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Carolinas case conference - Dr. C. COx

7/6/2017

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Picture
Right Heart Failure
  1. Symptoms of RV failure are VAGUE; If you do not consider it, you will not diagnosis it! 
  2. RV failure is rare… but bad. If RV failure requires pressors, mortality can increase to 60%.
  3. Most common cause = CHRONIC DISEASE + ACUTE INSULT
  4. RH failure follows an auto-aggravation pathway, following a vicious cycle.
  5. To treat: 1) Decrease RV afterload, 2) Augment RV contractility, 3) Optimize preload and 4) Maintain MAP

Pulmonary Embolism in Pregnancy…and a PERC reminder
  1. PERC Rule:   Apply to patients who are Well’s Low or with whom clinical gestalt for PE is < 10%. This allows your post-test probability to be <1.8% if patient is PERC negative.
    1. No prior VTE; No unilateral leg swelling; No estrogens; No hemoptysis; No surgery/trauma requiring hospitalization within 4 wks: Age < 50 YO; HR < 100; SpO2 ≥ 95%
    2. To be negative must meet all 8 criteria!
  2. PERC Limitations:
    1. Patients excluded from PERC during the study:
      1. Cancer, thrombophilia, strong FHx of PTE, transient tachycardia, beta-blocker use; Hx of chronic hypoxia, amputations, massively obese
    2. Be careful applying PERC to patient who:
      1. Are at increased risk of VTE
      2. Have a limited vital sign exam
      3. Have a limited physical exam
  3. D-dimer in Pregnancy
    1. Risk of PE/DVT increase as pregnancy progresses
    2. Highest risk of VTE is in the postpartum state (up to 1 mo), especially in C/S patients
    3. D-dimer increases during pregnancy
      1. Trimester-adjusted dimer studies currently with very small sample sizes
      2. No established risk stratification tool validated in pregnancy
      3. However, if d-dimer is negative. It’s negative.

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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