Conference Summary - February 8th 2018

Conference Summary - February 8th 2018


Thank you so much to Lauren McCafferty for this week's conference summary and to the attendings and residents who presented and attended conference this week.

 

2/8/2018 Conference
1200 - 1300 Management of Liver and Kidney Transplants - CME, Dr. Edmund Sanchez
1300 - 1400 Your Business of Emergency Medicine, Dr. Richard Nelson
1400 - 1500 Leg Pain - DVT Ultrasound, Dr Jess Rockwood
1500 - 1530 AED Toxicity, Dr. Apisa
1530 - 1600 Hypoglycemic Drug Toxicity, Dr. Sekoulopoulos
1600 - 1630 Equipment Changes - Central Line Kit, Jason Leimbach
1630 - 1700 Resident Meeting with Chiefs, Chief Residents

 

Solid Organ Transplantation - Dr. Sanchez 

- Vascular operation --- any transplant complication is vascular until proven otherwise

- Concern for rejection

- Adequate function relies on good blood flow in and out of organ 

Kidney Transplant

- Stent in post-op period – source of infx

- Daily assessment: UOP, I/Os, daily weight 

- Problems: decreased urine output/increased creatinine 

- Workup: RFP, Doppler US, angio, renal scan (r/o urine leak), surgery?, biopsy

Pancreas Transplant

- Problems: hyperglycemia, rising pancreatic enzymes 

- Workup: amylase, lipase, glucose, Doppler US, angio, surgery?, biopsy

Liver Transplant

- Dual blood flow: hepatic artery (bile duct highly dependent), portal vein

- Problems: rising LFTs, jaundice, mental status change, hypoglycemia, bleeding  

- Workup: HFP, BMP*, INR, glucose, ABG (*look for renal failure), Doppler US, angio, ERCP/MRCP, CT (IV contrast if able), surgery?, biopsy

- Important Hx: What/when/where was it transplanted? 

**Contacting transplant --- discuss/come up with plan for imaging 

- Transplant Surgery (#31330):  <1 year since transplant or if it’s a surgical issue 

- Transplant nephrologists: nonsurgical and >365 days from transplant 

- If transplant candidate: call surgery first 

 

Business of EM - Dr. Nelson

- break down your pay check 

- employee vs independent contractor

- employee: simpler W2, benefits, malpractice protection, less freedom 

- independent contractor: can incorporate yourself, more freedom, higher salary, cost/time commitment, variable malpractice 

- live like a resident as long as you can 

- extend your talents, entrepreneurship 

- maintain good work-life balance

 

POCUS: Lower extremity DVT - Dr. Rockwood 

- VTE relatively common; high morbidity/mortality if untreated 

- high sensitivity/specificity of POCUS in r/o DVT 

- sonographic diagnosis: non compressibility or incomplete compressibility of deep vein in setting of arterial wall deformation 

- must assess both the common femoral region (near saphenous junction) or popliteal vein in fossa (DVT almost always involve one of these regions)

- vein vs artery --- artery thicker walled, usually compressible (except severe hypovolemic states), pulsatile; if unsure can use doppler 

- use high frequency probe (curvilinear if obese), supine position, frog leg (femoral), flexed at knee/hanging/prone (popliteal)

- femoral region: identify common femoral vein with branching greater saphenous, scan distally until you reach SFV/DFV junction, compressing every ~1cm 

- popliteal region: 'double scoop' sign, vein superficial, scan to branch of arterial tibial vein or trifurcation

- advanced techniques: augmentation w/ doppler, respiratory variation

- pitfalls: lymph nodes, baker's cyst 

- image capture: Dual/split screen for images (with and without compression) or videos demonstrating compression 

- if negative but clinical suspicion is high, add D-dimer 

 

AEDs - Dr. Apisa

- phenytoin: Na channel blocker; toxicity commonly caused by IV loading -- avoid by slow infusion (fosphenytoin has better side effect profile) 

- carbamazepine (tegretol): Na channel blocker; can cause agranulocytosis 

- levetiracetum (keppra): mechanism unclear, biphasic, better safety profile 

- valproic acid: Na channel blocker, increased GABA effects, hepatotoxic; give carnitine 

- benzos: GABA; antidote: flumazenil (avoid if chronic use) 

- tx for all toxicity is supportive care (carnitine for VPA) 

- activated charcoal: contraindicated if unable to protect airway, no benefit if ingestion>1 hr 

 

Hypoglycemic toxicity - Dr. Sekoulopoulos 

- AMS --> check FSBG

- autonomic + neurologic sx

- risk factors: CKD, old age, EtOH, prolonged hospitalization

- endogenous vs exogenous insulin: check C-peptide (high if endogenous) 

- tx: D50 25g, octreotide, glucagon (to temporize) 

- metformin adverse effect: lactic acidosis 

 

Equipment Change - Central Line Kits

There is a new central line kit arriving in our department. Look out for a demo that should be in the Resident Lounge soon and touch base with Jason Leimbach if you have any questions.

 

Resident Meeting - Chief Residents

Any questions, concerns, comments about this meeting or otherwise, please contact your chiefs - via phone, text, email or in person...