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

December Conference Pearls

December 31, 2017

We had a great month of conference to close out the calendar year! Here are some learning points and follow-up resources from December 2017 EM Conference at Stony Brook.

 

Grand Rounds: HIV PrEP and PEP by Dr Eliscu

-ED visit is an opportunity to screen for HIV PreExposure Prophylaxis (PrEP) and referral to appropriate providers

     -NYS Provider directory: https://www.health.ny.gov/diseases/aids/general/prep/provider_directory.htm

     -Payment options: https://www.health.ny.gov/diseases/aids/general/prep/docs/payment_options.pdf

-CDC HIV PEP (Post Exposure Prophylaxis) Guidelines: https://www.cdc.gov/hiv/risk/pep/index.html

-For sexual assault, eval for injuries, but if SANE not available, also you perform assault history, hygiene history, full body exam, forensic collection

 

Visual dx by Dr Cohen and Dr Meyers

-Syncope: always assess for long QT, Brugada, WPW, HOCM, and ARVD

     -ARVD EKG: http://hqmeded-ecg.blogspot.com/2011/08/young-man-with-syncope-while-riding.html

-Pediatric EKG differences include TWI in V1-V3 and smaller intervals

     -https://lifeinthefastlane.com/ecg-library/paediatric-ecg-interpretation/

-Progression of hyperacute T wave in acute coronary occlusion

     -http://hqmeded-ecg.blogspot.com/2017/10/a-male-in-his-60s-with-chest-pain.html

 

QA/QI Cases

-Fatal Respiratory Depression after Multiple Intravenous Morphine Injections - PMID 17048971

     -This is a forensic analysis of a fatality. In short, 26 yo female is post-op and had pain. Got 5mg morphine, wait 45 min, 10mg more, wait 45 min, 10mg more, wait 15 min, 10 mg more morphine. This led to analgesia. 40 min later, she coded.

     -Note that plasma levels do NOT correspond to brain levels.

     -Furthermore, note Table 1, which shows the longer transfer half life of morphine vs hydromorphone and fentanyl.

-Teaching From Catastrophe: Using Therapeutic Misadventures From Hydromorphone to Teach Key Principles in Clinical Pharmacology - PMID 21098693

     -This is a series of deaths linked to hydromorphone administrations, with some spectacular doses used.

     -Even with the shorter transfer half life, it's possible to cause the ultimate harm.

-Pharmacokinetic Optimisation of Opioid Treatment in Acute Pain Therapy - PMID 9314613

     -This is more about the basic science and pharmacokinetics of opioids if you want to get into the nitty gritty of all this.

 

M&M

-Checklist your airway. Every time.

     -https://emcrit.org/emcrit/intubation-checklist-2-0/

-HOp killers:

     -https://emcrit.org/emcrit/tube-severe-acidosis/

     -https://emcrit.org/emcrit/intubation-patient-shock/

     -https://emcrit.org/emcrit/lamw-oxygenation-kills/

     -https://emcrit.org/emcrit/lamw-oxygenation-kills-ii/

-Surgical airway: finger-scalpel-bougie

     -https://emcrit.org/emcrit/surgical-airway/

-BVM and SGA (e.g. LMA) must have EtCO2 to ensure you're delivering adequate breaths

-Massive Hemoptysis:

     -https://emcrit.org/podcasts/massive-hemoptysis/

-SALAD technique for bloody airway management

     -https://emcrit.org/emcrit/having-a-vomit-salad-with-ducanto/

-Meconium aspirator on an ETT

     -https://www.youtube.com/watch?v=1jJndz9DDUI

 

STEMI Criteria: A Prison for Your Mind by Dr Meyers

-Universal Definition of MI is not founded on angiographic evidence

-25-30% of NSTE-ACS patients have acute 100% occlusion on their delayed cath, e.g. PMID 19332201

-"STEMI" traps your mind into thinking that the only thing that matters is ST segment

-EMCrit Podcast 146-147: Who to Activate Cath Lab

     - https://emcrit.org/racc/who-needs-acute-pci/

-EMRAP Dec 2017: Cardiology Corner

 

James' Corner of Wins and Sins by Dr Alva

-EMCrit Podcast 39 & 178: Hyponatremia

     -https://emcrit.org/racc/hyponatremia/

     -https://emcrit.org/racc/better-management-hyponatremia/

-Hyperkalemia

     -EMCrit Podcast 32: Treating HyperK - https://emcrit.org/racc/hyperkalemia/

     -LR > NS - https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/

     -EKGs - https://emcrit.org/racc/critical-hyperkalemia/

-EAST Guidelines on Blunt Abdominal Trauma

     -https://www.east.org/education/practice-management-guidelines/blunt-abdominal-trauma%2C-evaluation-of

-Piperacillin/tazobactam (Zosyn) is not recommended for meningitis treatment

     -Cephalosporins, e.g. ceftriaxone, have better CSF penetration

     -FDA Piperacillin/tazobactam Insert: https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/065446s000lbl.pdf

 

Interesting Cases by Dr Alva and Dr Alptunaer

-http://www.emdocs.net/multiple-sclerosis-ed-pearls-pitfalls/

-Peripheral IV has higher delivery rate than your standard triple lumen central line for massive quick infusion of fluids

     -http://etmcourse.com/large-bore-iv-access-showdown/

-LRINEC score has high false positive and false negative rate

     -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468074/

-With a solid peripheral IV in place, peripheral pressors are safe for resuscitating the patient until definitive access is obtained

     -https://emcrit.org/emcrit/peripheral-vasopressors-extravasation/

 

Acute Pain by Dr English

-Pain is most common CC in the ED - reassess; realize barriers to treating most vulnerable

-Responsible opioid practice - appropriate dosing; adjuvants and alternatives

-Oral Analgesics - cost conscious; instructions and expectations

-Multimodal pain mgmt - targeted approach

-Inferior Alveolar Block:

     -https://anatomyforemergencymedicine.wordpress.com/2017/08/01/044-sensory-innervation-of-the-face-part-04-inferior-alveolar-nerve/

     -https://www.nysora.com/oral-and-maxillofacial-regional-anesthesia-continued

 

Pediatric Asthma and Adult Asthma by Dr Bracey and Dr Morley

-https://www.aliem.com/2015/06/air-series-respiratory-part-1-2015/

-https://www.aliem.com/2017/02/air-series-respiratory-module-2017/

 

Carbon Monoxide/Cyanide/Smoke inhalation by Dr Lawrence

-https://lifeinthefastlane.com/ccc/smoke-inhalation/

-https://lifeinthefastlane.com/toxicology-conundrum-038/

-https://emcrit.org/emcrit/cardiac-arrest-after-smoke-inhalation/

 

EBM: Is Central Line Infection Rate Higher for the Femoral Site by Dr Sherman

-https://emcrit.org/emnerd/the-case-of-the-blind-allocator/

-https://emcrit.org/emcrit/femoral-central-lines/

 

PGY3 Senior Grand Rounds: Tourniquets by Dr Alptunaer

-EMRAP Feb 2016: Doc in the Bay: Stop Bleeding without a Hospital

-50 sec video on applying a CAT Tourniquet:

     -https://www.youtube.com/watch?v=Hz9qdjaHLVU

 

Appendicitis by Dr Singer

-2010 ACEP Clinical Policy on Suspected Appendicitis:

     -https://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Critical-Issues-in-the-Evaluation-and-Management-of-Emergency-Department-Patients-With-Suspected-Appendicitis/

     -Note that IV Contrast is not mandated

 

Tuberculosis by Dr Valenzuela

-WHO Guidelines on TB:

     -http://www.who.int/publications/guidelines/tuberculosis/en/

-CDC Guidelines on TB:

     -https://www.cdc.gov/tb/publications/guidelines/treatment.htm

 

Biliary Ultrasound by Dr Soto

-Stony Brook U/S website:

     -https://www.stonybrooksono.com/resources

-ACEP SonoGuide:

     -https://www.acep.org/sonoguide/biliary.html

-AEUS Biliary Ultrasound lecture:

     -https://vimeo.com/87759897

 

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