Conference Notes 9-16-2015

Williamson/Parker     Oral Boards

Case 1.  50 yo male with respiratory distress.  HR=100 BP=140/80RR=34T=98.7   Patient became SOB at subway station.   Exam reveals copious oral secretions. Patient also vomited and had abdominal cramping. EMS notes that other persons in the subway have similar symptoms.

*Cholinergic Toxidrome

Diagnosis is cholinergic toxidrome due to Sarin (organophosphate gas).   Treatment is high dose atropine until respiratory secretions have improved significantly, intubation,  and 2PAM.  Consult poison control.   Patient needs to be decontaminated. Staff needs to use PPI to prevent secondary exposure to toxin.  Patient’s clothing can off–let toxin for 30 minutes.  Sarin is colorless and odorless.

Elise comment: I saw a patient die of organophosphate poisoning in Africa.  It was horrible. The patient basically drowned in his own secretions because we did not have enough atropine.    Andrea comment: Initial dosing of atropine is 2-6 mg and go up from there until secretions are dried up.   There are stockpiles of atropine around the city and country.   The poison center has access to these stockpiles.  You have to get 2PAM into the patient as soon as possible to prevent irreversible aging of the acetylcholinesterase.

Case 2. 16 yo male with a headache for the last 10 days.  Vitals are normal.   Patient notes a weird feeling and paresthesias from waist down.  Legs have spasms occasionally.  Bedside ultrasound shows urinary retention.  MRI of the spine shows transverse myelitis. 

*transverse myelitis

Diagnosis is transverse myelitis due to multiple sclerosis.  Treatment is IV steroids.  Patient required foley catheter drainage of urine.   Transverse myelitis is an inflammation of the spinal cord.

In most cases a sensory level is documented, most commonly in the mid-thoracic region in adults or the cervical region in children. Pain in the back, extremities, or abdomen is also common while paresthesias (e.g., tingling, numbness, burning sensations) are typical in adults. Sexual dysfunction is also the result of sensory and autonomic involvement. Increased urinary urgency, bowel or bladder incontinence, difficulty or inability to void, and incomplete evacuation of bowel or constipation are other characteristic autonomic symptoms. Spasticity and fatigue are other symptoms common to transverse myelitis. Additionally, depression is often documented in TM patients and must be treated to prevent devastating consequences.  (Transverse Myelitis Association)

Case 3.  47 yo male presents with right foot pain for one week.  Vitals normal except for heart rate of 102.   Patient states that the pain began after a heavy board fell on his foot.   X-rays show lis franc injury.

*Lis Franc injury

Treatment requires ORIF and non-weightbearing for 6 weeks.   Harwood comment: this is a pretty severe lis franc injury.  Lis franc injuries usually involve the first and second metatarsals.  This xray shows all the metatarsals dislocated. 

Levato     Community Acquired Cellulitis

For uncomplicated cellulitis with no abscess use either cefazolin or clindamycin.   Elise raised concerns about the level of clindamycin resistance at our institution.   Harwood added that he would prefer to give Bactrim if you suspect MRSA.  

Levato’s Bottom line:  use more ancef and less vanco.  Patients without comorbiditities who have straightforward cellulitis with no fluctuance have a strep cellulitis. 

*Algorithm for soft tissue infections (Thanks Elise)

Remke      M & M

In order to respect the confidentiality of M&M, I am not going to give case details of M &M’s.  I will just present the take home points.

Be sure you have ordered a type and screen on pregnant patients who are bleeding.  If they deteriorate  and need transfusion, waiting for the type and screen can cause delay or necessitate the use of O negative blood.

Quantify vaginal bleeding based on whether it is more or less than a normal period.

On pelvic exam, if there is clot or tissue in the os, remove it.  Removing tissue and clot from the os can help the uterus to contract and lessen bleeding.

*Liklihood of Ectopic Pregnancy

In the setting of pregnancy, consult OB service for heavy bleeding, open cervical os, and positive beta hcg with no iup seen on ultrasound. 

Things to tell patients:

25% of pregnancies have bleeding

If a viable fetus is seen on ultrasound the risk of miscarriage is less than 10%.

Miscarriage is more likely with heavy bleeding, bleeding lasting a week or more, and if pain is associated with bleeding.

Emergency Physician Cognitive Issues:

Pay attention to subtle vital sign changes

Double check that the labs you need are ordered like type and screen.

Listen to your nurses when they raise a concern.

Get help from consultants when you are faced with a difficult situation.

Kelly Williamson comment: RH negative Patients who have a subchorionic hemorrhage on ultrasound but are not bleeding into the vagina do not need rhogam

Ortiz-Romero     Imaging the Pediatric Acute Abdomen

On ultrasound, a normal appendix is smaller than 6mm, compressible and has no surrounding free fluid.  Appendicitis is larger than 6mm, non compressible and hyper-vascular.  There will be point tenderness over the appendix with appendicitis.  Unfortunately 70% of the time the appendix is not visualized with ultrasound.

If you have an Alvarado score less than 5 and have an ultrasound with no inflammatory changes without visualization of the appendix, that clinical scenario has a negative predictive value of 99% for appendicitis!

Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

Blitman NM1, Anwar M, Brady KB, Taragin BH, Freeman K.

Author information

• 11 Department of Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY 10461.

Abstract

OBJECTIVE:

The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure.

MATERIALS AND METHODS:

We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports.

RESULTS:

Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%.

CONCLUSION:

Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.

When using CT for appendicitis, you need some peritoneal fat to identify the appendix.  So, very thin kids will be difficult to visualize the appendix on CT because they lack peritoneal fat.   However if there are no secondary signs of inflammation in the area of the appendix, that also makes appendicitis unlikely even if the appendix is not visualized.   To limit radiation exposure, you only need to do a pelvis CT.  Give IV and rectal contrast if the patient can tolerate them.   The cutoff for a normal appendix on CT is 7mm.

MRI can also be used to diagnose appendicitis. We are currently testing a MRI protocol for appendicitis.   The patient first gets scored on the pediatric appendicitis score.  If the score is 2 or more they are eligible for MRI testing.

Ultrasound is the first line test for identifying intussusception. 

Girzadas      ACGME Resident Survey Results

C Kulstad/Lovell    Preventing Diagnostic Error     Cognitive Bias

Misdiagnosis is the most common medical mistake and is a leading cause of malpractice claims. 

“Everyone is a human first and a novice or expert second”

There are 2types of causes for diagnostic error.  There are systems error and cognitive error.

*System and Cognitive Error

Error is more common when: uncertainty is high, the patient is unfamiliar to the physician, and the disease has an atypical presentation.   Cognitive error is a risk in high-pressure environments with many distractions. (the ER).

Nurses when acting as the wingman to the physician also need to be aware of their biases.  The nurse has the potential bias the physician either towards or away the right diagnosis.  If a nurse is biased against some aspect of the patient it can affect how the whole team approaches the patient. 

System 1 and System 2 Thinking.  To be a good EM Clinicianyou have to be able to switch back and forth between both systems.  Experienced clinicians have better developed system 1’s.  They have the experience to know when to switch into system 2 thinking.

*System 1 and System 2

Heuristics use pattern recognitions or mental shortcuts to solve problems.   Bias impacts heuristics a great deal.   This is a problem because ER docs use heuristics all the time in an environment that is prone to bias the heuristics.

Croskerry Six Biases:

1.     Over attachment to a particular diagnosis.  Anchoring on a specific feature too early and failing to adjust.

2.     Inheriting someone else’s thinking.  Following the cognitive path initiated by another provider.  This bias makes sign out a dangerous time.

3.     Failure to consider alternatives.  Tendency to stop looking once something is identified.

4.     Errors in estimation of prevalence.  Diagnoses that readily come to mind may be used more frequently.

5.     Bias related to patient characteristics or context.  Basically the physician has a personal perception about the patient and approaches the patient based on that concept of the patient.

6.     Errors associated with the clinician’s personality.  Over/under confidence is one example.   We need to have the appropriate level of both confidence and humility.

Tactics to overcome bias:

Cognitive debiasing:  Consider alternatives. Use metacognition or think about how you are thinking about a patient. 

Structured handovers:

Checklists :  Checklists help us to think of options we did not initially consider

QV&V: Qualify the source, validate the information, and verify the information.  Basically check that the info you are basing your decision on is correct and valid.

STEP Thinking: Story, Testing, Evaluate, and Plan

EMR Enhancements

Conference Notes 8-5-2015

E. Kulstad         Research Update

ACMC EM is #1 in the world in enrolling patients with intra-cerebral hemeorrhage  and hypertension into the ATACH 2 Trial!  Please continue to enroll these patients in the study.

The Macy Catheter can be used to give almost any medication rectally.   You can give up to about 500ml of water or pedialyte per hour rectally. This may be a therapeutic bridge option in the person who has a difficult IV access.

C. Kulstad       Study Guide Cardiology

There is no mortality benefit to routinely taking non-STEMI, ACS patients to the cath lab.   Thus, the patient with chest pain and bumped troponins and a non-STEMI EKG gets equal benefit from medical management as they would from going to the cath lab.

The absolute mortality risk reduction of ASA in ACS is 4%.  This data is derived from the 1988 ISIS study that showed ASA brought mortality down from 13% to 9%.  The absolute mortality reduction from heparin and LMWH in non-STEMI ACS is 0%.   The data for heparin and LMWH in STEMI is not known.  There is no Cochrane review on this topic.  We don’t really know the mortality benefit, if any, for heparin in STEMI.

POISE-2 study showed that you should hold ASA prior to abdominal surgery.  There is no increase in mortality if you hold ASA prior to abdominal surgery in patients with prior MI.  If you give ASA prior to surgery there is an increase in bleeding.  Elise comment: Most surgeons should not have a problem limiting surgical bleeding due to a patient’s ASA use.

*Electrical alternans is a poorly sensitive and reasonably specific finding of pericardial effusion.

Stress echo is a moderately sensitive (80%) and specific (80%) test for coronary stenosis.   It however is not a good test to identify risk for major adverse coronary events (MACE)

A murmur at the right 2nd intercostal space is consistent with aortic stenosis.  These patients can present with chest pain, dyspnea and exertional syncope.   It is a murmur that is easy to miss.  The prevalence of aortic stenosis in the elderly is 3% (pretty high prevalence).  There is now a new option of transcatheter aortic valve implantation that allows for valve replacement therapy without thoracotomy.

*Indications for temporary and permanent pacemaker

Hi dose NTG has shown mortality benefit in CHF.   We probably under dose IV NTG.   One strategy to get a higher dose of NTG into a patient is to use sublingual spray.  Each spray gives 400micro grams per spray.  You can give a spray every few minutes in the hypertensive, pulmonary edema patient.

Tobacco cessation is the single most profound risk reduction strategy in patients with CAD.

Pericarditis pain is worse lying down.  Patients can also have pain with swallowing.

Burns/C. Kulstad      Oral boards

Case 1.  24 yo male presents with agitation and hyper-adrenergic toxidrome. Patient had to be restrained by EMS personel and was fighting against restraints.   His troponin and AST are elevated.   His CK is markedly elevated.  Urine tox screen is positive for cocaine.  Patient management of cocaine overdose required relatively high dose IV benzo’s for agitation and hyperadrenergic vital signs. Treatment for cocaine toxicity is benzodiazepines as your  first/second/third line.  Patient also required  IV fluids for rhabdomyolysis.  A bicarb drip for cocaine-induced rhabdomyolysis is controversial.  Cooling measures were also indicated to manage hyperthermia. Avoid beta-blockers in cocaine toxicity.  You can get unopposed alpha effects.

Case 2.  28 yo female with left shoulder pain.

*Image

Diagnosis was AC joint separation.   Treatment is sling, pain control, and non-emergent orthopedic referral.  You have a two-week time frame to surgically repair an AC separation.   AC joint separation is the most common shoulder injury in athletes. High-grade separations require surgical repair.

Xray findings of AC separation: The acromion is not level with the lateral clavicle.

*AC separation Xray

Case 3.  20 month old female brought in for crying.

*Monitor strip

Exam shows enlarged liver.   Patient has cool extremities.

Diagnosis was SVT.  Treatment was IV adenosine 0.1mg/kg initial dose.  The rhythm slowed temporarily but then returned to SVT.  Second adenosine dose was 0.2mg/kg, which also did not convert the patient.  Child appeared more clammy/shocky so the next move was synchronized electrical cardioversion.  Patient was given intransal fentanyl prior to cardioversion.  Initial shock was 0.5j/kg.  Patient converted with first attempt at cardioversion.   If first attempt fails you can go to 1j/kg.

Remke    Pediatric SVT

Case 1.  7 day old with a heart rate of 300.   BP 75/47.   Afebrile.   Patient had been feeding well.  Lungs were clear.  Color was good.  Rythm Strip showed SVT.  Child was treated by peds cardiology in the ED with propranolol and rate was controlled.

 *3 Types of SVT

To diagnose SVT  in pediatric patients, the heart rate should be great than 220 in an infant and >180 in a child.   There should be no P waves on EKG.  The rhythm should be very regular with no variability.  Sinus rhythm has more variability than SVT.   Notching of the T wave suggests sinus rhythm with the P wave buried in the T wave. 

*Sinus Tach vs. SVT

*Pediatric SVT Management Algorithm

Vagal maneuvers include: ICE to the face, Valsalva maneuver, and rectal stimulation with a thermometer.

For known WPW use procainamide instead of adenosine.  Elise comment: For orthodromic narrow complex SVT it is ok to use adenosine even if it turns out to be WPW.  It is the AHA recommendation. 

Avoid verapamil in infants and children.  It is contraindicated in patients under 1 year of age because it can result in V-Fib and hypotension.   It can be used as a second or third line therapy for SVT in teenagers.

After cardioversion, admit infants and discharge older kids/teenagers after a 2-4 hour period of observation.  If you identify WPW discuss with cardiology about admission for ablation.

Ede      Low Risk Chest Pain

Chest pain patients are considered low risk if the probability of major adverse cardiac events is 1-2%.

Patient’s response to GI cocktail or NSAID or NTG is not reliable for ruling in/out ACS.

Women may have more atypical symptoms.

*HEART Score        Patients who are low risk by HEART score and have 2 negative troponins 3 hours apart have a less than 1% risk of MACE  (major adverse cardiac events)  in 6 weeks.

*Heart Score Decision Making

Hart        Tachyarrhythmias

*Tachycardia Algorithm.   I would only add that procainamide can also be used and is probably preferred for wide complex irregular tachyarrythmias (WPW).

If you have IJ central line access, you can use a lower dose of adenosine because of a faster transit time to the heart.  Braden Parker noted that 3mg of adenosine worked quite well in a patient with SVT that he treated through an IJ line. 

Adenosine causes a sense of doom or chest pain in patients.  You should give some sedation prior to administering adenosine.

*WPW Syndrome

Avoid AV nodal blocking agents (betablockers, calcium channel blockers)  in antidromic (wide complex) tachycardias.  Blocking the AV node in antidromic tachycardia can result in death.

Aflutter usually has a rate right around 150.

*Atrial Fibrillation and Atrial Flutter

Calcium Channel Blockers have been shown to be superior to beta-blockers for Afib.

*Junctional Tachycardia can be hard to diagnosis.  Consider digoxin toxicity when you see Junctional Tachycardia.

*Diagnosing V-Tach

*Girzadas note: Another Approach to Diagnosing V-Tach on ecgpedia.org. I have always struggled with differentiating VT and SVT with Aberrancy.  This seems like a simple way to do it.  In lead II if the initial upstroke or downstroke of the QRS takes more than a box it is likely VT.  A caution, It is not validated yet. 

First line treatment for Stable Ventricular Tachycardia is Procainamide.   Second line is Amiodarone.

*Torsades      Treat with Magnesium or Overdrive Pacing

Parker         PodCast Pearls  for Codes

Traumatic Arrest is usually due to one of a few things: exsanguination,  pericardial tamponade, or tension pneumothorax.    Based on that, is there any reason to do CPR for traumatic arrest?  CPR can also hinder other activities/procedures being performed on a trauma patient. CPR can increase the risk of blood exposure to the resuscitationist.

Mnemonic for PEA in the Trauma patient:  HOTT=  Hypovolemia, Oxygenation, Tamponade and Tension Pneumothorax.

C Kulstad and Girzadas comments:  We are uncomfortable dropping CPR completely from trauma resuscitation.  We think there is medical-legal risk to that.  Possibly a more middle of the road approach would be to prioritize life saving procedures.  If CPR is hindering other life saving procedures such as gaining IV access, relieving tamponade,  or relieving tension pneumothorax stop CPR for as short a time as possible and perform the procedure and re-start CPR as soon as possible.

PEA Management:  Use ultrasound to identify causes.  If the QRS in PEA is wide think metabolic causes like hyperkalemia, TCA overdose, infarction.  If the QRS is narrow think obstructive causes such as tamponade, tension pneumo, or PE.

Jamieson        Parasites

A parasite lives at the expense of the host.

The CDC Lists 5 Parasitic Infections we should know.

Chaga’s disease: Caused by protozoan Trypanosomi Cruzi.  Acutely, patients have fever and malaise.  They can also acutely have eyelid swelling, myopericarditis, and meningitis.  Chronically patients can have CHF or megaesophogus.   You need to get the treatment drugs from the CDC.

*Eyelid edema from acute Chaga’s Disease

Cystercercosis:  You get the worm from eating infected pork. Neurocystercercosis can result in seizures.   When the infection is in the muscle if feels like bumps.   Treat with albendazole, anti-seizure meds, steroids, and surgery.

*Nueorcystercercosis

Toxocariasis: Caused by ingestion of cat or dog feces. Acutely the patient will get a hepatitis or pneumonitis.  The pneumonitis can look like asthma.  Kids can also get unilateral visual impairment from fundal involvement.

Toxoplasmosis: Caused by ingesting cat feces.   Infection can be spread vertically from mom to infant.  Congenital toxoplasmosis can cause spontaneous abortion, fetal death, and fetal neuro deficits. Immunocompetent adult patients can have a mono-like syndrome.  Immunocompromised adult patients can get encephalitis.  

Trichomoniasis:  Most common non-viral STD.  Can be asymptomatic for months.  Women have vaginal symptoms.  75% of men are asymptomatic.  Can result in pregnant women having premature rupture of membranes and preterm delivery.

Conference Notes 7-22-2015

A special Thank you to Christine Kulstad for her help with the Conference Notes this Week!

Lovell/Htet        Oral Boards

Critical Actions Case 1:  Septic Shock from Capnocytophaga canimorsus/dog bite

--Identify Sepsis

--Rapid IVF, early broad spectrum antibiotics including dog bite coverage

--Elicit history of dog bite

--Reassessment

--ICU admission

(also consider Xray, irrigation of wound, consider tetanus update, rabies)

Teaching points:  Capnocytophaga canimorsus

--fastidious GNR identified in 1976, likes to eat iron

--normal oral flora of kitties and doggies

--Risk groups:  asplenic, alcoholics, beta thal, smokers (high iron), immunosuppression

--Alcoholics have high blood iron + immune comp.

--WORST OUTCOMES in asplenics:  high iron + decreased phagocytosis; high M/M!!

--Symptoms usually within several days

--Fever, V/D, malaise, abdominal pain, myalgia, confusion, dyspnea, headaches, rashes

--Special culture media

--Tx:   Dogmentin!  so use IV Unasyn, also susceptible to third gen. Cephalosporins

Critical Actions Case 2:  Submassive to Massive PE

--Recognize risk for PE (travel)

--Diagnose PE

--Risk stratify (Echo, BNP, Trop)

--Recognize decompensation and need for thrombolytics

--Assess contraindications to tPA

--ICU admission, Intensivist consultation

Teaching points:   Submassive/Massive PE

--Submassive:Normal BP but RV dysfxn (Echo or BNP) or myocardial necrosis (Trop)

--Massive: Low BP for 15 minutes or code or resp. failure or need for pressors

--Thrombolytics for massive, case by case for submassive

--r-tPA dose 100 mg IV over 2 hours

--Code dose, 50 mg bolus (maybe + 50 mg)

--start IV Heparin when PTT < 2X nml

--Lytics in PE:  2% ICH risk, 6% major bleed/transfusion

Critical Actions Case 3:  Jellyfish envenomation

--Identify as Jellyfish envenomation

--Irrigate 

--Consider vinegar, hot water

--Monitor for systemic sx, allergic sx

--Treat with benadryl, consider steroids, analgesics

Teaching points: Jellyfish Envenomation

--Mechanism-tentacles with venom containing nematocysts

--Symptoms--Itch, swell, burn, tingling/numbness.  Severe with N/V, HA, weak, dizzy, SOB

--Treatment-irrigate with NS or sea water (fresh water makes worse), remove possible remaining nematocysts by shaving skin or scraping skin

--Use benadryl, consider steroids, give analgesics

--vinegar-prevent further nematocyst firing, hot water to breakdown venom-some controversy over effectiveness

Levato     Pharmacy Update

Community-acquired but complicated UTI- E coli, Klebsiella, Proteus most likely. We have been using ceftriaxone for this but it is a broad spectrum antibiotic that is causing c diff in our hospital. Cefazolin found to be 89% sensitivity in E coli, 90% in Klebsiella, 100% Proteus. So new guidelines are to use cefazolin for these patients. CAUTION- not appropriate for nursing home patients. OK for pyleonephritis.

Ketaneh  (Class of 2014)  Starting out as a New Attending

Looking for a job: Take some pressure off- its just your first job, you can change it later. He interviewed all over and recommends it. Prospective employers will usually pay for your interview expenses so don’t shy away from multiple interviews. It helps to see a lot of practice environments too, see where you fit in.  Use the faculty resources here (they know somebody everywhere).

You will have a lot more money- try to live like a resident and save for a while. Student loans will come due, 401k should be funded. Need to find your work-life balance- how many shifts due you want to work to pay for your lifestyle.

Starting a new job- get familiar with the EMR before your first real shift. Will save you tons of time and pain before your first shift.

Have your charting macros prepared before you start.

Know where you are going to look stuff up.

Be super nice and respectful to everyone.

Get your charting done so you stay off the medical records radar. 

Get to know the culture of your workplace: protocols, antibiotic choices, sedative choices.

Nick told a scary story of how he ordered a fentanyl drip and the pharmacists and nurses were not familiar with using fentanyl as sedation and dosing errors were made.

At most ED’s you at times will be working alone with a couple of nurses.

Be very clear when communicating with nurses, they will do exactly whatever you say.

An important part of our job is charting and billing.  It’s just a fact of life.  Your income and job security depend on it.

*Ups and downs.   You have to be able bounce back from the downs as an ER doc and temper/be humble with the Ups

There are other jobs out there.  You can change jobs.   It is important to protect your reputation so people think well of you and you keep the door open to other opportunities.

Be smart with your money.   It is OK to rent for awhile until you have a clear idea of your monthly income.  Then live below your means so you are funding your retirement properly.

As a resident and attending, going the extra mile will not go unnoticed.

Get your paper work done. 

Favorite FOAM websites:  lifeinthefastlane.com, aliem.com, emcrit.com

The goal for an ED doc in the community is to not be ultra cutting edge and not be practicing medicine from 20 years ago.  You want to be somewhere in the middle and up to date. 

Regan       Seizures

*Causes of Seizures

Generalized Seizures: Affects both Cerebral Hemispheres. There is loss of consciousness.

*Seizure Types

Partial Seizures include: Simple in which conscious is maintained and Complex in which consciousness is altered.

Initial questions to ask the patient:  Do you have a seizure disorder?     Is there anything that would have lowered you seizure threshold?  (sleep deprivation, fever, etoh use, missed medication, stress)

EKG can be a quick initial test to pick up electrolyte abnormalities causing seizure.

*Medications for seizure management

Elise comment: In the Peds ED there is frequently the availability to get an EEG rapidly for a child with a new onset seizure.  This rapid turn around of an EEG can be very helpful to neurology to make good management decisions for the patient.

Case 1.  Etoh withdrawl seizures can be treated with Ativan first line and Phenobarbitol second line for persistant  seizures despite Ativan.    Christine comment: You can push the upper dosage range of Ativan in the ETOH withdrawal patient. Their GABA receptors are down regulated.   Elise comment: If your Ativan is not working in any type of patient, start thinking about underlying causes such as hypoglycemia, hyponatremia, INH poisoning, intracranial hemorrhage.

20mg/kg loading dose works for Phenytoin, fosphenytoin, Phenobarbital, Valproic Acid, and Keppra.  Basically 20mg/kg works for all commonly used epileptics other than Ativan.

Check the patient’s tongue for lacerations and hematoma.  Serious tongue injuries  could pose an airway obstruction issue.

Neuro exam in infants

Look for:

Balled fists with thumbs tucked in, this is an upper motor neuron sign (Babinski sign in infants)

Altered/increased tone

Abnormal Reflexes

Eye deviation

Elise comment: Midazolam IM is a very rapid acting anti-seizure medication that is useful in kids.   Eye deviation is an important finding in kids to identify a seizure.

30-50% of patients with pseudo seizures also have epileptic seizures.  This makes diagnosis and management possible psuedoseizures very difficult. 

Carlson                      Antidotes

*Antidotes

Isopropyl alcohol ingestion is not an indication for fomepizole.  It is metabolized to acetone.

Lead has 3 potential antidotes: BAL,  EDTA, and Succimer.   Peanut allergy is an absolute contraindication to BAL therapy.

Gyromitra mushrooms look like a brain and can cause seizures.  The antidote is pyridoxine (also the INH antidote/INH also causes refractory seizures).

*Gyromitra mushroom

Sodium Bicarbonate is an antidote for TCA poisoning.  The sodium overcomes Na Channel blockade.  The Bicarbonate decreases free TCA.   Andrea prefers bolus dosing with 1-2 ampules while closely observing the patient and the monitor.

Calcium channel overdose can cause bradycardia, hypotension, and hyperglycemia.  The antidote is the “perfusion salad”: calcium chloride, glucagon, intralipid, atropine, and insulin euglycemic therapy.

Deadly nightshade contains bella donna toxin.  Bella donna can be thought of as a Benadryl overdose.  Both cause an anticholinergic toxdrome.  The antidote for anticholinergic toxidromes is physostigmine.   Physostigmine should not be used in undifferentiated coma or in mixed overdoses.  However, it is safe in pure anticholinergic toxidromes.  

*Deadly nightshade berries

*Deadly nightshade leaves  (note the little “ears” small leaves around the big leaf)

Paint stripper that contains methylene chloride if ingested will be metabolized to CO.  Methylene chloride gets metabolized by liver to CO and can cause CO toxicity.    Antidote is hyperbaric oxygen. 

Statistically the most common cause of CO toxicity in the summer is indoor grilling or using a grill on a screened-in porch. 

*Hyperbaric indications for CO Toxicity

Causes of cardiac glycoside poisoning: digoxin, oleander, foxglove, Lilly of the valley, and the practice of toad licking.   Antidote is FAB fragments

West      Fever in Kids

Rectal temperature measurement is most accurate.   The temperature that determines a fever is 38C.

*Fever algorithm for kids </= to 3 months

For febrile kids (with immunizations up to date) over 3 months of age with no source on physical exam the next best diagnostic study is to check the urine.

Brain damage is not a complication of fever due to infection.

Faculty comment: Parents frequently under-dose Tylenol and Ibuprofen.  Check the dosing parents are giving to kids if the antipyretic is not bringing down the fever.

Harwood comment:  You may not need to do an LP on febrile kids age 30-60 days old if they have the following:

Well appearing child

Normal urine

Normal ANC

Normal Procalcitonin

This decision rule has not been validated. 

Elise comment: Right now there is a grey zone (based on age of infant) of whether there is a need to do an LP.  There is reasonable practice variation in non-toxic appearing, febrile kids age 30 days to 60 days.   Most faculty have a cut-off at 6 weeks, but up to 8 weeks is reasonable.  Ill appearing kids at any age require LP.

Fever Algorithm for ages Newborn to 36months

Bonder     Patient Satisfaction

Patient satisfaction rates are a factor in medicare reimbursement.

Research has shown that patient satisfaction measurements are biased and don’t correlate with clinical quality metrics.   Also, mortality rates tend to be higher in hospitals with high patient satisfaction levels.

Safety net hospitals and teaching hospitals regularly perform more poorly on patient satisfaction measurements.   There are geographic variabilities as well with California and East Coast hospitals usually scoring lower than other regions.

*Kaiser 4 Habits Model from Kaiser Health

Elise comment: Patient satisfaction measurements are not based on your clinical care or diagnostic accuracy.  They are based on how you communicate with the patient.

Christine comment: At the completion of the ED visit, take the time to explain to the patient what the tests showed and how they ruled out dangerous diagnoses.

*Patient Satisfaction Measures