Conference Notes11-23-2016

Lovell        Pulmonary Study Guide

 CHF is unlikely with a BNP <100.   CHF is more likely with a BNP>400.

In lung transplant patients, infection and rejection can look the same clinically.  Because it is so difficult to differentiate these two diagnoses, it is important to discuss the patient’s management plan with the transplant team.  The most common cause of death long term in lung transplant patients is bronchiolitis obliterans.  

Intubating the massive hemoptysis patient: Use a large ET tube to allow suctioning to clear the tube if necessary.  You can try to position the ET tube in the mainstem bronchus in the non-bleeding lung.  That isolates your non-bleeding lung for better oxygenation and potentially keeps blood out of the non-bleeding lung.  Position the patient in either the right or left lateral decubitus position to get the bleeding lung down.  This keeps the blood in a dependent location and keeps the non-bleeding lung elevated away from bleeding.

Get a CTA to evaluate  the source of bleeding.  Once the bleeding source is identified by CTA,  get the patient to IR for embolization.   These patients die from asphyxiation  (blood filling the airway) so protecting their airway is the critical management action.

Treatment for primary, spontaneous pneumothorax: If small and stable just put them on 15L NRB O2 and watch for 6 hours.  If repeat CXR is improved or not worsening, you can discharge the patient at that time.   If the patient has a moderate pneumothorax place a mini-chest tube with a Heimlich valve.  You can aspirate the pneumothorax thru this tube initially.  Discuss with pulmonary consultant about admission vs outpt follow-up.

*Management of primary spontaneous pneumothorax

5 risk factors for malignancy in a patient with hemoptysis: Smoking, age>40, male, recurrent hemoptysis, and no infectious symptoms.   Patients with 1 or more of these risk factors should get a contrast CT of the chest.

COPDer’s with bullae should not get a chest tube.  If you are concerned that a CXR in a COPDer may be demonstrating pneumothorax, get a CT chest to differentiate between a bullae and pneumothorax. 

*Bulla

*Pott Disease   TB in the spine.  The proper term is Pott Disease not Pott’s Disease but most of the Google Pics say Pott’s.

*Scrofula    TB related non-painful cervical  lymphadenitis

If you suspect TB in a patient, get them isolated in a negative pressure room.  All caregivers need to wear N95 masks.  Get a chest x-ray and discuss with ID further testing in the ED.    If you see upper lobe infiltrate, wide spread miliary distribution of infiltrate,  or granuloma with central adenopathy think TB.

Board scenarios for Pneumonias:

Sudden onset, chills, rust sputum =     Strep

Post-infuenza or cavitating lesion =        Staph

Alcoholics, current jelly sputum =    Klebsiella

Bullous myringitis, rash, joint pain, sore throat =   Mycoplasma

Pnuemonia and GI symptoms, possibly tourist in a hotel =  Legionella

CAP patients in general, benefit from steroids but don’t give steroids if you suspect influenza, the patient is pregnant, or the patient has poorly controlled DM.  Also avoid in patients with GI bleeding, receiving fluoroquinolone antibiotic (unclear why but no benefit shown with FQ’s), and those receiving neuromuscular blockers for intubation/ventilation (Can get myopathy.  I would discuss with intensivist.).

*Steroids for CAP

Menon      International EM

Vijay discussed his experience as an EM physician doing locums in New Zealand.

His message is basically, go to New Zealand if at all possible.

If you go you likely will work in a small town.  You will not be working in a large medical center in a big city.  The big cities have enough docs.  Minimum length of a contract for a locums job in New Zealand is a year.   

You have to pay taxes to New Zealand and the US.  The US taxes are not that bad.  You get significant credits and deductions for your US taxes.  

An opportunity cost of going abroad is that you will not be earning equity in a group like you would if you worked in the US.

You don’t go abroad to do locums to make more $.  You go abroad to gain that cultural experience and see the world and do something you will find fun and exciting.  The work culture in NZ is fantastic and you are given a lot of time off. Medical Malpractice is much less of worry there than in the US.

Vijay went to NZ to work for 2 years and wouldn’t trade that experience for anything.

Nejack     M&M

I will note only the take home points to keep the case details confidential.

With all trauma patients do a tertiary survey; basically go back when things have calmed down and fully re-examine patient for missed injuries.   Always look for a second fracture.

*CRITOE

*CRITOE

*When evaluating pediatric elbow injuries, check the alignment of the anterior humeral line.  Next, check the radio-capitellar line.  

*Look for abnormal fat pads

Finally check the boney cortices of the elbow

*Harwood made the point that if the figure of 8 on the lateral elbow is disrupted you have to consider a subtle supracondylar fracture.

Hart/Regan     Bread and Butter EM: Thanksgiving Cases

Case 1.  FB sensation in the throat after possibly swallowing a turkey bone.   You can initiate the work up with plain x-rays of the soft tissues of neck.  You can also get a CT neck.  If you identify a FB, discuss with ENT or GI for emergent or urgent endoscopy.  Sharp objects and batteries need emergent removal.   Other objects need urgent removal within 24 hours.

For patients with a Globus sensation in teir throat with no clear FB or unclear history.  Do a basic throat and neck exam. If no FB identified, you can consider using the fiberoptic scope to look further down the throat. If still no FB identified, reassure the patient. Start a PPI and arrange f/u with GI for endoscopy if symptoms don’t resolve.

Case 2.  2nd degree burns to arms from deep-frying a turkey.

*Rule of 9’s to estimate body surface area.

*Criteria for transfer to a Burn Center.   Even if the patient doesn’t meet the criteria for transfer, you can call the Burn Center and set up outpatient follow up in the Burn Center clinic. 

For patients with major burns, a clean dry sheet is the best dressing for transfer to Burn Center.

For minor burns, wound care at home is daily gentle washing of wound and applying antibiotic ointment and dry dressing. 

Case 3.  Treatment of flash pulmonary edema with hypertension

Aggressive NTG, start with nitro sprays(400mcg per spray) then rapidly titrate IV NTG up to over 100 mcg/min

Start Bipap

After maybe 30 minutes and BP improved give normal (40mg) dose Lasix.

These patients are usually not severely volume overloaded.  Flash pulmonary edema is really more of an acute vasculopathy that is treated with blood pressure reduction using hi-dose NTG.

Bamman      R&R Rapid and Random EM

* Unstable C-spine Fx’s

Treat Cystic Fibrosis pulmonary exacerbations similar to how you would treat a COPD exacerbation.  Give O2, nebs (albuterol/atrovent.  Also saline nebs have been found to be helpful), Bipap, steroids, and antibiotics to cover pseudomonas and MRSA.

Fitz Hugh Curtis syndrome is perihepatitis secondary to a chlamydia (more common) or gonorrhea pelvic infection.  Get cervical cultures.  Treat with Cefoxitin and doxycycline.  Consult gyne. Patients may need laparoscopy.

Harwood comment: CT Abdomen and Pelvis is not that sensitive for this disease.  It is more of a clinical diagnosis.

Mediastinitis is a life threatening emergency.  It can be a post-operative complication, result from trauma, or from esophageal perforation.  Diagnose with CT. Treat with big gun antibiotics (vanco, ceftriaxine, and flagyl) and most importantly emergent surgical debridement.

*Acute chest syndrome is a diagnosis made by vitals, lung exam, and CXR.  Any 2 of these categories with positive findings is consistent with ACS.  Treat with O2, cautious IV fluids, cefotaxime and azithromycin, transfusion (simple for less sick and exchange for more sick), and analgesics.

Thyroid storm treatment: Propranolol, PTU, SSKI (1 hour after PTU), Hydrocortisone

Alexander      Geriatric EM Patients

Belly pain in senior patients is tricky.  They are at higher risk for serious intra-abdominal problems but the clinical signs on their abdominal exam may be more subtle and non-specific.

Falls that present to the ED need to be evaluated for underlying medical problems.  Any senior with 2 falls in a1 year period may benefit from an in-home safety evaluation and general physical evaluation by PMD.  These evaluations can’t be done from the ED but care managers and the patient’s PMDcan be notified to provide a more global evaluation of the patient   

Harwood comment: 2 things that have found to be helpful for seniors at risk for falls are home safety evaluation, and physical therapy to improve strength and balance.

Polypharmacy is super-common in seniors.  Be cautious when adding narcotics, sedative hypnotics, nsaids,  antibiotics, and anticholinergics to their medication regimine.  Discuss with your ED pharmacist or consult an online medication interaction checker to avoid serious drug interactions.  

*To assess frailty you can watch a patient stand up from a chair, walk ten feet, walk back, and then sit down.   If it takes more than 20 seconds to do that, the patient may need help at home or physical therapy.

Bernard   Safety Lecture

Kyle covered our ED sepsis work flow and power plan.

He then discussed how we could be trained by the Chicago Recovery Alliance   www.anypositivechange.com to give out free Narcan to heroin users who come to the ED.