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Bed Bugs - Dr. Raper

6/29/2017

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​Bed Bugs
- Do not analyze a rash and simply call it bed bugs. There is a differential--includes scabies, fleas, bat bugs, dermatitis herpetiformis
- Bite mark: occasionally linear formation where bedbug makes its "path." usually on exposed skin. erythematous wheel with occasional bloody center
- 3/10 people bit will show NO symptoms. The skin changes that appear are an allergic reaction
- They DO NOT transmit disease. Hep B, Hep C, HIV-- die quickly within the bedbug gut
- They love warmth, dark and CO2. If bed bugs are seen in the well-lit ED, the patient likely has a MASSIVE infestation at home
- Hitchhikers: they latch onto anything. at the laundromat, the hotel, your scrubs...
- Oh not, not Diapause! Concept that bedbugs can remain without a meal for months and lie dormant. Even in cold as low as -12C. 
- Heat kills: Need 120 F for at least 30 minutes: kills all life forms. Dryer works. 
- Studies have shown "bug bombs" have no difference vs. controls
- Treatment for rash: supportive. Rash generally resolves within 7 days spontaneously. Can use antihistamines or topical steroids PRN. However, antihistamines can make it difficult to discern if rash is bed bugs
- Treatment at home: Combination of pest control, Heat, Sealing Cracks and Crevices, Treating Bed frames box springs and mattresses 
- Biopsy is of no use. 
...now go change your scrubs

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A-Fib w/ RVR - Dr. Okonkwo

6/29/2017

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​1) Afib RVR is often triggered by the same etiologies as sinus tachycardia.  Before treating the arrhythmia, treat the most likely etiology.

2) In a person with normal cardiac function and structure, afib RVR is not the cause of the patients shock.  Patients that are particularly sensitive to afib RVR include those with cardiomyopathies, recent MIs, severe diastolic dysfunction, HOCM, WPW, severe valvular disease, and severe coronary artery disease.  In these populations, afib RVR often manifest as hypotension, pulmonary congestion, and possibly ischemia.   

3) Procainamide should be the first line treatment in stable WPW with afib.  AV nodal blocking agents should be avoided.  

4) Review of recent literature suggest:
      - Diltiazem is more effective at controlling rate within 30 minutes when compared to metoprolol (Fromm 2015). 
      - Beta blockers may have a mortality benefit when used in afib RVR & sepsis (Walkey 2016).
      - Use of a rate of rhythm controlling agent in ED patients presenting with an acute underlying illness results in an increase in adverse events compared to patients who did not receive rate or rhythm controlling agents (Scheuremeyer 2015). 

5) Physicians should make an effort to optimize care and improve blood pressures before choosing a rate/rhythm controlling agent.  Physicians should consider the patient's clinical status and comorbidities when selecting a treatment option.  

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Case Conference - Dr. Thomas

6/29/2017

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- Child presents in cariogenic shock = think myocarditis
- There are times Circulation must be addressed before Airway to maximize circulation prior to intubation
- Think beyond tachycardia, symptoms of myocarditis also include: poor perfusion, hepatomegaly, respiratory distress

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Carolinas Case

6/22/2017

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​Case 1 -- Hypotensive Inferior MI
* Mmm bread and butter... Avoid nitroglycerin in the inferior MI. Preload!
* Hypotension prior to RSI drugs? Bad. Crystalloid not helping? Pressors.
* Make your FIRST attempt your best attempt.
* Cath lab is a farther walk than anticipated... and may not have airway resources!
* Be the leader: emphasize closed loop communication especially in code situations

Case 2 -- NAT
* Do not outsmart yourself. Do not talk yourself out of being suspicious for NAT.
* No injury is 100% specific for NAT. Our job is to be sensitive, not necessarily specific.
* Contact DSS! First encounter is mandatory reporter. Otherwise, story may change.
* Just because DSS investigates and clears does not mean NAT is ruled out.
* Be wary of your documentation: be objective, not a detective. Don't write things like "child consoled by mother after trauma"--remember, the victim often returns to the abuser
* Like it or not, we all have inherent bias in the way we approach patients from various backgrounds. Be mindful of your assumptions. 

* Be on the same page and contact your colleagues: Social work, CHIPS, Child Abuse team, Trauma


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tPA for CVA: Reconciling the ACEP, FDA, and ASA Guidelines - Dr. Asimos

6/8/2017

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  1. The controversy regarding IV tPA treatment for stroke cannot be resolved with the current evidence
  2. Recent FDA labeling changes and potential conflicts between the ACEP and the AHA/ASA policy recommendations have only fueled the tPA controversy 
  3. Advanced imaging practices will likely lead to improvement in determining which patients are likely to benefit or be harmed from IV tPA treatment
  4. You are much more likely to be sued for not treating a perceived IV tPA eligible patient than for treating someone who sustains an ICH after tPA treatment

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Upper GI Bleed in Pediatrics - Dr. Walker

6/8/2017

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1.  Signs and symptoms of an Upper GI bleed in the pediatric patient
            -most common presentation is hematemesis
            -melena also common presentation 
             -many things mimic GI bleed -> food coloring, raw meats, swallowed blood from oropharynx 

2.  Differential diagnosis for acute pediatric upper GI bleed
        -determine if variceal vs nonvariceal 
         -variceal bleed (uncommon but can be life threatening)-> portal HTN from congenital liver pathologies 
         -mucosal bleed -> gastritis, esophagitis, caustic ingestion, foreign body most common in pediatrics 

3.  ED diagnostic workup for an upper GI bleed in a pediatric patient 
       -CBC, BMP, LFT's, and Type/Cross essential to the workup

4. ED Management of Pediatric Upper GI bleed patient 
       -Place an NG tube 
       -Get GI, Surgery, and Interventional Radiology Involved early 
       -Octreotide and vasopressin are important treatments for variceal bleed 
      -For mucosal bleeds control acid production ​
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Carolinas Case COnference (Dizzy) - Dr. Cox

6/8/2017

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“You get to use the word ‘dizzy’ once.” Andrew Asimos
 
Categories of Dizziness
  • Vertigo
    • = Perception of movement
    • Due to dysfunction of an aspect of the visual, vestibular or proprioceptive systems
    • Need to distinguish if peripheral or central etiology
      • Peripheral causes:
        • BPPV, Vestibular neuritis/labyrinthitis, Perilymph fistula, Meniere’s disease
      • Central causes:
        • CVA/TIA, Head/Neck trauma (think dissection!), Vertebrobasilar insufficiency, Multiple Sclerosis, Mass, Chiari malformations, Migraine
      • Miscellaneous:
        • Drug-induced
    • BPPV accounts for the majority of cases BUT must have:
      • Short duration (<1min)
      • Triggered by head movement
                                                  * not worsened by movement
  • If does not fit these criteria, consider other diagnoses and dig deeper.
  • Key questions: Timing, trigger, and duration
  • Ask about associated symptoms such as vision changes, headache, ameliorating/aggravating factors, preceding illness
  • Cranial nerve exam (particularly CN II and III), cerebellar exam, and gait important
 
  • Disequilibrium
    • = Unsteadiness, imbalance, usually while walking
    • Due to dysfunction of sensory, motor control, or proprioception systems
    • More common in old people
      • Most commonly multisensory deficit e.g. diabetic neuropathy
    • Differential is broad (* below is not exhaustive):
      • Vascular: CVA/TIA, dissections, hypertensive emergency
      • Infectious: Syphilis
      • Metabolic/Pharm: EtOH, drug-induced
      • Endo: DM, hypothyroidism
      • Neuro: Tumor, Parkinson’s, Cerebellar ataxia, MS, neuropathies
    • A word about Romberg. It is influenced first by cerebellum, then visual, proprioceptive, and vestibular systems… You must have an intact cerebellum test other systems. If positive with eyes closed and open, cerebellum is not intact.
 
  • Presyncope
    • Sense of impending loss of consciousness
      • Distinguish if patient actually syncopized
    • Ddx: Vascular, autonomic dysfunction, cardiac
 
  • Lightheaded/Psychogenic Dizziness
    • NOT vertigo, presyncope or disequilibrium
    • Difficult for patients to articulate
    • Diagnosis of exclusion.
      • DDx includes hyperventilation, psychogenic, anemia, thyroid
 
Posterior Circulation Anatomy

Supplies:
1) Brainstem
2) Cerebellum
3) Thalamus
4) Auditory/vestibular structures
5) Visual occipital cortex
 
 
Neuro Exam for Posterior Circulation
  • Cranial Nerves
    • Key part of exam à localizes to the brain stem
    • Describe what you did:
      • Not “CNII-CNXII intact”
      • “EOMI, Palate elevates symmetrically, etc”
    • Visual fields are key     
      • Why? Field loss can be the only physical exam feature of CVA
      • Test UPPER and LOWER quadrants
  • Cerebellum
    • Subtle findings!
    • Think ATAXIA
      • Limb
        • Localizes to lateral cerebellum
        • Pick one exam: finger to nose, dysmetria, heel to shin
      • Truncal
        • Localizes to midline cerebellum
        • Ask to sit up in bed without aid of arms
      • Eye
        • Localizes to inferior cerebellum
        • Look for pathologic nystagmus
          • Vertical
          • Direction changing
 
  • Gait

Bias
  • We are all human, therefore we all have intrinsic biases
  • Stop points are critical and are an opportunity for executive override to protect against bias
    • Pick stop points that work for you and your work flow:
      • One-liners
      • Before finishing orders
      • Before landing on a discharge diagnosis: “What am I missing?”
      • Before discharge:  “Is this hospital course consistent with diagnosis?”
 

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Septic Emboli - Dr. Raper

6/8/2017

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When should I think about infective endocarditis and septic emboli?
-Consider in patients who raise your suspicion for sepsis and have any of these risk factors:
  • age>60
  • IVDA
  • Poor dentition
  • HIV/AIDS
  • Immunosuppression
  • Indwelling catheters/devices
  • Structural Heart Disesase
  • Chronic Hemodialysis
  • Hx of endocarditis
 
 
What exam findings are suggestive of IE?
-Some are more specific than others.  Roth’s spots, Osler’s nodes, and Janeway lesions are relatively rare but are essentially illness defining.  More sensitive but less specific findings include cardiac murmors, petechiae, splenomegaly, and splinter hemorrhages.
 
Who gets septic emboli?
-Patients with large lesions, unstable/multiple lesions, and left sided lesions are most likely to embolize secondary to higher left sided pressure gradients.
 
Where do the emboli go, and what does that look like?
- Right sided lesions (without PFO) go to the lungs, and typically manifest clinically as:
  • >2 imaging findings, often bilateral bilateral
  • Cavitary lesions
  • Nodules
  • Infiltrate
  • Empyema
 
-Left Sided lesions
  • CNS (45% mortality)
    • Ischemic Stroke/TIA
    • ICH
    • Meningitis/Abscess
    • Mycotic Aneurysms
  • Renal
    • Abdominal/Flank pain/Vomiting
    • Acute HTN (renal artery obstruction)
    • Hematuria/Proteinuria
  • Spleen
    • Abdominal pain
    • Infarct leads to abscess, which requires drainage
  • Mesentery
    • Pain out of proportion to exam
    • Surgical emergency
  • Mycotic Aneurysm
    • Infected material embolizes to downstream artery
    • Infection and inflammation extends into vessel, weakening it
    • Leads to spontaneous bleeding and persistent infectious nidus
  • Liver, Pancreas, Coronary Vessels, and Extremities are other less common embolic locations
 
Take Home Points
  • Appropriately diagnosing and treating IE/SE requires vigilance and a high index of suspicion
  • IE/SE is not just the disease of the young IVDA anymore
  • Anything is possible, and not in a good way… …take all complaints seriously in suspected sepsis
 

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  • RESIDENCY
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    • EMS
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      • Tox Faculty
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    • (All Others)
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    • PGY-3
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