Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Carolinas Case Conference - Dr. Lounsbury

6/10/2016

•Consider atypical presentation for ACS in elderly patients
•Risk factors for severity of acute pancreatitis include advanced age, obesity, organ failure, and pleural effusion

•Can use APACHE II score to risk stratify in the ED

•Blunt aortic injury (BAI) is a rare but often deadly entity
•Consider in all cases with significant mechanism
•Can have atypical/no symptoms or have distracting injury
•Management of BAI includes permissive hypotension and rapid transfer to the operating room

Carolinas Case Conference

5/31/2016

Diagnosis of orbital compartment syndrome can be remembered by the mnemonic: DIP (Decreased visual acuity, Increased IOP, Proptosis)
Indications for lateral canthotomy: Vision loss, proptosis, EOM palsy, Elevated IOP (>40mmHg)
Lateral canthotomy and cantholysis:

-- inject lidocaine with epi in lateral margin of eyelid;
-- clamp with hemostat for 2 minutes;
-- using crush mark from hemostat;
-- perform lateral canthotomy with scissors perpendicularly
-- dissect inferiorly and snip the inferior crus of the lateral canthal tendon
-- recheck IOP after procedure

Low risk of complication if only inferior cantholysis performed

Principles of Trauma Resuscitation - Dr. Gibbs

3/19/2016

Prehospital hypotension is bad! Even if normal BP upon arrival.
Vital signs are insensitive for traumatic shock.
Develop a strategy for bedside testing.
Be cautious with interventions.
If you are unsure, focus on the Basics!!
(see the slides below)

Head Trauma - Dr. Gibbs

2/22/2016

Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
·         GCS 15 ≠ 14 ≠ 13
·         Know what each CDR gets you
·         Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
·         Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)

Case #2 (TBI on warfarin) – SLIDE #49
·         Very high risk… be liberal with imaging
·         No CDR to identify the low-risk patient
·         Order INR on arrival
·         Reversal of anticoagulation = resuscitation!
·
Case #3 (severe TBI) – SLIDE #94
·         RSI with neuroprotective drugs
·         Hyperosmolar therapy with either hypertonic saline or mannitol
·         Do not hyperventilate unless there is clear clinical evidence of herniation

Carolinas Case Conference - Dr. Beverly

2/18/2016

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

Chest Trauma Pearls - Dr. Colucciello

9/13/2015

Indication for Pre-hospital needle decompression of chest for suspected tension pneumothorax is hypotension
1/3rd of traumatic aortic disruptions may not have external signs of trauma
ECG most important screening tool for myocardial contusion
Control HR and BP for patients with traumatic aortic disruption
Pulmonary contusions in children represent severe thoracic trauma

Trauma Imaging - Dr. Gibbs

8/20/2015

GCS = 15: 5-6% [+} CT, <1% surgery
Both the New Orleans and Canadian Head CT Rules are highly SENSITIVE for important TBI... the later is more SPECIFIC.
C-Spine Injuries: 1% children, 2% adults, 4% elderly.
NEXUS Clinical Decision Rule is effective in the elderly.
NEXUS does not have enough data for children < 8 years of age.
NEXUS Chest criteria is here! Use it!
No Clinical Decision Rule for Abdominal injury.
CT Abd best for Solid organs, but can miss Diaphragm & bowel injuries

Carolinas Case Conference - Dr. Nichols

7/16/2015

1) Respect the elderly, but especially in geriatric trauma!
-Many of these patients are beta blocked and anticoagulated
-High risk for occult fracture, higher risk for mortality following any trauma
-Remember to apply geriatric trauma scoring, and triage conservatively

2) Don't fear the chronic tracheostomy patient in respiratory distress
-Remember your airway toolbox, gauge how much time you have!
-A NG tube can be a great placeholder for trach exchange
-Never forget you can (usually) still intubate these people from above
-Fiberoptic nasotracheal intubation as a failsafe

3) Consider imaging of the hip in pediatric leg pain
-SCFE can present as subacute knee pain, patients may still be able to walk!
-Consider in both boys and girls, obese and average sized
-Low threshold for imaging of the hips with knee or thigh pain complaints

4) Ensure you examine every trauma patient's eyes, checking for ocular trauma
-Globe rupture requires immediate optho consultation
-Do not perform further exams until this is ruled in or out
-Hyphema is a collection of blood in the anterior chamber, usually traumatic
-More anterior chamber filling associated with worse visual recovery
-Emergent consultation with opthomology, elevate head of bed, check for coagulopathy

CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

Sneaky Ectopic - Dr. Nichols

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

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

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

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).

Complex Trauma Case - Dr. King

12/13/2014

- 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.