CMC COMPENDIUM
  • 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

Carolinas Case Conference - Dr. Beverly

2/18/2016

0 Comments

 
Picture
Trauma Resuscitation: Not ACLS
  • Trauma resuscitation should focus on treating the underlying cause.
    • Trauma patients need intubation, resuscitation with blood products and bilateral thoracotomies when in extremis
  • ACLS in trauma is not indicated.
    • Chest compressions and epinephrine are the cornerstone of medical resuscitation, not trauma.
    • In traumatic arrest, chest compressions are not attempted until underlying causes have been appropriately addressed including hypoxia, hypovolemia, tension pneumothorax and cardiac tamponade
  • REBOA now being explored and in place for patients with suspected or diagnosed intra-abdominal hemorrhage secondary to penetrating torso injuries, blunt trauma patients with suspected pelvic fracture and isolated pelvic hemorrhage and patients with penetrating injury to the pelvis or groin area with life-threatening hemorrhage. 
 
It's Not Always Sepsis!
  • Multiple physiologic processes can elevate lactate.
  • Be careful with premature closure in patients. It is not always sepsis. 
  • Reviewing old EKG’s in comparison to new EKG’s is invaluable. If you order it, make sure you review it. 
  • New EKG changes even in the absence of symptoms in the altered patients should always prompt further investigation 
​

0 Comments

Steroids for Shock - Dr. Thacker

11/5/2015

0 Comments

 
Picture
  • Consider administration of steroids in patients with shock that is unresponsive to appropriate IV fluid resuscitation and vasopressors.
​
  • Consider adrenal crisis in any patient who has risk factors (particularly chronic steroids), an acute stressor, and vague systemic symptoms.
​
  • Hydrocortisone is the steroid of choice in patients with adrenal insufficiency given it’s glucocorticoid and mineralocorticoid action.
​​
  • Etomidate has not been shown to cause clinically significant adrenal suppression. Use it for RSI in any appropriate clinical setting.
​

0 Comments

Delivery Complications - Dr. Lounsbury

10/22/2015

0 Comments

 
Picture
  • Uncommonly encountered however critical to manage
  • Always Type & Cross, difficult to predict complications
  • Stage 2 complications include
    • Shoulder Dystocia- difficult to predict and morbid. Consider HELPERR mnemonic and know maneuvers
    • Umbilical cord prolapse- Elevate fetal parts, tocolysis, and wait for OB
    • Uterine rupture- identify by acute pain, vaginal bleeding, and loss of station, wait for OB
    • Malpresentation- Best plan is tocolysis and wait for OB. If delivery is unavoidable, delivery is presentation-dependent
  • Stage 3 complications include
    • PPH- 4T’s (tone, trauma, tissue, and thrombin). Stepwise approach and know rescue measures
    • Uterine inversion- replace it early 

0 Comments

Sharpen Your Calipers: Wide Complex Tachycardia - Dr. Littmann

9/10/2015

0 Comments

 
Picture
General
1.     WCT algorithms do not work in the real life setting
2.     Don’t pay attention to what others have said; you need to evaluate the ECG yourself
3.     First question: is the WCT regular or irregular?

Sustained Regular WCT
I. Differential Diagnosis
1.     Sustained regular WCT: most likely ventricular tachycardia (VT)
a.     Spend 2 minutes searching for P waves – inconsistent P-QRS relationship is 100% specific for VT
b.     Bizarre QRS morphology that is not c/w RBBB or LBBB (negative QRS in lead I; QRS concordance in the chest leads) strongly supports VT

2.     Consider SVT if QRS morphology resembles RBBB or LBBB
a.     Find an old ECG: are the QRS morphologies identical?
b.     If no old ECG available, prove SVT by giving IV adenosine
c.     “I think this is SVT” is not good enough!

II. Therapy of Sustained Ventricular Tachycardia
1.     Unstable: electric cardioversion

2.     Clinically stable: one round of IV antiarrhythmic drug therapy allowed
          a.     IV procainamide may be the most effective agent (avoid in patients with severe systolic CHF and 

                   in patients with baseline prolonged QT)
          b.     IV amiodarone
          c.     Consider IV propranolol or IV metoprolol in ischemic VT and in patients with “electric storm” 

                  (repeat episodes of VT/VF)

Sustained Irregular WCT

I. Differential Diagnosis
1.     Sustained irregular WCT: most likely not VT but atrial fibrillation (AF)
2.     Rate 120-160; QRS morphology is c/w RBBB or LBBB: AF with bundle branch block
3.     Rate very fast; QRS morphology is bizarre, not c/w RBBB or LBBB: most likely AF with WPW (FBI – Fast, Broad-complex, Irregular)

II. Therapy
1.     AF with BBB: usual therapy for AF (IV diltiazem etc.)
2.     AF with WPW (“FBI”)
          a.     Clinically unstable or ventricular rate excessive: electric cardioversion
          b.     Clinically stable: IV procainamide or IV ibutilide
          c.     Clinically very stable, rate not very fast: PO flecainide or propafenone
NOT ALLOWED: IV verapamil, diltiazem, digoxin, adenosine

Picture
0 Comments

Ped Resuscitation: Basics are Best - Dr. Fox

7/9/2015

0 Comments

 
Picture
- Respect the anatomic and physiologic differences that exist between adults and kids.

  - Focus on the basics! 

          - Compressions >100/min, Good Depth, Good Recoil
          - Don’t hyperventilate.
          - EtCO2 can be a helpful guide.

- Have a Post-Arrest System in place... at the end of an arrest is not the time to try to figure this out.
         - Temperature management

         - ECMO?

- Ask the hard questions to help other family members.

         - Prior syncopal events? 
         - Prior “seizures?”
         - Prior Submersion Events?
         - Fam Hx of Sudden Death?
         - Fam Hx of Submersion Events?

0 Comments

TEAM Challenge Cases - Drs. Fox, Griggs, MacNeill

7/2/2015

0 Comments

 
Picture

Ovarian Torsion

 - Ovarian Torsion requires us to be vigilant.  It is often misdiagnosed initially by both EM and GYN physicians.
 - Reconsider your DDx.  "Appendicitis" and "Renal Colic" are common mimics of Ovarian Torsion.
 - Fight diagnostic momentum.
 - Don’t be fooled by “normal blood flow.” The ovary has two arterial supplies. Diminished venous flow should be alarming even if there is "normal" arterial flow. 
- See Ovarian Torsion.

Perforated Gastric Ulcer

 - Review your own films! Radiologists are human too. You know what your concern is and may be able to actively see the important abnormality more easily!
 - Concerning abdominal exam? You don't need to wait for images to call a surgeon.
- Think twice before sending to CT, especially with a concerning abdominal exam. 
- Resuscitate aggressively! Prepare for the patient to become dramatically more ill!
- Don’t forget the broad spectrum antibiotics!

Ruptured AAA

- Resuscitate! (ABCs, Large Bore Access), but be comfortable with permissive hypotension.
- Target SBP ~80-90 mmHg



- Do not be in a hurry to intubate the patient if they are breathing on their own.  Many arrest after intubation.  
- IF you must intubate, VENTILATE SLOWLY. Increased intra-thoracic pressure will crush their already tenuous pre-load and cause an arrest.

- Cross-matched PRBCs (consider massive transfusion protocol)
- Contact your Vascular Surgeon emergently
- At CMC, activate “Code Rupture”


0 Comments

Case COnference - Dr. Kiefer

3/26/2015

0 Comments

 

Intoxicated with Chest Pain

Picture
  • Intoxicated patients are a HIGH RISK patient population.  Always talk to the patient and take them seriously.  These patients need to be gowned appropriately.

  • EMS providers, nurses, and physicians frequently have significant emotional bias before ever interacting with these patients.  Understanding that bias exists, we must always be on guard for truly sick patients that have fallen through the normal triage system.  

  • Ripping/tearing chest pain (OR ~11) or migrating chest pain (OR ~7.5) are highly concerning historical features for aortic dissection.

  • Goals of initial medical management include first HR control for HR <60 BPM (i.e. esmolol, labetalol, etc) and then secondarily with BP control for SBP 100-120 mmHg (i.e. nitroprusside)


Infected Kidney Stone

  • Waiting for patients to urinate for a clean catch specimen is ONLY appropriate for stable patients where urine studies are NOT paramount to an evaluation.  Obtain cath urine specimens in ANY patient where a urinalysis is pivotal to patient care. 

  • Patient sign outs are the MOST dangerous time for patient care.  If a clear diagnosis has not been made then inform the oncoming provider and seek help in difficult patients. Sometimes a fresh set of eyes is all that is needed.

  • Interestingly, B-type natriuretic peptide (BNP) is frequently elevated in sepsis with proven distributive shock (as evidence by lactate >4, ScvO2 <70%) in patients with normal echocardiography.  Do not make a false assumption that elevated BNP = fluid overload, as this is NOT the case!  Patients with septic shock and an elevated BNP have a worse prognosis and severe intravascular volume depletion.

0 Comments

Case COnference - Dr. Allen

3/26/2015

0 Comments

 
Picture
• Aortoenteric fistula is the abnormal formation of connection between the aorta and bowel, typically occurring the 4th portion of the duodenum.

• Primary fistula formation due to atherosclerotic or infectious erosion of aorta into the bowel; secondary is the result of complications of aortic graft placement, either graft infection or pressure necrosis.


• Typically present with “sentinel bleed” followed by massive GI bleed and hemodynamic collapse; classic triad occurs <25% of patients.

• Vascular surgery consultation emergently if suspected; CT angiography can be helpful, but only after consultation and surgical evaluation.


0 Comments

Necrotizing Fasciitis - Dr. El-Kara

3/12/2015

0 Comments

 
Picture
  • Keep clinical suspicion high
  • Wide range of presentation - can be challenging!
  • Early surgical intervention is life saving
  • Consider the LRI-NEC Score for equivocal cases
  • Add Clindamycin to decrease mortality


0 Comments

EM Cases - Dr. King

3/5/2015

0 Comments

 
Picture
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.

0 Comments
<<Previous

    Archives

    August 2018
    February 2018
    January 2018
    December 2017
    October 2017
    September 2017
    August 2017
    July 2017
    June 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013

    Categories

    All
    Abdominal Pain
    Abdominal-pain
    Airway
    Back Pain
    Back Pain
    Bleeding
    Change-in-mental-status
    Chest Pain
    Dizziness
    Ecg
    Emboli
    Environmental
    Fever
    Gyn
    Headache
    Hypertension
    Infectious Disease
    Pain
    Pediatric Emergency
    Professionalism
    Psych
    Respiratory Distress
    Sepsis
    Shock
    Toxins
    Trauma
    Vomiting
    Weakness

    RSS Feed

    Tweets by @PedEMMorsels
Powered by Create your own unique website with customizable templates.
  • 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