Conference Notes 9-12-2018

This Week’s Conference was our City-Wide Windy City EM Conference hosted at ACMC and organized by Dr. Andrea Carlson. It was a tremendous event! These notes capture just a small portion of the great info presented.

Regan Disaster Medicine and Emergency Preparedness

EMTALA is not relaxed during disasters or mass shootings. All persons who present to your ED need to be evaluated and stabilized.

Because of the chaos around a mass shooting and the fact that police respond before EMS, victims will come to your ED by cars, pickups, and uber. Victims also don’t just go to the Level 1 hospital. In Vegas, most people went to the Level 2 hospital because it was the closest and many people took an uber.

Hospitals need to be able to surge hundreds of patients to respond to a mass casualty event.

Rate limiting hospital personnel will be your anesthesiologists, intensivists, and pediatric surgeons. It is very difficult to have enough of these specialists available during mass casualty events.

Hospitals have run out of supplies like ventilators and chest tubes in mass shooting events.

Emergency physicians are the best prepared physicians to provide care in these mass shooting events. We have a key role to play in the response to mass casualty events.

Sharp Wilderness Medicine: Desert Endurance Racing

The emergency physician’s home environment is in the ED. We know how to manage emergencies in the ED. Moving out into the wilderness takes us out of our normal environment to care for patients.

If you are the emergency physician in an austere environment, if you can, you need to plan carefully for what you will need when you go out to that environment. The main concerns for persons in the desert are hyperthermia, dehydration, and exercise induced hyponatremia.

It can be difficult to differentiate dehydration from hyponatremia in the field.

Athletes need 500cc of fluid, 500mg of sodium, and 500cal per hour in the desert. It’s kinda the 500/500/500 rule in the desert. Like the 1/1/1 rule for massive transfusion.

Athletes in the desert, if they get hypoglycemic can actually have hypothermia in the heat. This is postulated to be due to the need for glucose to generate body heat.

Champus Sports & Event Medicine

Communication and Incident Command preparations are critical for large sporting events like a marathon.

The Marathon is a pre-planned disaster. Planners know that there will be a 2%-10% illness rate depending on weather. You also have to make sure the city’s EMS and police can function during the marathon so that you can get patients to the hospital who need that level of care.

The life-threatening diagnoses that planners have to be prepared for are cardiac arrest, hyponatremia and heat stroke.

The marathon planners have all the light posts numbered, they have observers on the course. They have a communication system to keep the whole system coordinated.

Mass sporting event planning can improve the overall resilience of the EMS system in a city and improve the city’s ability to respond to disasters.

McCombs EM in the Military Settings

All patients presenting to forward medical stations are searched for ordinance.

IED’s were devised by the Taliban to maim but not kill the initial soldier. So when the rescuing team came to extract the injured soldier a second more devastating bomb would trigger and kill the responders.

Nelson Addiction Medicine

Unfortunately I missed this outstanding lecture

Hawkins/Chan/Checkett/Mikkilineni Global Health Panel Discussion

If you want to pursue global health in your career, fellowship is probably the most efficient way to jump start that pathway. Fellowship allows you to more quickly build your global health skill set, get critical mentorship and develop a professional network.

If you don’t do a fellowship, the pathway forward the panelists all suggested was to network with people in the field. Go to a meeting and reach out to speakers. Follow up with an email to those networking contacts. Identifying where to invest your time with a global health organization is best informed by people you know or have made a contact with.

Senior Residents Around the City Memorable Moments in the ED

editor’s note: Each Senior Resident told a wonderful, memorable story that occurred in the ED. Some were funny, some were touching, some were clinically great diagnoses, and some challenged us to be mindful of our biases when caring for patients. The notes for this section only take one general point from each story.

When providing bag valve mask ventilation and you are not able to acheive adequate oxygenation try using a Peep Valve. It will recruit alveoli and may improve the O2 sat.

Sometimes giving people a kind gesture is all you can do in the face of an untreatable, life-threatening illness. That kind gesture can mean the world to the patient and their family.

Basics like bagging, cpr, intubation, hemorrhage control will save lives, even neonates. Focus on the basics and it will serve you well.

Cultural awareness can help de-escalate tense situations. Understanding the root cause of a patient’s fears and anxiety can lead to the best approach to caring for that patient.

An insect in the ear canal can be very very uncomfortable. Trust the patient if they say a bug is in their ear. Kill the bug with viscous lidocaine, then remove the bug with an alligator forcep.

Sometimes when we have a difficult case in the ED it may seem a downer at the time but a more useful perspective is to view it as a power boost/opportunity to improve our practice.

We belong. Our work as emergency physicians is vitally important. We are a team and we all care for each other.

Conference Notes 8-22-2018

STEMI Conference

If a patient has the clinical picture of ACS with anterior ST depression you can activate the the Cath lab for suspected posterior MI.  The cardiologists present did not feel it was a requirement to have ST elevation on the the posterior EKG to activate the cath lab for suspected posterior MI.   Anterior horizontal ST depression can be enough with the right clinical picture. There is not a lot of data regarding the sensitivity and specificity of the posterior EKG.   The cardiologists felt the posterior EKG is very specific but the sensitivity is not known and may be too low.

Posterior MI

Posterior EKG showing ST elevation in posterior leads V7-9. The criteria of 0.5mm of ST elevation is not necessary to activate the cath lab.

New Left Bundle Branch Block in the setting of chest pain is very controversial.  A new LBBB when compared to an EKG from a year ago may not be an MI.  A new LBBB when compared to an EKG from a week ago is a different story and more concerning. 

New LBBB from MI will arise from an LAD occlusion.  With LAD occlusion, you should have echo findings of anterior wall motion abnormality to go along with the EKG findings.  Wall motion abnormalities will help identify AMI in the setting of LBBB.  The cardiologists felt that an AMI causing a new LBBB will cause the patient to be ill appearing. It is a relatively large infarct. 

There was consensus that a new LBBB is not very specific for AMI.  Sgarbossa criteria are specific but insensitive. Cardiologists want to be called on cases with concern for AMI in the setting of new LBBB.

You need 3 points to diagnose AMI

Decision rule using Sgarbossa criteria and ST/S ratio to diagnose AMI in the setting of LBBB

An example of how to calculate the ST/S ratio

Patients who have had a valve replacement and are sub-therapeutic on their INR can embolize to the coronary arteries causing AMI.  We think of embolic phenomena going to the brain most commonly.  The cardiologists have noted that emboli can also cause AMI.

Steroids are arthrogenic and can increase the risk of AMI.

Ryan/Hawkins     Oral Boards

Case 1. Patient presents unresponsive. EMS gave him narcan with no response.   In the ED the patient was intubated.  His blood sugar was normal.   Further history by EMS revealed the patient ingested GHB.  GHB overdoses frequently result in intubation and the patient later wakes up and self-extubates or can be extubated relatively quickly. 

γ-Hydroxybutyrate (GHB) is an endogenous molecule as well as a drug. GHB was originally used as an IV anesthetic, primarily in several European countries. In recent years, it has been marketed as a drug for body builders to improve body mass and reduce fat, as well as for use as a hypnotic, antidepressant, anxiolytic, and cholesterol-lowering drug.16 GHB has been found in drug-facilitated sexual assaults.17 Sodium oxybate (the sodium salt of GHB) is currently approved only for use within a highly regulated setting for the treatment of narcolepsy.18 In some European countries, GHB or sodium oxybate is used as a treatment for alcohol dependence and withdrawal.19 GHB can be formulated as a clear liquid or in solid form as a capsule, tablet, or white powder. GHB has many vernacular names, including "liquid ecstasy," "Georgia Home Boy," "G," and "Grievous Bodily Harm."

GHB has a steep dose–response curve with a narrow therapeutic ratio; doses of 10 milligrams/kg result in short-term amnesia, doses of 20 to 30 milligrams/kg result in sedation and drowsiness, and doses exceeding 50 milligrams/kg result in seizure, coma, respiratory depression, and cardiac depression.22 Bradycardia, hypothermia, and either miosis or mydriasis can occur.20 During recovery, the patients often wake up surprisingly quickly as opposed to the more prolonged awakening phase seen after an overdose with other sedatives. Despite co-ingestants being commonly encountered, most patients fully regain consciousness within 6 hours. The co-ingestion of ethanol can worsen hypoxia and possibly result in a longer elimination half-life of GHB.23

Treatment is largely supportive.20 Intubation is generally unnecessary, even in patients with severely depressed consciousness (Glasgow Coma Scale score ≤8) because patients are usually able to protect their airway and maintain ventilation.24 Once the patient is awake and alert, assuming no co-ingestants or secondary complications such as aspiration, the patient can be medically discharged or transferred.  (Tintinalli 8th ed.)

Dr. Carlson comment: You can never be faulted for intubating these patients to protect their airway.

Case2.  Patient was at a party and injured his shoulder.

Luxatio erecta, inferior shoulder dislocation

Clinical appearance of luxatio erecta

Reduction technique for luxatio erecta.  Harwood recommends gently walking the arm back down to the patient's side while maintaining traction-counter traction.

Case 3. Pregnant woman presents seizing.  Patient was treated with IV magnesium and IV lorazepam.  Seizure was terminated.  A magnesium drip was started.  OB was consulted for urgent delivery of the baby.

Management of eclampsia includes treatment of seizures, treatment of hypertension, and emergent obstetric consultation to facilitate urgent delivery of the fetus. Tintinalli 8th ed.

Bartgen     Study Guide      Heme-Onc

Leukemia buzz words: Problem of bone and blood, so back pain, fever, hematologic abnormalities, hepatosplenomegaly  are the buzz words.

Platelet transfusion thresholds for thrombocytopenia: ICH and surgery is 100K, GI or other serious bleeding is 50K, LP is 50K, asymptomatic is 20K, Central Line is  20K.  

Management of Rhabdomyolysis:  Once the patient is in the ED, continue aggressive IV rehydration for the next 24 to 72 hours. One method is rapid correction of the fluid deficit with IV crystalloids followed by infusion of 2.5 mL/kg/h, with the goal of maintaining a minimum urine output of 2 mL/kg/h.11 Another method is a goal of 200 to 300 mL of urine output each hour.12

No prospective controlled studies have demonstrated benefit from alkalinization of the urine with sodium bicarbonate or forced diuresis with mannitol or loop diuretics.12,13,14 Bicarbonate is widely recommended but without an evidence base. If bicarbonate is given, maintain an isotonic solution and avoid metabolic alkalosis or hypokalemia.12 Mannitol may be harmful because it may cause osmotic diuresis in hypovolemic patients. 

Hypocalcemia observed early in rhabdomyolysis usually requires no treatment. Calcium should be given only to treat hyperkalemia-induced cardiotoxicity or profound signs and symptoms of hypocalcemia. If hypercalcemia is symptomatic, continue saline diuresis. Treat hyperphosphatemia with oral phosphate binders when serum levels are >7 milligrams/dL. Treat hypophosphatemia when the serum level is <1 milligram/dL. Hyperkalemia, which is usually most severe in the first 12 to 36 hours after muscle injury, can be significant and prolonged. Traditional insulin and glucose therapy, although recommended, may not be as effective in rhabdomyolysis-induced hyperkalemia. The use of ion-exchange resins (e.g., sodium polystyrene sulfonate) is effective. Dialysis may be needed (see chapter 17, Fluids and Electrolytes).

Avoid prostaglandin inhibitors such as nonsteroidal anti–inflammatory drugs because of their vasoconstrictive effects on the kidney. Finally, treat the underlying cause.   (Tintinalli 8th edition)

Harwood comment: CPK less than 1000 I don't worry about rhabdo.  CPK  2-10,000 most can be treated with oral hydration.   >10,000 CPK usually will need IV hydration/OBS.  

A late complication of rhabdo is DIC.

Factor 8 replacement for Hemophilia is basically: 50u/kg for head injury and 25u/kg for all other injuries/bleeding.  1 unit/kg of factor 8 will raise factor activity 2%. 50u/kg will get factor activity up to 100%.   25u/kg will get factor activity up to 50%.   Give the factor 8 prior to CT for head injury. 

Treat VWD with desmopressin, VWF concentrates, or Cryoprecipitate. (Tintinalli 8th ed.)

Check ADAMTS13 levels when considering TTP. Treatment for TTP is plasmapheresis which is life saving. Consulting Hematology will expedite plasmapheresis.

Ahmad/Bernard/Destefani/Einstein/Nakitende/Regan                        Job Search Panel

Plan that it will take several months to get a permanent license in any state.

There are pros and cons to job searching early and late in EM-3 year.  Sometimes it's better to lock in the job early.  On the other hand, sometimes good jobs open up later in the year.

If you are doing independent contracting as part of your work-mix you need to hire a professional accountant manage your taxes/finances.

Don't be hesitant to ask and negotiate for more $ or time once you are offered the job. Everything is negotiable.

During the interview, no question is off the table.

You can probably create a individualized job for yourself anywhere if you plan it out carefully, have the right skill set, describe it well, list the metrics to measure your performance, and present yourself in excellent fashion to the employer.

There was tons more of great advice that I could not encapsulate in these notes.

Florek                Seizures

It is not necessary or recommended to give IV anticonvulsant medications during the course of an uncomplicated seizure, although the practitioner should be ready to administer these medications if seizures do not terminate. Most seizures will self-resolve within 5 minutes. Any unnecessary sedation at this point will complicate the evaluation and result in a prolonged decrease in level of consciousness.7 Seizures that fail to abate after 5 minutes are considered status epilepticus and require more aggressive medical interventions (Tintinalli 8th ed.)

Chart from Tintinalli 8th ed.

5 Causes of Seizures: 1. Abnormal Vitals(hypoxia, hypotension, hypertension)/Hypoglycemia, 2. Toxic-Metabolic (electrolyte abnormalities, ETOH withdrawal), 3. Infectious, 4. Structural, 5. seizure-like activity.

In nonconvulsive status epilepticus, the patient is comatose or has fluctuating abnormal mental status or confusion, but no overt seizure activity is present. The diagnosis is challenging and is typically made by EEG. Findings suggestive of nonconvulsive status epilepticus include a prolonged postictal period after a generalized seizure; subtle motor signs such as twitching, blinking, and eye deviation; fluctuating alterations in mental status; or unexplained stupor and confusion.25 (Tintinalli 8th ed)

To screen for pseudoseizure you can flush the eye with saline. This can frequently disrupt a pseudoseizure.

Dr. Williamson comment: Consider CT scan of the head for first-time seizures.   Instructions for patients with first-time seizure should include no driving or swimming, or dangerous work until cleared by neurologist.  Also if you have another seizure, you need to return to the ED.

Conference 8-15-2018

Ahmad      Difficult Conversations

Before you start a difficult conversation with a patient, have a plan. 

SPIKES:   Set an expectation,  Perception, Inform, Knowledge, Empathy, Summary.

Lovell comment:  The times of delivering bad news are incredibly important to our patients and their families.  We need to work on this skill to provide compassionate care to our patients.

Empathy is a critical virtue to being able to give bad news to a patient or family in a compassionate fashion.

Beware of traps:  Bias,  Ancillary staff perceptions of the patient,  Fatigue. 

Expect the unexpected:  Families may have intense emotional reactions, or indifference, or anger.

Know your audience.  Deliver your news with consideration of the patient's or family's healthcare literacy, culture, and their sensitivities.

When telling a family that a loved one died, use the words dead or died.  Don't use passed away.   To soften the blow,  use compassionate phrases right after you use the word dead or died.  "I am so sorry for your loss"  "You have my deepest condolences"   "You did everything you could"  

Delivering Bad News Workshop

Small group discussions of ED specific scenarios that required the emergency physician to deliver bad news.

Gerity       Endovascular Treatment of Stroke

Modified Rankin Score

MRI Cerebral Blood Volume and Blood Flow measurements can be used to predict the degree of ischemia of brain tissue .

CBF correlated with degree of ischemia

VAN Positive is Defined by unilateral arm weakness plus yes to any of the following:  visual disturbance, aphasia, or neglect.  If a patient is VAN positive, they need CTA of the head and neck in addition to CT head.

Lovell     2018 ACGME Resident Survey

Dr. Lovell reviewed this year's ACGME Resident Survey.

Humphrey     Bites/Stings/Envenomations   Wilderness Medicine

The risk of infection from a dog bite is @5%.  Prophylax with Augmentin ("dogmentin")    Dog bites are at risk of capncytophagia infection.

Tigers kill more humans than any other mammal except humans. Tigers have killed over a million people over the course of history.

Domestic cat bites have a higher risk of infection than dogs.  Pasturella multocida infection is a risk of cat bites.  Treat with Augmentin.

The black widow spider usually only bites defensively.  The bite of a black widow spider is painless but within hours patients can develop muscle cramps, diaphoresis, and hypertension. 

Cleansing of the bite site is reasonable. Pain and muscle spasms can generally be controlled with liberal doses of opioids and benzodiazepines.22 Although IV calcium has been advocated to relieve symptoms, a retrospective review of patients with Latrodectus envenomation indicated that this treatment is ineffective.22 For severe envenomations, admission may be required for continued analgesia. The most effective therapies for severe envenomation are parenteral opioids and Latrodectus antivenom.

Administration of Latrodectus antivenom often causes rapid resolution of symptoms and can significantly shorten the course of illness. Even in severely symptomatic cases of Latrodectus envenomation, patients can often be discharged from the ED after a short observation period when antivenom is administered. Successful treatment of latrodectism with antivenom has been described even with administration 90 hours after envenomation.23 Antivenin Latrodectus mactans is not contraindicated in pregnancy. (Tintinalli 8th ed)

Brown recluse spider bites cause a necrotic skin lesion.  Less commonly patients can develop coagulopathy and thrombocytopenia.

Patients with systemic symptoms following a bite warrant hospitalization. Various treatments have been advocated for brown recluse spider bites, including antihistamines, antivenom, colchicine, dapsone, hyperbaric oxygen, surgical excision, steroids, and topical nitroglycerin. None of these therapies have clear benefit, and most wounds from the brown recluse are self-limiting and heal without any medical intervention.  (Tintinalli 8th ed.)

Brown Recluse Bites are over-diagnosed and this decision rule helps avoid misdiagnosing another illness as a Brown Recluse bite.

Bark Scorpion sting  There is antivenon for scorpion bites.

New antivenin for crotalid bites has been developed called Anavip. The Anavip structure has 2 FAB fragments bound together.  There is slower renal clearance of this molecule and longer activity in blood stream. This results in less late term recurrance of coagulopathy from venom.

Conference Notes 8-8-2018

Editor's note: A Big Thank you to Mitch Lorenz and Anita Shroff for writing the majority of the Conference Notes this week!

Drs. Marek, Muhammad, Schroeder, Mishra, Kemp, Akhter

Joint EM/PEDs   Expert Panel on Asthma

PASS score- use the cumulative score to guide appropriate management and disposition

PASS Score   Can also be found in MD Calc App

A score of 3 or higher is severe asthma.

Albuterol dosing- when should we use continuous vs unit nebs?

-continuous nebs have lower admit rates and no difference in adverse events when compared to intermittent nebs (Carmago CA, Cochrane Database 2003)

-Schroeder comment: from a practical standpoint in the ED, it is difficult to do q15-20min reassessments, so it is often beneficial for the patient to start an hour long neb

-Muhammad comment: try to reassess them 15-20 min after the END of the albuterol treatment for it to take full effect

Ipratropium

-giving 2-3 doses in the initial dosing of asthma reduces the amount of total albuterol needed and the total length of stay, and had lower hospitalization rates

Steroids- who should receive steroids?

-Schroeder comment: anyone who gets an hour long neb gets steroids

Which patients need a CXR?

-routine CXR is NOT recommended

-it is recommended if the patient has  persistence  of any of the following: severe symptoms, significant hypoxemia, marked asymmetry on lung exam

-cxr is is infrequently associated with change of management  (Ann Emerg Med 2018)

-Kemp (PICU) comment: if patient is admitted to the PICU, they will get a CXR to assess for pneumomediastinum or pneumothorax. This info is critical when using higher nasal cannula flow rates, higher bipap or ventilator peak flow rates, or higher peep.

Who should receive antibiotics?

-NHLBI guidelines recommend not routinely giving antibiotics

Carlson/Lorenz        Oral Boards

1. Rocky Mountain Spotted Fever - treat tick borne diseases with doxy, think about these in anyone who has been camping, most prevalent outside of the Rocky mountains

The rash of  Rocky Mountain Spotted Fever starts on the ankles and wrists and moves toward the trunk.  Fever precedes the rash by a few days.

Dr. Lovell comment - check labs before a LP especially when you're not sure whats going on to make sure platelets/coags are normal

Rickettsia rickettsia, the causative organism of Rocky Mountain spotted fever (RMSF), is transmitted by the bite of an infected tick. Fever, headache, rigors, abdominal pain, myalgias, and malaise occur 2 to 14 days after inoculation. Three to five days after the onset of symptoms, the rash begins with erythematous, blanching macules on the distal extremities (wrists and ankles). This is followed by centripetal spread to the trunk and to the palms and soles. The lesions evolve into papules and petechia. Without treatment, RMSF has a 25% mortality; delayed diagnosis and delayed antimicrobial treatment results in 3% to 4% mortality. (Atlas of EM reference)

2. Heat Stroke - 2 types, diagnositic criteria > 40C, AMS.

-elderly more commonly not diaphoretic

-young/athletes more likely  to be diaphoretic

-treat w/ ice water immersion or evaporative cooling and benzos to control shivering

-antipyretics are normally ineffective

Tintinalli 8th edition

The cardinal features of heat stroke are hyperthermia (>40°C [>104°F]) and altered mental status. Although patients presenting with classic (nonexertional) heat stroke may exhibit anhidrosis, the absence of sweat is not considered a diagnostic criterion because sweat is present in over half of patients with heat stroke.15

The CNS is particularly vulnerable in heat stroke. The cerebellum is highly sensitive to heat, and ataxia can be an early neurologic finding. Virtually any neurologic abnormality may be present in heat stroke, including irritability, confusion, bizarre behavior, combativeness, hallucinations, plantar responses, decorticate and decerebrate posturing, hemiplegia, status epilepticus, and coma. Seizures are quite common, especially during cooling. Neurologic injury is a function of the maximum temperature reached and the duration of exposure.15

The distinction between exertional and classic (nonexertional) heat stroke is not clinically important, because immediate cooling and support of organ system function is the therapeutic goal for both. A delay in cooling increases the mortality rate.    (Tintinalli 8th ed)

3. intranasal foreign body - button battery

-do not attempt to irrigate out a button battery as it may cause it to leak its corrosive contents

-if it does not come right out, consult ENT

A button battery lodged in the ear can result in tympanic membrane perforation or destruction, necrosis of the epidermis of the external auditory canal, hearing impairment, destruction of ossicles, and facial nerve paralysis.25 Intranasal button batteries can produce chondritis, nasal septal perforation, and superficial burns of the nasal mucosa.35

A child with a button battery in his nose or external auditory canal should be immediately referred to an otolaryngologist for its removal. If its instillation was recent, for example, less than 1 to 2 hours, the emergency physician may consider an attempt of removal.   (Tintinalli 8th edition)

Carlson     Toxicology

Unfortunately I missed this outstanding lecture.

Kishi   Safety Lecture

Unfortunately I missed this outstanding lecture.

Hormese     New Medication Therapies for EM Applications

Angiotensin II is indicated for patients who are in shock despite high-dose norepinephrine.   Patients started on Angiotensin II need prophylactic heparin and SCD's because this medication increases patients' risk for DVT/PE

Patients with low risk DVT and PE can be discharged home on xarelto or eliquis.  Use modified Hestia criteria to decide who can go home.  Patients need PCP follow up and are reliable to follow up.  The first month of treatment with xarelto will be free of charge.  After the first month, the patient will need to pay for the medication through insurance or cash.

Hestia Criteria. If you answer yes to any of these questions, the patient cannot be treated at home.  Tintinalli also notes that an extensive DVT should be treated in the hospital.

Quick Pharmacy Factoids:

Ciprodex not covered by insurance.

Prednisolone ODT not covered by insurance

Zofran liquid not covered by insurance

Please list the ingredients and the volume of each ingredient of magic mouthwash on your script.  Pharmacies are calling our pharmacists with many questions about our magic mouthwash prescriptions.

Lovell                Town Hall Meeting

Conference Notes 8-1-2018

Lorenz        M&M

No Case Details, Just some take home points.

When you are wrong, admit it and move on.

“Any fool can try to defend his or her mistakes—and most fools do—but it raises one above the herd and gives one a feeling of nobility and exultation to admit one’s mistakes.”
― Dale Carnegie, How to Win Friends & Influence People

The secondary survey is critical in trauma to avoid missing more subtle injuries beyond that identified on the primary survey.

Paraphimosis: A retracted foreskin will block lymphatic drainage from the distal penis. As arterial inflow continues, lack of lymphatic drainage will cause a progressive edema of the penis distal to the retracted foreskin. As the foreskin continues to swell the phimotic ring becomes progressively tighter, and if not reduced, will eventually obstruct venous outflow. The distal penis will become painful and hyperemic. The edema will progress to ultimately obstruct arterial inflow resulting in penile ischemia, necrosis, and gangrene. This series of events, from retraction of the foreskin to arterial inflow obstruction, can occur over a few hours to 1 to 2 days. To relieve the obstruction, the phimotic ring must be advanced (reduced) over the glans of the penis. (Procedures in EM reference)  This diagnosis can be confused with other GU complaints or overlooked. Be cautious not to miss this diagnosis.

Respect the risks of placing a central line.  To verify placement of the line in the IJ, you can ultrasound the the IJ in the longitudinal plane.  With the wire still within the vessel, angle the probe into the thorax and you can see the IJ widen into the right atrium. If you can visualize the wire in this area you know you are good.  Alternatively, after pulling the wire, you can inject 10 ml of saline rapidly through the line and have an ultrasound probe on the heart to see turbulence in the right atrium and ventricle.

Kalnins     NeuroRadiology

Dense MCA sign

A dense MCA sign corresponds to a significant acute clot in the proximal cerebral vasculature. Patients with this radiographic finding may benefit from neurointerventional procedures to aid in clot lysis or mechanical clot removal in order to reperfuse ischemic brain tissue.  If you see this sign, consider consulting interventional neuro-radiology emergently.

Note the assymetry of the insular cortex from right to left.  Dr. Kalnins emphasized the importance of the insular ribbon sign in identifying early stroke.

Dr. Kalnins recommended the website http://www.radiologyassistant.nl   as a great resource to learn about radiology of all types.  editors note: I googled it briefly and it looks outstanding. 

Dr. Kalnins discussed cutting edge use of CT technology (perfusion, blood flow, cerebral blood volume, mean transit time studies)  to identify early stroke.

Hawkins      Interpreting CXR's

Unfortunately I missed this outstanding presentation.

Chiefs/EM Faculty      Orthopedic Lab

Conference Notes 7-25-2018

Lovell     Trauma Study Guide

Perimortem cesarean delivery should be performed only when the gestational age is greater than 24 weeks.

Some find that an incision from the umbilicus to the public symphysis is large enough to accomplish fetal delivery. The uterine incision should be vertical as well.

Perimortem cesarean delivery might actually improve maternal circulation and is better performed early rather than too late. There have been reports of maternal survival after perimortem cesarean delivery, even when the mother has been in cardiac arrest. Theoretically, delivery of the fetus can help restore maternal circulation and remove pressure from the inferior vena cava.  The primary goal is improvement of maternal, not fetal, resuscitation.

The procedure is ideally performed within 4 to 5 minutes of the loss of maternal circulation. Survival of the mother and the fetus is unlikely if the procedure is performed too late and is virtually futile if performed after 20 minutes of maternal cardiac arrest.

Handlebar injury in kids and adults:  look for pancreatic injury (CT, labs)

Seatbelt sign:  look for intra-abdominal trauma, especially small bowel injury. 

CT may be normal or nonspecific in both pancreatic and small bowel injury, so if persistent pain/tenderness, observe in hospital even with negative CT.

 SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) associated with pediatrics due to hyper-flexibility of spine, and in elderly secondary to spondylosis.  Refers to spinal cord injury with negative plain xrays and/or CT.  Currently an ambiguous term, as majority of SCIWORA has abnormal MRI imaging.  Important entity that can present with transient or delayed neurologic symptoms; do careful history, exam.

 Those hypermobile kids can also tear off the renal pedicle in blunt trauma, especially MVC, so a lower threshold of hematuria is used to prompt CT imaging.  For kids, if >50 RBCs/HPF in blunt trauma and hemodynamically stable get a CT abdomen.

Harwood comment:  Handlebar injuries are also associated with duodenal hematoma.  Vertical falls are also associated with renal pedicle injuries.

Cochrane Review September 2017: Lewis SR, et al. 

Hypothermia (body temperature cooling) for people with an injury to the brain

Review question

What is the effect of mild hypothermia (body temperature cooling) following a brain injury on whether a person dies, has a poor outcome, or gets a type of severe chest infection (pneumonia)?

Background

Hypothermia has been used for many years to treat people who have had a severe brain injury. This involves cooling the head or the whole body to a temperature below normal body temperature. We aimed to assess whether people treated with hypothermia after a brain injury are less likely to die or have a poor outcome (which we defined as death, coma or severe disability) and whether using hypothermia might increase the risk of a severe chest infection called pneumonia.

Study characteristics

We included 37 studies with 3110 participants. In each trial, patients were randomly divided into two groups: one group remained at normal body temperature of 36.5 to 38 °C, and the other group was cooled to a maximum of 35 °C for at least 12 hours.

Key results

We did not combine results of these studies to assess whether hypothermia improves patient outcome. This was because the results had large differences which we could not explain. We identified some differences in the ways in which the studies were carried out and the participants that study authors had recruited, but we did not assess whether this could explain the differences in results. We did not have enough good quality evidence that was sufficiently similar to be confident that treating people who have had a severe brain injury with hypothermia will reduce the incidence of death or severe disability, or increase the incidence of pneumonia.

Quality of evidence

Many of the studies were not well reported and we were unable to assess whether differences between the quality of the studies may also have affected our results. We used the GRADE approach to judge the quality of evidence. We judged the evidence for death or severe disability to be very low quality, and the evidence for pneumonia to be low quality.

Authors' conclusions: 

Despite a large number studies, there remains no high-quality evidence that hypothermia is beneficial in the treatment of people with TBI. Further research, which is methodologically robust, is required in this field to establish the effect of hypothermia for people with TBI.

Although the appropriate length of time to observe a child with a concussion in the emergency department for worsening signs and symptoms has not been definitively established, the PECARN authors recommend a 4- to 6-hour observation period; the likelihood of missing a delayed clinically important traumatic brain injury during this time seems to be rare. Inpatient observation, unless the family is not able to observe the patient at home and follow appropriate instructions, is generally not necessary.

Harwood comment:  Rule of thumb for return to play following concussions is: 1 week out of sport for first concussion.  1 month out of sport for second concussion. 1 year out of sport for third concussion.

Chance Fracture

A Chance fracture is a flexion-distraction injury, associated with MVC and flexion over a lap-belt (seatbelt).  There is complete disruption through the vertebral body and associated structures in a horizontal plane.  They are commonly misdiagnosed as compression fractures.   There is a high rate of associated intraabdominal injuries.  As the disruption is in the horizontal plane, sagittal CT images are more sensitive than axial CT for diagnosis

Burst fractures are associated with motor vehicle crashes, as well as falls from height.  Burst fractures are inherently unstable due to the potential for the retropulsion of bone fragments into the spinal canal secondary to disruption of the posterior column; about half of patients with this injury will have neuro deficits.  For this reason, additional imaging should be performed if there is clinical suspicion for a burst fracture, and neurosurgery consultation is required.

A “no-zone” approach to all penetrating neck trauma, with stability and presence/absence of hard findings informing the decision of CTA or surgery (hard signs indicate surgery, soft signs indicate CTA)  has gained favor compared to a zoned approach, with comparable outcomes.  Two other reasons to adopt no-zone:  injuries may  cross zones, and no-zone approach leads to fewer unnecessary neck explorations.

Lovell/Logan    Oral Boards

Case 1. 78 yo male bleeding from tracheostomy site.  Patient had tracheostomy placed within the last 2 weeks.

Use hyperinflation of trach tube balloon initially to compress the innominate artery. If that is ineffective, use your finger to hold pressure.  Third maneuver is apply traction to the tracheostomy tube to compress the vessel.

Any bleeding of more than a few milliliters of blood should raise concern for a possible fistula of the innominate artery. Prompt critical resuscitation measures and emergent consultation with a Vascular Surgeon and Otolaryngologic Surgeon is required. Definitive management is surgical. Techniques for temporarily controlling bleeding from the innominate artery include local digital pressure, hyperinflation of the tracheostomy tube cuff, and traction on the tracheostomy tube. An alternative method is to deflate the tracheostomy tube cuff, reposition the cuff at the bleeding site, and then reinflate or hyperinflate the cuff. When bleeding occurs, the tracheostomy tube should not be removed until the airway is secured by another means from above (orally or nasally).

Peak incidence is 1-2 weeks after tracheostomy surgery. 75% within 4 weeks post-op. Emergently consult thoracic surgery to take the patient to OR.

Case 2. 55yo female with weakness. HR=130. Other vitals OK.  Started chemotherapy for non-hodgkins lymphoma 3 days ago.

If you consider tumor lysis syndrome be sure to order phosphate and uric acid levels in addition to your usual CBC, CMP.

Treat tumor lysis syndrome with IV fluids, Hyperkalemia management, Rasburicase for elevated uric acid, phosphate binders, and dialysis if needed. 

Case 3. 8 month old male who won't stop crying.  Vitals all OK except for HR=110.  Patient appears fussy. Physical exam demonstrates a hair tourniquet on the toe.

Hair Tourniquet

Two standard approaches to salvage the compromised digit are to either unwind the hair or thread if possible or, otherwise, make a midline longitudinal incision along the extensor surface of the toe to cut the hair or thread.42 To cut the hair, it will often be necessary to split the fibers of the extensor ligament, but avoid transecting the fibers. The multiple strands of hair or thread are then removed using fine forceps without teeth. The toe often retains the initial appearance, making the physician uncertain whether all of the strands have been removed or cut. A novel but unvalidated method is to apply hair-dissolving compounds.43 Hair-thread tourniquet syndrome can cause deep cutaneous lacerations that result in tendon lacerations requiring operative repair.44 Hair-thread tourniquet syndrome is not the result of intentional injury and does not warrant reporting as suspected child abuse.   (Tintinalli 8th Ed)

Faculty comments:  Nair seems to work pretty well. It takes about 15 minutes to dissolve the hair fiber.  Otherwise a small incision on the lateral aspect of the digit down to bone will cut the fibers.

Incision to cut hair tourniquet

Hawkins       EKG's

Have a system to approaching EKG's the same way each time.

V-tach.   Harwood comment you know this is V-tach based on NorthWest axis (down in I and AVF) and QRS >140 ms. 

Williamson    AICD/Pacers

Unfortunately I missed a large portion of this outstanding lecture.

1/3 of patients with AICD shock will have troponin elevation. 

For a single shock, check a troponin, check lytes,  get an EKG. If patient is asymptomatic and has normal vitals and labs are consistent with prior levels, the patient can possibly can go home after discussion with cardiologist. 

If patient gets shocked twice they need a higher level of caution because either they are getting multiple appropriate shocks or the device is malfunctioning.  Consult Cardiology and likely admit.

If a patient gets 3 or more shocks that is considered electrical storm and the patient needs emergent cardiology consultation, antiarrythmic therapy, anxiolytic, and ICU admission.

JAMA 2006 reference.

Lovell    How to Give an Effective Lecture

Be the content expert. Make sure you know your topic.

Be enthusiastic about the topic you are speaking about. Enthusiasm shows and is important for gaining your audience's attention.

Work on your public speaking skills: Most important is to practice your presentation beforehand.     During the presentation, leave the podium and engage the audience.   

Get Creative.  When developing your presentation, think about how to make the content more engaging or interactive.

Pay attention to slide design. Don't put too much info on slide. Big picture/few words.  Make your slides visually appealing. Don't use slides as a crutch.

Conference Notes 7-11-2018

Cirone/Shroff       Oral Boards

Case 1. 20 yo female presents with fever, tachycardia, and hypotension.  Patient complains of right leg pain. Patient has necrotizing bullae on shin.  Patient was at beach/ocean yesterday and had a skin abrasion on her shin that got infected. 

Vibrio cellulitis

Patient was treated for septic shock with IV fluids, IV antibiotics and norepinephrine.

Vibrio is gram negative bacteria seen in coastal waters. Vibrio can cause blistering cellulitis. Almost always occurs at site of prior wound.  The infection can progress to necrotizing fasciitis.  Tintinalli says: Treat with 4th generation cephalosporin combined with doxycycline.  There is synergy with combining a 4th generation cephalosporin with doxycycline. If the patient develops necrotizing fasciitis they need emergent surgical debridement.

Dr. Lovell comment: For boards, bad infections associated with water are Vibrio for salt water and Aeromonas for fresh water.  Make sure you treat with a 4th generation cephalosporin plus doxy  or flouroquinalone.

Case 2. 25 yo male presents with altered mental status.  Patient was bit by a snake the day prior in the everglades.

Red on yellow Kill a fellow (coral snake).  Red on black venom lack.

Patient was treated with 3-5 vials of antivenin.  If there is a definite coral snake bite, the patient should receive antivenin.  If a patient has neuro symptoms, admit to ICU.  Obtain a NIF to identify early respiratory weakness.

Case 3. 19yo male presents with foot pain due to injury playing basketball. 

Jones fracture is also known as a Zone 2 fracture of the 5th metatarsal.

Jones fractures have poor blood supply and have risk of malunion.  Treat with post mold, non-weight bearing, and orthopedic referral.

Treatment and Follow-Up

Patients with nondisplaced Jones fractures should be non–weight bearing in a cast for 6 to 8 weeks. Complications of a Jones fracture treated nonoperatively include bony nonunion, which may later require intramedullary screw fixation. Shock wave therapy has also been reported for treatment of nonunion.17 Some orthopedic surgeons are advocating for early surgical correction, especially in athletes, so posterior splinting and outpatient referral to an orthopedic surgeon are appropriate initial treatment.18 Nondisplaced avulsion fractures of the tuberosity, also known as a pseudo-Jones fracture, can be treated with a walking cast and pain control with weight bearing as tolerated. (Tintinalli 8th edition)

Burns      Ultrasound Physics

Acoustic Impedance is due to the difference between tissue characteristics.  If there is a large difference in impedance of two tissues the ultrasound image will be reflected or refracted and will limit the image.    This is the problem with air and bone.  Because air and bone impedance are so different from water, tissue, and blood, the ultrasound image is very negatively impacted by the air or bone.

Water, blood, and tissue all have similar impedances ranging from 1.48 to 1.7.  Bone and air on the other hand have very different impedances from water, blood, and tissue. When bone or air is present in an ultrasound image, it will cause much reflection and refraction of sound waves degrading the image in the far field.

Gallstones are an example of a large difference of impedance between bile and stone.  Distal to the bile/stone interface is only shadowing.

Gain adjusts the strength of returning echos (brightness).  You want to have uniform brightness in both the near and far fields.

Higher frequency probes give better resolution.  Lower frequency probes give you better tissue penetration.  To image deeper structures, you may need to sacrifice some resolution to have deeper penetration of the sound waves.

Lambert        Emergency Echocardiography

Mike's tip for imaging the subcostal view of the heart is to start in the right sucbcostal region and image the liver then rotate the probe to point at the left shoulder and you should be able to image the heart.  Use the greatest depth to get this image.  It's a long way from the RUQ to the top of the heart with this imaging window. So you need the greatest depth to see the heart from this window.   Mike says the best subcostal images use the liver as a window to the heart. This is the best view to see pericardial fluid because you are looking at the base of the heart where dependant fluid would be.

Echo Windows: A. Parasternal long. B. Parasternal short.  C.  Apical.   D. Subcostal.

Subcostal view of a large pericardial effusion

Large RV on Parasternal short axis view due to PE.  Patient also has a "D sign" in which the large RV deforms the LV into a D shape.

Lambert        Ultrasound in Trauma

FAST is basically a search for blood in the pericardium, thorax, or peritoneum.

E-FAST adds lung windows to the traditional FAST to look for pneumothorax.

RUQ view on FAST showing blood in Morrison's pouch and blood in the right chest cavity.

Looking for sliding of pleural line is critical to identify pneumothorax.  With pneumothorax, the pleural line does not slide.

Lambert and Team Ultrasound       Ultrasound Lab

Conference Notes 6-6-2018

Tekwani        Medical Student Rotation Overview

Lovell      The Resident as Educator

2 Easy to use bedside teaching techniques:

1. 1 minute Preceptor: Get a commitment (get the student to commit to what they think is going on) , probe for supporting evidence (ask them how they reached that conclusion), teach a general principle, reinforce what was done well, correct mistakes (do this as kindly as possible), and identify next learning steps (suggest a topic to read further on).

2. SPIT=Serious,  Probable,  Interesting, and Treatable.   Have the student suggest 1-2 diagnoses for each of these categories that would fit the patient's presentation. This method is a quick way to build a broader DDX with a student learner.

Give feedback in as positive a fashion as possible.  Tell them at the beginning of your feedback:  "I am giving you some feedback now"

Remember, you are always "role modeling" to students

Send students to all codes and to interesting cases, rashes, or other significant physical findings.

Twanow       Myocarditis and Pericarditis

Myocarditis is most commonly a clinical diagnosis.  The diagnostic gold standard for myocarditis is endomyocardial biopsy which is rarely done.

Causes of myocarditis include viral infections, mycotic infections, RMSF, Chagas, Toxins, and medications.

Myocarditis can present as new onset heart failure, new murmur, new bundle branch block or heart block. Myocarditis can also present as persistent tachycardia, pericarditis with heart failure, arrythmias following uri, and unexplained heart failure.

Diagnose myocarditis with troponin, BNP, CXR and EKG. Echo is also important to make the diagnosis.  Inpatients can get Cardiovascular MRI which can also help to diagnose myocarditis.

In the ED, provide supportive care if needed with with pressors, anti-arrythmics, pacer, and anticoagulation.  Avoid NSAID's.  Cards may consider IVIG, ECMO, LVAD and other modalities.

Pericarditis can be caused by viral infections, TB, fungal, and parasitic infections.  Lupus, RA, and scleroderma can cause pericarditis. Neoplastic processes, post-MI, uremia, and radiation can all cause pericarditis.

Pericarditis classically has pain that is improved when sitting up.

Pericarditis EKG. There is diffuse ST elevation and PR depression.  AVR has the opposite changes with ST depression and PR elevation.  If you see localized ST depression in the inferior, anterior, or lateral leads that  is not c/w pericarditis and needs to be strongly considered for STEMI criteria.

Life in the Fast Lane reference

Dr. Lovell comment: Treat with ASA and Colchicine.  ASA has benefits over giving NSAID's.

(Tintinalli reference 8th ed.) Treatment of pericarditis depends on the cause.34 Most patients with idiopathic or presumed viral pericarditis have a benign course lasting 1 to 2 weeks. Symptoms respond well to nonsteroidal anti-inflammatory agents administered for 7 days to 3 weeks. Ibuprofen, 300 to 800 milligrams orally every 6 to 8 hours, may be preferred because of fewer side effects, limited impact on coronary artery blood flow, and large dose range. Colchicine, 0.5 milligram orally twice a day, may be a beneficial adjuvant and may prevent recurrent episodes.35,36 Hospitalization is not necessary in most cases, unless there is associated myocarditis, and follow-up or repeat echocardiography is not needed unless symptoms fail to resolve or reappear or new symptoms are noted.37 Indicators of a poor prognosis include temperature >38°C (100.4°F), subacute onset over weeks, immunosuppression, history of oral anticoagulant use, associated myocarditis (elevated cardiac biomarkers, symptoms of CHF), and a large pericardial effusion (an echo-free space >20 mm).38 In general, patients with these risk factors or with an enlarged cardiac silhouette on chest radiograph should be admitted for echocardiography to assess the extent of the effusion and degree of hemodynamic compromise and cardiac dysfunction.

Logan        Safety Lecture    New Stroke Pathway

Unfortunately I missed this excellent lecture but the new pathway is listed here.

Chastain/Felder/Paquette       Efficiency Panel

The panel discussed many excellent tips on being an efficient emergency physician in our ED. I was only able to capture a few of them.

When you have multiple patients who are waiting to be seen, one way to prioritize them is: 1. Time dependent complaints like chest pain and stroke should be seen first, 2. Patients with abnormal vitals next 3. Then quick complaints that can be dispo'd quickly 4. While you are seeing those patients, put in lab and imaging orders on the lower acuity  patients with complaints like abdominal pain or weakness.

Maintain excellent communication with the nursing staff regarding your plan and discuss any roadblocks the nurses are facing.

If you are going to be delayed to see a new patient, ask the patient's nurse to go into the room and inform the patient you are delayed because of a critical patient.  When you finally get to that patient, apologize to them and explain why you were delayed.

Keep you communication brief with admitting and consulting physicians.

Utilize the care managers to help set up patient follow up and specialist appointments.  Care managers can help patients with limited healthcare access. The Care managers are stationed in the old telemetry room in the hallway to radiology.  You can leave them a message on their voicemail or slip a note under their door at night.  They will address the issue when they start their shift in the morning.

Ask a patient what their fears are, and/or what their hopes or expectations are for this ED visit.

Tran      Radiology Lecture

Unfortunately I missed this outstanding lecture.

Florek/Lorenz/Pastore/Robinson/Wing         Trauma Lecture

Unfortunately I missed this outstanding lecture.

Conference Notes 5-9-2018

Almeida/Eastvold/Tomasello     EKG's

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

Posterior MI

A straightened ST segment is indicative of ischemia/evolving STEMI

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

DeWinter's T waves anterolaterally  STEMI equivilent

Know your epinepherine dosing for anaphylaxis

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

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

Conference Notes 5-23-2018

McKean/Logan   Oral Boards

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

CXR of bilateral pulmonary infiltrates due to hydrocarbon aspiration

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

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

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

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

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

Arrythmogenic RV Cardiomyopathy

Epsilon Wave specific for arrythmogenic right ventricular cardiomyopathy.

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

Quadricep tendon rupture with low riding patella on the right

Patient needs orthopedic consult for surgrical repair.

Kishi  5- Slide Follow Up

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

 Nitro sprays followed by Nitro drip at 100mcg/min

Start patient on bipap

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

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

Miner    5 Slide Follow Up

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

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

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

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

Jones    5 Slide Follow Up

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

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

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

Johns       5 Slide Follow Up

Consider headache "red flags"

Conference Notes 4-25-2018

Velamati/Lorenz       Oral Boards

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

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

Shiga-toxin HUS usually does not need plasmaphoresis.

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

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

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

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

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

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

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

Yapo       Non-Accidental Trauma

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

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

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

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

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

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

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

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

Mullen  5 slide Follow Up

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

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

Ebeledike    5 Slide Follow Up

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

Adlington    Care of Sexual Assault Patients

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

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

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

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

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

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

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

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

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

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

Hawkins    EKG's

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

Chinwala      Safety Lecture

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

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

Pastore      Safety Lecture

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

Twanow       Safety Lecture

Dr. Twanow discussed active shooter scenarios.

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

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

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

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

Shroff   ICEP Presentation

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

Conference Notes 4-18-2018

Denk/Traylor      STEMI Conference

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

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

Steps to distinguish pericarditis from STEMI:

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

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

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

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

From Life in the Fast Lane

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

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

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

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

Straightening of the ST segment suggestive of STEMI

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

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

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

Menon/Twanow     Oral Boards

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

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

CTA shows in aortic injury

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

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

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

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

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

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

HSP rash

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

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

Cardiac Output=Stroke volume X heart rate

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

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

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

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

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

Rescue Echo looks for causes of hypotension

Rescue echo utilizes parasternal, subcostal, and apical views.

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

Katiyar   Billing and Coding

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

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

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

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

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

Conference Notes 3-7-2018

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

Herron/Tran     Oral Boards

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

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

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

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

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

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

Patient is pulseless with polymorphic VT

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

Mechanism of comotio cordis   (Life in the Fast Lane)

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

Sklar     Study Guide        Infectious Disease

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

Stages of Lyme Disease

Erythema chronicum migrans rash of Lyme disease

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

Rabies post-expoosure treatment recommendations

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

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

Picture courtesy of Dr. Lovell.

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

Pustule from disseminated gonorrhea

Rocky Mountain Spotted Fever Rash

Rocky Mountain Spotted Fever Rash

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

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

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

Girzadas    Study Guide     Neurology

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

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

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

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

Tekwani     Airway Lecture

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

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

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

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

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

Hormese             Changes to Adult DKA Guidelines

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

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

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

Bicarb not indicated unless pH<7.0

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

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

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

Conference Notes 2-14-2018

Tekwani/Pastore    Oral Boards

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

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

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

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

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

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

Koplik's spots with measles

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

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

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

CDC Website snapshot of recent measles cases in US.

Usmani     Abdominal Compartment Syndrome

Normal abdominal compartment pressure is 5-7 mm/hg

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

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

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

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

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

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

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

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

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

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

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

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

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

Burns/Denk      Advanced Echo in the ED

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

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

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

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

Denk/Traylor           Board Review

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

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

6 Herniation Syndromes

Uncal herniation=blown pupil

Cerebellotonsillar herniation=pt is in extremis/dying

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

Central herniation=forced downward gaze

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

Katiyar       Toxicology

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

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

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

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

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

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

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

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

Conference Notes 2-7-2018

Paquette/Shroff     Oral Boards

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

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

Erythema Chronicum Migrans Rash

EKG showing 3rd Degree Heart Block on ED presentation

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

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

CXR showing Left Upper Lobe Cavitary Infiltrate consistent with TB

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

Ohl      M&M

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

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

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

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

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

Velamati     Pediatric  Resuscitation

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

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

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

100-120 chest compressions per minute in pediatric patients.

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

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

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

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

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

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

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

Felder/Naik/Schmitz      Admin Update

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

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

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

We discussed other challenges experienced in the ED

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

Stanek        Weight Discussions

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

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

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

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

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

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

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

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

Florek      Safety Lecture  Glycemic Control in the ED

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

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

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

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

Shroff     Safety Lecture

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

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

Conference Notes 1-24-2018

Airway Day

Patel        Airway Emergencies

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

Mnemonics to help answer the four questions above.

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

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

3-3-2 rule

Mallampati Scoring

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

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

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

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

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

Lovell      Airway Devices

Unfortunately I missed this outstanding lecture.

Airway Lab in the New ACMC Sim Center

Thanks to Liz Regan for the pictures!

Conference Notes 1-17-2018

Kernicki-Sklar      Study Guide Infectious Disease

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

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

Occular syphillis can have red spots on iris.

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

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

Strawberry Cervix of Trichomonas Infection

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

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

IDSA Antibiotic Recommendations for Necrotizing Fasciitis

Lambert       U/S  DVT

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

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

Common femoral vein that compresses normally

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

Lambert     MSK  Ultrasound

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

U/S can identify hip effusions as seen above.

Ultrasound can be used to identify tendon ruptures

Lambert and Team Ultrasound     DVT & MSK U/S Workshop

Awesome U/S Workshop in our new Sim Lab.

Conference Notes 1-10-2018

Denk/Traylor     STEMI Conference

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

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

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

Ahmed/Hawkins     Oral Boards

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

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

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

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

Wellen's syndrome is associated with proximal LAD occlusion.

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

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

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

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

Lovell       Intellectual Wellness

First, An Overview of the other components of Wellness:

Social Wellness:    Human interaction builds our resilience

Spiritual Wellness:   We benefit from connecting to a belief system

Occupational Wellness:   Finding purpose and meaning in our work

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

Emotional Wellness:     Conflict managment, narrative medicine

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

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

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

Naik     ED Operations Update

Trushar discussed strategies for managing our boarding patients.

DeStefani      HINTS Exam

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

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

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

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

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

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

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

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

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

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

Logan      Eye Emergencies

Ruptured globe with teardrop pupil

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

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

Donapudi       Pulmonary HTN and Pulmonary Fibrosis

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

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

There are multiple categories of pulmonary HTN based on etiology.

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

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

Conference Notes 1-3-2017

Harwood/Einstein    Oral Boards

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

Epidural hematoma

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

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

Case 2. 80 yo male with syncope due to PE

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

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

Case 3.

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

Katiyar      Toxicology of Moth Repellents

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

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

Cirone            HIV and Related Infections

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

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

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

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

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

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

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

Barounis           Sepsis

Sepsis is a dysregulated response to an infection.

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

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

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

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

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

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

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

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

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

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

Okubanjo               M&M

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

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

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

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

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

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

Hyperdense artery syndrome of basilar artery.

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

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

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

sudden death/loss of consciousness

top of the basilar syndrome

visual and oculomotor deficits

behavioural abnormalities

somnolence, hallucinations and dream-like behaviour

motor dysfunction is often absent

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

complete loss of movement (quadriparesis and lower cranial dysfunction)

preserved consciousness

preserved ocular movements (often only vertical gaze) 8

Radiopaedia Reference

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

Conference Notes 12-20-2017Dr.

Sunbulli       Respiratory Failure

Dr. Sunbulli discussed the 4 types of respiratory failure.

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

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

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

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

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

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

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

Friend           Bowel Obstruction

Most common cause of SBO is adhesions.

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

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

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

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

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

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

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

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

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

Pecha Kucha

Miner       Management of Constipation in the ED

I missed this outstanding Lecture

Tran       ED EKG Findings

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

Wellen's syndrome is associated with critical LAD stenosis

Johns   Targeted Temperature Management after Cardiac Arrest

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

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

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

Estoos     Evaluating the Patient with Altered Mental Status

mnemonic: He Stops for TIPS on Vowels

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

Delbar    Sports Injuries

Depressed skull fractures should be covered with broad spectrum antibiotics.

Posterior shoulder dislocation with humeral head behind the scapula.

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

Schroeder     Study Guide  Pediatrics

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

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

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

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

1ml/kg  of  D50  

2ml/kg of  D25    

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

10ml/kg of D5

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

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

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

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

Sweiss      Neurocritical Care  of Intracerebral Hemorhage

Unfortunately I missed this outstanding presentation.