Cardiovascular Review Questions – Dr. Ballew

• Reviewed ITE/Board style questions

Cardiology Review: Tachyarrhythmia Case – Dr. Roberts

• Great review of a patient who presented with a tachyarrhythmia
• Discussed general strategy for how to approach the tachycardic patient
• Reviewed multiple causes of narrow and wide complex tachycardic arrythmias
• Reviewed acute pharmacologic and non-pharmacologic methods for treating tachyarrhythmias
• Reviewed risk assessment tools such as CADS-VASC and HAS-BLED
• Discussed cardioversion and defibrillation

EKG Review – Dr. Stanforth

• Reviewed EKG cases from LITFL

Priapism – Dr. Stanforth

• Lecture followed by procedural SIM
• Discussed ischemic vs nonischemic priapism
• Reviewed risk factors and common causes of priapism
• Reviewed anatomy of penis in preparation for Dorsal Penile Nerve Block and Aspiration +/- Irrigation
• Reviewed alternatives including phenylephrine injections or OR intervention as well as disposition
• Discussed risks/benefits, alternatives (as above), equipment and how to properly perform nerve block and aspiration procedure
• Practiced aspiration during SIM

GU Trauma – Dr. Kuzel

• Non-op management is increasing, but operative management still gold standard
• Renal trauma:
  • High energy blunt trauma is most common
  • Best test: CT Abdomen and Pelvis w/ contrast
    • FAST is limited in renal and retroperitoneal injuries
  • Grade II renal lacerations or higher = admission to trauma
    • Grade I – III usually non-operative injuries
  • Gross hematuria OR microscopic hematuria + shock = CTAP w/ contrast
• Ureter Trauma:
  • 90% are penetrating trauma
  • Best test: Retrograde Pyelography
    • Urinalysis often does not show hematuria and even CTAP w/ contrast can be unhelpful
    • Ex-lap 88.9% sensitive causing increased nephrectomy rate
  • Treatment is always operative (consult urology), but high likelihood of complications (fistula, abscess, peritonitis, urinary leakage)
• Bladder Trauma:
  • High mortality (concomitant injuries)
  • Mechanism: direct blow to distended bladder
  • Best test: Retrograde cystogram
    • Gross hematuria + pelvic fracture = retrograde cystogram
• Urethral Trauma:
  • Anterior vs Posterior injuries
    • Anterior = operative
    • Posterior = Place suprapubic catheter
  • Mechanism: straddle injuries or blunt trauma
  • Blood at urethral meatus = anterior urethral injury
  • Best test: Retrograde urethrography
  • Prostate exam is unreliable to evaluate urethral injury
• Testicular or scrotal trauma
  • Best test: Doppler U/S
  • Consult urology
  • Testicular rupture = OR
• Penile Trauma
  • Zipper entrapment most common
  • Penile Fracture:
    • Rupture of corpus cavernosum from forceful bending
    • Mechanism: intercourse
    • Consult Urology for operative management
  • Penile Amputation:
    • Usually self-inflicted
    • Operative management
• Discussed Peyronie’s Disease and Foreign Bodies

Nephrolithiasis – Dr. Concepcion

• Good overview of definition, etiology, clinical presentation, diagnosis, and management of kidney stones.
• Discussed options for imaging including US and role of non-contrast vs. contrast CT scans.
• Most stones pass spontaneously, but prompt recognition of obstruction with infection is critical because delayed decompression can lead to sepsis and permanent renal injury.

Fournier’s Gangrene – Dr. Coleman

• Time is tissue! Fournier’s gangrene is a surgical emergency – recognize it early, start broad-spectrum antibiotics, and obtain immediate surgical consultation.
• Diagnosis is primarily clinical – do not delay treatment for imaging if suspicion is high.
• Usually polymicrobial infection (aerobic and anaerobic bacteria)
• Discussed role of clindamycin/linezolid in toxin production inhibition

Urologic Devices – Dr. Shaw

• Reviewed case of patient who presented with AMS, electrolyte abnormalities, AKI and infection from post-operative foley catheter placement.
• Reviewed EKG findings of hyperkalemia and hyperkalemia protocol – Calcium, Insulin + Dextrose, IVF, Beta-2 agonist
• Great review and “show and tell” of multiple urologic devices:
  • Foley catheter: discussed types, indications (acute urinary retention >300cc PVR, gross hematuria with clots, GU trauma, critical illness/strict I/O), use and troubleshooting
  • Suprapubic catheter: discussed indications (GU trauma, inability to pass standard foley in setting of retention), placement and exchange (<6 weeks, call urology, >6 weeks, replace)
  • Ureteral Stents: discussed indications (malignancy, nephrolithiasis, stricture), expected complications (irritative bladder, flank pain, hematuria), abnormal complications (sepsis, stent obstruction, migration or fragmentation, and fistulation)
  • Nephrostomy Tubes: discussed indications (ureteral trauma, complete ureteral obstruction, prolonged urine drainage), complications (accidental removal, anuria, sepsis, gross hematuria and fistulation)
• Bonus review! Supraglottic Airway Devices, indications, and insertion/use
  • Discussed Failure To Ventilate algorithm (jaw thrust + suctioning  nasal trumpet  BVM  oral airway  EGD or I-gel)
  • Reviewed nasopharyngeal airways, bag-valve mask, oropharyngeal airways, supraglottic/extraglottic devices (I-gel, LMA, etc.)

STIs – Dr. Price

• Image review game
  • Takeaway: clinically, many STIs look very similar and do not always present classically; important to recognize and send off testing.
• Discussed multiple GU emergencies that may present, specifically with acute urinary retention.

Sepsis Updates – Marianne Dorsey, RN

• Reviewed Sepsis Continuum
• RN can initiate TIO Sepsis Alert for 2 or more SIRS, suspected or confirmed infection, with or without organ dysfunction  Sepsis Alert paged overhead  RN to notify MD
• Sepsis Time Zero – earliest time that patient meets criteria OR time documented by MD
• Reviewed 3 hour and 6 hour sepsis bundles including Tissue Perfusion Reassessment
• Reviewed Sepsis PowerPlans (Med Sepsis_ULH)
• Document reason for withholding or not giving full 30 mL/kg IVF and excluding criteria for not ordering sepsis bundle

Medical Director Update – Dr. Ross

• Discussed new NES study on BP goals in hemorrhagic strokes
• Discussed a case on hyperkalemia and reviewed the hyperkalemia order set
• Discussed goals for stroke patients including stroke team pre-notification if concern for LVO PTA and TNK feedback
• No more fast-gut sutures, plan to use vicryl rapide instead
• Alert charge nurse about any concern for Decon – pesticides, acids/bases, toxic industrial materials, gasoline
• Discussed ongoing FLUID-TBI Study

Hernias and Testicular torsion – Drs. Franxman and Buechler

• Reviewed types of hernias.
• Discussed Twist score
• Manual detorsion – open the book

R2 Small Groups – Drs. Drury and Hudson

• Reviewed 4 great cases on GU/Renal Emergencies
• Case 1: Paraphimosis
  • Treatment = reduction (emergent)
  • Glans compression, osmotic agent (sugar/mannitol), reduction
  • Last resort option: band incision (use lido w/o epi)
• Discussed penile nerve block
• Discussed paraphimosis (can’t pull foreskin forward) vs phimosis (can’t pull foreskin back)
• Case 2: Epididymitis
  • Pain improves with testicular elevation
  • Treat as complicated UTI (levofloxacin), add ceftriaxone + doxycycline if c/f STI
• Case 3: Lithium OD
  • Timeline: Acute (GI symptoms) vs. Acute on Chronic (CNS depression)
  • Discussed complications including lithium induced thyroid dysfunction and EKG findings (nonspecific T wave inversion)
  • Management:
    • When do they need HD?
      • https://www.extrip-workgroup.org/recommendations
      • AEIOU
      • ISTUMBLED drugs
    • IHD vs CRRT vs SLEDD
      • CRRT and SLEDD easier on BP, better for ICU patients
• Case 4: Pyelonephritis
  • < 5 mm will pass
  • > 10 mm = surgery (and consideration of stent placement)
  • Complications:
    • Emphysematous pyelonephritis = gas in bladder wall, kidneys, pelvis
    • Renal abscess

Dialysis Fistula Complications – Dr. McGowan

• Fistula = artery to vein
• Maturation
  • At least 1 month, usually 6-12 months (for revisions)
• Physical Exam
  • Thrill = good, continuous buzz
  • Pulse = bad, generally downstream stenosis
  • One part has entirely different thrill than rest = c/f focal stenotic lesion
  • No thrill/ pulse = thrombosis
• Stop the bleed!
  • Bottle cap method (open side to fistula)
  • Hold pressure
  • Figure of 8 (not over entire vessel)
  • Purse string
  • Tourniquet
• Pseudoaneurysm vs aneurysm
  • Both look like bulging enlargement of fistula
  • **atraumatic bleed is huge red flag** = Call vascular
• Distal ischemia
  • Ex: HAIDI or DASS
  • Is one hand cold compared to other?
• Infection

Pediatric UTI and Renal Pathology 

• Kids under 24 months diagnosed with UTI require OP renal/ bladder US
• Discussed UTIcalc.pitt.edu/
• First line treatment for UTI = Keflex
• Discussed how to treat PSGN – treat underlying infection and treat nephritic syndrome with diuretics, antihypertensives and RRT
• Discussed Acute Nephritic Syndrome findings (hematuria, HTN, Edema – eyes, scrotum/labia, Oliguria)
• Discussed HUS – Supportive