Max continues his weekly conference summaries. Below is the abbreviated version (edited by our webmaster)
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%
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.
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!
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.
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.
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
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.)
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
1) STEMI criteria - the 2013 definition for STEMI is ST elevation in 2 contiguous leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads.
2) ECG lead placement - white to right (right arm lead), red to ribs (left leg lead), smoke above fire (left arm lead). That's how I remember where to place the monitor's ECG leads on the patient's chest.
3) Limb lead reversal - look for inverted P waves in lead I. Don't confuse it with dextrocardia - in limb lead reversal, the R wave progression is normal whereas in dextrocardia it is reversed!
Early pregnancy problems
1) Discriminatory zone - sac consistently visualized by ultrasound, measured in mIU/mL: 1,000-2,000 for a transvaginal sonogram, 6,500 for a transabdominal sonogram.
2) Hyperemesis gravidarum - first line agent is a combination of pyridoxine and doxylamine.
3) Asymptomatic bacteriuria - Always treat it: Amoxicillin 500mg TID or Ampicillin 250mg QID.
CQI/Intern Curriculum - attachment from JAMA
1) Acute aortic dissection management - Control dP with arterial vasodilators (nitroprusside, nicardipine) and dt with beta blockers (esmolol, metoprolol). Use both!
2) Acute type A aortic dissection presentation - 35% of patients are normotensive upon presentation.
3) Acute jaundice - there three different types: hemolytic, hepatocellular, and obstructive.
Atraumatic Musculoskeletal Complaints - attachment from Journal of Neurosurgery-Spine
1) Spinal epidural abscess - MR spine is the gold-standard test. CRP elevates before the WBC..
2) Septic arthritis - Up to 30% of patients with septic arthritis do not have a synovial WBC > 50k.
Dissociated ramblings - attachment from the department of infectious disease
1) Synovial lactates - A few studies suggest that a synovial lactate > 10 mmol/L is highly suggestive of septic arthritis. Not all hospitals are equipped to perform synovial lactates as many machines are only designed to do this for blood samples, not synovial fluid.
3) Idioventricular rhythm - ever wonder why after ROSC patients enter a slow, wide-complex rhythm after the arrest? The electrical origin of this rhythm are the Purkinje cells. Because of their proximity to the ventricular cavities, they are able to use cavitary blood (oxygenated) for metabolism - rather than relying on blood coming from the coronary arteries! This is also seen in the cath lab not infrequently and is thought of as a reperfusion arrhythmia.
Diabetic foot infections
1) Diabetic foot cellulitis - it comes from ulcers, if there is/was no ulcer, it's likely not cellulitis.
2) Limb-threatening diabetic foot infections - cellulitis extending >2cm from ulcer, probes to bone
3) Charcot foot - occurs in stages, no systemic symptoms, labs will likely be normal. 45% mortality in 4 years.
Orthopedic pearls/orthopedic lab
1) Shoulder dislocations - anterior dislocations are the most common, and most of those are subcoracoid dislocations. Least common dislocation is an inferior dislocation - aka luxatio erecta - the arm will be locked in abduction.
2) Nursemaid's elbow - reduce by supinating the child's forearm with the elbow flexed and apply pressure over the radial head. You should hear a 'click' as the annular ligament is liberated from the joint.
1) Withdrawal seizures - you should not need a lot of benzodiazepines to control alcohol withdrawal seizures. If the patient requires escalating doses of benzodiazepines to control seizures, consider additional seizure etiologies.
2) CIWA score - it is not diagnostic of alcohol withdrawal, just a severity score. Diagnose withdrawal based on signs and symptoms in the right context. The patient must be able to participate in questioning as 4 out of the 6 categories necessitate answers from the patient.
Dissociated ramblings - attachment from ASA (short read, funny)
1) Achilles ultrasound - sensitivities and specificities vary from paper to paper, however, you can use it to diagnose Achilles' tendon rupture. One difficulty with tendon ultrasound is a sonographic artifact called anisotropy. This occurs when the probe is not perpendicular to your higher-than-average refractive structure (ex: tendon) and will cause the structure to appear hypoechoic.
2) Local anesthetic toxicity (LAST) - the more lipophilic, the more potent the local anesthetic (the uncharged drug must penetrate nerve membrane as well as bind to a hydrophobic site on the sodium channel). If systemic toxicity occurs, you can consider giving lipid emulsion as a reversal agent. Lipid rescue is a big area of research in toxicology.