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

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

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

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

Management:

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

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

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

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

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

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

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

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

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

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

then read some retorts:

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

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

“Pigtail catheter” (wire, seldinger technique)

“Pneumothorax kit”-catheter over needle

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

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

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

Ketamine:  NMDA receptor antagonist, opioid receptor agonist.

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

Magnesium: 

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

Haldol:  Antipsychotic, dopamine antagonist, serotonin agonist

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

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