Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Head Trauma - Dr. Gibbs

2/22/2016

Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
·         GCS 15 ≠ 14 ≠ 13
·         Know what each CDR gets you
·         Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
·         Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)

Case #2 (TBI on warfarin) – SLIDE #49
·         Very high risk… be liberal with imaging
·         No CDR to identify the low-risk patient
·         Order INR on arrival
·         Reversal of anticoagulation = resuscitation!
·
Case #3 (severe TBI) – SLIDE #94
·         RSI with neuroprotective drugs
·         Hyperosmolar therapy with either hypertonic saline or mannitol
·         Do not hyperventilate unless there is clear clinical evidence of herniation

VP Shunts - Dr. Angela Johnson

2/18/2016

Be suspicious of shunt problems in …. Kids with shunts
HA, nausea, vomiting, irritability, behavior change are the weaker predictors you may miss if not vigilant
Malfunction common early, but eventually almost ALL get revised
Infection most common in first six months
Look at your own images!
Not stable – Call NSGY and consider tap

Cervical Artery Dissection - Dr. Asimos

10/22/2015

1. Remember to consider spontaneous cervical artery dissection in the differential diagnosis of a headache patient.

2. The majority of patients who develop an spontaneous cervical artery dissection will not develop a stroke.

3. Cerebral ischemia caused by cervical dissection is usually embolic rather than hemodynamic compromise caused by dissection-related stenosis or occlusion.

4. Stroke prevention is with antiplatelet or anticoagulant therapy, with no data supporting improved outcomes with either therapy compared to the other.

5. Endovascular therapy is increasingly being used in the acute treatment of stroke related to spontaneous cervical artery dissection.

Carolinas Case Conference - Dr. Beverly

10/1/2015

Cryptococcal Meningitis:

Opportunistic infection in HIV/AIDS patients
Symptoms can be vague but most commonly present with fever, neck stiffness, headache and altered mental status
Diagnosis is by lumbar puncture; if you are thinking about this, treat properly and treat fast
Mainstay of treatment is with Amphotericin B and Flucytosine

Ebstein's Anomaly:

Congenital malformation characterized by abnormalities of tricuspid valve and right ventricle
1 in 20,000 live births; No predilection for either gender
Chronic hypoxemia leads to changes in blood vessel function and structure
These changes are likely maladaptive and may increase risk for thrombotic events

Neuro Imaging - Dr. Asimos

8/27/2015

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

Benign Headaches in the ED - Dr. Goldonowicz

8/27/2015

- Only approximately 5% of all headaches that present in the ED are true emergencies
- After evaluating for potential emergencies and performing a full neuro exam, pause and consider if any of the following Red Flags are present:

First or worst
Neuro abnormalities
Associated symptoms
Persistent location/time of day
Unresponsive to treatment
Cancer, HIV, Trauma
Change in pattern, frequency, severity

To diagnose migraine, need 5 separate episodes of headache characterized by:

4 - 72 hours in length
Unilateral
Pulsating
Moderate or severe
Aggravated by routine activity
With nausea/vomiting and/or photophobia/phonophobia

"Migraine” or undifferentiated benign headache, you can treat the same way in the ED

Best evidence for acute headache treatment includes the following:

Dark and quiet room
1L Crystalloid
10mg IV or PO Reglan (or Compazine)
25mg IV or PO Benadryl +/-
30mg IV Toradol OR 550mg PO Naproxen OR 600mg PO Ibuprofen
Consider 10mg IV Decadron to prevent short term headache recurrence

Avoid narcotics and barbiturates out of concern for dependency and rebound effect

CMC Case Conference - Dr. Allen

3/12/2015

SINUSITIS
•Intracranial complications of acute bacterial rhinosinusitis include meningitis, brain abscess, subdural empyema and cavernous sinus thrombosis. Most common presenting feature of meningitis complicating sinusitis is seizure activity.

•IDSA encourages use of antibiotics for acute bacterial sinusitis when strict diagnostic criteria are met. Amoxicillin/clavulinateremains first line therapy.

NEONATAL VESICULAR RASH

•Many causes of vesicular rashes in the neonate are benign, but serious bacterial and viral infection must be evaluated.

•Neonatal scabies infestation presents with vesicular rash affecting the hands, feet, wrists and face of neonates. Treatment is with a single application of permethrin 5% cream, or 5-10% sulfur suspension in petroleum.

PANCREATIC CANCER
•Pancreatic cancer presents often in late stage due to vague symptoms of weakness, abdominal pain, diarrhea and jaundice.

•Recurrent visits for similar chronic complaints carry high risk. Consider serious pathology as underlying source.

M&M - Dr. Reyner

7/10/2014

Case 1 - S/P Arrest w/ STEMI

STEMI - >1 mm STE at the J point in 2 contiguous leads or greater than 2 mm STE in 2 contiguous leads isolated to leads V2-V3; reciprocal depression makes diagnosis more likely but not necessary for diagnosis.

RBBB - causes = ischemia, functional, iatrogenic
> Definition - QRS >120 ms; RSR' pattern v1-v3, slurring of S wave in lateral leads
Diagnosis of STEMI in the setting of RBBB does not require special diagnostic criteria.
Consider RBBB as the result of an anterior MI (LAD lesion) rather than as a “benign bystander.”

AHA recommends PCI for patients with aFMC-to-device time system goal of 120 minutes or less and fibrinolytics for patients > 120 minutes (FMC = first medical contact).
Using a cutoff of 20 minutes from arrest to ROSC captures 96% of survivors and achieves a survival rate of 82%.

Case 2 - Ear Pain and Facial Palsy

Gradenigo’s Syndrome: Triad of otorrhea, retro-orbital pain, and CN VI palsy (diplopia).
Consider Gradenigo’s in patients with a cranial nerve palsy in the setting of acute or chronic otitis media.

Case 3 - Ataxia and Headache after Rollercoster Ride

Wallenberg Syndrome- lateral medullary syndrome- is an acute infarct involving the lateral medulla oblongata
It is the most common brainstem stroke
Patients present with vertigo, facial numbness, dysarthria, dysphagia, ataxia, and cerebellar signs
Consider CNS pathology in patients presenting with neurologic complaints after a roller-coaster ride

Rocky Mountain Spotted Fever - Dr. Schneider

5/29/2014

School-aged kids are the most likely to get RMSF!
North Carolina has the most cases in the USA.
Summer time + Headache + Fever +/- rash / exposure = Just treat, because time is of the essence.
You can perform LP or not. Depends on your index of suspicion for other forms of meningitis. CSF is not helpful in the diagnosis of RMSF, but it can help rule-out other conditions.
Doxy is not the Devil! Children can have a full course of doxycycline and not ruin their teeth.

M&M - Dr. Bronner

5/1/2014

Thyrotoxicosis and Cardiomyopathy

Hyperthyroid effects on the cardiovascular system are not the same as hyperadrenergic states
Direct effects on vascular smooth and cardiac tissue leads to:

Decreased SVR
Decreased diastolic BP = Decreased afterload
Activation of Renin-Angiotensin-Aldosterone = Increased Preload
Direct cardiac inotropy + chronotropy

Ultimately, increased CO (HRxSV) that can lead to HF and dysrhythmias

May be catastrophically precipitated by stressors such as sepsis

Treatment of Thyroid Storm

B-Blockade
Thyroid Inhibition

Synthesis - PTU or Methimazole
Release - SSKI
Periph Conversion (T4 to T3) - Hydrocortisone

HIV and PID

Suspect HIV in any severe febrile illness without a source
Know emerging demographics - Minority, heterosexual, women
PID treatment in HIV+ patients has similar approach and outcome as HIV-

HIV+ may be more likely to develop TOA

IUDs are do not predispose to PID after the first 3 weeks post-placement
Usual culprit : Actinomyces, but treat for GC/CT!