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Principles of Trauma Resuscitation - Dr. Gibbs

3/19/2016

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  • Prehospital hypotension is bad! Even if normal BP upon arrival.
  • Vital signs are insensitive for traumatic shock.
  • Develop a strategy for bedside testing.
  • Be cautious with interventions.
  • If you are unsure, focus on the Basics!!
  • (see the slides below)

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Carolinas Case Conference - Dr. Beverly

2/18/2016

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Trauma Resuscitation: Not ACLS
  • Trauma resuscitation should focus on treating the underlying cause.
    • Trauma patients need intubation, resuscitation with blood products and bilateral thoracotomies when in extremis
  • ACLS in trauma is not indicated.
    • Chest compressions and epinephrine are the cornerstone of medical resuscitation, not trauma.
    • In traumatic arrest, chest compressions are not attempted until underlying causes have been appropriately addressed including hypoxia, hypovolemia, tension pneumothorax and cardiac tamponade
  • REBOA now being explored and in place for patients with suspected or diagnosed intra-abdominal hemorrhage secondary to penetrating torso injuries, blunt trauma patients with suspected pelvic fracture and isolated pelvic hemorrhage and patients with penetrating injury to the pelvis or groin area with life-threatening hemorrhage. 
 
It's Not Always Sepsis!
  • Multiple physiologic processes can elevate lactate.
  • Be careful with premature closure in patients. It is not always sepsis. 
  • Reviewing old EKG’s in comparison to new EKG’s is invaluable. If you order it, make sure you review it. 
  • New EKG changes even in the absence of symptoms in the altered patients should always prompt further investigation 
​

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Delivery Complications - Dr. Lounsbury

10/22/2015

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  • Uncommonly encountered however critical to manage
  • Always Type & Cross, difficult to predict complications
  • Stage 2 complications include
    • Shoulder Dystocia- difficult to predict and morbid. Consider HELPERR mnemonic and know maneuvers
    • Umbilical cord prolapse- Elevate fetal parts, tocolysis, and wait for OB
    • Uterine rupture- identify by acute pain, vaginal bleeding, and loss of station, wait for OB
    • Malpresentation- Best plan is tocolysis and wait for OB. If delivery is unavoidable, delivery is presentation-dependent
  • Stage 3 complications include
    • PPH- 4T’s (tone, trauma, tissue, and thrombin). Stepwise approach and know rescue measures
    • Uterine inversion- replace it early 

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CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

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Sneaky Ectopic - Dr. Nichols

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  • 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

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  • 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

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  • 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

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  • 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. Allen

3/26/2015

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• Aortoenteric fistula is the abnormal formation of connection between the aorta and bowel, typically occurring the 4th portion of the duodenum.

• Primary fistula formation due to atherosclerotic or infectious erosion of aorta into the bowel; secondary is the result of complications of aortic graft placement, either graft infection or pressure necrosis.


• Typically present with “sentinel bleed” followed by massive GI bleed and hemodynamic collapse; classic triad occurs <25% of patients.

• Vascular surgery consultation emergently if suspected; CT angiography can be helpful, but only after consultation and surgical evaluation.


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EM Cases - Dr. King

3/5/2015

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Thrombotic Thrombocytopenic Purpura:
- Can be hereditary or acquired.  Acquired forms can be found as a result of a multitude of disease states.
- Patients will more often present with vague symptoms including confusion/AMS rather than focal neurologic deficits attributable to a specific vascular distribution.
- Treatment to consider initiating in the ED includes steroids and FFP however be wary of volume in patients with underlying cardiac disease.
- VasCath can be placed in ED depending on provider comfort.
- Plasma exchange has decreased mortality from 85-95% to 10-20%.


Third Degree Heart Block:
-  Most often seen in elderly patients due to progressive fibrosis and calcification of conduction system and surrounding tissue, but can certainly be a complication of AMI.
- Particularly for your elderly patients, be wary of medication side effects.
- Atropine is always worth a try.  Just realize more often than not it won't help you.
- Hypotension?  Altered mental status?  Distress?  PACE THE PATIENT!
- Take the time to review initiation of transvenous pacing.  Like the infamous ED thoracotomy or  cricothyroidotomy, its a procedure we should know like the back of our hands.


Final Pearl:  if you're going to order an imaging study, look at the WHOLE image.

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The ACEP TPA/Stroke Policy: Putting Fires Out W/ Gasoline - Dr. Asimos

7/17/2014

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1. Perceived conflicts of interest resulting in blind spot bias exist among stroke opinion leaders and the authors of the ACEP tPA Clinical Policy.

2. For Clinical Guidelines to be trustworthy, they must: 1) have transparent methodology, 2) manage conflicts of interest, 3) have a balanced guideline development group composition, and 4) have undergone adequate balanced external review.

3. It is unlikely that the revised ACEP tPA Clinical Policy will substantially impact current perspectives related to the use of IV tPA for stroke


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M&M - Dr. Allen

7/3/2014

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CASE ONE: Epigastric pain after colonscopy

Colonoscopy complications

-Perforation - instrument vs air pressure
-Hemorrhage
-Visceral injury (spleen, diaphragm, volvulus)
-Infection (bacteremia, retroperitoneal abscess, appendicitis)
-Pneumatic injuries (Distention, pneumoperitoneum, pneumothorax)
-Rate of perforation 1/1500... increases with biopsy/polypectomy

Splenic laceration/rupture from colonscopy

-Incidence 0.00005-0.017%.  Likely under-reported. 14 Million colonscopies per yr in US
-Mortality 5%. Danger lies in delayed diagnosis.  Symptoms often attributed to air insufflation or serositis.
-Female predominance, increased risk prev abdominal surgeries
-Mechanism? Traction on splenocolic ligament, adhesions, direct trauma
-Presentation: Abdominal pain, dizziness, Kehr's sign, worsening anemia
    (Kehr sign referred pain from diaphragm to shoulder)
-Dx; Ultrasound, DPL, CT
-Management: Symptomatic, serial Hb and abd exam, possible surgery

CASE TWO: Sore throat


Uvular Edema: Rarely reported in isolation
Etiologies: Allergy/anaphylaxis, infection, angioedema, trauma
Quincke's Disease: Inhalation injury, hereditary angioedema, cocaine/marijuana abuse, idiopathic/snoring in obesity. 
Presentation: Dysphagia, odynophagia, sore throat, foreign body sensation.  Uncommonly resp distress, dyspnea, fever.
-Some association with epiglottis
-If infection suspect, cover strep species and consider lateral neck xray
-If not infectious, steroids +/- H2 blockers
-75% recurrence rate - either first 48 hours or remote


CASE THREE: Groin pain

Avascular necrosis of femur
-Risk factors.  Trauma, steroid use, hemoglobinopathy, dysbaric phenomena, autoimmune disease, storage disease, smoking, HLD, excess alcohol consumption
-Often present with groin pain, throbbing, deep. Bilateral disease 50-80%
-Can by identified by painful forced internal rotation at hip
-Radiographic findings: Crescent sign (intact bone with deeper area of necrosis).  On MRI "single density line" early, "double line sign" found in 80% cases, high intensity line surrounded by low intensity
-Treatment: 85% collapse rate, surgical intervention is mainstay.  Of those treated with conservative therapy, 76% proceeded to arthroplasty

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Lower GI Bleeding - Dr. Johnson

6/19/2014

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  • Take a good history! (Color, Amount, Time, Coagulant use, History of prior bleed) 
  • Ask about prior colonoscopy. 


Higher Risk Patients
  • Higher morbidly from lower GI bleeding comes from those who are unstable in the ED, have a nontender abdomen, syncopize, take Aspirin, or have other medical co-morbidities. 


Unstable Patients
  • In the unstable patient who is still bleeding, give blood and consider TXA. 
  • In the patient on aspirin, give platelets and/or desmopressin. 
  • For a Coumadin patient, give Vitamin K and FFP or consider prothrombin complex concentrate. 
  • If you're giving blood, think about calling surgery in addition to GI. 
  • If the bleed is ongoing BRB, talk to inpatient team about tagged RBC scan or angiography. 
  • "Rapid" colonoscopy is 3-4 hrs at the fastest. 
  • Get an upper endoscopy before a CT in patient with concerning symptoms for aortoenteric fistula. 

Mimics for Lower GI bleeding:
  • Melena - Pepto-bismol and Iron supplements
  • Hematochezia - beets, red grapes, vaginal bleeding, hematuria 
  • + FOB - red meat, Vitamin C, turnips, horseradish 

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Pediatric Bleeding Issues - Dr. SMith

6/19/2014

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Hemophilia
  • When concerned about intracranial hemorrhage in a patient with hemophilia, replace factor before even considering obtaining a head CT.

ITP
  • ITP is a diagnosis of exclusion and the big thing to exclude is leukemia.
  • A CBC, peripheral smear, PT, and aPTT should be your default screening labs in a patient with a concerning bleeding episode.

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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