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Carolinas Case COnference - Dr. Lawson

3/23/2017

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Picture
  • Lung down >72 hrs → Re-expansion Pulm Edema possible
  • Jammed finger → Test central slip tendon function
  • Central slip tendon rupture → Extension splint until OR
​
  • Congenital Long QT and Hypokalemia → Risk Factors for torsade de pointes
  • MANY MEDICATIONS (including zofran and levaquin) can precipitate torsade de pointer in patients with underlying risk factors.
  • Patient with torsade de pointes risk factors → Avoid QT prolonging meds

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Case Conference - Dr. Mollo

3/16/2017

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​-- Despite your location in the ER, treat all 'in extremis' patients with the same approach:
ABCs, reversible causes (glucose, narcan, epi), resuscitate patient and then move to higher care area

-- Contrast reactions cause an anaphylactoid reaction, which is treated with same supportive measures as an allergic reaction (epi, steroids, antihistamines)

-- There are almost no contraindications to receiving contrast (the shaky area is with CKD or patients with AKI) - be sure to hydrate patients before and after scans if they can tolerate it

-- Only need to order irradiated or CMV negative blood products for patients with leukemia/lymphoma or transplant patients

-- Order Type and Screen (rather than T&C) on patients unless they need to be transfused in the ED/imminently.

-- You can order MTP on patient as soon as they are registered; however, keep cooler closed until you definitively know you will need to transfuse

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Pediatric Abdominal Pain - Dr. Weihmiller

3/16/2017

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- Always think inside AND outside the abdomen when evaluating children for abdominal pain
- Obstruction in children does not always produce distension or peritoneal signs
- To accurately evaluate for obstruction you need supine and upright (or decubitus) Xrays
- Lethargy can be the sole presentation of intussusception in infants and toddlers (See PedEMMorsel)
- Bilious emesis in neonates is a surgical emergency even if they look well
- Pyloric stenosis rarely occurs after 8-10 weeks of age
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Carolinas Case COnference - Dr. Mollo

3/9/2017

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High ETOH concentration is protective against methanol and ethylene glycol (metabolized slower as ethanol is metabolized first)

Ethylene Glycol
- the metabolites, not ethylene glycol, cause acidosis and toxicity
- ethylene glycol itself, not the toxic metabolites, cause increased osmolal gap
- Fomepizole recommended

Methanol
- Permanent blindness has occurred after ingestion of approximately 1 teaspoon of methanol
- Fomepizole recommended

Isopropyl Alcohol
- Since the parent compound causes toxicity, not the metabolite (acetone), fomepizole not indicated. 
- Urine ketones will be positive (Ketosis without acidosis)
​


Picture
Photo credit: foamcast.org
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Toxin INduced Hypoglycemia - Dr. Alwasiyah

3/2/2017

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Definition of hypoglycemia:
  • Organ dysfunction in the setting of inadequate glucose concentrations
  • Whipple’s Triad:
    • Symptoms consistent with hypoglycemia
    • Low serum glucose
    • Improvement of symptoms after glucose levels have been raised

Interferences with Point of Care Glucose Testing:
  • Point of care testing can be inaccurate in both extremes of blood glucose.
    • From the package insert for Accu-Chek®
    • The ACCU-CHEK® test strips are for testing fresh capillary, venous, arterial, or neonatal whole blood. Cord blood samples cannot be used.
​











Important Toxicologic Considerations:
  • Beta blockers do not cause hypoglycemia
  • Sulfonylureas
  • Ethanol
  • Insulin
  • Salicylates
Pediatric Hypoglycemic Concepts:
  • Normal functioning pancreas:
    • Hypoglycemia can be profound
    • Dextrose boluses can stimulate insulin secretion
    • Increase basal insulin at night for growth demands
  • Low threshold for admission/observation
  • Prophylactic dextrose is not needed
  • IV dextrose if they are symptomatic
  • Oral carbohydrates if they are asymptomatic
Sulfonylureas:
Glimepiride
Glyburide
Chlorpropamide
Tolbutamide
Tolazamide
  • One pill can kill
  • Hypoglycemia can be delayed
  • Long duration of action
  • All patients must be observed for 24-hours
Meglitinides
Nateglide
Repaglinide
Similar action to sulfonylureas but shorter duration of action.
Ethanol:
  • Decreases glucose supply by:
    • Inhibiting gluconeogenesis
    • Decreased oral intake
    • Decreased glycogen stores leading to ineffective glycogenolysis.
GLP-1 analogs:
  • Do not Cause hypoglycemia
Albiglutide (Tanzeum®)
Dulaglutide (Trulicity®)
Exenatide (Byetta,Bydureon®)
Liraglutide (Victoza®)

Amylin analogue:
Do not cause hypoglycemia
Pramlintide (Symlin®)

Antidiabetic drugs that are expected to cause hypoglycemia
  • Sulfonylureas
  • Maglitinides
  • Insulin
  • SGLT-2 inhibitors, in overdose 


Normoglycemic Ketoacidosis:
  • Associated with SGLT-2 inhibitors:
    • End with “flozin”
      • Canagloflozin
      • Dapagloflozin
    • Can be in combination with metformin
  • Blood glucose less than expected for DKA
  • High anion gap acidosis
  • Ketosis:
    • Ketonemia with or without ketonuria
  • Pathophysiology:
    • Decreased glucose
    • Relative insulin deficiency
  • Risk factors:
    • Surgery
    • Infections
    • Reduction or omission of insulin
    • Excessive alcohol intake
    • Diet restriction
    • Late onset autoimmune diabetes
  • Management:
    • Insulin infusion
    • Hydration
    • Carbohydrate supplementation
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Animal-Borne Illness - Dr. Cox

3/2/2017

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​Cat Scratch Disease:
  • Clinical diagnosis!
  • Think Lymphadenopathy… then fever and constitutional symptoms
  • Usually self-limited, can treat with azithromycin x5days
  • http://pedemmorsels.com/cat-scratch-disease/
 
Toxoplasmosis
  • Immunocompetent: Vast majority asymptomatic
  • Immunocompromised
    • Toxoplasmic Encephalitis
      • Most common CNS infection  in AIDS pt  not on ppx
Presumptive Dx:
  • CD4+ <100
  • Not on appropriate PPx
  • Compatible clinical syndrome
  • T. gondii IgG Ab positive
  • Ring enhancing lesions on imaging
    • MRI preferred (more sensitive)
  • Tx: Pyrimethamine, Sulfadiazine, Leucovorin x 6 wks
 
Bites:
  • Check vaccination status of patient and animal
  • HIGH PRESSURE, COPIOUS irrigation
  • Dogs:
    • Close bites if <12 hours old, <24 hours on face
  • Cats: DO NOT CLOSE (unless terrible cosmetic injury)
  • PPx:           
    • ALL CAT BITES
    • Dog bites if:
      • >8hours old
      • Face, genitals
      • Tendon, joints, bone
      • Immunocompromised, poor wound healing
    • Tx: Augmentin x3-5days
  • Bad Pathogens:
    • Pasteurella = CAN’T use 1st gen cephalosporins or clindamycin
      • Tx: Augmentin, Unasyn, Zosyn
    • Capnocytophaga = Bad hombre           
      • Immunocompromised
      • Asplenic
      • Hepatic disease
      • Tx: IV Zosyn, cephalosporins, carbapenems
 
Toxocariasis:
  • Think Children, sandboxes, exposure to feces
  • Spectrum of disease: asymptomatic -> organ failure
  • 2 flavors:
    • Visceral Larva Migrans
    • Ocular Larva Migrans: vision loss
    • (3rd flavor is Cutaneous Larva Migrans. Caused by Ancylostoma)
  • Tx: VLM: Albendazole x5 days, +/- prednisone
       OLM: Prednisone (slow taper), Albendazole x2-4weeks
 

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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