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TEAM Challenge CoRE Concepts

7/30/2015

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Picture
Myocardial infarction with papillary muscle rupture
  • Rare complication, cited in 1-2% of acute MI. Most often secondary to papillary muscle necrosis following RCA infarction. 
  • Present with new onset severe mitral valve regurgitation with complicating heart failure.
  • Ultimately, patient requires surgical intervention for valve repair/replacement, though intra-aortic ballon pump can be used as bridge. 
  • Avoid fluids given heart failure; nitroglycerine also problematic given preload dependence. Need vasopressors, with dobutamine being mainstay of treatment. 
  • Literature cites usage of afterload reducing agents such as nicardipine, though difficult in practice. Emergent interventional cardiology and CV surgery consultation is paramount.
  • Intubation should be approached with great caution, given high risk of arrest in setting of preload reduction,  increased intra-thoracic pressure and catecholamine suppression.

Thyroid storm
  • Most commonly due to severe exacerbation of underlying hyperthyroidism (i.e. Graves’ Disease) caused by trigger (pregnancy, substance abuse, infection, surgery, trauma, iodine load).
  • Consider in young patients with new onset atrial fibrillation with RVR with concomitant altered mental status/agitation, GI disturbance, heart failure. 
  • Treatment must occur in stepwise manner to prevent worsening of disease process: 
  1. Block synthesis (methimazole, PTU)
  2. Block hormone release (iodine solutions given >1hr after methimazole)
  3. Block peripheral conversion (steroids)
  4. Block peripheral effects (propranolol)
  5. Give supportive measures/treat trigger.
  • May rapidly progress to high output heart failure! Endocrinology consultation and ICU admission a must!


Aspirated foreign body
  • 70% of aspirated FB occurs in pediatrics, with food items accounting for 49% of aspirations.
  • Important to assess level of obstruction: Larynx, trachea, bronchus.
  • Right primary bronchus most common level of deep aspiration.
  • Often objects not radio-opaque; consider expiratory/decubitus films.
  • All objects need to be removed, given potential for delayed complications (i.e. post-obstructive pneumonia).

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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