Carolinas Emergency Medicine Residency

Heat Exposure - Dr. Graboyes

5/28/2015

- 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!

0 Comments

CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

0 Comments

Sneaky Ectopic - Dr. Nichols

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

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

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

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).

0 Comments

Subarachnoid Hemorrhage - Dr. Asimos

5/21/2015

0 Comments

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

0 Comments

Eating Disorders - Dr. Callahan

5/21/2015

0 Comments

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

0 Comments

Case Conference - Dr. Kiefer

5/7/2015

0 Comments

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.