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CMC Case COnference - Dr. West

12/10/2015

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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 
​

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Osteomyelitis in Kids - Dr. Smith

11/12/2015

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1. Osteomyelitis can be difficult to detect in the ED so always maintain a high suspicion for it in children with refusal to bear weight or persistent pain in a long bone.

2. Bloodwork rarely helps diagnose osteomyelitis, but can be reassuring if normal and you have low suspicion.
​

3. X-rays help rule-out other causes of pain such as fracture but more definitive imaging (i.e. MRI vs bone scan) are usually needed to diagnose.

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Ketamine: Not Just for Kids - Dr. Mollo

10/1/2015

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Consider Ketamine for:
  • Awake patients who need short, painful procedures
  • RSI in critically ill trauma/burn patients
  • DSI (delayed sequence intubation) in patient with asthma/poor reserve
  • Hysterical patients in pain
  • Dangerous, actively suicidal patients
  • Chronic pain patients with high opiate demands
  • Pre-hospital setting for pain

Consider administering zofran concomitantly (NNT=7), but do not prophylactically treat with benzos

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Carolinas Case COnference - Dr. NIchols

9/18/2015

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Tuberculosis
-Immediately isolate any patient that you believe may have TB, and document that you have done so!
-Upper lobe pneumonia should always prompt further consideration of tuberculosis, screen with risk factors
-Patients with TB often have multiple ED visits with active disease, risk factors are often overlooked in triage
-Remember, PPD and IFN blood testing is for latent TB only and will not help you diagnose active TB
-Involve infectious disease, ensure that the health department is involved in the patient's case

Elderly Falls - Missed Femoral Neck Fracture
-95% due to falls, more than 300k admissions per year
-One year mortality in those over 65: 12-37%
-High risk of malunion, poor healing, and avascular necrosis if missed
-Surgical repair is performed as soon as medically stable for procedure
-Range all joints, low threshold to image
-Before discharge, consider home/social factors
-For a full reassessment, ambulate the patient personally or with the nurse to prevent missed injuries and assess feasibility of discharge


High Pressure Injuries
-Surgical emergency despite benign exam
-Paint/grease guns, pressure washers
-Material rapidly spreads to tissue spaces and can cause compartment syndrome
-Time Sensitive: Amputation rate 38% within 6 hours, 58% after that
-EMS transportation if transferring for ortho evaluation from OSH/Urgent Care

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What Goes Up, Must Come Down: Priapism - Dr. Puciaty

9/4/2015

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Picture
· Erections lasting more than 4 hours are a medical emergency.
· Secondary to impaired contraction of corporal smooth muscle.
· Immediate aspiration/irrigation and/or injection of phenylephrine are the mainstay of treatment.
· Don’t be afraid to use a big needle.




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Snake Bites - Dr. Kallgren

8/27/2015

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  • Epidemiology: vast majority of snake bites are from nonvenomous snakes, fatalities extremely rare
  • Crotalids (vipers) have hemotoxic venom, Elapids (cobras) have neurotoxic venom
  • Six venomous species in North Carolina, five are vipers so treated with CroFAB

Field treatment: don’t make things worse, get to the nearest hospital

In the hospital:                 

1.     ABCs
2.     Wound assessment and pain control
3.     Labs to assess for coagulopathy and rhabdomyolysis
4.     Call poison control – should always talk to toxicologist
5.     CroFAB vs observation only

                                      - Mild/dry bite: no CroFAB, just observation
                                      - Moderate/severe: one or more doses as needed based on wound progression

CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents

TNFa pilot study: active now, enrolling nonpregnant healthy adults



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CMC Case Conference - Dr. Beverly

7/9/2015

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Abnormal Presentations of ACS
-Always think of this on your differential
-Frequently re-evaluate patients
-Interpret ECGs in a systematic fashion - and do this every time!

RBBB and STEMI
- No criteria for STEMI as there are in LBBB
- Any ST elevation is abnormal 
- Read your EKG’s carefully and compare to old
- It is never a bad idea to get serial EKG’s if the presentation is unclear ("One ECG Begets Another")


De Winter’s Sign
- This is an Anterior STEMI Equivalent!
- Seen in 2% of acute LAD occlusions
- Criteria
     -Tall prominent symmetric T waves in the precordial leads
     -Upsloping ST segment depression > 1mm at the J point
     -No ST elevation in the precordial leads
     -ST elevation in aVR

aVR Sign
-Widespread horizontal ST depression, most prominent in I, II, V4-V6
-ST elevation in aVR >1mm
-ST elevation in aVR >V1


Hyphen
- Defined as blood in the anterior chamber
- Complete a full visual examination
- Must evaluate for ruptured globe 
- Ruptured Globe = Tetanus, antibiotics and emergency consultation

Siedel’s Sign
- Evaluates for aqueous humor leak secondary to violation of the anterior chamber
- Apply topical anesthesia
- Paint eye with fluorescein dye
- Test is positive if there is a stream of dye emanating from the wound site
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M&M - Dr. King

9/25/2014

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High Pressure Injuries

Picture
- Surgical issue - Don't send them home!
- Leave the finger alone 
- No Ice (decreases perfusion further)!
- High risk for amputation


Spontaneous Bladder Rupture

- Extremely rare diagnosis
- Expand your differential, use your diagnostic pause
- Consider in pts with chronic GU issues 
- Add creatinine to abdominal fluid studies

Heat Stroke

- Temp >40 with AMS
- Patients die from multisystem organ failure 
- Cooling and supportive care 
- Call Pearson for therapeutic hypothermia

Nec Fasciitis and Ultrasound

- Take time to ultrasound your patients 
- Look for air (hyperechoic areas with shadowing), fascial thickening, deep fluid
- Cannot rule out nec fasc with US
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Sickle Cell Pain - Dr. Young

9/11/2014

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1) SCD pain is complex and real (despite lack of objective findings).    
     - 1/2 have no objective findings. 
      - Those with higher baseline Hgb have higher risk of pain crisis. 
      - Adult patients increased pain frequency have higher mortality.


2) Evaluate for potentially critical masqueraders.


3) Give pain medications fast; strongly encourage
intranasal fentanyl as first-line opioid. 

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Transplant Emergencies - Dr. Goldonowicz

7/10/2014

0 Comments

 
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Transplanted organs 
- don't act like normal organs 
- won't hurt and are in weird locales


RAID - Potential Complications to Consider

Rejection
   - Hyperacute - w/in minutes - we won't see
   - Acute
   - Chronic   

Anatomy

   - Vascular - stenosis, aneurysm, thrombosis
   - Nonvascular - leak, scar formation, dislodged stint, stone formation

Infection
   - First 28 days - nosocomial
   - 1-6 months - viral infections - CMV, hepatitis, EBV, HH6; oppurtunisitcs - PCP, listeria, fungal
   - > 6 months - Healthy - UTI, PNA, cold, Chronic viral infection - EBV, zoster, HSV

Drug Toxicity
   - Transplant immunosuppressants - cyclosprine, tacrolimus > can hurt the kidneys; 
   - Imuran, cellcept - hematologic effects
   - Lots of Drug- Drug interactions

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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