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CMC Case COnference - Dr. West

12/10/2015

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Septic arthritis of the hip
-Most common hematongenous spread
- Up to 20% of patients with non-gonococcal septic arthritis will have 2 or more joints involved –> always do a full musculoskeletal exam!
- 50% will have positive blood cultures –> always obtain cultures.
- Risk factors: Extremes of age, hardware/recent instrumentation, skin infection, underlying arthritis, IV drug use
- You cannot rule out septic arthritis with inflammatory markers or any physical exam findings, so err on the side of obtaining joint fluid.
 
Pediatric septic arthritis vs. transient synovitis
- Kocher criteria can help differentiate: Temperature >38.5, WBC >12K, ESR >40, unable to bear weight.
  • 0/4: <0.2%, 1/4: 3%, 2/4: 40%, ¾: 93%, 4/4: 99.6
  • Note: this was a retrospective study and external validation studies did not perform as well.
  • Can not be used if patient recently on antibiotics.
- There is a MSK screening MRI protocol if you are concerned about LE deep space infection but having difficulty localizing the joint
 
Contrast Extravasation
  • Monitor area for signs of compartment syndrome or airway compromise (depending on location)
  • Complications rare now that we routinely use low-osmolar nonionic contrast
 
Spontaneous Pneumomediastnum
  • Under recognized cause of chest pain
  • Similar risk factors as spontaneous pneumothorax (asthma, tall, thin, valsalva, intense sporting activities)
  • Alveolar ruptures into surrounding bronchovascular sheath and free air tracks into mediastinum
  • Rarely causes tension physiology
  • If history concerning for esophageal pathology, consider CT esophagram
  • Treat conservatively by avoiding valsalva and barotrauma 
​

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Sedation After Intubation - Dr. Graboyes

12/10/2015

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  • ​Remember analgesia first strategy after intubations 
​
  • Goal RASS of -1 to -2, not -5
​
  • Limit use of benzodiazepines and paralytics

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Sharpen Your Calipers - Dr. Littmann

12/10/2015

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The Role of the ECG in Acute Nontraumatic BLE Weakness
 
Acute bilateral lower extremity paralysis
  1. The differential diagnosis of acute nontraumatic bilateral weakness is broad
  2. Most causes have unique manifestations and symptoms
  3. The two most common cluster of causes of acute nontraumatic BLE weakness without significant associated symptoms: spinal cord disease and periodic paralysis
  4. Patients with periodic paralysis have unique ECG manifestations
 
Hypokalemic periodic paralysis
I. Familial hypokalemic periodic paralysis
  1. Mostly Caucasian men
  2. First attack at age <25
  3. Most patients have family history
  4. Most patients have repetitive attacks
II. Thyrotoxic hypokalemic periodic paralysis
  1. Mostly Asian and Latino men
  2. First attack later (20s – 30s)
  3. Attacks only occur when hyperthyroid
  4. No family history of periodic paralysis
  5. Hyperthyroidism frequently indolent, easy to miss the diagnosis
III. Common ECG manifestations of thyrotoxic hypokalemic periodic paralysis
  1. Large distant U waves frequently reaching the next P waves
  2. Tall QRS complexes
  3. Slight PR prolongation
  4. Terminal notching of QRS complexes in anterior chest leads (rsR’ pattern)
IV. Emergency treatment of thyrotoxic hypokalemic periodic paralysis
  1. Propranolol
  2. Use caution with potassium replacement
 
Hyperkalemic paralysis
  1. Almost always acquired and/or iatrogenic
  2. Only occurs with severe, extreme hyperkalemia
  3. Wide bizarre QRS complexes, sine-wave appearance
  4. Usually no P waves present
  5. Most patients do not have PEA
 
ECG signs of severe hyperkalemia
  1. The more severe the hyperkalemia, the less you can expect peaking of the T waves
  2. Widened QRS complexes, new axis shifts
  3. Widened QRS complexes with ST-segment elevation in V1-V2
  4. Widened QRS complexes with the Brugada pattern in V1-V2
  5. Double counting of heart rate by the ECG interpretation software
  6. Sine-wave appearance


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CMC Case CONFERENCE - Dr. Nichols

12/3/2015

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Pediatric pericardial effusion/pericarditis
1) Kids with chest pain also hide gremlins
2) Consider bedside echo for all pediatric chest pain visits!
3) Effusions of 500cc, circumferential, or 2 cm on CT scan are by definition LARGE and likely mandate admission and stat echo looking for tamponade
4) Ultrasound guidance for bedside pericardiocentesis is the new standard
5)  Be vigilant in sign outs, always add an update note

Abdominal pigtail placement
1) Small bore seldinger technique makes abdominal placement more likely, you can't finger sweep
2) Consider clamping the introducer needle at the skin once air is aspirated to avoid unintentional advancement
3) Remember the triangle of safety, go as high as possible with pigtails
4) In the event of an abdominal mishap, scan the region and discuss with surgery

Headache with ICH/IVH
1) Be wary of the "different" migraine
2) Deep brain structure bleeding is associated with intraventricular extension
3) IVH carries a 20-50% in hospital mortality
4) ABCs, potential emergent EVD placement

5) Even though a CT head is negative within the window, the LP may give you additional information that makes the diagnosis (opening pressure, cell counts, etc)

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Toxic Alcohols - Dr. Snow

12/3/2015

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  • ​Always include toxic alcohols in your differential of anion gap metabolic acidosis.
  • K.I.L.R for acidosis: Ketoacids, Ingestion, Lactate, Renal 
  • Toxic alcohols in 3 easy steps: R.B.D. = Recognize the diagnosis, Block ADH, Dialysis when needed
  • Know how to calculate the osmolar gap  (Measured osm - Calculated osm)
  • Calculated osm = 2xNa + BUN/2.8 + Glucose/18 + ETOH/4.6
  • Must be drawn at same time as BMP
  • Do not wait on alcohol levels to institute alcohol dehydrogenase blocking therapy
  • Ethanol and Fomepizole appear to be equally efficacious as antidotes.  However, ethanol infusions have a much higher adverse event rate.
  • Ketosis/ketouria, osm gap, withOUT metabolic acidosis = isopropyl alcohol
  • High dose lorazepam or diazepam infusions: remember propylene glycol——lactic acid can produce acidosis.

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Case Reports & Case Series: Strengths, Weaknesses, and “How-To” of this low hanging fruit - Dr. PATTERSON

12/3/2015

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1: Case reports and case series are foundational to clinical research.

2: Case reports and case series provide the opportunity for clinicians to describe novel clinical management and treatment of patient case(s).

3: Case reports and case series provide clinicians to offer “clinical pearls” to trainees and junior clinicians.

4: Despite inability to perform hypothesis tests, case reports offer the opportunity clinician investigators to develop a command of a clinical condition/disease state and treatment/management protocol.


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TEAM Case: Ped Status Epilepticus - Dr. Magill

12/3/2015

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​Define status epilepticus:
  • >5 min seizure- impending status epilepticus
  • >30 min- established SE
  • >60 min- refractory SE

Consider etiologies:
  • Trauma/bleed
  • AVM Malformation
  • Febrile seizures
  • Infection
  • Tumor
  • Subtherapeutic meds
  • Lowered threshold with infection
  • Stroke
  • Cardiac/arrhythmia
  • Hypertensive Crisis
  • Pyridoxine deficiency/INH overdose
  • NMDA receptor Ab
  • FIRES

Remember ABCs and supportive care in addition to treating seizures

Learn dosing for hypoglycemic seizure with dextrose
  • Rule of 50's

Learn dosing for hyponatremia seizure with 3% NaCl 

Medications
First line:
  • Midazolam 0.15 mg/kg IV, 0.3 mg/kg buccal
  • Lorazepam 0.05-0.1 mg/kg IV, max 4 mg/dose rpt x 1
  • Diazepam 0.05-0.3 mg/kg IV, 0.5 mg/kg PR, max 5 mg

Second line:
  • Fospheny load 15-20 mg/kg IV
  • Levetiracetam load 15-20 mg/kg IV
  • Valproate load 20-40 mg/kg IV

Refractory/Third line:
  • Phenobarb load 20 mg/kg IV, 1 mg/kg/min
  • Pentobarb 5 mg/kg load
  • Propofol 2.5-3.5 mg/kg IV, rate 0.1-0.3 mg/kg/min
  • Ketamine 0.5-2 mg/kg IV, rate 5-20 mcg/kg/min
  • Pyridoxine 70 mg/kg max 5g, repeat as needed

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Disclaimer: All original material and images included on this website are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Information contained on this website is the opinion of the authors and does not necessarily represent the official opinion of Atrium Health or Carolinas Emergency Medicine Residency. 

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​
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Global EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • MATCH 2022
    • Alumni
  • STUDENTS/APPLICANTS
    • Prospective Visiting Students
    • UNC/Wake Forest Students
    • Healthcare Disparities Externship
  • #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