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Complex Trauma Case - Dr. King

12/13/2014

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- Hypothermia: Can cause significant physiologic disturbance, generally starting when body temperatures fall beneath 90 degrees (moderate hypothermia).  Moderate hypothermia should be aggressively corrected with both external and internal warming measures.  Risk of refractory VFIB increases as you approach 82.4degrees.  

- Severe hypothermia requires invasive rewarming techniques including invasive catheters (think therapeutic hypothermia in reverse).  This can include hemodialysis and ECMO. 

- Peri-intubation hypothermia:  associated with increased risk of mortality as well as increased ICU and hospital length of stay. Take steps to avoid it!  Think ketamine, fluids, pressors.  

- Spinal shock: sudden vasoplegia caused by loss of output from sympathetic system.  Classic presentation of hypotension and bradycardia is seen in less than 25% of cases.   Most recent guidelines recommend norepinephrine as pressor of choice.  Seen mostly commonly in injuries above T6.  

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Limping Child - Dr. Scarboro

12/11/2014

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  • History (Fever, trauma, chronicity) and Exam (localization of pain, signs of infection) are key (as always!) in directing a further work-up.
  • In a child with a limp, if the child has a fever > 101.3, WBC > 12, ESR > 40, or CRP > 2, consider an infectious etiology (Remember, the Kocher criteria were developed specifically for the septic hip).
  • Toddler’s fractures are very common and do not imply abuse (http://pedemmorsels.com/toddlers-fracture/).
  • In patients with a normal extremity exam and no focal pain, consider central causes (Guillian Barre Syndrome, transverse myelitis, cerebellar ataxia).

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Spinal Trauma - Dr. Gibbs

12/11/2014

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  • Spinal Cord Injury shifting towards an older demographic (mean age has increased from 20's to 40's).
  • Think T/L spine fracture with "unprotected" vector injury (ex, ejected MVC, motorcycle crash, pedestrian struck). 
  • Pick an imaging Clinical Decision Rule and stick with it! 
  • Be careful with children; limited data in kids < 8years of age. There is not a validated rule as of yet (PECARN has done a derivation study, not yet validated).
  • Documentation of clearance important!
  • Understand the column theory (posterior longitudinal ligament fulcrum).
  • C1 and C2 injuries complex and more common in the elderly.
  • Rx essential:
                                - ASIA evaluation the standard
                                - Maintain adequate hemodynamics (Maintain the MAP!)
                                - Steroids are out


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CT Perfusion Imaging for CVA - Dr. Asimos

12/11/2014

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1. Use of CTP imaging to determine eligibility for revascularization therapy is unproven in randomized studies. 

2.  Appropriately performed PCT performs reasonably well at identifying core acute infarct associated with large vessel ischemic strokes.

3.  PCT unproven in distinguishing penumbra from benign oligemia.

4.  Further standardization and validation of PCT needed.


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M&M - Dr. Kiefer

12/4/2014

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Case 1:  Missed appendicitis
  • Abdominal pain is most sensitive finding (sn 80-85%) for children newborn – 16 yo
  • Fever (sn 40-70%) and leukocytosis (sn 65%) are not a reliable findings
  • Perforation is common in children <6 years old due to difficult history and exam.  Have a high level of suspicion, especially on repeat evaluations for abdominal pain!
  • Additional features: low volume diarrhea is common (~32%) of leading to misdiagnosis of gastroenteritis, vomiting is more common (60-70%) and vomiting PRECEDED by pain should absolutely raise the suspicion for appendicitis.
  •  Even in adults, 15% of patients had isolated RLQ rebound tenderness, but were afebrile and had normal laboratory studies.

1. Appendicitis in children less than 3 years of age: a 28-year review.  Pediatr Surg Int. 2004 Jan;19(12):777-9. Epub 2004 Jan 16.
2. Acute appendicitis in children under 3 years of age. Diagnostic and therapeutic problems. Med Wieku Rozwoj. 2012 Apr-Jun;16(2):154-61.
3. The presentation of appendicitis in preadolescent children. Pediatr Emerg Care. 2007 Dec;23(12):849-55.
4.  Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis. World J Surg. 2010 Feb;34(2):210-5. doi: 10.1007/s00268-009-0349-z.



Case 2: Tako-Tsubo Cardiomyopathy and Hypertensive Emergency
  • Global deep wide symmetric T wave inversions with associated QT prolongation is often read by EKG software as concerning for ischemia, but these features actually far more typical of acute CNS event (ex. SAH) or acute adrenergic surge (ex. Emotional, Cocaine, Pulmonary Edema, Hypertensive Emergency, etc.)
  •  Inverted T waves from myocardial ischemia are typically characterized by a sharp symmetric T waves with quick downstroke


Case 3: Incidentalomas
  • It is our duty to the patient to ensure they understand incidental findings (laboratory, radiological, physical exam, etc.) and to ensure they understand follow up and have a means to obtain it.  
  • One effective method is to print out the report and give it to the patient at time of discharge.
  • This is a huge area of medico-legal risk.  Ensure adequate documentation in the chart to protect yourself.


Case 4: Sporotrichosis
  • Consider in patient with hard, red, nodules that are progressing up arm.  Class is patient involved in rose gardening or in situation with cuts to hands while working in soil.
  •  Treated with antifungals (Itraconazole) till 2-4 weeks AFTER lesions resolve.  Usually 3-6 months.

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Ultrasound Q&A - Dr. Weekes

12/4/2014

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Soft tissue Ultrasound:
  • Cobble stoning appearance - Cellulitis
  • Abscess: irregular edges , sonofluctuance, varied echogenicity
  • Fournier’s Gangrene -Echogenic spots (artifacts from tiny air pockets), irregularly arranged, moveable and not organized like a foreign body e.g. glass, needle 
NERD alert! : Artifacts do NOT actually represent objects but suggest intense US reflection as it encounters sharply contrasting tissue density (examples include bone, stone or air) after traversing soft tissue medium (e.g. muscle, liver).


Echocardiography Tips:

Eyeball qualitative LV systolic function assessment:
     -mitral annulus movement along the long/major axis
     -LV wall movement inward along minor axis
     -thickening of LV wall during systole
     -proximity of anterior leaflet of MV and septal wall

Eyeball qualitative RV assessment:
     - RV tends to dilate before it goes bad (with acute pulmonary embolism physiology)
     - RV shape and function more complex
     - Most significant movements of RV are along long/major axis [NERD alert!: TAPSE (tricuspid annular planar systolic excursion)]

Image Acquisition Tips:
     - Focused RV assessment:
         - Apical window: angle medially toward RV to get better view of RV apex, free wall and annulus
         - Use subcostal window… must view RV apex
         - Parasternal long: angle anteriorly and you’ll see both RV & RA
     - Looking for RV enlargement (RVE):
          - Look for RVE Apex enlargement + widened RV base
          - Subcostal and apical views to get a good look at the apex 
          - Parasternal short axis view
          - Normal contour of RV semilunar/croissant next to donut (LV)
          - RVE might show as ‘helmet’ rather than ‘croissant’

Tips to Avoid Trips
  • Rotate slightly on A4 view to optimize view/cuts of RV (to avoid underestimating)
  • Step 1: Make sure apex at center and no foreshortening (to avoid overestimating RV size)
  • Step 2: Adjust view of A4 for better view of RV free wall and annulus
  • Step 3: see if Subcostal 4 chamber view agrees with Step 1 and step 2 assessments

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Smoke Inhalation - Dr. Kerns

12/4/2014

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  • Most fire victims die from smoke inhalation rather than asphyxiation, thermal injury or burns
  • If a patient has both burns and inhalation injuries, mortality increases 3-4x
  • Soot acts as a carrier for other toxins which "piggy back" on soot into the pulmonary tree
  • CO and CN are the most common toxins produced with breakdown of different materials.

Aggressive treatment of cyanide
  • Often die from CNS effects - CN is a CNS stimulant
  • Soot and AMS from inhalation ---- think cyanide
  • Lactate over 10 --- think CN!
    Doesn't mean you exclude CN if lactate is under 10
  • Treat:
    Hydroxycobalamin - Adults get 5gm over 15 min; Kids get 70mg/kg up to 5gm

    Thiosulfate - cheap with few significant adverse effects

When to pursue HBO for carbon monoxide
Think of this in pts with LOC, cerebellar symptoms, persistent HA after 4 hrs of supplemental oxygen


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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction