroid hormone release

--Acute Angle Closure Glaucoma:  think about it in patient with a headache, vomiting.  Eye symptoms may be initially more subtle.  “Mid-dilated fixed pupil” for the boards.

Beta blocker and acetazolamide and alpha agonist to decrease aqueous humor production.  Topical steroids as anti-inflammatory agent.  May use oral glycerol instead of IV mannitol (both osmotic agents) if no diabetes and able to take po. Treating pain/nausea may also help decrease IOP. Pilocarpine administration should be delayed an hour, as initial elevated IOP can cause temporary ischemic iris paralysis.  Initial agents are given time to work, then pilocarpine helps with constricting ciliary muscle and relieving pupillary block.  Laser peripheral iridotomy is definitive treatment and can be coordinated with ophthalmology. 

--“Fight Bite” from clenched fist injury, concern for infected joint, needs IV antibiotics, usually Unasyn if no PCN allergy, doxy an alternative.  Buzzword is Eikenella but usually polymicrobial.  Avoid first generation cephalosporins.  Update tetanus, xray to eval for fracture/foreign body.  May need washout in OR.

9:00 am Dr. Kyle Bernard:  M&M.  Multiple excellent cases/learning points-a few pearls from 2 cases:

Cardiogenic shock:  sometime the subtle shock.  Patient with advanced CHF +/- ACS +/- dysrhythmia +/- valve disease +/- cardiac drug toxicity may be obviously short of breath, clammy and hypotensive, but they may also be living a very fine balance and initially present looking ok, maybe a little tachycardic, but with normal BP.  Will need to treat with O2, pressors, inotropes, possible IABP.  Key is recognition and early consultation with cardiology.

Important concept discussed-Lactate as reflecting catecholamine surge rather than anaerobic metabolism.  May see elevated lactate with compensated or “occult” shock in a patient with initially normal blood pressure who then crashes.

If you want to geek out on lactate, listen to contrarian intensivist Paul Marik:

https://intensivecarenetwork.com/understanding-lactate-paul-marik/

then read some retorts:

https://emcrit.org/emcrit/smacc-back-marik-lactate/

Heimlich valve in spontaneous pneumothorax:  we have a “pneumothorax kit” and can also find a “pigtail catheter kit.”  Both insert a small catheter and Heimlich valve. The pneumothorax kit uses a catheter over a needle attached to a syringe, and the pearl is that if you remove the syringe while the needle/catheter are in the chest, the pneumothorax may decompress and you’ll be unable to thread the catheter.  The pigtail catheter uses a wire/seldinger technique-more steps, but familiar to emergency physicians.

“Pigtail catheter” (wire, seldinger technique)

“Pneumothorax kit”-catheter over needle

10:00 am Dr. Liz Regan:  “Thinking outside the box-unusual uses for medications”

TXA:  mechanism of action: Tranexamic acid is a synthetic analog of the amino acid lysine. It acts as an antifibrinolytic by reversibly binding lysine receptor sites on plasminogen or plasmin.

Indications: Hemorrhagic Shock, Hyphema, post partum bleeding, menorrhagia, epistaxis, gum bleeding, hemoptysis. 

Ketamine:  NMDA receptor antagonist, opioid receptor agonist.

Uses include:  procedural sedation, analgesia, medical restraint, post intubation sedation, adjunct to asthma/COPD treatment (bronchodilator), anxiolysis/eg facilitate BIPAP

Magnesium: 

Uses:  Torsades, Magnesium deficiency, asthma/bronchospasm, pre-eclampsia/eclampsia, Afib RVR, Tocolytic, SAH induced vasospasm, migraine, constipation

Haldol:  Antipsychotic, dopamine antagonist, serotonin agonist

Acute Psychosis, chemical restraint, cyclic vomiting, gastroparesis, hypemesis cannabinoid syndrome, migraines

11:00 am -12:30 pm:  Head and Neck Trauma, Drs. Maddelynn Hawkins, Amanda Friend and Graeme Twanow.  Unfortunately I missed this outstanding lecture.

Conference Notes 9-20-2017

Cirone/DeStefani     Oral Boards

Case 1.   20 yo female who appears intoxicated. Patient was brought in by her roommate who was concerned about her.  Patient was at dorm party the night before.  On exam patient is disoriented.  She is tachycardic and her mucosa is dry. ABG shows metabolic acidosis.  Patient also has an osmolal gap.  Patient was treated with IV fomepizole.   Toxic alcohol screening was positive for ethylene glycol.

Anion and Osmolar Gap Calculations.  For the calculated osmolality, you can also factor in ETOH by adding ETOH/4.6.  The way to remember 4.6 is that there are 4 six packs in a case of beer. For easy calculations on boards round 4.6 to 5.

Case 2. 19yo female presents with "flu symptoms" with fever and muscle aches.  Patient had some nausea and vomiting.  She also had a bloody nose.  She is tachycardic and hypotensive.   On exam patient has a petechial rash. Labs show thrombocytopenia and AKI.  Lactate is also elevated.   Diagnosis is disseminated meningococcemia with DIC.

Meningococcemia Rash

It can be tough to differentiate these diagnoses but DIC has coagulopathy with prolonged PT/INR whereas the others do not.

Case 3.  19 yo female with blunt trauma to right eye.  Patient has worsening visual acuity of injured eye with associated afferent pupillary defect.   CT shows retrobulbar hematoma.   Treatment is lateral canthotomy.

Felder      OB-Gyne Jeopardy

Retained placental tissue can result in persistent vaginal bleeding days after delivery.

If a patient has a seizure in the second half of pregnancy or in the post-partum period, treat with magnesium for ecclampsia.  Mag dosing is 6g IV followed by a 2g/hr drip.

Molar pregnancy

Management approach to gestation trophoblastic disease.  It is a bit beyond what is needed to be known for EM but it may be helpful to know that OB will follow up with serial HCG's and a CXR and base further management on those screening tests.

If you have some clinical suspicion for cervicitis or PID, just treat them in the ED.  Don't wait for the results of testing.  Many patients cannot be contacted after they leave the ED.

In a child, foul smelling vaginal discharge is highly suggestive of vaginal foreign body.  The most common vaginal foreign body in a child is retained toilet tissue. You can most easily remove the foreign body with saline irrigation.

Most common organism causing mastitis is staph aureus.

Consider HELLP syndrome in every patient >20 weeks pregnant with RUQ pain.   LDH will be elevated in HELLP syndrome. 

Tubo Ovarian Abscess is usually initiated by GC or Chlamydia and as the infection progresses it becomes polymicrobial.  Treat with broad spectrum antibiotics.

Side effects of post-exposure prophylactic medication for HIV include fatigue, nausea, and abdominal pain.

When is radiation exposure the greatest risk to the fetus? 2-8 weeks during organogenesis.   At 8-15 weeks the fetus is prone to neurodevelopmental issues.   After 15 weeks there may be growth retardation.  However, all the ED imaging studies we do, including CT's, are under the 10rad threshold for causing teratogenic effects.

Muhammad        Pediatric Pearls

Treating a hair tourniquet

Hair tourniquets can be on multiple digits

Cut down to the bone in the mid-line dorsal position of the digit.  Alternate therapy is NAIR but Nair is not fool -proof.   Cutting down to bone is more reliable to remove the hair tourniquet.

 Other causes of fussiness to consider in an infant are #1 sepsis,  non-accidental trauma, and uti.

Colic is another common diagnosis for fussiness in an infant less than 3 months of age.

Paradoxial irritability, where the child does not want to be held, points to meningitis.

Purrulent eye drainage 3d-3weeks.  Get culture of eye drainage and treat with ceftriaxone and erythromycin to cover GC and chlamydia.

Uric acid crystals in the diaper can look like blood in the diaper. It will be heme neg.  It has a salmon color. No need to get a UA, it is benign. Encouraging parents to increase child's fluid intake may lessen this finding.

Uric acid crystals in diaper. 

Williamson   Physical Wellness

Take the time to see your doctor and to see your dentist!   We as docs don't take the time to do this.  It is important.

Sleep deprivation has major physical and cognitive impacts.  It will negatively affect your interpersonal relationships. So prioritize your sleep!  Sleep is the #1 factor to a person's wellness.

Eat food, mostly plants, not too much.  That is eat real food, not food-like substances. Don't drink your calories.  Plant-based foods should predominate in your daily food intake.  Watch your portion size. Leave the table a tad bit hungry. It takes your body 20-30 minutes to feel full and if you eat real fast you may overeat before you feel full.

Don't eat anything with more than 5 ingredients or with any ingredient you don't recognize.

You don't need tons of exercise to be healthy.  150 minutes a week of moderate exercise or 75 minutes of vigorous exercise a week is recommended.

Exercise is the #2 most important factor to a person's wellness.

Conference Notes 9-13-2017

SurvivED      Windy City EM

This week's Conference was a City -Wide meeting of all the EM Programs in Chicago.  Each Program presented one great "Save"  I will give just a few learning points from the day.

ACMC's own Mitch Lorenz      

 Severe hypokalemia and hypomagnesemia from GI losses can cause prolonged QT and torsades.  Torsades can result in cardiac arrest.  Keep severe electrolyte abnormalities such as hyperkalemia, hypokalemia, and hypomagnesemia in your differential for patients with arrhythmias.

Editors note: Another setting that can result in profound hypokalemia and malignant arrhythmia is when treating DKA with IV insulin and the potassium level is not carefully managed. 

Mitch Lorenz represented ACMC EM in outstanding fashion at the Windy City EM meeting.

Everyone else:

In hypotensive patients, the bedside ultrasound is your friend.  You can't see pericardial tamponade on CXR and it is hard or impossible to diagnosetamponade with physical exam.  Ultrasound at the bedside will drastically shorten the time to diagnosis of pericardial tamponade.  In the setting of hypotension it can also identify tension pneumothorax, a big RV due to PE, cardiogenic shock, intra-peritoneal blood, and AAA.

If you do identify a pericardial effusion in a patient with chest or back pain consider CTA of the chest to evaluate for aortic dissection.  Proximal aortic dissections can cause pericardial tamponade.

All the presented cases emphasized the importance of continually re-assessing your patients.

There is some data and anecdotal experience that ant/post placement of defib pads is more effective than shoulder/apex placement.  There was great save case discussed that hinged on placing the defib pads in the anteror/posterior position.  We may want to consider doing this in all cases.

Exerpt from Supporting Reference: Botto, BMJ Heart 1999;82:726–730

This reference discusses AFIB but the message I think would be similar for any arrhythmia.  CONCLUSIONS An antero-posterior defibrillator paddle position is superior to an antero-lateral location with regard to technical success in external cardioversion of stable atrial fibrillation, and permits lower dc shock energy requirements. Arrhythmia duration is the only clinical variable that can limit the restoration of sinus rhythm.

Patients who have experienced violence will internally feel severe anxiety, anger, and hyper-vigilance or awareness for future violence.  Healthcare providers can alleviate this somewhat by speaking in a friendly manner with the patient prior to delving into the medical issues at hand. Ask permission to examine them before touching their body.  The patient appreciates being treated as a person and having some small talk prior to doing the H&P.

Conference Notes 8-23-2017

Ryan/Traylor     Oral Boards

Case 1. 65 yo male with right flank pain.  He has a fever and is borderline tachycardic. Patient has history of lymphoma and is on Chemotherapy.   On exam, patient has a herpes zoster type rash on right flank and multiple other areas of his body. 

Diseminated Herpes Zoster (DHZ) Rash.  It is bilateral and is not localized to a single dermatome. The condition is called disseminated herpes zoster (DHZ) when more than 2 contiguous dermatomes are affected, more than 20 vesicles are observed outside the initial dermatome, or involvement is systemic. DHZ is rare and most frequently occurs in immunocompromised patients.

The patient has neutropenia on CBC.  IV acyclovir was started 10mg/kg Q8 hours.  Patient was also given antibiotics for neutropenia.

Airborne precautions: Airborne droplet nuclei measuring ≤5 μm can remain infective and suspended in the air for hours at a time, particularly in enclosed and poorly ventilated spaces. Airborne transmission of tuberculosis,63-65 measles,66,67 and severe acute respiratory distress syndrome (SARS)68–70 has been described in ED settings. Varicella(including disseminated zoster), highly pathogenic influenza, and smallpox may also be transmitted in this manner. Rapid identification and isolation of ED patients suspected of harboring an airborne disease hinges greatly upon heightened clinical suspicion, as in the case of tuberculosis.71Proper HCP protection against airborne droplet nuclei requires use of either an N95 or powered air purifying respirator. (Liang, Ann Emer Med 2014)

Case 2.  19yo female presents with right side abdominal pain.  She has fever and tachycardia. UCG is negative.  On history, patient has abnormal vaginal discharge.  Exam demonstrates RUQ tenderness as well as CMT and bilat adnexal tenderness on pelvic exam. 

Liver enzymes are not diagnostic.  They may range from normal to markedly elevated.

Treatment should include

• Doxycycline + cefoxitin or cefotetan

• Alternatives include gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline

• Continue parenteral antibiotic administration for 24 hr after clinical improvement, then switch to oral antibiotics to finish 14 day course

• Laparoscopy can be used to lyse adhesions in the acute and chronic stages of Fitz-Hugh–Curtis syndrome

• Add metronidazole when anaerobes are a particular concern

Case 3. 4 yo male with left hip pain and won't bear weight.  No fever. Other vitals are normal. History reveals patient had a mild viral illness a week prior.   X-rays are negative.  Labs are all normal. Diagnosis is toxic synovitis. 

You can differentiate toxic synovitis from septic hip by normal CBC, ESR, and CRP and no fever.  You should also get X-rays of the hip.   Harwood comment: Assessing the response to NSAID's is really a critical action.  If the child can walk after oral NSAID's that is a key finding to ruling out septic joint. 

2011 Singhal   Journal of Bone and Joint Surgery Br.   If a child has a normal CRP and can bear wieght, he/she has a low risk of septic joint.  Abscence of fever and low WBC count also help differentiate but are less predictive.

Toerne      ETOH Withdrawal

4 ETOH Withdrawal Syndromes include: Seizures, Uncomplicated withdrawal,  Alcoholic hallucinosis, and DT's.

Seizures: Occur early in the course of withdrawal. (within 48 hours of cessation of drinking) Commonly the first symptom of withdrawal.  These are brief, self-limited, generalized tonic clonic seizures.  

Uncomplicated Alcohol withdrawl: Hyperadrenergic vital signs and tremor.  There is no altered mental status.

Alcoholic Hallucinosis: Rare syndrome.  Patients have hallucinations with otherwise intact mental status.  Ted says he is not certain this syndrome exists.

Delirium tremens:  The patient has adrenergic storm plus delirium.  Delirium defines this syndrome.  This can occur 3-10 days after cessation of drinking.

First management goal is to identify the patients in withdrawal or at risk of withdrawal.

Ted-T's key screening questions: How many days per week do you drink? When you drink, how much do you drink?

Other clues to alcohol abuse include ruddy facial complexion, swollen hands and feet, hypokalemia, hypomagnesiemia, anemia with an MCV around 105, and thrombocytopenia.

Management: Provide a quiet environment with frequent re-assessment.  Screen these patients for other medical or traumatic problems.  Administer withdrawal-specific therapy.

Ted suggests:  Give two doses of lorazepam 2-4mg about 10-15 minutes apart.  If patient still has severe withdrawal symptoms following that, give 10mg/kg of phenobarbital.  If they still have severe withdrawal symptoms after lorazepam and phenobarbital, they are headed to the MICU.   At that point start 5mg/hour lorazepam drip.  Give another 5mg/kg of phenobarbital.    If still having trouble managing withdrawal symptoms, the third line drug would be ketamine.   Ted advocates early use of phenobarbital if the initial lorazepam is not controlling the patient's withdrawal signs.

Dawson          Pediatric Sepsis

Gabby's Law requires screening protocols and severity stratification of pediatric sepsis.  It also requires reporting of pediatric sepsis in Illinois.

Remember that irritability or lethargy can be a sign of organ dysfunction (CNS).   Lactate is not reliable for identifying sepsis in pediatric patients.  If it is high, it is concerning.  If it is normal the child may still be septic.

Risk factors for sepsis include: cancer, transplants, immunosuppression, short gut, congenital heart disease, indwelling lines and devices,  chronic medical problems.

We screen for pediatric sepsis with vital signs and a bedside huddle.

This child's vitals point to sepsis.  Next step is a bedside huddle with other caregivers to decide if further concern for sepsis is warranted and continuing down algorithm or if the patient has an alternative diagnosis.

In the first 20 minutes give a first IV fluid bolus 20ml/kg, start high flow O2, and get antibiotics ordered.

You need to get IV fluids into a kid rapidly using a push-pull method. Give 3 20ml/kg boluses in the first hour.  Give antibiotics in the first hour.  Start high flow O2 on all suspected sepsis patients.

Berklehammer        GI Bleeding

Unfortunately I missed this excellent lecture.

Conference Notes 7-26-2017

Carlson           Pediatric Toxicology Problems

Top 5 Pediatric Exposures in Frequency

1. Cosmetics and personal care products

2. Household cleaning products

3. Analgesics

4. Foreign bodies, toys

5. Topical preparations

Poison control centers are able to manage a large number of patients at home so they don't need to present to an ED.  There has never been a case in the last 15 years of a patient managed at home by the poison center who had a bad outcome.  They are very conservative in their management and will send the patient to the ED if any doubt.   So.....Support your local Poison Control Center!

Most common causes of pediatric deaths due to toxin exposure 2015:  (N=66) 1. Analgesics (ASA, APAP), 2. Button batteries, 3. Fumes, 4. Stimulants, 5. CardioVascular drugs.

How are products tested to determine if they are child-resistant?

Panels of 50 children (42-51 months) are tested sequentially following division into three age categories (42-44 months; 45-48 months; 49-51 months). The testing period is 10 minutes and children are instructed on how to open the package and that they may use their teeth.  If test results are inconclusive, additional testing involving one or more groups of 50 children each is required. A maximum of 200 children may be tested. (Consumer Healthcare Products Assoc)

Biggest EM Toxicology Concerns for Kids: Calcium Channel Blockers, Camphor, Clonidine, TCA's, Opioids, Lomotil, Methylsalicylate, Sulfonylureas, and Toxic alcohols.

Latest thinking on management of carfentanil (100 times more potent than fentanyl)is that it is very similar to the management of heroin.  Patients don't necessarily need huge doses of narcan.  They likely will respond to normal doses of narcan.  

Carfentanil:    "The drug was never intended to be consumed by humans. But it has been used to kill and immobilize humans — reportedly, in assassination attempts and by Russian Special Forces in 2002. They apparently used it in aerosol form as a knockout gas to end a hostage situation. Tragically, the gas ended up killing more than 100 hostages.

Boos is the section chief for the Diversion Control Division, of the DEA's Drug and Chemical Evaluation section. He says the only legitimate use of the drug is as a tranquilizer for very large animals, like elephants or hippos. So there's no medical literature to consult for its effects on humans. That knowledge is being gained the hard way, by first responders."  (NPR Reference)

For button batteries in the esophogus, ear or nose, get them out in 2-4 hours.  If it is in the stomach or GI tract it can be managed expectantly with serial abdominal xrays.

Really worry about these toxins: diltiaem/verapamil, methadone, methanol, hydroflouric acid, colchicine, paraquat, amanita mushrooms, cyanide.

Worry about these toxins: beta blockers, clonidine, TCA's, MAOI's, atropine, ethylene glycol, sulfonylureas, theophylline, carbamazepine, causits, salicylates

Dont worry about these toxins: brodifacum, Chlorox bleach(3% sodium hypochlorite), ACEI, ARB, diuretics, cholesterol medications, antibiotics, OTC camphor products, Ibuprofen, H2 blockers, Actos/Avandia.

It is always OK to not give activated charcoal.   There is a 1 hour window from the time of ingestion of toxin to give the charcoal.  Outside of the 1 hour window it has little effect. It is tolerated best when mixed with chocolate syrup and drinken with a straw from a closed cup.   Never place an NG tube to give charcoal.  Never force-feed charcoal to a child.  The risk of aspiration of charcoal is significant.

Traylor     Code STEMI

Start with IV access, consider O2 (some question of benefit), place patient on a monitor, give po ASA, give IV Heparin 4000U bolus followed by 12U/kg/hr drip.   Give Plavix vs Brilenta based on Cardiolgoy preference.

PAIL is a nice mnemonic to remember reciprocal changes.  The letter following the prior letter is where the reciprocal changes will be.  Posterior MI -Anterior depression, Anterior MI -Inferior depression, etc.  

With Inferior MI's, if the ST elevation in lead 3 is greater than lead 2 you are more likely to have an RCA occlusion.

EKG suggestive of RCA occlusion.   Editor note:  A mnemonic I just made up is 3-2-1. ST elevation in 3>2 and ST depression in Lead 1.

EKG suggestive of Circumflex Occlusion.  Editor note: My next mnemonic is 2-3-none.  ST elevation is 2 and 3 are equal with no ST depression in Lead 1.    So, 3-2-1 and 2-3-none are mnemonics you can use to differentiate a RCA and Circumflex occlusion.

Wellen's syndrome is a sign of critical LAD stenosis. These patients are at high risk for Anterior MI and should not be given stress testing.  They need a cath.

De Winter EKG changes are considered an Anterior STEMI equivalent

Lovell    Occupational Wellness

The work culture and the system you work in is the largest factors contributing to burnout.  Factors in the work environment that are detrimental to wellness include loss of autonomy, and feeling undervalued by leadership or administration. 

Ways to battle burn out: 

1. Find Compassion role-models.  Try to model your behavior on people who are genuinely caring toward others.  These people can be uplifting to you in your work.   Make a connection with each human being you care for.

2. Your patients are not your enemies.  Patients are just looking for help.  They may have low health literacy.  Be their ally.  That mind frame is much more positive and better for your own wellness.

3. Foster social resilience.   You and your co-workers are really a tribe .  Being able to rely on others in your tribe is a big factor in your personal wellness as well as in your fellow tribe members.

4. Coping with medical error.    Acknowledge your own imperfection, learn and teach about mistakes, and most importantly forgive yourself.

5. Develop a growth mindset.   Your learning and knowledge evolve over time.  Learn to value feedback and even look for feedback.  Support other people's successes.     Avoid the fixed mindset where you feel your knowledge is fixed and you see other's successes are a threat.

6. Read about Medical Humanism

7. Mitigate your Unconscious Bias    You can go to Implicit.Harvard.edu and measure your implicit bias.  Try to take the perspective of people different from you.  Read a the article "How to be a real EP; Advice to new Graduates"  Roberts.  Editor note: Great article and pops up with a quick google search.

Excerpt:

Always put the patient's well-being and the family's expectations first and foremost. Everyone thinks you know far more than you actually do, so take advantage of that lovely yet secret scam, and step up and portray the Godsend they expect and want to believe you are.

Above all, always, always, always be nice. Remember, patients and family rarely remember exactly what you said, but they always remember exactly how you made them feel. There is only one time to make that first impression, a great opportunity to brand yourself as a hero and angel of mercy or a complete jerk. Be nice to the cleaning lady, security guard, cafeteria worker, and x-ray tech. And learn their names; they know yours.

In the end be kind to everyone you meet for they are all fighting a hard battle.  Ian Maclaren

Sklar    Safely Discharging ED Patients

The ED discharge process is high risk.  However, many physicians find the discharge process time consuming and not all that important. We need to re-cnsider our approach to discharging patients from the ED. 

We overestimate the patients' understanding of discharge instructions.  Only 22% of the time do we confirm that the patient understands our instructions.   Only 16% of the time do we ask if the patient has any questions.

Patients who do not understand their diagnosis and treatment plan are more likely to be non-compliant, bounce back to the ED, have increased morbidity/mortality, lower satisfaction, and increased risk of pursuing malpractice litigation.

Poor discharge planning and instruction is the #2 cause of malpractice litigation in EM. 

Factors increasing discharge risk: incomplete or misunderstood instructions, overly-fast discharge due to production pressure, discharge without reconciliation of symptoms and test results.

Discharge is really a Hand-Off to the patient's self care.  Treat discharge time similar to how you sign out patients to another physician.  Take the time and care to discuss with the patient and their family what they need to do at home to get better.

The majority of malpractice cases involve a patient who was discharged home. The emergency physician should have a template or checklist for safely discharging patients.

mnemonic WTF DR DC:

What we found, Treatments, Follow up plan, Drugs, Restrictions, Diagnosis, Come back if.....

mnemonic as a Discharge TemplateWTF DR DC?

AMA is a high risk ED discharge situation.  The above points are all very important.

Great summary of using the discharge time period to make one last re-evaluation of the patient, their vitals, and their diagnostic testing results.

Walesa      Infection Control Update

Bottom line: Wash your Hands. It is the #1 way to prevent the spread of infections.   Minimize your use of urinary catheters. 

Hospital acquired infections are common (75,000 patients per year), potentially deadly, and very costly.

There are more bacteria in your mouth than there are people on the earth.

A handshake transfers 124 million bacteria between the two people.

Fingernails, thumbs, and webspaces are the spots most commonly missed when washing hands.

Hand sanitizer kills bacteria better than soap and water, except norovirus and c-diff.

When placing a central line, the chlorhexadine prep needs to dry to kill the bacteria.

Conference Notes 7-19-2017

Girzadas/Marshalla     Oral Boards

Case 1.  29 you female extricated from an MVC.  Patient is 35 weeks pregnant. Patient has abdominal pain and vaginal bleeding.  She is hypotensive.  Fast exam reveals no intra-abdominal bleeding. Pelvis is stable.  Diagnosis is traumatic placental abruption.  Management: With C-spine precautions, tilt patient to left side to displace uterus off the vena cava.  Replace volume loss with crytalloid and blood products.   Initiate massive transfusion protocol.  Monitor the fetus.  Patient needs to go for emergent c-section. 

Abruption can cause DIC which may necessitate FFP, Platelet, and or Cryopreciptate transfusion.  Consensus among the faculty was that TXA would also be indicated in this case.

U/S is insensitive for diagnosing placental abruption.  Fetal monitoring is more sensitive.  Have a low threshold in pregnant women with a viable pregnancy who suffer a fall, mvc, or other trauma to send the patient to L&D for monitoring.   The placenta is inelastic.  With trauma or deceleration the uterus will deform and the placenta won't causing a shear stress that results in abruption.

The initial symptoms of abruption can be mild or overlooked.  The standard fetal monitoring period is 4 hours.  If the monitor shows infrequent contractions and normal fetal heart rate, the patient can be discharged after 4 hours.  If the patient has more frequent contractions or a worrisome fetal heart tracing the patient will be kept for a long period of time.

Case 2.  31 yo man with palpitations.  Initial EKG shows fast, irregular rhythm with varying QRS intervals.

Elise comment: Know this EKG.  Irregular, wide and narrow, fast.  The answer for this EKGis always procainamide if stable, synchronized cardioversion if unstable.

Patient then became unstable with hypotension and altered mental status.  EKG now shows:

WPW with AFIB has degenerated to a wide complex, very fast tachycardia.  With the patient being unstable, immediate synchronized cardioversion is indicated.

EKG after cardioversion shows WPW syndrome with clear delta waves.

Patient was admitted to cardiology service for catheter ablation.

Case 3. 6 yo child with injury and gross deformity of left elbow after a fall from bike.  Xrays show displaced supracondylar fracture (Gartland 3)

Keys to management include careful neuro-vascular exam of injured extremity.  The most commonly injured nerve with supracondylar fractures is the median nerve.  A pure motor branch of the median nerve that is commonly injured is the anterior interosseus nerve.  This nerve is tested by seeing if the patient can perform the OK sign.

Supracondylar fractures have high risk for vascular (brachial artery) injury, nerve (median and radial) injury, compartment syndrome, and chronic boney deformity (cubitus varus).  Untreated, compartment syndrome can result in volkmann's ischemic contracture.

Non-displaced supracondylar fractures with intact NV status can be splinted and dc'd home with close Orthopedic follow up after consultation with Orthopedic Specialist.  Class 2 fractures with an intact posterior cortex will be treated on a case by case basis per Orthopedic surgery.  Some may be able to be discharged, some may need to have ORIF and admission.  All Class 3 fractures are going to the OR. If the patient has a good pulse and warm fingers there is no need for emergent manipulation of the fracture in the ED.  If the pulse is diminished and the fingers are warm, have cap refill, and/or have a good pulse ox wave form then again there is no need for emergent ED manipulation of the fracture.  This patient can be managed in the OR.  If the pulse is diminished and the fingers are cool or have poor cap refill or have poor pulse ox waveform and there will be a delay to going to the OR then after discussion with the Orthopedic Specialist, the emergency physician may need to attempt reduction of the fracture prior to the patient going to the OR.

Williamson      Study Guide      GI Emergencies

American College of Gastroenterology Guideline for Diarrhea Management 2016

Treat traveler's diarrhea with cipro or azithromycin.  Traveler's Diarrhea has high enough risk of bacterial pathogen to warrant antibiotics.  Below are recommendations by the American College of Gastroenterology

Viruses are the most common cause of diarrhea. Campylobacter is the most common bacterial cause of diarrhea presenting to the ED.  

Most common cause of food poisoning is staph gastroenteritis.

Glucagon showed no benefit over placebo for treatment of esophageal food impaction.

Crohn's and Ulcerative Colitis

Crohn's and Ulcerative Colitis

Ogilvie's syndrome can be treated with neostigmine.  Alternative treatment is colonoscopic decompression.

Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P<0.001). The median time to response was 4 minutes (range, 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine.  (NEJM 1999 341:137)

Anthony Gallaway Equality Illinois    LGBTQ Ally Development Training

Gender identity does not define Sexual Orientation and Sexual Orientation does not define gender identity.  

Sex assigned at birth does not define gender identity or gender expression or sexual orientation.  

As a physician, sometimes it is medically necessary to delve into a patient's gender status.  If there is some uncertainty on the physician's part about a patient's gender (biologic, identity, expression),  one suggested strategy is to introduce yourself and say these are my pronouns (she, her, her's, or he, him, his). You can then ask the patient, "what are your pronouns?"    If indicated to appropriately treat the patient, you can ask, "What gender were you assigned at birth?"    If medically necessary, you can ask further, "Do you have sexual relations with males or females or both?" If a genital exam needs to be performed, be sure to fully inform the patient what will be done as part of the exam.   Throughout all this history and physical process, it is most important to be supportive and caring. Demonstrating that you are an ally will help the patient the most.  Only delve into these questions if it is important to care for the patient medically.  If the answers to these questions are not directly relevant to the patient's care, don't ask them. 

Intention is everything.  If you make some mistakes while being well-intentioned and caring it is OK.

To re-emphasize, as a clinician you don't always need to know the patient's sexual assignment at birth or their gender status.  So you definitely don't always need to ask those questions.

LGBTQ patients have fear or discomfort with medical care because they don't know if the medical providers are going to be supportive or judgmental/disapproving of them.

A person can take Truvada with use of a condom to prevent HIV infection. This is called PREP (pre-exposure prophylaxis).

It means so much to LGBTQ patients to express a supportive and welcoming attitude.  Ask, "How can we help you today?"  Use your smile and your warmth when you ask this.

Ohl     Sedation and Paralytics

Sean discussed the sedation medications and neuromuscular blockers used for Rapid Sequence Intubation.

Sean then discussed the key points to rapid sequence intubation. 

Wing       EICU Process for Patients Awaiting a MSDU Bed

Elisa discussed the new process for initiating EICU coverage for patients boarding in the ED while waiting for step-down beds.

Conference Note 7-12-2017

Yappo         Review of 2016 AAP Practice Guideline for BRUE

BRUE= Brief <1 min, Resolved, Unexplained, Event in an infant less than 1 year old. The event needs to have 1 or more of the following: apnea, pallor, change in breathing, change in tone, or decreased responsiveness.  By the time the child is in the ED the exam must be normal to be a BRUE.

You can do a quick evaluation of an infant's growth by looking for a previous ED visit. If the patient was in the ED for a prior visit you can get their weight at that time.   You then plot out that weight and the weight from the current visit to see if the child is appropriately gaining weight.   You can also just check the child's current weight against expected weights on the growth curve.  If a child is significantly below the growth curve in the setting of BRUE, you may need to consider abuse, neglect, or metabolic problems. An under-weight infant would take the patient out of the low-risk BRUE category.   Additionally, head circumference larger than normal on the growth curve may be a marker of non-accidental head trauma.

For BRUE, the apnea described by caregivers should not just be peripheral cyanosis.  For BRUE criteria, cyanosis should be central cyanosis. 

Central Cyanosis

Low Risk BRUE: Born after 32 weeks, >60days of age, no CPR required by a medically trained provider, event lasted less than 1 minute.

High Risk BRUE: Prior BRUE, history of congenital heart disease or inborn error of metabolism, family history of BRUE or sudden death, bruising or other signs of trauma, abnormal growth, abnormal vital signs.

Management of BRUE.  If you are going to do some tests on low-risk BRUE patients, consider an EKG, it has good negative predictive value if normal.  Pertussis testing is another consideration based on immunization status and seasonal prevalence.  Infants with pertussis may have gasping or apnea prior to cough or other respiratory symptoms.   Monitor the child for 4 hours in the ED with pulse ox and document repeated exams.  No need to search for occult infection unless the child is less than 2 months or appears ill.  Same with inborn errors. No need to look for inborn errors unless child is <2months, ill-appearing, or has family history of BRUE or sudden death.

Editors note: BRUE reminds me of the practice guideline for bronchiolitis.  The goal is to minimize treatment and interventions unless history and physical exam indicate a need to evaluate or manage further. 

Elise comment: Identifying the low-risk BRUE is challenging. You can't do this off the top of your head in the ED.  You need to pull up the guideline and go step by step through it in real time to be sure you are not mischaracterizing a high-risk child into the low-risk group. 

Marshalla   EKG Basics

A quick way to determine the rate is to divide 300 by the number of big boxes in the RR interval.

Normal Intervals

Quick way to determine axis based on QRS orientation in leads 1 and AVL.

Lambert   U/S Basics   Image Acquistion & Instrumentation

The brighter an object appears on the screen the more reflective it is to sound waves.

Sound waves travel slowly through air compared to the speed of sound through tissue.  Air causes significant image degradation due to the slow speed of sound in air.   Examples:  bowel gas will make it difficult to image the aorta.  The lung will hinder imaging of the heart.

Anatomic Planes and Axes

Imaging planes

Low frequency sound waves travel deeper into the tissue than high frequency sound waves.  You can adjust the frequency of the probe to optimize your image in relation to the patient's BMI.  There is an easy button our ultrasound machines with pictures of a thin man and a thick man.  Click on the picture that most closely represents your patient. That will optimize the frequency for the patient's body habitus.

Lambert     Bedside Echo

The main 3 views you will use at the bedside are the subcostal, parasternal, and apical views.

U/S Images from the 4 basic views

Subcostal 4 chamber view is the best view for identifying pericardial effusion.

Mike said that if you see fluid between the liver and the heart on the subcostal view, it is always abnormal.

When evaluating for PE with echo, you basically are looking for a big RV.

Big RV on Left side image.  Normal RV on Right side image

Lambert        Central Venous Access

Most operators use a transverse view to image the vessel. Standing at the head of the bed with the screen facing you, the operator, make sure your probe indicator is matched up with the indicator on the screen. They should both be directed to the left.

You want to approach the vessel at a 45 degree angle. So puncture the skin at the same distance from the center of the probe as the depth of the vessel to the probe. It is important to identify the tip of the needle to know where you are at. 

A has to equal B to make the 45 degree angle with the needle approach.

You can move the probe proximally and distally from the puncture site to identify the needle tip. Once you have identified the needle tip tenting the IJ vessel, make a small jab with the needle to puncture through the vessel wall and obtain blood return.   Once you pass the guidewire, use the probe in a longitduinal orientation to verify that the guidewire is in the IJ.   If you verify the quidewire is in the IJ, then you can confidently use the central line right away before obtaining a CXR.

Ultrasound Lab    Lambert and Team Ultrasound

Conference Notes 7-5-2017

Lovell/Ohl      Oral Boards

Case 1. 35yo male fell off a boat and suffered a severe laceration to his mid thigh from a propeller injury. 

• Patient has severe bleeding and a tourniquet is applied to the left thigh by EMS. 
• Massive transfusion protocol initiated in ED. 
• Patient also has signs of worsening hypoxia due to drowning.  Patient was then intubated. Patient was evaluated for other injuries. 
• TXA was given for severe hemorrhage.
• Patient went to the OR for femoral artery injury. 

Do not explore the wound locally. This patient has hard signs for arterial injury and is going to the OR.

In accordance with the ILCOR guidelines, patients should be referred to as drowning victims if they have suffered a suspected respiratory injury following submersion in a liquid medium, regardless of their clinical status, which may vary from essentially asymptomatic to severely ill at time of presentation. Additional descriptors such as whether there was a precipitating event that led to drowning or whether the drowning was witnessed may be used as necessary. The primary outcome of a drowning episode is either death or survival. Adopting this clinical nomenclature will allow future studies to better characterize, study, and risk stratify drowning victims.   EM Reports Vol 16 N. 32015.

Hard and Soft signs of arterial vascular bleeding

Case 2.  20 yo female with a headache for a few hours.  Normal Vital signs. Patient has nausea and left anterior neck and face pain as well.   Patient was on a roller coaster ride prior to the onset of this pain.   On exam patient has a horner's syndrome on the left side ipsilateral to where she is having pain.

Horner's syndrome on the left.   Horner's caused by internal carotid artery dissection will have ptosis and miosis but not anhydrosis.  Anhydrosis is caused by sympathetic ganglia around the external carotid, not internal carotid. 

CTA of the neck shows that the diagnosis was internal carotid artery dissection. 

• Treatment for extra-cranial dissections is usually anticoagulation. 

Case 3.  28 yo male with joint pain in bilateral wrists/hands and ankles. Patient has a temperature of 38 and otherwise normal vital signs. Patient has a few pustules on his hands and ankles.

Pustule from disseminated ghonorrhea

• Treatment is parenteral ceftriaxone for a minimum of 7 days.   Treat chalmydia presumptively as well.   

Dissemenated ghonorrhea can present with one of two syndromes: 1. dermatitis-tenosynovitis or 2. oligo arthritis.  Get an RPR and HIV test on every patient.  It is tough to make this diagnosis so swab urethra/cervix. If you can get fluid from a pustule or a joint also culture and gram stain that fluid.

Schmitz    M&M  

No case specifics, just a couple of take home points.

Get a CT scan of the head in patients who are intoxicated and have suffered head trauma.   If the patient refuses the study you have to carefully balance the patient's decisional capacity with the risk of intracranial injury.  Err on the side of imaging and sedate if necessary to get the study done.  Observation in the ED in place of imaging can be problematic for many reasons so getting a scan is the more fail-safe approach.

Be aware of anchoring bias.  Patients triaged to the hallway can still have serious injuries.

Be cautious of your cognitive biases.  Cognitive bias can mislead us. 

Be careful not to attribute a patient's behavior to some personality or character flaw rather than to their illness, pain, or injury. This bias is called the "Fundamental Attribution Bias"

Chiefs      Codes (44, Sepsis, STEMI, Stroke)  in the ED

Approach all these rapid response codes in the ED the same way every time.  Assess the patient's airway.  Evaluate their breathing and circulation.  Do a rapid NIH stroke scale and expose them completely to look for other problems.    In short, ABCDE's, IV, O2, Monitor, Dexi, EKG on all these patients.

35% of patients with sepsis progress to septic shock.  So if you identify sepsis, call a CODE SEPSIS.  It will get you nursing and pharmacy help for the care of that patient.

Our Goal is administering IV antibiotics within 1 hour of identifying sepsis.  If the patient has hypotension (systolic BP<90 or MAP<65) or a lactate of 4 or above they need 30ml/kg of IV crystalloid fluids.  If you have concerns that the patient cannot handle 30ml/kg of crystalloid you can alternately give 126ml/hr or higher of IV fluids and write a note in the chart discussing briefly why you felt 30ml/kg was unsafe for the patient. 

For CODE Strokes you need to do an NIH Stroke Scale.   Girzadas comment:  The NIH Stroke Scale is the new defacto EM Neuro Exam.  You need to do this on your patients with neurologic symptoms.

NIH Stroke Scale

Absolute contraindications to TPA for Stroke.  Take a close look on this chart at the factors regarding bleeding diathesis. 

Traylor      Ventilator Management

Indications for intubation: 1. protect airway,  2. inadequate oxygenation and/or inadequate ventilation despite non-invasive O2 support, 3. Respiratory fatigue or anticipated respiratory failure.

Ventilator Lung Protective Strategy  

Obstructive Ventilation Strategy   EMCRIT reference

Denk    Management of Shock

4 types of shock.

Treat hypovolemic shock with volume (crystalloid or blood products)

Treat with distributive shock with volume and pressors

Treat obstructive shock with volume and concurrently a needle, chest tube, impella device, thoracotomy, or TPA.

Treat cardiogenic shock with dobutamine/norepinepherine and concurrently activate cath lab for PCI and or mechanical support device.

Conference Notes 6-14-2017

Felder/Chastain/A. Patel/Tekwani/DenOuden    Panel Discussion    Efficiency in the ED

Prior to Seeing the Patient

Before you see the patient, do a brief chart biopsy to identify their basic diagnoses and identify who their PMD is.  Also, find the EKG before you see the patient.

Conversations with admitting physicians and consultants

When talking with consultants and admitting physicians, keep the conversations as brief as possible.  Using perfect serve to text the initial info to the physician can be helpful. When you speak with an admitting doctor or consultant give them a brief synopsis of the case and give them what you think needs to be done during this admission. It may be helpful to keep a note of the patient's name, MR#, and one line on their case to be prepared when the consultant calls.

You only need to speak with a consultant if you have a clinical question that needs an answer acutely in the ED or if the patient has an acute management need from this consultant.

Many panelists commented on the excellent utility of Perfect Serve when contacting consultants and admitting physicians.

Interactions with Nurses and Techs

Make sure the nurse knows the plan and the to-do tasks for each patient so they can focus and streamline care as well.

Utilize the ED Techs to help you get tasks done.

Management of the Patient

Do your best to make a diagnostic plan and place orders all at one time and avoid adding on tests later.

Always be continually running your list to check what you can do to move patients along in the ED process. Always be alert to delays with labs and imaging.  If you are always alert to where each patient is in their ED work up you can be ready to sign out at any time.

Put your discharge instructions right after you talk with the patient initially.  That is the time when you will best recall your conversation with the patient and what your plan is.

Work to find the rate-limiting step for each patient and solve that rate-limiting step.

Interactions with Patients

Always ask the patient what they are worried about or what diagnosis they think they have.  Most patients google their symptoms and have preconceived concerns about what they have going on.  If you can specifically address their concern, you have a better chance to achieve higher satisfaction.

One strategy to end the conversation with the patient is "I am going to step out now and order your tests and get your work up started.  I will be back to check on you later."

Another closing strategy is to summarize with the patient what you perceive their diagnostic problem is how you are going to work it up, what the treatment plan in the ED will be,  and what the likely dispo will be. 

Schmitz     Safety Lecture     Sepsis

For the entire Advocate System, mortality for sepsis has decreased by close to 25% between 2015 and 2017!

Advocate is starting to gather data on patients that were seen as outpatients within 72 hours of an ED visit for sepsis.  The system is trying to find ways to earlier identify infections that can develop into sepsis.

Schroff      5 Slide Follow Up

Subclavian Steal   Because of a stenotic subclavian artery, exercise with the affected (left) arm steals flow from the vertebral artery which can result in syncope or neurologic symptoms.

Hart/Regan      Ortho Cases

EM Boards Classics: Montaggia and Galeazzi fracture dislocations. You gotta know these.  Montaggia is fracture of the proximal ulna with dislocation of the radial head.    Galeazzi is fracture of the distal radius with dislocation of the radio-ulnar joint.

This is a distal biceps tendon rupture.  The muscle is bunched up superiorly.  The proximal bicep tendon can also rupture and result in the muscle bunching up inferiorly

Best Conference Attendance for the Year

#1 Jeff Florek #2 Anita Schroff#3 Jenny Denk

Congrats to Jeff, Anita, and Jenny!!! Outstanding effort this year!!!!!

Garrett-Hauser     Ethics

Steps to taking custody of a child: #1 Call the Hospital Administrator to notify them.  #2 Call DCFS #3 Discuss with the parent. You may need security on hand when you have this conversation.  These are very high risk situations. Utilize all your hospital resources: risk management, chaplain, security, nursing, and if needed, the police.

How do you change the code status for wards of the state?   The most straight forward way is to call the phone number of the patient's guardian listed on their paperwork and and discuss the management of the patient with the guardian.

For developmentally delayed patients who are not kids or elders and have a need for placement in a NH or safe environment, utilize the care managers.  They have the skill set to get the patient placed in a safe environment.  PLOWS is the state agency that helps to place adult patients who do not fit into the pediatric or elderly categories.

Regan and Alexander     The Last Lecture

Very clever, heart-warming, and funny reminiscing of the Class of 2017.  

ALL the BEST to the Class of 2017!  

Conference Notes June 7

Kettaneh/Destefani    Oral Boards

1. 65 yo male with severe vomiting. Initial vitals normal except for tachycardia.

Boerhaave's syndrome can have findings of minimal mediastinal air such as this CXR or large pleural effusion and even pneumothorax as discussed in this case.  Esophogus usually ruptures at the left, posterior aspect. Thus you should look to the left side of the thorax for air and fluid on CXR.

Treatment was thoracic surgical consultation, IV fluid resuscitation, broad spectrum IV antibiotics, and chest tube to drain large pleural effusion.

2. 54 yo female with URI symptoms and headache for 5 days. Vitals are normal except for mild increased respiratory rate and fever.  Diagnosis was meningitis. Give steroids before or at the time of antibiotics. IV steroids have shown the most treatment effect for meningitis due to Strep pneumo.  Strep pneumonia is the most common bacterial cause of meningitis in adults.  Give vancomycin and ceftriaxone.  Consider ampicillin for listeria in patients over age 50.  Consider acyclovir for herpes encephalitis.    Nick and Andrea made the same comment: Strep meningitis may present with mild symptoms initially. So you have to keep your guard up. 

Graph showing the incidence of different etiologic agents of meningitis base on age. Strep pneumo is predominant after for patients 19yo and up. Listeria is increased at less than 1 month and over age 60. 

3. 5 yo male with URI symptoms for 5 days. Vitals are normal.  Patient has had fever during the last 5 days.

Patient had clinical findings consistent with Kawasaki's disease

Diagnostic criteria for Kawasakis Disease.  It is also called muco-cutaneous lymph node syndrome.  This term is a brain hack to remember the criteria for diagnosis.

ESR and CRP are usually elevated in the setting of Kawasaki's.  Treatment is po ASA and IVIG.

Carlson      Toxicology Axioms for the EM Graduate

Toxicologic Mimics

Iron toxicity, ASA, and toxic alcohol poisoning can mimic DKA

CO, arsenic, and digoxin toxicity can mimic food poisoning

CO poisoning can mimic SAH hemorrhage

Salicylate overdose can mimic meningitis

Cyanide, CCB's and ASA overdoses can mimic sepsis

Toxidromes

CCB's, Beta blockers, Organophosphates, botanical cardiac glycosides, flourides, clonidine, sodium channel blocking drugs, INH and gyromitra will all need very large doses of antidote.  Carfentanyl also requires very high doses of naloxone. Most protocols for treating carfentanyl overdoses recommend early intubation to avoid using up stockpiles of narcan.  

Gastric lavage is rarely necessary to manage an overdose.  Charcoal administration is also very infrequently required to manage an overdose. If you have any concerns about vomiting or aspiration, you can feel OK about not giving charcoal. 

Get serial levels of salicylate, vlaproate, lithium, tegretol, and theophylline if you have concerns that any of these substances could have be taken in overdose.

Even if you aren't sure of the overdosed medication, many time you can still treat effectively. This is because most of toxicology is supportive care: protect the airway, treat hypotension, cool the hyperthermic patient, correct acid/base abnormalities, prevent renal injury, dialyze as needed, and protect against self-harm.

Williamson      "So you got a Subpoena"

This lecture is not about medical malpractice but rather about subpoenas physicians receiveto testify as a medical professional.

If you receive a subpeona for medical records, refer the request to risk management.

3 types of cases you may be asked to testify: civil, criminal, DCFS.   For civil cases provide testimony on the substance of treatment, the patient's medical condition, and their prognosis.   For criminal cases, you may be asked to provide medical testimony regarding a crime.  DCFS may subpoena you to testify regarding your clinical findings about a child who may have suffered abuse or neglect.

Always contact risk management when you get a subpoena.  Check with your hospital whether they provide legal counsel for treating physician testimony that is not medical malpractice related. Most hospitals do not offer legal counsel for non-malpractice issues.  However, if they do, take advantage of it. It is always helpful to have a lawyer advising you.

The scheduled time on the subpoena is not accurate.  You need to contact the law office to find out the real time.  There is usually some flexibility regarding the date and time of your testimony that you can negotiate with the lawyer.  For depositions, you can ask for a location that is convenient for you.

For depositions for civil suits you should ask to be paid.   Most faculty say they ask for somewhere between $300-500 per hour.   You will be paid at the time of deposition.  When calculating your time, include your travel time.

AMG suggested fee schedule for depositions, testimony, and record review.

There was a discussion about whether it is reasonable to review the chart prior to going to a deposition or trial.  Most faculty said they would ask for the chart through risk management and not go into the patient's medical record on their own. 

Wear a suit to the deposition or trial.  You are being judge on your appearance and statements. Many depositions are recorded on video.

Always review the transcript of your testimony.  Don't waive your right to review the transcript of your testimony.

When giving a deposition always tell the truth.  Your answer has to be right, correct, and accurate. Do not answer hypothetical questions.

Elise comment: You have to be like a rock during a deposition, emotionless.   The lawyers are trying to get you to react.  Don't take the bait.  Always, answer calmly sticking to the direct facts that are documented on the medical record.  If they are asking questions of the case beyond the medical record, you can say repeatedly "I have no independent recollection"

Dennis comment: Cautiously give as focused and as limited an answer that you can give to each question.

If you get served a subpoena for medical malpractice, contact risk management immediately and don't discuss with anyone else.

Logan    5 Slide Follow Up   20+ week Peripartum Emergencies

Peripartum Cardiomyopathy   Diagnose with echo.  Treat with nitorglycerine, diuretics, inotropes, and heparin.

Thromboembolic disease   5 times greater risk during pregnancy and 60 times the risk for 3 months after pregnancy .  Treat with heparin which does not cross the placenta.

Pre-Ecclampsia and HELLP   Diagnose with a straight-cath Protein/Creatinine ratio.   Treat with magnesium, BP control, and delivery.

Placental Abruption   Diagnose with fetal monitoring.  U/S is not sensitive for placental abruption.

Hawkins    5 Slide Follow Up    Calcium Channel Blocker Overdose

Management(Life in the Fast Lane Reference)

• early intubation and ventilation when life-threatening toxicity is anticipated
• Early invasive blood pressure monitoring if evolving hypotension and shock; initiate therapies below

Specific treatment (support cardiovascular system)

• Fluid resuscitation (up to 20 mL/kg crystalloid)
• Calcium
  • can be a useful temporising measure to increase HR and BP
  •  options
    • 10% calcium gluconate 60mL IV (0.6-1.0 mL/kg in children)
    • 10% calcium chloride 20mL IV (0.2 mL/kg in children) [must be given via CENTRAL VENOUS ACCESS – it burns!]
  • repeat boluses can be given up to 3 times
  • consider calcium infusion to keep serum calcium >2.0 mEq/L
• Atropine: 0.6mg every 2 min up to 1.8 mg (often ineffective)
• High dose insulin – euglycaemic therapy (HIET)
  • see below
• Vasoactive infusions
  • titrate catecholamines to effect (inotropy and chronotropy); options include dopamine, adrenaline and/ or noradrenaline
  • if vasoplegic, consider noradrenaline and vasopressin. Consider methylene blue if refractory (to decrease cGMP formation, scavenge nitric oxide, and inhibit nitric oxide synthesis leading to vasoconstriction).
• Sodium bicarbonate
  • consider in severe metabolic acidosis
  • 50-100 mEq sodium bicarbonate (0.5-1.0 mEq/kg in children)
• Cardiac pacing
  • electrical capture may be difficult to achieve and may not improve overall perfusion
  • use ventricular pacing to bypass AV blockade, typical with rates not in excess of 60/min
• Intralipid
  • consider in refractory cases, as calcium channel blockers lipid soluble agents
• Circulatory support devices
  • consider in refractory cases
  • VA ECMO or cardiac bypass is preferred to intra-aortic balloon counterpulsation (useful if poor inotropy, will not correct refractory vasoplegia)

High-dose insulin euglycaemic therapy (HIET)

• The place of HIET in the step-wise approach to managing cardiovascular toxicity has evolved
• Formerly considered a last ditich measure, early is use is increasingly advocated. This is important as the beneficial effects of HIET are not immediate

Elise and Harwood both made the point of avoiding charcoal in any patient with altered mental status or risk of seizure, vomiting, or needing intubation.

Recommended high-dose insulin euglycaemic therapy protocol based on the clinical experience of the Western Australian Toxicology Service, published case reports, reviews and animal studies (from Nickson and Little, 2009)

Schmitz      Administrative Update

Regan/Hart   Visual Diagnosis

Cannon ball metastases are associated with renal cell carcinoma and choriocarcinoma.  Less commonly prostate cancer, synovial sarcoma, and endometrial cancer.

Diffuse ST depression with ST elevation in AVR is consistent with Left Main coronary Artery occlusion.

Glioblastoma classically has butterfly appearance on CT.  See image below as well.  

Glioblastoma