Carolinas Emergency Medicine Residency - CMC COMPENDIUM

M&M - Dr. Kiefer

10/23/2014

Case 1: Venous Sinus Thrombosis

- Headache evaluation should always include:
1. Fundscopic exam
2. Posterior circulation- gait, coordination, speech
3. Cranial nerve exam
4. History for HIV, immunosuppression, thrombophilia

- Venous sinus thrombosis
1. Largest risk factor is in young females (presumed secondary to pregnancy and OCPs)
2. Sx can range from severe headache only, to coma
3. Only 1/3 have neurological deficit
4. Diagnosis by either CT venography or MR venography (MR will give more information regarding edema and effects if clot if present)

Case 2: Tension Pneumothorax following CPR

- Always look at CT C spine or other studies that offer extra views of the lungs. Occult pneumothorax Is a frequently missed radiological entity because the radiologists are not looking for it.

- Protective ventilator strategies reduce risk of barotrauma
1. Tidal volume 6-8 ml/kg of predicted body weight (Always calculate predicted weight!!!)
2. Plateau pressure less than 30 mmH2O
3. Accept lower oxygen saturation

- Anytime a major hemodynamics change occurs, a FULL assessment should be performed and documented

Personal Protective Equipment

10/23/2014

Personal Protection is NO JOKE! (but it can be fun.)
Always have your buddy to watch your back!
PPE can make you STRONGER!

HAZMAT Buddies

HAZMAT Buddies - Fox and Kerns

PPE

PPE makes you Stronger!

Cushing's Syndrome - Dr. Goode

10/23/2014

Cushing's Syndrome can present in a wide variety of ways with multiple etiologies. Have a clinical suspicion of it! It can be treated and cured!
Steroids have numerous side effects and not all are benign. Be judicious with their use.
Look for clinical signs of Cushing's Syndrome in the Ill and Unstable patients!
Emergencies associated with Cushing's Syndrome: Adrenal Crisis, Perforated Viscera, and Opportunistic Infections.

TIA Evaluation in Podunkville: Part 1 - Dr. Asimos

10/23/2014

1.  For patients diagnosed with a presumptive TIA, it is relatively common to have infarction demonstrated on DWMRI within the first 24 hours (~33% overall and 30-50% for any time epic within the first 24 hrs).

2.  Based on a Scientific Statement issued by the American Stroke Association in 2009, a Transient Ischemic attack (TIA) is best defined as a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction (Easton JD et al. Stroke 2009;40:2276-2293). Importantly, no symptom duration limitation is specified in this revised definition.

3.  Pure sensory syndromes involving the contralateral face, arm, and/or leg have been described in both ischemic and hemorrhagic thalamic stroke, but these are relatively uncommon and the prevalence of TIAs isolated to the thalamus is unclear.

Trauma Cases - Dr. Gibbs

10/16/2014

Traumatic Brain Injury Management

Avoidance of secondary injury by aggressive airway management and maintenance of CNS perfusion.
ICP control with mannitol and reserve hyperventilation for clear signs of herniation.
CT imaging if on Warfarin OR Plavix.
Early Reversal is part of resuscitation.

Blunt Aortic Injury

Know the Chest X-Ray findings associated with blunt aortic injury.
CT is the Gold Standard for definitive diagnosis and TEE can be helpful.
Injury Staging is important.
Blood pressure control if definitive management is delayed.

Pelvic Fractures

Pelvic ring fractures are associated with major hemorrhage, especially when pelvic volume is increased (ex, open-book fractures).
Know plain film classification.
Early pelvic stabilization save lives.
Angiographic embolization when arterial injury is suspected!

Penetrating Neck Trauma

External findings may be minimal.
Immediate airway and hemorrhage controlling the unstable patient.
Know the three zones of the neck, as this will clarify your diagnostic strategy.

Pediatric Analgesia - Dr. Fox

10/16/2014

Why it Matters

Patient Satisfaction - Pain management is a very prominent driver of patient satisfaction.
Our Satisfaction - Caring for our patients and alleviating discomfort is part of why we got into this job.
Departmental Function - Patients in pain slow your department down!

It is often a slippery slope between being Compassionate and becoming Cruel.
Simple strategies can help you from sliding down this sadistic hill.

Intranasal Fentanyl

Intranasal Fentanyl is as efficacious as IV Morphine... but doesn't require the IV.
This means it can be started soon after initial evaluation.
Dose = 1-2 micorgrams/kg
Don't use more than 0.3 mL per nostril at one time.
Use an atomizer!
http://pedemmorsels.com/intranasal-analgesia/

Nitrous - It's NOt Just for Dentists!

Nitrous works great - it gives analgesia, anxiolysis, and anesthesia.
It is nearly the ideal sedative -- onset is rapid and offset is even more rapid.
It has minimal side-effects - nausea and vomiting.
Contra-indicated for patients with areas of entrapped air (ptx, bowel obstruction) and in pregnant women.
Can really help make those minor procedures (I+D, lac repairs, Lumbar punctures) easier.
If the patient is giggling during your I+D, you will have a good day.
http://pedemmorsels.com/nitrous-oxide/

NEonates Feel Pain too!!

Consensus Statement for Prevention and Management of Pain in the Newborn (2001) states:
NEONATES DO FEEL PAIN.
NEONATES MAY HAVE GREATER SENSITIVITY TO PAIN.
NEONATES ARE MORE SUSCEPTIBLE TO LONG TERM EFFECTS OF PAIN.
Use LMX (or other topical lidocaine) along with oral sucrose to help manage the neonates pain during lumbar punctures!
This will help them as well as help you be more compassionate and likely improve your success rate!
http://pedemmorsels.com/neonatal-analgesia/

Pediatric M&M - Dr. Schneider

10/16/2014

Approach to the Ambiguously Sick Neonate
THE MISFITS
T - trauma
H - heart
E - endocrine

M - metabolic (electrolyte imbalances)
I - inborn errors of metabolism
S - sepsis
F - formula mishaps
I - intestinal catastrophes
T - toxins/ poison
S - seizures

More Pearls
In the sick neonate have a low threshold for:
- EKG, placing NG/OG, considering steroids, considering prostaglandins, considering upper GI series, and DONT TAKE YELLOW PUKE FOR GRANTED (yellow is just a mild shade of green).

Infective Endocarditis - Dr. Yavorcik

10/9/2014

Radar:
Who - Previous heart valve damage, prosthetic valves/cardiac device, congenital heart disorders, previous diagnosis of IE are highest risk factors.
*Don't forget: Poor dentition, HIV, IV drug users, chronic hemodialysis

What - Fever, murmur, cerebral/renal/splenic complications.
Classic IE lesions - Janeway, Osler, Roth spots, splinter hemorrhages - much less common, <10%, but more specific to IE.

Actions:
ECHO - in search of vegetations
Blood cultures - x3, will help identify 90% organisms
Antibiotics - unasyn and gentamicin for native and prosthetic valve. Vancomycin/daptomycin for suspected IV drug users/MRSA.
CT Surgery - emergent call for hemodynamic compromise

Myocarditis - Dr. Baxley

10/2/2014

Clinical Presentation

In adults – ask about preceding viral illnesses and pay attention to chest pain in young healthy patients
In kids – respiratory complaints predominate, GI complaints are more common in older kids, tachycardia out of proportion of fever or dehydration is variable but should always make you think about the diagnosis

Testing

EKG – nonspecific but uniformly abnormal in peds and adults
Obtain troponin in all cases of suspected myocarditis – CKMB, LFTs, ESR should be considered but haven’t shown great sensitivity or specificity
Echo all presumed myocarditis to rule out other causes of symptoms

M&M - Dr. Bryant

10/2/2014

Case 1 - SAlicylate Toxicity

Findings:

Resp alkalosis followed by metabolic acidosis
Fever, tinnitus, HTN, tachycardia, hyperventilation, abd pain, GI pain, noncardiac pulmonary edema

Toxicity:

Toxicity starts at 20-45 mg/dL
Toxicity treatment - charcoal if early on, sorbitol, urine alkalinization need a bolus of bicarb then a drip
In salicylate toxicity, alkalinization of the urine requires large amounts of bicarb.
Hemodialysis is effective at removing free salicylate in cases of AMS, inability to alkalinize the urine, pulmonary edema/ALI and severe acidosis.
Salicylate level units for toxicity are mg/dL. Chronic level >40 mg/dL and acute level >100 mg/dL requires dialysis.

Case 2 - Dengue Fever

Pt with extensive travel presents with viral symptoms - fever, muscle pain, malaise. Had hematuria, persistent fever and tachycardia in the ED. Progressive pulmonary edema

Dengue virus infection has a broad spectrum of disease, including Dengue Shock Syndrome.
Hemodynamic collapse happens at the conclusion of febrile phase.
If stable for outpatient management, will need PLT count and HCT daily.
For non-cardiogenic pulmonary edema, remember NOT CARDIAC.