Conference Summary - February 22nd 2018

Conference Summary February 22nd 2018

1200 - 1400 High Yield ITE Review - Dr. Sarah Tehranisa

1400 - 1500 EM M/M - Dr. McCafferty, Dr. Carter

1500 - 1700 Journal Club - Dr. Jen Li, Dr. Lauren McCafferty, Dr. Nicholas Parmar

1200-1400 High Yield ITE Review - Dr. Sarah Tehranisa
Thank you to Dr. Tehranisa for arranging an awesome ITE review and to the attendings who added to the conference discussion.  See below notes for a rapid review of useful tidbits - relevant even after inservice exam!

EM M/M - Drs. Lauren McCafferty and Leah Carter

M&M

Lauren McCafferty shared a missed case of HbSS meningitis. Be vigilant about vital sign abnormalities or a bandemia even without total leukocytosis. Some good reminders about infection in sickle cell disease:

SS patients have functional asplenia which put them at danger for infection with encapsulated organisms

  • S pneumo > H. Flu > N. Meningitidis > Salmonella
  • Be suspicious for bacteremia, pneumonia/ ACS, meningitis

  • Empiric antibiotics for fever are: vanc/ceftriaxone

  • Vaccinations: pneumococcal 23, 13; H. flu, meningococcal

  • Daily amoxicillin prophylaxis under age 5

 

Leah Carter shared a return visit where statutory rape was uncovered. Minors are able to consent in the following situations:

  • diagnosis and treatment for STD

  • contraception

  • SANE exam - parent/guardian must receive written notification of exam

  • mental health eval/treatment - if 14 years or older

  • substance use treatment - if 12 years or older

 

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Journal Club

 

Drs Jen Li, Nick Parmar, and Lauren McCafferty took us through 3 articles regarding diagnosing posterior stroke in the persistently dizzy patient.

  • Posterior circulation strokes are missed twice as often as anterior

  • The HINTS exam is extremely sensitive in the right population:

    • Head impulse test only validated in people with nystagmus

    • Head impulse test ABNORMAL is REASSURING

  • Imaging performed within 48 hours of stroke is falsely negative in 12-18% of MRIs- your physical exam is extremely important

  • Walk your patient! If patient cannot sit up, stand, or walk by themselves, this is concerning.

  • Remember the 4 other Ds of posterior stroke when a patient complains of dizziness-- if there is dizziness AND another symptom, this is very concerning.

    • Diplopia

    • Dysarthria

    • Dysphagia

    • Dystaxia

 

 

Few-beat horizontal nystagmus can be normal. Nystagmus patterns to look for:

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Flowchart from “Diagnosing Patients with Acute Persistent Dizziness,” which when combined w/ gait assessment had a 100% sensitivity in one study.

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STANDING algorithm from “Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm, “ which showed a negative predictive value of 99%.

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Rapid Review Notes from ITE Review

  • HSP: IgA vasculitis, associated with intussusception

  • Epidural hematoma

    • Be able to identify epidural, subdural, IVH, and SAH

  • Wellen’s

    • Be able to ID EKG

    • LAD

    • Can be chest pain free

  • HSV keratitis

    • Tx with acyclovir, trifluridine

  • Salter harris types

    • ID them

  • Blast injuries

    • Know which injuries you see with each level

  • Pyloric stenosis

    • MC electrolyte abnormality: Hypokalemic, hypochloremic metabolic alkalosis

    • Males 2-12w

    • RF: first born, male, c-section birth

  • Seidel sign: leaking of fluid seen on fluorescein exam from globe rupture

  • Brainstem herniations

    • Uncal: ipsilateral pupil dilation, bradycardia, down and out pupil, contralateral posturing

    • Central: small but reactive pupils with down faze posturing

    • Tonsillar: neck rigidity, opisthotonus, irregular resp, bradycardia

  • Car detailers, glass etchers can present with HFl acid burns

    • Tx: Calcium gluconate paste.  Can escalate to local infiltration of calcium gluconate or intra-arterial calcium gluconate

  • Tx of intussusception is with air enema

    • Present 6-18mo old

    • Associated with HSP, CF

    • MC at ileocecal junction

    • 5-10% reoccur

  • Central Retinal Artery Occlusion

    • Cherry red macula

    • Sudden painless vision loss

    • Tx within 90 min with ocular massage, anterior chamber paracentesis (maybe don’t try this?), hyperbaric chamber

  • Flexor tenosynovitis

    • Know Kanavel Signs

    • Tx: IV abx, hand surgery for OR

  • Lunate dislocation

    • FOOSH with ulnar deviation

    • Slipped tea cup sign on xray

    • Requires reduction with sugar tong and ORIF

    • Perilunate dislocates posteriorly

  • Kawasaki

    • Requires 5d of high fever + of following

      • Cervical LAD (often unilateral)

      • Oropharyngeal changes (cracked lips, strawberry tongue)

      • Erythematous palms/soles

      • Macular rash over body

      • Conjunctivitis

    • Rx: ASA, IVIG

    • Complication = coronary artery aneurysms (develop 2-4 weeks after disease)

  • SCFE--ID on xray

    • Obese adolescent boys

    • 40% bilaterally

    • Can Irritate obturator nerve causing knee pain

    • Tx: NWB and surgical repair

    • Be able to distinguish between this and Legg-Calve-Perthe

  • Colles fracture versus Smith fracture--be able to ID on xray

  • Sail Sign

    • Radial head in adults

    • Supracondylar fracture in kids

  • Hypertrophic Cardiomyopathy

    • EKG: dagger-like Q waves

    • Murmur increase: valsalva and standing (decrease preload)

    • Murmur decrease: Squatting and straight leg

    • Rx: beta blockers and fluids

  • Neonatal conjunctivitis

    • Chemical (24h of birth)

      • Result of erythromycin eyedrops

    • Gonococcal (3-5d of birth)

      • Severe eyelid edema, mucopurulent discharge

      • Tx: systemic abx

    • Chlamydia (5-14d after birth)

      • Less discharge

      • Tx: systemic abx

  • Acute angle closure glaucoma

  • Measles (Rubeola)--be able to distinguish from German Measles

    • Cough, coryza, conjuctivitis

    • Koplik spots

    • High fever with rash from head to toe

    • Can develop subacute sclerosing panencephalitis, corneal ulcerations

  • Retinal detachment--ID on US

  • Coxsackie virus causes HFM disease

  • Hypopyon--be able to identify

  • ID heart blocks on EKG

  • Roseola

    • Exanthem subitum, 6th disease, 3d fever

    • HHV 6 &7

    • rash : trunk-> ext

    • Associated with febrile seizures

  • Ramsey Hunt syndrome

    • AKA herpes zoster oticus

    • Zoster lesions on auricle or in EAC, of tongue anteriorly, or on hard palate

    • Ipsi facial palsy

    • Can have tinnitus, facial palsy, lacrimation

  • SVT

    • Tx: vasovagal, adenosine, CCB or beta blockers

  • Interior STEMI: RCA infarct

  • Black widow spider bite

    • Severe pain, cramping, sweating

    • Systemic neurotoxin

  • Brown recluse

    • Systemic hemotoxin

    • Causes necrotizing skin lesions, hemolysis, thrombocytopenia, DIC

  • Scromboid

    • Peppery test

    • Histamine

    • Tuna, mackrel, mahi-mahi, marlin

  • Ciguatera

    • Dinoflagellates in seafood

    • Grouper, snapper, sturgeon, amberjack

  • Gram stains

    • Neiserria: gram neg diplococci

    • Strep pneumo: gram positive lancet shaped cocci

    • C diff: Gram positive bacillus with spore

  • Organophosphate poisoning: atropine or 2-PAM

  • Snakes

    • Coral snake: neurotoxin (Elapidae)

      • Paralysis, respiratory depression

      • Supportive care

      • Observe for 24 hours

    • Rattlesnakes: hemotoxin (crotalinae)

      • Dry bite versus invenomation (necrosis and coagulopathy)

      • 4-6 vials of crofab with additional 4-6 vials q60min until improvement

      • Maintenance 2 vials q6h for 24h

  • Altitude sicknesses

    • Acute mountain

      • Mild HA, nausea, fatigue, insomnia, peripheral edema, malaise

      • Tx: supportive, acclimatization, acetazolamide

    • HACE

      • AMS with severe symptoms, including cerebellar ataxia

      • Tx: descent, dexamethasone, HBO

    • HAPE

      • Non-cardiogenic pulm edema

      • SOV, CP, cough, tachycardia, tachypnea

      • Tx: descent, O2, dexamethasone, nifedipine

  • CMV retinitis

    • Immunocompromised

    • Tx: PO valganciclovir; IV ganciclovir or foscarnet

  • WPW: ID ekg

  • Spinal Cord syndromes--be able to ID

    • Brown Sequard

    • Anterior Cord

    • Central Cord

  • Look at all imaging on test closely--may be subtle

  • Sigmoid versus cecal volvulus

    • Know the difference

  • Le Forte Fractures--ID them

  • Parkland formula (IVF = 4 x %TBSA x kg)

  • Toxic metabolite in tylenol OD: NAPQI

    • NAC replenishes glutathione to react with NAPQI

    • Know phases of symptoms (1-3)

    • Check nomogram @ 4h post ingestion

  • Unstable C spine fracture (Jefferson Bit Off A Hangman’s Thumb)

    • Jefferson: C1 burst from axial loading

    • Bilateral facet

    • Odontoid fx (type 2 or 3...type 1 is stable)

    • Atlanto-occipital dislocation

    • Hangman: C2 pedicle fx from hyperflexion

    • Teardrop fx from flexion

  • Which substances are radio-opaque: CHIPES

    • Calcium / chloral hydrate

    • Heavy metals

    • Iodine

    • Psychotropics (TCAs, phenothiazines)

    • Enteric coated

    • Solvents/Salicylates

  • Dysbarism

    • Arterial gas embolism

      • Often from pulm barotrauma with ascent which causes gas into venous outflow

      • Can cause CVA or MI

      • 0-20min of ascent

    • Decompression sickness

      • Bends

      • Chokes

      • Staggers

  • Early finding on US for pregnancy

    • Fetal pole, yolk sac

  • Infectious diarrhea

    • Campylobacter jejuni is associated with GBS, appy mimic

    • Yersinia: post-infection arthritis, appy mimic

    • HUS: dont give abx

  • Bullous myringitis

    • Infection of TM

    • Strep pneumo, mycoplasma, h flu

  • Inhalational Anthrax

    • Bacillus anthracis: gram +, rod shaped spore

    • Africa, SE asia

    • Cutaneous: boil with eschar

    • GI: abd pain, GIB

    • Pulmonary: viral illness severe disease with mediastinal widening almost always fatal

      • Can see mediastinal widening with tularemia but not as aggressive

    • Rx: cipro, doxy, PCN

  • Iron Poisoning

    • Acute

      • 4-6h: abd pain, vomiting, diarrhea, confusion, HA

      • 6-12h: improve

      • 12-24h: metabolic acidosis, MSOF

    • Toxic dose: 40-60mg/kg

    • Gastric obstruction can occur later

  • TCA OD

    • Terminal R waves in aVR

    • Wide QRS

  • J waves (Osborn waves)

    • Hypothermia

    • Hypocalcemia

  • Brugada syndrome

    • Na channel malfunction

    • Southeast asian populations

  • INH toxicity give B6 to stop seizures

  • Sgarbossa Criteria: use in LBBB, paced rhythm

  • Lightning strike

    • Single strike of current

    • Lichtenberg rash