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Pediatric Altered Mental Status - Dr. Neal

1/29/2015

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Keep a broad differential in pediatric altered mental status.

Be systematic in your approach to pediatric AMS.

Avoid common pitfalls in management such as:

    - Assuming no head trauma b/c none stated

    - Failing to secure airway prior to imaging/ transport

    - Assuming no toxin b/c none stated in history


    - Forgetting to check the glucose!

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Ocular Trauma - Dr. Thacker

1/29/2015

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  • In all ocular trauma, first priority is to rule-out open globe injury.

  • Eyelid lacerations that are medial or have exposed fat warrant repair by a specialist.

  • Primary goal in traumatic hyphema is to prevent/treat the associated complications: clot dislodgement and rebleeding, glaucoma, corneal staining.

  • In orbital hematoma-> goal is to assess for signs of ortbial compartment syndrome.

  • The portable slit-lamp is your friend. Using it regularly may help you pick up occult globe rupture.

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Cases - Dr. King

1/29/2015

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Post-op Incisional Hernia
- Seen in over 10% of patients; up to 25% of patients with incision infection.
- More common in midline incision, more common in upper abdomen vs lower abdomen.
- Dr. Gibbs Pearl: If a patient presents to the ED with 30 days of their surgery (and is not there for an obviously unrelated complaint) contact the Surgeon to discuss the patient's presentation.
- Surgery Pearl: evaluation for post-operative pain from lap chole can involve RUQ ultrasound to look for signs of abscess.  Also consider biliary studies if concerned for biliary leak, biloma development.


Negative CT Calcium score in ACS
- Negative CT calcium score misses ACS very rarely.
- Quick test that is non-invasive, has no contrast, does not require patient participation, does not rely on patient heart rate or ability to exercise.
- If used in correct patient population, NPV is between 93-97% with a sensitivity of 99-100%.
- Dr. Garvey Pearl: Recognize that your clinical gestalt trumps any protocol or clinical decision rule and do what you think is best for the patient.

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Wernicke's  - Dr. Godfrey

1/29/2015

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- Wernicke's is an underdiagnosed constellation of neuropsychiatric symptoms that include altered mental status, confusion, memory impairment, nystagmus, gaze palsy, and ataxia.
-Symptoms are due to dietary thiamine deficiency that impairs energy utilization in the brain
-Wernicke's is not exclusive to alcoholics. High risk: the elderly, pregnant women, bariatric surgery pts, HIV/AIDs, diabetics, TPN-dependence, and hematologic malignancy 
-Treatment: thiamine 200mg IM or IV.  ORAL IS NOT EFFECTIVE.
-Treat with parenteral thiamine if a patient is altered, ataxic, has ocular abnormalities, impaired memory, hypotension, or hypothermia.
-We are on the front lines to make this diagnosis. Don't miss it.


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Resident as Educator - Dr. Fox

1/22/2015

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"Academia" wants you to be good educators!
  • You become a "faculty extender"
  • You Sell the program to students
  • You improve patient satisfaction
  • You establish good habits for life-long learning

You benefit from being a good educator!
  • Maximize your medical mastery by learning as you teach
  • Improve you clinical skills (students always highlight your areas of weakness)
  • Become proficient at communicating in a hectic environment, which helps you in the long run
  • Gives you unique perspective
  • Improves patient satisfaction



Teaching Tips for the Emergency Department
  • Introduce yourself (write their name somewhere so you will remember it)
  • Set Ground Rules (defines what the expectations are and helps you evaluate later)
  • Assess the learner (How many ED rotations, "are you comfortable with this exam, etc)
  • Prepare the learner ("I need an ECG within 10 min for that patient chest pain.")
  • Tell them how you expect presentations to be done BEFORE they start
  • Do not overwhelm them with your knowledge. Use Sniper Points not a Firehose.
  • Evaluate in real time.



PITFALLS
  • Not waiting for a commitment
  • Answering your own questions
  • Teaching too much
  • Focusing on your interests
  • Not explaining any variance in practice
  • Setting the student up for failure (not preparing for difficult scenarios, not preparing for consults)

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Head CT for Non-Trauma in Kids - DR. Scarboro

1/22/2015

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  • Neuroimaging is not required for recurrent headaches in children with a normal neurologic exam.
  • Conversely, consider imaging for children with abnormal exams or findings suggestive of increased ICP.

  • Brain CT in the ED for the 1st unprovoked afebrile seizure is usually not indicated.
  • Exceptions include focal seizures in children < 33 months or children with predisposing conditions.

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Parapharyngeal Penetrating Trauma - Dr. Smith

1/22/2015

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IcePopsicle Stick Impaled into Parapharyngeal Space
  • Be wary of objects stuck in children's mouths and please don't pull them out!
  • The best time to plan for the "Disaster Airway" is before the disaster occurs!
  • See Morsel


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Prothrombin Complex Concentrates - Dr. Kiefer

1/15/2015

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Traumatic Intracranial Hemorrhage in Patients on Warfarin.  
Prothrombin complex concentrates (PCC) vs Fresh frozen plasma (FFP)


Efficacy:
- PCC normalizes the INR much more rapidly than FFP  (0.5 hr vs 6-12 hours from initiation of administration)

- Rapid normalization/and protocol driven care which expediates administration of either FFP or PCC has demonstrated a reduction in the expansion of traumatic intracranial hemorrhage

- ... however, this has never been demonstrated to improve mortality or neurologic outcomes.

- Similarly rapid INR correction can lead to faster neurosurgical intervention... although no proven improvement in outcomes


Safety:

- FFP is associated with considerable risk of fluid overload (TACO- 1:68-1:1500 units transfused) in a volume dependent manner and is more likely in patients with chronic kidney disease and congestive heart failure (precisely the patients who frequently are on warfarin).  FFP is also associated with rarer complications such as viral transmission and anaphylaxis.

- PCC does not have any of the complications associated with FFP, although it is believed to have an increased risk of thromboembolic events with incidence of ~1.8% based of retrospective studies primarily.


Cost: 

(note the below are COSTS which are usually multiple times less than CHARGES to patients)

- PCC is considerably more expensive than FFP.

- FFP is estimated to cost ~$1 mL.  With average patient requiring 4 units of FFP that equals approximately $1000 in COSTS.

- PCC is $1.27 per UNIT.  Dosing costs typically range from 2500-5000 units, which corresponds to costs of $3157 and $6350 respectively.  CHARGES to patients are typically ~3x this amount.



Bottom Line:  If cost were no issue then PCC would be the treatment of choice for probably all patients.  Data appears to trend towards improved outcomes with more rapid reversal, which of course is a logical conclusion in a bleeding anticoagulated patient.  Cost, however, is a consideration and at this time patient selection is key.  For the younger, healthy patient with intracranial hemorrhage with high propensity for expansion (ex. subdural hematoma, epidural hematoma, intraparenchymal hemorrhage) reach for PCC without second thought.  Patients with high risk of fluid overload are also a key population to consider PCC as treatment of choice.


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Sodium Derrangements - Dr. West

1/15/2015

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Hyponatremia
- Classically, classified based on tonicity and volume status, but consider acuity when treating in emergency department.

- Do not feel you have to treat asymptomatic patients while in the ED.

- 1 ml/kg 3% saline will raise sodium by 1 mEq – start with 100 mL over 10-60 min  and re-evaluate.

- Do not exceed 6 meq in 24 hours  (consider D5W 6mL/kg and 1 mcg DDAVP if you overshoot).

- Send labs for admitting team to help with work up including urine electrolytes/osm, UA, serum osmoles, uric acid.


Hypernatremia
- Acute (salt ingestions or DI with acute inability to obtain water) 

– 3-6 mL/kg/hr D5W with goal to decrease serum sodium by 1-2 meq/L/hr

- Chronic – 1.35 mL/kg/hr D5W with a goal to lower no more than 10 mEq/L in 24 


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Multiple Myeloma - Dr. Lunsford

1/15/2015

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1.  Most commonly presents with anemia, bone pain, elevated creatinine, fatigue, and asymptomatic hypercalcemia.

2.  Suspect in elderly who present with vertebral or chest pain with anemia, hypercalcemia, or elevated creatinine.

3.  Multiple myeloma emergencies include acute/chronic renal failure, infection, and more rarely hypercalcemia and spinal cord compression.

4.  Best imaging for punched out lesions are plain films of axial skeleton and proximal humerus/femur.


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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction