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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

6/30/2016

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​• If even considering CVA as diagnosis, call Code Stroke
• Consider mechanical thrombectomy in CVA patients who may not be IV tPA patients
• Role of head trauma in IV tPA exclusion criteria poorly defined
• Always consider VTE in pregnant patients with leg pain
• Pregnant & postpartum patients are at significantly increased risk of VTE
• Diagnostic workup with Modified Well’s Criteria
• Lovenox is the treatment of choice for VTE in pregnancy

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Alcohol Use Disorder and the ED Patient: More Than Just MTF - Dr. Awad

6/30/2016

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  • Alcohol use is the leading cause of morbidity and mortality in the US with huge social, economic, and healthcare impacts.
  • Alcohol Intoxication is a DIAGNOSIS OF EXCLUSION! Always consider other causes of altered mental status and address immediate life threats.
  • Most patients can be managed with supportive care and reassessment. IV fluids and vitamin repletion are largely unnecessary and are not supported by current literature.
  • Be wary of Wernicke’s, Withdrawal, and Ketosis in chronic alcoholic patients.
  • The ED is often the only place where alcoholics seek care, we should give patients all the opportunities and guidance our facility can offer to seek help once discharged.

​

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Carolinas Case COnference - Dr. West

3/3/2016

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Psychiatric and medical co-morbidities
  • Schizophrenia associated with 10-25 year decrease in life expectancy
  • Increased risk of medical conditions with psychiatric conditions related to compliance, access to care, and substance abuse
 
ERIC forms
  • Must be mentally ill AND dangerous to self or others
  • All patients being admitted for psychiatric reasons need an ERIC form
  • Use facts, not conclusions (eg. do not state patient is suicidal, say the patient wants to kill himself by jumping into traffic).
 
Restraints
  • Often needed, but have associated risks
  • A new oxygen requirement suggest hypoventilation, monitor for hypercapnia
  • Make sure to put the order in and complete the face to face encounter (R icon in tool bar) within one hour of initiation of restraints. 

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Carolinas Case CONFEREnce - Dr. Beverly

1/14/2016

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​Case 1:
  • Excess iodine exposure can lead to the Jod Basedow effect:
  • In presence of excess iodine, patient’s have autonomous production of thyroid hormone independent of normal regulatory functions
 
  • Average iodine intake for an average adult is 150ucg.
  • Iodine load in 1 CT scan averages 370mg/ml.
  • Each scan loads with 100-120ml.
  • Can affect patients will underlying thyroid disease

  • Treatment in the ED focuses on symptomatic care, adrenergic receptor blockade, blocking thyroid hormone synthesis, inhibiting hormone release and decreasing peripheral conversion
 
 
Case 2:
  • Postural orthostatic tachycardia syndrome is defined by excessive increase in heart rate (greater than 30bpm) when supine to standing in the absence of other overt orthostatic symptoms
 
  • Treatment focuses on preventing hypovolemia and treating excessive sympathetic tone. 
 


Case 3:
  • Cerebellar strokes present with vague symptoms and are hard to diagnose. 
 
  • Pitfalls in ED diagnosis include failure to recognize risk factors in young patients and failure to understand that there is a spectrum of disease. 
 
  • Consider inpatient hospitalization for patients at higher risk. 
 
  • Do not delay consultation if you are worried. 

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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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Naloxone and Street Drugs - Dr. Murphy

11/5/2015

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​Naloxone:
  • Think about having a discussion regarding use of IM/IN naloxone and the availability of kits with our high risk patients or their families – if they have a ton of opioid/opiate prescriptions on the prescription monitoring database, they are high risk.  
  • Other groups: sickle cell, cancer patients, chronic pain, fibromyalgia, elderly patients on opioids/opiates, heroin overdose patients.  Think about offering this to parents of pediatric patients with sickle cell disease and other young children in the home.
 
  • Kits are $32.29 at the Walgreens across from CMC University and you can walk in without a prescription and get a kit from the pharmacy.
  • Great resources available at the NC Harm Reduction Coalition and Project Lazarus websites.
  • There are many good You tube videos demonstrating use out there. 
 
Cocaine:
  • Most cocaine in US adulterated with levamisole.
  • Agranulocytosis can occur in patients exposed to levamisole repeatedly leading to immune compromise or more serious infections.
 
Heroin:
  • Be on the look out for clostridial infections in patients using IV or skin popping.
  • Consider asking this sub group of patients about tetanus status at they are at increased risk for developing tetanus.
  • Be wary of patients with heavy eyelids, complaints of dysphagia and dysphonia who use IV/subcutaneous heroin as they are at risk for developing wound botulism – a clinical diagnosis.
  • Treatment of wound botulism is more involved than infant botulism – patients need wound debridement, antibiotics AND antitoxin.
​

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Sharpen Your Calipers: Wide Complex Tachycardia - Dr. Littmann

9/10/2015

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General
1.     WCT algorithms do not work in the real life setting
2.     Don’t pay attention to what others have said; you need to evaluate the ECG yourself
3.     First question: is the WCT regular or irregular?

Sustained Regular WCT
I. Differential Diagnosis
1.     Sustained regular WCT: most likely ventricular tachycardia (VT)
a.     Spend 2 minutes searching for P waves – inconsistent P-QRS relationship is 100% specific for VT
b.     Bizarre QRS morphology that is not c/w RBBB or LBBB (negative QRS in lead I; QRS concordance in the chest leads) strongly supports VT

2.     Consider SVT if QRS morphology resembles RBBB or LBBB
a.     Find an old ECG: are the QRS morphologies identical?
b.     If no old ECG available, prove SVT by giving IV adenosine
c.     “I think this is SVT” is not good enough!

II. Therapy of Sustained Ventricular Tachycardia
1.     Unstable: electric cardioversion

2.     Clinically stable: one round of IV antiarrhythmic drug therapy allowed
          a.     IV procainamide may be the most effective agent (avoid in patients with severe systolic CHF and 

                   in patients with baseline prolonged QT)
          b.     IV amiodarone
          c.     Consider IV propranolol or IV metoprolol in ischemic VT and in patients with “electric storm” 

                  (repeat episodes of VT/VF)

Sustained Irregular WCT

I. Differential Diagnosis
1.     Sustained irregular WCT: most likely not VT but atrial fibrillation (AF)
2.     Rate 120-160; QRS morphology is c/w RBBB or LBBB: AF with bundle branch block
3.     Rate very fast; QRS morphology is bizarre, not c/w RBBB or LBBB: most likely AF with WPW (FBI – Fast, Broad-complex, Irregular)

II. Therapy
1.     AF with BBB: usual therapy for AF (IV diltiazem etc.)
2.     AF with WPW (“FBI”)
          a.     Clinically unstable or ventricular rate excessive: electric cardioversion
          b.     Clinically stable: IV procainamide or IV ibutilide
          c.     Clinically very stable, rate not very fast: PO flecainide or propafenone
NOT ALLOWED: IV verapamil, diltiazem, digoxin, adenosine

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Neuro Imaging - Dr. Asimos

8/27/2015

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The mnemonic for systematically evaluating a non-contrast head CT is “Blood Can Be Very, Very Bad”.

A  Reassuring CT:

·         No Blood is seen

·         All Cisterns are present and open

·         Brain is symmetric with normal gray-white differentiation

·         Ventricles are symmetric without dilation

·         No hyperdense Vessels are present

·         No Bone fractures


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UPDATE on the EndoVascular Tx of CVA - Dr. Asimos

3/26/2015

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1.       Four recently completed trials demonstrate that early mechanical stent-thrombectomy after tPA in patients with large vessel occlusion and salvageable tissue on brain imaging results in improved reperfusion and functional outcomes.

2.       The details of the patient selection paradigm remain a key discussion, but favorable penumbral imaging is a consistent feature of all trials.

3.       
Systems of acute care, including transfer protocols, will need to be re-organized to deliver this therapy effectively in the real world



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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