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.
Psychiatric and medical co-morbidities
Sneaky Ectopic - Dr. Nichols
GIB and Aortic Graft - Dr. Beverly
Pulmonary embolism + pleural effusion - Dr. West
Traumatic Ptx, Be Kind - Dr. Robertson
EM Cases - Dr. King
Thrombotic Thrombocytopenic Purpura:
- Can be hereditary or acquired. Acquired forms can be found as a result of a multitude of disease states.
- Patients will more often present with vague symptoms including confusion/AMS rather than focal neurologic deficits attributable to a specific vascular distribution.
- Treatment to consider initiating in the ED includes steroids and FFP however be wary of volume in patients with underlying cardiac disease.
- VasCath can be placed in ED depending on provider comfort.
- Plasma exchange has decreased mortality from 85-95% to 10-20%.
Third Degree Heart Block:
- Most often seen in elderly patients due to progressive fibrosis and calcification of conduction system and surrounding tissue, but can certainly be a complication of AMI.
- Particularly for your elderly patients, be wary of medication side effects.
- Atropine is always worth a try. Just realize more often than not it won't help you.
- Hypotension? Altered mental status? Distress? PACE THE PATIENT!
- Take the time to review initiation of transvenous pacing. Like the infamous ED thoracotomy or cricothyroidotomy, its a procedure we should know like the back of our hands.
Final Pearl: if you're going to order an imaging study, look at the WHOLE image.
Cases - Dr. King
Post-op Incisional Hernia
- Seen in over 10% of patients; up to 25% of patients with incision infection.
- More common in midline incision, more common in upper abdomen vs lower abdomen.
- Dr. Gibbs Pearl: If a patient presents to the ED with 30 days of their surgery (and is not there for an obviously unrelated complaint) contact the Surgeon to discuss the patient's presentation.
- Surgery Pearl: evaluation for post-operative pain from lap chole can involve RUQ ultrasound to look for signs of abscess. Also consider biliary studies if concerned for biliary leak, biloma development.
Negative CT Calcium score in ACS
- Negative CT calcium score misses ACS very rarely.
- Quick test that is non-invasive, has no contrast, does not require patient participation, does not rely on patient heart rate or ability to exercise.
- If used in correct patient population, NPV is between 93-97% with a sensitivity of 99-100%.
- Dr. Garvey Pearl: Recognize that your clinical gestalt trumps any protocol or clinical decision rule and do what you think is best for the patient.
Complex Trauma Case - Dr. King
- Hypothermia: Can cause significant physiologic disturbance, generally starting when body temperatures fall beneath 90 degrees (moderate hypothermia). Moderate hypothermia should be aggressively corrected with both external and internal warming measures. Risk of refractory VFIB increases as you approach 82.4degrees.
- Severe hypothermia requires invasive rewarming techniques including invasive catheters (think therapeutic hypothermia in reverse). This can include hemodialysis and ECMO.
- Peri-intubation hypothermia: associated with increased risk of mortality as well as increased ICU and hospital length of stay. Take steps to avoid it! Think ketamine, fluids, pressors.
- Spinal shock: sudden vasoplegia caused by loss of output from sympathetic system. Classic presentation of hypotension and bradycardia is seen in less than 25% of cases. Most recent guidelines recommend norepinephrine as pressor of choice. Seen mostly commonly in injuries above T6.
M&M - Dr. King
High Pressure Injuries
- 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
- 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
M&M - Dr. Kiefer
Missed Dialysis & Syncope
- PR prolongation, QRS widening - can be a full block
- Sine wave
RUQ Abdominal Pain
**** Can have ectopic pregnancy with declining beta****
Missed Pubic Rami Fracture
**** Fully examine your patients and document well & make sure to reassess****
Ultrasound QA - Dr. Tayal
1. Primary objectives of EM pregnancy US = IUP = midfundal GS with YS or fetal pole
2. Use your skills of depth, focus, frequency, and zoom to look for a YS or FP in a nice round sac in the middle of uterus.
3. Adnexa should be reviewed for ovaries, and then other.
4. Ovaries are medial to the internal iliac vessels and lateral to the uterus.
5. Don’t reverse your probe when doing transverse (coronal) views of the uterus and adnexas. Marker to the patient’s right leg.
6. Label images appropriately and delete the ones that are incorrect.
7. Finish your reports. Physicians outside our department are looking at them.