Thyrotoxicosis and Cardiomyopathy
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Immune System is the Bouncer - We know that there are bad microbes and good microbes. - It is now believed that the healthy Immune System acts much like a Bouncer at a Bar... allowing the good microbes in and keeping the bad microbes out. Illnesses associated with alterations in indigenous microbes - When "Bouncers go bad," illness like Obesity, IBD, Cdiff, asthma, or MRSA occur - Obesity - Giving antibx to animals make them gain weight - Obese people have less bacteroides - Markedly different gut flora in obese and skinny people - Inflammatory Bowel Disease - Increased correlation with antibiotic use - unclear causation - MRSA - Changes in microbiota related to MRSA status - Fecal transplants for recurrent C. difficile - Stool administered via NG tubes have a high success rate *Theoretically antibiotics in the last 70 yrs have altered normal human microbes* Electrical Storm - Refractory Ventricular rhythm , >3 episodes in 24 hours - Fix the underlying causes (ischemia, electrolytes, arrythmogenic meds) - LBBB & MI - difficult to interpret - remember your Sgarbossa Criteria! - Amiodarone is medication of choice, add beta blockade early with refractory condition Ectopic Pregnancy - Ectopic pregnancy - number 1 cause of 1st trimester deaths - Goal of the ED provider - EXCLUDE ECTOPIC by confirming IUP! - Start scan by finding the uterus! - Endomyometrial mantle - distance from the wall of the gestational sac to the outer wall of the uterus - in a normal pregnancy, measurement should be >0.8 cm - Switch to transvaginal probe if unable to obtain adequate views - IUP can only be diagnosed by yolk sac or fetal pole within gestational sac Central Cord Syndrome -Generally caused by hyperextension. Patients with history of central canal stenosis at risk -Upper extremities affected > lower extremities -Distal affected > proximal -Usually bladder dysfunction Opioid Induced Hearing Loss -Occurs <72 hours after use (seen in both acute and chronic users) -MCC is hydrocodone and heroin but seeing more with methadone lately -May be unilateral or bilateral -Most resolve within 72 hours but may be permanent -Treat with cessation of narcotics and possibly cochlear implants if permanent Rhabdomyolysis -Fluids, fluids, fluids as treatment -Diuretics (mannitol) and bicarb are controversial -Risk of AKI is lower when CK <5,000 but can be seen at CK levels of 1,000 -Urine dipstick + for blood with urinalysis - for blood has sensitivity of 80% for diagnosis Myocardial Infarction in TTP
Penetrating Scrotal Trauma:
Diagnotic Error in Medical Decision Making
The Return ED Visit
"BB" Shot to Right Groin...
- Bullet embolism is extremely rare. - Requires multidisciplinary management. - Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations. - Venous more common than arterial FLU 1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
Tamiflu is not magic...
* Propofol is used in >95% of residency training programs - well established to be safe & effective* > Propofol - Fast onset (2-5 min) fast recovery (5-10 min) - Great for short painful procedures - fracure DL, I&D, etc - Possible ADR - hypoventilation, partial obstruction, apnea, hypotension, bradycardia - No analgesia - however most patients do not recall or report pain; if you give additional opiods - taper propofol dose > Get equipped! {These are specific for CMC at current date} 1. Oral & nasal airways, O2, ambu bag with mask, direct or video laryngoscopes, ET tubes, suction, ECG monitoring with pulse ox, End tidal CO2 , code cart, narcan and flumazenil 2. For ASA class 1 & 2, Mallampati class <3 - consult anesthesia if outside these guidelines or pregnant 3. NPO for 2 hrs from clear liquids, 6 hrs nonclear liquds & food; deviation MUST be justified by attending physician 4. Need 2 physicians - attending needs to push meds 5. QA review - things that must be documented - apnea > 15 sec, ETT PPV, O2 dsat < 90% for > 90 sec, vomiting, unexpected change in vital signs, use of reversal agent, emergent anesthesia consultation, NPO guideline deviation 6. Nurses CANNOT push; only attending can push or a resident under direct supervision of attending not also doing the procedure (required 3 docs at bedside) 7. Doses - 0.25 - 1 mg/kg bolus (adults and peds) then q3-5 min can give 0.2-0.5 mg/kg; - Draw up 1 mg/kg & infuse slowly over 3-5 min 8. Consider lidocaine or fentanyl predosing to help ease pain at injection site (fentanyl 1mcg/kg IV in same line you're giving propofol) FOAM- Free Open Access to Medical Education > Web 2.0 - collaborative info; 2 way connections > Build your filter - feedly, flipboard, pulse > Pitfalls of Social Medial / FOAM - once you post it's hard to get rid of... so always BE PROFESSIONAL!! - peer review? The more partitioners who use FOAM, the better the inherent peer review becomes. - quality can become an issue (know who you are listening to). > Always read and listen with skeptism > Always ask questions before implementing things you learn > When in doubt leave it out > Ask yourself - is this anecdotal? Pneumococcal Meningitis with HUS Usually serotypes outside of 13-valent vaccine If you suspect, initial treatment with: - Cefotaxime 300 mg/kg/day IV (max 12g/day) in 3 doses OR - Ceftriaxone 100mg/kg/day IV (max 4g/day) in 2 doses PLUS - Vancomycin 60mg/kg/day IV (max 4g/day) in 4 doses Pneumococcal HUS Recognize classic triad: - Microangiopathic hemolytic anemia - Thrombocytopenia - Acute Kidney Injury Sources: - PNA - 70% - Meningitis - 20-30% - Others - Otitis, sinusitis, bacteremia - Not like STEC-HUS - Needs Tx with Abx - Pneumococcal leads to higher M&M Hemoptysis from 5-yr old retained GSW Delayed Pulmonary Hemorrhage from FB - Up to 30 yrs latency reported - Present with intermittent hemoptysis Complications: - Pulm Art or Aortic Pseudoaneurysm - AVMs with R -> L shunts - Embolization - arterial or venous Massive Hemoptysis No universal definition - "Is this life threatening?" Initial ED Management - ID bleeding lung and position dependently - A - Establish airway (8-0 ETT or bigger for bronchoscope) - B - Ensure good gas exchange on vent - C - Stop bleeding! Restore volume, give PRBCs, reverse coagulopathy,etc... Regular Wide Complex Tachycardia
- Consider VT until proven otherwise!!! - 80% is VT by numbers - Algorithms to differentiate SVT are difficult to remember - If you treat for VT, won't harm SVT - Nodal blockers for SVT can send VT into VF -- PLACE PADS with Adenosine! A great analysis of EP and Cardiologist failure in applying Brugada to electrophysiologically proven VT. Two fantastic talks from the ever-salient @amalmattu - VT vs SVT with Aberrancy - Adenosine Sensitive VT > Up to 100,000 deaths in the US hospitals each yr related to medical errors > Types of errors 1. Affective Errors - idea that we may treat a patient differently because there is something about them or about the circumstance that evokes either a negative or positive emotion - Positive - more time spent; some literature that we may avoid painful procedures - Negative - premature closure, less time, less care, less analgesia 2. Cognitive errors - Faulty knowledge, faulty data gathering, faulty synthesis, affective errors, external factors - Feedback failure - if you don’t know you screw up you don’t change your thought processes or practices = Confirmation bias; want to avoid over recalibration too - System 1 thinking - Illness script - pattern recognition comes from education and experience > Fast but can be unreliable, dependent on experience and not all illness follows illness scripts - System 2 Thinking - Cognitive Checkpoints - specific tests Cognitive Dispositions
- Premature closure = most common error in acute care medicine
Strategies to avoid error a. Admitting you have a problem is the first step b. Improve accuracy of judgements through cognitive aids c. Simulation d. EVERYTHING around you on any given day will influence how you take care of your next patient e. Metacognition - “thinking about thinking” -requires self awareness, ability to be self critical, & ability to introduc deliberate pause during the decision making process Train yourself to do a diagnostic pause - think about serious or alternative diagnosis, evaluate feelings, make sure there’s no extraneous information you’re missing, evaluate if theres anything today that’s impacting your decisions |
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