Carolinas Emergency Medicine Residency

Kidney Stones - Dr. Baxley

7/25/2013

We all know that Flank Pain and Hematuria = Kidney Stone. Right?

First Time Flank Pain
10-30% of patients, when CT scan obtained, had an alternative diagnosis (even with good pre-test probability for kidney stone)

10-15% - GYN conditions
9% - Pyelo
5% - Appendicitis
Diverticulitis, Pancreatitis, Renal Cell Carcinoma
Vascular Disease

Low Threshold to image patient with First Time Flank Pain - CT would be the preference!

Hematuria

Urinalysis cannot be used as the solitary diagnostic tool for Kidney Stones.
It is neither sensitive nor specific enough to rule it in or rule it out.
In 43% of patients diagnosed with AAA, hematuria was present!!

Repeat Renal Stones

50% of Kidney Stones will recur within 5 yrs
This had lead to numerous patients having multiple CT Scans (naturally, this is a potential problem)
Of patients who had a history of kidney stones who received CT to work up recurrent kidney stone, 90% did not have change in their management.

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Pediatric M&M - Dr. Agarwal

7/25/2013

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8 day old with Respiratory Distress, Mottling, and Hypoxia
Intermittent grunting
Poor feeding
No fevers
Jaundiced

DDX:
Very Broad and includes terrible potential problem. Keep the following in mind!
THE MISFITS

Trauma
Heart Disease, Hypovolemia
Endocrinopathies
Metabolic
Inborn Errors of Metabolism
Sepsis
Formula Mishaps
Intestinal Catastrophes
Toxins/poisons
Seizures

Concern for Cardiac Etiology?

Check 4 extremity BPs
Pre-Ductal and Post-Ductal Sats
Hyperoxia Test (see PedEMMorsel)
Look for Hepatomegaly!

_____________________________________________________________

2 year old s/p Fall
Fall not witnessed
Possible LOC
Fussy initially, then baseline
Blood tinged emesis x 1
Neuro exam unremarkable

To CT or Not to CT?
PECARN
Minor Head Injury Rule - see PedEMMorsel

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Fun with Documentation - Dr. Sullivan

7/25/2013

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Documentation = Communication

Tells the story
Medico-Legal
Billing / Compliance
Reimbursement

Review of Systems Pointers

"All systems otherwise negative" : can be used, but don't be a cheater! Develop a system that works for you and covers the appropriate amount of systems
"High Acuity Caveat" : Unresponsive, Intubated, AMS - these count. Language Barrier does not count!!

Wound Repair

The length drives the billing - But measure it after the wound is closed!
Layers, Revising the Wound, Contamination? - lead to complexity
These are not Time-Based codes. Conscious Sedation is a Time-Based code (need to document start and stop time)

Pitfalls

Review of systems : Do NOT RUBBER STAMP
HPI : try to get at least 4 elements
PMHx, Family Hx, Social History : if you put a pt in OBS you need ALL three!
Medical Decision Making : Reference the reviewed documentation, labs, and images. Document your Ultrasounds!!
Watch your dictation: particularly left vs right

Document integrity is important and defines you as a physician.
Avoid cloning notes, document what you do and that will suffice.

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Back Pain - Dr. Carey

7/25/2013

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Basics

~3% of all primary care visits are for lower back pain, the vast majority of which is mechanical or non-specific in origin.
>90% of low back pain has spontaneous resolution within two weeks regardless of treatment modality.
Less than 5% have serious pathology.

EM Perspective

Time-sensitive emergencies = epidural abscess, cauda equina syndrome and vertebral osteomyelitis.

Red Flags
-Trauma
-Unexplained fever
-Immunosuppression/DM/steroid use
-IVDU
-Age >70
-Focal neurologic deficit
-History of spinal instrumentation
-Duration longer than 6 weeks

Limit imaging to patients with the ‘red flag’ symptoms, MRI is the test of choice. If MRI is unable to be obtained, CT is the second choice.

Greater than 90% of disk herniations occur at L4-5 and L5-S1. Test these motor distributions by examining ankle and great toe dorsiflexion as well as ankle plantarflexion. Sensory distributions run along the posterior and lateral aspects of the lower extremity.

2007 ACP/APS Joint Practice Guidelines recommend NSAIDs as the first line of therapy for acute lower back pain. Studied regimens were Ibuprofen 400-600mg QID or Naproxen 220-500 mg BID for 2-4 weeks. Other studies have shown that NSAIDs combined with Skeletal Muscle Relaxants were the most effective regimen with symptom relief at one week.

The classic triad of back pain, fever, and neurologic deficits only occurs in 13% of spinal epidural abscesses.

The most common symptom of cauda equina syndrome is urinary RETENTION. If this pathology is suspected, provide the patient with 10mg Decadron IV prior to MRI scan to prevent progression.

All pediatric low back pain is ‘red flag’ back pain. Up to 31% of these patients have a specific diagnosis such as tumors, discitis or malignancy.

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Envemonations

7/17/2013

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Crotalid Envenomations Dr. Beuhler

2 classes of poisonous snake in NC - pit vipers & coral snakes. Pit vipers make up the majority of bites we're going to see (Eastern diamondback, Timber rattler, Pygmy rattlesnake, cotton mouth & copperhead)

The venom in the pit vipers is made to digest tissues - has proteolytic and hyaluronisdase activity - this leads to localized extremity dysfunction & systemic effects (emesis, tachycardia, hypotension, flushing, mytoxicity, renal toxicity, allergic reactions, angioedema, coagulopathy, and renal dysfunction)

Pit viper venom has a degree of neurotoxin activity as well which can lead to weakness, ptosis, and fasiculations as well as localized numbness at bite site

Important steps in management of bite care:

First aid: NO ICE; NO TOURNIQUET; Elevation of affected site - don't bend major joints 90 degrees - need to make sure there is good lymphatic flow
Grade bite - this will help determine administration of Crofab, length of observation vs admission

Mild - mild swelling, no systemic involvement or lab abnormalities
Moderate - <50% limb involvement, minimal systemic involvement
Severe - >50% of limb involvement (crosses major joint), lab abnormalities, systemic effects

3. Decision to treat with Crofab is multifactorial - should be used only in high risk populations or those with moderate to severe envenomations.

Don't just treat lab abnormalities

a. Crofab = 10cc/hr; 4 vials & reevaluate after 1-2 hrs.
Remember crofab interrupts coagulopathy & helps lower compartment pressures & possibly helps with pain - it will NOT stop or reverse local tissue destruction

If you DC home have follow up in < 24 hrs for wound reevaluation

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Dr. Gibbs' Trauma Pearls

7/16/2013

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Neck trauma - zones of the neck:
    I - Inferior aspect of cricoid cartilage to thoracic outlet
    II - Cricoid to angle of mandible
    III - Angle of mandible to base of skull
   *Zone II is more easily evaluated by surgical intervention; zones I and III by
    imaging"

Traumatic Eye Injuries:
    1. Hyphema - needs optho follow up - possible complications include
        a. Corneal staining, Increased pressure and acute glaucoma, Rebleeding
    2. Globe rupture - DO NOT MEASURE PRESSURES
    3. Medial canthus injury - think about damage to lacrimal duct

Face Injuries:
    1. Lefort Fractures:
        I. Fracture line passes through the alveolar ridge, lateral nose and inferior
            wall of maxillary sinus.
        II. Fracture arch passes through posterior alveolar ridge, lateral walls
            of maxillary sinuses, inferior orbital rim and nasal bones
        III. Fracture line passes through nasofrontal suture, maxillo-frontal
             suture, orbital wall and zygomatic arch.
    2. Mandibular Fractures - things to look for:
        a. Sublingual hematoma (pathognomonic), malocclusion, tongue depressor
           test (pain with biting down), limited mouth opening, mental nerve
           paresthesias
    3. Auricular Hematoma & septal hematomas - drain to avoid pressure necrosis
        and cauliflower ear & saddle nose deformity respectively

Aortic Injury - CXR findings
    1. Mediastinal widening
    2. Loss of aortic knob
    3. R mainstem bronchus misplaced
    4. Apical cap
    5. Tracheal deviation
    6. L pleural effusion

Neuro Trauma:
    1. Hangman's Fracture - pedicle of C2 - caused by extension mechanism
    2. Jefferson's Fracture - fracture through posterior & anterior arches of C1 > caused by axial loading - the ring breaks outward
    3. Pseudosubluxation - normal mobility of C-2 on C-3 in flexion which be mistaken for pathologic motion; (is normal in children < 8 years old);
    4. When managed properly SDH = greater morbidity than epidurals

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Kidney Stones - Dr. Baxley

Pediatric M&M - Dr. Agarwal

Fun with Documentation - Dr. Sullivan

Back Pain - Dr. Carey

Envemonations

Dr. Gibbs' Trauma Pearls

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