Grand Rounds Recap 9/30/2015

Grand Rounds Recap 9/30/2015

September Morbidity and Mortality Conference - Dr. Toth

Cases reviewed were from the month of August. We saw greater volume in 2015 than 2014 with longer ED hold times. We reviewed multiple cases including:

Acute Inflamatory Demyelinating Polyneuropathy

  • Pain is a common presentation, and cranial nerve palsies are not infrequent, but they usually follow weakness and numbness of the extremeties.
  • The diagnosis is in large part clinical, with progressive areflexia and sensory loss being the hallmarks. CSF studies showing albuminocytologic dissociation is confirmatory.
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What is Useful in the ED to Help Diagnose or Rule Out Septic Arthritis?

What is Useful in the ED to Help Diagnose or Rule Out Septic Arthritis?

History

There are many risk factors for septic arthritis including age >80, Diabetes, Rheumatoid Arthritis, recent joint surgery, prosthesis, cellulitis.  The absence of risk factors does not make septic arthritis less likely in an acute monoarticular arthritis

Physical

Monoarticular arthritis is often characterized as a warm, painful, swollen joint with limited range of motion.  No studies to date have quantified specificity data on the physical exam.  Therefore, clinicians must use their own clinical gestalt when interpreting physical exam findings.

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Interpreting Chest X-rays

Interpreting Chest X-rays

There isn't a day that goes by in the ED that a patient does not get a chest x-ray.  Whether the indication is chest pain, shortness of breath, cough, or line placement or intubation, interpreting chest radiographs is a critical, necessary skill for anyone working in the Emergency Department.  Here you will find a brief video explaining how to interpret CXRs and 6 practice cases.

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Grand Rounds Recap 9/16

Grand Rounds Recap 9/16

Air Care Grand Rounds

What do I need to assess before I load this patient in the heli?

  •  Does your patient need plastic? (ETT, needle/finger thoracostomy)
    • Get breath sounds / anticipate your possible interventions you may need
  • Is your patient in shock?
    • Don't have a lactate? Hyperglycemia in the absence of diabetes, thirst and diaphoresis should lend you towards 'yes'
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Annals of B-Pod: Fall 2015 Issue

Annals of B-Pod: Fall 2015 Issue

Hot off the Press!

#allinadayswork

Sometimes an issue’s theme is evident from the beginning- a well planned coordination of cases and perspectives that delivers a set message. Other times, an issue’s theme develops itself over the course of publishing the issue- a common thread manifests itself to us as editors as the issue comes together. Every so often, as was the case with this issue, AOBP ends up like a B-pod shift itself- a glimpse of the vast and varied pathophysiology that can present to us as Emergency Physcians at any point. 

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Grand Rounds Recap 9/9

Grand Rounds Recap 9/9

Case Follow up with Dr. Winders

The Sick Patient with Pulmonary Artery Hypertension (PAH)

  • PAH defined as right heart catheterization with mPAP > 25mmHg, which can be estimated by echo
  • Readily associated with right ventricular failure, measured by TAPSE < 1.8 with M mode over tricuspid annulus
  • EKG can also help identify these patients with right axis deviation or right atrial enlargement
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Annals of B-Pod: Pediatric SVT Case and Expert Discussion

Annals of B-Pod: Pediatric SVT Case and Expert Discussion

Neonatal SVT

The patient is a healthy 3 week old male with no past medical history. He was born full term via uncomplicated Cesarean Section who presents with increased fussiness. His mother states the patient has simply not been acting like himself.  He was taken home on hospital day 1 without issues, but in the last 24 hours, he has been quite fussy.  His mother became concerned when he was unable to take his bottle today.  The child has been refusing to eat and has been increasingly difficult to console. He has also had less wet diapers than normal today. Mom has not noticed cyanosis during feeding, recent illnesses or fevers. She also denies the presence of emesis, diarrhea, rashes, congestion, or cough.

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Annals of B-Pod: Shortness of Breath

Annals of B-Pod: Shortness of Breath

A Case of Postpartum Preeclampsia

The patient is a multiparous female in her 20s, post-operative day 8 from an uncomplicated repeat low transverse cesarean section at 39 weeks gestation after an uncomplicated pregnancy, who presents with SOB. She was discharged home on post-operative day 2 with a healthy female infant. She returns today with complaints of shortness of breath for 3 days and swelling in her bilateral lower extremities for 6 days. Over the same time course she endorses orthopnea, paroxysmal nocturnal dyspnea, weight gain, and chest pain. She describes the chest pain as substernal and intermittent. She also feels as if her chest is making a crackling noise when she exhales. She denies fevers, cough, nausea, vomiting, headache, or abdominal pain. She reports that her incision is healing well. She denies pain or drainage from the incision. She is breast-feeding her daughter, who is doing well at home. She has not yet seen her Obstetrician in follow-up but did receive all appropriate prenatal care.

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The Approach to the Undifferentiated Patient

The Approach to the Undifferentiated Patient

Welcome to Bread and Butter Emergency Medicine; a back to basics, chief-complaint-based podcast series where we get a chance to pick the brains of various faculty members and residents regarding their plan of attack for a particular presenting symptom.  Imagine your first shift in the emergency department (or think back on it if you’ve been doing this for a while); a man or woman with the label of “chest pain” or “headache” or “medication refill” is sat down in front of you, staring at you through the glass of your workstation. 

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Annals of B-Pod: Quick Hit Case

Annals of B-Pod: Quick Hit Case

Fibular Head Dislocation: An Uncommon Cause of Knee Pain

The patient is a male in his 20s who was playing soccer and felt a pop in his left knee followed by pain in his left knee. He has not been able to ambulate since the injury. He has an obvious deformity to the lateral aspect of his left knee. His x-ray was read as normal. Given his pain and mechanism, there was concern for fibular head dislocation so a CT of the knee was ordered. This showed an anterior, inferior subluxation of the fibular head. 

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Grand Rounds Recap 8/26

Grand Rounds Recap 8/26

M&M with Dr. LaFollette

Case 1: Troponin Use in ESRD

  • Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
  • Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
  • Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
  • Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.  
  • Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality
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STEMI and STEMI Equivalents, i.e. Who Needs the Cath Lab Now!

STEMI and STEMI Equivalents, i.e. Who Needs the Cath Lab Now!

1. The ACC/AHA Criteria (1) (2) 

ST-elevation in 2 contiguous leads that is:

  • Men < 40: 2.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

  • Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead

  • Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

STEMI's have a 90-minute door-to-balloon time mandate from the Center for Medicare Services (CMS). To be good stewards of our resources we need to be familiar the false positive STEMI patterns.  Ultimately, however, some degree of over triage and activation for false positives is expected and (potentially even) desirable.

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Ground Rounds Summary 8/19/15

Ground Rounds Summary 8/19/15

Simulation - Clonidine Overdose

  • 30 yo FM presents after having taking a handful of pills with the following VS: HR 45, BP 83/60, RR 8, 100% RA, T 98.  FS101. It gets better—there's a baby behind that baby bump.  
    • Ddx for AMS, hypotension and bradycardia? Tox, hemoperitoneum, spinal shock, myxedema coma, and a quite atypical sepsis. 
    • By EMS report this lady reportedly took a handful of unknown pills in an effort to harm herself. Remember to consider clonidine overdose in addition to beta blockers and calcium channel blockers. This lady found herself a bottle of clonidine and a near successful suicide attempt.
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