Trauma Resuscitation: Not ACLS
It's Not Always Sepsis!
Sneaky Ectopic - Dr. Nichols
GIB and Aortic Graft - Dr. Beverly
Pulmonary embolism + pleural effusion - Dr. West
Traumatic Ptx, Be Kind - Dr. Robertson
• Aortoenteric fistula is the abnormal formation of connection between the aorta and bowel, typically occurring the 4th portion of the duodenum.
• Primary fistula formation due to atherosclerotic or infectious erosion of aorta into the bowel; secondary is the result of complications of aortic graft placement, either graft infection or pressure necrosis.
• Typically present with “sentinel bleed” followed by massive GI bleed and hemodynamic collapse; classic triad occurs <25% of patients.
• Vascular surgery consultation emergently if suspected; CT angiography can be helpful, but only after consultation and surgical evaluation.
Thrombotic Thrombocytopenic Purpura:
- Can be hereditary or acquired. Acquired forms can be found as a result of a multitude of disease states.
- Patients will more often present with vague symptoms including confusion/AMS rather than focal neurologic deficits attributable to a specific vascular distribution.
- Treatment to consider initiating in the ED includes steroids and FFP however be wary of volume in patients with underlying cardiac disease.
- VasCath can be placed in ED depending on provider comfort.
- Plasma exchange has decreased mortality from 85-95% to 10-20%.
Third Degree Heart Block:
- Most often seen in elderly patients due to progressive fibrosis and calcification of conduction system and surrounding tissue, but can certainly be a complication of AMI.
- Particularly for your elderly patients, be wary of medication side effects.
- Atropine is always worth a try. Just realize more often than not it won't help you.
- Hypotension? Altered mental status? Distress? PACE THE PATIENT!
- Take the time to review initiation of transvenous pacing. Like the infamous ED thoracotomy or cricothyroidotomy, its a procedure we should know like the back of our hands.
Final Pearl: if you're going to order an imaging study, look at the WHOLE image.
1. Perceived conflicts of interest resulting in blind spot bias exist among stroke opinion leaders and the authors of the ACEP tPA Clinical Policy.
2. For Clinical Guidelines to be trustworthy, they must: 1) have transparent methodology, 2) manage conflicts of interest, 3) have a balanced guideline development group composition, and 4) have undergone adequate balanced external review.
3. It is unlikely that the revised ACEP tPA Clinical Policy will substantially impact current perspectives related to the use of IV tPA for stroke
CASE ONE: Epigastric pain after colonscopy
-Perforation - instrument vs air pressure
-Visceral injury (spleen, diaphragm, volvulus)
-Infection (bacteremia, retroperitoneal abscess, appendicitis)
-Pneumatic injuries (Distention, pneumoperitoneum, pneumothorax)
-Rate of perforation 1/1500... increases with biopsy/polypectomy
Splenic laceration/rupture from colonscopy
-Incidence 0.00005-0.017%. Likely under-reported. 14 Million colonscopies per yr in US
-Mortality 5%. Danger lies in delayed diagnosis. Symptoms often attributed to air insufflation or serositis.
-Female predominance, increased risk prev abdominal surgeries
-Mechanism? Traction on splenocolic ligament, adhesions, direct trauma
-Presentation: Abdominal pain, dizziness, Kehr's sign, worsening anemia
(Kehr sign referred pain from diaphragm to shoulder)
-Dx; Ultrasound, DPL, CT
-Management: Symptomatic, serial Hb and abd exam, possible surgery
CASE TWO: Sore throat
Uvular Edema: Rarely reported in isolation
Etiologies: Allergy/anaphylaxis, infection, angioedema, trauma
Quincke's Disease: Inhalation injury, hereditary angioedema, cocaine/marijuana abuse, idiopathic/snoring in obesity.
Presentation: Dysphagia, odynophagia, sore throat, foreign body sensation. Uncommonly resp distress, dyspnea, fever.
-Some association with epiglottis
-If infection suspect, cover strep species and consider lateral neck xray
-If not infectious, steroids +/- H2 blockers
-75% recurrence rate - either first 48 hours or remote
CASE THREE: Groin pain
Avascular necrosis of femur
-Risk factors. Trauma, steroid use, hemoglobinopathy, dysbaric phenomena, autoimmune disease, storage disease, smoking, HLD, excess alcohol consumption
-Often present with groin pain, throbbing, deep. Bilateral disease 50-80%
-Can by identified by painful forced internal rotation at hip
-Radiographic findings: Crescent sign (intact bone with deeper area of necrosis). On MRI "single density line" early, "double line sign" found in 80% cases, high intensity line surrounded by low intensity
-Treatment: 85% collapse rate, surgical intervention is mainstay. Of those treated with conservative therapy, 76% proceeded to arthroplasty
Higher Risk Patients
Mimics for Lower GI bleeding: