Evidence Based Medicine on Tachydysrhythmias with Drs. Ludmer and Miller
- SVT is an umbrella term that includes AVNRT, atrial fibrillation and flutter, and polymorphic multifocal atrial tachycardia (MAT)
- AVNRT (AV Node Re-entrant Tachycardia) is the correct term for what is commonly diagnosed as SVT,
- MAT usually occurs in critically ill elderly patients with respiratory failure and is a poor prognostic sign, associated with 60% in hospital mortality. Treatment is to treat the causative pathology.
- REVERT Trial: Modified valsalva vs standard valsalva performed in 10 EDs with 428 patients in England. Findings included a 17% conversion with standard methods and 43% with the modified valsalva.
- Be on the lookout for the complete updated algorithm coming soon to CPQE
R1 Clinical Diagnostics on Arthrocentesis with Dr. Summers
- In addition to consulting orthopedics for confirmed septic joints, concern for septic arthritis in prosthetics and septic hips should receive formal ortho evals as well.
- Differentiating gout and septic joint can be difficult as septic arthritis may be present in joints with synovial fluid positive crystals on the order of 1.5-5%
- Irreversible cartilage damage may occur within 8 hours of onset of septic joint
- Synovial gram stain is helpful if the test is positive however negative does not rule out septic joint
- Synovial fluid analysis
- WBC: >100k has a positive likelihood ratio of 28 vs >50k has a likelihood ratio of> 7.7
- Synovial lactate, if greater than 10, has a positive LR>1
- Ultimately, if you are concerned about a possible septic arthritis, there is no one test that will make the diagnosis. The H&P should be used in conjunction with arthrocentesis results to make the best possible decision for the patient.
- For more information on evaluation of the septic joint, take a look at our CPQE algorithm and Dr. Summers' asynchronous learning module here.
Visual Diagnosis with Dr. Otten
- A picture says a thousand words... for those of you missed out you can email Dr. Otten sample slides or re-acquaint yourselves with an Atlas of Emergency Medicine
R1 Clinical Knowledge on Tick-Borne Illness with Dr. McKee
- Lyme disease often (though not always) presents with a classic bulls-eye, target rash called erythema migrans within days of being bit by Ixodes Scapularis
- Bilateral Bell's Palsy is Lyme Disease until proven otherwise
- Treatment is doxycycline 100 mg BID for two weeks
- Erlichiosis and Babesiosis can also be spread by Lyme Disease
- Rocky Mountain Spotted Fever: Due to bites by Brown Dog ticks carrying Rickettsia Ricketsii classically associated with a progressive petechial rash classically involving palms and soles that can become gangrenous due to thrombocytopenia and associated coagulopathy
- RMSF: Treat with doxycycline for 5-7 days; these patients can be SICK
- Tularemia. Comes from infected rabbits (get from ticks). Again, doxycycline is the treatment.
- Official CDC recommendation for tick removal: grab tick with forceps, grab as proximal to skin as possible and pull
R4 Capstone with Dr. Doerning: Precipitous Deliveries
- Observational Hennepin Study of deliveries in the ED from 00:00-08:00: 80 deliveries: 12 without prenatal care, 4 breech (with 2 deaths), 7 nuchal cords (1 death), 2 shoulder dystocia
- Shoulder dystocia occurs between 0.2-3% of deliveries and can compromise mother and child; maternal diabetes increases risk by 70%
- HELPERR: Call for Help, evaluate for Episiotomy, Legs (place pts in McRoberts=push legs up and flatten out back), Pressure (suprapubic region, not fundus), Remove posterior arm, Roll mom onto all fours (Gaskin maneuver)
- McRoberts maneuver alone alleviates 41% of dystocias
- Breech deliveries account for 3-5% of presentations with 65-70% of these frank breech (both legs up in the pelvis and bottom at cervical aperture)
- Approach to breech? Less is more. Your goal is to allow for spontaneous delivery to level of umbilicus and then rotate baby to back is anterior
- Pinard Maneuver: Attempt to deliver one of the legs by inserting fingers into vagina
- Once legs are delivered support passively with gentle traction on hips until scapulas/shoulders are
- Mariceau-Smellie-Veit Maneuver--pushing down head with suprapubic maneuver
- Cord Emergencies
- Cord Prolapse: Your goal is to relieve pressure on cord which you can do by elevating presenting part mechanically. You can also place foley and fill bladder with 500-700ccs fluid.
- Nuchal cord: Reduce as much as possible mechanically and as a last resort cut (deliver as much of baby as possible first)
CPC with Drs. Goel and Srivistava
- 31 yo relatively well appearing female with sickle cell presents with pain all over her body somewhat similar to prior sickle cell pain crises although with new meningismus and a WBC count of 25k.
- Dr. Srivistava: Get the CT head.
- Dr. Goel: Got 'em. CT head reveals acute ICH
- Take-Home: Patients with sickle cell disease are at higher risk for stroke (300% greater risk than average patient population), both for acute thrombotic events due to hypoxia-induced sickling and rouleaux formation but also hemorrhagic stroke due to chronic wear and tear on vessel intima by sickled RBCs
- Patients with high rates of sickle cell burden, sickle crises, severe anemia are at higher risk
- Moyamoya: chronic occlusion of circle of Willis vessels causing collateralization of these vessels associated at increased risk of aneurysms and stroke
- LDH 3 times greater than the upper limit of normal has a high association with pro-thrombotic events in sickle cell patients
- Remember, sickle cell patients are at much higher risk of ischemic and hemorrhagic stroke and exchange transfusion may be indicated (particularly with ischemic strokes)
R4 Case Follow Up with Dr. Selvam
- Minimally responsive male presents to the SRU with a core temp of... less than 80 F
- For the second time this year, please check out this prior grand rounds recap for an in-depth discussion about the management of the hypothermic patient
- This patient shortly after had a cardiac arrest followed by aggressive resuscitation including bilateral high-low chest tubes and active intra-thoracic rewarming. With a core temp of 82 the patient had ROSC. A central line catheter was placed for infusion of warmed IVF as well.
CEC Operations with Dr. Miller
- We have entered the age of data-driven medicine where analytics are playing a huge role in optimizing efficiency
- As we apply these tools to our own system we can expect systems-level changes that are already under way... stay tuned...
- As UCMC EPIC is updated there will be a number of changes that will potentially allow EDPs to improve their workflow