Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Wide Complex Tachycardia in the ED - Dr. L. Littmann

10/26/2017

General recommendations

When the heart rate is fast and the QRS complexes are wide, don’t fall into the trap of trying to define the QRS morphology before determining what the rhythm is
Establish the fact that you are dealing with a wide-complex tachycardia (WCT) and review its differential diagnosis

Place the WCT into a clinical and ECG category

Conscious and relatively stable patient with WCT --> diagnose, then treat
Unconscious, unstable or pulsless patient with WCT --> immediate treatment
1. SHOCK!
2. IV calcium
3. IV bicarbonate

Rheumatic Fever - Dr. S. Zeller

10/12/2017

Treating strep throat with antibiotics is aimed at preventing Acute Rheumatic Fever (ARF)
Diagnose ARF using Revised Jones Criteria - which includes evidence of a strep infection + either 2 major or 1 major & 2 minor criteria
There is "no rheum for SPECCulation" - meaning the major criteria include Subcutaneous nodules, Polyarthritis, Erythema marginatum, Chorea, & Carditis
Crucial to prevent repeated bouts of ARF in patients with history of rheumatic carditis
RHD is MC cause of acquired heart disease in developing countries (Kawasaki's in U.S.)
RHD tends to present with early mitral valve regurgitation (MR) & delayed mitral valve stenosis (MS)

Schizophrenia & Its ED Presentation - Dr. K. Roedershimer

10/12/2017

Safety for you, staff and the patient is priority on initial evaluation
Decide whether psychosis is new in onset
Decide whether it is related to a medical illness or psych related using; head to toe physical exam, vital signs, age > 40, mental status and standard orientation questioning
Some patients with known diagnosis of schizophrenia are appropriate for discharge and outpatient follow up
If patient is deemed unsafe, even if they are not homicidal/suicidal, then psychiatry consultation should be obtained

Carolinas Case Conference - Dr. J. Raper

10/12/2017

Appendicitis

Overview:
- Usually the result of obstruction of the lumen of the appendix which results in bacterial overgrowth and increased pressure, ultimately leading to perforation
- Luminal obstruction can occur secondary to fecoliths, malignancy, and lymphoid proliferation
Diagnosis by CT scan
- Normal luminal size is ~6mm, however an inflamed appendix is usually >10mm
- On contrasted CT, the inflamed appendix wall is thick with contrast enhancement
- Fat stranding & fluid may be noted surrounding the appendix
- Concurrent findings may include a small bowel obstruction, mesenteric lymphadenopathy & free fluid
Perforation
- Free Perforation
  - The perforation does not get walled off, but spreads throughout the abdomen and often results in SIRS response and sepsis
  - Treatment is emergent surgical intervention with washout
- Loculated Perforation
  - The perforation is walled off, usually by the omentum and forms a periappendiceal abscess
  - This commonly requires drainage with CT or U/S guidance, and interval appendectomy in 6-8 weeks

Contrast Induced Nephropathy

Proposed Mechanism of Injury
- Evidence in animal models suggest hypoxia and mitochondrial dysfunction are a result of contrast administration
- Increased viscosity in the blood following contrast administration results in decreased oxygen delivery to tissues
- Increasing concentrations of contrast in the blood result in mitochondrial dysfunction
Patients At Risk
- Patients with a history of CHF and CKD are more likely to develop AKI following contrast administration
- In our shop, GFR<30 or Cr>2.0 is a soft cutoff due to prior studies demonstrating increased odds ratio of AKI in these patients
Questioning the Status Quo
- A recent study by Hinson et al. examined >17K patients in a single center retrospective cohort fashion
- Primary outcome was AKI and secondary outcomes were the development of CKD or need for dialysis within 6 months
- They found no association of AKI with contrast administration (primary outcome), and no association of CKD or need for dialysis (secondary outcome)
- Limitations limit applicability, as patients in the contrast group received IVF administration at more than twice the rate of the noncontrast group

Bioterrorism - Dr. K. Kopec

10/5/2017

It is not a question of if bioterrorism will occur, it is a matter of when and where.
Bioterrorism is the intentional or threatened use of biological agents to care fear or actual disease or death upon a population for political, religious or ideological reasons.
Qualities of an ideal biological weapon are: inexpensive, easy to produce, small size to be aerosolized, can survive the environment, causes lethal or disabling disease, easy to distribute, minimal or no effect treatment or prophylaxis.
There are three types of bio-agents: bacteria, viruses, and biotoxins.
It is often difficult to identify biological agent exposure because they often mimic other things and require large numbers of infected patients before awareness occurs.
They often all presents with an initial influenza-like illness.
Some identification keys are: clusters of cases, symptoms that unusual for an age group, unusual time of year for symptoms, rare infection type to region, dead animals before humans.
The CDC has classified various biological agents in categories based on the potential morbidity and mortality, delivery potential, public perception of fear, civil disruption, and the public health preparedness needs.
Level A agents are the highest threat to national security. Agents include: anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fevers.
Level B agents are: brucellosis, clostridium perfrinogens, salmonella, escherichia coli O157:H7, melloidosis, psittacosis, Q fever, ricin, staphylococcal enterotoxin B, typhus, viral encephalitis, cholera, shigella dysenteriae, cryptosporidium parvum.
Level C agents are: nipah virus, hanta virus, tickborne hemorrhagic fevers/encephalitis viruses, yellow fever, multidrug resistant tuberculosis.

Carolinas Case Conference - Dr. S. Pecevich

10/5/2017

Pulmonary Hypertension

WHO classifies 5 types of Pulmonary Hypertension:

Pulmonary Arterial Hypertension
Left Heart Failure
Cor Pulmonale
Chronic Embolic Disease
Miscellaneous (Sarcoid, etc)

Generally, Class 1 is a type that will be prescribed and also potentially respond to vasodilators including prostacyclins, endothelin receptor antagonists, and other vasodilators--sildenafil, tadalafil. Other types need to have underlying cause addressed
Withdrawing from a pulmonary hypertension drug infusion can be LIFE THREATENING. It is imperative to restart an infusion, for example epoprostenol, if there is any concern about port compromise or malfunction
Respect Pulmonary Hypertension as these patients decompensate rapidly!
Respect the RV! -- pulmonary hypertension, and subsequent RV failure, is difficult to manage. Most patients are volume overloaded yet also preload dependent. If you overload them, this can cause worsened LV function (septum flattening) and subsequent decreased cardiac output.
Even the slightest systemic illness can lead to rapid hemodynamic compromise
Call for help -- generally cardiologists manage these complicated cases
In the acute setting, consider 250cc crystalloid boluses and perhaps more importantly, use norepinephrine as your pressor. Phenylephrine & Dobutamine = Bad.

Hemorrhagic Shock in a Jehovah's Witness

Elevated lactate does not necessarily mean sepsis, it can imply malperfusion
Consider your types of shock and then frame your differential accordingly
Elevated Cr with active bleeding? Push the contrast for the CT, fix the kidneys later
Be wary of INR with novel anticoagulants. This is not specific or sensitive for anticoagulation status on NOACs.
If administering K-Centra for these medications, do it ONCE. NOAC's are inhibitors, they do not disrupt clotting factor synthesis like Warfarin. Therefore, there is concern for hypercoaguable state with multiple doses of K-Centra, particularly once the NOAC wears off
Jehovah's Witnesses have the same HIPPAA rights as any other individual. You should inform him or her of the right to privacy were he or she to accept blood products
Not all blood products contain human factors. Have a discussion with the patient about what types of blood products he or she might be willing to accept. For instance, patients are occasionally willing to undergo autologous transfusions or receive plasma
Generally with children, your decision as a physician to medically treat a patient, especially in emergent circumstance, supersedes the desire of a parent for his or her child not to receive blood products

Tenants of this concept:

Immediate interests of child and state generally > that of the parents' wishes
Parents do not have right to life/death over another individual who lacks capacity
Parents do not hold right to refuse medical treatment for this patient

These are ethically challenging cases. If uncomfortable, consult with another physician or risk management/ethics board, if appropriate

The Wheezer the Wasn't - Dr. S. C. Scarboro

10/5/2017

1st step is considering the diagnosis – All that Wheezes is not asthma
Alternatives to reactive airway disease may be difficult to diagnosis; remember that vital signs are VITAL
Myocarditis and pericarditis are rare but important causes of pediatric chest pain and important causes of morbidity/mortality in the pediatric population.
Consider myocarditis with new onset CHF or arrhythmia – MUST assess Perfusion and palpate the liver for hepatomegaly. Skin mottling and an enlarged liver may be subtle, so you must be looking for it!
Fear the grunting child!
Identification and treatment of pericardial tamponade can be life saving. Remain vigilant and have a low threshold to "take a look."