Thromboelastography (TEG)

Presenter: Dr. Isaac Shaw

Utilize to guide your blood product resuscitation.

Trauma patients or severe UGI bleed presenting in hemorrhagic shock and requiring MTP in the ED.

Image Source: https://www.tamingthesru.com/blog/grand-rounds/teg

• Prolonged R-time –> administer FFP
• Decreased Alpha angle –> administer cryoprecipitate
• Decreased MA –> administer platelets
• Increased LY30 –> administer TXA

TEG turn-around time: Final result in ~30 minutes

Room 9 computer has TEG software – can begin to see graph form in 5-10 minutes.

Oral Boards Case

Presenter: Dr. Isaac Shaw

28 year-old male presents for hemoptysis in the setting of recent tracheostomy placement.

Differential diagnosis for bleeding tracheostomy site:

• Tracheoinnominate fistula
• Tracheal irritation
• Bacterial Tracheitis
• Surgical site bleeding or infection
• Pulmonary Embolism
• Diffuse Alveolar Hemorrhage

Sentinel bleed: small bleed prior to large volume hemorrhage due to tracheoinominate fistula formation

It takes ~1 week for tracheostomy tract to mature

Image Source: http://emdaily.cooperhealth.org/content/emconf-tracheoinnominate-fistula

Management:

1. Hyperinflate tracheostomy cuff (~40-50cc)

2. Consider replacing trach with standard ET tube and then hyperinflate ET tube cuff (may help if bleed is further down)

3. Insert fingers in trach site and apply pressure anteriorly against back of sternum

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Lighting Lectures:

Presenter: Dr. Jordan Martinez and Dr. Adam Lehnig

Retropharyngeal Abscess

• Age: 2-4 years old most common
• Often presents after an infection, usually URI
• May be precipitated by trauma, dental procedure, intubation, etc
• Polymicrobial infection

Management:

• Evaluate for airway compromise –> ABCs
• Obtain CT soft tissue neck W (historically lateral neck X-ray was used)
• Antibiotics: IV Unasyn or IV Clindamycin
• Consult: ENT

Image Source: https://www.slideserve.com/derora/deep-neck-infections

Image Source: https://www.wikidoc.org/index.php/Retropharyngeal_abscess

Ludwig’s Angina:

• Bilateral infection of submandibular space
• Dental source = most common cause
• “Hardening of floor of mouth”
• Tongue swelling and elevation; neck swelling

Management:

• Evaluate for signs of respiratory distress: drooling, dyspnea, dysphonia, dysphagia
• Fiberoptic nasal intubation if necessary
• Consider CT imaging
• Antibiotics: IV Unasyn – first line
• Polymicrobial infection – consider broad spectrum if known MRSA or pseudomonal exposure
• ENT consult

Room 9 Follow-Up:

Presenter: Dr. Dylan Nichols

Two patient cases discussed. Both patients with bradycardia in the setting of acute renal failure and severe hyperkalemia. Both patients demonstrated transient bradycardia which eventually resolved.

BRASH Syndrome:

• Bradycardia
• Renal Failure
• AV blockade
• Shock
• Hyperkalemia

Consider in: Elderly patients with cardiac disease on BB/CCB

Trigger: hypovolemia or AKI

Image Source: https://litfl.com/brash-syndrome/

Epistaxis

Presenter: Dr. Matthew Eisenstat

Anterior Bleed (90%): comes from Kiesselbach’s plexus

Posterior Bleed: (10%): higher concern severe bleeding or arterial bleed (sphenopalentine artery)

May use nasal speculum for better visualization.

Image Source: https://www.aafp.org/afp/2018/0815/p240.html

Management:

1. Direct pressure (consider taping together tongue depressors)
2. Oxymetazoline (Afrin) spray – have patient blow nose to remove clots prior to application
   1. May also consider lidocaine w/ epinephrine or phenylephrine spray
3. Chemical cauterization with silver nitrate stick – do not apply bilaterally due to decrease flow to nasal septum
4. TXA soaked gauze/pledget or Surgicel gauze
5. Traditional nasal packing with Vaseline gauze
6. Nasal Tampon Device (Merocel) – expands when exposed with liquid, tape string to patient’s face
7. Nasal balloon device (Rhino-Rockets) – inflatable device applies direct pressure

Image Source: https://www.capesmedical.co.nz/medical-products/woundcare/epistaxis-control/epistaxis-rapid-rhino-device-unilateral-airway

Disposition:

• Admit posterior bleeds and severe anterior bleeds requiring nasal packing
• Consider admission in patients with multiple comorbidities or on anti-coagulation
• No definitive recommendation on blood pressure management in epistaxis
• If discharging recommend removal of nasal packing in 48-72 hours to avoid development of toxic shock syndrome

Nasal fracture:

• No imaging required in isolated injury
• Immediate reduction or reduction at follow up in:
  • Children: 2-4 days
  • Adult 6-10 days
• Nasal septal hematoma: requires immediate drainage followed by bilateral nasal packing and ENT follow-up within 24 hours
• Children + epistaxis: evaluate for foreign body

Ophthalmology for the ED Provider

Presenter: Dr. Sanket Shah, Ophthalmology PGY-4

Image Source: https://www.allaboutvision.com/resources/anatomy.htm

Eyelid lacerations

• Laceration involving eyelid border = ophthalmology consult
• Laceration to medial canthus = concern for disruption of lacrimal duct = ophthalmology consult

Visual acuity

• Check each eye individually
• With glasses on or utilize pin hole in patient >40 y/o
• Counting fingers, hand motion, light perception if patient unable to read eye chart

Pupillary exam

• Size, shape, response to light

IOP

• Utilize anesthetic drops and Tonopen
• Normal is up to ~21 mmHg; in the ED up to 30 mmHg is reasonable
• Ensure no pressure on the eye from hands; patient no holding their breath during exam

Subconjunctival hemorrhage

• may follow-up in clinic

Subconjunctival hemorrhage + chemosis

• depends on severity and percent of chemosis; consider ophthalmology consult in severe cases

Corneal abrasion

• Evert eyelids and exam – utilize cotton tip
• Evaluate with fluorescein staining
• Small, normal vision
  • erythromycin ointment QID 4-5 days
• In setting of wood, sticks, fingernail, contacts
  • moxifloxacin eye drops
  • avoid ciprofloxacin drops due eye toxicity
• Large, central, concern for corneal ulcer:
  • Immediate ophthalmology consult
  • Antibiotic drops

*Never discharge patients with anesthetic eye drops (tetracaine or proparacaine); Toradol drops are a safe option

Foreign body removal

1. damp cotton swab
2. 18g needle
3. Eye burr – recommend ophthalmology consult prior to trying this

Chemical burns

• Check pH prior to application of any drops
• Irrigate copiously and recheck pH
• Consider Morgan Lens

Corneal Ulcer

Staining corneal ulcer = Ophthalmology emergency and immediate consult

Traumatic Iritis

• Blunt trauma
• Visual deficit = ophthalmology consult
• Tx: dilating drops (cyclopentolate); Ophthalmology may start steroids

Hyphema

• >50% consider ophthalmology consult

• Consult ophthalmology in all sickle cell patients

Orbital Fracture

• Ophthalmology requests full eye exam prior to consult
• Entrapment higher concern in pediatric population

Retrobulbar hemorrhage

• Ophthalmology Emergency – Immediate consult
• Check IOP
• Consider lateral canthotomy if increased IOP, decreased visual acuity, or proptosis present

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

Ruptured Globe

• Ophthalmology Emergency – Immediate consult
• Apply eye shield
• Obtain CT Orbits WO
• Update Tdap
• Broad Spectrum Antibiotics: Prefer Vancomycin and Levaquin

Painful Vision Loss:

• Acute angle closure glaucoma
  • IOP lowering drops

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/b-pod-case/angle-closure-glaucoma

• Optic neuritis
  • MRI Brain/Orbit W&WO
  • Neurology consult
• Uveitis
• Endophthalmitis
• Corneal hydrops

Painless Vison Loss:

• Giant Cell Arteritis (GCA)
• Central Retinal Artery Occlusion (CRAO)
• Central Retinal Vein Occlusion (CRVO)
• Retinal Detachment
  • Utilize ultrasound for evaluation

Image Source: https://jetem.org/retinal_detachment/

• Vitreous Hemorrhage
• Amaurosis Fugax

Chronic Eye Disease:

• Cataracts
• Open angle glaucoma
• Dry eye
• Diabetic retinopathy
• Macular degeneration