Some Awesome Pearls at Conference this week! But first gotta promote the Foundation:
SAVE THE DATE for the ACMC EM Foundation Golf Outing
What: Emergency Medicine Golf Outing – October 1, 2013
Location: TBD
Time: Following the Emergency Medicine Conference/Early Dept Meeting and Vice-Chair Vote
Cost: $150/golfer (includes golf, dinner & drinks)
Purpose: To raise awareness for the Emergency Medicine Endowment which provides funding for residents to further their education
Contact: Jason Keene, Director of Development 708-684-2012 or jason.keene@advocatehealth.com
*Proceeds will benefit the Emergency Medicine Endowment
*Electronic Invitation to follow
McKean/C. Kulstad Oral Boards
Case1. TTP Critical Actions: plasmapheresis (the same thing as plasma exchange) is the key treatment, CT head, No LP, Admit to ICU, get Hematology Consult. Optimal care: DIC panel, discuss FFP transfusion, assess for life threatening bleed, discuss steroids with hematology. Classic TTP Pentad: microangiopathic hemolytic anemia (MAHA), neurologic abnormalities, fever, renal disease, thrombocytopenia. Frequently the pentad is not present. The cornerstones of the diagnosis of TTP are thrombocytopenia and hemolytic anemia. Most patients have some neurologic and renal abnormalities but the severity of the neuro and renal abnormalities is highly variable. This disease is more common in middle age persons. Females more commonly affected than males. TTP has high mortality 90% untreated and 20% treated. Don’t give platelets. TTP and HUS are very similar disease processes in adults.
Group discussion about management of TTP in regard to LP. Most agreed when there is diagnostic uncertainty between TTP and meningitis give antibiotics and steroids prior to getting labs back and prior to CT/ LP. If platelet count is less than 50K (Harwood’s cutoff) don’t do LP. If platelets above 50K probably safe to do LP. Girzadas: Some case series have shown no bleeding complications with very low platelet counts. Erik comment: If you do a LP for possible meningitis and the platelet count comes back below 50K, the patient will likely be fine. Everyone agreed though that Harwood’s cut off at 50K was prudent.
Up to Date reference: It is traditionally stated that a platelet count greater than 40,000 to 50,000/microL provides safety for interventional procedures such as lumbar puncture [11-13]. In certain procedures where bleeding risks are greater, or the risk of complications from minor bleeding is high, a platelet count greater than 80,000 to 100,000/microL is often required by surgeons (especially neurosurgeons) or anesthesiologists.
A quick Abstract on this topic:
The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals.
van Veen JJ, Nokes TJ, Makris M.
Source
Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK. joost.vanveen@ukgateway.net
Abstract
Neuraxial anaesthesia is increasingly performed in thrombocytopenic patients at the time of delivery of pregnancy. There is a lack of data regarding the optimum platelet count at which spinal procedures can be safely performed. Reports are often confounded by the presence of other risk factors for spinal haematomata, such as anticoagulants, antiplatelet agents and other acquired or congenital coagulopathies/platelet function defects or rapidly falling platelet counts. In the absence of these additional risk factors, a platelet count of 80 x 10(9)/l is a 'safe' count for placing an epidural or spinal anaesthetic and 40 x 10(9)/l is a 'safe' count for lumbar puncture. It is likely that lower platelet counts may also be safe but there is insufficient published evidence to make recommendations for lower levels at this stage. For patients with platelet counts of 50-80 x 10(9)/l requiring epidural or spinal anaesthesia and patients with a platelet count 20-40 x 10(9)/l requiring a lumbar puncture, an individual decision based on assessment of risks and benefits should be made.
Case2. Achilles tendon rupture Critical actions: Complete extremity exam, consult ortho, splint in moderate plantar flexion. Tear is usually just above the calcaneus. Surgical repair has less risk of re-rupture but of course carries surgical complications. Plantaris tendon rupture causes whip like pain in calf. Treatment of plantaris rupture is pain control and ace wrap. Medial gastrocnemius tear also can cause sudden calf pain and is treated with conservative measures.
Thompson's Test: Right leg in photo is abnormal and doesn't plantar flex with squeezing the calf (positive test=tendon rupture). You can also do the test with the patient prone and knee flexed.
Discussion between Harwood and Elise about best position to splint ankle with Achilles tendon rupture. Harwood basically said it is not that important to splint in plantar flexion. Elise felt plantar flexion de-stressed the tendon and was preferred over splinting at 90 degrees.
Case3. Perforated Ulcer Critical actions: IV antibiotics (cover gram negatives & anaerobes) and emergent surgical consult. Optimal care: PPI, NG, foley.
Free air under the diaphragm on CXR:
C. Kulstad Study Guide Trauma
Nexus
The NLC decision instrument stipulates that radiography is not necessary if patients satisfy ALL five of the following low-risk criteria:
- § Absence of posterior midline cervical tenderness
- § Normal level of alertness
- § No evidence of intoxication
- § No abnormal neurologic findings
- § No painful distracting injuries
Canadian C-spine rules
The CCR involves the following steps:
- § Condition One: Perform radiography in patients with any of the following:
- · Age 65 years or older
- · Dangerous mechanism of injury: fall from 1 m (3 ft) or five stairs; axial load to the head, such as diving accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car
- · Paresthesias in the extremities
- §
- · Simple rear end motor vehicle accident; excludes: pushed into oncoming traffic; hit by bus or large truck; rollover; hit by high speed (>100 km/hour [>62 mph]) vehicle
- · Sitting position in emergency department
- · Ambulatory at any time
- · Delayed onset of neck pain
- · Absence of midline cervical spine tenderness
Patients without any of the low-risk factors listed here are NOT suitable for range of motion testing; they must be assessed with radiographs.
If a patient does exhibit any of the low-risk factors, perform range of motion testing, as described in Condition Three below.
- § not
Head injury on Coumadin: Check INR, observe in ED for a few hours Observe in hospital if INR is very high.
Pregnant patient with chest trauma and pneumothorax: Place tube in the 3rd intercostal space in the mid-axillary line. It’s alittle higher placement than in a non-pregnant patient.
In contrast to orbital floor “blow out fx’s”, Orbital roof fractures and fractures through the naso-ethmoid bone risk injury or infection to the brain. These roof and naso-ethomid fractures need admission and consult of neurosurgery.
Stable C-spine fractures: compression less than 25%, spinous process fracture, transverse process fracture.
Fractures of spinous and transverse processes are stable.
Treatment of severe blunt laryngeal injury (laryngeal fx). Group discussion on this one: Start with RSI but be prepared to have great difficulty with the airway. You want to paralyze the patient to give you an optimal look but loss of muscle tone may cause the airway to collapse. There is a high risk of creating a false passage with the ET tube. Your rescue approach is problematic as well. Cricothyrotomy is not recommended due to disruption of the normal cricothyroid anatomy. Harwood and Kelly Williamson suggested being prepared to do a seldinger cric through the trachea in this situation. Everyone cringed at facing this difficult situation.
Zones and Triangles of the neck
Girzadas comment: Way to remember that zone 1 is at the bottom and zone 3 is at the top. Big Red 1= Aorta is in zone 1 and Zone 3 is up toward the Third ventricle.
Open mandible fractures require admission for IV antibiotics. Open fracture is identified by blood between teeth. Tongue blade test is 96% sensitive for identifying mandible fracture. Closed mandible fractures can go home.
NG and foley sizes for kids are 2X the ET tube size. Chest tubes are 4X the ET tube size. ET tube size is age/4 + 4.
Evaluate for incomplete cord injuries with anal wink, cremasteric reflex, and bubocavernosis reflex.
Chest tube output to prompt OR in Kids: 15ml/kg initially and 4ml/kg/hr ongoing. For adults: 1500ml initial and 200ml/hr x 4 hours
Central cord syndrome: Upper extremities weaker than lower extremities and proximal weakness more pronounced than distal weakness. Man in a barrel is the classic analogy for this neuro deficit.
Brown Sequard syndrome : Ipsilateral paralysis and loss of pain and temperature on the contralateral side.
Subdural/Epidural/SAH Bleeds
Williamson/Patel/Tekwani Post-Partum Emergencies
Case 1: 36 yo female G2P2 s/p c-section one week ago. Pt had headache. She then developed some chest pain. BP 132/80 P 52 P/O 98%. Broad ddx of head and chest emergencies was considered. Kari was thinking pt had predominantly a headache problem. Pt improved with treatment. D-dimer was 17. CXR was pretty much pristine. CT-PE study showed aortic dissection extending to innominate and carotid arteries. There was debate between radiology and CT surgery about whether the CT findings were artifact. Kari called in Cardiology to do transesophageal echo. TEE showed/confirmed dissection. Pt went to OR. Discussion about CT evaluation of PE vs. Dissection. If you are specifically looking for one disorder (Dissection or PE) get the appropriate test. If both are in the differential, get the CT PE. You are probably more likely to see a dissection on the PE study than see a PE on the dissection study.
Kari comment: The presentation of dissection can be extremely protean or subtle.
Case 2: 38yo female with chest pain 9days after c-section. DDX was PE, dissection, musculoskeletal pain, pre-ecclampsia, nstemi, cardiomyopathy. EKG showed subtle inferior depression and high lateral minimal ST elevation. Most people in the room read it as nonspecific. Nobody would have called a STEMI on this EKG. Troponin was elevated. Pt got cathed and was found to have LAD dissection. There are multiple case reports of post-partum woman having spontaneous coronary artery dissections.
Coronary artery dissection or thrombosis is more common in the post-partum patient than acute coronary syndrome. These patients don’t usually have underlying atherosclerosis.
Case 3. 31 yo female 1 week after delivery. Pt has sob. Went to an urgent care center the day before. Pt had nl ekg and neg d-dimer, trop from previous visit at urgent care center. DDX=PE, post-partum cardiomyopathy, pericardial effusion, anemia, pre-ecclampsia. EKG did not show any acute ischemia. CXR is pristine. Trops are negative. Hgb is 11.6. VQ is low prob. Venous dopplers are negative. Ambulatory pulse ox was nl. Pt had no protein in urine. BP was 156/83. Pt was dc’d home….. Pt develops a headache 5 days later and she collapses. Pt was severely hypertensive. She arrests in the ED. Difficult intubation. CT head was neg. Pt was placed on magnesium and labetalol. She remained in a coma and support was withdrawn. Diagnosis was pre-ecclampsia.
20% of patients present with htn alone (>140/90) and no proteinuria. Ecclampsia can present up to 8 weeks after delivery. It is critical to get a urine protein/creatinine ratio. This can be ordered as a single urine test from lab. Anything above 0.19 suggest pre-ecclampsia. Also get CBC and CMP. Treat pre-ecclampsia with magnesium.
Lecturers comments: The post-partum patient should be considered very carefully and deserves a more detailed work up.
#1 risk factor for endometritis is C-section. Harwood comment: There is a sub population that can be treated as an outpt. Kelly’s comment: If patients receive IV antibiotics in the hospital, when they clinically improve and defervesce they no longer need any antibiotics IV or oral.
Peripartum cardiomyopathy can go out to 5 months after delivery.
PE is more likely post-partum than during pregnancy.
Harwood comment: Pregnancy is a stress test. Some women fail this stress test and get head bleeds, aneurysms, post partum cardiomyopathy, pe’s , and dissections.
Frazer Safety Lecture
Sign out: Admit to MICU for ativan overdose. Pt is somnolent but stable and is boarding in the ER waiting for the ICU to open up. Pt has been in ED for several hours. He becomes more alert. He gets downgraded to step down unit. Pt gets transferred up to floor. Although the ICU attending was contacted, no one ever contacted the floor attending that the patient was going to the floor. The patient spent several hours on the floor with no orders.
All attending should be contacted when there is an upgrade or downgrade of admission destination.
There was a trouble shooting discussion and the group felt that putting the medical team as a consult with the reason as MICU admit. At sign out we should be asking each other is this patient downgradable? If so who needs to be contacted.
Felder CV Workshop
It should be a “map” of your career and interests.
Put information lines under each heading in reverse chronological order.
Keep it concise. If you have a lot of pubs just list topics and the number of references under each topic. Then add at the bottom: Detailed list of publications on request.
Make a top 5 list of achievements/strengths/interests. Be sure your CV highlights these strengths.
Girzadas comment: Use the decision points in residency to differentiate yourself on your CV. Lectures, elective rotations, resident project, and leadership positions all can be used strategically to demonstrate a focus in your residency training.
5 quick fixes:
-
- Creative editing like bolding should be used to highlight your strengths.
- Make your career timeline easy to follow.
- List your publications but if you have many make it more conscise as described above.
- Make the CV easy on the eyes
- Make formatting consistent.
You may want to customize your CV to different jobs you are applying to.
Before you interview for your dream job, think about applying and interviewing for a job you are not super-interested in to give yourself a chance to practice.
Cover letters should give alittle more definition to who you are and what kind of doctor you are beyond the objective work milestones on your CV. Christine comment: It should give the employer some info about why you are interested in a particular geographic area or hospital.
Altman comment: Personal connections such as phone calls and networking are the most powerful way to get jobs. Say, “Dr. X told me to call you”
Ryan Medical Student Review