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Carolinas Case Conference - Dr. Mollo

8/18/2016

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- Ultrasound has utility in almost all ED patients and should be a cornerstone of both diagnosis and aiding in resuscitation for a critically ill patient (don't forget to document your images!)
- Utilize peak flow to trend patient's burden of illness in asthma exacerbations.
- Consider single/two dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.
- Think about myiasis in a non-healing papule/plaque/ulcer in a patient coming from a tropical area. Treatment is skin biopsy with removal of larvae.

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The significance of Respiratory artifact (RA) in the ECG - Dr. Littmann

5/5/2016

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I.  Characteristics of respiratory artifact
  1. Repetitive microoscillations, best seen in the inferolateral leads; rarely seen in leads I and V1
  2. Occasionally, the microoscillations are preceded by what look like P waves - the presence of pseudo-P waves may mimic atrial dissociation
  3. The RA corresponds to the inspiratory phase of the respiratory cycle
  4. Duration of the RA corresponds to duration of the inspiratory phase of respiration
 
II.  The clinical significance of respiratory artifact
  1. The presence of RA always indicates increased work of breathing, respiratory distress
  2. It allows precise measurement and tracking of the respiratory rate - count the number of RAs in the 10-sec 12-lead ECG and multiply it by 6; measure 1 or more respiratory cycles in mm and divide it into 1,500 or its multiples
  3. 44% of pts with RA required ventilation support; 28% required intubation, mechanical ventilation
  4. Successful treatment of the underlying condition resulted in a decreased rate or elimination of RA
 
III.  Respiratory artifact can aid in the recognition of sleep-disordered breathing
  1. Central sleep apnea is characterized by
                a. marked sinus deceleration or AV block followed by
                b. an abrupt increase in heart rate and the
                c. simultaneous appearance of very fast RA
  1. Obstructive sleep apnea is characterized by
                a. profound sinus bradycardia with
                b. simultaneously occurring very long respiratory (snoring) artifact followed by
                c. a sudden increase in the heart rate and resolution of the RA
  1. Cheyne-Stokes breathing is characterized by
                 a. periodic, cyclic clustering of RA
                 b. the onset of most periods which contain the RAs show the characteristics of central sleep apnea
​


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Sedation After Intubation - Dr. Graboyes

12/10/2015

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  • ​Remember analgesia first strategy after intubations 
​
  • Goal RASS of -1 to -2, not -5
​
  • Limit use of benzodiazepines and paralytics

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Carolinas Case Conference - Dr. Young

9/3/2015

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Myocarditis:
- broad spectrum of disease, high level of suspicion is essential
- myocarditis can mimic STEMI and Wellens syndrome among others
- EKG, echo, and cardiac enzymes cannot rule in/out the diagnosis
- No hesitation to consult Peds Cards

NAT:
- no discrimination, occurs in all people groups
- history, exam, and physical findings may raise suspicion for abuse. 
     - must place child in gown.
- make sure story matches up... loose ends must be tied


Marfan and PTX:
- Must be personally knowledgeable about equipment associated with procedures (ie: suction device for chest tubes)
- Pigtail catheters equivalent to thoracostomy tubes for uncomplicated PTX with decreased pain - 
http://pedemmorsels.com/pigtail-catheter/

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COPD Exacerbation - Dr. Akomeah

7/9/2015

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• Acute treatment: bronchodilator and steroids
   – Consider antibiotics with sputum changes
• Use NIV early for increasing WOB


• Disposition guide:
   – Sa02, treatment response, COPD severity
• Discharge meds: SABA, steroids
   – 
Consider antibiotics and LABA/ICS

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CODE PE - Dr. Troha

8/28/2014

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Thanks to Dr. Troha's diligent efforts, we will be initiating a new protocol to help streamline the decision making and coordination of care for patients with small PEs, Submassive PEs, and Massive PEs. 

Step 1: Risk stratification
- Obtain BNP, troponin, perform echo and assess vitals

Step 2: If massive or submassive, call out Code PE. Pull Code PE pack that contains treatment algorithm and lysis checklist

Step 3: Administer heparin

Step 4: Assess bleeding risk using lysis checklist

Step 5: If decision is made to give IV lysis, stop heparin drip during infusion

Step 6: If decision is made to administer catheter-based lysis, contact interventionalist on call

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Congenital Heart Disease - Dr. MacNeill

4/10/2014

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Heart Lesions

    1. Left to right - VSD, ASD, cushion defect, PDA

    2. Cyanotic - truncus, transposition, total anomalous, tricuspid atresia, tetralogy

            a. Cyanosis - decrease of deoxygenated hgb by 3-5 mg/dl

                  1. Shunting from lung

                  2. Mixing blue and red blood     

    3. Single ventricle

Break the left side of the heart (Hypoplastic left, aortic stenosis, coarct) --> hepatomegaly, gray, pulmonary edema, etc

Break the right side of the heart (hypoplastic right heart, tricupsid atresia, pulmonary atresia, tetrology of fallot) --> Blue, poor perfusion, acidosis  

Not all ductal dependent lesions are cyanotic - AS, coarct 

Not all cyanotic lesions are ductal dependent - truncus arteriosis, TAPR



Cyanotic Lesions 

    a. Truncus Arteriosus -

                Blue because they're mixing - mixing happens before duct, therefore not ductal dependent  -
                Pulmonary exam will vary;
                You can give them O2 - won't worsen cyanosis but won't help

    b. Transposition of Great Arteries -

                Cyanotic because you have mixing blood;
                 If you find these later (ie, in the ED and not immediately after birth) these kids will all have VSD;
                 Ductal dependent
                 O2 wont help but wont hurt

    c. Tricuspid Atresia -

                  Blue because not perfusing lungs; Right ventricle doesn't develop (Hypoplastic right heart)
                  Ductal dependent; only pulmonary artery flow will come through ductus from aorta
                  ECG will show LVH but only because right side isn't balancing it out
                  O2 will prob not help, but won't kill

    d. Tetrology of Fallot -

                  Cyanotic because of decreased pulmonary perfusion and mixing -
                  O2 can help

    e. Totally Anomalous Pulmonary Venous Return  -

                  Cyanotic because of mixing

     
Hyperoxia Test 

- 10 minutes of 100% O2 and see response > may help differentiate between pulmonary and cardiac etiology

* For cyanotic lesions oxygen is not going to kill - it just may not help*  
* O2 can hurt you on left to right shunts*

  
           Left to right shunts are usually dyspneic/hypoxic because they are over-perfusing the lungs and they get fluid overload.

           Oxygen will cause vasodilitation of the pulmonary vessels and increase left to right shunting worsening the problem.

Prostaglandins - 0.05-0.1 mcg/kg/min > will cause apnea - tube the kid   

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Pleural Effusions - Dr. Graboyes

3/20/2014

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Pathophysiology
Based on 2 concepts
    - Increased hydrostatic pressure
    - Decreased oncotic pressure


CXR
- Upright films will detect effusions >400mL
- Lateral decubitus films will detect as little as 50mL of fluid

Fluid analysis
- Order: cell count, gram stain, culture, pH, protein, LDH

Exudate vs transudate - use Light's Criteria

    Transudates:
            CHF
            Nephritis
            Nephrotic syndrome

    Exudates:
            Infection
            Traumatic HTX
            Malignancy
            CT disorders

Management:

- Treat the underlying pathology!
- Avoid large volume taps (>1L) if CHF, renal or hepatic pathology
- Unstable - septic shock, tension hydropneumothorax

- If tapping:
    - Avoid NV bundle
    - Have patient lean over table
    - Use ultrasound

- When to tap:
    - Typically, these patients will not need a tap or tube in the ED.
    - If patients have persistent hypoxia in spite of other interventions, consider tap.
    - Severe respiratory failure.

Complications:
PTX
Infection
Hemorrhage
Rare - air embolism, sheared catheter loss


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Airway Management Issues - Dr. Cordle

3/20/2014

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Kids are Different

- Larger heads, tongues, smaller nostrils
- Cricoid ring determines size of ET tube
- Bradycardia is a BAD SIGN.

Signs of Increased Respiratory Effort

- Assumed position
- Bobbing head
- If kids are pulling off their mask, they might need to be intubated.

Positioning

- sniffing position, sometimes achieved without any padding
- jaw thrust is preferred to chin tilt
- always use an oral airway, measure from angle of mouth to angle of jaw

DOPE for ETT problems


- Check ETCO2 waveform

- Dislodged
- Occluded
- PTX
- Equipment

Pitfalls

Not recognizing compromise early
!

Not thinking to clean out the nose
!

Not thinking in terms of axis alignment
!


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M&M - Dr. Zahn

3/7/2014

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The Return ED Visit
  • Learning points - everyone has biases - realize yours
  • Errors in medicine do happen. Learn from these errors. Make a personal protocol/checklist to review all data before any major decision (admission vs discharge).
  • Pneumonia - know what the risks are (we have a powerplan! - ED Adult pneumonia - community acquired)
  • Provide excellent documentation in pneumonia patients. Clearly document risk factors (or lack of) for HCAP, MRSA, Pseudomonas. This will allow you to choose appropriate antibiotic coverage. 

"BB" Shot to Right Groin... 
  • Xray showed "BB" above right inguinal ligament. 
  • CT showed ballistic had moved further.
  • Repeat films showed BB in the chest.
Bullet Embolism 
- Bullet embolism is extremely rare. 
- Requires multidisciplinary management. 
- Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations. 
- Venous more common than arterial


FLU
1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
  • Vital signs are vital.
  • Consider second visits as opportunities to not make the same mistake twice. Doesn't mean admit them; means re-consider the bad things.

Tamiflu is not magic... 
  • When prescribing Tamiflu, know the evidence and pros/cons. Cost, side effects, limited efficacy, and possibility of causing resistance strains should all be considered. Have this discussion with your patients.

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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