Conference Notes 10-9-2012

Conference Notes  10-9-2012

McDermott/C. Kulstad  Oral Boards

Sorry I missed this Oral Boards Triple Cases but the highlights per Dr. Kulstad were:

Case 1: spinal shock fro cspine injury:  treat with iv fluids, pressors if needed.  Board Question Alert! Pt’s may be paradoxically bradycardic with hypotension.  Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications. An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury. Albeit with little empiric supporting data, guidelines currently recommend maintaining mean arterial pressures of at least 85 to 90 mmHg, using intravenous fluids, transfusion, and pharmacologic vasopressors as needed

Case 2: Heat stroke: Rapid cooling.  Altered mental status  separates heat stroke from heat exhaustion.

Case 3: Stingray injury:  Hot water treatment and don’t close wound.  Xray to make sure no fb

Kessen   Hand Trauma (Sorry missed a lot of this lecture)

Jersey finger is due to rupture of the flexor tendon. Pt can’t flex finger.  Called Jersey finger because football players would get this when tackling someone by grabbing their jersey.

For amputations: get all the pieces and x-ray all the pieces.    Digit survival is 12 hours when warm, 24 hours if cooled.    Major replant survival is 6 hours warm,  12 hours cold.     Keep amputated digit cool by wrapping in saline soaked gauze, place in a plastic bag and put the plastic bag on ice.  We have a cool to keep on patients cart.  

Harwood comment: MRI can be used to identify FB and many specialists have access to MRI in their offices.   Using a tourniquet to get a bloodless field will be less painful for a patient if you keep the cuff pressure only 20 mm hg above the patient’s systolic BP.  Current standard of care is that EP’s don’t do tendon repairs in most areas of the US.   Hand specialists and ortho specialists will take almost all tendon injuries.  

Discussion of Regional anesthesia for the hand.   See Diagrams Below

 Flexor tendon approach

 Web space approach

Levato   UTI treatment  (I missed a lot of this lecture also)

Uncomlicated UTI’s use macrobid for 5 days or keflex for 7 days.  Bactrim has too much resistance to be considered reliable.     Cipro should be used only if other options not possible because cipro use has complications of c-diff/neuro effects/tendonopathy/interactions with Coumadin.  Use cipro for only 3 days for cystitis.

Collander  Unstable C-spine Injuries

Intubate for Cspine fractes C5 or higher.

Rectal tone presence identifies incomplete cspine injuries.

Nexus criteria are 99.6 % sensitive for clinically significant Cspine injuries.

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

Insignificant injuries were defined as those that would not lead to any consequences if left undiagnosed. The NEXUS investigators evaluated 34,069 blunt trauma patients who underwent radiography of the cervical spine comprised of either a 3-view cervical spine x-ray or a cervical spine computed tomography (CT) scan. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value (NPV) of the NLC were found to be 99.6 percent (95% CI 98.6-100), 12.9 percent (95% CI 12.8-13.0), and 99.9 percent (95% CI 99.8-100), respectively

Canadian Cspine rule is 100% sensitive for clinically significant spinal injury.

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 who do not exhibit any of the low-risk factors listed here are NOT suitable for range of motion testing and 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

In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying clinically important cervical spine injuries

 Flexion teardrop fracture: Anteroinferior portion of vertebral body is fractures off.  Can have associatated anterior cord syndrome.   May have widening of spinous process spaces.

Wedge Compression fracture:  Posterior ligament disruption may be associated.  Considered unstable if >25% compression of the anterior border of the vertebral body or widening of the spinous processes.

Extension teardrop fracture: Anteroinferior portion of vertebral body is avulsed.  Fragment is usually taller than wide.

Hangman’s fracture: Fracture of both pedicles of C2. C2 displaces anteriorly.  Usually see in car and diving accidents.  Patients can be neurologically intact because there is a wide canal at that level.

C1 Jefferson Burst Fracture: Due to an axial load.  C1 is laterally displaced on C2.   If sum of total displacement of lateral masses from body of c2  is greater than 7mm that is the criteria.

Occipital-atlantal Dissociation: figure

The Powers ratio is commonly used to assess for atlanto-occipital dislocation (figure 9). It is defined by the ratio of BC:OA, where BC is the distance between the basion and the midpoint of the posterior laminar line of C1, and OA is the distance between the midpoint of the posterior margin of the foramen magnum (opisthion) and the midpoint of the posterior surface of the anterior arch of C1 [17]. A ratio greater than one suggests anterior subluxation.

Another radiologic finding suggestive of an atlanto-occipital dislocation is disruption of the “basilar line of Wackenheim,” a line drawn from the posterior surface of the clivus to the odontoid tip [18,19]. Normally, the inferior extension of this line should just touch the posterior aspect of the tip of the odontoid. If the line runs anterior or posterior to the odontoid tip, this suggests an atlanto-occipital dislocation.

Carlson  Salicylate Toxicity

1960’s there was concern for ASA causing Reyes syndrome and people were told not to have asa at home.  Toxic ASA exposures decreased for a few decades because people didn’t keep ASA at home as much.  Since the 1990’s ASA use has again resurged due to it’s value for cardiac disease.

Board Question Alert! Oil of wintergreen has a very high concentrate of methylsalicylate.   7grams of ASA in a teaspoon!

Enteric coating of ASA prolongs absorption to 4-6 hours and asorption is less predictable.

ASA inhibits cycloxygenase to block prostaglandin synthesis.  Toxic levels stimulate respiratory center (respiratory alkalosis), stimulates vomiting center, increased capillary permeability (pulmonary edema) and uncouples oxidative phosphorylation (metabolic acidosis, fever).  Pts will develop ketosis and hypokalemia in addition to metabolic acidosis and respiratory alkalosis.  Toxic patients also will have tinnitus.

More severe toxicity will cause agitation, dehydration, acid/base disturbances, pulmonary edema.

A death from ASA is a CNS death.   ASA is a brain poison.

ASA poisoning gets missed  because it looks like sepsis or alteredmental status or chf.

Toxic dose is >150mg/kg.   Serious toxicity can be approximated by 1 (325mg) tab per kg.  therapeutic level of salicylate is 3-6mg/dl,  toxic level is >30mg/dl.   Levels correlate poorly with toxicity.  Done nomogram is no longer used because it is inaccurate.   Don’t use the Done nomogram. 

Board Question Alert!    If you need to intubate a patient with severe ASA toxicity or any patient who is markedly tachypneic, be sure to set your ventilation parameters  to maintain the patient’s minute ventilation so they don’t become more acidotic.

Management: Activated charcoal,  additional dose 2 hours later of activated charcoal,  alkalinize blood and urine (target urine ph is 7.5-8),  need to keep potassium in normal range or you will not be able to effectively alkalinize the urine.  You will usually need to hang a lot of potassium.   Hemodialysis is indicated for severe overdoses. (acute level>100, chronic level>60, pulmonary edema, renal failure, pulmonary edema, rapidly rising levels, altered mental status and academia.

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Mistry  FirstNET EMR

Tech support continues thru 10-17.  Make sure you work some shifts/see some patients while tech support is her on site.

Chintan went through multiple optimizations of First Net.

Conference 10-2-2012

Conference Notes 10-2-2012

Gottesman/Anderson   Oral Boards

Case 1: CO poisoning

Case2: AKA:  Treat with IV fluids and glucose

Case3: Morbidly Obese Patient with respiratory failure:  

Harwood comment: The lesson of these 3 cases is getting the ABG. It will help you solve all 3 cases.  VBG can be used frequently in place of ABG.  If you want a CO level on the VBG, make sure to tell the respiratory therapist. They may not run the CO.    The caloric content of a bag of D5 is 200 calories, so you may need to give D10 or food or Amps of glucose to correct marked hypoglycemia.

Girzadas comment: For the SuperObese patient be sure to use RAMP positioning and call for back up from anesthesia or other EM physician

Kulstad Study Guide CV Disease

Aortic insufficiency murmur is heard in 32% of patients with aortic dissection.

Best work up for iliac dvt in a pregnant patient is MRI.

Work up for ischemic limb is Vascular consult and CT angio of limb.  Heparin is usually indicated.  Definitive therapy is thrombectomy and embolectomy.  Harwood comment: Just give heparin and consult vascular surgery.  Ct angio may be a time waster.

Signs of Aortic dissection: wide mediastinum, tracheal deviation, and aortic shadow beyond calcified wall.   Harwood comment: there is a difference between traumatically torn aorta and aortic dissection.  Xray findings are not all common to both.

Phlegmasia cerulea dolens: Severe ileo femoral dvt with venous engorgement.  Can lead to compartment syndrome and gangrene.   Treat with heparin and IR thrombolytics.   Phlegmasia alba dolens is called the milk leg.  Much less common and is a dvt resulting in decreased arterial perfusion.

High risk patients with concern for dvt who have a negative U/S, they need f/u U/s in 7 days.  2 negative U/S makes risk of PE or DVT less than 1% in 3 monts

Wells criteria and modified Wells criteria: clinical assessment for pulmonary embolism

Clinical symptoms of DVT (leg swelling, pain with palpation)	3.0
Other diagnosis less likely than pulmonary embolism	3.0
Heart rate >100	1.5
Immobilization (≥3 days) or surgery in the previous four weeks	1.5
Previous DVT/PE	1.5
Hemoptysis	1.0
Malignancy	1.0
Probability	Score
Traditional clinical probability assessment (Wells criteria)
High	>6.0
Moderate	2.0 to 6.0
Low	<2.0
Simplified clinical probability assessment (Modified Wells criteria)
PE likely	>4.0
PE unlikely	≤4.0

Data from van Belle, A, et al. JAMA 2006; 295:172.

Most common extremity aneurysm is  popliteal .  Often bilateral and rarely rupture.

Treatment of aortic dissection: reduce shear force with esmolol and drop MAP to 60.  Can add nitroprusside or other agent if needed to get map to 60.  Start though with esmolol.    Labetalol would be another option.

Be very cautious managing asymptomatic htn.   There is a risk of causing stroke with rapid lowering of BP.  Restart their medications.  If they are untreated you can start a low dose diuretic.

Thrombotic cause is more common than embolic cause of limb ischemia.   This is due to good anticoagulation management of patients with Afib and valve replacements.

There is no distinct number that identifies a hypertensive emergency.   Emergency is defined by end organ damage.   Harwood comment: pre-ecclampsia  is a hypertensive emergency with a relatively low bp cutoff.  Usually 140/90.

The following eight factors constitute the PE rule-out criteria

• §  Age less than 50 years
• §  Heart rate less than 100 bpm
• §  Oxyhemoglobin saturation ≥95 percent
• §  No hemoptysis
• §  No estrogen use
• §  No prior DVT or PE
• §  No unilateral leg swelling
• §  No surgery or trauma requiring hospitalization within the past four weeks

Coghlan comment: Why not include cancer in the PERC rules.  Barounis response that when Jeff Kline discussed on previous podcast he said cancer did not change the probability in his study.  

Harwood and Barounis felt that if a cancer patient has neg perc/neg dimer/neg trop then they likely don’t have a PE.   Elise and Barounis disagreed on whether CT would be indicated in this situation.  There was some heated discussion between Harwood/Elise/Christine/Barounis on this topic.  There was not consensus on whether a CT was absolutely necessary in the cancer patient who has a neg perc/neg dimer/neg trop.

Best treatment for  patient with asymptomatic htn who is not on meds currently:   HCTZ, Lisinopril .  Pharmacy student comment: Lisinopril may be less effective in African American patients.  Harwood comment: Chlorthaladone is a thiazide diuretic that is more potent than HCTZ.  Consensus was that you don’t need to start potassium therapy with low dose HCTZ or Chlorthaladone.  Hypokalemia is not a big problem with HCTZ 25mg or less.

Maslar  Dive Medicine

Humans can’t breathe under water through a long snorkel tube because there is water pressure pressing on our chest and increasing the air pressure in our bodies.  Our diaphragms cannot overcome this pressure.

Dybarism: most common source of diving problems. Ear squeeze is usually a problem of descent. Ear pain can develop.  TM can rupture.   Valsalva is treatment for ear squeeze but If you overdo it you can cause round window rupture resulting in hearing loss/vertigo/tinnitus.   Sinus pain is usually a problem of ascent resulting in sinus pain.  Pulmonary barotraumas can also occur on ascent in a diver breathing pressurized air.  The diver  needs to exhale as you ascend or the expanding air can cause alveolar rupture.  Patients can have pneumomediastinum.   Worst case scenario of dysbarism is air embolism.  Arterial gas embolism will occur almost immediately upon surfacing.  Of all dysbarism injuries, only the air embolism requires hyperbaric treatment.

Diver descending: ear squeeze.   Diver ascending:sinus pain, pulmonary barotraumas, arterial gas embolism

Decompression sickness (Bends): Usually involves nitrogen which is most prevalent atmospheric gas and is inert.  Joe used the can of coke metaphor to describe decompression sickness.  If you open a can of coke real fast you get a lot of bubbles. If a diver surfaces too fast relative to the time they were underwater you get bubbles in the blood/tissues/joint.  Interestingly, we don’t really know where bubbles come from or how they hurt us.   Gasses coming out of solution with decompression sickness usually affect the spine rather than the brain. Acute stroke symptoms should point more to arterial gas embolism than decompression sickness. Treatment is hyperbaric oxygen to push bubbles back into solution.

Who needs hyperbaric recompression tx: decompression sickness, arterial gas embolism, CO toxicity

Christine comment: If you have to treat a patient with a diving related malady and have questions or need guidance you can call the Diver’s Alert Network (DAN).

Lovell    Targeted Temperature Management Post-Cardiac Arrest

Post cardiac arrest syndrome: precipitating disorder, tissue ischemia,

Therapuetic hypothermia: mechanism of action is to slow down brain/heart/overall metabolism and slowing the inflammatory cascades that are negatively impacting brain.

Ice packs have been shown to effectively cool patients.  So low tech cooling means have been shown to be just as effective as the hi tech options.  We have cold IV saline in the ER to use to start cooling patients early.

Hypothermia therapy either results in patients with good neurologic outcomes or they die.  Hypothermia treatment does not result in more patients with a persistent vegetative state.

Number needed to treat for therapeutic hypothermia: good neuro outcome=6,  lower mortality=7.  These are great numbers!

 AHA guidelines: Class 1 recommendation for comatose patients with ROSC after V-Fib arrest. Should also consider with patients resuscitated from other types of arrests.

Complications to be expected: infection and coagulopathy, bradycardia, electrolyte abnormalities, 5-20% rate of seizures, labile BP, hyperglycemia, avoid hyperthermia with re-warming.  Keep patients below 37.5C.

Can use therapeutic hypothermia even if prolonged resuscitation and/or unwitnessed arrest or prolonged down time prior to resuscitation or cancer.  Elise made a strong point that in all decisions to initiate hypothermia treatment to consider their pre-arrest health status and pre-arrest prognosis. Can even use therapeutic hypothermia when given lytics for PE.  Don’t use it for patients who arrested from bleeding because hypothermia will result in coagulopathy.   In patients on Coumadin, you don’t need to reverse or correct their inr’s.  Plavix does not preclude therapeutic hypothermia.  Elise would also cool patients with hemophilia who were not actively bleeding.  Patients with risk for head bleed due to trauma need head ct prior to cooling.

PICIS has algorithm for hypothermia.  We will have to find out where algorithm will be stored in FIRST NET system.

There is some data to suggest that delay to cooling increases risk of death.  Minnesota study shows 20% increase in death with each hour of delay to starting cooling.

New study coming down the pike: Do we need to actually cool pt’s down to 33C or is 36C good enough? European study of 875 patients is looking at this question.

Post-arrest prognostication: You have to wait until 72 hours when using therapeutic hypothermia.  Cooling and associated meds can decrease brain function for 72 hours after ROSC.

Harwood question: what is the definition of coma in the post arrest patient?  Elise answer: If you give a verbal command with no response or GCS <8.

Can also use hypothermia in neonatal hypoxic ischemic encephalopathy. NNT=7 to reduce death or major neurodevelopmental disability. Can use in Pediatric Cardiac Arrest.

New research to use therapeutic hypothermia for traumatic brain injury.

Remember that there is usually a culprit coronary lesion with cardiac arrest. So patients should go to cath lab after resuscitated V-Fib arrest.

Use left femoral vein for cool guard catheter.

Sam Lam Question: What about patients that re-arrest? Elise answer: if patients re-arrest or require hi dose or multiple pressors then stop cooling.  Outcome is dismal.

SEE THE ACMC PROTOCOL ON THE NEXT PAGE

Levato   Febrile Neutropenia

Absolute neutrophil count less than 500 is neutropenia.  Temp>38 is a fever

ABx choices are Cefipime or Primaxin.   Vanco is limited to specific categories listed on form (shock, skin,foreign device infection, mucositis).  For beta lactam allergy: aztreonam/cipro/tobramycin. Pick 2 of these three.

Main concern in these patients is on gram neg infections.

Conference Notes 9-18-2012

Conference Notes 9-18-2012

Kutka/Urumov  Oral Boards

Case 1: Crytpococcal meningitis in a man with AIDs. Critical actions include ordering cryptococcal antigen and/or india ink test (usual csf studies won’t pick up crytpococcal infection), giving antifungal medication (amphotericin B), rewarming for hypothermia, get a head ct prior to LP.

Andrej’s comments: cryptococcal meningitis is rare if CD4 count is greater than 100.  Opening pressure can be high.  High opening pressure portends a worse prognosis.  Routine CSF studies can be completely normal so cryptococcal antigen and/or india ink studies are essential to making the diagnosis.  

Case2:  Intracranial hemorrhage.    Critical actions include airway management, treat BP, elevate head of bed, treat intracranial hypertension with mannitol.

Andrej’s comments: Treat BP if over 180 systolic with a iv drip antihypertensive medication.   Anti-seizure meds not routinely indicated.  Some weak data showing worsened outcome with seizure prophylaxis.  

Case 3:  7yo with BB gunshot to eye with a retro-orbital hematoma.  Critical actions include lateral canthotomy, consult optho, pain management and prophylactic antibiotics.

 Elise comment: Think about doing ct scan brain with iv contrast in patients with hx of cancer and immunocompromised patients.

Chastain    7-UP Scan for Hypotension

Non-invasive study to augment clinical evaluation in the hypotensive patient.

7 UP scan includes FAST plus lungs, aorta, parasternal echo views.

When in the sucostal window you should look at the heart for pericardial fluid, RV dilatation, and overall contractility.   Paradoxical movement of ventricular septum is also an indication of PE.  The septum should move from LV toward RV.  If it is moving from RV to LV think PE.  Also look at the cava to see if it collapses.  More than 50% collapse indicates a CVP less than 10.  You should take this measurement as close to the heart as possible.  A crude indicator of location is that you should be looking at the ivc right by the liver.

In PSL window if aortic root is more than 4cm think about dissection.    Be sure to image this window with enough depth to see the descending aorta.  Frequently pericardial fluid will collect in the pericardium anterior to the descending aorta.  

Lung windows can help with causes of dyspnea.   Use the linear probe in the 2^nd and  3^rd intercostal spaces bilat.  No sliding of pleura means pneumothorax.   Increased vertical comet tails (B lines) indicates chf.  Increase horizontal A lines indicates COPD or Asthma.

Apical view of heart can also show RV dilation and bowing of the septum to the the left.

LUQ view usually needs the probe to be “closer to the bed and closer to the head” than when viewing the RUQ.   The spleen/liver tends to be more superior/posterior than the liver/kidney. 

Wise   Deadly Triad in Trauma

Hypothermia/acidosis/coagulopathy comprise the deadly triad.

Damage control surgery is temporizing procedures to obtain hemostasis. 

Hypothermia: trauma causes loss of thermoregulation.  Hypothermia exacerbates coagulopathy by decreasing platelet activation and altering enzyme kinetics. It also alters fibrinolysis. 

Acidosis: Causes decreased contractility, vasodilation, an worsened coagulopathy.   Base deficit >6 and elevated lactate  correlates with increased mortality.

Fluids can cause dilutional coagulopathy and hypothermia.

2002 study with sick trauma patients:  coagulopthy required BOTH tissue injury and hypotension.  Protein C is over-activated in severe trauma that may be the mechanism of the coagulopathy.

Tranexamic Acid:  CRASH-2 trial showed all-cause mortality benefit.   Benefit in bleeding patients depended on time of administration.  First hour had most benefit.   After 3 hours may increase mortality.  

Elise comment:  ACMC does not have tranexemic acid currently.

Permissive hypotension: goal is to maintain BP only to the point of maintaining minimal adequate perfusion.   Resuscitation fluids/blood products are restricted.   Goal BP is 70-90 systolic.   Generally accepted that patients with penetrating trauma should not be resuscitated to normal BP prior to gaining hemostasis.

Damage control resuscitation: permissive hypotension  plus damage control surgery plus resuscitation volume is predominantly blood products rather than crystalloid.

Factor 7 was discredited as a resuscitation drug.   Erik and Elise pounded  Factor 7 into the ground during the discussion.     Erik said there is new data supporting further tranexemic acid. 

Recommendations: shoot for a lower BP goal, avoid large volumes of crystalloids, use the massive transfusion protocol, give TXA in the first hour, keep patients warm. 

TABLE 112-1   -- Categorization and Initial Treatment of Hemorrhagic Shock*

	CLASS I	CLASS II	CLASS III	CLASS IV
Blood loss (mL)	≤750	750-1500	1500-2000	≥2000
Blood loss (% of blood volume)	≤15	15-30	30-40	≥40
Pulse rate	<100	>100	>120	≥140
Blood pressure	Normal	Normal	Decreased	Decreased
Capillary refill test	Normal	Positive	Positive	Positive
Respiratory rate	14-20	20-30	30-40	>35
Urine output (mL/hr)	≥30	20-30	5-15	Negligible
Mental status	Slightly anxious	Mildly anxious	Anxious and confused	Confused and lethargic
Fluid replacement (3:1 rule)	Crystalloid	Crystalloid	Crystalloid + blood	Crystalloid + blood

Chandra   Massive Transfusion Protocol (MTP)

Massive transfusion:  10 units of prbc’s in 24 hours,  or replacement of 50% of total blood volume in 4 hours.    Kids is >40ml/kg prbc’s  in 4 hours.

Who gets MTP?: ABC rule includes heart rate >120/bp<90/positive fast/penetrating mechanism.  More than 2 criteria activate MTP.    TASH score bp<100/hr>120/hgb<7/FAST/ Long bone fx/male gender.

1 unit of prbc’s increases hgb by 1.   Patients that receive FFP in a 1:1 ratio with prbc’s have a lower mortality.   Consensus for MTP is 1:1:1 ratio for prbc’s: platelets: ffp.   Battle field data from Iraq shows improved mortality with this ratio.

ACMC protocol: 10 units prbc’s, 6 units ffp, 1 unit aphoresis platelets, and 2 units of cryoprecipitate.  ER or  Trauma attending has to order this protocol.   The SYMS know how to order this. 

Goal of MTP: Map of 65 with adequate perfusion; basically bp of 80/60 with palpable pulses and warm extremities.    

Sam Lam comment: He questioned the component make up of the ACMC MTP because it is a little atypical based on trauma data in the literature.

OMI  Traumatic Brain Injury

Brain injury classification: Mild GCS=14-15    Mod GCS=9-13     severe GCS=3-8

Canadian head injury rule is a validated tool to identify patients at risk for positive ct or brain injury.

40% of moderate head injury patients(GCS9-13) have abnormal ct findings and 10% require surgery.

Severe head injury patients have the highest likelihood for brain injury and highest potential for benefit from surgery.   Get these patients to CT in 30minutes.   Tube all these patients.   Don’t routinely hyperventilate these patients.   PCO2 less than 25 increases mortality.

SAH from trauma are relatively benign.   Subdural hematomas tend to have significant underlying brain injury.   Epidurals often have little underlying brain injury.  Epidurals have great outcomes if manage properly.  Epidural hemorrhages may have a lucid period between initial loss of consciousness and later deterioration.    CT will be abnormal in these epidural cases from the time of initial injury.

Diffuse brain injury: concussion usually resolves in 6 hours.   Diffuse axonal injury due to shearing forces from high speed mvc’s.  Initial Ct will be normal despite severe coma.   Later CT’s or MRI will show punctuate hemorrhages.   Outcome for DAI is poor and any improvement takes months to years.

Monro-Kellie Doctrine: increasing volume inside fixed volume boney skull causes rapid increase in intracranial pressure.     

Cerebral perfusion pressure=MAP- ICP.   There is little data that medical care impacts outcome of brain injury.   Prevention of injury and prevention of secondary injury are keys to limiting morbidity/mortality.  Preventing hypoxia is probably the most important thing we can do to prevent secondary injury and  lower  patient mortality.   Hypotension is the second most powerful factor increasing mortality in brain injured patients.   After preventing hypoxia and hypotension, there is not much evidence that anything else helps outcome.

 ICP monitor:  keep ICP less than 20 and CPP>60. Improved outcome in patients who respond to hyperosmolar therapy.   This means mannitol at 1gm/kg.   Mechanism is osmotic mobilization of water across blood brain  barrier.  You can get hypotension from mannitol.   Hypertonic is an option for osmotic therapy that does not cause hypotension.

Some centers are studying hypothermia and suspended animation for severe brain injury.  The current thinking is that patients need low temp cooling for prolonged time (>48 hours).

Brain oxygenation are also being studied.

Hyperventillation:  works by dropping pco2 causing vasoconstriction.  This causes decreased brain blood flow and reduction in intracranial volume/pressure.  It can however cause brain ischemia.  So it has gone out of fmavor.

Kascia Nosek comment:  If patient is breathing over the vent settings, do you sedate them to avoid hyperventilation?   Dr. Omi,  yes.

Steroids: no benefit in brain injury.

Anticonvulsants:  Phenytoin reduces the incidence of seizures in the first week but not after.

Brett Negro comment: What are criteria for using steroids?   Dr. Omi,  patients with parenchymal brain injury including subdural hematomas should get phenytoin or phosphenytoin.  Keppra may be another option.   Anticonvulsants are all stopped at about a week.

Elise comment: Ketamine is probably a good choice for an induction agent in the hypotensive brain injured patient.   The risk of increasing intracranial pressure is low and it is less likely to cause more hypotension than etomidate.  

Conference Notes 9-11-2012

Conference Notes 9-11-2012

Kettaneh   5 Causes of ST Elevation

1. STEMI
2. Benign Early Repolarization: People under 50yo, J point notching, concave up ST elevation, Prominent T waves concordant with QRS
3. Pericarditis: Diffuse STE and/or PR Depression,  Reciprocal changes only in AVR (ST depression and PR Elevation) 

For deciding between  Early repol and pericarditis: ST segment elevation  compared to T wave height ratio in V6 is greater in pericarditis  (STE height/T wave height).   The T wave in early repol is taller than in pericarditis and the ratio is lower in early repol.

1. Bundle Branch Block.   Sgarbossa criteria: 1mm Concordant st elevation, 1mm Concordant st depression, discordant st elevation >/= to 5mm.  Cabrera’s sign: notching in S wave in V3-4.  Chapman’s sign notching in the R wave V6.
2. LV Aneurysm: can lead to sudden cardiac death,  arrhythmia, thrombus.  Consider after MI, absence of hyperacute T waves.

Other causes: brugada, lvh, hyperkalemia, hypercalcemia, myocarditis.

Girzadas question: Is benign early repol actually benign?  Answer: there is controversy but most references feel it is benign .   Silverman comment: BER has an emerging literature that shows a possible risk of sudden cardiac death.   However, no one knows what to do with this EKG finding.  There is no treatment protocol currently for this.

Harwood comment: Pericarditis vs. Early repol use tp segment as your baseline for identifying PR depression.  For figuring out the ST to T wave ratio use the PR segment as your baseline.  PR depression boosts the  ST elevation part of the equation increasing the ratio in pericarditis.

Herrmann  5 Causes of Wide QRS

Harwood comment: The best lead to measure the width of the QRS is the lead with the widest QRS.

1. Bundle Branch Blocks: QRS>120ms.  RBBB can be associated with heart disease and PE but can also be present in normal hearts.   RBBB in an acute MI confers increases mortality.   If wide and up in V1 it is RBBB.  If wide and down in V1 it is a LBBB.
2. Ventricular Rhythms: PVC’s are common in nl hearts.   Rules of malignant pvc’s : frequent pvc’s, couplets/triplets, multiform, pvc on t wave.  Ventricular escape rhythms are another cause of wide qrs. Accelerated idioventricular rhythm is associated with reperfusion with TPA.
3. TCA  Overdose:Look for wide QRS generally and tall/wide R wave in AVR
4. Hyperkalemia: Always consider this if the QRS is wide.   The ekg may also show a slow rhythm with loss of p wave.
5. WPW: Slurred upstroke of the QRS complex (delta wave) due to accessory pathway.  Delta wave widens the QRS and shortens the PR interval.

Barounis STEMI Conference

Case 1: LR’s for historical items indicative of AMI is  highest for radiation to both arms, radiation to right arm, diaphoresis, and radiation to left arm.   Pressure has a relatively low LR of 1.3.   chest pain that is reproducible has a LR of 0.4 which lowers the risk but does not make the risk 0.    When you don’t have an old ekg to compare with, make an old ekg by getting another ekg to look for evolution.

Comments: The ekg had subtle st depression in 1/AVL. Some subtle st segment straightening inferiorly.

2^nd EKG was diagnostic for inferior STEMI (STE greatest in 3)  

Harwood/Silverman  Comment:  Gotta get a repeat EKGwithin 10 minutes.  MD may have to stay at bedside for 10 minutes to get another EKG in high risk patients.

Other guest comment: Women will present with symptoms that can be atypical.

Case 2:  Evolving Inferior MI.    Cardiology comments an evolving ekg with chest pain should go to cath lab.  Recent normal stress test does not preclude AMI.   PT should go to cath lab even if ekg improves with ntg if other ER ekg’s were concerning.   

Dr. Silverman comment: Don’t delay more than 3 minutes waiting for return call from patient’s primary cardiologist.  After a 3 minute delay gotta contact intervential cardiologist on call.  He felt safest option is to call STEMI first and after that attempt contact with the primary cardiologist.   That way you get both cardiologists as rapidly as possible.

Case3: EKG initially was non diagnostic in a young patient with chest pain.  Dr. Silverman  advised stat echo in this situation.   If echo is nl, ekg is likely not stemi but more likely BER.  If echo is abnormal, then pt should go to cath lab.

CT angio for CAD:  Cardiologists generally not for it due to radiation exposure and low sensitivity.  Dr. Trevedi did say it has a good negative predictive value.  Dr. Trevedi felt hypertensive patients with chest pain may be a good pt group to use this test.  It give info about aortic dissection in addition to showing the coronary arteries.

Mila Felder’s summary points:

1. Repeat EKG in 10-15 min if questionable EKG and/ or persistant pain. EKG department and ED techs are accountable for giving it to physician to review. There is follow-up pending to making sure copies of EKGs are placed on the chart.
2. In case of dynamic EKG and consistent story, activate code STEMI. During the day, the patient's cardiologist may be able to take them to lab if ready to go and able to get to the hospital immediately. Do not delay care/ cath for convenience, and ok to use interventionalist on call to avoid delay in door to cath.
3. Pay attention to early repolarization (no longer considered benign). In case of consistent story, evaluating heart rate, other lead changes, potassium level, and other historical facts, be suspicious of early MI. Additionally, easy to miss the blocks in conduction when only looking for ST changes.

McKean  Syncope

Brugada:  Has been diagnosed in patients age 2-82. EKG findings can be transient. Pt’s have RBBB pattern with STE in septal leads.   Fever can bring out the findings.  Treatment is an AICD.

WPW: Treat with electricity for unstable patients and procainamide for stable patients.

Long QT syndrome: risk of polymorphic V-Tach.   Measure from start of Q to end of T. Quick and dirty is QT should be less than 0.5 the RR interval.   Treat with AICD.

HOCM: LVH without inciting stimulus.  Thickening of intraventricular septum.  You can get exertional syncope due to dynamic  LV outflow changes.   On EKG pt’s will have LVH and deep narrow q waves V4-V6.  Treatment is myomectomy and pacer/aicd

PE: Sinus tach is most common EKG abnormality.  Also look for RV strain pattern (t wave inversions inferior and anterior-most specific finding).   Pt’s may have RBBB.   S1Q3T3 is nonspecific.

A number of ekg examples were discussed along with some embarrassing old pictures of residents especially Barounis.

Harwood pimp question: What is LGL?  Brian Febbo knew it is WPW with no delta wave.  Lown-Ganong-Levine Syndrome is diagnosed by the presence of a short PR interval and normal QRS complex on the surface electrocardiogram (ECG).

Kessen  Heart Blocks

Sorry I missed part of this lecture.

Lenegre’s DZ:  fibrotic sclerodegenerative change of conduction system progresses to complete heart block

Lev’s DZ: sclerosis of left side of heart in older patients causing heart block

1^st degree av block: PR interval >0.2msec=5 small boxes.

2^nd degree AV block Type 1=Wenckebach.  Progressively longer pr intervals.  RR interval shortens until the qrs gets dropped.   Not treatment indicated.

2^nd degree AV block Type 2: PR interval remains constant before and after non-conducted atrial beat.   Atrial rhythm is regular and ventricular rhythm is irregular.

Look for AV block with inferior MI’s.

Harwood comment:  SA block is uncommon but it happens.  You can only see type 2 Sinus block on an ekg.  You can’t see Type 1 or 3 SA block.   SA block is different than AV block. 

Second degree SA nodal exit block has two types.

• § 
• §  In type II exit block, the P-P output is an integer multiple of the presumed sinus pacemaker input

Sayger/Felder/Katiyar /McGurk   Billing and Coding

All pneumonia patients going to ICU require blood cultures before antibiotics.

You need 10 ROS systems for level 5.

Document that you visualized and  interpreted the xray and give your interpretation.

Document the number of and type and drug that you used for nebulizer treatment.

You need either a social or family hx to get a level 5.

Keep track of your time you spend with critically ill patients.   Any time the attending spends on the care/ordering/discussion/documentation/decision making with the critically ill patient should be counted toward critical care time.

You need 8 organ systems on physical exam to bill a level 5.

Mnemonic: FORTUNATE    4-2-10-8.  4 HPI items, 2 history items, 10 ROS items and 8 physical exam items to bill level 5.

Ryan  Medical Student Review     Confidential Meeting

Conference Notes 8-28-2012

Conference Notes 8-28-2012

Grippo  Ortho Jeopardy

Perilunate Dilocation: Look at the lateral view of the wrist.   The capitate/lunate/radius need to line up.  If the capitates is dorsal to the lunate the dlx is perilunate.   If the lunate is dislocated volarly, it is a lunate dlx.

Supracondylar FX: 60% of peds elbow fxs.   Severe fractures that are not treated properly can develop Volkman’s ischemic contracture.

Femoral neck fractures: Have risk of avascular necrosis.   Older patients will get a arthroplasty.

Scapholunate DLX:  widening of space between scaphoid and lunate.  Terry Thomas sign.  Treat with radial splint.

Montaggia Fx:  Proximal ulnar fx with dislocation of radial head.

Galeazzi Fx:  Distal radius fx with dislocation of radio-ulnar joint.    Mnemonic is MUGR=montaggia/ulnar fx galeazzi/radial fx

Bennet’s Fx: Intra-articular fx at base of thumb. 

Barton’s Fx: Distal radius fx with intra-articular involvement.  Usually fx goes thru volar aspect of radius.  Can have either dorsal or volar angulation.

Bohler’s Angle: Normal is greater than 20 degrees.   If less than 20 degrees that is indicative of a calcaneous fracture.    With calcaneal fractures check for compartment syndrome in foot.  Also look for other joint and spinal injuries in patients who fell from height.

Lis Franc Fx:  tarso-metatarsal FX/DLX.  Look for fx at base of 2^nd mt and/or non-allignment of based of second MT and middle cuneiform.

Boxer’s fx: Needs reduction if angulation >40 degrees.  If pt has associated fight bite give antibiotic prophylaxis.    After reduction place in ulnar gutter splint with finger in flexion.

Lovell comment: Frequently fight bite injuries require OR irrigation and debridement.   Harwood added that in the OR it can be determined whether the bite went into the joint space.    Both felt IV antibiotics were indicated and hand consult for either OR or Obs admit or Very close follow up.   This is high risk medico-legal situation.

Jone’s Fx:  Fx of metaphysis/diaphysis junction of 5^th MT.  Risk of nonunion.  Non-weight bearing for 6 weeks.   Needs Ortho follow-up.  Psuedo-Jones Fx is basically an avulsion fx of tuberosity of 5^th MT.   These heal well and only require cast shoe.

Salter Harris FX:  Type 2 is most common.    Mnemonic is ME: metaphysis involvement is a  2, epiphysis involvement is a 3.  1 is easy to remember because it is just thru the physis and 4 is also easy because it goes thru both the metaphysic and epiphysis.   5 is a compression injury to the physis.  

Pilon Fx: Bad comminuted distal tibial fx due to talus ramming into tibial plafond due to a fall from height. 

Chauffeur’s(Hutchinson’s)  Fx:  Fx of the radial styloid.   Used to occur when turning the crank of early model  cars.  

Barounis     Undifferentiated Shock

Shock: Inadequate O2 delivery to meet tissue demand.

Oxygen delivery=(HR x SV) x 1.34 X HGB X SAO2 X10.    HGB and O2 Sat are the most important factors for O2 delivery.

Shock is bad because it results in anaerobic metabolism and lactate production.   The sodium potassium pump malfunctions.  Lactate is the cry of poorly perfused mitochondria.

Types of shock: 

Obstructive (tamponade/tension pneumo/pe/auto peep/rv infarct) Eval for this is to listen to breath sounds, use ultrasound.  Check EKG for signs of RV infarct; lead III will have more st elevation than lead II. Check for auto-peep on vent.

Distributive shock: (sepsis/cyanide/anaphylaxis)  Bounding pulse with hypotension.

Cardiogenic Shock: cool clammy, altered mentation

Hemorrhagic shock:  the patient is bleeding.

Approach to shock: Assess heart rate (pulse is not the main issue between 60 and 180),  make a volume assessment/obstructive assessment (cvp/U/S of VC /urine output/gingival mucosa),  assess contractility with U/S,  figure out the SVR (check extremities for warmth/bounding pulse/coolness/decrease pulse)

On ultrasound if IVC collapses more than 50% with inspiration the patient is volume responsive.  This assessment is obtained with the subcostal long view of aorta.   You also want to check the abdominal aorta/pericardium/rv /morrison’s pouch.  

History is unreliable in the assessment of shock.   Physical findings are more reliable than history.

PEEP helps push fluid out of the lungs into the right heart.  Also the increased thoracic pressure from PEEP helps move blood to abdominal organs/brain/extremities by pressure gradient.

Jim Jensen  PharmD   Vasopressor Review

Dopamine:  Indications septic shock, hypotension without hypovolemia, symptomatic bradycardia.  Can cause arrhythmias.

Levophed: More potent alpha agonist.   Indicated for septic shock or hypotension due to low svr.  Increases myocardial oxygen demand, may cause arrhythmias. 

Phenylepherine: Soley an alpha agonist with no beta effects.   Last line pressor .  Start high dose and titrate down because it is a relatively weak vasopressor.   Harwood comment: Only use for this agent is  neurogenic shock.     

Epinepherine: Mixed alpha and beta agonist.   Indicated in ACLS, septic shock after dopamine or norepi, anaphylactic shock.

Vasopressin: Smooth muscle vasoconstriction.  Inidcated in ACLS and is an option in septic shock with catecholamine resistance.   

If a vasopressor extravasates out of the vessel, you can use phentolamine locally to counteract the effects of the vasopressor.   Harwood comment: Give the phentolamine through the IV that extravasated so that the antidote goes right to where the  tissue injury has occurred.

Central line is required for Epinepherine drip and norepi drip.   Central line not required for dopamine, phenylephrine, vasopressin.

Dobutamine:Beta agonist that  increases cardiac contractility/cardiac output and vasodiates.   Can cause arrhythmias and hypotension.

Milrinone: Phosphodiesterase inhibitor increasing CAMP.  Increases cardiac output but does cause vasodilation. 

Plavix vs. Ticagrelor (Effient):  Ticagrelor has a stronger antiplatelet effect and has been shown to reduce thrombotic events compared to Plavix.  This comes with the cost of higher rate of  bleeding.  ASA dosing over 81mg decreases the effectiveness of Ticagrelor.

Carlson  Toxicology Antidotes

Antidote: Any treatment that lowers the LD50 of a toxin.  Direct antidotes act right at the site of the toxins action.    Indirect antidotes are supportive such as cooling, oxygenation, folate co-factor replacement etc.

Fomepizole is antidote for toxic alcohols.  Blocks alcohol dehydrogenase.   Pyridoxine is co-factor antidote for ethylene glycol.   Folate is a co-factor indirect antidote for methanol.

Lead poisioning:  Antidotes are succimer, BAL, EDTA.  In severe cases use BAL and EDTA both.   Can’t give BAL to patients with peanut allergy.

Mushroom poisoning with seizure:  Antidote is pyridoxine for gyromitra poisioning.    Gyromitra acts similar to INH and blocks GABA production.  

Clonidine poisoning: Antidote is narcan.  May need higher dose.  Repeated 2mg doses up to 10 mg.  There is controversy about the effectiveness of this antidote.

Hydrogen sulfide poisoning: Antidote is sodium nitrite for the sulfhemoglobinemia.   HBO is a second line direct antidote for this as well.

Calcium channel blocker OD: First line tx for severe OD’s is Insulin 0.5U/kg bolus followed by 0.5U/kg/hr drip and supplemental glucose therapy.

Anticholinergic toxidrome: Antidote is benzodiazepines first line.   Physostigmine is a direct antidote that should only be used with caution.  There is EM literature that shows physostigmine is actually relatively safe in patients with clear cut anticholinergic symptoms without other coingested substances.  The problem is that clear cut isolated anticholinergic OD’s are not very common.   

 Paraquat: Antidotes are Fuller’s earth, bentonite.  Don’t give O2 because it will cause pulmonary fibrosis.  

Coral snake: Red on yellow, Kill a fellow.   Coral snake (elapid) antivenin.    Red on black, venom lack refers to a non-venomous milk snake.   

Sulfonylurea overdose: Antidote is glucose and  octreotide.

Methylene Chloride:  Methylene chloride is broken down to CO in the liver.   Treat with HBO.  Methylene choloride has a long duration of action so patients may need multiple dives.

 Lily of the valley, fox glove,and oleander are plant sources of cardiac glycosides (digoxin): Antidote is digibind.   Atropine can also work by reducing vagal tone.

Rattle snake bite: Antidote for crotalid bites is crotalid antivenin.  Indications for antivenin are local spread,  coagulopathy , abnormal vitals.   Mnemonic: Spread, bled, almost dead.   Give 5 vials minimum.  Be prepared to manage anaphylaxis.

Hydroflouric acid:  Treat with calcium gluconate.   Don’t use calcium chloride because it can cause tissue damage.  Pt will have a lot of pain.  Can give calcium gluconate via topical gel, local injection, and intra-arterial infusion.   Needs hand consult or transfer to burn center.

Methemoglobinemia:  Treat with methylene blue.   HIV patients with G6PD deficiency  on dapsone for PCP can develop methemoglobinemia.

Amanita Phylloides muchroom.  Will cause vomiting more than 6 hours after ingestion.  Amanita acts like amped up apap resulting in centrilobular necrosis of liver.   Antidote is nac.

Organophophates: Treat with atropine and 2-PAM.   If you have tachycardia with cholinergic OD think hypoxia as secondary to pulmonary/airway secretions.   Still need to give atropine. 2-PAM regenerates acetylcholinesterace.

Willison/Carlson   Oral Boards

Case 1. Transverse myelitis.  Critical actions were perform detailed neuro exam, rule out cord impingement with mri, foley decompression of bladder.  Triad of sudden onset back pain, sensory changes (including allodynia) and weakness/sphincter dysfunction.   #1 thing for emergency physician to do is rule out cord compression.   Most references advise steroid treatment.   Can be a harbinger of MS or sarcoid.  

Case2. Depakote(valproic acid)  overdose with severely high ammonia level.  Critical actions were  intubation, check valproic acid and ammonia levels, treat with L-carnitine.  Can dialyze for severe cases.   Metabolism of depakote requires carnitine.  When you use up your carnitine you produce the toxic metabolite ammonia.  Giving l-carnitine allows normal metabolism of depakote.

Case3. Molar Pregnancy.  Critical actions were give iv fluids, get beta hcg, get u/s and identify molar pregnancy, consult ob-gyne.  Molar pregnancies occur 1 in 1200 pregnancies. Increased risk at extremes of age.  Two types genetically 69xxx or 69xxy or 46xx or 46 xy.  There is a chance of malignancy in both types.  Worst outcome is with patients that present with lung mets.  BHCG is usually great than 100,000. Uterus is larger than expected for age.  

Conference Notes 8-21-2012

Conference Notes  8-21-2012

Schwab/Barounis    Oral Boards

Case 1.  Toxic Alcohol-Methanol ingestion.  Recognize anion gap acidosis.  Calculate osmolal gap. Give Fomepizole.   Arrange for hemodialysis.    Pt required intubation to protect airway.   Bicarb drip may be used for acidosis but it is not a critical action.

Case 2.  Anterior Shoulder Dislocation.   Perform neuro-vascualar exam of injured extremity.  Give procedural sedation or intra-articular anesthetic.  Use any described reduction technique.

Case 3.   Retropharyngeal Abscess.  Identify pre-spinal soft tissue swelling. >7mm at C2 or >14 at C6 is abnormal.  The pre-vertebral soft tissue width should not exceed the width of the vertebral bodies.  CT of neck will give more detail of soft tissues than plain radiograph.    Give appropriate IV antibiotics.  Intubation is rarely required unless patient  looks very sick and is planned to be transferred.  Surgical airway may  rarely be required.

E Kulstad   Work up for PE

The prevailing thought is that we try to identify PE’s to save someone’s life.   This idea is based on older data that found PE’s to have a reasonably high mortality.  Current data from Jeff Kline 2008 shows that in 13 ED’s in the  US and NZ the overall PE mortality is 0.2% (13/8138).

Is PE mortality lower today because of better treatment?  There is only 1 controlled trial of anticoagulation for venous thromboembolism.   This one study showed no treatment difference between heparin and ibuprofen.   The thought is that mortality is better today due to emergency physicians casting such a wide net that we are identifying small clinically insignificant PE’s.  That broader group has a much lower overall mortality.

Small peripheral PE’s pose an unknown threat.   Small clots may be transient and normal.   If we scanned everyone in the audience, we would find a few small PE’s.  One study showed a 20% rate of PE in autopsies for persons killed instantly by a traumatic accident.

When using a low specificity test in a population with a low prevalence of disease (ie. CT for PE in low risk patients) false positives exceed true positives.   The PERC study showed a 7% prevalence of PE based on imaging.   Probably many (most?) of these positive scans were false positives.   To make matters worse inter-rater reliability between radiologists reviewing scans to identify PE is not very good.  The more likely prevalence based on calculations Erik walked us through is 2.3%.

Assume there is an 80% reduction in mortality of PE due to heparinization.  This is likely a gross overestimation of treatment effect.  Erik then walked us through calculations of harm and benefit of identifying and treating PE.  Risks of harm include renal injury, cancer risks, risks of hemorrhage. The final calculations show that work up and treatment for PE causes more harm than benefit for patients.   These calculatons  use conservative estimates of harm and generous estimates of benefit.   The conclusion  is that current practice of working up PE’s  has 6X greater chance of harm than benefit.

In the US standard of care probably forces us to persist in working up patients for PE.

Lovell comment:  Can we use normal vitals to not pursue a work up?    Can we use a higher d-dimer cut off for low risk patients?    Erik responded yes to both.    You can use a double of the standard d-dimer cut off for low risk patients.

Barounis comment:   He got a response from the author Dave Neuman that pt’s with a Well’s score less than 2 need no further work up .

Gourineni    Peds Ortho

If pt has limb ischemia due to a fx or dlx you should immediately attempt reduction.   Then consult both Ortho and Vascular Surgery.   Don’t allow the child to eat or drink  in the ER if there is any chance of patient going to OR.

Compartment  syndrome:  Gourineni  feels compartment pressure measurements are not accurate.  He prefers the symptom of muscle pain and sign of tense compartment.    He also likes the delta pressure which is the difference between diastolic blood pressure and compartment pressure.  Pain with passive movement is also a sign he favors.   If you suspect compartment syndrome call both the Ortho resident and Ortho Attending.    Keep limb at heart level, remove any bandages, reduce any deformity.   These patients require surgery in 3-4 hours.

Open fractures: Early antibiotics with ancef is more important than timing of surgical debridement.  Open fractures of hand do not require surgery.  Irrigation and antibiotics in the ER is adequate for hand or  distal extremity open fracutes.

Dislocations:  All dislocations need to be reduced in ER.   Delay in reduction in elbow/knee/ankle/foot will result in ischemic injury.   40% risk of posterior tibial artery injury in knee dislocations.   Make sure joint has good range of motion after reduction.  If it doesn’t, Dr. Gourineni wants to know about it.

Fractures: Boney deformity tends to straighten out.   Deformity does not improve around elbow.  So, all displaced elbow fractures require ORIF.    Splints should be long for supracondylar fx’s to proximal humerus.    Femur fractures need a splint extending up to chest wall.

Clavicle: most clavicle fx’s are treated non operatively.   Surgery is required for skin tenting or posterior sterno-clavicular dislocation.

Proximal humerus fx: 100% displacement and 1cm of shortening will spontaneously remodal.  This is due to majority of bone growth at proximal humerus.

Supracondylar Fx:  Look at anterior humeral line.  If it bisects the condyle there is minimal displacement.  These patients can be splinted and discharged with close ortho follow up. If the condyle is posterior to anterior humeral line there is significant displacement and pt should be admitted for surgery.   If there is vascular compromise, pt will go to OR in a few hours.  Splints should not be at 90 degree flexion.  30-45 degrees  is better.   Check interosseus nerve and radial nerve function with thumb IP flex/extension or OK sign.

  Monteggia Fx-Dlx:  Think of this any time you see a proximal ulnar fx.   It is the combination of proximal unlar fx and radial head dislocation.   If the radial head doesn’t line up with the capitellum it is dislocation.

 Elbow dislocation:  For all elbow dislocations do the Roberts maneuver.  Extend and supinate wrist to remove any boney particles in elbow joint.

Displaced distal forearm fractures will frequently heal and remodel in 2-3 months.  You don’t need to reduce most of these.   If parents want it reduced and you feel you can reduce it, it is ok to attempt reduction.

Any hip pain should initiate an Ortho consult.

MCP dislocations that are angulated not parallel to bone should be reduced by not pulling the digit but  rather pushing the digit closer to the metacarpal bone and sliding the digit back into place.

Lis Franc: If patient has tenderness with torsion of forefoot. Get an xray looking for fx of prox 2^nd metatarsal or non-allignment of middle cuneiform and 2^nd metatarsal.  Either way if xray is nl or abnormal splint patient and keep them non-weight bearing with follow up in Ortho clinic.

Joint Aspiration and Reduction Clinic

Conference Notes 8-14-2012

Sorry, I was on Vacation.

Conference Notes 8-7-2012

Conference Notes  8-7-2012

Grippo/Lovell  Oral Boards

Case 1:  Central Cord Syndrome:  Treat with application of cervical collar,  ct the cspine for evaluation for fracture.  Recognize weakness in upper extremities.  MRI to evaluate the spinal cord.  Steroids for this injury is controversial.   Consult neurosurgery.  ICU admit.   Identify urinary retention.   Central cord is the most common incomplete spinal cord injury.   Classic case is old person/hyperextension injury/arms weaker than legs.   Check for pain and temp perception in suspected cord injuries.

Case 2: Cardiogenic Shock:  Patient with Hypotension and hypoperfusion with AMI. Treat with BIPAP or intubation.  Diagnose STEMI.  Support hemodynamics with inotrope and pressor (dobutamine/dopamine).  Cardiovert unstable VT.  Get to the cath lab.   These patients look very sick and may have altered mental status.

Case 3: Nasal Foreign Body: Treat with parent giving forceful breath into patient’s mouth.   Works 50% of the time with non-sharp edged objects.   Multiple other techniques are available to remove the FB (suction, fogarty catheter).  Button batteries in nose can cause necrosis.

Harwood comment:  Best approach to the steroid issue is discuss that it is controversial and then either give or not give.   Probably better to intubate the patient so they can be more safely managed in the cath lab.  

BINGISSER   Geriatric EM

Dr. Bingisser is a practicing EP in Switzerland. ED’s in Switzerland also have crowding issues.

Seniors take taxis to the ER because it is cheaper than an ambulance.   The Rolling Stones took along a geriatrician on their last European tour.

Problems managing elderly patients: poor communication/atypical presentations/broad spectrum of illness/complex interaction of social/medical problems/non-specific complaints/subtle vital sign changes to serious illness.

Triage in the elderly is difficult for the above reasons.  Elderly patients are commonly undertriaged.  Vital sign abnormalities were commonly unrecognized. Also high risk situations are frequently unrecognized.

Localized weakness: 75% were strokes 25% were stroke mimics.    Genralized weakness complaints turned out to include diagnoses from all ICD9 code  chapters.

Non-specific complaints:  1 year mortality for elderly patients with nonspecific complaints in Dr. Bingisser’s study was 13.5%.  30 day mortality was 6.4%.   In 1210 patients, they made over 300 different diagnoses!  Uti was most common cause and over 50% of those also had sepsis.    50% of ED diagnoses for non-specific complaints were incorrect.   6 predictors for serious outcomes of elderly patients with nonspecific symptoms  are elevated BUN,  low sodium,  elevated CRP, history of exhaustion, clinician gestault, chf.

Viswanathan/DKA

I missed this lecture giving Dr. Bingisser a tour of our ER,  sorry.  But, I did hear,” don’t bolus insulin or Dr. V. will hurt you”.

Roy  Peds Vignettes

Case 1: Lethargic 6 month Infant, ddx includes CNS/tox/sepsis/metabolic/trauma/hypoglycemia/inborn errors/intussusception.    Toxic encephalopathy can include hypertensive encephalopathy in kids due to post-strep glomerulonphritis.   MCAD is a substrate dependent inborn error of metabolism that presents as hypoglycemia when a child doesn’t eat as regularly as normal due to an illness or sleeping longer. Unexplained neuro symptoms in an infant, you should think GI process.   Think shigella in a febrile infant with diarrhea and seizure.   Classic case of intussusceptions is lethargic kid in second half of first year of life.  KUB in intussusceptions may show paucity of gas on right side.    Intussusception used to be uncommon in kids under 4 months.  However, now with rota virus vaccine it is possible under 4 months.  Dr. Roy has seen 5 cases in the last two years in kids under 4 months.  If the child has not had a rota  virus vaccine, it is unlikely to get intussusceptions under 4 months of age.    HUS is another cause of lethargy and seizures in an infant.   Think HUS in a kid with gastro that got better then gets sick again 1-2 days later.   Check a CBC in a gastro kid who has had a course of illness of 4-5 days to look for low platelets or hemolysis/anemia.  CBC findings will precede bun/cr changes.  Dr. Roy makes a point about  the change in color in kids with intussusceptions or HUS.  Kids can also get HUS from pneumococcus.

Unexplained respiratory symptoms in an infant think: Heart-CHF (check the liver for swelling).  Myocarditis clues are marked tachycardia, tachypnea, murmur.   GERD.   Upper airway obstruction such as laryngo-tracheomalacia/sub-glottic stenosis/croup is unlikely in a young infant

Xrays are not necessary in most  asthmatics or most simple croupers.   Epiglotitis doesn’t bark like a seal.  They usually have muffled voice and are drooling because swallowing is painful.

Nausea/vomit/abdominal pain without fever or diarrhea is DKA until proven otherwise.

Fever for 5 days is Kawasaki’s until proven otherwise.

Puffy eyes and puffy hands in kids is a renal problem until proven otherwise.

Do a CBC in a limping kid to eval  for leukemia.   1 out of 7 kids with new onset leukemia presents with musculoskeletal pain.  Don’t believe the parents’ story of trauma.

Case 2/3: 3 week old infants with vomiting.  Think pyloric stenosis.  Olive mass in ruq is uncommon.  If child has low sodium and high potassium think congenital adrenal hyperplasia.  Look for hyperpigmented scrotal skin in kids suspected of congenital adrenal hyperplasia.

Sickle rules: fever warrants admission.   Get a retic count to r/o aplastic crisis.   Respiratory or chest complaints require a CXR for acute chest syndrome.  Check spleen for sequestration crisis.  Most of the sequestration crises at ACMC over the last decade have been kids over the age of 10.

Grippo   ACLS Update

Switch out your persons doing compressions every 2 minutes.    Avoid over-bagging.

Defib with 200J biphasic.

1mg epi or 40u of vasopressin

Amiodarone 300mg IV

PEA: consider causes like pneumothorax, hyperkalemia

Bradycardia: Atropine 0.5mg to 3mg max.   Transcutaneous pacing.  If you can’t capture with TCP,try epi drip or dopamine drip.  Last line is transvenous pacing.

Wide Complex Tachycardia: If unstable with pulse cardiovert.  If no pulse defibrillate.

Narrow complex tachycardia: SVT/AFIB with RVR/AFutter/MAT

Wide and Irregular:  WPW with AFIB,   AFIB with BBB

Harwood comment: Use your right hand to help differentiate RBBB  and VT.  In RBBB second rabbit ear should be taller like your right hand with the 3^rd finger taller than the index finger.  If the first rabbit ear is taller, it is more likely to be V-tach.

Conference Notes 7-31-2012

CONFERENCE NOTES 7-31-2012

CHASTAIN/GIRZADAS  ORAL BOARDS

n  CASE 1: Ethylene glycol poisoning. 

n  Intubate (PC)

n  Treat with 4-Methyl Pyrazole ( fomepizole 15 mg/kg) or ETOH (PC,MK)

n  Arrange Hemodialysis (MK,SBP)

n  Give Antibiotics for aspiration pneumonia (MK, PC)

n  Anion Gap= Na-(CL + HCO3)<15

n  Osmolal Gap= 2X Na + Glucose/18(20) + BUN/2.8(3) + ETOH/4.6(5)

n  Measured Value - Calculated Value <20

CASE 2: Femoral artery injury due to GSW

n  IV fluid bolus 20ml/kg (PC)

n  PRBC transfusion 15ml/kg (MK, SBP)

n  Identify Hard Signs of vascular injury and perform ankle/brachial index (MK)

n  Trauma/Vascular surgery consultation (SBP, PC)

n  Hard signs of vascular injury mandate angiography or surgery.

n  Pulsatile bleeding

n  Pulsatile hematoma

n  Bruit/thrill

n  Absent/diminished pulse distal to injury=ABI<0.9

n  Ischemic signs (pain, pallor, coolness, paralysis)

CASE 3: Pyloric Stenosis

n  Consider Pyloric Stenosis (pmh, olive, BMP, U/S, Upper GI) (PC,MK)

n  IV hydration (20ml/kg)

n  Admission for planned surgery (SBP)

n  Hypo-chloremic/kalemic/natremic metabolic alkalosis

n  Today most are diagnosed prior to electrolyte abnormalities

n  Males more common 5:1

n  Associated with macrolide antibiotics

n  Laproscopic Pyloromyotomy

WOOD   MEDICAL-LEGAL ASPECTS OF EM

Philosophy: the study of questions that can’t be answered.  Religion:the study of answers that can’t be questioned.

Case 1 Chronically ill elderly patient with hypoxia.  Husband wants everything done.   Autonomy is the primary ethical rule but pt’s have to have understanding.  If pt can’t make decision.  There is a principal of implied consent in situations of emergency.  Husband has the power to decide for wife.  But what if husband is demanding futile care?  Decision making can only be taken away from husband if he lacks decisional capacity.  Answer is to inform husand that further work up/treatment may worsen suffering and palliative care may lessen suffering.    It is ok to discontinue ventilator.  There is no distinction between action and inaction.  Taking patient off ventilator is acceptable.  It is ok to give small doses of opioids/benzodiazepines to relieve suffering.  Don’t give a large dose that could kill a terminal patient.  Document how the patient looks and document your intent to relieve suffering.

Case 2  Man found unresponsive in his car. He is a nurse who is abusing oxycontin.  It is ok for doctors to speak with other MD’s if it is in the context of treating the patient.  Confidentiality is well supported by law and custom but it is not absolute.  Exceptions exist due to societal interest.  Doctors are required to report child abuse or turn in weapons.    Doctor-patient relationship is much less protected legally than attorney-client relationship.  The doc has a duty to turn drugs (evidence) over to the police or security. You are more likely to get sued for not reporting something than for reporting something.

How do you determine decisional capacity.  If you have a 0.8 etoh level, there is a legal presumption that you have lost the psycho-motor skill to operate a car. There is NOT the legal presumption that a patient gives up all their rights to leave the ED as long as they are not driving.   An etoh level above 0.8 is not grounds alone to forcibly restrain a patient from leaving the ED.  

Case 3   16yo female who had sexual encounter.  Doctor refused to give post-coital contraception based on his own moral code.  There is no statute in any state that says you must be 18yo to consent for medical care.  No doctor has ever been successfully sued for non-negligent treatment of kids over 14 without consent from parents.   32 states have a statute saying it is ok for docs or pharmacists to not tell a patient about contraceptive/abortion options if it is against their conscience.   If a patient asks the doc if there is a morning after pill option for her, the doc can’t lie and say there isn’t.  

Dr. Woods Notes: Notes and Bibliography

Legal and Ethical Issues in Clinical practice.

Joseph P. Wood, M.D.,J.D

Principles of medical ethics

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.


A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.


A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.


A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.


A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.


A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.


A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.


A physician shall, while caring for a patient, regard responsibility to the patient as paramount.


A physician shall support access to medical care for all people.

Adopted by the AMA's House of Delegates June 17, 2001.

Case of Patient in a Vegetative State

Medical definition

Any person with an illness that is not able to function properly without artificial help.

Legal/ethical definition

As opposed to brain death and comatose, PVS is not recognized as death in any legal system. This ethical grey area has led to several court cases involving people in a PVS, those who believe that they should be allowed to die, and those who are equally determined that, if recovery is possible, care should continue. This ethical issue raises questions about autonomy, quality of life, appropriate use of resources, the wishes of family members, professional responsibilities, and many more.

History

The syndrome was first described in 1940 by Ernst Kretschmer who called it apallic Syndrome.[1] The term persistent vegetative state was coined in 1972 by Scottish spinal surgeon Bryan Jennett and American neurologist Fred Plum to describe a syndrome that seemed to have been made possible by medicine's increased capacities to keep patients' bodies alive.[2][3]

[edit]

Classification

Terminology in this area is somewhat confused. While the term persistent vegetative state is the most frequent in media usage and legal provisions, it is discouraged by neurologists, who favour the terminology of the Royal College of Physicians (RCP) which refers only to the vegetative state, the continuing vegetative state, and the permanent vegetative state.[4]

The vegetative state is a chronic or long-term condition. This condition differs from a persistent vegetative state (PVS, a state of coma that lacks both awareness and wakefulness) since patients have awakened from coma, but still have not regained awareness. In the vegetative state patients can open their eyelids occasionally and demonstrate sleep-wake cycles. They also completely lack cognitive function. The vegetative state is also called coma vigil. The continuing vegetative state describes a patient's diagnosis prior to confirmation of the permanence of the condition. The permanent vegetative state occurs when the vegetative state is deemed permanent; a prediction is being made that the patient will never recover awareness. This prediction cannot be made with absolute certainty. However, the chances of regaining awareness diminish considerably as the time spent in the vegetative state increases (Royal College of Physicians, 1996).

This typology distinguishes various stages of the condition rather than using one term for them all. In his most recent book The Vegetative State, Jennett himself adopts this usage, on the grounds that "the 'persistent' component of this term ... may seem to suggest irreversibility".[2] The Australian National Health and Medical Research Council has suggested "post coma unresponsiveness" as an alternative term.[5]

[edit]

Signs and symptoms

Most PVS patients are unresponsive to external stimuli and their conditions are associated with different levels of consciousness. Some level of consciousness means a person can still respond, in varying degrees, to stimulation. A person in a coma, however, cannot. In addition, PVS patients often open their eyes, whereas patients in a coma subsist with their eyes closed (Emmett, 1989).

PVS patients' eyes might be in a relatively fixed position, or track moving objects, or move in a disconjugate (i.e. completely unsynchronized) manner. They may experience sleep-wake cycles, or be in a state of chronic wakefulness. They may exhibit some behaviors that can be construed as arising from partial consciousness, such as grinding their teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming without any apparent external stimulus.

Individuals in PVS are seldom on any life-sustaining equipment other than a feeding tube because the brainstem, the center of vegetative functions (such as heart rate and rhythm, respiration, gastrointestinal activity), is relatively intact (Emmett, 1989).

 (Available on Wikipedia.org with essentially no copyright restrictions).

Conflict with Surrogate Decision-Maker

1)       Baruch Brody, Special Ethical Issues in the Management of PVS Patients, 20 L., Med. And healthcare 104 (1992)

2)       In Re Wanglie, No. PX-91-283 (Minn.D.Ct. June 28, 1991)

(Hospital sought order to replace Husband as the surrogate decision-maker. Court did not address the substance of the decisions made by the Husband finding that the only materially relevant question was whether the Husband was in the best position to know what the patient would want done if she was able to speak for herself).

3)       “The Physician-Surrogate Relationship” Archives of Internal medicine, June 11, 2007

4)       “Time to Move Advance Care Planning Beyond Advance Directives” Chest 2000

May a Physician Sedate a Terminally ill Patient to the Point of Unconsciousness?

5)       Vacco v. Quill, 117 S. CT. 22293 (US 1997)

6)     Quill, T. E., Byock, I. R., for the ACP-ASIM End-of-Life Care Consensus Panel. Responding to

intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids.

Ann Intern Med. 2000;132:408-414.

7)       See CEJA Report 5-A-08 Referred to Reference Committee on Amendments to Constitution and Bylaws (Available at www.ama-assn.org)

Privacy and Confidentiality

45 CFR 164.506(a) Healthcare entities (Hospitals, Doctors etc.) May share otherwise protected information on patient if purpose is to facilitate care.

45 CFR 164.510(b) May share information with family or close friend if this facilitates care and patient does not object.

For a good summary of HIPPA go to:

www.hhs.gov/ocr/privacysummary.pdf

Treatment of Minors

“Informed Consent to the Treatment of Minors” Schlam and Wood, Journal of Law-Medicine Vol. 10 Number 2, Summer 2000 (Case Western Reserve University School of Law)

Healthcare Provider’s Right to Follow Their Conscience.

Curlin, Lawrence, Chin, Lantos: Religion, Conscience, and Controversial Clinical Practices; N Engl J Med 2007; 356: 593-600

      (745 ILCS 70/) Health Care Right of Conscience Act.

(745 ILCS 70/2) (from Ch. 111 1/2, par. 5302)

    Sec. 2. Findings and policy. The General Assembly finds and declares that people and organizations hold different beliefs about whether certain health care services are morally acceptable. It is the public policy of the State of Illinois to respect and protect the right of conscience of all persons who refuse to obtain, receive or accept, or who are engaged in, the delivery of, arrangement for, or payment of health care services and medical care whether acting individually, corporately, or in association with other persons; and to prohibit all forms of discrimination, disqualification, coercion, disability or imposition of liability upon such persons or entities by reason of their refusing to act contrary to their conscience or conscientious convictions in refusing to obtain, receive, accept, deliver, pay for, or arrange for the payment of health care services and medical care.

(Source: P.A. 90‑246, eff. 1‑1‑98.)

(745 ILCS 70/6) (from Ch. 111 1/2, par. 5306)

    Sec. 6. Duty of physicians and other health care personnel. Nothing in this Act shall relieve a physician from any duty, which may exist under any laws concerning current standards, of normal medical practices and procedures, to inform his or her patient of the patient's condition, prognosis and risks, provided, however, that such physician shall be under no duty to perform, assist, counsel, suggest, recommend, refer or participate in any way in any form of medical practice or health care service that is contrary to his or her conscience.

    Nothing in this Act shall be construed so as to relieve a physician or other health care personnel from obligations under the law of providing emergency medical care.

(Source: P.A. 90‑246, eff. 1‑1‑98.)

A Simpler Ethical Code:

Harry Truman was a different kind of President. He probably made as many important decisions regarding our nation's history as any of the other 42 Presidents. However, a measure of his greatness may rest on what he did after he left the White House.

The only asset he had when he died was the house he lived in, which was in Independence Missouri His wife had inherited the house from her mother and other than their years in the White House, they lived their entire lives there.

When he retired from office in 1952, his income was a U.S. Army pension reported to have been $13,507.72 a year. Congress, noting that he was paying for his stamps and personally licking them, granted him an 'allowance' and, later, a retroactive pension of $25,000 per year.

After President Eisenhower was inaugurated, Harry and Bess drove home to Missouri by themselves. There was no Secret Service following them.

When offered corporate positions at large salaries, he declined, stating, "You don't want me. You want the office of the President, and that doesn't belong to me. It belongs to the American people and it's not for sale."

Even later, on May 6, 1971, when Congress was preparing to award him the Medal of Honor on his 87th birthday, he refused to accept it, writing, "I don't consider that I have done anything which should be the reason for any award, Congressional or otherwise."

As president, he paid for all of his own travel expenses and food.

Modern politicians have found a new level of success in cashing in on the Presidency, resulting in untold wealth. Today, many in Congress also have found a way to become quite wealthy while enjoying the fruits of their offices. Political offices are now for sale.

Good old Harry Truman was correct when he observed, "My choices in life were either to be a piano player in a whorehouse or a politician. And to tell the truth, there's hardly any difference."

WOOD   AAEM

AAEM is an outstanding organization representing the board certified emergency physician.

GARRET-HAUSER    ETHICAL ISSUES

Breaking Bad News:   Ask patient what they are concerned about.  It may help discuss bad news.

Warn the patient that bad news is coming.  Use non-technical terms so patient can understand.  Anticipate the level of their understanding.

ED conversations with patients can veer toward being too blunt due to time constraints.   Be cautious about being too blunt.  Give enough time to be human with the patient or family.

C. Kulstad comment:  When discussing concerning test results like a lung mass on ct, We have an obligation to tell the patient that the most likely diagnosis is cancer based on the test findings.  Other faculty agreed with this.  

Tell patients what the next step is going to be.

Telling family that someone died:  Find out who the family members are in the room.  Get some info from family if you need it before you tell them the person died.   Gotta use the word dead, died or death so families fully understand the irrevocable nature of the situation.

Family requests for non-disclosure of results to the patient:  Ask the family why the request is being made.  Negotiate with the family the best way to handle this situation.  You can ask the patient if they prefer to get the infothemselves or discuss with the family.  You may want to inform families of the standard of truthfulness with patients in this country.   You have a duty to ask patients how they want medical information handled.  If they want the info given to them, you need to give it to them despite the family’s wishes.

Power of Attorney gives the surrogate the same decisional capacity as the patient would normally have.  There cannot be 2 powers of attorney.  It can only be one person.  There can be a successor named but they cannot make decisions if the power of attorney is present.

Surrogate act allows spouse, adult children or moving down the hierarchy, other family members or close friends to make decisions for a patient with a qualifying condition who doesn’t have decisional capacity.   

To fill out the form to withdraw care (like taking out the ET tube or taking out feeding tube) you need two docs to sign off the WITHDRAWL OF CARE FORM  that patient has a terminal condition.

Harwood comment: Utilize ethics committee to help with management of difficult clinical decisions when there is some time.  Also when breaking news to a family that a patient has died he prefers tell them the patient has died very early in the conversation.

KUTKA  M AND M TRAUMA

21yo male shot in buttock.

Get prepared prior to patient arrival even if the EMS report on the radio says “stable vitals”

DDX of Combative behavior: guy is a jerk, intoxication, hypoperfusion.    Assume hypoperfusion until proven otherwise.

Even if bleeding seems venous don’t downplay the volume or significance of the blood loss.

Even if it appears to be a “simple” trauma don’t treat it like that.  Treat aggressively and discuss your concerns with attending.

When giving blood products in a bleeding patient be sure to give enough prbcs AND ffp and platelets.  Follow the massive transfusion protocol.

Criteria for Massive Transfusion: Penetrating mechanism, positive fast, arrival BP<90, arrival HR>120.  2criteria=40% chance and 4criteria=100% chance of needing massive transfusion.

When breaking bad news: discuss with Chaplain, have security with you, limit the # of family members in the quiet room, make sure you have an exit strategy.

Barounis comment: If you order the massive transfusion protocol and don’t use all the blood, it will be sent back to the blood bank to be used again. 

Conference Notes 7-24-2012

Conference Notes 7-24-2012

WILLIAMSON  STUDY GUIDE  RESUSCITATION QUESTION SLAM

Junctional rhythm does not occur in healthy hearts so you have to investigate for ischemia or other pathology.

Brugada Syndrome is a genetic condtion that affects phase 0 sodium channels.  Causes sudden death in structurally normal hearts.   Affects asian men more commonly.   EKG demonstrates RBBB with j point elevation and widening in leads V1-3.   

Elise comment:  not everything that looks like Brugada is Brugada so you need cardiology to consult on these EKG’s if there is a question.

Treat WPW with afib with procainamide if stable.  If unstable, cardiovert. 

Norepi is a good pressor to use if you don’t want to increase tachycardia too much.  Alpha effects (vasoconstriction) are more prominent.

When resuscitating a patient with septic shock, vasopressors work best with a full vascular bed.   Pressors can falsely elevate cvp so be sure you are giving adequate fluids.   There is no evidence that trandelenburg position improves pt outcome or cardiopulmonary function.  There is some evidence it may worsen cv status.  So don’t use it.

For massive transfusions, pt’s should receive prbc’s/platelets/ffp in 1:1:1 ratio.

For pelvic or abdominal injuries  you want iv access above the diaphragm.  IO in the proximal humerus is a great second line access means is you can’t get peripheral iv access.

Anaphylaxis is an IGE-mediated immune reaction.   IM Epinephrine in the thigh (0.3-0.5mg) is the treatment for adults.  If you have two of the following: skin/respiratory/gi/cardiovascular symptoms you have anaphylaxis.  

Transvenous pacing for an unstable patient with bradycardia or heart block is indicated if transcutaneous pacing at max output is not getting good capture.  In the meantime try atropine. 

Barounis comment: Check for  hyperkalemia if transcutaneous pacing is unsuccessful.

Initial management of rapid afib is rate control with cardizem.

Barounis comment: I would prefer elective cardioversion for acute rapid afib.  Elise comment: totally would want to be shocked for rapid afib of less than 48 hours.

BAROUNIS/GRIPPO    INTRO TO CODE 44

SORRY I MISSED THIS LECTURE

KETTANEH  INTRO TO SEPSIS

SIRS: hr>90, tachypnea, elevated wbc, abnormal temp either hi or low

Sepsis is SIRS plus an infection

Severe sepsis is sepsis with hypotension prior to IV fluids

Septic Shock: severe sepsis not responding to fluid bolus of 20cc/kg

 Sepsis patients need at least 20ml/kg of NS with a minimum of 1 liter over 30 minutes.

Broad spectrum in the first hour improves mortality.  Delay of antibiotics increases mortality of about 7% per hour.

Early Goal Directed Therapy: has been shown to reduce sepsis mortality compared to standard care.  Indication of EGDT is persistent hypotension or lactate >4 despite initial fluids.  Place a CVP line above the diaphragm.  CVP is a proxy for preload.  CVP helps you to optimize volume status.  Goal is CVP of 8-12 or 12-15 if the patient is on a ventilator.  If CVP less than 8 give more fluids.   Next step is to start vasopressors.  Vasopressors do not improve mortality.  No data to say which pressor is superior.   Norepi however is the drug of choice due to less adverse effects.    Central venous oxygen satuation is a marker of success/mortality.  So get a VBG off your central line.   If Scv02 is <70% you got problems.   Intubate/Check hgb/start dobutamine as an inotrope.  Transfuse if hgb less than  7. 7-10 is a grey zone.  Lactate  clearance is a reasonable proxy for Scvo2.  

No steroid use/not indicated for sepsis. Steroids only if pt’s on chronic steroids and are steroid dependent.   Procalcitonin if nl may be a sign you can stop antibiotics but evidence is weak.

Wise comment: if Scvo2 is low, early intubation with neuromuscular blockade is indicated.

C Kulstad: Sepsis patients ned high fluid maintenance rates like 200ml/hr

Lovell comment:  If you give fluid bolus to patients give a liter not 200ml bolus.  Also use EGDT protocol in our EMR.

Hermann comment:  IV infusion pumps do not get the fluids in fast enough.  You have to hang fluids with a pressure bag and no pump.   Corroborated by Dr. E Kulstad/Lovell

Harwood comment: Questioned that pressors in septic shock don’t improve mortality.

MCDERMOTT    SEVERE COPD EXACERBATIONS

Definition: increase in symptoms of cough/sputum/dyspnea.  All copdr’s  have a decreased FEV1/FVC ratio.

Treatment priority is to ensure oxygenation.   Hypercapnea is well tolerated.    Get O2 sat to 92% and 95% in dark skinned patients.   Can use venti masks but usually 4L pnc is enough to correct oxygenation problems in copdr’s.  If you need more oxygen support you gotta think about other things.

Bipap has been shown to decrease need for intubation, decrease risk of nosocomial infection, and decrease mortality.    Intial settings are 8-12 inspiratory and 3-5 expiratory.  If you need to adjust settings a reasonable move would be 15/7.

Vent management for intubated patients: high inspiratory flow rates and low tidal volumes (5-7ml/kg) and low rates.  This will help to minimize airway pressures.

Treatment: Nebs are more effective than in mdi’s in COPD exacerbation.   Magnesium can be used.  Theophylline has not been shown to improve outcomes in COPD.  Chest PT also not indicated in acute COPD exacerbation because it can worsen an acute exacerbation.   Steroids have been shown to improve symptoms, lung function and decrease hospital stay.  About a third of COPD exacerbations are triggered by bacterial infection so antibiotics are indicated for acute exacerbations.  Sputum cultures are not useful.   Pseudomonas risk factors:4 episodes/year, recent hospitalization, previous pseudomonas, or severe copd.   If risk factors for pseudomonas are present give zosyn, if not then ceftriaxone.    

Most common causes of death in an admitted COPD patient: heart failure, pneumonia, PE, then COPD.

Work UP: CXR, EKG, Troponin, CBC, BMP,  ABG,  +/- Blood cultures.

Girzadas comment: What triggers PE work up (one study showed 20% incidence of pe in COPD exacerbation but my experience does not match that)?    Robbie: persistent hypoxia or remarkable risk factors,  exam findings, lab or cxr findings suggestive of PE.

Harwood comment:   CO2 narcosis is very common due to excess O2 administration.  Beware of giving too much oxygen to COPDR’s.   If the patient needs to be intubated for CO2 narcosis, they likely will be hard to get off the ventilator.   Try bipap first to reduce CO2 retention but for very high PCO2’s it may not work.

PUTMAN SEVERE CHF EXACERBATION

  Common ED clinical conundrum is separating out pneumonia/chf/copd.

Bipap has been shows to decrease intubations/admissions/mortality.   PEEP helps.  12/5 again is a reasonable starting point for the bipap machine.

Nitroglycerine (both IV and Sublingual) is the key medication treatment.   Give 4 sprays of ntg to give a 1600microgram bolus rapidly.   Start 50mcg/min drip and titrate up rapidly to around 200 mcg/min.  If patient still not improving and BP still up, you can add nitroprusside drip.

Beckemeyer and Harwood comments: Look for improvement from ntg by improved dyspnea and improved blood pressure.   You will only be at the very high levels of ntg administration for a short while because BP will start going down.  You will need to be alert as to when to start going down on ntg dose.

Diuretics alone can increase mortality. Diuretics can worsen renal function.  You need to not give lasix until you have ntg going.

ACE-I ‘s have been shown to improve patient outcomes.

Contraindications to  NTG vasodilatation:  RV infarct, aortic stenosis, hypertrophic cardiomyopathy, hypotension.

Barounis comment: how do you manage patient pulling off bipap mask?   Elise and Christine say give ativan cautiously.   If they either keep pulling of mask or become too somnolent you proceed to intubation.

Girzadas comment: Be alittle bit patient for the NTG to work for the first 15 minutes.  Most patients don’t need to be intubated.  The nitro will work magic if given alittle time.

BAROUNIS   ALTERED MENTAL STATUS

SORRY I MISSED THIS LECTURE

Conference Notes 7-17-2012

CONFERENCE NOTES 7-17-2012

MOTZNY   EMS STUDY GUIDE

Triage colors: green = walking wounded, red=emergent, yellow=care can be delayed for a few hours, black=dead.

JCAHO requires a hospital disaster plan to be activated 2 times per year.

A disaster is defined when an event overwhelms a facility’s ability to respond appropriately.

The most common important problem in a disaster is communication difficulties.

Mass gathering =1000 or more people at an event.  The most common injuryat a mass gathering is dermal injury.

Triage is a dynamic process that requires re-eval and re-assessment of patients.

The command station at a HAZMAT scene should be uphill and upwind from the hazardous materials.

Regarding decontamination; if there is ocular exposure address eye irrigation first.  Gross decontamination takes precedence over airway management.  Removing clothes is the first and usually most effective step of decontamination.

Class A bioterrorism agent:  Anthrax, plague, ebola, small pox, botulism, tularemia.     

Radiation:  Alpha particles can be blocked by paper or clothing.  It is unlikely to give whole body radiation unless ingested.   The earliest lab indicator of acute radiation syndrome is decreased lymphocyte count.  

Under NIMS, in a disaster situation, materials management is under the responsibility of the Logistics Section of the disaster response team.  Logistics is in charge of all the equipement and materials necessary for a disaster response.

START triage algorithms are based on a quick assessment of the patients respirations, perfusion and mental status.  

TOERNE    ACETAMINOPHEN AND SALICYLATE TOXICTY

Acetaminophen (APAP):  Completely absorbed within 4 hours.   A 2 hour Tylenol level predicts a 4 hour level.   APAP is eliminated by glucuronidation and sulfation.  5-10% is metabolized by the cytochromes to NAPQI which is the toxic metabolite.   NAPQI attacks cells in the liver.  Glutathione detox’s normally .  But if glutathione gets depleted in a Tylenol overdose you get liver damage.   Extended relief acetaminophen tab has similar overdose characteristics as regular tab.  If your 4 hour level is non-toxic then your 6 and 8 hours levels will likely be non-toxic as well.  Still, check 6 and 8 hour levels.

APAP overdose is initially asymptomatic.  After 24 hours pt’s develop nausea and vomiting.   Time of ingestion is the earliest time, not the latest time of ingestion.  

No routine gastric lavage or activated charcoal for APAP overdoses.  

Toxic ingestion of APAP=150mg/l at 4 hours  to 4mg/l at 24 hours.

N-acetylcystine (NAC) is the antidote for Tylenol overdose.  Oral dosing is  140mg/kg initial dose  followed by 70mg/kg q 4 hours for 72 hours.   Now IV Nac is available with a 21 hour protocol.  You can probably stop NAC when serum Tylenol level is less than 10mg/l.   NAC can falsely elevate the INR slightly.   If patient has signs of liver damage, you give NAC until liver enzymes are less than 1000.  Ted recommends using IV acetadote over po NAC.   It is just easier.  

Liver transplant criteria: Elevated INR, elevated Cr, and encephalopathy.    To increase sensitivity to pick up all potential transplant patients is lactate >3.5 or abg <7.3 after initial resuscitation.    You will see these abnormalities in late presenting patients or patients in the ICU who are not doing well.   If a patient with acidosis or diminished liver function, transfer that patient to a transplant center.

Salicylate (ASA):  Oil of wintergreen has a massive amount of salicylate in it’s formulation.   ICY-HOT also has salicilyate in it’s formulation.   

Treat with IV fluids, Bicarb drip and repeated doses of activated charcoal.   You want to alkalinize the serum and urine to ion trap the ASA in the urine.   This mechanism also keeps hydrogen ions out of the cns and heart.   You need to supplement potassium as well.

ASA  uncouples oxidative phosphorylation.   Most common cause of death is cardiac dysfunction.   Pt’s will have tinnitus.   Pt’s will have tachypnea due to metabolic acidosis and primary respiratory alkalosis.

Chronic ASA is very problematic due to whole body burden of ASA.

Harwood Comment: Is there vomiting with oral potassium supplementation in these patients.  Ted replied he has not seen that problem.

Indications for dialysis: deterioration, aletered mental status, pulmonary edema, severe acidosis, renal failure, worsening coagulopathy, ASA concentrations of 80-100 mg/dl.

Ted made a comment that there are case reports of ASA toxicity developing in a patient with an initial neg level due to irregular absorption of ASA.

VILLANO   SNAKE ENVENOMATION

Red on yellow, Kill a fellow=Coral snake.   Red on black, venom lack=non-venomous king snake.  Coral snakes are common in the southern US.

Crotalids (Rattlesnakes and others) have elliptical eyes, triangular head, a heat sensing pit, and retractible fangs.

Snake venom: crotalids have proteolytic venoms and can cause systemic toxicity.  Elapid venoms are neuro toxins.

Crotalid bites cause local reactions.  Can have systemic symptoms as well including hematologic and gi symptoms, rhabdomyolysis.

Elapid bites (coral snakes): pt can be asymptomatic up to 12 hours then develop paralysis.

Poison control center # anywhere in US 1-800-222-1222.

Asymptomatic patients: crotalid bites observe for 8 hours.   Elapid bites give antivenin.

Field management: ok to irrigate and splint wound and avoid strenuous exertion, and take a picture if snake if easily available.  Don’t use tourniquets, suction, direct handling  of snake.

Management: Antivenom, tetanus prophylaxis, avoid blood products unless pt is hemorrhaging to death.  Antivenom should be used prior to fasciotomy for swollen limb.   Anti-venom is not a weight based dose.  Same dose for adults and kids.   Patients may have an anaphylactoid reaction from antivenom.   4-6 doses of Crofab antivenom given for spread of swelling, hematologic abnormalities, or unstable vital signs.  (spread-bled-almost dead)

Elapid (coral snakes) bites management: look for signs of weakness including respiratory parameters such as low maximal inspiratory pressure, capnography.  Everybody gets coral snake antivenin because pt’s can be assymptomatic initially.  Repeat dosing based on clinical status.  This antivenin can cause anaphylatoid reactions as well.

Non-venomous snakebites: get xray to check for fb. Give prophylactic antibiotics (gram positive coverage). 

Gila monster bite: wound care, antibiotic prophylaxis. No anti-venin.

Harwood comment: for the snake mnemonic start with red like a fang mark.  Red on yellow, kill a fellow. Red on black, venom lack.    

KATIYAR  MARINE ENVENOMATIONS

Jelly fish have nematocysts with venom that is painful and toxic to humans.  Nematocysts can be rinsed off with vinegar.

Cubozoa: Box Jellyfish is indigenous to northern Australia and SE asia. Clear color. Can cause local reaction and in worst case cardiovascular collapse. Rinse off with vinegar.  Don’t rinse with fresh water or urine.  Nematocysts need to be removed afterward with tweezers or razor.  Give antivenom 1-2 amps IV or 3 amps IM.  It is sheep derived.  Can cause anaphylaxis or serum sickness.

Irukandji Jelly fish:  Irukandji syndrome=30 minutes after stung, low back pain, muscle cramps, hair stands up, anxiety, sweating, tachy, vomit, oliguria, cerebral edema, pulmonary edema.   Lasts 5 days to 2 weeks.

Portuguese man of war: Larger than box jelly fish, Blue color. Has blue sail above water. Tentacles may be 100 feet long. Complex venom that is hemolytic and cytolytic.  Intense local pain, hemolysis, cardiac conduction abnormality, recurrent urticaria.   TX: neutralize with salt water.  Don’t use vinegar because it causes 30% nematocyst discharge.

Seabathers eruption: Due to larvae of jelly fish.  Contact dermatitis.  Pruritic papules.  Lasts for 2 weeks.  TX with steroids and antihistamines.

Stingray: Has a serrated spine with venom. If you step on them they can sting you.  Steve Irwin was killed by one.  Local reaction, tremors, convulsions, CV collapse.  Tx with tetanus shot, hot water deactives venom (soak extremity), irrigate wound, systemic analgesia, cover gram negs with abx.

Lionfish:  Envenomation causes pain, swelling, blistering, weaknss.  Treat with hot water and wound care, and tetanus shot.

Stonefish: Highly toxic.  Immediate and intense pain, delirium and cardiovascular collapse.   Treat with hot water, support vitals, wound care, and tetanus shot, antibiotics.

Sea Urchins: pain and pruritus.  Relatively benign envenomations.  Treat with hot water.  Get xray to check for retained spine.  Treat pain.

NIKKI NINO   MD DOCUMENTATION

Laceration repair is the most common missing piece of documentation.

For all procedures use the procedure macros in Picis.  

Conference Notes 7-3-2012

Conference Notes 7-3-2012

Chandra/Harwood   Oral Boards

Case 1.  Multiple Blunt Trauma with left hemothorax, splenic injury and epidural hematoma.   Management  required  intubation, left chest tube, identify epidural hematoma/splenic injury. Pt needs to go to OR emergently.

Harwood comment: You can identify epidural hematoma (between dura and skull) by thinking high pressure causes bulging toward the midline.  Low pressure subdural (between dura and arachnoid)does not cause a bulge toward the midline.

Case 2.  Syncope due to PE/FX toe.   Management requires identify CT, give heparin, reduce toe fx.

Harwood comment: S1Q3T3 on EKG and Westermark sign (unilateral oligemia due to clot) on CXR were present in this case.

Case3.  Maisonneuve Fx.  Identify fracture pattern, splint, urgent ortho consult.  Surgery not required emergently but in a prompt fashion.

Asokan  Emergency CXR Evaluation

If patient has hx of a fall, a radiologist looks for pneumothorax, pleural fluid, rib fx’s, or vascular injury.

If the trachea deviates toward a soft tissue density, the soft tissue density is likely not a mass but some scarring or buckling.

If a patient has a widened mediastinum due to a dissection, it is because of a mediastinal hematoma.  The dissection itself does not cause a widened mediastinum.

Indications for surgery in aneurysm is 6cm in the thoracic aorta and 5cm in the abdominal aorta.

Superior mediastinal widening  has a differential of 4T’s: thymoma, teratoma, thyroid, terrible lymphoma.

On lateral view: Posterior infiltrates are in either right or left lower lobe. Anterior infiltrates are in the RML or left lingula.  On anterior view: RLL infiltrates should basically be on the diaphragm.  RML infiltrate may obscure the right heart border. RUL infiltrate should be at apex.

Hemithorax with whiteout : if trachea deviates to side of white out consider collapse or pneumonectomy.  If trachea deviates away consider hemothorax/mass/effusion.

CHASTAIN  SIGN OUT

Transfer of information AND responsibility for the patient.

IPASS: illness severity, patient summary, action list, situation awareness, and synthesis.

It is important for the receiving team to ask questions about the case.

Signed out patients need to have a complete H and P note written by the leaving team.

WILLISON  EKG

Osborne waves  indicate hypothermia

WPW: accessory tract can lead to SVT’s of different types.  Antidromic conduction has a wide QRS and requires procainamide or cardioversion.

V1 if RBBB pattern: Taller left rabbit ear suggests ventricular tachycardia.

If you find non-specific st changes in a anatomic distribution, get serial ekg’s to look for st elevation.

AVR with tall/wide terminal r wave think: TCA, or Benadryl or cocaine.

Cerebral T waves: huge deep inverted t waves due to acute intracranial hemorrhage.

Wellens: biphasic t wave in V3 suggests severe proximal LAD lesion.  High risk for v-fib on treadmill.

Brugada: Saddleback t wave changes in septal leads.  Associated with sudden death.  Needs AICD.

WISE HEMOPTYSIS 

Gas exchange impaired with >400ml of blood in alveolar space.

Mild hemoptysis without risk factors: CXR and outpt f/u

Causes: bronchitis, pneumonia, abscess, tb, lung carcinoma, pe, behcet, goodpastures, bronchiectasis, warfarin, crack lung, bioterrorism-agents .  Top 3 in US: bronchitis, bronchiectasis, cancer, pneumonia.  Tops in world: TB

Earlier bronchoscopy= higher yield.  CT may be useful in massive hemoptysis. CT plus bronch identified source in 93% of patients.

Lateral decubitus position with bleeding lung on downside may protect the good lung.  Selective mainstem intubation or double lumen ET tube may also be effective. 

Consider FEIBA for the massive hemoptysis pt on warfarin or other anticoagulant.

Use an 8FR ETT when intubating to allow for bronchoscope.

 Barounis comment: Dr. Hanif said you can pass a pediatric foley through the ET tube and pass the foley into right mainstem bronchus and inflate balloon to occlude right bronchus.   

KULSTAD/TEKWANI/WATTS    STATS

High specificity tests rule in disease. SPIN=specificity, positive results, rules in the diagnosis.

High sensitivity tests rule out disease. SNOUT=sensitivity, negative result, rules out the diagnosis.

Positive predictive values is highly dependent on prevalence rate of a disease. PPV can change despite no change in the sensitivity or specificity of a test based only on  the different prevalances.

Bayes’ theorem: new info should be interpreted in light of what is already known.  You need to consider the pre-test probability of disease.  Can base on the literature or clinical gestault.

Positive Liklihood ratio: prob of + test in presence of dz/prob of + test in absence of disease.  If LR is >1 the result is more likely to be positive in a pt with disease than without disease.  The benchmark for A very good  LR+ is 10.  The benchmark for a very good LR- is  0.1.

Harwood Comment: Determining the pretest probability is key to determining an accurate post test probability.   

Heart Score for Chest Pain:

History	Highly suspicious	2
	Moderately suspicious	1
	Slightly suspicious	0
ECG	Significant ST-depression	2
	Non specific repolarisation disturbance	1
	Normal	0
Age	≥ 65 years	2
	45 – 65 years	1
	≤ 45 years	0
Risk Factors	≥ 3 risk factors or history of atherosclerotic disease	2
	1 or 2 risk factors	1
	No risk factors known	0
Troponin	≥ 3x normal limit	2
	1 – 3x normal limit	1
	≤ normal limit	0

HEART Score	Risk of MACE	Proposed Policy
0 - 3	0,9%	Discharge
4 - 6	12%	STRESS
7 - 10	65%	ANGIO

We then discussed 8 cases in small groups developing post test probabilities for strep testing, d-dimer, ct for appy, and dopplers for dvt.  

JAKUBOWITZ   CHF/ASTHMA

Observation status delivers equivalent clinical care to admission at a lower cost.

Asthma Protocol: Bread and butter asthma patient not better in 3 hours should go into this protocol.  DC home with albuterol/oral steroids/inhaled steroids/asthma action plan/follow up.

CHF Protocol:  Patients with new CHF, abnormal labs, unstable vitals, o2sat <90% are excluded.

Less than 10 patients last year were admitted into each of the CHF or Asthma Protocols.

Observation management may be more expensive for patient than inpatient management.  However, some of these protocol patients may not meet criteria for admission.

Conference Notes 6-12-2012

Conference Notes 6-12-2012

JOINT PEDS/EM CONFERENCE NEONATAL EMERGENCIES

Case #1:  Hypoplastic Left Heart Syndrome

MISFIT mnemonic : Metabolic, Inborn Errors, Seizures, Formula problems (hypernatremia/hyponatremia), Intestinal disasters, Toxins, Sepsis.  

If neonate presents with hx of fever but afebrile in ER.  Panel recommended partial septic workup with CBC, blood culture, and urine dip and observation period with recheck of temp.  If you admit for obs, if you want to give antibiotics, you have to do LP.  

In sick neonate you want to get an ABG.   

Go rapidly to IO line if you have difficulty getting IV access in a neonate.  Bolus IV fluids in rapid fashion over about  5 minutes.  You may have to give by push syringe thru iv/io.

Hyper-oxygenation test is not reliable.  It can give misleading results and increase pulmonary flow and worsen patient’s condition.  Similarly the BNP test has no utility in this age group.  Very ill hypoplasts have normal BNP’s.

Agreement among panel that if patient is unstable don’t do lp prior to antibiotics.  But Dr. Collins pleaded to get at least a blood culture prior to antibiotics.

Dr. Roy: If child is grey color (poorly perfused)not cyanotic you have to work up sepsis/cardiac/in-born errors/non-accidental trauma.  

Panel: nightmare baby is shocky baby with low normal O2 sat.  Gotta treat sepsis and at the same time work up cardiac and in-born errors and non-accident trauma.  Panelists suggested giving both antibiotics and prostaglandin if you can’t get a rapid echo and need to transfer patient.

Pre and Post Ductal Pulse Ox measurement (pulse ox on right hand and either foot) can be a sign of ductal dependent congenital heart disease.    Could be used in ER.  If one measurement is less than 90% or is significantly lower than the other measurement the test is abnormal.

Too much oxygen in these kids is more dangerous than too much fluids.  20cc/kg bolus was considered safe  by all panelists.

Case #2:   Evaluate for sepsis first because it is most common,  congenital heart dz and inborn errors are much less common.   Again, ABG was touted as a useful test by the panel in the undifferentiated ill neonate.   Panel felt Ammonia level was not a test to be getting in all these kids until you have considered other diagnoses.  Ammonia levels can be unreliable in the acutely ill child.  

Sam Lam: Inborn error of metabolism kids look sick, vomiting, shocky.  Labs will show hypoglycemia and acidosis.     Dr. Collins pleads again for blood cultures and antibiotics in this kid because sepsis is still the most common diagnosis.   If you do an LP the most important test is the culture.   If you have enough fluid then get cell count, gram stain, protein, and glucose.   Extra fluid can be saved for HSV pcr later if indicated.

Lovell chiming in to emphasize my favorite pearls from joint Peds/EM conference:

Common things common:  r/o sepsis, peds cards problems before worrying about inborn errors of metabolism (really rare) in a sick neonate-think about and treat both.  Get the blood culture before antibiotics, but defer the LP in shocky kids-stress of LP can make them worse.  

Hyperoxia test probably not helpful due to mixed lesions being able to mount reasonable sats, and putting cyanotic heart lesion kids on high flow oxygen can make them worse (adversely affect perfusion).  Instead, think about doing a O2 sat on right arm and either leg (pre/post ductal) to look for discrepancy and pick up ductal lesions.

DAVE CUMMINS    MY FIRST YEAR OUT  AFTER RESIDENCY

Dave discovered that single coverage ER’s can be a lonely place for a doc.

People don’t really question you that much as an attending.

Pacemaker mediated tachycardia is best treated with a magnet or pacemaker computer rather than cardioverting.

Not every ED operates the same as ACMC.   They may manage afib and other problems differently than we do.

Dave had to treat a case of trachea-inominate fistula bleeding.  This is frequently a lethal complication of tracheostomy.

From Robert’s Clinical Procedures in EM Text: Control of innominate artery bleeding by digital pressure. Be aware that minor bleeding may be a sentinel event, and a harbinger of a subsequent major hemorrhage. When major bleeding occurs and a cuffed tracheostomy tube is present, overinflation of the tube cuff may temporize (see text). When this is unsuccessful or a cuffed tube is not available, use the illustrated maneuver; digital pressure should be applied to the anterior tracheal wall through the tracheostomy. The index finger is placed within the trachea and then pulled against the anterior tracheal wall, allowing the airway to remain partially open. The artery is compressed between the index finger and the thumb—placed over the neck. Digital compression of the innominate artery is a temporizing procedure, until definitive (operative management) of the bleed is obtained.

Success comes mostly from the relationships you build with others.  It has much less to do with how good you are.

Dave’s Top Suggestions for year 1

1. Be nice
2. Never yell
3. Mirror the behavior of your favorite attending
4. Be decisive and have a plan
5. Don’t take yourself/status too seriously
6. Learn everyone’s name quickly
7. Work less than in Residency
8. Spoil yourself then SAVE ALOT!!!!!
9. Get a good financial planner
10. Develop another work interest.
11. Be generous with your time/money/espertise
12. Don’t prescribe  narcs or benzos to friends/family

ERIN ZIMNY   PALLIATIVE CARE

Palliative care is symptom management, communication, and coordination of care.

ED is critical setting for pt’s with cancer and other terminal illnesses because we initiate the trajectory of care.

Patients with cancer or other chronic illnesses: 94% have physical symptoms, 72% have financial concerns.

Goal: Cancer patients go to ER only once in last 30 days of life.

Palliative Care does the right thing for the patient and also saves $.

Case #1: Hospice Patient in the ER.  They may come for increased symptom,  new problem, self referral for stress/inability to cope.

New care model for advanced cancer is a relative gradient of cancer therapy and palliative care.  This is a change from the past which was cancer treatment alone until it was determined unsuccessful then palliative care.

Hospice Myths:  Pt’s have to be DNR to be in hospice.   Hospice does not treat infections.  Hospice withholds parenteral nutrition.    Hospice has to be revoked on arrival to ER.

ER staff should call hospice staff.  Identify trigger for ED visit.   If deterioration is imminent discuss with pt and family.   Give family/patient emotional support.    Dispo can be home, hospice, revoke hospice.

IV decadron makes cancer patients feel a lot better.  It relieves symptoms from tumor burden.  It will also increase appetite.

Treatment of Nausea: There is more than zofran.   Benzos, antihistamines, raglan, compazine, haldol 2-5mg IV (blocks the chemoreceptor trigger zone), droperadole is another option.

Treatment of Constipation: Use a combination of a stimulant and a stool softner.   Senna and colace is a good combination for constipation prophylaxis. Harwood recommends Pericolace as a combo med with both senna/colace.    Methylnaltrexone blocks opioid receptors in gut.  Works like a miracle but is expensive.     If patient comes to ER with constipation Erin recommends  giving lactulose from above and ducolax from below.

Case #2: Dementia Patient

Dementia is a progressive terminal disease which is irreversible.  There are identifiable stages.  Stage 7c with loss of ambulation and not speaking, they have less than 6 months to live.

It is ok, if in your medical judgment the patient is going to die soon, to decide for the family that the patient is DNR.   If they assent to this decision, you make the patient DNR.  

Delivering Bad News:  Advance prep, build a relationship, communicate well, deal with reactions, encourage and validate emotions.      Find out what they know, be frank but compassionate, allow silence/tears,  summarize and repeat info, encourage questions.   

Things not to say: I understand how you feel.  It could be worse. Nothing more can be done. We all die. Avoid euphemisms, use the word death/dead.

Case #3:  Patient with metastatic lung cancer in extremis.   Husband screaming “do something!”

Erin stabilized patient with intubation and pressors.   Then had long discussion with husband.  Daughter comes and says “mom never wanted to be on a ventilator”.  It was decided to extubate patient in ER.  Dyspnea treated with morphine.

Treat dyspnea with: oxygen, fans may be effective, morphine 2-5mg Q15-30 min (this is symptom treatment not euthanasia), ativan 0.5, humidiity , elevate head of bed, educate family, treat secretions with atropine.

Oral morphine 15 mg is a reasonable starting dose q4 hours for cancer patient failing norco.

SubQ dosing of opioids is less painful than IM dosing.

Don’t start a patient new on a fentanyl patch in the ED.  You can increase the patch dose for someone already using a fentanyl patch.

ACMC has a Palliative Care Team 684-8117.  Dr. Kozyckyj and Lynn Sevic, RN. 

SINNOTT     SENIOR PEARLS 

Conference Notes 6-5-2012

Conference Notes 6-5-2012

STRASBURGER     PSYCHIATRIC STUDY GUIDE

Droperidol and haldol can prolong the QT interval and precipitate torsades.   Check an EKG prior to giving either drug.

Treat dystonic reaction with benztropine (cogentin) and Benadryl.

Harwood comment: sometimes Benadryl doesn’t work in that case give cogentin and a few for home to prevent recurrence.

Low potency antipsychotics have more sedation and hypotension and anticholinergic symptoms

High potency antipsychotics have more dystonia and tardive dyskinesia.

Harwood comment: It’s ridiculous that there is a question about low potency  anti-psych drugs because they aren’t used anymore.

Harwood comment: Most people with panic attacks will not have a persistent resting tachycardia.  If pt is persistently tachycardic, check thyroid studies and consider other diagnoses.

3% of patients with steroid psychosis commit suicide.

Conversion disorder:  symptom that is a change or loss of function. Recent stressor, symptom not explained by any organic disease.  Labelle indifference.

Harwood comment:  Consult appropriate specialist to eval patient prior to making diagnosis of conversion disorder and discharging patient.

Munchhausen by proxy: caregiver fabricates illness in those who are in their care.   Form of child abuse.

SADPERSONS: mnemonic for suicidal risk.  Sex, age, depression/hopelessness, previous, excessive etoh, rational thinking loss, separated, organized attempt, no social support, stated future attempt.   Hopelessness, loss of rational thinking, stated future attempt all get 2 points and are higher risk than the other factors which get 1 point each.

TCA overdose: look for wide QRS and tall R wave in AVR on EKG.

Effexor (venlafaxine) has sodium channel blocking effects and will have similar EKG findings to TCA’s.

Discussion on neuroleptic malignant syndrome among attending: cool patient, use benzos, consult tox/neuro, give dantrolene.   

COLLANDER    5 SLIDE F/U

Patient with purple urine in foley bag.   Urine culture was positive for proteus and e coli.  Both organisms susceptible to cipro.

Purple urine bag syndrome: tryptophan metabolized to indole.  Liver converts indole to indoxyl sulfate.  Bacteria convert indoxyl sulfate to indirubin and indigo.   Usually in asymptomatic patients with chronic foley catheters.  Constipation predisposes to more uptake of tryptophan so more likely to have purple urine.   Multiple gram neg organisms can cause this.   Treatment is change out the catheter and burine bag and treat uti.  You can use the usual urine antibiotics.

Child with blue urine is likely to be due to food coloring or familial hypercalcemia.  Check a calcium level.

RICCARDI    M AND M

75 YO male, multiple chronic illnesses, hx of cholangitis. Presents febrile and tachy with green biliary drainage.    Antibiotics started.

Cholangitis: bile stasis that develops infection.   High rate of sepsis.  Stones can act as a nidus for infection.   Treatment is biliary drainage and antibiotics.

Charcot’s triad; fever, pain, jaundice.  Reynold’s pentad is the addition of hypotension and altered mental status.

80% will respond to antibiotics.  20% require emergent decompression of biliary blockage.

Patient deteriorated in ER.  Developed an urticarial rash.   Pt was treated successfully for anaphylaxis.  It was later learned pt has a pcn allergy.

Anaphylaxis criteria  there are three: 1. Acute onset of skin and respiratory or low bp effects. Or  2.  Any 2 of skin, gi, respiratory, bp  effects after allergen. or 3. Low bp after exposure to known allergen.

Treat with epinephrine 0.01mg/kg    in thigh.

Biphasic reactions are possible up to 72 hours out.   Patients should be observed for 4-6 hours in ER.

Pt had antibiotics changed, went for ERCP and eventually was dischared from hospital.

Dr. Riccardi discussed the importance of being alert to anchor bias.  Just because the patient is triaged to a lower acuity area of the ED does not preclude they may have a serious, or emergent illness or injury.   Elderly are more prone to under-triage.

Dr. Riccardi also discussed confirmation bias.  The EP is suspicious of a certain diagnosis and uses data collected to confirm this bias.   The EP tends to discount non-confirmatory data or not pursue data that would lead to another diagnosis.

Beyesian reasoning may help fight confirmation bias.  Does my test results raise or lower my pretest probability?

C. Kulstad comment: Be alert for under-triaged nursing home patients in the hallway.

Joan Coghlan  comment: Ask yourself, if I saw this patient in the Critical Care room would I do the same thing?   Frequent ED users also require extra vigilance.

McDERMOTT AND LAMBERT     ORAL BOARDS

 Case 1.   Pregnant patient with adominal pain.  Distended bladder.  Incarcerated uterus. Rarely  uterus can’t come out of the pelvis at about 10-12 weeks and will block bladder drainage.   

Case2.  Lower extremity compartment syndrome.     Severe calf pain.  Use Stryker to measure compartment pressure.   Normal pressure is 0-5.   Admit for pressure over 20.  Surgery for pressure over 40 or within 20 of diastolic blood pressure.

Case3. Optic Neuritis due to Multiple Sclerosis.  Treatment with IV Solumedrol.  Fundus will be normal.  Pt will have an afferent papillary defect.   Pts may have eye pain.

Joan Coghlan comment: Pain out of proportion should make you think either ischemia, compartment syndrome, phlegmasia, tendon rupture.     Know the likely disease entities at various  gestational ages.  Ectopic at 6-8 weeks, uterine entrapment at 10-12 weeks,  second trimester is appy or cholecystectomy, third trimester is abruption and previa.

CALLAHAN  FOSTERING RESILIENCE

Resilience: the ability to bounce back and endure adversity during residency.

Not resilient resident:

Resilient resident:

Hero’s Journey: Described in 1949 by Joseph Kimble.  Start with known (home field) and travel to unknown world (call to adventure), work thru challenges and temptations, reach an abyss (doubt of success), revelation, transformation, atonement, success and return to the known (home field).

Nutrition, aerobic exercise, sleep lead to healthy living but do not guarantee resilience.

Lessons from Athletics: How you think about failure whether it is permanent of fleeting is a part of resilience.  2^nd category is locus of control.  If a person takes more internal control of their performance and not blame external factors they are more likely to be resilient.  3^rd category is a sense of hope/optimism/higher purpose.

You have to dispute negative thoughts.  Either do it yourself or have a mentor to help you do that.

Decatastrophize problems.    Consider worst case scenario, consider best case scenario, and settle on most likely scenario.

Lessons from the military: NAVY SEAL’s are considered the most resilient people on the planet.  Optimism, perseverance, responsibility, integrity, support each other during training, self-efficacy (they believe they control their destiny), earned.

Comprehensive Soldier Fitness: Family, physical, social, emotional, and spiritual facets.  Military doesn’t have time to wait because currently there are more military deaths from suicide than from combat.

Marty Seligman: Formula for resilience or positive thinking: Content with the past, happy in the present, hopeful for the future.    Authentichappiness.com.   Dr. Seligman runs the Comprehensive Soldier Fitness program.

Not much data to support specific resilience training.   3 factors do have some support: positive thinking, positive affect, positive coping.   2 other factors also important: realism and behavior control.

Positive coping, support from family/resident class, positive climate in Unit/program, Belongingness in Community/hospital.    Physical fitness is not a link to resilience.

Lessons from Medical field: SMART program at Mayo: Attention wanders to threats/pleasure/novelty.  Spend a lot of brain power in the past and future.   We should switch to the present moment.   Gotta override the limbic system.  Gotta train the mind to quiet the limbic center.   Focus on the current moment.  Interpret life with more flexibility, gratitude, compassion, forgiveness, and higher meaning.

Conference Notes 5-29-2012

Conference Notes 5-29-2012

GRIPPO-FELDER ORAL BOARDS

Case 1:  Borhaave’s Esophogus.    Consider PE, consult surgery, start broad spectrum antibiotics.    Pregnancy and ETOH are risk factors for esophageal rupture.   Don’t do a barium swallow because  arium is not good for the mediastinum.  Gastrograffen is preferred to evaluate with a swallow study or chest CT.

Harwood comment: If you see mediastinal air or air in soft tissue either on CXR or CT with this symptom complex, just consult surgery and start antibiotics.   The ER doc doesn’t need to order an esophogram.

Case 2: Lyme Disease.  Recognize erythema chronicum migrans, treat with doxy  for kids over 8 and non-pregnant.  21 day course of doxy, amoxicillin, cefuroxime, or macrolide.   Tick has to be on the patient for 36 hours to transmit disease.

Harwood comment:  For oral exam with non-critical/toxic patient you don’t have to put an IV in. You may get scored down for system based practice.  Think out loud so the examiner knows what you know.

Case 3: Polytrauma.  Cspine immobilization, secure airway, chest tube, re-assess vital signs.   Always remember to get complete set of vitals including accucheck glucose and UCG.  Ask for family/paramedics. Treat pain. Be systematic in your exam for injuries.

BOLTON   FUTILITY

Decisions: Respect the patient’s autonomy.  The decision should be impartial and follow the Golden Rule (treat others as you would want to be treated) or Platinum Rule (treat other as they would want to be treated).   Universable=categorical imperative=moral act that is always right in the same situation.  Interpersonal justification=would you be comfortable with your decision if it is written in the newspaper?   

Futility= action that has no useful purpose.   AMA CEJA: there is no accepted definition of medical futility.

80% of persons die in a medical environment.  People prioritize quality of life, touch of family at the time of death.  They don’t prioritize prolongation of life at any cost.

Futility problem: patients and families have unreasonable expectations of the capacity of medical care to return the patient to prior state of health.   This is based on peoples exposure to TV and movies  where CPR and ICU care provide miracle saves.   Physicians have a lot of difficulty prognosticating to patients and family with the goal of lower expectations.   We frequently abandon patients/families to their own autonomy. (Do what you think is best).

We should help families/patients understand their goals prior to making end of life decisions.

You don’t have to be a DNR patient to be in hospice.  It is however somewhat contradictory philosophically.  The criteria for hospice is only an expected life span of less than 6 months.

Pt’s don’t have the right to demand treatment.  Beneficence: CPR has 0% chance of survival with metastatic neoplasm admitted to the hospital.  Justice: Fair resource allocation.

Harwood comment:  After every successful resuscitation, look for the underlying cancer.

Girzadas comment:  The EP can also factor in the pain or  lawsuit  that may  impact the treating physician from the family.

Barounis comment:   Recent case in ER having to decide whether to give post-resuscitation hypothermia in a young patient with metatstatic cancer who had ROSC following CPR. Some ICU personnel complained that the ER staff should not have cooled the patient.    Everyone agreed that the case was extraordinarily difficult.   Most agreed that if pt was not DNR and resuscitation was done and had ROSC then  you have to give hypothermia therapy.    

Willison comment:  The LET form is very imperfect.   Most people at the lecture agreed that the multiple check box format brings up ethical inconsistencies.

WILLISON/SALZMAN  TRAUMA RESUSCITATION

Be sure to use personal protection like masks/eye shields/gloves/gowns/shoe covers.

Try to organize your team as much as possible.

Abnormal vitals, pregnant patients, elderly, another fatality, fall over 20 feet, auto vs. ped are all prearrival markers for badness.

To intubate, loesen c-collar but have a second person hold in line stabilization until tube is secured.  Then re-apply the collar.

New info:  28 or 32 FR tube was no better or worse than 38 or 40FR tube.

Don’t  “rock the pelvis”  just give one firm push on the ASIS bilat. If it moves it is fractured.

Fix scalp lacs. Patients can bleed severely and even  rarely bleed to death.  Tourniquets (BP cuff at 300mm hg) can sometime be life saving but use these rarely and cautiously.

When transfusing large volume of prbc’s, match units of prbc’s, ffp and possibly platelets.

Positive FAST scan, Systolic <90, HR>120, penetrating injuries: 3-4 of these are high risk for needing massive transfusion.  1 probably not.

Penetrating wounds to abdomen/flank/low back/pelvis require rectal exam.  Other injuries you can be more selective with rectal exams.

Keep patients warm in ER.

New Thoughts from Scott Weingart for Traumatic Arrest: No closed chest CPR, no acls meds, first airway is LMA, bilat finger thoracostomy, cardiac ultrasound looking for tamponade.

Salzman comments: ED thoracotomy only good for penetrating chest wounds (optimally stab wound to heart) that cause tamponade.  Heart is very delicate and it can be easily damaged by a scalpel or by fingers during internal CPR.   ED thoracotomy  for blunt trauma is futile.

Can consider ED thoracotomy to cross clamp aorta for a patient who has exsanguinated from a limb amputation.  Give patient rapid prbc transfusion and do cardiac massage.

Harwood comment: It’s a thought.

Barounis comment/Salzman response: Massive transfusion protocol for untable, hypotensive pelvic fractures should be started in ED.      Pt’s with other types of injury, the protocol  has to be used more judiciously.   If the protocol is initiated you can always back off if bleeding lessens.  Patients that need to go to IR are more likely to need the protocol than patients going directly to OR.   Level 1 transfuser is a critical tool during resuscitation.

FORT   5 SLIDE F/U

Poly drug overdose including TCA.   PT was agitated.   Intubated, sedated with propofol.   Toxsicon recommended charcoal, serial ekg’s and bicarb for QRS >100ms.   Initial ekg was ok/not wide/no terminal prolongation of QRS (big R wave) in AVR.   Remained stable over 16 hours in ER.   Was extubated and transferred to psychiatry.

TCA: sodium channel block, antihistamine,  anti-muscarinic, K efflux blockade, alpha blocker, and gaba blockade effects.  “Dirty Drug”   has multiple effects.   

Treatment: Seizures give Benzos.   Hypotension give fluids and pressors.   QRS prolongation give sodium bicarb.   Dialysis is worthless due to high volume of distribution.

Harwood comment: Bicarb is the main treatment for EKG abnormalities.   Brian said if bicarb not helping  consider magnesium.

HERRMANN  5 SLIDE F/U

Child with GSW to right thigh.  Pt had right femoral arterial injury.  Hard signs with loss of distal pulses and pulsatile bleeding. Pt also had abnormal ABI’s.  CTA showed injury to femoral artery.   Prbc’s transfused.  Pt went OR.   Surgeons used saphenous vein from contralateral leg in reverse orientation (to negate the venous valves) to fix artery. 

ABI has 98% diagnostic accuracy.   Measure BP in all 4 extremities.   Divide ankle systolic BP by higher of two upper extremity systolic bp’s.   ABI<0.9 is abnormal and pt should get CTA or go to surgery.

Hard signs: abnormal pulse, arterial bleeding, pulsatile hematoma, bruit, thrill, distal ischemia.

Barounis comment: Vascular injury signs can wax and wane.  These patients are tricky.  Need re-exams if the initial decision is to observe so not to miss developing hard signs.

Chastain comment:  Compartment syndrome has been known to develop on trauma patients after the initial injury.  Stay alert even if you are tired.

KESSEN  RSI DRUGS

Pre-treatment: moderates reflexic sympathetic response to laryngoscopy.  Phayrnx and larynx are highly innervated with sympathetic and parasympathetic nerves.  LOAD:  Lido (no study shows neuro outcome improvement/Opioids (fentanyl  can be considered for pain) /Atropine (for kids <5yo getting succ)/

Nelson comment: Contrarian view is that all these pretreatment drugs increase complexity and delay intubation.

Etomidate is most hemodynamically neutral sedation drug.  Consider Ketamine as an alternative in the septic shock patient to avoid adrenal suppression.

Ketamine provides anesthesia and analgesia.   Increases cerebral blood flow.  May increase BP.  It is a bronchodilator.  May elevate ICP.   Watch out for emergence phenomenon.

Propofol causes anesthesia and amnesia.  May cause hypotension.  No analgesic properties.

Versed provides anesthesia/amnesia but not analgesia.   Can cause hypotension.

Barbiturates can provide anesthesia/amnesia and analgesia.   Hypotension.  Suppresses WBC function/recruitment.

Succinylcholine contraindicated in patients who have had  severe trauma,  burns, neuro injury  all more than 72 hours prior to ED visit.  These are not a problem if insult occurred the day of ED presentation.

Mistry comment:  Many absolute contraindications to succinylcholine are actually relative contraindications and succ is pretty safe.

Rocuronium has less than 1 minute onset. Intubation conditions are similar to succinylcholine.

Sugammadex is a reversal agent for rocuronium that is being tested in Europe.  Cuts the spontaneous ventillarion time from 400s to about 200s.

Harwood comment: Kid with severe astha, “Your risk of killing this patient is going up and up”    Use etomidate, atropine to decrease secretions, and succinylcholine if airway is not  predicted to be overly difficult.

Conference Notes 5-22-2012

Conference Notes 5-22-2012

BENJAMIN TICHO  OPHTHO TRAUMA

 20:20 vision means you see at 20 feet what a normal person is expected to see at 20 feet.  20:40 means you need to be at 20 feet to see what a normal person sees at 40 feet.   Basically think of it as the first 20 is the patient in comparison to the second number which is the normal person. 

CRAO have a generally poor outcome no matter what you do but you should still contact ophtho emergently.

The cornea has the most dense distribution of nerve endings in the entire body.

Dr. Ticho has seen severe injury to cornea requiring corneal transplant in patients who used topical anesthetic at home for corneal abrasion.   He advised strongly against giving topical anesthetic to patients with corneal abrasion.

Patching the eye for large corneal abrasions can speed healing.  Don’t patch more than 12 hours and the patch has to be tight enough to keep eyelid from opening.

Base injury to eye is worse than acid because base injury causes sapponification.   For both acid and base injury immediately irrigate the injured eye.   Get ph before and after irrigation.  Irrigate until ph gets between 7.3 to 7.7.

Treat superglue exposures to the eye with topical antibiotic ointment. 

KERWIN    STUDY GUIDE   IMAGING

Deep sulcus sign= pneumothorax

Delta sign=cerebral venous thrombosis.  Finding on posterior aspect, sagital sinus on CT brain.

On Chest xray, left mediastinal width greater than 5mm is a marker for aortic injury.  Left mediastinal width is measured from the spinous process to lateral border of aortic knob.   PAL CXR should be less than 5mm,   AP CXR the measurement should be less than 5.4mm

Bohler angle should be 20-40 degrees normally.   Less than 20 degrees suggests a fracture.   (memory hint: low score when bowling is bad.)

Hold patient’s metformin for 48 hours after they receive iv contrast to avoid metabolic acidosis.

Tram lines or train-track lines describe pneumatosis intestinalis and is indicative of NEC.

Thickened, non-compressible appendix of greater than 6mm in diameter is diagnostic for appendicitis. (memory hint: appendix is six)

Fluid in morrison’s pouch on ultrasound has pretty close to %100 positive predictive value for ruptured ectopic pregnancy.  

Scapho-lunate dissociation has a gap between the scaphoid and lunate called the Terry Thomas sign.

 Duodenal atresia, volvulus, annular pancreas are the differential diagnoses for the “double bubble sign”.

Cardiac standstill on echo during resuscitation has 100% PPV for death.

Can’t give gadolinium to pregnant patients because it crosses the placenta.  It is contraindicated, but there have not been reported fetal defects however.

Snowman sign of CXR in kids is a sign of Total Anamolous Pulmonary Return.  (memory hint: Frosty said he would “be back again some day”  that would definitely be an anamolous return)

 CT scan for PE in a pregnant patient has lower radiation dose to child than a VQ scan.  If you have to do VQ scan in a pregnant patient,  you can reduce radiation exposure to child by putting foley catheter in mom to remove radioactive urine.

MENON  M AND M

Obese=BMI of 30, Morbidly obese=BMI of 40, Super Obese=BMI 50

Obesity Hypoventilation Syndrome=Pickwickian syndrome.  BMI>30 PCo2>45 while awake, no other source of hypoventilation.  

When Intubating obese patients use  RAMP positioning.   Have the patient’s head elevated and face and jaw  parallel to the ceiling.  The patient’s external auditory meatus should also line up with their sternal notch.        

Pre-oxygenation increases the patient’s oxygen reservoir and denitrogenates the residual capacity of lungs.   3 minutes on 15 L NRB or 8 tidal volume breaths on 15L NRB will accomplish this.

With the difficult to ventilate patients you can use a PEEP Valve on the ambu bag. Respiratory therapists have access to the PEEP valves.  If you also put a nasal cannula on the patient (15 liters thru the cannula =passive apneic oxygenation) You in affect are giving CPAP.

BVM ventilate with low pressure(<25mm hg), low volume(6 ml/kg) and low rate (6-8/min).  It is also important to use a two handed thumbs down technique to hold mask on face.

Our ED has an awake look intubation kit in the omnicell.   It includes 4% lidocaine to nebulize and spray with mucosal atomizer, viscuous lidocaine also is included to put in back of throat.

NAP 4 Data: Higher mortality in ED and ICU, ETCO2 is the standard of care, awake intubation was not use when indicated, Failure to plan for failure, obesity was independent risk factor in a large %age of airway deaths.

Joan Coghlan made a great point that LMA is a great bridge device and a great device to help ventilate the difficult airway patient.

References for this talk:

1. Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emerg Med. 59, 3: 165-175

Second is the executive summary for NAP 4 and/or the full report (website)

2. http://www.rcoa.ac.uk/nap4

WALCHUCK   RECTAL FB/PRIAPISM

You gotta get these out.  Never leave in place and wait for spontaneous passage

Look for signs of perforation on imaging studies.

Sedation may be helpful to remove.  Viscous lido can be used to help lubricate. Have patient in Sims or lithotomy position.  Sim’s position is with pt on their side with superior leg flexed at hip and knee.

Can attempt to place one or more foley balloons proximal to fb to remove fb.   .  Many patients will require GI to scope them to remove FB.  Sharp or  broken objects require surgery

Observe patient for 4-6 hours after removal to see if any signs of perforation develop.

 Priapism: corpora cavernosa become engorged with blood,  painful, can be due to sickle cell disease/thalassemia/leukemias, many other pharmacologic causes, erect penis with flaccid glans, tx with terbutaline in deltoid muscle, ice to perineum/penis/scrotum, narcotic analgesia, penile block at 11 and 1’oclock positions, aspirate the corpora at 10 and 2 o’clock, instill phenylepherine/saline, cardiac monitoring, for sickle cell patients exchange transfusion is indicated.

Penile fracture: rupture of the tunica albuginia, u/s is helpful for diagnosis, treatment is surgical, pt should not be sent home to follow up as an outpt.

WATTS      CENTRAL LINE PLACEMENT

TIP: Stretching the guidewire wil straighten the curved tip.

Avoid air embolism by flushing all lumens of CVC with saline prior to puncturing skin.  Also keep thumb over hub of needle when it is in the vein.

Avoid wire embolism but not using force to pull wire out.  If you meet resistance, remove needle and wire together as a unit.

WASH YOU HANDS PRIOR TO PROCEDURE!   USE STERILE TECHNIQUE INCLUDING GOWN/GLOVE/MASK/DRAPE.

Trandelenburg is important to distend the IJ.  For IJ central lines, turn the patient’s head to the left but over rotation can increase the risk of arterial puncture.  

NEJM video was shown demonstrating proper placement of IJ central line.

Femoral lines are the highest risk lines so try to avoid them.  CVP measurement is not reliable with femoral lines.  

Supraclavicular approach for subclavian vein: Puncture skin one finger breath lateral to SCM and superior to clavicle. Aim toward contralateral nipple.  

Harwood Comments: Look with U/S prior to draping patient and getting sterile.  The RIJ may have an old clot precluding that site.   Getting in the central vein requires a confident jab or poke through the vessel wall.     You don’t need to place the wire all the way into the vein to just pull it back to thread thru the catheter.  You can put the wire in part way and have the external wire to thread thru the catheter.

Coghlan: comments: Line up needle bevel  with  numbers on syringe so you know what direction your bevel is oriented when it is in the patient.  With the subclavian approach if you turn your bevel downward after getting in the vessel will direct the wire into the chest.

Place catheter about 15 cm(14-20cm) into the chest.   You should make an estimate prior to placing catheter.  Extremes of body habitus will affect this distance.

Never let go of the guidewire!

ERIKSON   GU EMERGENCIES

 Balanoposthitis: evaluate for diabetes, treat with retraction of foreskin and cleansing with soap and water, topical antifungals or oral fluconazole. Some cases may require anti-staph antibiotics.

Phimosis: foreskin cannot be retracted. Treat with hygiene and topical steroids.  If pt cannont void then emergent surgical procedure is indicated.

Paraphimosis: inability to reduce retracted foreskin.  Tx with manual reduction, multiple small needle punctures of glans to release edema fluid.  Can also try compression/ice cooling to decrease swelling.

Testicular torsion: cremasteric reflex is unlikely to be normal with torsion but this sign is not 100%.  Gotta get a testicular u/s when considering torsion in the diagnosis.  Treatment is surgery.  Manual detorsion may be indicated.  “open the book” is the way to think about how to reduce torsion.  This is most commonly successful motion. If pain worsens then stop and try to detorse in opposite direction.

Torsed appendix tesis: blue dot sign. Treamtment with NSAIDS

Epididymitis: gradual onset, fever, dysuria, urethral symptoms.   Pyuria in 50% of cases,get cultures of urine and urethra,  r/o torsion.   Tx with antibiotics.  If sexually active treat with rocephin and doxy.  If likely coliform source, give bactrim.

Fournier’s  Gangrene: Polymicrobrial infection, imunocompromised patients,  pt’s will have pain and look sick, check for crepitence in genital area, treat with big gun antibiotics Imipenem and Vanco. SURGERY is required.

Zipper entrapment injury: Cut bar of zipper

Harwood comment: Is Nair an option for hair tourniquet?  Many people felt this would be irritating to skin.  Also discussed was using sugar to decrease edema of a paraphimosis.

Conference Notes 5-15-2012

Conference Notes 5-15-2012

Patel/Collins    Oral Boards

Case #1:  Hemophiliac with an intracranial hemorrhage.   Give factor 8 to get level to 100%=50U/kg.  Give factor 8 prior to CT imaging.  If compartment syndrome suspected don’t check pressure  until after giving factor 8. 

Case #2: Splenic injury with intraperitoneal bleeding.   Diagnose with FAST exam.  Treat with fluid and PRBC resuscitation.   Spleen is the most common organ injured due to blunt abdominal trauma in both adults and kids.

Case #3:  Firefighter  exposed to heat and smoke.  He has airway injury, burns, and CO exposure.   Have to know the Parkland Formula for burns.(4ml/kg/%BSA burned; half given in first 8 hours post injury, 2^nd half given over the next 16 hours)  Treat CO exposure with 100% FIO2 and get hyperbaric therapy arranged.   Treat with pain meds/update tetanus status.     CO is the most common tox cause of death.    Smokers can have a baseling CO level up to 10%.   Give hyperbaric therapy for syncope, confusion, seizure, neuro deficit, cardiac ischemia or level more than 25% in a normal adult or more than 15% in a pregnant patient.

GROMIS   M AND M

Flash Pulmonary Edema:

STuPID HPI: Surgeries/Trauma/Pain or paresthesias/Infection or fever/Drugs or toxins.  Ask this in a format to get yes or no answers.

Communication is vital during a resuscitation.  You have to take leadership of a code situation and designate team members to certain tasks.   Consider what the ramifications of your action will be prior to taking an action.

Dan discussed the multiple utilities of using ultrasound in the crashing patient.   Do RUQ view, suprapubic view, sub-xiphoid and parasternal long views.  

There are cardiac and non cardiac causes of Flash pulmonary edema.   Non-cardiac causes  include ASA or opiate overdose and HAPE.

Sgarbossa  Criteria for AMI in LBBB: 5mm of discordant ST elevation anteriorly,  or 1mm of concordant st elevation or depression in any lead.

Comments from Joan Coghlan:

First I would reiterate what all the attendings voiced:  this wasn't a case to feel chagrined about.  It was a sick lady on the cusp and she was going to get sicker no matter what was done.  In fact she survived because of your actions.

 

Just in terms of approach to the acutely dyspneic patient:

As true of every patient and every condition, stay diagnosis-oriented.

SOB?  Listen to lungs -- should get a good feel if it is COPD (quiet, no air movemnt), pneumothorax or effusion (decreased on one side only)  or CHF (rales) or noncardiogenic pulm edema or pneumonia.

 

If lungs seem clear and well aerated, then consider

PE

Angina

Tamponade

Arrhthmia

Valvular disease, aortic stenosis/regurg

Septic Emboli to the lungs

Generalized sepsis

Lymphangitic spread of undiagnosed cancer

Sarcoid, TB, etc.

 

Or  tox/metabolic like DKA or lactic acidosis or ASA causing compensatory resp alkalosis and fatigue.   Anemia  also may cause some low grade DOE, though not severe like this pt.

 

 

The point is stay DIAGNOSIS- ORIENTED  and use your physical exam and cxr, ABG to help you systematically rule each in or out.

 

Also remember if you decide the pt has copd or chf, you need to consider what CAUSED the pt to go into that state.  Don't just stop at that condition, find the DIAGNOSIS.

 

Once you established the pt is in Pulm edema, consider the causes of pulm edema --

 

1.Acute ischemia/MI    

 

   2. Arrhythmia -- this pt clearly had p waves on EKG but sometimesyou can miss slow VT when pt has those wide complex LBBB

 

3. Acute valvular incompetence due to ruptured papillary muscle/MI or to aortic dissection into aortic root (or endocarditis)

 

4.  Hypertensive emergency.   

5. High output failure from thyrotoxicosis or anemia (maybe beri beri or something like that)

 

6.  Acute myocarditis/ cardiomyopathy

 

 

Third, in addressing the fluid bolus, I totally agree with Christine and Elise, I would have given fluids.  I don't consider that as a mistake.  Again this lady decompensated due to her disease process not something you did.

 

BUT ask yourself what DIAGNOSIS you are treating if you give fluids --  the patient got hypotensive while you were in the process of discerning the cause of her acute dyspnea. Ask yourself why pt got hypotensive (dont just shoot from the hip as Gromis mentioned; ie an automatic reflex, hypotension = fluids) 

 

Lets get DAIGNOSIS-ORIENTED in deciding what to do for that hypotension:

 

1. sepsis  -- fluids

2. tamponade -- fluids

3. Pe with right heart failure -- fluids

4. pneumonia and dehydration -- fluids

5. vasodilation due to meds like ntg/morphine  --- fluids

6. tension pneumothorax --- NOT fluids ( REassess pt when RN says they got hypotensive, look at them, listen to lungs, check trachea for deviation, look at vent, make sure IV didnt infiltrate or central line got disconnected and pt is bleeding out --for real)

 

Many of the diagnosis you are contemplating are treated with fluid boluses.

And when you look at the diagnoses that may not especially benefit from fluid boluses, you are probably going to intubating them anyway because their disease state is going to follow its natural course which will need ventilatory support.     Once these patients are on the ventilator,  oxygenation is not a problem. So give them the fluids to expand their intravascular volume, fill their right heart because they may need that and if you get behind the 8-ball on that there is no coming back.  Conversely, if you overshoot on volume, you can intubate and support them through some diuresis.   ARDS is going to be the only major problem with oxygenation and again, somebody with ARDS has much greater problems.

 

So, my few comments became diatribe but I think we do best when we stay DIAGNOSIS-ORIENTED  and tailor and modify our treatments based on those assessments.   I would have done the same thing Gromis did and I would still do that today.  Don't fear the fluid. (fear the reaper).

 

WORKSHOP: CRITICAL CARE NURSING PROCEDURES

Conference Notes 5-8-2012

Conference Notes 5-8-2012

RYAN         MUSCULO-SKELETAL STUDY GUIDE

Medial meniscus injuries present with clicking, locking or pain with extension of knee.

Osteoarthritis: Gradual onset, pain is moderate.  Joint not clearly “hot”.

>50,000 WBC’s on joint aspiration points to septic joint.   This is a boards type cut off.  Real life is less clear cut but it is a guideline.  If you have a high suspicion of septic joint and the WBC count is less than 50,000 you should still culture the aspirate and consult ortho for close follow up or possible admission.

Sciatica can linger for 8 weeks duration.

Cauda Equina causes acute urinary retention and overflow incontinence.  Also look for saddle anesthesia and lower extremity weakness.

Spinal stenosis: Pain with walking due to neurogenic claudication.  Patient walks with anterior flexion of waist  to reduce traction on spinal cord. 

Empty can test specifically evaluates the supraspinatus muscle  of the rotator cuff.   The rotator cuff activates abduction and int/ext rotation of shoulder.

Foot puncture wound thru a gym shoe, prophylax  for pseudomonas.    If puncture wound thru sock or bare foot prophylax for staph/strep.  Get xray for foot puncture wounds.  Have high index of suspicion for fb especially if pt has fb sensation.

Treat a felon with a longitudinal incision at area with most fluctuance.

Carpal tunnel syndrome: Risks include obsesity, pregnancy, dm.   Phalen’s and Tinnel’s tests.  Tx with splint and analgesics.  Refer to ortho.

Amputated digit:  wrap in saline gauze, put in plastic bag, place bag on ice.

Finklestein test evaluates for De Quervan’s tenosynovitis.

CHASTAIN/BAROUNIS      STEMI CONFERENCE

Think circumflex lesion with minimal inferior ST elevation, tall R waves anteriorly and lateral st depression and mostly anterior st depression.   Circumflex lesion=posterior infarction.

Give 2b3a inhibitors in patients with chest pain and not STEMI but has ST depression or dynamic EKG changes.

Cardiac patients who are unstable get kicked out of STEMI bundle.  Resuscitate them first.

Consider strongly balloon pump in the patient with cardiogenic shock.   Before placing a balloon pump, you have to exclude aortic dissection.  

Neuro events can cause an adrenergic output that can make the cardiac apex ischemic.  You can see ST segment elevation with no reciprocal changes.

STRASBURGER-VILLANO    ORAL BOARDS

Case 1: Optic Neuritis due to MS.   Usually a monocular condition.  Painful with eye movement.  Treat with IV steroids (has to be IV not po steroids).  Be sure to get visual acuity on all eye related cases both for the boards and in real life.   

Case2: PEA cardiac arrest due to variceal bleeding and pneumonia.  

.Case3:  Dislocated patella.    Treat with passive extension of knee with firm pressure on patella redirecting it to the normal position.     There was debate about the need for moderate sedation.  Some felt pain control with no or light sedation was adequate.

CARLSON    TOXICOLOGY    MEDICATIONS FOR DIABETES (Sorry I missed the beginning portion of the lecture)

IV d5 or d10 drips give miniscule amounts of glucose.  To replace glucose more robustly, feed pt if at all possible.   If you need IV dextrose you will need to give 1 or more amps.  

Octretide can be used for sulfonylurea and meglitinide toxicity   

Admit: Any long acting insulin OD, intentional insulin OD, recurrent hypoglycemia, sulfonylurea/meglitinide, hypoglycemia related to significant change in renal function or liver function.

Glucophage can cause MALA (metformin associated lactic acidosis).   It interferes with normal cellular aerobic  metabolism.   Mechanistically looks like a mild/non-fatal  cyanide overdose.   Can occur in mono-overdose.    Treat with hemodialysis.   Fatal cases prognostic factors are low ph 6.9 or lower, lactate over 25 or metformin level over 50.    Should dialyze if ph around  7 or heading downward.

Avandia/Actos: increase insulin sensitivity and decreases glucose production in liver.   Doesn’t cause hypoglycemia in OD.

Januvia: Stimulate insulin release with an elevated glucose.   Has not been shown to cause hypoglycemia in OD.

Byetta: Glucagon-like peptides.   Stimulate glucose dependent insulin release in gut.   Does not cause hypoglycemia in OD.

Victoza: similar mechanism to Byetta.  Can cause pancreatitis.

Symlin: Amylin agonists.   Slows gastric emptying, decreases gluconeogenesis, increases satiety.  No reports yet of hypoglycemia.

Insulin/Sulfonylureas/Meglitinides/Biguanides:  These all can cause hypoglycemia in overdose.  

MISTRY        ROOM COVERAGE PROPOSAL

PUTMAN          THERMAL BURNS IN THE ED

Stop the burning process by removing any object such as clothing or rings/watches that can retain heat and further burn or produce a tourniquet effect.

IV fluid resuscitation with Lactated Ringers

Treat with appropriate pain medications.

Get further history:  chemicals/closed space/explosion/CO/cyanide/electrical injury.

Burn-specific secondary survey: eval for inhalational injury.   Intubate for early signs of airway injury.

Estimate body surface area involved in burn with rule of 9’s,  palm,  Lund-Browder chart.

Burn depth: first=erythema of epidermis only,   2^nd=blistering, 3^rd=thru epidermis and dermis involving nerve endings and should have no pain in area of 3^rd degree burn. 4^th= involve deeper structures such as tendon and bone.  

Intact blisters can be left alone.

Transfer criteria:  probably need a check list to remember all of them.

Escharotomy for circumferential burns that are causing ischemia.

Skin is burned by temperatures over 113F.

Cellular Na pump is disrupted by burns.   Depression of cardiac contractility can be caused by burns.  Lactic acidosis can occur from burns.

Fluid resuscitation:  Parkland formula is  4ml XKG X %BSA burned= volume.   50% given in first 8 hours after injury (no ED arrival).   Remaining 50% given over the following 16 hours.  This is a guideline that can be altered based on urine output/cvp/pulmonary status.  Peds patients also need weight-based maintenance fluids.

Half of all fire related deaths are due to smoke inhalation.

Think cyanide for fires in which wool, silk, polyurethane have  burned.

IV antibiotics not indicated for prophylaxis of burns.   Only use if infection is evident.

Tegaderm or duoderm can be used as burn dressings for smaller burns.

Pregnant burn patients should have fetal monitoring for viable age gestations.

If the Burn Center asks for a photo of a potential transfer patient, do not identify the patient with any facial views.    Document in the chart that patient consented to the photo.

Conference notes 5-1-2012

Conference Notes 5-1-2012

SCHROEDER/CHANDRA   ORAL BOARDS

Case 1  Eczema herpeticum.  Treat with anti-virals and anti-staph antibiotics.   Acyclovir takes mortality down from @10% to 0%.  Can complicate eczema.   Staph is a frequent co-infection.   Eczema herpeticum is more likely to be painful lesions in contrast with impetigo. Diagnosis more likely in patients taking immunomodulators for eczema.    DO NOT GIVE STEROIDS!   

Case 2   Fish hook embedded  in thumb.  EP should remove fishhook, examine for nerve or tendon injury.  Irrigate wound if possible. Consider prophylactic antibiotics.  Check tetanus status.

Case 3 Cervical Epidural Abscess.  MRI is superior to CT for diagnosis.  Consider in pt’s with: iv drugs, dm, steroids, invasive procedures, trauma, immucompromised.   Consult neurosurgery.  IV antibiotics.

SMALL GROUP SESSIONS PEDIATRIC MEGACODES

1. Peds SVT : treat with adenosine 0.1-0.2mg/kg, next amiodarone 5mg/kg.  If unstable can cardiovert 0.5-1j/kg.
2. V-fib: Defibrillate with 2j/kg double dose if unsuccessful.  Epi  0.01mg/kg, amio 5mg/kg.  Post resuscitation avoid hyperoxia and consider cooling.
3. V-tach: synchronized cardioversion 0.5-1j/kg,  if failure then increase to 2j/kg.
4. Hypoglycemia and shock: 0.5-1g/kg dextrose which means D25W: 2-4 mL/kg, D10W: 5-10mL/kg.  For hypovolemic shock give repeated 20cc/kg boluses

LAM  PEDIATRIC U/S APPLICATIONS

Use a high frequency 5-10MHz probe

Graded Compression: slow gently increased compression on abdomen.

Appendicitis:  Appendix is medial to psoas and anterior to iliac vein.  Target sign on transverse view.  Non compressible, Fluid collection, Target sign, Diameter>6mm (mnemonic is NFTD nothing further to do)

Intussusception: Use graded compression.  Follow the expected contour of the colon.  Again look for a target sign.

Pyloric Stenosis: find stomach first and go to pyloris.  Anterior and lateral to aorta. Abnormal pyloris is too thick or too long.

BAROUNIS  ABG BASICS

The 4 step approach to acid base disorders

Step 1: Get the labs (VBG=ABG), you need Na, Cl, HCO3, pH and PCO2

Step 2: Calculate the anion gap (Na - (HCO3+ Cl) Normal is < 15, abnormal > 15

Step 3: RULE of 15, the PCO2 and the last two digits of the pH should be the bicarb + 15. 

ie- if bicarb is 15, PCO2 should be 30 and the pH should be 7.30

3 Possibilities of PCO2:

1. it is what it should be (simple wide gap metabolic acidosis with respiratory compensation)

2. The PCO2 is lower than it should be (patient is breathing faster) primary respiratory alkalosis

3. The PCO2 is higher than it should be (patient is breathing slower) primary respiratory acidosis

Step 4: 1:1; Normal bicarb - 24, normal gap = 15

The CHANGE or increase in anion gap from baseline should = the change or decrease in the bicarbonate

ie if the anion gap is 30, the change or delta gap is 15 (30-15=15) therefore the bicarb should decrease by 15 (24-15= 9)

3 possibilities of bicarb:

1. It is what is should be (simple wide anion gap acidosis)

2. The bicarb is LOWER than it should be (in the above case if the bicarb was 5 instead of 9) additional primary non-gap metabolic acidosis

3. The bicarb is HIGHER than it should be (in the above case if the bicarb was 15 instead of 9) additional primary metabolic alkalosis

Remember at SEVERLY low bicarbs the pH and the pCO2 will be less reliable. the PCO2 is not +15 when bicarb <5, it is 15. 

Sorry I went a little fast and I can send out the ppt later if you want to practice the cases.

VILLANO   ABCD’S OF HYPOTENSION AND BRADYCARDIA IN TOXICOLOGY

Alpha Agonists, Beta Blockers, Calcium Channel Blockers, Digoxin

Alpha Agonists (clonidine): centrally acting antihypertensive.  Onset  30-60 minutes after ingestion.  Pt will get hypotensive.   They wil have respiratory depression, lethargy and coma, miosis.   Treatment is supportive.   Try narcan, it may help.   This overdose will look somewhat like an opioid overdose with more hypotension.

Beta blockers:  Usually symptomatic by 2 hours.  Look for hypotension, bradycardia, and early altered mental status.   Seizures are possible.     Pt’s can have normo to hypoglycemia and mild hyperkalemia.  Tx with atropine,  glucagon (activates g protein that increases cyclic amp by alternate no beta receptor pathway) 5 mg over 5 minutes.   Glucagon may induce vomiting.  Tx also can include calcium, pressors,  hyperinsulinemia-euglycemia ,  intra-lipid can be tried in crashing pt.   Pacing and balloon pump may be required.   Can d/c to psych for immediate release form and asymptomatic after 6 hours.  All other admit to tele or icu if abnormal vitals.

Calcium Channel Blockers: Dihydropyridines cause decrease in smooth muscle tone andlower bp.  Monohydropyridines affect cardiac conduction and cause bradycardia.   Look for hypotension, bradycardia, hyperglycemia, late mental status changes, acidosis.  Treat with Calcium  (1g chloride central, 3g gluconate peripherally) , iv fluids, iv atropine,  insulin-glucose therapy (insulin is a pressor/response may take 60 minutes/bolus 1u/kg and infuse 0.5-1u/kg/hr/titrate to bp>90/give D50/hypoglycemia doesn’t happen as much as you would think), glucagon, intra-lipid.  Have a low threshold to put pt in ICU.

Digoxin:  Recently covered in a previous conference.   Look for nausea/vomiting and arrhythmia.

Conference Notes 4-26-2012

Conference Notes 4-26-2012   ICEP Spring Symposium

Research Presentations

Dr. Phillips: Absorbable sutures are a lower cost method compared to non-absorbable sutures to repair wounds.   No difference in scar outcome, and similar complication rates.   Also easier on the patient.  No need for suture removal.

Dr. Cambride: Intubation during CPR (manual vs. automated).  Success rate and time to intubation was no different when compressions were or weren’t being done.  No difference between manual or automated compressions either.   So don’t stop compressions to intubate.

Dr. Hartman: Patient follow up requirements are carried out in widely different manners across the country.  Program Directors are generally dissatisfied with patient follow up learning methods.

Dr. Rifenburg: PE patients presenting with syncope are more likely to have a saddle embolus and less likely to have a small embolus than PE patients without syncope.  PE patients with syncope were more likely to have EKG changes.  PE patients with syncope were more likely to have RVH than non-syncope patients.

DR. CANTOR   MISTAKES YOU DON’T WANT TO MAKE-PEDIATRICS

Investigation priorities in seizures: infection, mass, metabolic (electrolytes), toxins.   Dilutional hyponatremia can occur from not mixing formula correctly.  Genital ambiguity suggests congenital adrenal hyperplasia.  

Progressive causes of altered mental status: mass, meningitis, opioids, hypoglycemia.  All must be treated emergently.    Don’t give full  dose narcan to heroin addicts.   Beware of hypoglycemia.  It can mimic any neuro deficit.  If you can’t talk to someone, check their blood glucose. 

Anticholinergics      vs.  Sympathomimetics= Dry skin    vs.  diaphoresis

Pheochromocytoma can mimic sympathomimetic overdose.

Psoas abscess can cause limp.   If work up of febrile limping patient with leukocytosis is not fruitful, consider ct abd/pelvis to look for abscess.

Encephalitic patients should be treated with acyclovir.  Look for cold sores to suggest HSV encephalitis.   Pt’s can have seizures with HSV that appear like unusual behavior or agitation. 

Common cyanotic heart lestions: truncus, transposition, tricuspid atresia, tetrology of fallot, total anamolous return.   Tetrology is the one that can present with a patient 1-2 years old.    Failed hyperoxia test strongly favors cyanotic heart disease

Dr. Thompson      Toxicology: What’s New in the Street

 Sorry I missed this one, talking with old friends.

Dr. Allen   To DNR or CPR

1960 was the first description of modern CPR (ventilation,chest compressions, defibrillation).   1974 were first ACLS Guidelines.

22% overall rate of survival from CPR in ED’s across the country.  This is better than any other setting.  In general, survival is around 17% in all settings.

EP’s have reservations about CPR: overhyped, can cause suffering, costly, benefit is mostly extra days alive but not quality of life.

Slow CODE is not acceptable.    It is deception and could lead to survival with poor neurologic outcome.

APPLE   Shared Decision Making with Patient/Family at End of Life: Awareness , Prognosticate (make an estimate of short term outcome), Plan (basically figure out the patient’s goal and it is ok to give recommendation),  Lay the ground work, Empathize (sit down, be quiet and spend time listening, express regret, hopeful attitude)

NEXT Lectures

Dr. Kegg: Within 6 hours CT brain may have a high enough sensitivity to rule out SAH.

Dr. Mehan: Itralipid for local anesthetic toxicity acts as a lipid sink, metabolic substrate, or direct activation of CA channels.   Can also be used for beta blocker and CCB, TCA, Atypical antipsychotics and buproprion  Od’s.  Downsides: ARDS, pancreatitis, has compatibility issues with other meds.

Dr. Oh: You can use IVC/Ao ratio to evaluate dehydration in pediatric patients with diarrhea.  Serum bicarb over 15 is reasonable cut off for non-serious dehydration.  ETCO2>34 ruled out HCO3<15.  Check glucose because hypoglycemia is present about 10% of the time in pediatric patients with diarrhea.  Can give up to 60ml/kg bolus of saline for more severe dehydration.   

Dr. Pirotte: CDC and NIH say we should not due femoral lines (cat 1a recommendation) unless we have no other options.   They are more likely to cause infection.  Complications are worse, retroperitoneal hemorrhage, DVT, fistula, pseudoaneurysms.   Consider IO line in place of doing femoral line.

Dr. Rushforth:  Tranxemic Acid (TXA)will be more likely to be used in Trauma patients due to efficacy reports, no evidence of theoretical complications, inexpensive.   Most studies on this drug were done in under-developed countries where the baseline mortality may be higher to start with and critical care resources are less than in the US.  

Dr. Vogt: Scombroid most common around Florida and Hawaii.    Supportive care is the indicated treatment for all common fish toxins.  Ciguatera symptoms can persist for weeks to months.  Mannitol is still controversial as a treatment for ciguatera.  Alcohol can cause recurrence of ciguatera symptoms.  Be aware that fish flown in from other areas can cause various fish toxidromes.

Dr. Williamson:  Allergy to shellfish is due to shell proteins and not iodine .  Patients with shellfish allergy can receive radiology contrast.  Scombroid poisioning is due to bacterial overgrowth of improperly stored fish producing histidine.  The histidine is converted to histamine.  Pt’s will have flushing, rash, palpitations.   Treat with antihistamines.   Fugu is due to tetradotoxin that binds to sodium channels. Treat with supportive care and charcoal.