CMC COMPENDIUM
  • 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

Carolinas Case Conference - Dr. Lounsbury

6/30/2016

0 Comments

 
Picture
​• 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

0 Comments

Carolinas Case Conference - Dr. Lounsbury

6/10/2016

0 Comments

 
Picture
•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

0 Comments

Carolinas Case Conference - Dr. Lawson

6/2/2016

0 Comments

 
Picture
  • Aortic dissection is an uncommon but important cause of chest pain in the ED. 
  • The classic presentation of severe (sudden onset, tearing/ripping chest pain that radiates to the back) 9 and the absence of these features is not associated with a significant negative likelihood ratio. As a result diagnosis requires a high degree of suspicion.
  • For patients determined to be low risk by the AHA aortic dissection risk stratification score, a negative D-dimer confers a negative likelihood ratio of 0.05 (CI 0.02-0.09). Clinicians may consider using D-dimer in the appropriate patient population to further assess their risk for dissection. 

0 Comments

Carolinas Case Conference - Dr. Robertson

5/5/2016

0 Comments

 
Picture
Post-Stroke Seizures:
1. CVA is the most common cause of seziures and secondary epilepsy in adults.
2. Blood in the brain is BAD for seizures (ICH and even more so with cerebral infarction with hemorrhagic transformation).
3. In patient's with early-onset (< 30 days) or late-onset (> 30 days) seizures after CVA consider consulting neurology for EEG or initiation of AEDs.  

Missed ACS/Physician Wellness:
1. Keep a broad differential for hypotension, especially in the diabetic population. 
2. Appreciate the affect of stress and poor patient outcomes on you as a provider. 
3. Develop strategies for managing stress and proactively addressing your own well-being.
​


0 Comments

Carolinas Case Conference - Dr. Beverly

2/18/2016

0 Comments

 
Picture
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 
​

0 Comments

Sharpen YOur Calipers - Dr. Littmann

1/28/2016

0 Comments

 
Picture
What is STEMI without STE?
  1. Patients presenting with acute chest pain may have clinical STEMI (acute total thrombotic occlusion of a large coronary artery) but no obvious ST-segment elevation in the ECG
  2. This occurs with STEMI locations that are not well represented by conventional ECG leads
  3. Such patients are at high for not receiving timely reperfusion therapy and for having poor outcomes
  4. Easily memorizable ECG signs can help raise awareness of the possibility of STEMI without STE
  5. If suspected, placing exploring electrodes to the area of interest can quickly uncover the STEMI
 
Posterolateral or High Posterior MI
  1. The most common type of missed STEMI
  2. Almost always due to acute occlusion of the LCX
  3. May involve the posterior papillary muscle and can cause severe mitral regurgitation
  4. Earliest ECG sign: ST depression in the anterior chest leads (mirror image of posterior ST elevation)
  5. Frequent associated findings: subtle Q waves or subtle ST elevation in the inferior or lateral leads
  6. Can be uncovered by placing exploring electrodes to the back (V7-V8-V9)
 
High Lateral MI
  1. The second most commonly missed STEMI
  2. Almost always due to acute occlusion of the first diagonal branch of the LAD (LAD-D1)
  3. Fortunately usually small
  4. Earliest ECG sign: ST elevation in leads I, aVL and V2, but not in V1 or V3, and ST depression in III and aVF
  5. With the conventional 4x3 lead display format, the spacing of ST deviation resembles the shape of the South African flag (the “South African Flag Sign”)
  6. Can be uncovered by placing the V4-V5-V6 ECG leads 1 and 2 interspaces higher
 
RV infarct
  1. Almost always due to acute occlusion of the proximal RCA
  2. Almost always associated with acute inferior STEMI
  3. Recognition of RV infarct, therefore, is now less important because code STEM is usually called anyway for the inferior MI
  4. Recognition can be important, however, if the ST elevation in the inferior leads is subtle or nondiagnostic
  5. Clues to suspect RV MI:
    1. Inferior STEMI with marked ST depression in I and aVL (left leads)
    2. Inferior STEMI with ST elevation in V1 only but not in V2
  6. Can be uncovered by placing right-sided chest leads
  7. If inferior STEMI has been diagnosed, there is no need to waste time to record right-sided chest leads
  8. Suspected RV MI:
    1. Use caution with vasodilators (nitrates)
    2. Consider IV fluids for hypotension with JVD

0 Comments

Carolinas Case CONFEREnce - Dr. Beverly

1/14/2016

0 Comments

 
Picture
​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. 

0 Comments

Esophageal Disasters (When it Really isn't the HEart) - Dr. Jannach

1/14/2016

0 Comments

 
Picture
1. Remember esophageal etiologies as a cause of life threatening chest pain.
2. Esophageal perforation is rare, deadly, and fast acting. Delay in diagnosis can cause doubling of mortality.
3. Know best imagning studies available at facility, and have low threshold for surgical consultation.
4. Quick recognization and initation of medical management is key:
NPO, PPI, and antibiotics (ie zosyn) in all cases.
5. Be familiar with the latest management of esophageal perforation: medical
management vs surgical management vs stent placement.

0 Comments

CMC Case COnference - Dr. West

12/10/2015

0 Comments

 
Picture
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 
​

0 Comments

Aortic Dissection - Dr. Jackson

9/24/2015

0 Comments

 
Picture
​- We are not very good at making the diagnosis…correct as initial diagnosis only 15-50%
- Type A involves ascending aorta and requires immediate cardiothoracic surgeon, Type B does not.
- CT Angio is the study of choice in stable patients
- Normal CXR in 12% of patients. Abnormal findings include wide mediastinum, abnormal aortic contour, pleural effusion, and wall Ca+ displacement
- If no clinically apparent aortic insufficiency or CHF, then treat first with labetalol/esmolol then nitroprusside.



0 Comments
<<Previous

    Archives

    August 2018
    February 2018
    January 2018
    December 2017
    October 2017
    September 2017
    August 2017
    July 2017
    June 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013

    Categories

    All
    Abdominal Pain
    Abdominal-pain
    Airway
    Back Pain
    Back Pain
    Bleeding
    Change-in-mental-status
    Chest Pain
    Dizziness
    Ecg
    Emboli
    Environmental
    Fever
    Gyn
    Headache
    Hypertension
    Infectious Disease
    Pain
    Pediatric Emergency
    Professionalism
    Psych
    Respiratory Distress
    Sepsis
    Shock
    Toxins
    Trauma
    Vomiting
    Weakness

    RSS Feed

    Tweets by @PedEMMorsels
Powered by Create your own unique website with customizable templates.
  • 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