Carolinas Emergency Medicine Residency

Carolinas Case CONFERENCE - Dr. Mollo

7/7/2016

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All presumed septic patients should receive antibiotics before being transported to an inpatient bed.
Those with demonstrating signs of septic shock should have antibiotics within one hour of diagnosis.

A ruptured AAA should be in the differential diagnosis for any patient older than 50 years with abdominal, back, or flank pain.
In a patient with an AAA who develops acute pain, assume rupture is imminent or has already occurred.
The patient with a ruptured AAA who is hemodynamically stable can deteriorate at any time.
Patients with ruptured AAA need emergent surgical intervention.
Aggressive fluid resuscitation can worsen hemorrhage and should not delay transportation to the operating room.

Use the appropriate order set for all "Code" patients!

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Carolinas Case Conference - Dr. Lounsbury

6/10/2016

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•Consider atypical presentation for ACS in elderly patients
•Risk factors for severity of acute pancreatitis include advanced age, obesity, organ failure, and pleural effusion

•Can use APACHE II score to risk stratify in the ED

•Blunt aortic injury (BAI) is a rare but often deadly entity
•Consider in all cases with significant mechanism
•Can have atypical/no symptoms or have distracting injury
•Management of BAI includes permissive hypotension and rapid transfer to the operating room

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Carolina Case CONFERENCE - Dr. West

4/28/2016

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Retained Foreign Body

X-ray or US if mechanism involves glass or is high risk
Consider retained FB if wounds not healing well
US will demonstrate wooden foreign bodies
Common cause for EP to be sued

Ectopic pregnancy

2 % all pregnancy are ectopic in location – increasing risk if history of ectopic
9% will present with only painless vaginal bleeding
Can be associated pseudogestational sac

Mushroom induced hepatotoxity

Most common Amanita ingestions
Consider in new immigrants to the US who present with acute liver injury
Consult your local toxicologist, treatment can include silibinin, NAC, high dose PCN, and ultimately possible liver transplant

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Appendicitis - Dr. Craig

4/15/2016

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The classic presentation of appendicitis is seen ~50% of the time.
There are several well-known atypical presentations that are commonly misdiagnosed at the initial encounter.
The common theme is that symptoms are NOT localized to the right iliac fossa.
Know these atypical presentations so that you can nail the diagnosis:

·         Young healthy male with cystitis symptoms
·         Toddler with a RLE limp
·         Infant with inflamed right hemiscrotum
·         Pregnant female with right flank pain, pyuria
·         Right sided truncal cellulitis
·         RUQ discomfort with normal RUQ ultrasound
·         Urinary retention

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STDs in 2016 - Dr. Callahan

3/23/2016

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CDC 2015 recommendations include screening all patients age 13-64 for HIV, especially if they have another STD in opt out approach. We need to consider working towards doing this here at CMC and wherever you go practice.
Managing sexual partners: options include patient referral, provider referral, expedited partner therapy (EPT). EPT based on multiple RCTs appears to be superior and involves sending prescription with patient to give to partner.
Sexual Assault victim: treat with rocephin, azithromycin, flagyl, hepatitis B vaccine. CDC with algorithm for HIV prophylaxis. If significant exposure and presents within 72 hours treat with zidovudine for 28 days.
PID: spectrum from cervicitis to TOA and peritonitis. Strongly consider ultrasound as first line imaging. 50 % STD related. Treat uncomplicated with rocephin and 2 weeks doxycycline. TOA, pregnancy, ill appearing admit for IV antibiotics/OB GYN consultation.
Epidydimitis: Consider US also. Less than 35 or STD exposure-treat rocephin, 2 weeks doxycycline.
Complications of gonorrhea: PID, septic arthritis, Fitz Hugh Curtis, disseminated gonococcemia, meningitis, conjunctivitis. Neonates-day 2-5, full sepsis workup and admit for IV antibiotics.
Complications of chlamydia: infertility, PID, Reiter syndrome. Recommend treating with PO azithromycin 1 g including pregnancy.
Syphillis: treat with penicillin, different regimens depending on stage. Ocular and neurosyphilis requires CSF, admission, IV antibiotics.
Less common STDs include Chancroid, Lymphogranuloma Venereum, Donovanosis. Treat with rocephin and doxycycline.

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Carolinas Case Conference - Dr. Beverly

8/20/2015

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Bariatric Patients

Operations for weight loss include a combination of volume restrictive and nutrient malabsorptive procedures that affect satiety, absorption, and insulin sensitivity hormonal or enteric derived factors, in conjunction with behavior modification to achieve and sustain weight loss.
Patients need a multi-disciplinary team to provide extensive education on nutrition, psychological deterrents, and lifestyle modification.

Roux-en-y is most common performed bariatric procedure.
Common complications include marginal ulcers, anastomotic narrowing, obstruction, VTE/PE and internal hernias.
Management in the ED should include specialized CT protocols and early involvement of patient's surgeons.

Aortic DIssection

Type A involves the ascending aorta and Type B does not.
Risk factors involved hypertension, cocaine use, congenital defects, pregnancy, prior heart surgery and prior heat catheterization.
Most sensitive symptoms include chest pain, “worst pain ever”, and abrupt in onset.
CXR will commonly show widened mediastinum but can be normal.
Test of choice is CT angio.
Treatment in the ED includes rapid vascular consultation, pain relief, and blood pressure control.

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TEAM Challenge Cases - Drs. Fox, Griggs, MacNeill

7/2/2015

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Ovarian Torsion

- Ovarian Torsion requires us to be vigilant. It is often misdiagnosed initially by both EM and GYN physicians.
- Reconsider your DDx. "Appendicitis" and "Renal Colic" are common mimics of Ovarian Torsion.
- Fight diagnostic momentum.
- Don’t be fooled by “normal blood flow.” The ovary has two arterial supplies. Diminished venous flow should be alarming even if there is "normal" arterial flow.
- See Ovarian Torsion.

Perforated Gastric Ulcer

- Review your own films! Radiologists are human too. You know what your concern is and may be able to actively see the important abnormality more easily!
- Concerning abdominal exam? You don't need to wait for images to call a surgeon.
- Think twice before sending to CT, especially with a concerning abdominal exam.
- Resuscitate aggressively! Prepare for the patient to become dramatically more ill!
- Don’t forget the broad spectrum antibiotics!

Ruptured AAA

- Resuscitate! (ABCs, Large Bore Access), but be comfortable with permissive hypotension.
- Target SBP ~80-90 mmHg

- Do not be in a hurry to intubate the patient if they are breathing on their own. Many arrest after intubation.
- IF you must intubate, VENTILATE SLOWLY. Increased intra-thoracic pressure will crush their already tenuous pre-load and cause an arrest.

- Cross-matched PRBCs (consider massive transfusion protocol)
- Contact your Vascular Surgeon emergently
- At CMC, activate “Code Rupture”

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CMC Case Conference - Dr. Robertson

6/25/2015

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Ruptured Appendicitis:
–Can occur in Toddlers
–Very challenging diagnosis: consider in FUO with GI symptoms

–Factors to consider:
•Younger patient population
•Diffuse tenderness to palpation
•Longer duration of illness

–CLOSE FOLLOW-UP IS CRITICAL

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CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

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Sneaky Ectopic - Dr. Nichols

Don't let a beta HCG lull you to sleep, if your suspicion is high, get an ultrasound and/or discuss with OBGYN.
Beta HCG assays vary significaltly between labs, for accurate results try to maintain the same testing assay.
Anchoring is a dangerous bias that places you at high risk to miss key and potentially life-threatening diagnoses.
To avoid anchoring, be judicious about a "diagnostic pause" and await diagnosing patients until all information is available.

GIB and Aortic Graft - Dr. Beverly

History and physical is the foundation of medical decision making. Complete a good chart biopsy. Undress the patient fully. If not, you may miss a crucial piece of information that will alter your decision making.
Aortoenteric fistula is a can't miss diagnosis. In a patient with a GI bleed and a known graft, this is your diagnosis until proven otherwise. 100% mortality if left untreated.
Consult vascular early of you suspect this diagnosis. Treatment involves early resuscitation and rapid operative intervention.

Pulmonary embolism + pleural effusion - Dr. West

Up to one half patients with PE’s with have a pleural effusion on CT, one third if just looking at CXR
Usually unilateral and small
Usually exudative
If a patient has a small pleural effusion and pleuritic chest pain, think pulmonary embolus

Traumatic Ptx, Be Kind - Dr. Robertson

Set your trauma rooms up ahead of time, know what to look for early in the patient's physical exam.
Review the concepts of correct position and chest tube insertion techniques
Pigtail catheters are as efficacious as large bore chest tubes for traumatic pneumothorax
Keep an eye out for more data on Pigtails for blood in the chest.
Large bore chest tubes remain standard of care for hemothorax, hemopneumothorax or concern for barotrauma in already vented patient's (even if pneumothorax is small).

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Case COnference - Dr. Kiefer

3/26/2015

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Intoxicated with Chest Pain

Intoxicated patients are a HIGH RISK patient population. Always talk to the patient and take them seriously. These patients need to be gowned appropriately.

EMS providers, nurses, and physicians frequently have significant emotional bias before ever interacting with these patients. Understanding that bias exists, we must always be on guard for truly sick patients that have fallen through the normal triage system.

Ripping/tearing chest pain (OR ~11) or migrating chest pain (OR ~7.5) are highly concerning historical features for aortic dissection.

Goals of initial medical management include first HR control for HR <60 BPM (i.e. esmolol, labetalol, etc) and then secondarily with BP control for SBP 100-120 mmHg (i.e. nitroprusside)

Infected Kidney Stone

Waiting for patients to urinate for a clean catch specimen is ONLY appropriate for stable patients where urine studies are NOT paramount to an evaluation. Obtain cath urine specimens in ANY patient where a urinalysis is pivotal to patient care.

Patient sign outs are the MOST dangerous time for patient care. If a clear diagnosis has not been made then inform the oncoming provider and seek help in difficult patients. Sometimes a fresh set of eyes is all that is needed.

Interestingly, B-type natriuretic peptide (BNP) is frequently elevated in sepsis with proven distributive shock (as evidence by lactate >4, ScvO2 <70%) in patients with normal echocardiography. Do not make a false assumption that elevated BNP = fluid overload, as this is NOT the case! Patients with septic shock and an elevated BNP have a worse prognosis and severe intravascular volume depletion.

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<<Previous

Carolinas Case CONFERENCE - Dr. Mollo

Carolinas Case Conference - Dr. Lounsbury

Carolina Case CONFERENCE - Dr. West

Appendicitis - Dr. Craig

STDs in 2016 - Dr. Callahan

Carolinas Case Conference - Dr. Beverly

Bariatric Patients

Aortic DIssection

TEAM Challenge Cases - Drs. Fox, Griggs, MacNeill

Ovarian Torsion

Perforated Gastric Ulcer

Ruptured AAA

CMC Case Conference - Dr. Robertson

CMC Chief Case Conference - '15-'16 Chiefs

Sneaky Ectopic - Dr. Nichols

GIB and Aortic Graft - Dr. Beverly

Pulmonary embolism + pleural effusion - Dr. West

Traumatic Ptx, Be Kind - Dr. Robertson

Case COnference - Dr. Kiefer

Intoxicated with Chest Pain

Infected Kidney Stone

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