Conference Notes 9-13-2011

Conference Notes 9-13-2011
GROMIS   ASOKEN   Use of Contrast for imaging studies
Most abdominal studies can be done without contrast.
Rectal contrast can save you time when doing a abdominal study.  Downsides are pt discomfort,  and pt having release of contrast from rectum. 
If the pt has some abdominal fat ct without contrast should be fine because the fat will outline the organs.
IV contrast is critical to opacify blood vessels example pe and aortic dissection. IV helps with inflammatory changes.   Looking for mets/tumor is aided by iv contrast. 
Oral contrast is much less likely to cause allergy compared with iv contrast.  IV contrast is iodine based so more allergic potential. Probably not a true allergy but more likely an idiosyncratic reaction.  
IV contrast is unpredictable in relation to causing an allergic reaction.  Patients with any type of allergy may be at increased risk.   Seafood allergy doesn't specifically mean a pt will be allergic to iodine based contrast.
GFR less than 30 is high risk for iv contrast.   GFR between 30 and 60 needs a risk/benefit analysis between radiologist and EM Doc.
IV or PO  hydration is the key to preventing increase in creatinine due to contrast. 
You probably don't need contrast for ct abd/pelvis for appy, obstruction, diverticulitis.
HINTON   CT ABD/PELVIS
Fat stranding is important marker of inflammation
Appendicitis shows an appendix greater than 6mm in width and associated inflammatory changes.   Start looking for the appendix at the cecum. 
U/S is better than CT for picking up gallstones.   Ct is better than U/S for identifying inflammatory changes around gallblader. 
Portal venous gas extends out to periphery of liver and is a poor prognostic marker.
Feces in the small bowel is a sign of bowel obstruction. 
SAWLANI   MANAGEMENT OF UTI
Who needs a urine culture?  If you decide to give antibiotics to a child up to 24 months for fever without clear source get a urine culture. 
Get urine for ua and culture by catheter or suprapubic tap. 
Risk factors for uti are fever equal/more than 39 and greater than 1 day of fever. Uncircumcised male is higher risk.  White girls and nonblack males are higher risk. 
If a ubag specimen urinalysis or dipstick is neg you are done. If it is positive you got to do a cath specimen.
A uti is diagnosed by a positive ua and culture of at least 50,000 cfu's. 
Uti and fever in kids under age 2 is considered pyelonephritis. 
ABX treatment for pyelo is omnicef.  it is covered by public aid as well. 
Febrile infants with first uti should get an ultrasound of urinary tract.  No VCUG unless u/s is abnormal.
Recurrent uti gets a VCUG.    Prophylaxis is not indicated.
HINTON AND CARLSON   ORAL BOARDS
Case 1 Methylene Chloride and Methanol.  Treat with oxygen and fomepizole. Consult hyperbaric chamber.  Always ask for co-oximetry.
Case 2 Pneumonia with adrenal crisis.   Give iv fluids, hydrocortisone, treat hypoglycemia, abx for pneumonia
Case 3  Measles.  Isolate patient, get confirmatory testing, arrange treatment of at risk contact (vaccinate or immunoglobulin), report case to health department.  Measles has cough/coryza/conjunctivits, rash moves head to toe, look for koplik's spots. 
WATTS   VAGINAL BLEEDING
menorrhagia  too much bleeding or too long or too frequent
metorrhagia   is off cycle
menormetorhagia is both of the above
4 stars on chicago flag is for chicago fire, fort dearborn, columbian exposition, century of progress exposition
Polycystic ovarian syndrome: high estrogen, low progesterone, endometrial hyperplasia.   Obesity, hirsuitism, anovulatory.
Over 35 with abnormal vaginal bleeding is cancer until proven otherwise.   They need follow up for u/s and biopsy. 
IV estrogen can help decrease bleeding in 5 hours in the unstable patient who then needs hysterectomy or embolization
PO estrogen  for stable vaginal bleeders.    3 tabs/day of orthocyclin for 7 days.   After that patients will have a heavy period.  The estrogen stabilizes the endometrium.      In young, non smoking pts not at risk for dvt/pe.  Patients over 35 are at some risk of cancer so probably don't give ocp's.
 

Conference Notes 8-30-2011

Conference Notes  8-30-2011
VISUAL DIAGNOSIS    SHANNON
Jones fracture is a linear fracture at the metaphysis of the the 5th MT.   Treatment is non weight bearing in cast for 6 weeks.    Fracture at the 5th MT tuberosity is called pseudo-jones and does not require casting.
Erythema Chronicum Migrans is target-like rash associated with  Lymes Disease. Treat with  doxycycline, rocephin or amox.  Erythro also acceptable on paper but Harwood says don't use erythro.
RMSF  treat with doxy in kids and adults.   Use choramphenicol in pregnant women.
HSV encephalitis shows bright temporal lobe on MRI
TEN/ Steven Johnson's associated with antibiotics like bactrim.   Transfer to burn unit.  Stop the drug needless to say.
Phlegmasia Cerulean Dolens is a severe dvt compromising venous outfow.  Leg is swollen and Purple
Phlegmasia Alba Dolens is a severe dvt with a white leg.  Arterial inflow is compromises
Pityriasis Rosea starts with a herald patch then becomes generalized.  Not contagious.  Thought to be viral.   Christmas tree pattern of rash on skin is key word for tests.
END TIDAL CO2  VIJAY
Colormetric Co2 detectors can falsely stay purple in the cardiac arrest patient.  The detectors need to see 4% co2 in exhaled breath and co2 may be less in the arrest patient.
End tidal   has close to 100% sensitivity for detecting tracheal intubation.
If you are in the trachea you will see a wave form on the capnograph. 
Capnography in the Cardiac Arrest Patient can guage effectiveness of CPR.  Your co2 with good cpr should be around 10.   If you see a sudden rise of 10 on the capnograph suggests ROSC.    Capnography can be used in place of pulse check.   If end tidal co2 is less than 10, 20 minutes out they are effectively dead.  This probably also applies to kids.  
Bicarb iv can falsely elevate entidal co2.
Capnography can demonstrate early apnea during procedural sedation
In copd and bronchospasm  the capnography wave form can demontrate breath stacking early. 
In patients with metabolic acidosis, ETCO2 will be high.   In DKA it will be low. 
CXR  DAN BARTGEN
Pneumomediastinum due to Macklin Effect in which alveolar air ruptures into interstitium and dissects toward hilum. Examples are asthmatics, scuba divers, smoking crack pipe etc.  If pneumomediastinum is not due to esophogeal rupture or tracheobronchial trauma it is benign.  If it is due to esophogeal rupture or trach-bronch trauma this is an emergency with high risk of mortality.  Requires surgery.
Mach Band can mimick a pneumediastinum.  The Mack band lacks a thin bright white line of the pleura.  This is very common.
Deep sulcus sign is a low/deep diaphragm and cp angle that indicates a pneumothorax.     The deep sulcus sign may be the only indication of a pneumothorax on CXR.  
TRANSFUSION MEDICINE     Dr. HAMILTON
Most common cause of fatal transfusion reaction is giving the wrong blood to patient and ABO incompatibility is present. 
Only use IV Saline with PRBC transfusion.  D5 can cause hemolysis. LR has CA which can cause clotting. 
O-pos blood can be used a an uncrossmatched resucitative transfusion instead of  O-neg in males and females over 50.
Blood transfusion requires a filter in the iv line. 
Transfuse as fast as tolerated.  If chf run it in slowly.   Gotta transfuse under 4 hours.   There may be some bacteria in the unit of blood or plasma and it is felt that transfusion under 4 hours limits the chance of increasing bacteria in blood. 
1 unit of PRBC's should raise hgb by 1.
1 unit of aphoresis platelets increases the platelet count by 20-40,000.
Criteria to transfuse for adults is hgb <8 or hgb 8-10 with symptoms or COPD/CAD/Other CV disease.  There is debate about the 8 hgb cut off.  Pt's with heart disease do better with blood.   Also transfuse pt's with acute blood loss >2% blood volume.
If pt has history of allerigic reaction to prbc/platelet transfusion, ask for washed or twice washed      
prbcs/platelets.
In patients with severe immunosuppression needs irradiated blood to prevent graft vs. host disease. 
GUNS AND MISSILES  KELLY WILLIAMSON
Tissue damage is mostly related to velocity based on the equation KE=1/2mass x (velocity squared)
Cavitation is movement of soft tissue as missile passes and severity is based on velocity.     
Handgun accuracy is low.  11% of perps and 25% of cops hit their intended target. 
High velocity is >2000 ft per second.
Wound care: irrigation, tetanus update, cover with gauze.   GSW's are not sterile but infection is rare.  If infection develops it is usually due to gram positives from skin flora.   Routine abx prophylaxis is not indicated. 
Indication for bullet removal: superficial and irritating, cosmetic reasons, joint space, globe of eye, in vessel lumen, nerve impingement, abscess, forensic investigation, elevated lead levels.
Do bullets set off metal detectors?  Yes
Missiles in joint spaces are most prone to cause lead poisoning.  Also bullets in bone are at risk. 
ACUTE STROKE   DR.  GRYSIEWICZ
Desmoteplase for strokes.  It is a plasminogen activator.  70% similar to TPA.
You can give up to 4.5-9 hours out. No neuro toxicity. More fibrin specific than TPA.  Half life is 4.5 hours.  Found naturally in the saliva of a vampire bat.  
 
Clinical equipose:  Genuine uncertainty as whether treatment in one arm of a clinical study has  benefit over treatment in the other arm. 
Intra-arterial thrombolysis (neurointerventional stuff) can be used 4-6 hours out from onset of stroke.
Studies have also looked at surgical recanulization out to 8 hours after onset of stroke. Clinical outcome data on these neurointerventional techniques are limited.
If you have a patient more than 3 hours out from onset of stroke, get a CTA in addition to CT.   Neuro will decide whether pt gets  Desmoteplase vs. Neurointervention.  No one knows if either helps patients.  
NARROW QRS COMPLEX  TACHYCARDIA    KUTKA
In afib,  F waves can look like p waves but have variable morphology. 
Aflutter should have very consistently symmetric flutter waves.  If they have differing morphology, then you have afib. 
Adenosine dosing thru central line is only 1-3 mg.   You might want to give sedation prior to giving Adenosine to lessen the feeling of impending doom/chest discomfort.
Heart rates 140-160 is usually aflutter with 2:1 conduction.
Retrograde P Waves should make you think AVNRT
You can't identify WPW in a narrow complex svt.   Orthodromic WPW SVT looks like any other narrow complex SVT.    Narrow complex tachycardia adenosine is ok.  Wide complex use procainamide. 
 

Conference Notes 8-23-11

Conference Notes 8-23-2011
ORAL BOARDS   ANDREJ and GROMIS
1.TTP
2.Orbital Cellulitis in an infant
3. Mastitis
TRAUMA   CHASTAIN
Hemorrhagic shock  class 1= 750ml, class 2=  750-1500ml, class 3=  1500-2000ml, class 4   =more than 2000ml
Lethal triad=acidosis, hypothermia,coagulopthy
Hemostatic Resuscitation  for penetrating trauma with short transport times get blood pressure to MAP of 65
Crystalloid only for keeping pt alive until they get blood. 
For large blood loss shoot for ratio of 1 unit prbc's:1 unit of ffp and possibly 1 unit of platelets.
Be extra thorough with trauma transfers and sign outs. 
Call for blood early
Fentanyl is a good analgesic choice for the hemodynamically unstable
AFIB CINDY CHAN
Agents for pharmacologic conversion of afib all lengthen the QT interval. So caution warranted.  Amio, Ibutalide, Propafenone.  Procainamide is another good choice. 
To reduce stroke  warfarin reduces risk  by 64%.   Asa instead of wrfarin is less effective but does reduce risk of stroke by itself.  Dabigatran (Pradaxa) is a direct thrombin inhibitor.  Expensive alternative to warfarin.  Indicated in non valavular/non renal/non liver disease related afib.  Anecdotal stories from audience relate experiences with severe bleeding.  
SAH and CEREBRAL VASOSPASM   LAURA
Blood sugar >200 increases risk of vasospasm
GCS can predict vasospasm.  The lower the score the hihger the risk of vaspasm.  SIRS also predicts vasospasm and overall poor outcome.   2 SIRS criteria gives you a 9.1 OR for vasospasm and poor outcome.  Elevated troponin also increases risk of mortality. 
LIFE  AFTER RESIDENCY   MIKE ANTONIS
Detorsion of testicular torsion can buy you time to pt to OR.
Groups in desirable cities like chicago/boston/denver will likely pay less than groups in less desirable cities. 
Hook Effect or Prozone Effect falsely low values on immunoassay due to extremely high levels of antigen.  Molar pregnancy was the example. Pt has a beta-hcg of greater than 1million and had a negative ucg.
Develop a track record with your group to allow you to negotiate from a position of strength on your contract.
STATS   Christine
Evaluating meta analyses;  Strict inclusion/exclusion criteria, include valid studies (RCT's best),   the included studies and their results should be similar, Funnel Plot make the results more trustworthy

Conference Notes 8-16-2011

Conference Notes 8-16-2011
DKA     JOELLEN CHANNON
Cerebral edema has unclear etiology.   Higher risk in kids less than 5yo, initial presentation, severe acidemia, dehydration,  serum sodium not rising as expected. 
Easy version of giving fluids is 1.5X maintenance.  
No insulin bolus.  Give insulin at 0.1 unit/kg.  Insulin supresses glucose and ketone production.
Give K if potassium is less than 5.5 and pt has made some urine.  Give 30meq of KCL in a liter of saline. 
Na should increase by 2.4 for every 100 decrease in glucose. 
Don't worry about phos unless it falls below 1. 
No bicarb unless cardiac arrest or ph is <6.9.
 If you suspect cerebral edema developing give mannitol or 3% saline (5ml/kg)
STUDY GUIDE   PEDIATRIC EMERGENCIES   ELISE
Electrolyte abnormalities causing seizures:    hyponatremia, hypocalcemia, hypomagnesium
Bilious emesis in the first year of life : volvulus due to malrotation diagnosed with upper gi series.   needs surgery
Complications of HSP: renal involvement, intussusception, gi bleed, hypertension, pseudotorsion, joint involvement.    HSP is an IGA vasculitis. 
MANTRELS for appy: migration, anorexia, nausea/vommit, tenderness in RLQ, rebound tenderness, elevated temperature, leukocytosis, shift of wbc's to left.   Score less than 5 makes appy unlikely,  score more than 8 is highly likely.
Life threats from nephrotic syndrome are infection and thromboembolism.  They have increased levels of thrombolytic inhibitors and increased viscosity. 
Post-strep glomerulonephritis: facial edema, hematuria/proteinuria/casts, tea colored urine, htn.  Restrict fluids, na restriction, lasix. Excellent prognosis. 
Diagnosing SCFE: Use Kline's Line.  A line along the lateral aspect of the femoral neck  should intersect the epiphysis in a symetric fashion bilat. 
SALTER HARRIS FX:  physis=1, metaphysis=2, epiphysis=3, metaphysis and epiphysis=4,  impacted=5
CRITOE= Capitellum 1yo, Radial head 3 yo, Internal Epicondyle 5yo, Trochlea 7yo, Olecranon 9 yo, External Epicondyl  11yo
Cardinal features of HUS are Microangiopthic Hemolytic Anemia, Uremia and Thrombocytopenia. 
CALCIUM CHANNEL BLOCKER OVERDOSE  ANDREA
Gastric lavage only with massive ingestion in the first hour with protected airway.
Whole bowel irrigation for sustained release preparations, early presentation, pills seen on xray.  Contraindicated for hypotension and decreased bowel sounds. 
Give charcoal up to 2 hours out.   
 Give calcium,  try glucagon,  and the main thing is Insulin and glucose to increase transmembrane calcium flux.  Insulin also has a pressor/inotrope effect.  Insulin also pushes glucose into the myocyte to feed the heart.   Insulin dosing is being ramped up by toxicologists.   High dose insulin is a first line therapy for CCB OD.  Insulin dose is 1u/kg bolus and then 0.5u/kg drip.   Give 1 amp glucose push then D10/.45ns at 80% maintenance.  Keep close eye on potassium.
IV fat emulsion can also be used. It acts as a lipid sink for lipid soluable drugs like local anesthetics and calcium channel blockers.  Also feeds the myocytes and opens calcium channels in myocytes.  Lipid  emulsion can mess up lab tests like measuring potassium.
Immediate release preps can dispo home after 6 hours on a monitor.  Sustained released preps or amlodipine admit for 24 hour monitoring. 
NEONATAL RESUSCITATION ALGORITHMS   BADILLO and SINNOTT
Escalating actions are the cornerstone of NALS.   Tactile stimuli and warming> bagging with room air for 90 seconds>  bagging with oxygen> intubation>  chest compressions>   iv epi 0.01mg/kg 1:10,000 iv/io/uvc. 
If meconimum present: child vigorous no suctioning; child not vigorous suction with et tube.

Conference Topics 8-9-2011

Conference Notes 8-9-2011
STEMI CONFERENCE
If pt has other issues such as endocarditis, fever, mental status changes in addition to STEMI, discuss with cardiologist prior to activating STEMI alert.   Going to cath lab is not always the best option for the complicated MI patient. 
Biphasic t waves V1-V3/4 identifies Wellen's Syndrome.   Which is a tight proximal LAD lesion.  Don't do a Stress Test in this case.   Consult cardiology for consideration of a cath. 
Think twice about activating STEMI when any of these Red Flags are present: Fever, Altered Mental Status, Severe Acidosis or Hyperkalemia, or Trauma.
ORAL  BOARDS   C. KULSTAD  vs.  BADILLO
Case #1   Pediatric SVT treated with Adenosine (0.1mg/kg up to 0.4mg/kg) and then Cardioversion with 0.5-2J/KG
Case#2 Posterior Shoulder Dislocation.  Xray shows lightbulb on a stick.  This is a rare dislocation.    Treat with traction/counter traction.
Case #3 Cyanide Poisoning from a house fire.   Pt with severe metabolic acidosis, nl SPO2, and had a CO level of 12.   Tx with Hydroxycobalamine or sodium thiosulfate or both.
CASE F/U  TESTICULAR PAIN   ANNA
Testicular torsion is complete when cord is twisted over 360 degrees.
Inadequated fixation of testes to tunia vaginalis allows twisting
Bell Clapper deformity is a transverse lie of testicle in scrotum.
Common ages are neonates and 12-18yo.  But can occur at any age. 
Torsed teste should have an absent cremasteric reflex but its not a perfect sign.
Salvage is 90% if you get to OR by 6 hours.   50% salvage at 12 hours.  0% salvage at 24 hours.   
To manually detorse, open the book motion.   End point is pain relief.  Problem is 30% are torsed laterally and opening the book will increase the torsion in these cases.
Patient will likely need pain control or mild sedation to make manual detorsion  possible. 
Epididymitis TX= Rocephin/Doxy for sexually active patients.  Flouroquinalone for those not at risk for STD.    Keflex for kids. 
Torsed appendix testes is the third ddx for the acute scrotum. 
TIPS FOR RESUSCITATION OF THE MEDICAL PATIENT  BAROUNIS
AABBCCDDEE and F
A=aorta (dissection or aaa) A=acidosis (6-8cc/kg TV with high rate maybe 18 for the severely acidotic patient),   B=bagging (watch for overventilation), 
Baby on board (think ectopic, displace uterus from ivc, defib is ok, avoid amio), C=chest compressions (100/min and minimize interruptions),  C=cooling,  D=defibrillation, D=dopes (dislodgement, obstruction, pneumothorax, equipent failure, stacking breaths), E=echo for effusion and embolism (t wave inversion inferior and anterior and tall terminal r wave in avr is  specific for pe), F= forget about it (bicarb, mag, amio, lido, atropine, trandelenburg, lido/defassiculating dose prior to intubation)
TIPS AND TRICKS   GROMIS
Car Buyers can ask the Dealer what their profit  margin is on the car. They are legally required to tell you.   Bottled water has a higher fecal content  than tap water.  
Getting to know how to minimally troubleshoot problems with the IV pumps improves your professionalism with your patients and with the nurses on the care team. 
Cannulate the basilic vein using u/s if you have a patient with poor iv access. Gotta use the long angiocaths.   You can also use u/s to identify veins in the antecubital fossa that can be cannulated. 
When doing IJ central line, pt should be in about 10 degrees of trandelenburg. Don't use too much suction with the syringe.  You can collapse the vessel around the needle.   If the wire gets hung up turn the bevel of the needle 180 degrees.
Bimanual intubation is a very effective way to improve your view of the larynx. 

Conference Topics 8-2-2011

8-2-2011  Conference Notes
Peds Study Guide  Bill Schroeder
Persistent unilateral nasal drainage, think nasal foreign body.
Unilateral air trapping on expiratory films points to an aspirated fb. 
Throat culture for strep has a 10% false negative rate.  Traditionally it is accepted that abx tx for strep throat shortens course of illness and prevents rheumatic fever.   (there is some debate about the significance of both these rationales)
Strep throat is uncommon under age 3 because kids at this age lack the necessary protein in the throat that binds strep. 
SIDS is due most frequently to an asphyxation event.  Basically child is suffocated by prone sleeping position or sleeping in bed with parents.
Diagnosis of acute otitis media depends on effusion (distortion of tm) and inflammation (injection).  Light reflex is not significant for diagnosis.  Insufflation is the best for diagnosing aom but is difficult. 
Crying infant think corneal abrasion
Conjunctivitis after erythromycin topically in infants think chlamydia and give oral erythro or azithro.
LIFE AFTER RESIDENCY   SUE NEDZA
50% of EP's are employees of a hospital
Additional career challenges other than clinical EM promote longevity in the specialty.
If you leave clinical medicine, it is hard to make equal or more money.  You are paid very highly for your clinical work. 
Invest in quality disability insurance.
When you look at a new group to join, ask how they are doing with their quality measures.  Do they use them to decide on your salary?
 Does the group have a good position in the hospital to get their share of bundled payments. 
More people are on medicaid then medicare. 
10,000 baby boomers enter medicare a day for the next 19 years with no added funds.
MEGA CODES
PEA :  Hypovolemia, Hypoxia, Hyper/Hypokalemia, Hypothermia, H+(acidosis)   Toxins, Tension Pneumo, Tamponade, Thrombosis (PE,AMI)
PEDIATRIC SKIN INFECTIONS   Beau
Keryon is a large boggy mass on scalp that is caused by tinea capitis.  Do not incise.  Treat with griseofulvin or diflucan po. 
I and D of pilonidal cyst stay just lateral to the midline for improved wound healing.
For Bartholin's Abscess, word catheter stays in for 4-6 weeks. 
Consider necrotizing fasciitis when pain is out of proportion to exam. 
Preseptal cellulitis: no impaired eom, no proptosis, no pain with eom, 
Augmentin or Clinda/bactrim or clinda/cipro for mammilian bites.
Id reaction: pt has a fungal infection on foot or hand and due to circulating antigen and  pt develops rash on a remote site of body.
ETHICS    SHAYLA 
Surogates Rank order: Guardian/ Spouse/ Adult Child/ Parent/ Adult Sibling/ Close Friend
Withdrawl of Care: Can't pull ET tube without being sure neuromuscular blockers and major sedatives are out of patient's system.
The LET form is important.  Fill it out please in the ED!  
 

Conference 7-26-11 Topics

7-26-11
DR. GOURINENI'S LECTURE
Iv Antibiotics are critical for open fractures.  Reduce fracture so bone is not exposed.  Don't use betadine dressings
After reducing a disolcation, put joint thru easy range of motion to assess the patients range of motion.  This is helpful info for the orthopedist.
Very few pediatric fractures have to be reduced in the ED.   If fracture is in plane of joint it will remodel very well even if there is diplacement and shortening
Supracondylar Fractures:  Admit all Gartland 3's (displaced fractures)
Pulselss but pink hand does not need emergent surgery.  Ischemic hand requires emergent surgery.
If there is varus angulation of elbow they need operative reduction within a week or they will have dformity for life.
When splinting elbow fractures don't splint with elbow flexed more than 90 degrees.   It decreases venous return.
If you are treating a pediatric elbow dislocation and on the f/u xray do not see the medial epicondyle, it may be stuck in the joint.
Femoral shaft fracture in kids under age 5 can go home in a splint from the rib cage to the lower leg.  Don't include the ankle in the splint.  Gotta rule out child abuse before they go home.  
Velcro splint is acceptable for a buckle fracture.
DR. HOYME'S LECTURE
Reducing paraphimosis: thumbs on glans and index middle fingers on parphimotic ring
Use absorbable sutures when repairing the genitalia
Any young adult with painful scrotum needs an u/s.  Testicular cancer can present in a myriad of ways.
Blue dot sign on scrotum signifies torsed appendix testes.  Appendix testes is the remnant of the mullerian duct.   The wolfian duct forms the vas deferens, epidymus and ejaculatory duct.
Strangulated hernia will obscure the spermatic cord.
Varicocoele is usually on the left side.   Varicocoele is more prominent when standing and can go away when laying down.  If it stays prominent when laying down you have to consider retroperitoneal neoplastic process.
Priapism stems from the god Priapis who is the protector of the male genitalia.  (Not sure if that is greek or roman god)  Many drugs can cause priapism. Treat priapism  with phenylepherine injection.   First aspirate the corpora cavernosum on one side 50ml of blood (the copora communicate) then inject phenylepherine 1ml Q3min for one hour.  If that fails, GU will have to do a shunting procedure.
Ureteral stones more common with increase BMI, sunny climate, males, caucasions.  Stones more likely to pass if <6mm and distal ureter.  If  a patient has a stone <10mm and symptoms controlled, pt can be discharged.   If stone >10mm they will need a procedure.   Stone and sepsis needs iv abx and urgent drainage (stent or nephrostomy)
ORAL BOARDS
Traumatic placental abruption
AFib RVR and WPW
Supracondylar Fracture
TONY'S LECTURE
ST segment elevation mi's
Look for R wave amplitude to decrease as mi evolves
Criteria for st elevation= 2mm in men, 1.5mm in women in precrodial leads, 1mm  for men and women in other leads
Inferior mi with st segment elevation of lead3>lead2  suggests right sided mi
Beware posterior mi with st depression and tall r wave in V1-V3 (carosel pony)
Code STEMI  requires attending to attending discussion
JOE LAVATO LECTURE
Vancomycin ominously has MIC creep with decreasing ability to treat MRSA. 42% has MIC of 1.
VRE already has 14% resistance to Linezolid
Gram neg can produce amp-C beta-lactamase which gives resistance to ceftriaxone and zosyn.
There is a new hyper toxin producing strain of c-diff (NAP-1 =60% of isolates at ACMC). Gotta use vanco.
Uncomplicated uti recommendations: 3 days bactrim, 7days of nitrofurantoin, or single dose 3g of phosphomycin (50bucks), or 3 days of a second generation cephalosporin.
Recommendation for community aquired cellulitis=ancef or nafcillin.  Early cellulitis in diabetic=unasyn.   severe diabetic foot infection=vanco/zosyn.
PARUUL'S LECTURE
Verapamil Sensitive V-Tach
Differentiating vtach from svt with abberrancy: concordance, fusion or capture beats, morpholgy that is not c/w classic lbbb or rbbb, pt with hx of heart disease, av dissociation, rbbb with left ear>right ear, v5,6 predominantly negative all point to vtach.
Idiopathic Vtach occur in young patients with no heart disease. Excellent prognosis. QRS duration is around 120ms, left axis deviation, rbbb.  Responds to iv verapamil 2.5mg.


Conference July 26, 2011

Dr. Gourineni:  Pediatric Orthopedics

1.  Remodeling:  Children have tremendous potential to remodel fractures, especially with boys <12, girls <10, often do not need to reduce fractures in younger children, especially in cases of distal radius and proximal humerus fractures, and when fracture in plane of movement of extremity.  On the other hand, valgus/varus displacements not tolerated (for example in supracondylar fx) and will more often need reduction/surgical repair.

2.  Buckle Fracture Treatment:  Literature to support minimal immobilization for simple buckle fractures (ace wrap!).  For Dr. Gourineni, velcro splint is fine.

 

Dr. Hoyme:  Urology Tips for the ER

1.  Hematuria:  DDx:  SHIT3.   Use large (24F) 3 way catheter for irrigation.  Manually irrigate clots out of bladder before hooking up CBI (Continuous Bladder Irrigation).

- Stone

- Hematologic (bleeding) diathesis

- Infection

- Trauma

- Tumor

- TURP

2.  Foley insertion:  use plenty of lubrication; Urojet is viscous lidocaine-extremely helpful.  Be very careful to have urine return before blowing up balloon (inflated balloon in urethra --> urethral stricture).

3.  Urethral stricture:  when suspected, try small (14F) catheter, or talk to your attending about using the Urology tray (in inventory).

4.  Varicocele:  if large and doesn't reduce at all when laying flat, consider retroperitoneal tumor (obstructing venous return).

5.  Stones:  AUA guidelines, if healthy non-pregnant pt with 2 kidneys and no infection, ok to discharge if stone <10 mm and pain/nausea controlled.  Use tamsulosin and urology f/up.  Outpatient KUB to track stone passage, may take one month to pass.

6.  Sepsis + Stone:  broad spectrum antibiotics and emergent stent or nephrostomy tube.  Nephrostomy tube preferred as larger tube, can monitor drainage to ensure patency, and do not need general anesthesia for placement.

 

 

 

Conference 7-19-2011

7-19-2011  Conference Highlights
STUDY GUIDE Tetanus shot  (td) safe in pregnancy.   Avoid Tdap in pregnancy.  Rapid sequence drugs are ok. Propofol and narcotics are ok if not near delivery.   Avoid NSAID's because it reduces uterine blood flow.
Highest radiation risk to fetus neuro development is 8-15 weeks post conception  Highest teratogenicity is 2-8 weeks as this is period of organogenesis.
Mastitis: staph most common organism, have mom continue breast feeding unless there is an abscess
Hydatidifrom mole:  presents with 1st or 2nd trimester bleed, hyperemesis, very high beta hcg.  Treatment with d and c.   Associated with choriocarcinoma.
Kleihauer Betke test is basically only for identifying large fetomaternal hemorrhage that would require extra rhogam. 
Mondor's Disease:sperficial phelbitis nar breast, benign and disappears spontanously
JOELLEN'S LECTURE  
Arachnoid Cyst:  Can present with headache or seizure.   Cysts can also occur in spine.   JoEllen's pt had cervical cord compression from the cyst.
In the fussy child always consider shaken baby or other types of abuse.   Look for incarcerated hernia, hair tourniquet, corneal abraision, torsion, cardiac disease etc.
Intussusception:  usually ileocolic junction.  6-36 month old child.  male:female ratio 4:1.   70% will be heme positive.  Atypical presentations include lethargy in 20%.   Child will progressively worsen.  
Diagnosis with ultrasound or barium enema. Recurrence rate of 30% usually in the first 48 hours. 
MICHELLE'S LECTURE
EKG Basics:  Systematic Approach is Rate,  rhythm, axis, conduction, s-t segments
wandering pacemaker=slowed down version of MAT 
Heart Block analogy of your significant other "stepping out on you" .  The relationship gets worse untile in third degree block,  the p and the QRS never see each other. 
Tachyarrythmias:  Break it down to Wide/Narrow and Regular/Irregular
V-tach has fusion and capture beats
Can't miss issues:brugada, wellen's,  long qt, wpw
EKG case presented with tachycardia and posterior ami findings
ORAL BOARDS
Vijay and Elise
Case #1=Lemierre's Syndrome (septic thrommbophlebitis of IJ) with septic emboli to lungs.  Lungs are most common secondary site.  Broad spectrum abx and consider anticoagulation.  Affects young patients.
Case#2=Multiple Trauma with flail chest/ pulmonary contusion and hemoperitoneum.    Hypoxia is max at 48 hours after pulmonary contusion.
Case#3=Ulnar Collateral ligament rupture of thumb.  Thumb spica Splint with outpt ortho follow up.
RICARRDI LECTURE
KILLER BABIES, HTN in pregnancy
Treatment of pre-existing htn: don't treat for less than 150/100.  po labetalol or methyl dopa
Gestational htn: no proteinuria
Pre-ecclampsia: BP=/>140/90, proteinuria, edema no longer in definition.  risk fractors: first kid, obesity,htn, dm.   Severe pre-ecclampsia is defined by signs of organ failure.  Definitive treatment is delivery. Treat BP with labetalol or hydralazine.  Get BP down to 130/80
Ecclampsia: seizures are self limited.  It can be ecclampsia even if BP is ok and there is no proteinuria.  Also consider other structural or metabolic causes of seizure in the patient without elevated BP or proteinuria.
Magnesium 6 grams bolus then 2gram/hour.  Can give IM magnesum 5gm in each buttock.   Calcium gluconate is antidote for magnesium toxicity.  
Preecclampsia/ecclampsia can occur up to 6 weeks after delivery.
THink HELLP Syndrome in pregnant patients with epigastric or ruq pain.
JIM JENSEN LECTURE
Intra-nasal administration of drugs: need low volume and high concentration of drug to use this route.   Can use this route for fentanyl, versed, narcan, flumazenil.     
Fentanyl dosing this route is 2micrograms/kg.  Morphine is 0.1mg/kg.  Versed is 0.2mg/kg.  Narcan is 1mg in each nostril.  Ref.  intransal.net

conference pearls 7-5-2011

  • 7-05
  • cool  heat stroke as fast as possible.  mist and fan technique probably easiest to get together quickly, also can use cool guard
  • if nurse asks if there is anything else you want to do on oral boards, there is.
  • be agressive on oral board cases, do everything now
  • disciplined exam is critical on oral board cases
  • pres syndrome   tx= calcium channel blockers
  • preecclampsia  can test with  urine protein/ urine cr ratio,  serum uric acid
  • air in ventricles from epidural anesthesia can cause headache. tx with 100%oxygen
  • blood patch very effective for post lp or post epidural headache
  • Systematic cxr eval  A=air and airway, B=breathing aka lungs and bones, C=cardiac and mediastinum,  D=devices, diaphragms, and data,  E=external to rib cage
  • mediastinal hematoma caused by rupture of smaller vessels like azygos
  • wide mediastinum is >8cm   on PA chest
  • Overall incidence of SBI in kids is @10%,   meningitis is 1%.   
  • Incidence in well appearing kids is @7%.
  • SBI includes pneumonia, uti, bone/joint infection, meningitis, cellulitis, bacterial enteritis
  •  Cautious simple approach to fever in kids:  up to 8 weeks of age do a full septic workup, give ceftriaxone and decide dispo with pediatrician
  • 3-36 months  get urine in girls up to  24 months, uncircumcised boys up to 12 months,  circumcised boys up to 6 months
  • RSV in kids less than 60 days old the risk of SBI is 7% and risk of meningitis is close to 0.  Consider getting urine and blood cultures in these kids. 
  • Vaccination up to date in the 3-36 month kid lowers risk of SBI

7/5/11

Pneumocephalus is rare complication of epidural anesthesia. Usually characterized by acute onset of headache after procedure. +/- neuro deficits. Giving O2 speeds absorption of air. Can also be seen after trauma, cancer, otogenic infection. Prognosis based on cause, but generally good. Remember peripartum headache can be bad.

Joint Pediatric/EM conference 6.14.2011

Topic:  Infectious Disease (panelists Dr. Maryanne Collins, Dr. Bill Schroeder, Dr. Omar Sawlani, Dr. Surasek P.)

1.  Consensus of panel-avoid alternating acetaminophen and ibuprofen.  Using both increases medication errors, doesn't significantly improve fever control, and adds to fever phobia.  To mitigate concerns of "brain damage" from fever, explain that fever is the body's internal response to illness and will not cause harm.  This is in contrast to the potential dangers of external/environmental heat such as heat stroke.

2.  The pediatricians in the audience encourage the continued culturing of SSTI (skin and soft tissue infections/abscesses).  When a child shows up in the office with a worsening SSTI, it help the PMD to know the resistance pattern.  FYI, at ACMC, approximately 50% of SSTI are MRSA.  

3.  When to admit pediatric SSTI?  Per Dr. Collins, consider age of patient, site, size of infection, prior infections, followup, and toxicity of patient.

4.  Periorbital vs. Orbital cellulitis.  We rely on globe pain, restricted eye movements/pain with eye movements, high fever, proptosis, spread/amount of erythema/swelling, overall toxicity when distinguishing the two clinically.  Orbit CT is indicated if concerned about orbital cellulitis, but for the gray zone cases, no need to CT in the ED.  Initial management is IV antibiotics, and if poor response, the CT can happen the next day.  Treatment difference for the two conditions is twofold:  potential for surgery and longer duration of antibiotic treatment for orbital cellulitis.

5.  Fever 3-36 months in well appearing child:  There is a variety of acceptable work-ups, ranging from nothing to partial septic work-up.  Much depends on followup/where you see the patient:  more tests usually performed in ED, when doctor doesn't know family and there may not be great followup.  Remember, children need the first two sets of vaccines (2 and 4 months) to be considered "immunized"; after this, no testing usually necessary except for the consideration of a UA and urine culture (always send both in diaper wearing kiddos).  Urine may be deferred for happy kids with one day of fever, but need to warn parents that if fever continues for more than 2 days, UA/culture may be needed.