Case 1 - S/P Arrest w/ STEMI
Case 2 - Ear Pain and Facial Palsy
Case 3 - Ataxia and Headache after Rollercoster Ride
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Infective Endocarditis • Consider Infective Endocarditis in patients with multi-system organ failure and an acute embolic event • High risk groups for developing IE: prosthetic valves, indwelling lines, HD, IV drug users, CHD • Septic Emboli primarily involve the CNS (65%) Immunosuppression and Sepsis • Patients undergoing chemotherapy typically reach their ANC nadir between 7-12d • Patients with chemotherapy induced neutropenia are at highest risk for bacterial translocation in the gut secondary to cytotoxicity to GI flora • Sepsis management is time critical! • Abx within 1 hour has been shown to improve mortality! 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 GU & Pelvic Trauma Basics
Bladder injury - Pelvic fracture, direct blow, penetrating injury - bladder rupture in 5-10% of pelvic fractures (more fractures = higher risk of injury) - Intraperitoneal - dome is the weakest part (surgical repair) - Extraperitoneal - manage with foley Evaluation of the GU Tract
- Look for extravasation & look for contrast in bladder - if no contrast in the bladder = complete disruption of urethra - this requires surgery; some partial injuries can be managed with Foley catheter.
Upper Tract Injury - flank bank or abdominal pain with gross hematuria or microscopic hematuria with shock - 85% of renal injuries are secondary to blunt trauma; - any penetrating trauma near this area requires evaluation of kidneys - management depends on grade of injury - Ureteral injuries - easy to miss; tend to present late Pelvic Ring Fractures - pelvis is strong - takes a lot of force to break it; Assess for injuries: a. Proximate - urethra, bladder, vagina, sciatic nerve b. Distant - brain, chest, aorta, intra-abdominal Who to image- physical findings suggestive of injury, shock Types: 1. Lateral compression - horizontal anterior ring fracture- look for sacral fracture 2. AP - open book fracture - high risk of bleeding out - "mac daddy of pelvic fracture" 3. Vertical Sheer - high risk of vascular injury - if no femur fracture put in traction 4. Posterior ring disruption - increased mortality Unstable patients with pelvic fracture - angio vs OR: if grossly positive FAST, OR first. If not, angio first. Heart Lesions 1. Left to right - VSD, ASD, cushion defect, PDA 2. Cyanotic - truncus, transposition, total anomalous, tricuspid atresia, tetralogy a. Cyanosis - decrease of deoxygenated hgb by 3-5 mg/dl 1. Shunting from lung 2. Mixing blue and red blood 3. Single ventricle Break the left side of the heart (Hypoplastic left, aortic stenosis, coarct) --> hepatomegaly, gray, pulmonary edema, etc Break the right side of the heart (hypoplastic right heart, tricupsid atresia, pulmonary atresia, tetrology of fallot) --> Blue, poor perfusion, acidosis Not all ductal dependent lesions are cyanotic - AS, coarct Not all cyanotic lesions are ductal dependent - truncus arteriosis, TAPR Cyanotic Lesions a. Truncus Arteriosus - Blue because they're mixing - mixing happens before duct, therefore not ductal dependent - Pulmonary exam will vary; You can give them O2 - won't worsen cyanosis but won't help b. Transposition of Great Arteries - Cyanotic because you have mixing blood; If you find these later (ie, in the ED and not immediately after birth) these kids will all have VSD; Ductal dependent O2 wont help but wont hurt c. Tricuspid Atresia - Blue because not perfusing lungs; Right ventricle doesn't develop (Hypoplastic right heart) Ductal dependent; only pulmonary artery flow will come through ductus from aorta ECG will show LVH but only because right side isn't balancing it out O2 will prob not help, but won't kill d. Tetrology of Fallot - Cyanotic because of decreased pulmonary perfusion and mixing - O2 can help e. Totally Anomalous Pulmonary Venous Return - Cyanotic because of mixing Hyperoxia Test - 10 minutes of 100% O2 and see response > may help differentiate between pulmonary and cardiac etiology * For cyanotic lesions oxygen is not going to kill - it just may not help* * O2 can hurt you on left to right shunts* Left to right shunts are usually dyspneic/hypoxic because they are over-perfusing the lungs and they get fluid overload. Oxygen will cause vasodilitation of the pulmonary vessels and increase left to right shunting worsening the problem. Prostaglandins - 0.05-0.1 mcg/kg/min > will cause apnea - tube the kid 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...
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 Gastric Perforation 13 yr old female w/ abdominal pain - recent admission for abdominal pain with EGD (with biopsies taken). Became hypotensive, tachycardic, lactate 3.5 - surgery consulted & CT showed gastric perforation.
Hypotension - Beta Block Toxicity 49 y/o male from rehab - was found obtunded and hypotensive w/ BP 60/20 > ESRD dialysis patient > Hypothermic w/ temp of 93, pulse 59, BP 60/18; answering questions > Labs relatively unremarkable, EKG basically unchanged, CXR with pulmonary vascular congestion > List of meds reviewed - a LOT of antihypertensives including 1600 mg of labetolol in the past 24 hrs
Wernickes Encephalopathy 57 yr old "drunk" from medic > Normal vital signs, hx of COPD cirrhosis GERD and no meds > Wide based gait & tremulous & confused; while at rest normal neuro exam > Wernickes Encephalopathy - got thiamine and got better - Thiamine i500 mg iV over 30 minutes - At risk patients - anyone prone to malnutrition - Clinical diagnosis - consider with 2/4 nutritionally deficient, ocular findings, encephalopathy, ataxia QUICK HIT CORE CONCEPTS
***Mortality in trauma increases dramatically with increased age, inc 7% mortality for each year over 65 in trauma ***Liver disease is the worst premorbid condition for trauma ***Standard trauma assessment is inadequate in elderly, particularly vital signs insensitive ***Falls: 10% significant injury, in geraitric population cervical spine fractures common ***Have decreased cardiac output, may not be able to mount adequate tachycardic response, may have occult shock. Have consideration for peri-traumatic MI both prior to trauma or stress of trauma causing MI ***Pulmonary issues: Decreased reserve, increased risk ARDS and atelectasis, CO2 narcosis ***CNS: High risk of subdural, clouded by questionable baseline mental status ***Renal: Often baseline poor GFR, CT Contrast can cause significant injury ***Trauma triage poor in elderly: Age >55 should be at a trauma center ***CMC TRAUMA ACTIVATION for geriatrics ATC 1:: Age >65: HR>100, SBP<110 ALERT:: Age >65 involved in MVC or fall from height ***MANAGEMENT Airway: Increased aspiration risk. Consider dentures. Consider high cervical spine risk and maintain proper imobilization. Consider increased response to induction agents: decreased your dose. Breathing: Decreased reserved, rapid desaturation. Use passive oxygenation. Use ETCO2. Consider increased risk of rib fractures. Circulation: Decreased response to catechols, on beta blockers; may not mount tachycardia appropriately. Consider RELATIVE hypotension. --Journal trauma study shows HR >90 and SBP <110 significant increased in mortality Disability: Central cord syndrome more common in elderly, may have "Hand burning", will have upper extremity weakness and capelike paresthesia ***SHOCK INDEX HR/Systolic blood pressure Normal less than 0.6, realistic threshold <0.8 More sensitive than HR or BP alone Even better: Shock index * Age should be <50 ***If concerned about fluids, use repeated small boluses (250ml) ***Anemia: Follow serial hemoglobins and transfuse early. Transfusion threshold controversial, starting thinking about it around 8 or persistent hypotension ***History: Keep in mind precipitating events, syncope in 10-15% of geriatric fall/MVC ***Identify blood thinner use!! Coumadin, plavix, ASA, Anti 10A, anti thrombin ***CAREFUL chest exam: Must identify rib fractures, flail chest; XRAY low sensitivity for these. Traumatic aortic dissection often does not have external signs of injury. ***Abdomen: Geriatric may NOT develop peritonitis despite significant intraabdominal injury ***LABS: Always get lactate; highly predictive of bad outcome >2 admit, >3 ICU, >4 call chaplain. (40% mortality in lact >4) Upgrade to ATC 2 if INR >2 or Lactate >2.5 ***ECG Routine in geriatric trauma ***Careful with opiates in elderly, start low doses ***Head trauma: 80% mortality if GCS<8 Any anticoagulation with head trauma = scan ***Anticoag reverse> Coumadin, see protocol Antithrombin: May try FFP but pretty much screwed Anti Xa: PCCC may be beneficial (see protocol for dosing) ***Rib fractures: Risk of atelectasis, resp faulire, pneumonia Admit if >3 rib fx. Consult if 1 or more if frail, live alone, any concern really ***Elderly aorta Eggshell appearance distant from border of aorta may indicate dissection (Egg shell or Halo sign) ***Pelvic fx mortality 50% if hypotension, 90% if open. Eval for hemoperitoneum and aortic rupture ***Burns.. Baux index: Mortality = age + TBSA. Age >50 with bad burns, = burn center **BEWARE Cold and quiet, elderly trauma patient! HIGH YIELD CONCEPTS:
- Bifacet dislocation - Type II odontoid fracture - Hangmans fracture - distraction & rotation injury - posterior element of C2 gets fractured & spondylolisthesis of axis - Flexion Teardrop - most serious of all Cspine fractures |
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