Carolinas Emergency Medicine Residency

Weakness extravaganza - Dr. Asimos

8/25/2013

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Horizontal, forced gaze deviations with seizures are usually contralateral to the seizure focus, and epileptic gaze deviations are seldom sustained for more than a few minutes

A caveat is that temporal and parietal partial seizures don’t produce forced eye version, but can occasionally produce neglect, resulting in a tendency for ipsilateral eye deviation - but not a forced deviation

Guillain-Barre Syndrome (GBS) and myelopathies are frequently heralded by paresthesias of the limbs.
Any patient presenting with bilateral paresthesias, these two entities must be acknowledged in decision making.

The main morbidity ED physicians will encounter with GBS or Myasthenia Gravis is respiratory insufficiency requiring ventilator support.
Any ED patient diagnosed or presumed to have these diagnoses requires assessment of a:

Forced Vital Capacity (FVC)
Negative Inspiratory Force (NIF)
Maximum Expiratory Force (MEF).
Intubation is recommended by the “20/30/40 Rule" (FVC < 20 mL/kg, NIF < -30 cm H2O, or MEF < 40 cm H2O)

Locked–in Syndrome is due to a lesion of the ventral pons and “classically” consists of anarthria and quadriplegia, with preservation of consciousness and vertical eye movement.
This entity must always be considered in patients in a comatose-like state.

Ptosis and diplopia are frequent presenting symptoms of neuromuscular junction pathology (MG and botulism), along with other bulbar signs.
The “bulb” is an archaic term for the medulla oblongata, so the word bulbar refers to the nerves and tracts connected to the medulla, and also by association the muscles thus innervated (i.e. tongue, pharynx and larynx).
Bulbar signs include difficulty with phonation, dysarthria, and dysphagia.
Bulbar signs could also represent a brainstem lesion.

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Multiple Sclerosis - Dr. Allen

8/24/2013

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Dr. Allen

Definition:

Chronic inflammatory demyelinating disease.
Widespread effects on CNS.
Often relapsing and remitting

Epidemiology:

Affects more than 1 million worldwide.
Prevalence may be as high as >200 per 100,000.
Peak age of onset = third decade

Presentation:

Characterized by "attacks" often composed of optic nerve, brainstem or spinal cord abnormalities.
"Attacks often subactue in onset and resolve over 4-6 weeks.
Mimicked by a broad spectrum of diseases! Need to consider and exclude others first!
Treatment - begins with high dose IV steroids (Methylprednisolone 1,000mg) for 3-5 days

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Botulism - Dr. Kerns

8/24/2013

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Infantile Botulism

Consider botulism in the differential of any patient with bulbar palsy/descending paralysis
Three most common botulism scenarios:

Infantile
Food-borne
Wound

Newly approved botulism anti-toxin: BAT, an Fab immunotherapy against all 7 serotypes

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Pediatric M&M - Dr. Neal

8/24/2013

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16 yo with syncope

16 yo who passed out on airplane with lots of social stressors.

Keep your differential broad - avoid premature closure and don't get complacent just because the patient is a child.
Despite the patient's many social stressors and apparent anxiety, she still had a large Pulmonary Embolism.
PE in Kids

Very rare, but still occurs
Pursue risk factors
Symptoms are often the same as in adults
Central venous cath was highest risk factor in one study

Syncope as presenting symptom of PE

Associated with more severe disease.
More likely to have right heart strain.

A combination of biochemical markers, imaging, EKG, echo, hemodynamics should factor into patients trajectory and decision for lytics.
Indications for lytics in kids are only for 'life or limb saving' conditions.

13 yo with abdominal pain

"Chronic" abdominal pain over past 2-3 months.

Be aware of diagnostic momentum.....
For persistent abdominal pain, make sure that you consider conditions that are "outside" the abdomen.
Always, reconsider Pregnancy!
Always reconsider your diagnosis, particularly when the family is being "difficult."
Rhabdomyosarcoma

Most common soft tissue tumor in children
They are very difficult to diagnose!

Red Flags

Pain that awakens at night
Extremity dysfunction
Prolonged pain
Unusual fracture.

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"Low Risk Chest Pain" - Dr. Chang

8/19/2013

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Always beware of diagnostic momentum!
Young age alone does NOT rule out ACS

Very Low risk patients are defined and may be D/C'd with no further ED evaluation

<40 and negative cocaine
no history of CAD, no classic cardiac risk factors
NORMAL ECG (That means completely Normal!!)
Normal biomarker

Non-specific ST changes are NOT negligible in the symptomatic patient.

PITFALL: Placing too much emphasis on "atypical" symptoms for ACS

Things that Increase Likelihood Ratio for ACS/MI

Radiation of pain to BUE or RUE
Diaphoresis
Nausea/Vomiting
Exertional

NO Studies risk-stratify patients to NO risk.

Characteristics of pts D/C'd with missed MI

Young
Atypical

Know your ECGs! You need to strive to be the ECG Master in your hospital!
So invest some time and effort into it... Learn from the best: http://www.mededmasters.com/ecg-lessons-by-amal-mattu.html

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Chest Trauma - Dr. Colucciello

8/19/2013

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What's wrong with this picture?

Basics

Chest Trauma - often occurs with associated injuries!
May be asymptomatic or in severe distress.
Most important blood test in trauma = Type and Cross
Second most important test in trauma = Base deficit / lactate (strong predictor of occult shock, especially important in elderly).
ECG should be obtained on pts >45yrs, precordial tenderness
ELDERLY - check Geriatric Trauma Score!!!!

NEXUS Criteria for Chest Imaging
see article (http://archsurg.jamanetwork.com/article.aspx?articleid=1724982)
see review (http://www.2minutemedicine.com/nexus-chest-decision-criteria-sensitive-for-thoracic-injury/)
Tells you who does not need chest imaging.

If the patients LACKS the following, then you do not need chest imaging:

Age > 60
Rapid deceleration
Intoxication
Chest Pain
Altered Mental Status
Distracting injury
Chest wall tenderness

PTX

When called by EMS for concern for "decreased BS" requesting to "needle the chest" ask "WHAT IS THE BLOOD PRESSURE?" SHOCK is the most important factor in that equation.
SIZE Matters (when it comes to needle decompression of tension ptx) - use 4.5 cm catheter

Palpation is important! Sub Q air - fell for it!!
Inspection is valuable! Watch for paradoxical chest rise concerning for Flail segment.
Deep Sulcus Sign for supine CXR for Ptx
Use U/S for Ptx (more sensitive than portable CXR)

Traumatic Aortic Injury

Chest CT's primary role now is to evaluate for traumatic aortic injury!
Chest Pain + Neuro Deficit = Aortic Injury!!
TAI has 5% increase in Mortality per hour
50% of Traumatic Aortic Injuries have normal physical exam
7-15% of TAI will have a normal CXR
Main management is Control HR and BP (Esmolol or Labetolol) with goal of SBP around 100.

Rib Fx

More than 3 = admit
>55 yrs with more than 2 = admit
Upper rib / scapular fx - consider CT
Sternal Fx - check ECG
Posterior sterno-calvicular dislocation - CT!

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Herpes Zoster - Dr. Callahan

8/19/2013

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Complications of Zoster

Ramsay Hunt Syndrome (CNVII involvement, facial palsy, unilateral motor weakness, altered taste on ant 2/3 of tongue, deafness / vestibular problems - look in the ear!)
Herpes Zoster Ophthalmicus - CNV involvement - Hutchinson sign - need to do slit lamp and fluorescein exam - Ophtho follow-up!
Postherpetic Neuralgia (10-15%) can be difficult to treat! - Incidence not affected by any medication regimen
Disseminated Disease - diagnose with PCR, start IV acyclovir and admit.
Aspectic meningitis
Bacterial superinfection
Bell's Palsy
Transverse Myelitis
Motor neuropathy

Indications for Treatment

Age > 50
Moderate or sever pain
Severe rash
Involvement of the face or eye
Other complications of Herpes Zoster
Immunocompromised
Within 72 hours of onset is preferred (but if new lesions are being formed, there still may be benefit)

Medical Management

Antivirals - hasten resolution and decrease severity of acute pain

Acute zoster- Valacyclovir 1 g TID for 7 days (preferable for higher drug activity, ease of dosing) or Acyclovir 800 mg 5 times/day for 7-10 days (if no insurance)
Valtrex or Famvir are preferred for Herpes Zoster (but cost is a concern - acyclovir is less expensive)

Steroids? Simple answer "NO." - Harm likely outweighs benefit during ACUTE phase.

Pain Management:

NSAIDs
Opiods
Capsaicin (may be useful for post-herpetic neuralgia)
Gabapentin (may be useful for post-herpetic neuralgia)
Lidocaine pathches one intact skin

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Pediatric EM - Chad Scarboro

8/19/2013

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Pediatric myocarditis

Background

Inflammation of the myocardium
End Result is mycardial dysfunction and possible failure.
16-20% of presumed SIDs and 17% of Sudden Death in adolescents.
Viral infections are most prevalent cause of myocarditis (coxsackie virus is good board answer)

Clinical presentation

Most with viral prodrome 10-14 days prior to presentation (but with large range of 10-80%)
Chest pain may or may NOT be present.
83% are missed on first presentation.
66% have a NORMAL heart rate!
50% will have hepatomegaly!! {Get in the habit of checking for hepatomegaly and documenting it}
60% with tachypnea

ECG - 93-100% are abnomal, but often that is sinus tachycardia, so the diagnosis requires high index of suspicion.

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EMR Best Practices - Dr. Modisett

8/19/2013

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SOCIAL HISTORY

What counts as a social history: a lot!

Martial status
Employment
Occupation
Drugs, ETOH, Illicits
Schooling

Does it need to be in the Social Hx Section: No

It can be obtained from HPI (ex, 63 yo sent from Skilled Nursing facility... or, 4 yo who fell at Pre-School... all of that counts).

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M&M - Dr. Zahn

8/19/2013

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Case 1 - 61 year old with Rapid Heart Rate

When dealing with A-Fib with RVR, consider what is making the patient tachycardic, in addition to ensure you manage the arrhythmia.
Communication is key. Talk to transferring physicians/facilities. Clarify any discrepancies.
Acute limb ischemia is a time sensitive diagnosis. Order an arterial duplex and page Vascular.

Case 2 - 30 year old with abdominal and rectal pain

Be leery of the diagnosis of constipation. Be even more leery of multiple ED visits for the same complaint!
Mesenteric Ischemia

Arterial - ~85%
Non-occlusive ~ 15%
Venous thrombosis - very rare

Venous thrombus develops more insiduosly - should be higher on differential in those with vague abdominal pain complaints with pain out of proportion and a family/personal history of DVTs/hypercoagulable.

Case 3 - 63 year old with dyspnea and uri symptoms

For patients that are being admitted who are staying in the ED for prolonged periods, ensure that they are being reassessed.
It is also important that vital admission medications (ex, continued respiratory therapies) are ordered while in the ED.
Notes must be completed on all admitted patients before leaving the hospital.

ABG vs VBG

Venous blood gas is excellent for pH in most situations (excluding profound shock).
Utilization of pCO2 is cautioned except for screening for hypercarbia and trending the level.
Still need to obtain ABG for exact pCO2 level.
Encourage ABG in mixed acid base disorders and when performing acid base calculations that will change management.

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<<Previous

Weakness extravaganza - Dr. Asimos

Multiple Sclerosis - Dr. Allen

Botulism - Dr. Kerns

Pediatric M&M - Dr. Neal

16 yo with syncope

13 yo with abdominal pain

"Low Risk Chest Pain" - Dr. Chang

Chest Trauma - Dr. Colucciello

Herpes Zoster - Dr. Callahan

Pediatric EM - Chad Scarboro

Pediatric myocarditis

EMR Best Practices - Dr. Modisett

SOCIAL HISTORY

M&M - Dr. Zahn

Case 1 - 61 year old with Rapid Heart Rate

Case 2 - 30 year old with abdominal and rectal pain

Case 3 - 63 year old with dyspnea and uri symptoms

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