8.16.18 Conference Summary

Wellness and Time Management: Dr. Amy Pound

  • The key to time management is organization
    • "A task without a plan is just a dream"
  • The Eisenhower Matrix is one way of organizing your priorities:
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  • "The key is not to prioritize what's on your schedule, but schedule your priorities" 
  • Use a calendar (and share it with the significant people in your life)
  • Procrastination often hinders our goals
    • "Do not wait until the conditions are perfect to begin. Beginning makes the conditions perfect." 
      • Attempt your most difficult or most cumbersome tasks first
      • How can we apply this information to the emergency department?
    • ED physicians are interrupted 11 times per hour!!!!!!!
    • Example of ED Checklist: place initial orders from note, write HPI, tasks for each patient, and run your list at designated time intervals 
  • The Pomodoro Technique
    • Decide on the task to be done
    • Set a timer to a specified amount
    • Work on the task until the timer rings
    • Take a short 5 minute break
    • Repeat the previous steps 4 more times
    • Take a 15-30 minute break 
  • There are multiple references to consider: 
    • "The 7 habits of Highly Effective People" by Stephen Covey 
      • "Eat that Frog" by Brian Tracy

Clinicopathological Conference #1: Drs. Julietta Lacey (PGY-2) and Dr. Bobby Hughes (Emergency Medicine Attending)

  • The clinicopathological conference, popularly known as CPC primarily relies on case method of teaching that illustrates the logical, measured consideration of a differential diagnosis used to evaluate patients. The process involves case presentation, diagnostic data, discussion of differential diagnosis, logically narrowing the list to few selected probable diagnoses and reaching a final diagnosis and its brief discussion. 
  • Case as presented by Dr Lacey: Elderly F with a hx of poorly controlled HTN  who presents for abnormal labs. She feels well and is without complaints aside from weakness and lightheadedness for 2 weeks. Her WBC count was 42.7k and potassium was 2.5 and was told to present for further evaluation by her doctor. She reports diffuse abdominal pain, present for 1 year, intermittent although had a recent flare this past week, associated with intermittent nausea/vomiting, and has noticed a "few pounds" of lost weight over last year. She is currently scheduled for a CTA of her abdominal vessels to evaluate for worsening renal artery stenosis as a cause of her difficult-to-control HTN. 
    • PMH: HTN, HLD, COPD, L carotid stenosis s/p endarterectomy, hypothyroidism s/p thyroidectomy, renal artery stenosis 
    • PSH: per above
    • Meds: metoprolol, nifedipine, Protonix, Crestor, Synthroid, Breo Ellipta, Zolpidem
    • SocHx: drink 4 oz of vodka daily, 100 pack year smoking history, quit 5 years ago
  • PE: 
    • VS: T 36.9, HR 86, BP 83/42, RR 16, 97% on RA
    • Appears well, although thin; sitting up in bed and answering questions with no confusion 
    • CV: diminised L radial pulse compared to R
    • Abd: tender to palpation over lower abdomen without guarding or rebound
    • Extremities: unable to palpate DP/PT pulses in lower extremities
  • First degree AV block found on EKG
  • Rebuttal by Dr. Hughes
    • Multiple pieces of information that need to be weighed in context of each other 
    • Dr. Hughes DDx: hypothyroid (myxedema), thyrotoxicosis, medication side effect, BB or CCB overdose, lung cancer, lymphoma/mediastinal mass, shock (sepsis, cardiogenic, tamponde, PE), vascular (AAA, dissection, coarctation of aorta), dehydation, blood loss, trauma, shyperaldosteronism, adrenal failure  
    • "The push and pull of the DDx"
    • History, physical exam guide further work-up and management 
  • Step 1: confirm the tests: lab abnormalities, constitutional symptoms, physical exam abnormalities
    • Is this a life threat? Symptomatic or asymptomatic?
    • Hypokalemia, hypotension, leukocytosis
    • Why is she hypotensive? (she has good perfusion and mental status)
      • To do? RUSH ultrasound, cardiac monitor, repeat labs

The presumed dx provided by Dr. Hughes: Leukemia/Lymphoma with compression of the aorta, concern for renal artery stenosis causing secondary hyperaldosteronism causing hypokalemia

His single diagnostic test of choice: CT angio of the chest with abdomen/pelvis

  • Case Discussion by Dr. Lacey: WBC of 49.1, no anemia, platelets normals, increased neutrophils
    • Peripheral smear: neutrophilia and thrombocytosis; cannot exclude neoplasm vs myeloproliferative disease
  • CXR: calcified aorta, no other obvious masses or consolidations
  • The diagnostic test ordered: CT chest/abdomen/pelvis with IV contrast
  • AND THE RESULTS OF THE CT: gallbaldder wall thickening and concern for acute on chronic cholecystitis and possible perforation
    • Path report of gallbladder: acute on chronic cholecystitis and perforation 
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EM/Trauma Collaborative Lecture Series, Shock: Dr. Jeffrey Ustin

  • The general approach to the patient in shock...
    • How do we apply some form of organization to the chaotic, crashing patient?
  • Shock: "malperfusion in some form", resulting in hypoxia, cellular dysregulation, and inflammation
    • Obstructive shock causes: PE, pneumothorax, tamponade, abdominal compartment syndrome
    • Cardiogenic shock causes: MI, arrhythmia, blunt cardiac injury, acute valvulopathy
    • Distributive shock causes: "the tank is too big"; sepsis, anaphylaxis, adrenal insufficiency, toxins, neurogenic (typically traumatic from injury to the upper/mid cervical spine), poly-pharmacy 
      • "Tank" can fill 8x normal amount (i.e. 40 L total circulating blood volume)
        • Hypovolemic shock causes: hemorrhagic vs. non-hemorrhagic 
          • Average adult blood volume: 70 cc/kg
          • Average pediatric blood volume: 80 cc/kg
          • Average neonate blood volume: 90 cc/kg
  • Context to the cause of shock is key
    • Diagnostic tests are secondary 
  • Classes of shock
    • Class 1: <15% blood volume loss, pulse normal, BP normal, UOP adequate
    • Class 2: 15-30% blood loss, HR >100, normal BP with decreased pulse pressure, slightly decreased UOP
    • Class 3: 30-40% blood loss, HR >120, hypotension
    • Class 4: >40% 
  • 6 "locations" of traumatic blood loss:
    • Thoracic cavity (i.e. hemothorax)
    • Intraperitoneal cavity (i.e. splenic, liver, bladder injury)
    • Retroperitoneal (i.e. renal, pelvic fractures); determination of injury severity depends on amount of energy and how deep it propagates; anterior SI joint injury is concerning for high degree mechanism; remember to place pelvic binder over the greater trochanters; Solid organ injuries with bright area around organ: performed delayed contrast study to eval for true extravasation
    • Long bone fractures with subsequent hematomas (does not necessarily have to involve solely a femur; can involve multiple shorter bone injuries) 
    • Environment
    • Morel-Lavallee: sheering of deep fascia with subsequent large per-fascial hematoma (consider  in overweight MCC with poor-protective clothing who skids on hard surface)
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  • "Permissive hypotension" in trauma: 
    • Principle that guides the fluid resuscitation of traumatic patients who arrive hypotensive  to stay somewhat hypotensive until blood loss is source-controlled 
    • The thought behind this is that you dilute out all the coagulation factors and you increase the rate of blood loss if you give too much fluid initially (particularly crystalloid fluids) 
    • It is unclear if this effect is only seen true for crystalloid fluid administration or if this is a true hypotension issue 
    • Always use balanced resuscitation during trauma: use a balance of pRBCs, platelets, and FFP (1:1:1) 
    • The recent literature supports whole blood administration for blood loss (as opposed to split products such as pRBCs, platelets, etc.) as this improves mortality and decreases bleeding and thrombosis problems 

Pediatric Pain Management: Dr. Anne Stormorken

  • How do we assess pediatric population for pain?
    • Similar to adult scales with a score from 1-10
    • If patent unable to self-report, can use FLACC, CRIES or other pain scales for help
  • The same side effects occur in pediatric population with opiates as in adults: pruritus, hypoventilation, dysphoria
  • Children often self-report that the worst type of pain is that associated with blood draws and IVs (as opposed to fracture, NG tube placement, surgical scars, etc.)
  • IM injections are not appropriate for children!
  • Attempt to use non-pharm and pharm options for pain control
  • When pharm options necessary, consider opiate and non-opiate medications 
  • Within Rainbow B&C Hospital, PRN medications are often discouraged so consider scheduled medications as often as possible
    • Non-opiate options: acetaminophen, NSAIDs
    • Opiate options: morphine, hydromorphone, fentanyl, oxycodone
    • Adjuvant options: precedex, ketamine, TCAs, NSRIs, gabapentin
    • Acetaminophen (particularly in IV form): 
      • Most commonly used analgesic in children
      • Highly effective when used in combination 
    • NSAIDs
      • Also highly effective
      • Relative contra-indication in gastritis, PUD, bleeding problems, renal insufficiency 
      • IV toradol is an excellent option and particularly helpful in post-operative care
    • Tramadol is rarely used in children 
      • Only available as a PO option
    • Opiates: 
      • Morphine is most commonly used of this drug class in pediatric population
      • Pharmacogenomic research is revealing that both pediatric and adult population respond very differently to different opiates because of metabolism variations (i.e. morphine may be unsuccessful in relieving pain, while hydromorphone is effective in same patient)
      • Do not combine Percocet or Darvocet with Acetaminophen (children are highly sensitive to acetaminophen toxicitiy)
      • PCAs (patient-controlled analgesia) is commonly used in children in which there is a basal rate of pain medication and patient can control how much additional medication they receive on top of this (research shows this is more effective in pediatric population and has little overdose potential in this situation)
      • Codeine is rarely used currently (some evidence for anti-tussive effect), but because it is metabolized to morphine at highly different rates in different populations, the analgesic effect is highly variable and greater concern for overdose potential
    • MULTIMODAL ANALGESIC REGIMEN SHOULD INCLUDE NON-OPIATE OPTIONS
      • State of Ohio has most stringent rules for opiate prescription laws of all 50 states (max 7 days for adults and 5 days for children)
      • If physician feels a longer amount of opiate is required, must document in EMR and give reason for longer duration 

Advanced EKG Interpretation Part II: Dr. Jeffrey Luk


  • Cardiac ischemic injury occurs in a spectrum: unstable angina -> NSTEMI -> STEMI
    • Ischemia -> injury -> infarction
      • First signs of infarction: peaked T weaves
    • >13 MM
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  •  Peaked T waves are seen in hyperK and bundle branch blocks as well
    • ST segment elevation must be >1 mm in limb leads and >2 mm in precordial leads
    • Don't just focus on depressions or elevations; look for both when evaluating for ischemia 
    • Inverted T waves in III, aVL, or V1 is considered normal 
  • Q waves indicate old infarction
  • Benign J point elevation: concave and upward shape
    • Seen as a normal variant or in pericarditis 
  • LVH with strain: large QRS complex and uneven inverted T waves 
  • Territorial STEMIs: 
    • Posterior MI: EKG depression changes seen in anterior precordial leads V1-3 but are the mirror image of the anteroseptal MI
      • "Poor man's posterior EKG": consider flipping the EKG along the Y axis and look for elevations 
    • Single lead aVR ST elevation greater than V1 is highly predictive of LMCA or LAD occlusion or triple vessel disease; aVR and aVL ST elevations are also highly specific 
      • Some argue that antiplatelet agents should be withheld initially in this situation as many patients will require CABG emergently 
    • Inferior MIs often present with dysrhythmias 
      • Avoid nitroglycerin (can worsen hypotension if R ventricle is involved because this MI is "pre-load dependent")
      • Consider obtaining a R sided EKG (move V4 to R side of chest) to evaluate for R ventricular damage
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  • New LBBB with no old EKG changes
    • Consider looking for Chapman sign: notch in R wave of I, aVL, or V
    • Sgarbossa's criteria: evaluating MIs in presence of LBBB
      • Look for concordant ST elevation in limb leads and discordance ST elevations in precordial leads 
      • ST elevation >1 mm in a lead with a upward QRS complex - 5 points
      • ST depression >1 mm in lead V1-3- 3 points
      • ST elevation >5 mm in a lead with downward QRS complex - 2 points
      • If > 3 points, 90% specificity for acute STEMI
        • Modified Sgarbossa's criteria
          • ST elevation/S wave amplitude < -0.25 is indicative of STEMI
  • Highest Odds ratio for PE on EKG is T wave inversion in V2 or V3 (6.94x or 7.07x respectively)

An Emergency Medicine Guide to Complications in the First Trimester: Dr. Clodagh Mullen

  • First trimester is from 0 weeks - ~13 weeks
  • Gestational age: crown-rump length, FDLMP, among others

 

  • Bleeding occurs in 7-25% of 1st trimester patients
    • Of patients in the ED who present with bleeding, 13% of first trimester bleeds are ectopics 
    • Threatened abortion: uterine bleeding with viable IUP and closed cervix
      • If fetal cardiac activity, <10% will go on to miscarriage
      • Subchorionic hemorrhage result in ~9% miscarriage rate 
    • Incomplete abortion: dilated cervix and fetus may have partially passed but insignificant amounts of retained placental tissues
    • Inevitable abortion: dilated cervix with increasing uterine bleeding, often with palpable products but POCs have only minimally descended into cervix 
    • Missed abortion: nonviable retained IUP with closed cervix 
      • Crown rump length >7 mm and no HR or mean sac diameter of > 25 mm and no embryo are diagnostic of missed abortion 
      • Management: intravaginal Misoprostol to dilate cervix and help passage or D&C
    • Pregnancy of unknown location: pregnancy without an IUP visualized 
      • If methotrexate given, increasing pain can be a sign of ruptured ectopic vs tubal distention 
    • Complete abortion: previously documented IUP with complete passage of tissue and/or pathology consistent with products of conception (POCs) 
  • Nausea in 90% of 1st trimester patients
    • Severe nausea/vomiting occurs more often in urban areas, twin gestations, younger mothers, or genetically predisposed patients 
    • Important to ask about frequency, PO intake, length of time, sick contacts 
    • Labs to obtain: UA, complete metabolic panel; can consider lipase, magnesium, phosphorus, TSH
      • Diagnosis of hyperemesis gravidarum requires at least one of the following: serum or urine ketones, hypokalemic hypochloremic metabolic alkalosis, weight loss of 5% of prepregnancy weight, orthostatic hypotension, transaminitis
    • Management: pyridoxine-doxylamine (Diclegis- category A), diphenhydramine (cat B), Reglan (cat C), phenergan (cat C), compazine (cat C), zofran (cat B)
    • Education to avoid nausea/vomiting in pregnancy: avoid triggering foods, drink water 30 minutes before or after meals, sit up after meals, use ginger, avoid prenatal vitamins with iron (gummies are fine)
  • Other complications: cramping, pain, fatigue