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Heat Exposure - Dr. Graboyes

5/28/2015

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- Heat stroke is a serious illness that requires rapid recognition and care

- Active cooling and supportive care are the mainstays of treatment

- Keep your differential for the febrile patient with altered mental status broad!



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CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

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Sneaky Ectopic - Dr. Nichols

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  • Don't let a beta HCG lull you to sleep, if your suspicion is high, get an ultrasound and/or discuss with OBGYN.
  • Beta HCG assays vary significaltly between labs, for accurate results try to maintain the same testing assay.
  • Anchoring is a dangerous bias that places you at high risk to miss key and potentially life-threatening diagnoses.
  • To avoid anchoring, be judicious about a "diagnostic pause" and await diagnosing patients until all information is available.


GIB and Aortic Graft - Dr. Beverly

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  • History and physical is the foundation of medical decision making. Complete a good chart biopsy. Undress the patient fully. If not,  you may miss a crucial piece of information that will alter your decision making.
  • Aortoenteric fistula is a can't miss diagnosis. In a patient with a GI bleed and a known graft, this is your diagnosis until proven otherwise. 100% mortality if left untreated.
  • Consult vascular early of you suspect this diagnosis. Treatment involves early resuscitation and rapid operative intervention.


Pulmonary embolism + pleural effusion - Dr. West

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  • Up to one half patients with PE’s with have a pleural effusion on CT, one third if just looking at CXR
  • Usually unilateral and small
  • Usually exudative
  • If a patient has a small pleural effusion and pleuritic chest pain, think pulmonary embolus


Traumatic Ptx, Be Kind - Dr. Robertson

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  • Set your trauma rooms up ahead of time, know what to look for early in the patient's physical exam. 
  • Review the concepts of correct position and chest tube insertion techniques
  • Pigtail catheters are as efficacious as large bore chest tubes for traumatic pneumothorax
  • Keep an eye out for more data on Pigtails for blood in the chest. 
  • Large bore chest tubes remain standard of care for hemothorax, hemopneumothorax or concern for barotrauma in already vented patient's (even if pneumothorax is small). 

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Subarachnoid Hemorrhage - Dr. Asimos

5/21/2015

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Ottawa SAH Rule mneumonic: “ANT LEaF” (warning – this rule not yet validated)

·         Age >40
·         Neck pain or stiffness
·         Thunderclap headache
·         Loss of consciousness (witnessed)
·         Exertion (onset during)
·         and
·         Flexion (limited of the neck on exam)


Asimos approach is no “routine” LP needed if thunderclap onset H/A with normal head CT performed within 6 hours of H/A onset, with the following caveats:

·         Recognize this approach is not incorporated into any published guidelines
·         Assumes all of the following:
1.       Classic thunderclap headache
2.       No neurological findings
3.       No meningismus
4.       No prominent neck pain
5.       No family history of SAH
6.       CT performed within 6h of onset, and read by a neuroradiologist


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Eating Disorders - Dr. Callahan

5/21/2015

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Eating Disorders: Chronic disorder with acute complications:

1.Clinically prevalent eating D/O 16%; 3rd most common adolescent females, increased ED utilization,  Anorexia highest mortality rate of psych D/O

2. Dx: High index of suspicion, screen with SCOFF (Sick, Control, One stone/14 lbs, Fat, Fear)- 2 or more suggests Eating Disorder

3. Complex pathophysiology: dysrhythmias, CMP, re-feeding, osteoporosis, GI, neuro, etc

4. Dispo- involve social work & psych or ensure good follow up. Admit if abnormal vs, syncope, electrolyte derangement, Suicidal Ideation

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Case Conference - Dr. Kiefer

5/7/2015

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Case 1: Tattoo Reactions
  • Allergic Reactions usually from red dye pigment
  • Light reactions usually from yellow dye pigment
  • Can be range of severity from granuloma or erythema to frank ulceration to anaphylaxis
  • Treatment: Attempt topical steroids.  Usually requires removal.  Caution: warn patients they can have anaphylactic reactions during removal as pigment is dispersed, consider EPI Pen!


Case 2: Missed Central Cord Injury in Intoxicated Motor Vehicle Collision

  • Sign out of trauma patients must include concerns and expectation of complete tertiary survey
  • Take “drunk patient, just needs to sober up” out of vocabulary when transferring care
  • Pre-existing spondylosis is MAJOR risk factor for central cord injury even after mild trauma. I.E. Fall from standing.  Don’t assume neurological complaints are pre-existing.
  • Treatment: Collar and admission to ensure no worsening of neurologic function.  This is an evolving injury!

Case 3: Secondary Syphilis

  • Classic are copper colored macules on palms and soles +/- exfoliation.  Non-painful and non-pruritic.
  • DDx to consider: Erythema multiforme, RMSF, meningococcemia, Hand-foot-mouth disease
  • Tx: Penicillin G LA 2.4 million units IM x1 (for primary of secondary)
  • Note: Jarisch Herxheimer Rx- fever, fatigue, myalgias, headache, tachycardia following administration of treatment and destruction of spirochetes.  Self limited and resolves 24-48 hours but can be severe.  Treat with NSAIDs.

Case 4: Osteomyelitis in Adolescent

  • ALWAYS consider osteomyelitis in patient with pain with movement of an extremity, refusal to bear weight or pain to palpation over boney structure (it’s not just rule out septic joint!)
  • Usually patients will have vague systemic symptoms (ex. Fever, fatigue, headache, etc.) so we must keep a high level of suspicion.
  • If there is a concern get testing:  CRP >10 is ~90% sensitive a few days into illness, however, standard of care is MRI (Xrays are frequently completely normal)
  • It is always reasonable to have a patient return to ED in 24 hours for re-evaluation

Case 5: Guttate Psoriasis

  • Generally rare disease process, but most common in children and young adults <30 years old
  • >50% associated with recent or active group A streptococcal infection
  • Heralded by acute eruption of erythematous, patches, +/- some scale.  Often mildly pruritic.  Typically begins over proximal extremities and spreads to trunk.  Guttate means “drop” and rash typically appears as “drops” over the skin surface in appearance.
  • Treatment: Phototherapy and topical steroids.  For recurrent can consider tonsillectomy if secondary to recurrent GAS infections.
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Ortho Pitfalls - Dr. Colucciello

5/7/2015

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Wounds over knuckles = fight bites
  • Don’t close
  • Consult

Pain out of proportion
  • Compartment syndrome
  • Stretch muscles involved
  • Compromised NV supply = too late!

Injection Injury
  • Bad news!
  • Consult / transfer early

Sudden calf pain
  • Achilles Tendon Rupture?
  • Palpation / US

Maisonneuve fracture
  • Always check prox fibula
  • Look at mortise

Knee dislocation/relocation
  • Compare color, warmth, pulses both feet
  • ABI

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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