• 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
•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
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.
Trauma Resuscitation: Not ACLS
It's Not Always Sepsis!
What is STEMI without STE?
Posterolateral or High Posterior MI
High Lateral MI
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.
CMC Case COnference - Dr. West
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.
Aortic Dissection - Dr. Jackson
- 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.