Leave it to Dr. Sam Antar to keep a topic light, elegant, and entertaining while still very educational. Thanks for a great Senior Grand Rounds!
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In our last Senior Grand Rounds, Dr. Colton Langridge discussed transplant emergencies. Check out his picture summary below. Next up will be Dr. Sam Antar.  The MegaShelter is scheduled to demobilize this week after a huge contribution to the community affected by Hurricane Harvey. Huge thanks to all the volunteers and our disaster team. So far, there have been over 2500 patient encounters at the facility.
In a new series from AliEM, chief residents combined to help improve splinting and orthopedic care in the ED. Including contributions from our very own Dr. Hockstein, this should be a great guide to your orthopedic care. Click the image to check it out.  Max continues his weekly conference summaries. Below is the abbreviated version (edited by our webmaster)
Transplant emergencies 1) Fever - only 50% of transplant patients with infection have fever, don't rely on fever! 2) Rejection rates - kidney 20%, heart and lungs 30%, liver 66% Ultrasound updates 1) Supraclavicular CVC -The landmark for needle insertion is posterior to the clavicle at the middle/medial third (point needle towards the ipsilateral sternoclavicular joint) 2) US-guided vs landmark guided CVC placement - 12% reduction in unsuccessful line attempts and 71% fewer IJ complications when US is used over a blind technique. Developing world EM 1) Congenital hypothyroidism - failure to meet developmental milestones, thickened skin, increased abdominal girth, and macroglossia. 2) Conjunctival suffusion - red conjunctiva without inflammatory exudate. Seen in Weil's disease (severe Leptospirosis). Treatment(like any other weird disease) is doxycycline and/or penicillin G. 3) Scrub typhus -Transmitted by mites, presents with rapid onset fever, headache, altered mental status, and inoculation eschar. Again, doxycycline. Tachyarrhythmias 1) Ultra-simple Brugada criterion - R wave to peak time (RWPT) of > 50ms predicts ventricular tachycardia. 2) Unclear regular wide complex tachycardia origin - when in doubt, treat as ventricular tachycardia! Dissociated ramblings 1) Torsades de Pointes - for polymorphic VT from long QT syndromes, after Magnesium, consider overdrive pacing and chronotropic support (isoproterenol, epinephrine). 3) Propofol infusion syndrome - acute refractory bradycardia and eventual asystole in patients on >4mg/kg/hr for two days in the presence of metabolic acidosis, rhabdomyolysis, hyperlipidemia, and fatty liver. Max continues his weekly conference summaries. Below is the abbreviated version from our webmaster. One of our finest residents, Dr. Sciano, reviewed the crashing trauma patient and the upcoming literature on the subject. Thanks for a great grand rounds!   Predicting over 5,000 evacuees, UTSW Emergency Services and Disaster Division have rallied their resources. Click HERE for a brief interview with attending, Dr. Raymond Fowler.
1) Cervical myelopathy - indications for surgical repair: neurologic deficit, compression of cervical nerve root or cord, and intractable pain.
2) Myasthenic crisis - consider intubation when forced vital capacity (FVC) is < 10-15 mL/kg or when negative inspiratory force (NIF) is under -20 cmH2O. 3) Vertebral artery dissection - headaches are not present in all patients. Most heal spontaneously. no difference in efficacy of anticoagulants vs antiplatelet agents from death or subsequent stroke 4) Hyperkalemia on ECG - the ECG changes for hyperkalemia are neither necessarily sequential nor present for all potassium levels. Consider giving Calcium. 5) Recurrent CBD stones after cholecystectomy - This can happen in approximately 10% of patients! Journal club for the academic year began this week. Thank you to our host and sponsor, EMC! It was a great turn out and discussion featuring neuro topics. Thanks to our neuro residents who attended and weighed in on the conversation.  End-tidal CO2
1) Obstruction - slope of the plateau phase = consider obstruction 2) ACEP Level B recommendation to use capnography 3) ETCO2: <10 during CPR, improve chest compressions. Foundations/CC/Business 1) Acute pulmonary edema - Goals: preload reduction (nitrates, additional preload with BiPAP) 2) STEMI complications/frequency - LV free-wall rupture (1-2 weeks out) > VSD (3 days - 1 week out) > papillary muscle rupture (3 days - 1 week out) 3) Medicare Part B eligibility - > 65yo & U.S. citizen/resident who has been here five years CQR 1) Volume resuscitation in HF - Sepsis still need some volume resuscitation - don't jump directly to pressors! 2) The blood pressure number doesn't lead to improved outcomes without end-organ damage 3) DKA - don't always assume non-compliance. Consider infection (find. the. source.), new onset DM, or any other physiologic stressor (infarction, adrenalitis, etc.) Dissociated ramblings 1) ECMO - consider for cardiogenic shock from cardiotoxic drugs (beta blockers, calcium channel blockers) when refractory to medical therapy. 2) HINTS - outperforms MR with DWI within the first 48 hours. Not ideal for the ED |
