Monthly Archives: August 2023

Conference Notes 08/30/23

Posted on by
Reply

Emergency Management of Dentition and Midface

  • Dentoalveolar trauma can include fractures, avulsions, displacement of teeth
  • An avulsed tooth is only viable within one hour, however, even outside of this window it is still worth replacing the tooth. In some cases, they may then get a root canal with dentistry
  • Alveolar fractures need timely treatment or risk poor cosmetic outcome and infection
  • Most oral abscesses can be drained in the ED with close dental follow-up
  • The need to obtain CT is dependent on the full clinical picture. If pt has significant RFs for deep space infection or cancer, it may warrant a face CT
  • Trismus sometimes can be confused with guarding due to pain. Can be worthwhile to provide analgesia and reassess
  • Buccal and canine space infections can present with significant facial swelling. These should be assessed with CT, drainage should occur from within the oral cavity near the involved tooth, not through the skin of the face
  • Radiology reads will frequently indicate Ludwig’s, however, this is often overread. True Ludwig’s is a surgical emergency. Can cause significant airway compromise
  • As a general approach to anesthetic for oral abscesses, should first infiltrate around the abscess, then can attempt direct injection
  • Inferior alveolar N blocks can be challenging due to surrounding vessels as well as the parotid gland that can be inadvertently damaged

Anti-Arrhythmics

  • Among the sodium channel blockers, they are divided into IA, IB and IC. Procainamide is the common IA, Lidocaine is a IB and Flecanide is IC
  • Class II antiarrhythmics are the beta blockers
  • Class III antiarrhythmics are K channel blockers. Amiodarone is the most common example
  • Class IV antiarrhythmics are the Ca channel blockers
  • Beta-blockers and calcium channel blockers should be used with caution in the setting of CHF exacerbation given their negative inotropic effects
  • Amiodarone has both rate and rhythm-control properties
  • Ibutilide and procainamide are the safest medications to give in the setting of WPW
  • Dr Huecker: Can also consider adding magnesium to any of the aforementioned therapies

Infective Endocarditis

  • Defined by the Modified Duke Criteria
  • Most commonly caused by Staph species
  • Don’t forget about pseudomonal coverage in those with prosthetic valves
  • Valves are at high risk of infection given their lack of robust vasculature as well as the turbulent flow around them
  • IE cases are increasing due to both increased IVDU as well as increased prosthetics being placed
  • The average age of IE is now >65. Majority will require surgical intervention
  • Recall Osler nodes, Janeway lesions, splinter hemorrhages, Roth spots/ conjunctival petechiae
  • IVDU leads to right-sided IE
  • When IE is diagnosed don’t forget to get blood cx from 3 separate sites
  • Empirically give Vancomycin. Add on pseudomonal coverage if pt has a prosthetic valve
  • The biggest RF for IE is prior IE
  • Undomiciled patients are at increased risk of IE due to Bartonella species given flea exposure

Ultrasound in the Unstable Patient

  • CXR sensitivity for edema/ effusions is low
  • Ultrasound has good sensitivity in confirming ETT placement
  • Palpating pulses during ACLS has poor sensitivity/ specificity, another area where ultrasound can be helpful, in addition to checking for reversible causes of a patient’s arrest
  • Ultrasound can be used to find the CO plus the SVR, which together can be very valuable information when resuscitating an undifferentiated shock/ SOA/ hypotensive patient

08/16/23 Conference Notes

Posted on by
Reply

Oral Boards Review

  • Always be reassessing the patient, especially after interventions are given
  • Don’t be afraid to stand your ground when consults give pushback
  • Think about what critical actions need to be taken for each patient
  • Be thorough with your history taking, the examiner may not always be forthcoming with critical information

Cardiac Toxins

  • When a pt presents with Bradycardia and hypotension, these medications should be on your differential
  • Two different major categories: “Pump Killers” and “Electrical Disruptors”
    • Pump killers are your negative inotropes
    • In the setting of BB overdose, selective agents lose their selectivity and begin affecting both B1/B2 receptors
    • BBs in comparison to Ca channel blockers cause more profound AMS, classically cause hypoglycemia in contrast to Ca channel blockers which cause hyperglycemia
    • Early interventions include IVF, glucagon, atropine, and calcium. Consider placing a CVC early and gi decon
    • Bedside echo can be very valuable in helping guide management
      • If those interventions fail, move on to either Vasopressors or 1unit/kg insulin. End of the line is ECMO
      • In the setting of digoxin toxicity, potassium level is extremely valuable; One study found K+ >5.5 had a 100% mortality in those not given an antidote while <5.0 had 100% survival

EMS Radio Calls

  • Main call-ins are for prearrival notification, requests for orders, requests to cease resuscitation or a patient refusing medical care
  • There are strict guidelines for when we can vs cannot cease efforts in the field
  • Often have to make critical decisions with very little information

Conference Notes For 08/09/2023

Posted on by
Reply

Infective Endocarditis Lightning Lecture

  • Pathophysiology: Usually starts with an insult to the endothelium, leading to formation of sterile vegetations. Then, an episode of transient bacteremia may seed an infection to these pre-existing vegetations
  • Infected vegetations often embolize, leading to a wide range of symptoms and secondary effects
  • Prevalence is as high as 10-15% in those who abuse IV drugs
  • The Modified Duke Criteria is used for diagnosis
  • When you suspect IE, three blood cultures from three different sights should be drawn
  • Antibiotic selection varies depending on native or prosthetic valve

Pericarditis and Myocarditis Lightning Lecture

  • Myocarditis is inflammation of the muscle cells of the heart. Can be acute, subacute or fulminant
  • Wide range of etiologies including viral/ bacterial infections and autoimmune diseases
  • Can lead to dilated cardiomyopathy and heart failure
  • Up to 80% of cases of pericarditis have an idiopathic etiology. Other causes include infections, radiation, Dressler’s syndrome
  • Pericarditis can lead to effusions/ adhesions, leading to constrictive pericarditis or even tamponade
  • Pericarditis does have some characteristic EKG findings. Important to differentiate from a STEMI

Pediatric Congenital Heart Disease

  • CHD is the most frequently occurring birth defect
  • Cyanotic lesions- think the “Five T’s” plus pulmonary atresia
  • When you’re concerned about a ductal-dependent lesion, don’t hesitate to give prostaglandins; biggest side effect is apnea, which can be managed
  • First two things to get when a newborn presents with suspicion of a CHD: All four extremity BPs and preductal+ postductal O2 sats
  • First two things to do during a suspected tet-spell: Squat/ knees to chest and give O2
  • If a baby is tachycardic, try to address potential secondary causes before giving adenosine

EKGs

  • When interpreting EKGs, especially early on you need to be systematic
  • A “significant” Q wave will be > 1/3rd the height of the R wave
  • When you see STD, you should be asking yourself “where is the STE?”
  • Most important factor to consider when evaluating for ischemia is the history, don’t get caught up too much on risk factors or lack thereof
  • Hyperacute T waves are broad-based, become asymmetric as the J point begins to elevate
  • Convex STE is very specific for ischemia
  • Don’t forget to get serial EKGs when there’s any suspicion; If you’re repeating troponin, you should also repeat EKGs. Don’t be afraid to get a quick repeat in 15-20 minutes when they’re actively in chest pain and you’re concerned

R3 Procedure Sim: Pericardiocentesis + Transvenous Pacing

  • Pericardiocentesis has three different approaches. No consensus on which is best
  • If performing the parasternal approach be careful to avoid the thoracic artery
  • Major indications for transvenous pacing include unstable bradycardia, sick sinus syndrome with pauses or failure to pace with the transcutaneous approach
  • RIJ is the preferred approach for floating a transvenous pacer

Conference Notes 08/02/23

Posted on by
Reply

Lightning Lectures

  • -Average lifespan of the pulse generator is 6-10 years
    • -Leadless pacemakers are in the works. Can help reduce many of the risks associated with current pacemakers
  • -Indications for pacemaker placement include Sinus Node dysfunction, high degree AV block or high risk to progress to high degree AV block
  • -Magnet placement will revert any pacemaker back to the factory rate
  • -Iphone 12s and newer models are known to be strong enough magnets to revert to factory settings
  • -When a pacemaker is malfunctioning, interrogation is usually the first investigative step
  • -AAAs that are symptomatic or > ~5cm require surgical repair
  • -Most common complication of AAA: rupture
  • -Risk Factors for AAA include Male gender, Smoking, HTN, age >50
  • -Gold standard for diagnosis is CT, however, US can also be quite sensitive
  • -Overall Tx goal is reducing shearing stress. Aggressively control pain, HR and BP

Using Self-Directed Learning Skills To Pass The Boards The First Time

  • -Nationally across all specialties 20% of residents fail boards on the first attempt
  • -Self directed learning has 4 main parts: Define a goal, identify the steps, choose the best strategy and asses
  • -Important to try to identify gaps in knowledge; can help to ask yourself reflective questions
  • -Try to create frameworks to organize your knowledge
  • -How to read to gain knowledge: Ask yourself 1. What did I just read? 2. Why was it important? 3. How does it connect to something I already know?

PGY2 Clinical Pathway: Pulmonary Embolism

  • -Helpful to divide acute vs subacute vs chronic. Stable vs unstable. Saddle vs segmental vs subsegmental
  • -Wide variety of presentations ranging from asymptomatic to profound shock
  • -ABG can sometimes be helpful (unexplained hypoxia should raise suspicion)
  • -EKG abnormal in up to 70% of cases, however specific findings can vary widely
  • -CTPE is 90% sensitive.
  • -Treatment dependent on a number of factors including hemodynamic status and bleeding risk
  • -Empirically anticoagulate those with low risk of bleed and high pre-test probability of PE