Conference Notes December 2023

Conference notes 12/6

  • Ovarian cysts, rupture, and torsion (Dr. Williams)
    • Ovarian cysts: If cyst size is greater than 10cm consider OB consult for potential surgery
    • Infundibulopelvic ligament (suspensory ligament) contains the ovarian aa, vv, nn and is cause of ovarian torsion
    • If concerned for torsion and US inconclusive can get MRI
  • PID (Dr. Mattingly)
    • Most common in 18-44 yo F
    • Physical exam findings: lower abdominal tenderness, cervical motion tenderness, cervical purulent drainage, adnexal tenderness or mass
    • Admission criteria: severe n/v, fever, pelvic abscess ruptured TOA, need for invasive diagnostic eval, unable to tolerate PO, concern for nonadherence
    • IP Tx: ceftriaxone and doxycycline+ flagyl, OP: ceftriaxone 1x then doxycycline + flagyl x 14d
  • Perimortem C Section (Dr. Boland)
    • Gravid uterus can compress IVC impeding venous return> compressions w L lateral uterine displacement can alleviate this pressure
    • If fundus height at or above the umbilicus and ROSC is not achieved> recommend perimortem c-section (estimated gestational age >24wks)
    • Should be considered at 4 minutes after the onset of maternal cardiac arrest or resuscitative efforts
    • Do not attempt to take to the OR for the procedure
  • Operations Update (Dr. Ross)
    • If an abortion presents to ED and ‘fetal tissue’ is removed, a series of forms regarding remains, cremation, and ‘death certificate’ must be completed by nursing staff.
    • Minors cannot give consent for cremation/disposal of fetal remains. If the patient refuses to tell their guardian about the pregnancy and abortion- ULH will manage tissue. ** Dr. Ross is in the process of confirming this.
    • ‘Fetal tissue’ must be sent to pathology.
    • CAR T-Cell Therapy Adverse Events: CRS (cytokine release syndrome- patients appear septic, fever, tachy, hypoxic, dyspneic, hypotensive) vs ICANS (Immune-effector cell-associated neurotoxicity syndrome- AMS, seizures, cerebral edema). Will be admitted to BMT. BMT Cytokine release syndrome and ICANS management order set on Cerner
  • Preeclampsia and Eclampsia (Drs. Huttner and Stults)
    • HTN in pregnancy = >140/90 (gestational = diagnosed >20wks gestation and resolves after 12 wks post partum)
    • Pre-eclampsia: HTN w proteinuria (protein/Cr ratio >0.3 or 2+ protein on urine dipstick) or evidence of end-organ damage
      • PLT< 100,000
      • Cr> 1.1
    • Ecclampsia:
    • Pathophys- abnormal placentation leading to poor placental perfusion and hypoxia-reperfusion injury. Inflammatory markers target maternal endothelium.
    • Sxs: elevated BP, SOB, rapid weight gain, pitting edema (hands/face), decreased UOP, AMS, RUQ/epigastric pain, HA
    • Labs: thrombocytopenia, incr Cr/AST/ALT (HELLP), LDH (hemolysis), coagulopathy
    • Severe Pre-E management:
      • Seizure ppx: Magnesium
      • BP management
        • Labetalol, hydral, nifedipine
      • BP goal: decrease MAP by 20% in the first several hours
      • Labetalol 20 mg IV  q30 min total 300 mg
      • Hydral 10 mg IV q 20 min total 30 mg
      • Mag 4-6 g IV
      • Deliver at 37 weeks if regular pre-e; if severe: deliver at 34 wks
    • Eclampsia management
      • L Lat decubitus position
      • RSI if needed
      • Seizure treatment
        • Mag 4-6g bolus (over 20 min) followed by 1-2 g/hr infusion
        • Benzos if refractory
      • Delivery of fetus
    • Complications: pulmonary edema, MI, stroke, ARDS, coagulopathy, renal failure, retinal injury
    • Dispo: pre-e wo severe features likely dc, severe or eclampsia: admit

Conference 12/13

  • Hyperemesis Gravidarum (Dr. Taylor)
    • Severe nausea/vomiting
    •  Weight loss >5% of pre-pregnancy weight
    • Onset <9 weeks gestation
    • Occurs in 0.3-3% of pregnant patients
    • Symptoms resolve 20-22 weeks
    • Risk factors
      • Family hx
      • Prior pregnancy with hyperemesis gravidarum
      • Hx of motion sickness, migraines
      • N/v related to estrogen medications
    • PUQE score to determine severity, based on duration, number of episodes of emesis
    • Complications
      • Dehydration
      • Electrolyte derangements
      • Mallory Weiss tear/esophageal injury
    • Treatment
      • For DC: Pyridoxine +/- doxylamine
      • In ED: IVF, diphenhydramine, metoclopramide, promethazine, prochlorperazine, Zofran is controversial
  • Labor (Dr. Blair)
    • Shoulder Dystocia
      • HELPERR mnemonic
        • Help (call for help)
        • Empty bladder
        • Leg- McRoberts
        • Pressure- Suprapubic
        • Enter- Rotational maneuver
        • Remove posterior arm
        • Roll the patient onto her hands and knees
    • Umbilical cord prolapse
      • Have mom stop pushing
      • Use hand to elevate presenting part and decrease compression of cord
      • Attempt to not manipulate cord> can lead to vasospasm
    • Post-Partum Hemorrhage
      • Most common> uterine atony
        • Fundal massage
        • Oxytocin 10u IM/40 u in 1 L
        • Misoprostol 800-1000 mcg rectal or buccal
        • Methergine 0.2 mg IM/IV q2-4hr PRN
  • Neonatal (Dr. Bhargava)
    • Neonatal conjunctivitis
      • Often without fever, just discharge
      • Ddx: gonorrhea vs chlamydia
        • Gonorrhea- first week of life
        • Chlamydia- day 7-14 of life
          • Pneumonia is common complication
      • Management:
        • Admit for abx
    • Neonatal mastitis
      • Etiology staph aureus
      • Dispo: admit for abx, drain abscess if present
      • Peak incidence at 2wks of life
      • Complications: cellulitis, necrotizing fasciitis, osteomyelitis
    • Neonatal seizures
      • Often focal- lip smacking or leg pedaling
      • Causes: hypoxic-ischemic encephalopathy, infection, ICH, metabolic abnormality, meningitis
      • First line tx is phenobarbital
    • Inconsolable infant
      • Easily consoled without source of crying> can be discharged
      • IT CRIES, causes for crying infant
        • Intussusception
        • Trauma
        • Cardiac
        • Rectal/anal fissures/reflux
        • Ingestion
        • Exposure, eyes (corneal abrasion, FB)
        • Sepsis, strangulation (hernia)
      • Hair tourniquet
        • Try application of Nair (less than 10 mins)
        • If color of extremity/ physical exam does not improve> cut down to bone with scalpel
    • Newborn rashes
      • Erythema toxicum neonatorum:
        • papules, pustules, erythema
      • Herpes simplex:
        • lesions are vesiculopustular on ill appearing neonate
      • Milia:
        • 1-1 mm pearly keratin plugs
      • Neonatal cephalic pustulosis:
        • unclear etiology, can be inflammatory reaction.
        • Tx daily cleaning with soap and water ***
      • Seborrheic dermatitis
        • Yellow flaky, often starts in scalp
        • Typically resolves in weeks to month
        • Can use emollient or low potency steroid
        • Ketoconazole shampoo if severe
    • Hypoglycemia
      • Rule of 50s
        • < 1 year old use D10 (5 mL/kg)
        • 1-8 years old use D25 (2mL/kg)
        • Greater than 8 years old D50 (1mL/kg)
    • Jaundice
      • ABO incompatibility: first day of life. Typically, mother’s blood type is O and Baby is A or B
      • Physiologic jaundice: seen at day 2-3 due to decreased conjugation of bilirubin due to immature liver
      • Severe neonatal hyperbilirubinemia
        • T bili > 25 mg/dL
        • Bili crosses BBB and causes neurologic dysfunction
    • Lower GI bleed
      • Meckel diverticulum is most common cause at 2y of age
      • Milk protein allergy should be suspected after introduction of new formula
      • NEC is complication of premature infants and presents with. Abdominal distension, bloody stools and feeding intolerance
      • To eval for swallowed mother’s blood as cause of blood in stool can use Apt Test
    • Pediatric vital signs
      • For children >1 y old SBP= 70+2x age (lower limit of normal)
    • Abdominal wall defects
      • Omphalocele
        • Often with other congenital defects
        • Membranous covering over abdominal contents
      • Gastroschisis
        • Direct exposure of abdominal contents
    • Omphalitis
      • Most often cause s. aureus
      • Presents before 14 days of life
      • Can become necrotizing fasciitis or sepsis
      • High morbidity and mortality rates
    • Intestinal malrotation
      • AXR: double bubble sign
      • Upper GI series: corkscrew sign
      • AIR in biliary tree is most often seen with NEC

4 thoughts on “Conference Notes December 2023

  1. Hip thrusts could be carried out with body weight or with the
    addition of a barbell or resistance band for added intensity.
    To get correctly set up for this exercise, you’ll want a bit
    of kit called a glute ham developer or GHD. GHDs are angled benches that let you secure your toes and relaxation your weight on a pad that sits on the decrease part of your hips.

    Sometimes carried out on a Glute-Ham Developer (GHD) machine, this exercise is
    renowned for constructing energy and enhancing muscle endurance within the decrease physique.
    For seasoned lifters looking to improve the challenge of glute-ham raises,
    including resistance is a good way to ramp up depth. A weighted vest, resistance bands, or even holding a
    barbell throughout the shoulders can considerably increase the load, forcing your
    hamstrings and glutes to work harder. These modifications not
    solely construct strength but in addition put together your posterior chain for handling
    heavier hundreds in different compound actions like deadlifts and squats.
    While it’s a easy bodyweight motion, the glute-ham increase packs an analogous punch to huge barbell
    workouts. As the name implies, glute ham raises goal your hamstrings and
    glutes concurrently, but when you’re doing them appropriately, you should
    feel the burn in your hamstrings the most. This train is very
    efficient, not just because it isolates these two main muscles but
    as a outcome of it also trains them in their full range of motion.
    Incorporating these alternative exercises into your routine
    may help you goal your glutes and hamstrings successfully while
    offering selection and decreasing the risk of overuse
    accidents. Begin with a weight or issue level that challenges you but allows you to preserve proper form, and progressively improve the intensity as you progress.
    Glute equipment can make glorious additions to your home gym as you probably can typically use them for a multitude of workouts and
    coaching regimens. As you noticed from the glute ham developer machines above, the costs can range from just over $100 to round $1,000.
    Earlier Than you purchase gym gear it’s essential to know what
    your fitness level is and what your finish targets are.
    The best glute workouts for males are workouts that focus on the gluteal muscular tissues and promote bodily traits which would possibly be well-liked among men.
    The foot rollers need to be secured to a rig or rack, preferably one that’s bolted to the ground.
    They are also an absolute must for athletes of all
    ages, regardless of measurement, that wishes to find a way to run faster, bounce larger and overpower the competitors.
    Athletes ought to be ready to do at least 10 body weight reps on their
    very own and then start to add weight by holding a weight plate to their chest so as to
    compete at a excessive level. If we had to determine on between these two machines, we’d choose
    the GHD machine as a end result of we are more thinking about strength gains rather than rehab.

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    It is also nice at relieving back ache, as plenty of my shoppers inform me that their again pain has improved or is non-existent now that we’ve begun implementing
    this train. Nonetheless, if you really want improvement then you’ll
    find a way to perform this three days per week and overtrain the realm.
    If you move too slowly on the concentric portion of
    the exercise, you teach the hamstrings and glutes to fireplace slowly,
    and this is precisely what they’ll do when you go to squat or deadlift.

    There are a number of glute exercises, options, and variations that increase strength,
    mobility, and aesthetic appearance. The Glute and Ham Elevate is a complicated bodyweight train primarily
    targeting the hamstrings and glutes. It entails a
    managed decreasing and elevating motion, where the athlete leverages the posterior chain muscle tissue to raise
    and decrease the body.
    The following nine steps illustrate the right form for doing hip extension workouts safely.

    Set-up a hip thrust in exactly the identical means you’ll normally by
    utilizing a bench to push your again in opposition to. The solely difference is
    that you will want your feet farther forward. Often, if you do a barbell hip thrust, your shins will be vertical when on the prime place.
    With the hamstring-centric model, you want your shins to actually be angled away.

    You nonetheless need to pull until your body
    is fully prolonged then pause, give your glutes
    a squeeze after which decrease the barbell down. Many starting
    weightlifters tend to carry out this glute ham raise train incorrectly, but this could be very necessary to perform this train accurately if you
    would like to avoid harm.
    Conversely, many individuals carry out back extensions thinking they’re focusing on their hip extensors, after they’re truly
    working their erectors extra. But it’s not just about aesthetics—your glutes are the engine behind sprinting, leaping, squats, and deadlifts.
    Robust glutes shield your lower again, enhance hip mobility, and improve lifting efficiency.

    Whether your aim is to lift heavier, run sooner, or fill out that again of your jeans, the hip thrust must
    be in your exercise rotation. Stiff-legged deadlifts, then again, are
    extra glute/hamstring-focused.
    Sure, you’ve accomplished hamstring curls, and they’re nowhere
    near as powerful because the glute-ham increase, however they are
    often with a small tweak. What we miss in an isolated hamstring curl is the hip
    extension we get in a glute-ham elevate. As Soon As
    you’re experienced with it, the glute-ham raise can be trained through a number of completely
    different rep ranges. If you get comparable pain, the probably
    culprit is an under-trained decrease again, glutes, or hamstrings.
    To right this, you’ll have the ability to perform glute exercises at
    residence, on glute machines, and even on a weight bench.

    There are also plenty of full again exercises that focus on the upper a half of your posterior chain. The glute hamstring developer
    AKA GHD machine is an underutilized piece of gym gear that may do wonders on your power
    training objectives.
    This will assist build the energy wanted to boost your physique again up.
    This is a wonderful hypertrophy exercise because it works the posterior chain as a
    whole. Yes, it locations main emphasis in your hamstrings, but it’s going to additionally construct your spinal erectors, glutes,
    and calves. Severe lifters know that competitions
    are gained from the backside, and this train is a superb addition to building muscle in that space.
    Whether Or Not carried out on a machine or tailored with house
    tools like a stability ball, it promises significant muscles features, energy, and
    practical efficiency. In Distinction To isolated workouts, the Glute-Ham Raise is a closed-chain motion that recruits the entire posterior chain, together with the hamstrings, glutes, calves, and decrease again muscle tissue.

    In the world of decrease body workouts, there’s a sea of workout routines
    claiming to focus on your glutes and hamstrings.

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  2. Keep your elbows at forty five diploma angle, pause
    here earlier than explosively urgent back up. All participants, no matter their stage of
    train expertise can embrace the incline dumbbell press in their
    programme to see power and muscle gains. If you are not doing so already, add incline presses to your upper physique days to
    construct sleeve-busting shoulders and a chest that turns heads.

    Here are two sample chest exercises demonstrating the method to add the incline dumbbell press to your routine.
    For instance, when you’re doing a push-pull split, the dumbbell incline
    press is a superb major exercise on push day. From there, you possibly can target the triceps and shoulders
    with isolation workouts, even peppering in some chest
    flys or different variations from above. If you do not have
    entry to dumbbells, wish to make your incline dumbbell press harder, or choose other equipment, there are other
    variations.
    The DB bench press is a extra accessible pressing choice for people who practice at lodge gyms, house gyms or gyms with less strength gear.
    Discover out why the dumbbell bench press is value your time and the way to grasp the strength-building move.
    You’ll see lots of people being lazy with their ft, or placing their toes on the bench — a lot
    of issues they don’t need to do. “The motion of your lower physique is important on a bench press, particularly should you’re coping with a barbell and pushing heavy weight,” says Samuel.
    “Take the time to learn that decrease body action now and develop good habits.”
    Again, Bench Press within the Power Rack so the safety pins can catch failed reps.
    Set the pins even when you have a spotter.
    Then Bench Press with correct type to reduce back the danger of losing the bar.
    Use a full grip, lock your elbows and rack correctly.
    Don’t put your ft on the bench or in the air to feel your muscular tissues better.

    Now, there are additionally some notable advantages of dumbbell bench press.

    With dumbbells, you simply can’t go as heavy because you must
    bring them off the ground and into place. Furthermore, each arm is
    independent of each other, which forces more stability, thus making issues tougher.
    Overall, by squeezing your shoulder blades together, your chest will carry up a bit
    in direction of the ceiling and you will naturally have a light arch in your thoracic backbone.
    This will ensure safety of your shoulder joint and maximum energy.
    Here are some key cues to observe when bench pressing…

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    However again, most individuals don’t know tips on how
    to spot. They can unrack the bar with too much drive and pull your shoulders out of place.
    Their hand off can do more injury than good.
    The dumbbell bench press is a well-liked exercise that folks have been using for many years.
    After reading this article, you want to have a great understanding of the means to perform the motion and what muscle groups it targets.
    Thus, the dumbbell bench press may be the primary exercise of your workouts or the secondary
    exercise.
    Pause for a second at the prime, then slowly bring them again down as you inhale.
    “This angle means the elbows could be tucked in, quite than flared out from the shoulder whenever you press,” says Horton. The dumbbell bench press
    is equivalent to the barbell bench press by way of method, besides you
    employ dumbbells as an alternative of a barbell. I’ve been trying into proper
    type for dumbbell bench press and have found there to be quite a couple of contradictions as
    to what correct form is. Wanting to extend muscular endurance, or make the DB bench press tougher without needing heavy weights?
    The alternating bench press is a superb option. Alternating makes your set last more so
    you may really feel more challenged with less weight.

    It additionally compresses your spinal discs and can cause back ache.
    This is about making your Bench Press type safer in your shoulders and more effective.

    Your elbows must lock on the high of every Bench Press
    rep or it’s a fail.
    Change from Bench Urgent once a week to twice
    per week. Bench Press Monday, rest, then do it once more on Friday.
    Use the same Bench Press fashion on both days,
    the one you need to enhance. For most people meaning flat Bench Pressing on each days.
    By rising your Bench Press frequency you apply the motion more.
    Your type improves and turns into more effective.
    You can’t turn out to be higher at an exercise you don’t do.
    To increase your Bench Press, you have to Bench Press.
    The best method to grow an even bigger upper-chest is to increase your
    Bench. The Bench Press works your upper-chest as a outcome of your chest contracts as a complete.

    The incline barbell variation offers comparable outcomes to the dumbbell variant.
    The barbell engages the same muscle tissue, however
    doesn’t have a unilateral motion pattern. It will let you
    build the baseline power wanted for the train whereas bettering shoulder stability with out further strain. The seated
    dumbbell press is a vital train, however there are many
    different variations out there. The dumbbell press, seated or
    not seated, is an excellent method to bulk up shoulders, back, and chest
    muscles. The only tools needed for a seated dumbbell press is a set of dumbbells and an incline bench.

    Here’s my friend and world champion Mike Tuchscherer Bench Urgent
    over 200kg/440lb. He Benches all alone, with out spotter, in his home gym as I do.
    However he’s protected as a outcome of he Bench Presses contained in the Power Rack with the security pins
    set. For relaxation durations in between sets, you’ll need to relaxation for 1-3 minutes depending on how heavy
    you are going with the train.
    Bench Press with your heels about shoulder-width apart. Don’t Bench Press with a slender stance, it’s much less steady.
    You have better steadiness on the bench with a wider stance.

    If your hips damage or cramp whenever you Bench Press,
    your stance is too wide (or you’re tight).
    It moves freely so you can balance it your self. If you fail a rep, Energy
    Racks have two horizontal security pins to catch the bar.
    High Quality racks can maintain heavier weight than you’ll ever bench.
    If you Bench Press in the Power Rack as I do, you don’t want a spotter.
    Half reps work less muscle, develop zero power within the bottom
    and yield half the gains.
    Maintain your palms on the bar and help him by urgent
    the weight up with no matter energy you’ve left. As Soon As the bar
    is racked in the uprights give him a giant thanks for helping you.
    You might have to unload the bar to get it in the uprights after a fail.

    Bench Press with free weights on StrongLifts 5×5.
    Bench Press in the Energy Rack so you can do it safely
    without spotter. The Smith Machine forces a vertical bar path.
    But benching in a vertical line over your shoulders isn’t safe.
    It forces your elbows out which impinges your shoulders.
    Vertical line over chest doesn’t work both.
    It places the bar in front of your shoulders on the high.

    “The bench press uses your shoulders, triceps, forearms, lats, pecs, traps, rhomboids, and pretty much every muscle in your upper physique,” says Niren. The dumbbell
    bench press is a compound exercise that targets the pectorals, triceps,
    deltoids, and rotator cuffs.. It’s useful for athletes hoping to overcome a
    plateau with the barbell bench press or trying to steadiness the chest muscle tissue.
    Moreover, this train gives athletes a larger vary of movement than the
    normal barbell press. Once you’ve determined roughly what elbow angle
    is finest for you and your physique, it’s now time to arrange your grip width.
    This is the factor that’ll allow you to actually use
    that elbow angle as you press. This shifts more of the emphasis to your triceps quite than your chest.

    Pressing with a reverse grip will goal your higher chest
    in particular, especially whenever you perform the exercises on an incline
    or decline bench. The workouts force you to stay tight and powerful at all times, making you concentrate on your
    breath and bracing your total body by way of the complete vary of
    motion. The movement improves your grip and forearm power,
    so if strength improvement is your major focus, you have to use a low rep count and a heavier weight.
    Another major benefit of the reverse grip dumbbell press is that it does not put
    any compression on your backbone or your joints.
    The reverse grip dumbbell press can be a extremely effective coaching exercise.

    As lengthy because the benching is pain-free, you should be okay—it won’t look textbook excellent on day one.
    Testosterone is primarily known as the male sex hormone, which accounts for men’s larger dimension and extra simply constructed muscular
    tissues. However, testosterone is present in all genders and might help muscle construct quickly, develop hair, and increase vitality throughout workouts.
    Any physical activity impacts the hormones in your body.

    Studies present that elevated levels of exercise and bodily
    fitness can improve dopamine, the happiness hormone. Your brain will naturally start to
    produce more dopamine after a while, and you will be happier
    and fewer anxious. Using different kinds of dietary supplements may also
    be a great technique.
    The Bench Presser obtained up however the bar tore his diaphragm
    and broke his ribs. The lesson here is spotters don’t guarantee safety.

    I all the time Bench Press in the Power Rack with security pins and recommend you do the identical.
    You’ll bench what you suppose you are capable of do,
    not what you’ll find a way to actually do.
    Possibly you could have benched these two
    final reps. You can’t know because you didn’t attempt.
    And you can’t try it safely with out spotter or Power Rack.

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