Carolinas Emergency Medicine Residency

Carolinas Case Conference - Dr. Goode

9/29/2016

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In the management of Submassive and Massive PE:

Emergency physicians can reliably perform and interpret goal-directed echocardiogram to diagnose RV strain...so do it.
Avoid positive pressure ventilation and IV fluids in shock, start vasopressors early!
Unless contraindicated, always consider thrombolysis to unload that RV.

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Transvenous Pacing - Dr. Pecevich

9/29/2016

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Transcutaneous pacing: painful, difficult, complicates things. Needs 10x the milliamps.
Don’t get behind -- concerned about an MI? Mortality can be significant! -- fatal bradycardia
Place the sheath (6 french, not 9 french cordis) and be prepared
Use your drugs -- push dose epi / isoproterenol. Dopamine?--don’t bother.
Location matters: R internal jugular or L subclavian. The wire has memory.
Not so fast with the Cordis -- use 6 French, 9 French is too wide
3 dials: rate, output, sensitivity. 80 beats. --- Start at 20 mA, decrease until capture loss

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TIA in 2016 - Dr. Asimos

9/29/2016

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None of the current short term risk stratification tools for TIA perform well enough to identify patients for outpatient versus pre-discharge work-up.
Large artery atherosclerosis (usually carotid bifurcation stenosis) accounts for the largest proportion of early strokes after TIA; therefore, a crucial part of the pre-discharge work-up is assessment for carotid stenosis.
Level C data indicate carotid ultrasonography, MRA and CTA have similar accuracy for carotid screening.
An EKG and continuous cardiac monitoring are indicated while a TIA patient is being evaluated in the ED or observation unit. Ambulatory or continuous cardiac telemetry for a few weeks after TIA or minor stroke detects AF significantly more frequently than conventional AF evaluation methods

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1.       Be wary of ECG Early Depolarization (ER) pattern limited ONLY to the inferior limb leads. ER is most typically found in anterolateral precordial leads, and may extend to inferior leads (roughly 50% of cases). Rarely is ER found ONLY in inferior leads.

2.       In the setting of RBBB, follow typical interpretation scheme for myocardial injury, as suggested by the Universal Definition of Myocardial Infarction statement paper.

3.       LVH is typically associated with ST amplitude changes DISCORDANT with the major forces of the QRS complex. That is, when the QRS is predominantly upright, the ST segment may be depressed; when the QRS is predominantly down going, the ST is often elevated.

4.       When in doubt regarding the ECG diagnosis of an occluded epicardial coronary artery (STEMI call??), engage in immediate discussion with your interventional cardiology physician colleagues. These decisions are not always straight forward or easy. Share the ECG image with your cardiologist, and provide clinical scenario background to inform the decision you all will make together.

5.       Francis N. Wilson MD (1890 – 1952): originator of Wilson’s Central Terminal (reference electrode for unipolar precordial leads)

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Submersion Injuries - Dr. Awad

9/15/2016

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Prompt rescue, bystander CPR, and cerebral reperfusion/oxygenation are most important for survival.
Hypoxia and Acidosis are main mediators of injury, and most important to treat.
No cervical collar unless there is trauma.
Keep an open mind: check glucose, UDS, ETOH and consider antecedent events like MI or seizure!
You’re not dead until you’re warm and dead (34°C), but then consider cooling the comatose.
No empiric antibiotics, steroids, barbiturate comas, or ICP monitoring.
Survival highly unlikely with >25 minutes of resuscitation.
Asymptomatic patients can be observed for 4-6 hours and discharged.

Additional coverage of Submersion Topics:
See PedEMMorsels - Submersion Basics
See PedEMMorsels - C-Spine Injuries and Submersions
See PedEMMorsels - Prolonged QTc and Submersions
See PedEMMorsels - Submersion Prevention

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The Opioid Epidemic - Dr. Griggs

9/15/2016

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Patients with chronic pain are at higher risk of opioid misuse, including dose escalation and self medication of negative emotions.

Responsible opioid prescribing in the ED entails maximizing the use of opioid sparing medications before progressing to opioids.

Tylenol and Ibuprofen show greater efficacy in nociceptive pain.

Educating patients on cognitive and emotional aspects of pain and setting expectations for functional improvement, can help to reduce use of opioids.

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Carolinas Case COnference - Dr. Mollo

9/15/2016

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When approaching patient's with vague neurological symptoms, try to localize a lesion or overriding, unifying pathology that could explain the process.
Be prudent to identify objective neurological findings.
Think of myasthenia gravis in patients with primarly bulbar or ocular symptoms

Most AV Fistula bleeding can be stopped with direct manual pressure
More complicating bleeding may require tourniquets, figure-of-eight suture or reversal/hemostatic medications
Ongoing bleeding or hemodynamic instability requires vascular surgery consultation

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Pregnancy Over 35 - Dr. Pelucio

9/8/2016

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Advanced Maternal Age

Societal impact of pregnancy in advanced maternal age
Risks of infertility and dangers delaying reproduction are rarely taught even at college or professional graduate level
Older gravidity is always associated with higher risk
These risks include:
1. Miscarriage
2. Pre-eclampsia
3. Small for gestational age (SGA)
4. Gestational diabetes
5. Caesarean section
Advanced maternal age and IVF is NOT associated with increased risk of ovarian or breast cancer

Peripartum Cardiomyopathy

Peri-partum Cardiomyopathy (PPCM) is on the rise, possibly associated with increase in maternal age
Risk factors for PPCM include:
1. Black race
2. Advanced maternal age
3. Tocolytic therapy
4. Twin pregnancies
Early signs of PPCM mimic pregnancy
Orthopnea, persistent dyspnea, and tachypnea are not typical for normal pregnancy
Echocardiogram is the Gold Standard for LV systolic dysfunction
Treatment includes BP control, afterload reduction, diuresis, possible anticoagulation
Black race and indigence associated with poorer prognosis

Assisted Reproduction

IUI- intrauterine insemination after ovarian stimulation with clomiphene
IVF- more potent ovarian stimulation with both egg and sperm being handled outside uterus
Ovarian Hyperstimulation Syndrome
1. Associated with IUI and IVF
2. Pathophysiology is associated with increased vascular permeability mediated by hCG or LH
3. More prolonged and severe in cycles when conception occurs
4. Nausea, vomiting, abdominal bloating in mild to moderate cases; significant ascites and pleural effusions in more severe cases
Risk of ectopic, interstitial, cervical, and heterotopic pregnancies are increased in ART

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Carolinas Case Conference - Dr. Goode

9/8/2016

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1. When resuscitating DKA patients, avoid chloride-rich fluids as to not worsen acidosis.
2. Fight the urge to give bicarb! It does not address the pathophysiology of DKA and will likely harm the patient.
3. Mind the gap! Remember to follow the closure of the anion gap to guide treatment, not the serum glucose.
4. Not all "respiratory distress" is due to pulmonary etiology - think about metabolic causes of tachypnea as well!

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Advanced Strategies in Non-invasive Ventilation - Dr. Pearson

9/8/2016

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1. Understand non-invasive ventilation settings:

Mode: pressure support
Trigger: patient-initiated only
IPAP (Inspiratory Positive Airway Pressure) = Ventilation
EPAP (Expiratory Positive Airway Pressure) = Oxygenation

2. NIV adjustments made according to disease state:

Crashing Acute Pulmonary Edema patient: ↑ EPAP (Start: 15/5)
Decompensating Asthma: ↑ IPAP (Start: 10/2)
Decompensating COPD: ↑ IPAP (Start: 12/2)
Chest Trauma: Both IPAP/EPAP (Start: 10/5)
For palliative care patients or those not tolerating the NIV mask: Consider Heated, Humidified High-Flow Nasal Cannula (HFNC).
Pneumonia/ARDS patients: Intubate early, as this is not reversible disease process in the short-term.
Maximum: 18/12

3. Remember the rule of 15’s for pre-oxygenation:

Position: Head of bed @ > 15º
Non-rebreather mask @ 15 L / min
Nasal cannula @ 15 L / min
CPAP / BVM + PEEP valve @ 15 cm H2O

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<<Previous

Carolinas Case Conference - Dr. Goode

Transvenous Pacing - Dr. Pecevich

TIA in 2016 - Dr. Asimos

The ST Segment - Dr. Garvey

Submersion Injuries - Dr. Awad

The Opioid Epidemic - Dr. Griggs

Carolinas Case COnference - Dr. Mollo

Pregnancy Over 35 - Dr. Pelucio

Carolinas Case Conference - Dr. Goode

Advanced Strategies in Non-invasive Ventilation - Dr. Pearson

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