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Critical Ischemia - Dr. Littmann

2/25/2016

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Picture
I.  STEMI without STE
  1. Discussed last month
  2. ST depression in anterior chest leads: consider posterolateral STEMI – electrodes to the back
  3. Subtle ST elevation in I, aVL, V2, ST depression in III (“South African flag sign”): consider high lateral STEMI – place V4-V5-V6 1 and 2 interspaces higher
  4. Subtle ST elevation in the inferior leads with ST elevation in V1 but not in V2: probable RV MI – obtain right-sided chest leads
  5. Medical emergency; door-to-balloon time < 90 min
 
II.  de Winter sign
  1. Usually in young males who present with severe chest pain
  2. Always in the chest leads
  3. J-point depression followed by upsloping ST segments followed by tall “hyperacute” T waves
  4. Usually signifies subtotal or total occlusion of proximal LAD
  5. Medical emergency; immediate cath
 
III.  aVR sign
  1. Presentation with acute chest pain (ACS)
  2. Diffuse ischemic ST depression
  3. ST elevation in aVR ≥ 1 mm
  4. ST elevation in aVR usually higher than ST elevation in V1
  5. 80% specific for left main or left main equivalent coronary artery obstruction
  6. High risk of acute MI and cardiogenic shock, death
  7. Urgent cath indicated (probably within hours)
 
IV.  Wellens sign
  1. Presentation with acute chest pain (ACS)
  2. Deep symmetrical T-wave inversion in the anterior chest leads, or
  3. Biphasic (positive-negative) T waves in the anterior chest leads
  4. Suggests tight proximal LAD occlusion
  5. High mortality without cardiac cath, PCI
  6. Most patients should undergo cardiac catheterization
  7. Degree of urgency is uncertain

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Head Trauma - Dr. Gibbs

2/22/2016

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Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
·         GCS 15 ≠ 14 ≠ 13
·         Know what each CDR gets you
·         Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
·         Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)
 
Case #2 (TBI on warfarin) – SLIDE #49
·         Very high risk… be liberal with imaging
·         No CDR to identify the low-risk patient
·         Order INR on arrival 
·         Reversal of anticoagulation = resuscitation!
·          
Case #3 (severe TBI) – SLIDE #94
·         RSI with neuroprotective drugs
·         Hyperosmolar therapy with either hypertonic saline or mannitol
·         Do not hyperventilate unless there is clear clinical evidence of herniation


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Carolinas Case Conference - Dr. Beverly

2/18/2016

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Trauma Resuscitation: Not ACLS
  • Trauma resuscitation should focus on treating the underlying cause.
    • Trauma patients need intubation, resuscitation with blood products and bilateral thoracotomies when in extremis
  • ACLS in trauma is not indicated.
    • Chest compressions and epinephrine are the cornerstone of medical resuscitation, not trauma.
    • In traumatic arrest, chest compressions are not attempted until underlying causes have been appropriately addressed including hypoxia, hypovolemia, tension pneumothorax and cardiac tamponade
  • REBOA now being explored and in place for patients with suspected or diagnosed intra-abdominal hemorrhage secondary to penetrating torso injuries, blunt trauma patients with suspected pelvic fracture and isolated pelvic hemorrhage and patients with penetrating injury to the pelvis or groin area with life-threatening hemorrhage. 
 
It's Not Always Sepsis!
  • Multiple physiologic processes can elevate lactate.
  • Be careful with premature closure in patients. It is not always sepsis. 
  • Reviewing old EKG’s in comparison to new EKG’s is invaluable. If you order it, make sure you review it. 
  • New EKG changes even in the absence of symptoms in the altered patients should always prompt further investigation 
​

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VP Shunts - Dr. Angela Johnson

2/18/2016

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  • Be suspicious of shunt problems in …. Kids with shunts
  • HA, nausea, vomiting, irritability, behavior change are the weaker predictors you may miss if not vigilant
  • Malfunction common early, but eventually almost ALL get revised
  • Infection most common in first six months
  • Look at your own images!
  • Not stable – Call NSGY and consider tap


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Fever of Unknown Origin- Dr. Young

2/18/2016

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#1. FUO is most commonly: 1) infection, 2) collagen vascular disorder, and 3) neoplasm

#2. Always consider uncommon presentations of common diagnoses

#3. Repeating the clinical exam is key
     a) think about the child that has returned to the CED for the 3rd time in as many weeks... the new findings on your exam may be what leads to the final diagnosis

#4. No clear-cut rules for home vs. admit, but consider age, follow-up, and clinical severity 

See Ped EM Morsel - http://pedemmorsels.com/fever-of-unknown-origin/

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Pediatric Airway - Dr. Goode

2/11/2016

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Picture
• The pediatric airway has known unique challenges. Prepare yourself physically and cognitively!

• Maintain spontaneous ventilation if there is any doubt about obtaining successful advanced airway.
​

• Practice using airway equipment when you don't need it, so you are ready when you do need it
.


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Ped EM Case COnference - Dr. Smith

2/11/2016

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Picture
1.  Never get involved in a land war in Asia.
2.  Never go in against a Sicilian when death is on the line.
3.  Headache with an abnormal neuro exam is always worrisome... and always look at there fundus.
4.  Avoid diagnostic momentum - just because it sounds like gastroenteritis doesn't mean it is.
5.  If a child has conjunctivits, always look at the ears and consider treatment should include oral antibiotics covering beta-lactam producers. 

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Disclaimer: All original material and images included on this website are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Information contained on this website is the opinion of the authors and does not necessarily represent the official opinion of Atrium Health or Carolinas Emergency Medicine Residency. 


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​
  • Prospective Applicants
    • 2020 MATCH
    • About CMC
    • Our Curriculum
    • Our Residents
    • Our Fellowships
    • Program Leadership
    • Explore Charlotte
    • Official Site
  • ROTATING STUDENTS
    • Prospective Visiting Students
    • UNC Students
    • Healthcare Disparities Externship
    • Current Students
  • Current Residents
    • Airway Lecture!
    • PGY - 1
    • PGY - 2
    • PGY - 3
    • Simulation Reading
    • Blogs >
      • EM GuideWire
      • CMC ECG Masters
      • Core Concepts
      • #FOAMed
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
    • Board Review
    • Journal Club
    • Resident Wellness
    • Resident Research
  • Top 20
  • Chiefs Corner
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Individualized Interactive Instruction
    • Evaluations/Interview Season
    • Contact Info
    • Resume Builder