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M&M - Dr. King

8/28/2014

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Staph Aureus Infections
- Hospital acquired infections relatively stable over the past 5 years
- Community acquired infections on the rise
- One ED visit increases risk 4-fold -  Protect your patients!
- Patients on hemodialysis have a 50-180 fold increased risk for developing infective endocarditis 
… be wary the vague presentation of endocarditis!

Globe rupture:
- Protect without pressure!
- Prevent vomiting/valsalva
- Don’t forget your tetanus
- Avoid ultrasound (just don't tell Dr. Tayal)


Hypocalcemia:
- Potassium is not the only electrolyte that causes rhythm disturbances
- When facing new EKG changes, consider magnesium and calcium

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CODE PE - Dr. Troha

8/28/2014

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Thanks to Dr. Troha's diligent efforts, we will be initiating a new protocol to help streamline the decision making and coordination of care for patients with small PEs, Submassive PEs, and Massive PEs. 

Step 1: Risk stratification
- Obtain BNP, troponin, perform echo and assess vitals

Step 2: If massive or submassive, call out Code PE. Pull Code PE pack that contains treatment algorithm and lysis checklist

Step 3: Administer heparin

Step 4: Assess bleeding risk using lysis checklist

Step 5: If decision is made to give IV lysis, stop heparin drip during infusion

Step 6: If decision is made to administer catheter-based lysis, contact interventionalist on call

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EM Documentation - Dr. Sullivan

8/21/2014

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1. Billing is fairly algorithmic and requires good communication to coders about the work done.

2. Documentation for coding is not always the same as documentation for good care.

3. Avoid all rubber stamp, Copy/Paste maneuvers, and “Dragonisms” if you can. Be thorough and vigilant!

4. Medical Decision Making drives the chart complexity and reflects the care you give.


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CODE COOL UPDATES - Dr. Pearson

8/21/2014

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** The New Code Cool is being launched across our system.
** Focus on: Cooling times, resuscitation, hemodynamic management, ventilator management.
** Literature supports cooling to either 33C or 36C; we will continue to cool to 33C pending additional ongoing studies.


1.       Use new “Code Cool – Induction” order set.

2.       Activate Code Cool via PCL line (essential for nursing resources, ICU bed allocation, and patient tracking).

3.       Consult cardiology and intensivisits on all Code Cools.

4.       Cool to 33C unless intolerance to cooling (dysrhythmia), sepsis, or bleeding, then cool to 36C.

5.       Induce cooling with ice packs, cold fluids 30cc/kg, and long-acting neuromuscular blockade (vec 10 mg IV)

6.       Goal MAP > 70 mmHg at all times (> 80 mmHg if chronic HTN)

7.       Treat blood pressure aggressively with norepinephrine (not dopamine)

8.       Titrate FIO2 on ventilator down to 40% if possible while maintaining O2 sat > 95%.

9.       Code Cool/STEMI: Activate Code STEMI also with age < 75, downtime < 20 min; others discuss immediately with intensivisits; don’t delay cooling.

10.   Don’t delay initiation of cooling for CT imaging. Recall, few VF/VT arrests (< 5%) are due to PE.

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Pediatric M&M - Dr. Smith

8/21/2014

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1. Papilledema is very specifically optic disk swelling in the presence of ICP.
2. Vomiting and abdominal distention should always worry you.
3. Bilious vomiting is a surgical emergency 40-60% of the time
4. Think non-typable haemophilus when you see conjunctivitis and otitis in tandem.
     - See Conjunctivitis-Otitis Morsel

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Pediatric Ataxia - Dr. Neal

8/7/2014

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Common causes for acute ataxia in children are as follows:
  • Acute cerebellar ataxia
  • Drug ingestion
  • Guillain- Barre syndrome
Life threatening causes are rare but should be excluded.  
They include:
  • Vascular events
  • Infection
  • Processes leading to increase intra-cranial hypertension.
Acute cerebellar ataxia is a diagnosis of exclusion.
Ataxia management follows a stepwise algorithm.

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Labs in Trauma - Dr. Colucciello

8/7/2014

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COre Concepts

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  • Type and Cross and Lactate most important lab studies in trauma.
  • Use clinical decision rules to guide imaging in trauma.
  • Clinical judgment must always be used to supplement CDRs.
  • Use radiation reduction strategies to avoid unnecessary radiation in children.
  • Be thrifty in imaging children and expansive in imaging elderly.

Some Specifics

Type & Screen 
- cheaper and doesn't hold blood and doesn't do whole cross match
- Consider in severe mechanisms, blood loss, tachycardia, concern for intraabdominal injury

Type & Cross 
- holds blood
- Consider in coagulopathy & severe trauma; significant mechanism with known blood loss; base deficit < -6, lactate > 4, low Hgb; +FAST

Serial H/H 
- not routinely used 
- consider in pelvic fractures (q1hr)

CBC 
- WBC rarely useful; 
- Consider to use to look at platelets (head trauma, liver disease, long bone Fx); 

PT/INR 
- For liver disease or anticoagulated; 
- Get coags for severe head trauma

Lactate 
- Strongly associated with blood loss and mortality in the setting of trauma

Urinalysis
- adult patient not in shock - gross hematuria matters; 
- microscopic hematuria - in stable patients don't worry; 
- in adult patients with shock - get CT scan - marker for intraabdominal injury; 
- in pediatric population with microscopic hematuria - need CT scan - marker for intraabdominal injury - most commonly splenic injury

Special Trauma COnsiderations

Electrical injuries 
- CPK now and at 4 hrs 

Elderly 
- get PT/INR and lactate > 2 is concerning 

Pediatric 
- UA, LFT, lipase, Hgb

Spearing injuries
 - serial pancreatic enzymes 
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Pesticides - Dr. Buehler

8/7/2014

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Organophosphates
  • DUMBBBELLS  - Diarrhea, Urination, Miosis, Bronchorrhea, Bronchospasm, Bradycardia, Excitation, Lacrimation, LOTS of Emesis, Salivation
  • Can have persistant symptoms that can happen days after initial exposure 
  • Intermediate syndrome - develop days after exposure
  • Chronic symptoms - neuropsychiatric changes 
  • Treatment - remove exposure!!!
  • Muscarinic antagonist/ blockers; anticholinergics
- Atropine - MUCH higher doses than normal
- Valium
- Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion

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M&M - Dr. Kiefer

8/7/2014

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Case 1: Inferior shoulder dislocation and traumatic pneumothorax

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When Evaluating Complex Patients:
-        Always regroup and reassess.  It is okay to start over from scratch.
-        Ensure work up is complete for life threatening pathology before patient leaves the ED

Inferior Shoulder Dislocation:
-        High incidence of vascular and nerve injury.  You must document a thorough exam!
-        Reduction via hyperabduction with traction-counter traction or convert to anterior dislocation and then reduce.

Occult Traumatic Pneumothorax (i.e. visible on Chest CT but not on supine CXR):
-        Supine CXR has sensitivity of ~50%
-        Supine Ultrasound has sensitivity of ~90%.  We should be doing FAST with thoracic windows on all patients, especially those with no plans for CT Chest

-        Know/ Reference our trauma guidelines!
-        No hard and fast guidelines in regards to management.  Needs a chest tube if progresses (visible on CXR or if patient has respiratory distress).
-        Most still feel positive pressure ventilation with occult PTX deserves a chest tube... although debated.

Case 2: Black Dot Poison Ivy

-        Treat contact dermatitis with high potency topical steroid (ex. Clobetasol) for 2 weeks.
-        If treating with PO steroids remember needs tx for 2-3 weeks with taper.
-        Don’t forget adjuncts: Zanfel, Ivy Block (Research supports usage of both).

Case 3: Hx of Devic disease with missed posterior circulation stroke

-        Know your limitations and don’t develop tunnel vision.
-        A thorough CN II exam involves visual acuities, visual fields, light reflex and color testing.
-        Optic neuritis typically has pain with eye movement (92%) and impaired color vision (Red first).
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Airway COurse - Basics: Dr. Gibbs (Airway Master)

8/1/2014

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Core Concepts

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  • First Do NO Harm!
  • ED intubations are High-Risk
  • Assessment = Anatomy & Physiology
  • Hypotension is a significant cause of increased mortality
  • Use "sophisticated Pre-oxygenation" - good positioning, Bag-valve mask oxygenation and continuous apneic oxygenation are essential

The stakes are high!

  • Risk of Adverse Events (aspiration, desaturations, esophageal intubation, hypotension, dysrhthmia, arrest) increases significantly with each attempt.
  • One study showed: 1st attempt - 14%; 2nd - 47.2%; 3rd - 63.6%; 4th - 70.6%

Stepwise Assessment Goals

  1. Is Intubation Required?
    • Failure to protect airway
    • Traumatic Brain Injury with a GCS </= 8
    • Inadequate oxygenation
    • Inadequate ventilation
    • Uncontrollable agitation
    • Anticipated course
  2. Will it be Difficult?
    • Difficult Bag-valve mask?
      MOANS - Mask Seal, Obesity, Aged, No Teeth, Stiff Lungs
    • Difficult supraglottic adjunct insertion?
      RODS - Restricted, Obstruction/Obese, Distorted, Stiff Lungs
    • Difficult Laryngoscopy?
      LEMON - Look externally, Examine (3-3-2), Mallampati, Obstruction, Neck mobility
      3-3-2 rule - Mouth opening <3 = DL difficult; Mandible <3 = Tongue in your way; Thyromental distance < 2 = Anterior Airway.
      Criteria most associated with difficult intubation = Large teeth, small mouth, and short neck!
    • Difficult Surgical Airway?
      SHORT - Surgery previously, Mass (ex, goiter), Access/Anatomy, Radiation, Tumor
      
  3. Best Technique?
    • Neuromuscular blockade (Y/N)?
    • Laryngoscopy vs adjunct?
    • DL vs VL?
    • Double Set-up (with cric ready)?

  4. Will Physiology Suffer?
    • Hypotension?
    • Desaturation?
    • Aspiration
    • Dysrhythmia
    • Increased Cardiac Demand
    • Increased ICP
    • Increased IOP
    • Drug Effects - hyperkalmia, myoclonus, rigid chest, adrenal suppression

  5. Best Rescue Strategy?
    • Must contemplate BEFORE you start!
    • Mastery of 3-4 airway rescue devices will get you out of a jam 99.9999% of the time...

Anticipate Trouble!!

Always ask yourself:
  1. Do I need more help?
  2. Do I need more equipment?
  3. Do I need a different plan?
  4. Does the patient need additional resuscitation before proceeding!
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction