3.7.19 Conference Summary

Ultrasound Jeopardy - Dr. Jason Tehranisa, Ultrasound Fellow

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  •  Sonographic artifacts/terms

    • Posterior acoustic shadowing = shadowing that is seen deep to an echodense/hyperechoic structure (i.e. gallstone) due to its high attenuation; prevents visualization of true anatomy

    • Posterior acoustic enhancement = when the area deep to a low attenuating structure appears hyperechoic due to greater amount of returning echoes; most commonly seen deep to fluid-filled structures, i.e. bladder  

    • Reverberation = artifact where sound waves bounce back and forth between two strong reflectors before returning to the probe, creating multiple equally spaced echoes (i.e. A lines)

    • Anisotropy = normal finding; tendons change echogenicity based on angle of probe; can be misinterpreted as free fluid

    • Hydrodissection = injection of fluid with needle advancement; technique used for nerve blocks to ensure anesthetic enters the correct fascial space

    • Twinkle artifact: stationary, highly echogenic object (i.e. calculi) lights up with color doppler

  • “Signs”

    • Double Barrel Sign = dilated CBD (CBD similar size as portal vein)

    • McConnell’s Sign = hypokinesis of RV with sparing of apex, which moves inward/up & down on apical 4 view; specific for PE

    • Wall-Echo-Shadow (WES) sign = GB contracted around multiple stones (or one large stone), creates posterior shadowing

    • Squish sign = movement of echogenic debris with compression, indicative of abscess

    • Keyboard sign = prominent plicae circulares seen in SBO

    • Spine sign = RUQ/LUQ FAST views, spine (hyperechoic) extends above diaphragm, seen with fluid in lungs (i.e. pleural effusion)

  • Diagnostic US findings

    • Cholecystitis = sonographic Murphy’s sign, anterior wall thickening (>3mm), pericholecystic fluid, stone(s) especially in neck, gallbladder distention; CBD dilation >6mm suggestive of choledocholithiasis

    • SBO = diameter >2.5cm, fluid filled bowel with to-and-fro peristalsis, thickened bowel wall with plicae circulares; free fluid surrounding bowel is poor prognosis

    • Intussusception = telescoping, most common ages 6-24 months

    • Appendicitis = blind pouch, poorly compressible, periappendiceal free fluid

    • Aortic dissection = hyperechoic ‘flap’ in the lumen

    • Shoulder dislocation = humeral head no longer at the same level as glenoid; anterior vs posterior

    • Quadriceps tendon rupture = discontinuity of smooth fibrillar appearance, hypo/anechoic fluid indicative of hemorrhage

    • Flexor tenosynovitis = fluid near/above tendon

    • Vfib = disorganized quivering movement of heart

    • Vitreous hemorrhage = pooling of blood (echogenic) posteriorly —washing machine sign

    • Retinal detachment = linear hyperechoic structure tethered posteriorly to optic nerve (doesn’t cross midline)

      • Mac on - macula always lateral; true emergency (vision may be salvageable)

      • Mac off - damage already done, less emergent

    • Mitral valve prolapse = bowing of MV into atrium, associated with mid-systolic click with late systolic murmur

    • Hydronephrosis

      • Mild = dilation of renal pelvis

      • Moderate = dilation of pelvis + calyces

      • Severe = marked dilation with cortical thinning (often difficult to tell this is a kidney)

    • Pyloric stenosis = thickened (>3mm) and elongated; most common seen in first 3-5 weeks of life, rarely after 12

    • Necrotizing fasciitis = thickening of deep fascia and fatty tissue, fluid layer of at least 4mm thick along the deep fascia; gas appears hyperechoic and is pathognomonic

  • Diagnostic/management pearls, complications

    • Valve with fish mouth appearance = mitral valve (in short axis)

    • Splenic vein is anatomic landmark for pancreas; always runs posteriorly

    • SBO - Free fluid between loops of bowel associated with poorer prognosis

    • Most specific finding in diagnosing PTX = lung point

    • First sign that confirms of IUP = yolk sac (fetal pole also confirms but seen after yolk sac)

    • Earliest/most sensitive finding in tamponade = RA systolic collapse

    • B lines rule out pneumothorax; they originate from the pleural line, require visceral pleural contacting chest wall, move with respiration

    • Dynamic air Bronchograms = pathognomonic for pneumonia; represents air trapped in fluid-filled alveoli within consolidation, moves independent of respiration

    • Most common side effect of Interscalene block = decreased pulmonary function

    • Nerve block useful for central lines without upper extremity involvement = superficial cervical nerve block; inject lidocaine between superior SCM and lever scapulae muscles

    • Retroflexed uterus can lead to increased risk of urinary retention in pregnancy due to bladder compression

    • Transcranial ultrasound - can use doppler through transtemporal view to assess MCA flow

    • Measuring gestational age:

      • 1st Trimester = crown rump length

      • 2nd/3rd trimester = femur length, head circumference, biparietal diameter

    • Endotracheal intubation confirmation = look for tracheal rings; if esophagus is well-visualized, tube is most likely in esophagus

    • Most common side effect from interscalene block = diaphragmatic hemiparesis from ipsilateral phrenic nerve block (PTX 2nd most common)

       

Bariatric Emergencies- Dr. Mujjahid Abbas

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  • Dealing with emergencies primarily associated with obesity (BMI>30)

  • Causes of obesity: diet, pregnancy, environment, genes, lack of exercise

  • Treatment of obesity

    • Initial: lifestyle changes such as diet, exercise, behavioral modification

    • Pharmacotherapy

    • Bariatric surgery

      • Indications: BMI>40, unsuccessful attempt at weight loss by non-operative means

  • Bariatric surgery options: gastric band, sleeve gastrectomy, gastric bypass, vertical banded gastroplasty, gastric balloon, endoluminal gastric stapling, implantable gastric vagal nerve blocking, endoscopic gastrointestinal bypass device (EGIBD), A-tube gastrostomy tube

    • Gastric banding is rarely performed today because of the multitude of complications

      • Barrett’s esophagus

      • Esophageal perforation

      • Band slippage into the stomach

      • Band erosion from pressure necrosis resulting in intra-luminal presence of the band

      • Pouch prolapse

      • Lack of effective weight loss because patient’s switch to excessive sugary liquid intake

    • Sleeve Gastrectomy

      • Stomach is physically made smaller by removing greater curvature of stomach

      • Complications

        • Dehydration

        • Staple line (sleeve) leak (1-3%)

          • Treatment: broad spectrum abx, anti-fungals, and emergent surgical consult

          • Bleeding

          • Stenosis/stricture at staple sites

          • Subphrenic abscess

          • Mesenteric Portal Venous Thrombosis

            • Usually occurs early in the post-operative period

            • CT angiogram required for diagnosis

            • Treatment: IV hydration, heparin, surgical consult, possible IR intervention

          • Gastroesophageal reflux

    • Roux-en-Y Gastric Bypass

      • Small gastric pouch with a gastrojejunal and jejunojejunal anastomosis and gastric remnant

      • Complications

        • Gastric remnant syndrome

          • Fluid (2-3L) from non-functional stomach can accumulate and distend the stomach and proximal pancreas

            • Caused by downstream obstruction or internal hernia; both require surgical repair usually

        • Gastric or ostomy leak

        • Stomal stenosis

        • Dumping syndrome

          • Often present with palpitations, flushing, nausea, diarrhea, and tachycardia after eating a meal, in which food contents are dumped into jejunum

          • Results ~15 min after eating, rapid entry of food into the small bowel with sympathetic nerve response

          • Uncomfortable, but not dangerous; avoid simple sugars and eat small frequent meals

        • Marginal ulcers at ostomy site

          • More common in smokers who continue to smoke after surgery

          • Treatment: PPI, sucralfate

        • Internal hernias

          • Feared complication

          • Must have high index of suspicion

          • “Mesenteric swirl” sign on CT scan is best indicator of hernia following gastric bypass

            • Require emergent decompression as bowel quickly becomes ischemic

        • Bowel obstruction

        • Cholelithiasis

          • Rapid weight loss increases the lithoogenicity of the bile

        • Intussusception

          • Most often occurs at jejuno-jejunostomy site

        • Gastro-gastric fistula

        • Vitamin deficiencies and malnutrition

    • Gastric Balloon

      • Complications

        • Persistent nausea and vomiting

        • Pressure necrosis with gastric perforation (rare)

  • Most helpful imaging studies in bariatric surgery patients presenting with severe abdominal pain or excessive nausea/vomting: upper GI study and CT abdomen/pelvis with PO/IV contrast

  • Preferred fluid for resuscitation in bariatric surgery patients is lactated ringer’s

  • Acute thiamine deficiency in bariatric patients is very common

    • Bariatric surgery patients are at increased risk of developing thiamine deficiency, particularly after an episode of intractable vomiting

    • 200 mg IV thiamine prior to dextrose containing fluids for resuscitation is recommended

  • Antiemetic options: zofran, reglan, promethazine, scopolamine


EBM: Peritonsillar Abscess - Dr. Nicolas Saenz, PGY-3

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  • Definition: abscess formation lateral to uvula causing swelling, odynophagia, fever

  • Fun fact: trismus caused by “reflux spasm” by internal pterygoid muscle

  • Background and Epidemiology

    • ~30/100,000

    • Typical ages 18-35 yo

  • Pathophysiology (unclear)

    • 2 leading theories:

      • Pharyngitis -> peritonsillar cellulitis -> peritonsillar abscess?

      • Obstruction of Weber’s salivary gland -> infection

    • Infection often polymicrobial (strep, staph, fusobacterium, prevotella)

  • Complications (rare)

    • Obstruction

    • Aspiration pneumonia

    • Jugular vein suppurative thrombophlebitis

    • Mediastinitis

    • Recurrence (~50%)

  • Diagnosis

    • Primarily clinical, but submandibular or intra-oral POCUS may play a role

    • Laboratory work-up not helpful

    • CT imaging helpful to exclude deep neck space infection

  • Treatment

    • Antibiotics

      • IV: Unasyn 3g Q6H or Clindamycin 600 mg Q8H

      • PO: Augmentin 875 mg BID or Clindamycin 450 mg BID

    • Steroids

      • Single dose 10 mg dexamethasone IV or 2-3 mg/kg IV methylprednisolone mildly improves pain and ability to swallow by 24 hours (data is weak, but adverse effects are minimal)

      • Steroids seem to be more effective in simple pharyngitis

    • Needle aspiration vs I&D?

      • Cochrane review examined patients with recurrence after intervention and adverse effects after intervention

        • Recurrence rate is higher in aspiration, although data is limited and there is no high quality evidence to suggest one over the other

    • Is needle aspiration adequate?

      • A small subset of patients will require I&D

    • Needle aspiration technique

      • Topical anesthetic (i.e. benzocaine)

      • Consider using an upside down lit laryngoscope blade for better visualization

      • Avoid posterior and lateral internal carotid artery

      • Landmarks: aspirate from same side of mouth (don’t cross midline)

    • Comparison of medical vs. surgical therapy

      • In select patients, trial of medical management is appropriate

Toxicology Series: Life Threatening Withdrawals, Dr. Stephanie Hutchinson, PGY-1

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Alcohol Withdrawal

  • General withdrawal

    • Onset 6-36 hours after last drink

    • Symptoms: tremor, tachycardia, diaphoresis, mild agitation

    • Treatment: lorazepman, diazepam, chlordiazepoxide

    • Use CIWA scale to determine severity and need for medication intervention

  • Seizures: most likely to occur 6-48 hours after last drink

    • Treatment: benzos; if refractory, phenobarbital or propofol

    • Risk factors: previous withdrawal seizures, sudden drop in ETOH consumption, hypokalemia

  • Alcoholic Hallucinosis: visual, auditory or tactile hallucinations

    • Key difference between hallucinosis and DT is lack of altered mental status or disorientation

  • Delerium Tremens (DT): onset 48-96 hours after last drink

    • Symptoms: delirium, disorientation + general withdrawal symptoms + more severe hyperthermia, tachycardia, diaphoresis

    • Always look for comorbid conditions

    • 5% mortality

    • Increased mortality risk: older, CV or pulmonary comorbidities, T > 40C, coexisting liver disease

    • Treatment: benzos, thiamine, folate, multivitamin, dextrose containing fluids, replete electrolytes

      • Consider phenobarbital early: loading dose of 10mg/kg (ideal body weight) over 30 min

  • Disposition

    • Homegoing for CIWA <5

    • Admission for CIWA >16 and ICU consideration if CIWA>20 with comorbid conditions

Barbiturates and Benzodiazepine withdrawal

  • Onset within 24 hours

  • Symptoms are similar to ETOH withdrawal

  • Management: consider restarting medication at lower dose or longer acting version (i.e. diazepam or diazepoxide)

  • Will require gradual taper off medicine over multiple months to avoid repeat withdrawal

Opioid withdrawal

  • Symptoms: mydriasis, tearing/sneezing/rhinorrhea, n/v/d, abdominal cramping, piloerection, myalgias

  • Not technically life threatening, but can be severely uncomfortable

  • Treatment

    • Clonidine 0.2 mg TID

    • Antispasmodics like dicyclomine

    • Buprenorphine (requires special license to use)

Supertrack Series: Approach to Red Eye, Dr. Blain Tesfaye, PGY-1

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  • History: onset, duration, unilateral vs bilateral, vision changes, discharge, trauma, contact lens use

  • Physical Exam

    • Pupil size, reactivity EOM

    • Discharge, foreign body (be sure to evert the eye)

    • Visual acuity

    • IOP

    • Fluoroscein eye exam

  • Red Flags

    • Decreased acuity

    • IOP >40 mmHg

    • Severe pain

    • Irregular pupils

    • Photophobia

    • Hx of trauma

  • Extra-Ocular

    • Hordeolum/Chalazion

      • Hordeolum found on lower eyelid and painful

      • Chalazion is upper eyelid and painless

      • Treatment for both is proper hygiene and warm compresses

    • Preseptal or Septal cellulitis

      • May require CT orbits w/ contrast to differentiate diagnosis (must consider if proptosis present)

      • Preseptal can usually be DC’d with PO antibiotics like Augmentin or clindamycin

    • Blepharitis

      • Swelling or crusting at eyelid margin (can be viral or allergic or irritant)

    • Trichiasis: eyelash touching ocular surface

    • Entropion (eyelids inverted) vs. Extropion (eyelids exverted)

      • Both are usually harmless a product of aging

  • Ocular Surface

    • Conjunctivitis

      • Adults

        • Allergic

          • Bilateral, minimal discharge, itching

        • Viral

          • Unilateral, clear discharge

          • No tx necessary

        • Bacterial

          • Unilateral, purulent discharge

          • Topical ABX preferred with attention to pseudomonas coverage in contact lens wearers

      • Neonatal

        • N. Gonorrhea: 2-5 days old

          • Ceftriaxone IM or IV, admission, and ophthalmology consults

        • C. trachomatis: 5-14 days old

          • Erythromycin PO x 4 weeks, discharge

        • Chemical from topical erythromycin ointment from birth

    • Subconjunctival hemorrhage

      • Hx of mild trauma or vomiting/coughing with sharp borders

      • Blood usually clears in 2-3 weeks

      • Treatment: reassurance

    • Pinguecula

      • redness usually resulting from prolonged sun exposure

    • Pterygium

      • Starts at medial surface and can cover pupil and affect vision

      • More common in dry, sandy environments

  • Internal Eye

    • Corneal abrasion

      • Soft tissue defect in epithelium

      • Symptoms: photophobia, pain, tearing, FB sensation

      • Ask about contact lens use to consider coverage of pseudomonas

    • Corneal ulcer

      • Deeper defect with super-infection

      • Consult ophthalmology as these often require scraping and close follow up

    • Chemical burns

      • Alkali more severe than acid because of liquefactive necrosis causing deeper injuries

      • Irrigate with Morgan Lens with 2 L sterile water or NS or until normal pH

    • Keratitis

      • Environmental, Viral, bacterial vs fungal

      • Need fluorescein staining often to detect

    • Hyphema

      • Collection of blood in anterior chamber, can be spontaneous or traumatic

      • Treatment: elevate head of bed, consult ophthalmology

      • Avoid carbonic anhydrase inhibitors in sickle cell patients

    • Episcleritis/Scleritis

      • Autoimmune vs idiopathic

      • Treatment: topical or systemic steroids

    • Iritis (anterior uveitis)

      • Symptoms: pain, photophobia, decreased vision, redness

      • Perilimbal redness associated with hypopyon

    • Acute Angle Closure Glaucoma

      • Acute onset severe eye pain, headache, decreased vision, nausea/vomiting

      • Hazy cornea, dilated, non-reactive pupils

      • Measure IOP

        • IOP >25 abnormal

      • Consult ophthalmology emergently

      • Treatment: topical timolol/pilocarpine, PO/IV mannitol/acetazolamide


EKG Review - Dr. Sara Pope, PGY-4

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  • Atrial fibrillation

    • Medication options for tx: BBs, CCBs, digoxin

  • Slow Atrial Fibrillation

    • Pathognomonic to Digitalis toxicitiy

  • Multifocal atrial tachycardia

    • Often caused by lung pathology (COPD, pulmonary fibrosis, pHTN)

  • QT Prolongation

    • Causes: medications, hypomagnesemia, hypocalcemia, hypokalemia, congenital, ischemia, hypothermia, increased ICP

  • TCA overdose EKG

    • Terminal R in aVR

    • Give NaHCO3 for Na channel blockade

  • Ventricular tachycardia

    • Stable patients medication options: amiodarone, lidocaine, procainamide, sotalol

  • U wave EKG

    • Potential causes: hypokalemia, hypocalcemia, hypothermia, increased ICP

  • Wolf-Parkinson-White Syndrome (WPW)

    • Medications to avoid: amiodarone, adenosine, digoxin

  • Epsilon Wave

    • Patients presenting with syncope may have ARVD, but multiple things can cause U waves

  • Inferior STEMI

    • Don’t give nitroglycerin as heart is preload dependent

  • Wellen’s Syndrome (critical LAD)

    • EKG will show changes when patient is pain free

  • Brugada syndrome (Na channelopathy)

    • Needs AICD