Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

November Conference Pearls

December 1, 2017

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

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