Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Carolinas Case Conference - Dr. Nichols

8/27/2015

Wellens Syndrome
-Remember, there are both Type A and Type B Wellens findings on EKG
-Both are extremely high risk for unstable LAD occlusion and reperfusion
-Treat like a ACS
-Emergent cardiac consultation for catheterization
-Beware the Wellens patient that develops chest pain

Medical/Trauma Resuscitation Conundrums
-Never let an initial impression turn off your medical thinking
-If the clinical trajectory isn't making sense, revisit your diagnosis and plan
-Ongoing hypoxia and hypotension demands a full reevalution, consider repeating bedside imaging and ultrasound is your best friend
-Upright film more sensitive than supine for blood in the chest, US even better
-Hemothorax rules: 1500 cc immediately, or 200 cc/hr x 4 hours = OR

Neuro Imaging - Dr. Asimos

8/27/2015

The mnemonic for systematically evaluating a non-contrast head CT is “Blood Can Be Very, Very Bad”.

A Reassuring CT:

·         No Blood is seen

·         All Cisterns are present and open

·         Brain is symmetric with normal gray-white differentiation

·         Ventricles are symmetric without dilation

·         No hyperdense Vessels are present

·         No Bone fractures

Benign Headaches in the ED - Dr. Goldonowicz

8/27/2015

- Only approximately 5% of all headaches that present in the ED are true emergencies
- After evaluating for potential emergencies and performing a full neuro exam, pause and consider if any of the following Red Flags are present:

First or worst
Neuro abnormalities
Associated symptoms
Persistent location/time of day
Unresponsive to treatment
Cancer, HIV, Trauma
Change in pattern, frequency, severity

To diagnose migraine, need 5 separate episodes of headache characterized by:

4 - 72 hours in length
Unilateral
Pulsating
Moderate or severe
Aggravated by routine activity
With nausea/vomiting and/or photophobia/phonophobia

"Migraine” or undifferentiated benign headache, you can treat the same way in the ED

Best evidence for acute headache treatment includes the following:

Dark and quiet room
1L Crystalloid
10mg IV or PO Reglan (or Compazine)
25mg IV or PO Benadryl +/-
30mg IV Toradol OR 550mg PO Naproxen OR 600mg PO Ibuprofen
Consider 10mg IV Decadron to prevent short term headache recurrence

Avoid narcotics and barbiturates out of concern for dependency and rebound effect

Snake Bites - Dr. Kallgren

8/27/2015

Epidemiology: vast majority of snake bites are from nonvenomous snakes, fatalities extremely rare
Crotalids (vipers) have hemotoxic venom, Elapids (cobras) have neurotoxic venom
Six venomous species in North Carolina, five are vipers so treated with CroFAB

Field treatment: don’t make things worse, get to the nearest hospital

In the hospital:

1.     ABCs
2.     Wound assessment and pain control
3.     Labs to assess for coagulopathy and rhabdomyolysis
4.     Call poison control – should always talk to toxicologist
5.     CroFAB vs observation only

- Mild/dry bite: no CroFAB, just observation
- Moderate/severe: one or more doses as needed based on wound progression

CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents

TNFa pilot study: active now, enrolling nonpregnant healthy adults

Trauma Imaging - Dr. Gibbs

8/20/2015

GCS = 15: 5-6% [+} CT, <1% surgery
Both the New Orleans and Canadian Head CT Rules are highly SENSITIVE for important TBI... the later is more SPECIFIC.
C-Spine Injuries: 1% children, 2% adults, 4% elderly.
NEXUS Clinical Decision Rule is effective in the elderly.
NEXUS does not have enough data for children < 8 years of age.
NEXUS Chest criteria is here! Use it!
No Clinical Decision Rule for Abdominal injury.
CT Abd best for Solid organs, but can miss Diaphragm & bowel injuries

Carolinas Case Conference - Dr. Beverly

8/20/2015

Bariatric Patients

Operations for weight loss include a combination of volume restrictive and nutrient malabsorptive procedures that affect satiety, absorption, and insulin sensitivity hormonal or enteric derived factors, in conjunction with behavior modification to achieve and sustain weight loss.
Patients need a multi-disciplinary team to provide extensive education on nutrition, psychological deterrents, and lifestyle modification.

Roux-en-y is most common performed bariatric procedure.
Common complications include marginal ulcers, anastomotic narrowing, obstruction, VTE/PE and internal hernias.
Management in the ED should include specialized CT protocols and early involvement of patient's surgeons.

Aortic DIssection

Type A involves the ascending aorta and Type B does not.
Risk factors involved hypertension, cocaine use, congenital defects, pregnancy, prior heart surgery and prior heat catheterization.
Most sensitive symptoms include chest pain, “worst pain ever”, and abrupt in onset.
CXR will commonly show widened mediastinum but can be normal.
Test of choice is CT angio.
Treatment in the ED includes rapid vascular consultation, pain relief, and blood pressure control.

Sharpen Your Calipers - Dr. Littmann

8/20/2015

Bifascicular Block and Second Degree AV Block

1.     In asymptomatic individuals, chronic bifascicular block does not usually require cardiac work-up; the prognosis is generally benign

2.     The following high-risk features, however, warrant urgent evaluation:
a.   Bifascicular block and syncope
b.   Bifascicular block and intermittent second degree AV block
c.   1:1 AV conduction at slower sinus rates but higher grade block (i.e., 2:1 AV conduction) at faster
sinus rates (“acceleration-dependent AV block”)

3.     Evaluation and management of patients with bifascicular block:
a.   Actively search for nonconducted P waves in the 12-lead ECG
b.   Always review telemetry strips and actively search for episodes of second degree AV block
(blocked P waves)
c.   In symptomatic patients with bifascicular block who develop acceleration-dependent second
degree AV block and a very slow ventricular rate, carotid massage or IV beta blocker can
paradoxically restore 1:1 AV conduction
d.   Patients with bifascicular block and syncope require admission and cardiology consultation for
possible pacemaker implantation
e.   Patients with bifascicular block and intermittent second degree AV block require cardiology
consultation for possible pacemaker implantation

The Pacemaker ECG

1.     Ventricular pacing: always try to determine what the atria are doing

2.     Sinus P wave in front of each paced QRS complex indicates dual chamber (A-V sequential) pacemaker where the ventricular pacer is tracking sinus rhythm

3.     Two pacer spikes about 5 mm apart indicate AV sequential pacing

4.     If there are no P waves or 2 pacer spikes, search for the presence of retrograde P waves after the paced QRS complexes; retrograde P waves are sharp negative in the inferior leads (in II, III and aVF) and usually upright in V1

5.     If there are no P waves in front of the paced QRS complexes and no retrograde P waves present, always consider the possibility of underlying atrial fibrillation

team challenge core concepts

8/6/2015

1. Pediatric Chest Pain - Myocarditis

Difficult diagnosis to make and often missed, occasionally with fatal consequences. Remain vigilant!
ECG is most sensitive study, though still only 90% Sinus tachycardia may be only sign.
Viral etiology most common, though can be bacterial, autoimmune or toxic.
Treatment is supportive, with pediatric cardiology involvement early.
Lyme carditis presents most commonly as complete heart block, complicating 1% of Lyme disease cases.
Other rare causes of carditis include Rickettsial disease, Chagas disease, Dengue fever, West Nile virus and Chikungunya.

2. Neuroleptic Malignant Syndrome

Multiple diagnostic criteria, but all have hyperthermia and muscle rigidity as core components. Other elements are altered mental status/agitation, autonomic instability, dyspnea, dysphagia and incontinence.
Typical antipsychotics are the most frequent culprit, but can be seen with all antipsychotics as well several other medications. Also seen following withdrawal of Parkinsonian medications (L-dopa).
Supportive care is paramount! Fluid resuscitate, cool patient and consider intubation/paralysis to prevent complications associated with severe muscle rigidity (rhabdomyolysis). Dantrolene/bromocriptine/amantadine discussed in literature, but secondary to symptomatic support.

Carolinas Case conference - Dr. robertson

8/6/2015

1. Foreign Body Ingestion
- Think about with wheezing, drooling, stridor OR a good story.
A. Esophageal:

Objects: Tacs, pins, pills, magnets, batteries
Remember that batteries are TIME SENSITIVE (<2hrs)
Size: > 6cm long, > 2cm in diameter cannot cross the pylorus

B. Tracheal:

Start with a AAS, if nothing think about Inspiratory and Expiratory films.

2. Pulmonary embolism:

Need an angiogram? Use GFR to assess whether the kidneys are “too sick” for contrast (GFR< 30).
GDE: RV size (> LV base and chamber), septal bowing, RV function (TAPSE > 16mm),

3. Pyloric Stenosis:

More common in males, typically showing up in first 2-8 weeks.
Non-bloody/Non-bilious vomiting, but kids are hungry after they vomit
50-90% have a palpable olive, look for visible peristalsis on the abdomen
Key is electrolyte replacement: 20cc/kg NS bolus then either D51/2NS or D10NS drip at 2-4x maintenance depending on fluid status.