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GU & Pelvic Trauma - Dr. Gibbs

4/27/2017

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  • Suspect GU injury (often occult)
  • Look for hematuria
  • Stability permitting, evaluate the GU tract in a retrograde fashion
  • Become proficient with ED procedures (retrograde urethrogram & cystogram)
  • Know the strengths and pitfalls of the studies you select

  • Recognize that pelvic ring fractures are a major cause of M&M
  • Associated GU injury common
  • Identify the injury type on X-ray:
                       - Lateral compression
                       - AP compression
                       - Vertical shear

Resuscitation essentials:
  • Anticipate and treat shock
  • Use the FAST to identify the major source(s) of hemorrhage
  • Transfer to an appropriate center
  • Early pelvic stabilization
  • Identify and prioritize injuries
  • Mobilize resources (e.g.: angiography)

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From Ordinary to Extraordinary - Dr. Pearson

4/27/2017

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  • Post-Intubation Hypotension: 15% higher in-hospital mortality
    • Predictors:
      • Pre-intubation shock index (SI ≥ 0.8)*
      • Chronic renal disease
      • Intubation for acute respiratory failure
  • Push-dose (Bolus-Dose) Pressors:
    • Supportive bridge in selected patients:
      • Peri-intubation hypotension
      • Procedural sedation
      • Transporting long-distances from the ED
    • Push-dose Pressor Options
      • Phenylephrine in pre-mixed “STICK” (most common – be careful in brain injured or heart failure patients)
      • Epinephrine – will need to mix yourself
  • Pre-oxygenation: Rule of 15’s: Preoxygenation
    • Position: Head of bed                     @ > 15º
    • Non-rebreather mask                     @ 15 L / min
    • Nasal cannula                                    @ 15 L / min
    • CPAP / BVM + PEEP valve              @ 15 cm H2O
  • Delayed sequence intubation (DSI) Overview
    • “A procedural sedation, where the procedure is pre-oxygenation”
    • Basics: Delirious patient with hypoxia -> ketamine 1-2 mg/kg IV -> Preoxygenate (Preferably with CPAP/BiPAP)  ->  Wait 2 to 3 minutes ->  Administer paralytic -> Wait 45 to 60 seconds -> Intubate
  • DSI: Safe Apnea 
    • Safe Apnea = Duration of apnea until a patient reaches a saturation of 88-90%
    • Patients with increased metabolic demands and shunting desaturate faster.
  • DSI: Who might benefit from it? Patients with vital signs that are unobtainable, or unacceptable:
    • “Good Lungs, Bad Brains”: Agitated head injury / ETOH / Psych
    • Bad Lungs: Hypoxic  COPD, Pneumonia, ARDS
  • Apneic Oxygenation:
    • Alveoli continue to take up oxygen even without ventilation
    • Keep Nasal Cannula in place at 15 L/min during intubation attempt(s) to further prolong duration of safe apnea


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    Scary Neonate Case COnference - Dr. Bryant

    4/20/2017

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    - Neonate in respiratory distress: remember NRP!
    - Neonate in respiratory distress with true unilateral absent breath sounds = Congenital Diaphragmatic Hernia??!!-> confirm with CXR

    Congenital Diaphragmatic Hernia (CDH)
    - Neonates likely have high risk for pulmonary hypertension!
    - Do not give PPV -> worsens GI distention/lung compression = worsening pulmonary HTN
    - In neonates intubate early to prevent hypoxia (hypoxia worsens pulmonary HTN) with low pressure vent settings
    - Maintain systemic BP to reduce right to left shunting
    - Older children with CDH, less likely to have significant pulmonary HTN, keep calm and try to avoid intubation
    ​

    - Persistent/worsening cyanotic neonate - think cyanotic congenital heart defect -> Start Prostaglandins
    - Remember Prostaglandins cause apnea, will likely need intubation
    - Neonate in extremis = call for back-up early!

    ​


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    Devastating Neurologic Emergencies - Dr. Asimos

    4/20/2017

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    1. ​When documenting a neuro exam, document what you did and reserve deductive reasoning for medical decision making
    2. Unaltered documentation templates that contradict important features of the history, ROS, or exam, will undermine the credibility of all documentation
    3. To avoid misdiagnosed neuro gone bad: watch them walk, listen to them talk, and look at their eyes
    4. Dizzy is not a medical term, and vertigo is not a diagnosis
     

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    Drug-Seeking Behavior - Dr. Pecevich

    4/20/2017

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    ​* Our lizard brain -- addiction affects the most primitive structures using the mesolimbic dopaminergic system
    * Try to hate the drugs, not the patient -- animal studies have repetitively shown that drug seeking behaviors are easily reproduced
    * May be self medication -- chemical coping for psychiatric disorder or  pseudoaddiction

    * Yeah, I've heard that story -- behaviors more predictive of abuse are not that surprising. The more one has, the more likely it is opiate use disorder
    * "Nah, I don't want that" -- diversion patients will be uninterested in alternative therapies. People in actual pain will try anything just to feel relief (ketamine, nerve blocks, acupuncture)
    * We've all heard "avoid opioids for acute pain", but the chronic pain patient presents the greatest challenge
    * I want to relieve your pain, but... -- Have a script / set expectations with the patient -- there is little use in arguing if someone is in pain or not. 
    * Hyperalgesia -- chronic pain can worsen not despite opioids but because of opioids creating new pain pathways
    * The emergency department is just a step in the process of recovery. We're not here to win the game for the patient to change but to at least get it started
    * Evidence is limited, but some suggest that PO Morphine less euphoric than oxycodone or hydrocodone with similar analgesic efficacy
    * Communicate! -- judging drug seeking behavior from a history is relatively unreliable, use the drug database, use past records, call pharmacies and send messages in Cerner

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    Domestic Violence - Dr. Pelucio

    4/13/2017

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    1.  Intimate Partner Violence/Domestic Violence is the leading cause of injury in women aged 15-44.
    2.  1 in 4 women will be victims of intimate partner violence.
    3.  Intimate Partner Violence is about control, not violence.  
    4.  Women who leave a battering relationship are 75% more at risk of being murdered than those that stay.

    5.  US Preventative Services Task Force and JCAHO support universal screening of women for IPV in primary care settings and emergency departments.
    6.  Teen Dating Violence is an important risk factor for teen depression, suicidal ideation, drug and alcohol use, and pregnancy.
    7.  IPV can present without physical injuries, and can be related to multiple ED visits, anxiety and depression, chronic pain syndromes, and substance abuse.

    8.  As in child abuse, certain physical findings are important to recognize as non accidental and highly correlative to IPV injuries.  These include bruises in multiple stages of healing, injuries not compatible with history, strangulation, bite marks, injuries to breast, abdomen, and perineal area.
    9.  Children in homes with IPV are at risk for neglect, emotional and physical abuse, and may become future perpetrators of IPV themselves.

    10.  It is important as ED physicians to develop supportive and non judgmental ways of screening all patients for IPV, and to maintain a high degree of suspicion with trauma victims, psychiatric patients, and patients with multiple ED visits. 
    11.  Referrals to our Domestic Violence Healthcare Project WILL help victims gain access to services, provide counseling, and help with safety and discharge planning.  Healthcare providers do NOT need patient consent to make a referral for DVHP services. 
    12.  Physician documentation of physical abuse is the SINGLE MOST important correlate to successful prosecution of IPV cases in court.  Remember to document patient history and injuries well.

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    Tox & Dermatology - Dr. Kopec

    4/13/2017

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    • Warfarin can cause two dermatologic syndromes: Warfarin Skin Necrosis (thrombotic) and Purple Toe Syndrome (embolic)
    • Cutaneous Anthrax starts as a small, painless papule that transitions to a vesicle then necrotic ulcer with surrounding edema. It is most common on the head, neck, forearms and hands.
    • Blistering Agents are sulfur mustard and lewisite. Sulfur mustard has no pain initially while lewisite there is immediate pain. 
    • Chronic arsenic toxicity is associated with hyperkeratosis, skin pigmentation changes, Blackfoot's disease, lung, bladder and skin cancer. 
    • Mee's line can be seen with arsenic, thallium, heavy metals, renal failure, chemotherapy and sepsis. 
    • Inorganic mercury has been associated with a skin finding called Pink's disease or acrodynia. 
    • Basophillic stipling and Burton's lines can be seen with lead toxicity. 
    • The most common cause is allergic dermatitis is nickel. 
    • Levamisole has been a known contaminant of cocaine causing skin necrosis. 
    • To make the diagnosis of DRESS there must be: rash, fever, and end organ dysfunction.
    • To differentiate between carotenemia vs jaundice, carotenemia can be wiped off with an alcohol wipe and it does not involve the sclera. 
    • Red man syndrome is most commonly seen with vancomycin and rifampin. 

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    Case COnference - Dr. Lounsbury

    4/6/2017

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    • Myxedema coma can closely mimic cardiogenic shock
    • TSH is an inexpensive screening tool to rule out myxedema coma
    • Management of myxedema coma includes airway management, IV levothyroxine, IV hydrocortisone, and supportive care

    • Greater than one half of patients presenting with sepsis syndrome will have negative blood cultures
    • Do not be falsely reassured by the presence of fever and leukocytosis

    • Always consider RUSH exam and reconsider differential diagnosis in complex hypotensive patients! 

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    Exanthems - Dr. Zeller

    4/6/2017

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    ​Key history & PE components for diagnosing viral exanthems:
    - Hx: Where did it start, & where has it spread?  Pruritic?  Associated symptoms?  
    - PE: Appearance?  Confluence?  Palms & soles?  Oral lesions?  Lymphadenopathy?

    Key clinical features:
    - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots
    - Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots
    - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia
    - Roseola - Centripetal spread, fever defervesces before rash
    - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic

    - Mumps - Parotitis, orchitis
    - Coxsackie - Rash not just on hands, feet, & mouth

    - Mono - Rash not just after ampicillin
    - Nonspecific - MC viral exanthem

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    Viral Exanthems - Dr. Zeller

    4/6/2017

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    Picture
    - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots

    - Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots

    - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia, fetal   hydrops

    - Roseola - Centripetal spread, fever defervesces before rash

    - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic

    - Mumps - Parotitis, orchitis

    - Scarlet Fever - During strep throat, sandpaper rash, strawberry tongue, pastia's lines

    - Coxsackie - Not just on hands, feet, & mouth

    - Mono - Rash after ampicillin

    - Nonspecific - Most common viral exanthem we will see

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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
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        • 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