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
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.
Traumatic Brain Injury Management
Blunt Aortic Injury
Penetrating Neck Trauma
Why it Matters
Nitrous - It's NOt Just for Dentists!
NEonates Feel Pain too!!
Approach to the Ambiguously Sick Neonate
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
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).
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.
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
Case 1 - SAlicylate Toxicity
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