Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Carolinas Case COnference - Dr. Lawson

2/23/2017

Case 1:
Deterioration post intubation: DOPES
- Dislodged ETT
- Obstruction
- Pneumothorax
- Equipment failure
- Stacked breaths

Consider prone positioning for patients with severe ARDS and refractory hypoxemia

Case 2:
Do not forget nephrolithiasis as a cause of colicky abdominal pain with hematuria
Be wary diagnostic momentum in ED bounce back patients
Review your own images

High Risk EM - Dr.

2/16/2017

1. Lawsuits are inevitable, but excellent documentation can make the process much easier for you.
2. One of the first steps is treating people well, large percentage of plantiffs want to teach physician a lesson.
3. Most common and costly area of litigation is related to delayed or missed diagnosis.
4. Consider test you order, if they are needed, but be sure to review all results and follow-up on incidentals.
5. Know the evidence that supports the protocols that you follow in your institution, such as chest pain, and make sure that are supported in the literature.

Fever & Headache in Peds ED - Dr. Lawson

2/16/2017

The incidence of bacterial meningitis has decreased significantly since the development of the Hib, PCV, and meningococcal vaccines.
This means that it's important to remember there are other causes of "fever, headache, and stiff neck" in the pediatric population.

Retropharyngeal abscess will cause young children to have fever and resist moving their necks...but these children are generally non-toxic appearing.
CT with contrast of the neck will help you with your diagnosis.
It can often be treated with antibiotics only.

Acute Disseminated Encephalomeningitis (ADEM) can cause "fever, headache, and stiff neck" in addition to neurologic symptoms such as weakness, motor deficits, or seizures...the neurologic findings depend on where in the brain and/or spine demyelination occurs.
CSF will show an elevated protein count with lymphocytic predominance, and MRI will show areas of T2 hyperintensity.
It can be treated with high-dose methylprednisolone, intravenous immune globulin (IVIG), and plasmapheresis.

Rocky Mountain Spotted Fever (RMSF), despite its name, has the majority of its cases in five states NOT in the Rocky Mountains (North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri).
Clinical suspicion should be high, and patients with possible RMSF should be treated with doxycycline.
Treatment is often complete before confirmatory laboratory results are available.

Blood in the brain can be very irritating and can cause children to have headache, stiff neck, and sometimes even fever.
Intracranial hemorrhage has been known to present with "fever, headache, and stiff neck," so remember to keep diagnoses such as AVM on your differential.

Case Conference - Dr. Lounsbury

2/16/2017

• Cerebral venous thrombosis is a rare and difficult to diagnose cause of headaches
• Risk factors include prothrombotic states, pregnancy, infection, or inflammatory conditions
• Diagnose with CTV or MRV as D-dimer is not sensitive or specific
• Always consider VTE in pregnant patients with leg pain or hip pain
• Pregnant & postpartum patients are at significantly increased risk of VTE
• DVT’s in pregnancy tend to be left sided, proximal, and massive!

High Output Heart Failure - Dr. Dozois

2/9/2017

Remember to consider high-output heart failure in patients who present with undifferentiated shock.
Florid heart failure may be the initial presentation of certain rare causes of AV Fistulae.
Often traditional treatments of heart failure such as inotropes and vasodilators may be harmful treatment of HF with an elevated ejection fraction.
Definitive treatment of the underlying etiology is central to the management of high output heart failure.

LEadership Conference - Dr. Robertson

2/9/2017

1. Emergency medicine is an exciting but still profoundly challenging and taxing field.
2. Identifying core strengths and weakness is critical to personal growth, longevity and overall satisfaction in your vocation.
3. Feedback is focused on actions/behaviors. Use action words and verbs to describe these things, stick to facts, use sensory language (saw heard, touched, etc.). Statisitical information can be helpful if gently (I've seen this happen twice.) One strength, one weakness.
4. Session WILL BE uncomfortable if discussing critical areas of growth and if people are willing to be vulnerable. This is not an attack or a change to "get back" at anyone.

Case COnference Core Concepts - Dr. Goode

2/9/2017

• When your sepsis workup doesn’t reveal a source, continue the search, often times these patients need a surgeon.

• When presented with an acute decompensation after a recent illness, consider it’s complications and treat aggressively.

• Our ED diagnoses set patients in a trajectory, avoid premature closure.

Unusual Infections and cutaneous manifestations - Dr. Young

2/2/2017

Thorough history and exam are essential
Beware the persistent diaper rash
Always consider mimics to common pediatric illnesses
Neonatal pustules - not always benign
Be on the lookout for HSV

Tox Tips - Dr. Snow

2/2/2017

1) Always be able to explain anion gapped metabolic acidosis.
2) Remember K.I.L.R for causes of AG metabolic:

Ketosis
Ingestion
Lactate
Renal

3) If no ketosis, elevated lactate, and no renal failure you better consider ingestion/Tox exposure

Think Tox
•GI & small pupils = cholinergic
•Old, Deaf, & acidosis = ASA
•Bradycardia, Hypotension, & Elevated BS = CCB
•Acute Hepatic Failure: APAP, Acute Hepatitis, Med list!!!
•Sepsis in pump pt = consider withdrawal

Don't forget the Tox triad for most exposures EKG, BMP, and APAP level