Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Carolinas Case Conference - Dr. Lounsbury

6/30/2016

• 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

Carolinas Case Conference - Dr. Lounsbury

6/10/2016

•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

Carolinas Case Conference - Dr. Lawson

6/2/2016

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.

Carolinas Case Conference - Dr. Robertson

5/5/2016

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.

Carolinas Case Conference - Dr. Beverly

2/18/2016

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

Sharpen YOur Calipers - Dr. Littmann

1/28/2016

What is STEMI without STE?

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
This occurs with STEMI locations that are not well represented by conventional ECG leads
Such patients are at high for not receiving timely reperfusion therapy and for having poor outcomes
Easily memorizable ECG signs can help raise awareness of the possibility of STEMI without STE
If suspected, placing exploring electrodes to the area of interest can quickly uncover the STEMI

Posterolateral or High Posterior MI

The most common type of missed STEMI
Almost always due to acute occlusion of the LCX
May involve the posterior papillary muscle and can cause severe mitral regurgitation
Earliest ECG sign: ST depression in the anterior chest leads (mirror image of posterior ST elevation)
Frequent associated findings: subtle Q waves or subtle ST elevation in the inferior or lateral leads
Can be uncovered by placing exploring electrodes to the back (V7-V8-V9)

High Lateral MI

The second most commonly missed STEMI
Almost always due to acute occlusion of the first diagonal branch of the LAD (LAD-D1)
Fortunately usually small
Earliest ECG sign: ST elevation in leads I, aVL and V2, but not in V1 or V3, and ST depression in III and aVF
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”)
Can be uncovered by placing the V4-V5-V6 ECG leads 1 and 2 interspaces higher

RV infarct

Almost always due to acute occlusion of the proximal RCA
Almost always associated with acute inferior STEMI
Recognition of RV infarct, therefore, is now less important because code STEM is usually called anyway for the inferior MI
Recognition can be important, however, if the ST elevation in the inferior leads is subtle or nondiagnostic
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
Can be uncovered by placing right-sided chest leads
If inferior STEMI has been diagnosed, there is no need to waste time to record right-sided chest leads
Suspected RV MI:
1. Use caution with vasodilators (nitrates)
2. Consider IV fluids for hypotension with JVD

Carolinas Case CONFEREnce - Dr. Beverly

1/14/2016

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.

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

1/14/2016

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

12/10/2015

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

Aortic Dissection - Dr. Jackson

9/24/2015

- 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.