THE MORNING REPORT

The Best in FOAM Education

  • Shah, MD

November Conference Pearls


We had another fantastic month of conference! Here are some learning points and follow-up resources from Nov EM Conference at Stony Brook.

Critical Care by Dr Weingart: Post Arrest Management

Immediate priorities:

-pulse check

-airway confirmation - EtCO2 waveform

-Fingerstick

-RUSH U/S (they coded for a reason...try to find it)

-EKG

-art line

-pressors (their massive epi doses will wear off)

Next set:

Temp management:

-32-34C at SBUH

-easier maintenance but more platelet dysfunction and pressor needs vs 36C

-must wait at least 72 hour post warming to prognosticate

-with 32-34C, possible hibernation response means you should use confirmatory testing

-How to cool: if arctic sun available, use it

-If you want to use arctic sun competitor (due to $$$), make them show an in vivo study showing tight temp control vs just the manufacturer specs

-Shivering management

Hemodynamics:

-U/S to titrate IVF

-Pressors: norepi beats dopamine in cardiogenic shock

-SOAP 2 - NEJM 2010 (PMID 20200382): http://www.nejm.org/doi/pdf/10.1056/NEJMoa0907118

-Aim for at least MAP 65, but if easily obtained, get to MAP 80

-Anti-arrhythmic not used automatically unless it's what terminated their arrest

Ventilation:

-7cc/kg IBW

-These patients are at huge risk for lung injury due to massive inflammatory response

-ABG changes with temp; so, use uncorrected numbers and aim for 100-120 paO2 and 40-45 paCO2

https://lifeinthefastlane.com/ccc/arterial-blood-gas-in-hypothermia/

https://emcrit.org/hypothermia/

Grand Rounds: Dr Moore - Imaging in the 21st Century ED - Ultrasound

-The "5Es" of emergency physician-performed focused cardiac ultrasound: a protocol for rapid identification of effusion, ejection, equality, exit, and entrance - Moore - Acad EM 2015 (PMID 25903585)

http://www.iuemed.com/40years/wp-content/uploads/2016/11/5Es-of-Cardiac-Ultrasound-Hall-2015.pdf

-Ultrasound first, second, and last for vascular access - Moore - J Ultrasound 2014 (PMID 24958398)

https://com-anest.sites.medinfo.ufl.edu/files/2015/06/2014-Vascular-1.pdf

-Sonography first for acute flank pain - Moore - J Ultrasound Med 2012 (PMID 23091240)

http://www.ultrasoundleadershipacademy.com/wp-content/uploads/2014/01/US_First_for_Kidney_Stone.pdf

Sim: NIH Stroke Scale/tPA

-AHA/ASA 2015 Guidelines for who gets tPA and exclusion criteria (PMID 26696642)

http://stroke.ahajournals.org/content/early/2015/12/22/STR.0000000000000086

-Evidence behind tPA in stroke comes from 2 positive trials out of 12 (i.e. NINDS-2, ECASS-3)

http://www.thennt.com/nnt/thrombolytics-for-stroke/

-Note that the reported benefit is at 30 days

-So, we watch for the post-tPA adverse event (symptomatic intracranial bleed), not for improvement, in the ED

https://stroke.nih.gov/resources/scale.htm

-Kartik's NIHSS mnemonic: SELLF (Speech/EOM/LOC/Language/Fields) SAME (sens/ataxia/motor, extinction)

Speech (dysarthria; slurring)

horizontal EOM

LOC (Month/age & Close eyes/grip hand)

Language (aphasia; comprehension)

visual Fields

Sensation

Ataxia

Motor (face/arm/leg)

Extinction/hemi-attention

Sim Case: Myasthenia Gravis (MG) Crisis

-Get the FVC and NIF

-Fluoroquinolone adverse effects include tendon rupture, CNS effects, peripheral neuropathy, QT prolongation, worsening of myasthenia gravis

-Half dose paralytic if intubating (NMJ ACh receptors already partly occupied by MG patient's autoAb)

-EMRAP C3 Dyspnea Case 2 (at the end) reviews ddx for bulbar symptoms + dyspnea (e.g. Miller Fisher GBS, Botulism, MG)

Sim Case: Massive SAH and Neuro-safe intubation

-Controlling ICP: EMCrit Podcast 78

https://emcrit.org/emcrit/high-icp-herniation/

-Neuro-safe intubation: EMCrit Podcast 129

https://emcrit.org/emcrit/neurocritical-care-intubation/

-BP goals and mgmt summary for various brain bleeds via Brain Trauma Foundation

https://www.aliem.com/2017/09/intracranial-hemorrhage-management/

Sim Session: Difficult LP and Ultrasound guidance

-http://5minsono.com/lp/

Mock Oral Board Case: STEMI and cardiogenic shock

-STEMI reperfusion

-dual antiplatelet therapy

-heparin bolus

-if >2 hr delay to PCI (as in this case), ask for transfer; if not, and no contraindications (Table 6 in 2013 guidelines below), give lytics

-patient went into cardiogenic shock during wait

-use pressors!!!

-norepi to get MAP > 65 (SOAP 2 trial - PMID 20200382), then dobutamine or epi for ionotropy

-2013 AHA/ACC STEMI Guidelines:

https://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_453635.pdf -EMCrit Podcast 10 (Cardiogenic Shock):

https://emcrit.org/emcrit/cardiogenic-shock/

Mock Oral Board Case: Beta-blocker OD

-Check the FSG

-Eu/hypoglycemia more common with beta-blocker OD (in non-diabetic); hyperglycemia more in CCB OD

-As last resort, consider ECMO

https://lifeinthefastlane.com/ccc/beta-blocker-overdose/

Senior Grand Rounds: Complications of Bariatic Surgery by Dr Lohse

  • Staple line leak, abscess

  • Treatments: IR drainage, reoperation, GI bypass stenting

  • Gastric Bypass: anastomotic leak, most within 10 days postop need reop

  • Hemorrhage

  • Intraluminal: Presents like UGIB

  • Marginal Ulcer (esp. Roux-En-Y G-J junction)

  • Extraluminal: Next to staple line

  • Splenic Injury

  • Usually 2/2 vascular injury while devascularizing greater curvature of stomach.

  • Portomesenteric thrombosis

  • Stricture

  • Acute: 2/2 postoperative edema; self-limiting

  • Chronic: More common, p/w progressive food intolerance, dysphasia

  • Dx: Upper GI series

  • Tx: EGD w/ balloon dilation

  • Other Obstruction

  • Internal Hernias – particularly common

  • Roux-en-Y: If the biliopancreatic limb is obstructed, this is particularly dangerous as the blind end has no outlet and dilates very rapidly with no way to decompress by NG

  • IR gastrostomy

  • Nutritional deficiencies

  • More common in gastric sleeve and roux-en-Y where parts of the stomach are resected

  • B12, Iron, calcium malabsorption esp. Roux-En-Y. Fat-soluble vitamin deficiency

  • Requires VERY good nutritional follow up

  • Dumping Syndrome:

  • Early: 15-30 minutes after eating

  • Late: 1-3hrs after eating

  • Worsened by high-sugar food bolus

  • Lap band erosion, slippage

  • More likely to have cholelithiasis

Case Presentation by Dr Wright: Cerebral Venous Thrombosis

  • In patients with a bleed on CT, patients >45 with HTN and a basal ganglia or thalamic hemorrhage, you can safely assume it’s a hypertensive hemorrhage

  • In patients with a bleed who do NOT fulfill those criteria, work them up for other causes, specifically vascular lesions, bleeding tumors, venous sinus thromboses.

  • Cerebral venous sinus thrombosis

  • Many have risk factors for other coagulopathy

  • Pregnancy, OCPs, and puerperium are some of the BIGGEST risk factors

  • Sx: Pain on Valsalva, 90% have headache, many have visual Sx

  • 37-44% have focal signs/Sx

  • Papilledema

  • Ultrasound: 3mm back, >5mm optic disc

  • Protuberant optic disc >0.6-1mm into vitreous

  • Seizures!

  • Can lead to herniation, hemorrhage, ischemia/infarction – this is like a compartment syndrome of the brain

  • Infarcts and hemorrhages NOT within an anatomic arterial distribution

  • If you diagnose this, work up for coagulopathy

  • Factor V Leyden

  • Antiphospholipid/Cardiolipin

  • ATC III

  • Protein C/Protein S

  • Coags

  • Management

  • Antiepileptic Drugs

  • HOB 30 deg

  • HTS, Mannitol; possibly acetazolamide

  • Consider serial LPs to decompress brain if there are no mass lesions

  • Heparin even if the patient has hemorrhage!!!

  • Use heparin and NOT lovenox as the patient may need surgery

  • Call NSG for eval for Bolt, EVD/Shunt, thrombectomy

US guided regional anesthesia by Dr Kneib

  • Advantages: Complete anesthesia even for grievous injuries, minimal systemic toxicity

  • Disadvantages: Lose your sensory exam, risk of intraarterial injection

  • Technique

  • Localize nerve under US

  • Hyperechoic epineurium, hypoechoic fascicle

  • Hard to find, may need to try multiple angles/rotation

  • Confirm location of adjacent artery with color flow

  • Advance needle IN PLANE to target nerve (because it’s a pretty small target and you don’t want to skewer it

  • Stop advancing when needle has approached (but not punctured) nerve

  • Inject lidocaine – correct position confirmed by dissection of fluid between fascial plane and around nerve as visualized on US. ~60% of nerve surrounded makes for a good block.

Meningitis and Encephalitis by Dr Newton

  • Bacterial Meningitis

  • Bacterial meningitis rates have decreased markedly since Hib, S. Pneumonia, and recently meningococcus vaccines. Decrease is esp. amongst kids >1mo.

  • S. Pneumonia is most common amongst all age groups; N. Meningitidis very common in the young, Listeria uncommon but significant in infants and old people.

  • Viral meningitis/encephalitis

  • 3/4 viral meningitis caused by enteroviruses (coxsackie, echo), 15% HSV, other common ones include VZV and West Nile

  • Encephalitis is most commonly caused by Herpes Simplex – this is also often a very lethal encephalitis

  • PCR and viral cultures are actually not that sensitive or specific

  • Decision to CT before LP: Do NOT always have to CT before LP, and doing so could unduly delay antibiotic administration

Pediatric Stridor/Drooling by Dr Hom

-Clinical diagnosis

-Fever and stridor = potential badness, since they can potentially decompensate

-Croup, tracheitis, epiglottitis, retropharyngeal abscess is the acute febrile ddx

-last three get sick quickly

Pediatric Pneumonia by Dr Hom

-H&P and CXR are often equivocal

-Risk of resp distress in infants is high

-3-6 mo and younger should be admitted due to risk of resp arrest

-If see pleural effusion, get blood cultures

-Does this child have pneumonia - Rational Clinical Exam Series - JAMA 2017 (PMID 28763554)

Interesting Case by Dr Weiss: Apnea -> narcan -> neuro deficits afterwards

-Naloxone, then re-start your exam from the beginning

-Dense MCA sign

-https://radiopaedia.org/articles/hyperdense-mca-sign-brain

-Re-eval airway in neuro patients often

-CT perfusion

-In area of increased MTT, the mismatch in volume = penumbra

-MIP (a recon) is also helpful

-https://radiopaedia.org/articles/ct-perfusion-in-ischaemic-stroke

-CTA and CTP are not just about head; check the neck too

Subtle inferior acute coronary occlusion by Dr Meyers

-aVL is key to whether inferior changes are real

-aVL and 3 are almost perfectly opposite of each other.

-EKG is a snapshot in time; if see reperfusion, at high risk of reoccluding

Lung Ultrasound by Dr Reardon

-Probe selection

-linear for pneumothorax (ptx) only or for kids

-resusc, phased array

-otherwise, curvilinear

-Normal lung is A lines (though doesn't exclude asthma, copd, ptx)

-Wet lung - interstitial edema - B lines

-check if focal vs diffuse

-Pneumonia - B lines, consolidation, bronchograms, pleural effusions

-Lung sliding: absence + A-lines = ptx until proven otherwise

-B-lines mean no ptx!

-Ptx imposters: apnea, pleural adhesions, main stem intubation, blebs, pleurodesis

-Rib and sternal fracture eval with linear probe

Anticonvulsants and sedatives by Dr Weiss

  • Seizures generally arise from a combination of glutamate hyperactivity and/or GABA hypoactivity.

  • Antiepileptic drug mechanism

  • GABA agonist: BZDs, barbs (direct agonist), propofol, etomidate

  • NMDA blocker: Ketamine, MgSO4

  • AMPA blocker: Barbs

  • Na blocker: Dilantin, Carbamazepine, Keppra etc.

  • T-type Ca blocker: Ethosuximide

  • Side effects:

  • Phenytoin: Gingival hyperplasia

  • Barbs/BZDs: Paradoxical agitation

  • Valproic acid: Hepatic failure

  • Many:

  • DRESS: drug rash with eosinophilia

  • P450: Carbamazepine, phenytoin, valproic acid

  • Overdose

  • Valproic acid: Cerebral Edema

  • Seizures: Carbamazepine, Lamotrigine, topiramate

  • QRS prolongation is a marker for likelihood for developing seizures from antiepileptic overdose

  • These seizures are usually refractory to regular therapy

Toxins that can cause seizures by Dr Francis

  • INH, Ginseng, and False Morels

  • Require administration of Vitamin B6 to break

  • Will be BZD refractory until B6 is administered

  • Camphor: Knockoff Vicks Vapor Rub, Mothballs

  • Withdrawal Seizures: BZDs, EtOH, Baclofen

  • GABA receptor downregulation

  • TCAs

  • Characteristic EKG with terminal R wave, long QRS

  • Requires HCO3 administration

  • Refractory to phenytoin

  • Cholinergics

  • Atropine – give until secretions dry up. This will be a LOT of atropine

  • Strychnine: Severe muscle spasm/opisthotonos, respiratory failure, cardiac arrest, cerebral edema

  • Generally not true seizures

  • Very poor prognosis


Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

  • Facebook Social Icon
  • Twitter Social Icon
  • Instagram Social Icon

Copyright 2020

Designed by Michael Beck, MD and Bassam Zahid, MD