Carolinas Emergency Medicine Residency

CTP Imaging for Acute Stroke: Has Its Time Finally Come? - Dr. Asimos

6/30/2016

1.       CTA is becoming the standard for acute stroke imaging, but options remain for collateral/penumbral assessment in selecting patients for endovascular reperfusion therapy

2.       Non-randomized data support the target mismatch theory for patient selection for endovascular reperfusion therapy

3.       NCCT remains the standard for IV tPA treatment decision making, but increased use of routine advanced imaging may ultimately provide data supporting CTP use for IV tPA decision making

4.       Ability for advanced imaging to predict who will bleed after reperfusion therapy remains a challenge

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Carolinas Case Conference - Dr. Lounsbury

6/30/2016

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• If even considering CVA as diagnosis, call Code Stroke
• Consider mechanical thrombectomy in CVA patients who may not be IV tPA patients
• Role of head trauma in IV tPA exclusion criteria poorly defined
• Always consider VTE in pregnant patients with leg pain
• Pregnant & postpartum patients are at significantly increased risk of VTE
• Diagnostic workup with Modified Well’s Criteria
• Lovenox is the treatment of choice for VTE in pregnancy

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Alcohol Use Disorder and the ED Patient: More Than Just MTF - Dr. Awad

6/30/2016

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Alcohol use is the leading cause of morbidity and mortality in the US with huge social, economic, and healthcare impacts.
Alcohol Intoxication is a DIAGNOSIS OF EXCLUSION! Always consider other causes of altered mental status and address immediate life threats.
Most patients can be managed with supportive care and reassessment. IV fluids and vitamin repletion are largely unnecessary and are not supported by current literature.
Be wary of Wernicke’s, Withdrawal, and Ketosis in chronic alcoholic patients.
The ED is often the only place where alcoholics seek care, we should give patients all the opportunities and guidance our facility can offer to seek help once discharged.

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Carolinas Case Conference - Dr. Lounsbury

6/10/2016

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•Consider atypical presentation for ACS in elderly patients
•Risk factors for severity of acute pancreatitis include advanced age, obesity, organ failure, and pleural effusion

•Can use APACHE II score to risk stratify in the ED

•Blunt aortic injury (BAI) is a rare but often deadly entity
•Consider in all cases with significant mechanism
•Can have atypical/no symptoms or have distracting injury
•Management of BAI includes permissive hypotension and rapid transfer to the operating room

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June 02nd, 2016

6/2/2016

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URIs are common in children... acute sinusitis is not. Approximately 6-8% of children with URI symptoms meet criteria for acute bacterial sinusitis

Diagnostic criteria for acute bacterial sinusitis have been revised in the last few years. There are three clinical courses that constitute a diagnosis acute bacterial sinusitis...

- persistent symptoms without improvement
- severe onset of symptoms
- worsening clinical course

So that means, we don't diagnose sinusitis in children with imaging studies.
However, if you are worried about orbital or CNS involvement, it is recommended to evaluate with contrast CT or MRI.
It is most often caused by S. pneumoniae, H. influenzae, and M. catarrhalis. S. aureushas not been identified as a major etiology.

Antibiotic treatment should take into account S. pneumoniae resistance patterns and beta lactamase production of H. influenzae and M. catarrhalis - high dose amoxicillin (90mg/kg/day BID) or Augmentin (90mg amoxicillin/kg/day BID) are first line choices.

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Carolinas Case Conference - Dr. Lawson

6/2/2016

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Aortic dissection is an uncommon but important cause of chest pain in the ED.
The classic presentation of severe (sudden onset, tearing/ripping chest pain that radiates to the back) 9 and the absence of these features is not associated with a significant negative likelihood ratio. As a result diagnosis requires a high degree of suspicion.
For patients determined to be low risk by the AHA aortic dissection risk stratification score, a negative D-dimer confers a negative likelihood ratio of 0.05 (CI 0.02-0.09). Clinicians may consider using D-dimer in the appropriate patient population to further assess their risk for dissection.

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CTP Imaging for Acute Stroke: Has Its Time Finally Come? - Dr. Asimos

Carolinas Case Conference - Dr. Lounsbury

Alcohol Use Disorder and the ED Patient: More Than Just MTF - Dr. Awad

Carolinas Case Conference - Dr. Lounsbury

June 02nd, 2016

Carolinas Case Conference - Dr. Lawson

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