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Carolinas Case Conference - Dr. Robertson

5/5/2016

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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.
​


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Carolinas Case COnference - Dr. West

3/3/2016

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Psychiatric and medical co-morbidities
  • Schizophrenia associated with 10-25 year decrease in life expectancy
  • Increased risk of medical conditions with psychiatric conditions related to compliance, access to care, and substance abuse
 
ERIC forms
  • Must be mentally ill AND dangerous to self or others
  • All patients being admitted for psychiatric reasons need an ERIC form
  • Use facts, not conclusions (eg. do not state patient is suicidal, say the patient wants to kill himself by jumping into traffic).
 
Restraints
  • Often needed, but have associated risks
  • A new oxygen requirement suggest hypoventilation, monitor for hypercapnia
  • Make sure to put the order in and complete the face to face encounter (R icon in tool bar) within one hour of initiation of restraints. 

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Leadership in the Trauma Bay - Dr. Colucciello

7/16/2015

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  • Cooperation and communication key
  • Attention to Trauma Protocols
  • Keep track of the time!!
  • Team Captaincy Skills
  • Control Pain
  • Dangers of Distracting Injuries (Physician gets distracted)


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CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

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Sneaky Ectopic - Dr. Nichols

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  • Don't let a beta HCG lull you to sleep, if your suspicion is high, get an ultrasound and/or discuss with OBGYN.
  • Beta HCG assays vary significaltly between labs, for accurate results try to maintain the same testing assay.
  • Anchoring is a dangerous bias that places you at high risk to miss key and potentially life-threatening diagnoses.
  • To avoid anchoring, be judicious about a "diagnostic pause" and await diagnosing patients until all information is available.


GIB and Aortic Graft - Dr. Beverly

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  • History and physical is the foundation of medical decision making. Complete a good chart biopsy. Undress the patient fully. If not,  you may miss a crucial piece of information that will alter your decision making.
  • Aortoenteric fistula is a can't miss diagnosis. In a patient with a GI bleed and a known graft, this is your diagnosis until proven otherwise. 100% mortality if left untreated.
  • Consult vascular early of you suspect this diagnosis. Treatment involves early resuscitation and rapid operative intervention.


Pulmonary embolism + pleural effusion - Dr. West

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  • Up to one half patients with PE’s with have a pleural effusion on CT, one third if just looking at CXR
  • Usually unilateral and small
  • Usually exudative
  • If a patient has a small pleural effusion and pleuritic chest pain, think pulmonary embolus


Traumatic Ptx, Be Kind - Dr. Robertson

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  • Set your trauma rooms up ahead of time, know what to look for early in the patient's physical exam. 
  • Review the concepts of correct position and chest tube insertion techniques
  • Pigtail catheters are as efficacious as large bore chest tubes for traumatic pneumothorax
  • Keep an eye out for more data on Pigtails for blood in the chest. 
  • Large bore chest tubes remain standard of care for hemothorax, hemopneumothorax or concern for barotrauma in already vented patient's (even if pneumothorax is small). 

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EM Cases - Dr. King

3/5/2015

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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.

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Cases - Dr. King

1/29/2015

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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.

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Complex Trauma Case - Dr. King

12/13/2014

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- 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.  

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M&M - Dr. King

9/25/2014

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High Pressure Injuries

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- 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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M&M - Dr. Kiefer

9/18/2014

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Missed Dialysis & Syncope

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  • K+ was 7.4
  • Hyperkalemic EKG changes
       - Narrow based peaked T waves, bradycardia
       - PR prolongation, QRS widening - can be a full block
       - Sine wave
  • New blocks in setting of bradycardia - be concerned for hyperK+ (most other blocks are acceleration dependent)

RUQ Abdominal Pain

  • RUQ wnl except some ascites & UPT positive 
  • Initial Transvaginal US - no IUP; left adnexal mass with beta < 300
  • Pt seen by OBGYN... decision to follow beta levels as outpatient.
  • Beta quant levels noted to be decreasing, but found to have increasing adnexal mass.
  • Worsening pain. Went to OR. Histology was consistent with ruptured ectopic pregnancy!
** important note - can have bradycardia with 40% of cases of hemoperitoneum**

**** Can have ectopic pregnancy with declining beta****
  • In order to be able to manage a possible ectopic expectantly you need:  compliance, demonstrate some sort of resolution, no evidence of rupture. 

Missed Pubic Rami Fracture

  • Elderly patient s/p mechanical fall with resultant proximal humerus fracture > missed pubic rami fracture.
    **** Make your patients walk when they leave the ED****
    **** Fully examine your patients and document well & make sure to reassess****
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Ultrasound QA - Dr. Tayal

9/18/2014

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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.


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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