Carolinas Emergency Medicine Residency

Epistaxis - Dr. Mollo

9/8/2016

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RED FLAGS

Patients on full dose anticoagulants (eg, warfarin or heparin infusion)
Patients who continue to bleed despite two good attempts at nasal packing
Trauma patients - internal anatomy may be deformed

ED MANAGEMENT

Suction/Blow nose>apply Afrin>Direct pressure x20 minutes
Cauterize with silver nitrate if visible, nonbleeding vessel
If posterior bleeding or continued anterior bleeding, proceed with packing
T&S, Coags, Hgb if on anticoagulation/hemodynamics change
ENT consultation for posterior/refractory bleeding, IR/OMFS if unstable

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Case Conference Core Concepts - Dr. Lounsbury

9/2/2016

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Consider syncope as a differential diagnosis of seizure activity
GI bleed can present with AMS, rectal exam should be done
The present presentation is often dependent upon the past... don't overlook the past medical history or recent presentations.

Tension pneumoperitoneum is a clinical diagnosis characterized by hypotension, dyspnea, and massive abdominal distension.

Classic x-Ray finding is the "saddleback sign" with medial displacement of the liver
Treatment, infraumbilical paracentesis if decompensating and emergent surgical consult.

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Case Conference - Dr. Thomas

9/1/2016

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1. Consider plain film imaging early in cases of suspected bowel obstruction
2. Involve surgical consultation early and get a lactate to evaluate for signs of bowel ischemia

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ETOH Withdrawal - Dr. Snow

9/1/2016

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Always consider withdrawal in your undifferentiated agitated delirium patients!
The pathophysiology of AWS (alcohol withdrawal syndrome) is complicated, but simply stated involves down regulation of GABA receptors with Up regulation of NMDA receptors. This excess neuroexcitation and decreased inhibition is what leads to the clinical symptoms patients with AWS demonstrate.

AWS symptoms can begin as early as 6 hours after a patients last drink.
Benzodiazepines are still the 1st line therapy for alcohol withdrawal. Benzodiazepines are best administered in a symptom triggered fashion in rapid escalating doses with frequent reevaluation of the patient. (example: Diazepam 10 mg, 20 mg, 50 mg, 100 mg; every 15 mins until symptoms improved.)
No study or review has demonstrated a clear winner in superiority when it comes to benzodiazepines.
Adjunctive therapies (i.e.Barbiturates, Propofol, Dexmedetomidine) can be useful in severe AWS or Benzodiazepines resistant cases

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Ped EM: Seizures - Dr. Bryant

9/1/2016

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Some pediatric dosing important to memorize:

Lorazepam - 0.1mg/kg
Midazolam - 0.2mg/kg
Diazepam - 0.2mg/kg
Phenytoin - 20/mg/kg
Fosphenytoin - 20 PE mg/kg
Phenobarbital - 20mg/kg

Neonatal status epilepticus

Slightly different then pediatric status epilepticus
Neonatal status epilepticus - not a Benzo deficiency (See PedEMMorsel)
Load with Phenobarbital (classic) or fosphenytoin

Important causes of pediatric status epilepticus: Remember GLITTER!

GLucose
Infection (Don’t forget: “Glitter is the herpes of craft supplies” - Remember HSV!)
Trauma (Remember to look for NAT!)
Tox
Electrolytes
Random - Remember B6!

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Forward>>

Epistaxis - Dr. Mollo

Case Conference Core Concepts - Dr. Lounsbury

Case Conference - Dr. Thomas

ETOH Withdrawal - Dr. Snow

Ped EM: Seizures - Dr. Bryant

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