EMDoc

Archive for the ‘Uncategorized’ Category

READ THAT EKG!

In Uncategorized on December 2, 2011 at 11:48 pm

 

EKG 1 belongs to a 41yo M no PMhx presenting with CP since last Nite. Worse with laying down. Improved with sitting up. Currently having 8/10  CP.

 

EKG 2 belongs to a 50 yr old man presenting with CP x1hour. Onset while doing heavy lifting at home. Actively having CP.

 

Read the EKG and make a decision – to cath or not to cath?! If cath, name the potential culprit lesion.

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what am i?!

In Uncategorized on November 9, 2011 at 11:40 pm

What is the diagnosis?!

What is the treatment?!

What is the feared complication?!
w

 

 

answer>>>>>>>>>

Herpes Zoster Ophthalmicus!

Most feared complication – blindness in the affected eye.

Management – PO/IV antivirals (acyclovir), CLOSE OPHTHALMOLOGY FU!

The stroke of insight.

In Uncategorized on September 30, 2011 at 2:09 am

A fascinating TED talk from a neuroanatomist who studied her own stroke as it happened!

 

Abdominal Pain

In Uncategorized on September 12, 2011 at 7:50 pm

 34 yo M with no PMH presents 2/2 diffuse abd pain that began yesterday AM after waking. It has worsened since onset. It is intermittent, pressure-like. No n/v, no f/c, no diarrhea. No urinary sxs. Pain is worse with eating or ambulating. No relief with motrin, maalox, or peptobismol. Pain radaites around to his lower back. Pain is moderately severe. Pt has never had this pain before. Pt also tried a “Mexican medication” for his belly pain with no relief. 

On exam pt appears nontoxic and in no acute distress. RRR heart sounds, Pulm exam CTA b/l, no CVAT, abd exam with mild-moderate epigastric ttp without rebound or guarding, no abd masses.
Labs were ordered.
45mins later, the lab called to state ‘we cannot run the labs because the patient’s blood is ‘milky”
RN was asked to redraw the blood work, and this was noted in the patient’s room.
WHAT IS THE DIAGNOSIS?
 Cholesterol                              666        H      (150-250)        mg/dL
  Result Comment:
 HDL-Cholesterol                          70                                 mg/dL
 Non-HDL Chol (Calc)                      596                                mg/dL
 Direct LDL:                              42                (0-100)          mg/dL
 Triglyceride                             3937
 Lipase                                   44                (13-60)          U/L

IMPRESSION:

Peripancreatic stranding with thickening of the anterior renal and

lateral conal fascia consistent with acute pancreatitis. No

collections identified.

I thought this was a very cool case! The 2 most common causes of pancreatitis are alcohol(35%) or gallstones (40%). Other causes include post-ERCP, trauma, and Infection.

In medical school we learn the other rare but possibly causes – such as hypertriglyceridemia (<1%)! Usually occurring with TG’s >1000. Remember acute pancreatitis doesn’t always present with an elevated lipase (especially if the pancreas is pretty burned out prior to presentation).

REMember – management of acute pancreatitis – NPO, IVF, admit! 

What is wrong with this CT?

In Uncategorized on August 2, 2011 at 11:02 pm

Here’s the scoop… The patient (aka the owner of this CT) is a 60yo M presenting to the ED with acute onset shortness of breath and dyspnea on exhaustion x3days. dyspnea with talking or walking 5 feet with dizziness, nausea and diaphoresis  . denies chest pain, syncope, or lower extremity swelling. Patient states he’s been monitoring his resting HR at home and they’ve ranged from 92-120’s.

PMHx – patient was recently diagnosed with bilateral DVT’s about 3months prior to this presentation. He declined anticoagulation therapy (due to personal beliefs – being a vegan, stating he won’t be compliant with the meds and generally refusing any long term medication therapy). Otherwise no medical history.

FHx – DVT and PE;

ROS – mild conversational dyspnea.
VS: 99.6, 117/82, 98, 18, 97% on RA. PE: patient is in no distress. No rales/rhonchi/wheezing on lung exam. No new murmurs in the heart. RRR. S1/S2. no LE edema. otherwise unremarkable.
DO WE REALLY NEED A CT TO MAKE THIS DIAGNOSIS?!!!!
Teaching Points: Prognosis of untreated non-massive Pulmonary Embolism!

Acute PE is divided into 2 categories – Massive (meaning the patient presents with hypotension – SBP<90mmHh) or Non-massive/submassive (meaning the patient is normotensive – SBP>90mmHg). Submassive PE’s are about 95% of the presenting cases of pulmonary embolism.

Remember your PERC rule Or Well’s criteria for evaluating low-risk PE patients. These rules help you calculate your pretest probability. However, dont forget to include your clinical picture and gestalt in the equation.
We can discuss these rules specifically in another TP but for this case, the PERC rule didnt apply since the patient didnt meet all 8 criteria; Based on Well’s criteria, this patient is at least a moderate-high risk of PE.
Rx.
Lovenox is generally prefered cause of its easier dosing (1mg/kg) however cant be used in patient with renal dysfunction
Heparin is also a choice.
tPa is usually reserved for patient with hemodynamic compromise.
CT read – multiple bilateral pulmonary embolism! Prognosis for this patient….not good (i’m still searching for a more scientific response, with percentages and all. :D)!

Name that poison!

In Uncategorized on July 22, 2011 at 1:31 am

10yo F (otherwise healthy), being managed by dermatology for bilateral lower extremity Molluscum, was scheduled for her Derm appt today to have “Molluscum” of her lower ext removed. Prior to this visit, patient was asked to premedicate her lower extremities with 2.5% EMLA cream and was prescribed (2) 30G tubes. Mum applied the entire 60G 2.5% EMLA cream to both lower extremities and wrapped it with seran wrap 2hours prior to the patients’ appointment. Just before leaving for the appt, patient noted that she felt dizziness. While at the derm office, Pt’s legs became dusky, she became restless and confused. On her mother’s insistence, patient was taken to the nearby ED. Upon arrival, pt was noted to be confused, Oxygen Sats 83-94% while on non re breather, skin looked dusky/grey. Vital signs were otherwise unremarkable.

What poisoning does this child have?

What antidote would you use?

What lab studies are indicated?

Teaching Points: Lidocaine/Methemoglobin toxicity

EMLA is a topical anesthetic made up of Lidocaine + Prilocaine.

Mechanism: These two anesthetics (either individually or in combination) are part of the many drugs that inflict Large oxidative stress on the body and can cause methemoglobinemia. Methemoglobin causes oxygen delivery to tissues to be impaired (by causing oxidation of iron to the ferric state thus reducing the oxygen-carrying capacity of hemoglobin and producing a functional anemia). The oxygen hemoglobin dissociation curve shifts to the left.

Clinical presentation: headache, dyspnea, lightheadedness. Could also lead to cardiac arrhythmia, CNS depression and metabolic acidosis.

Labs:Methemoglobin level, ABG, BMP, Lactate(based on clinical presentation, to look for end-organ damage)

Antidote : Methylene Blue (dose 1-2 mg/kg IV over 5 min. Its effects should be seen in approximately 20 min to 1 h). If ineffective (or if the patient has G6PD and thus is not a candidate for methylene blue), hyperbaric oxygen or exchange transfusion should be considered.

Other interventions: Dermal decontamination (wash the affected skin with skin and water), supplemental oxygen.

Outcome: After discussion with Poison control, it was determined that the patient applied more than 5x the dose of EMLA recommended. Skin was washed off. Labs showed no signs of end organ damage. Methemoglobin level was 15.1mg/dl. Patient was given methylene blue and within 20mins, her dizziness/dyspnea resolved and she regained good color in her extremities. She was admitted overnight for observation.


 

 

 

 

 

 

 

 

To rhogham or not to rhogam?

In Uncategorized on June 28, 2011 at 3:00 am

29yo F g3p1 about 14wks pregnant by LMP presents after being physically assaulted. Patient states she was in an altercation with another female and was punched multiple times to the abdomen. denies any vaginal bleeding but does note some mild abdominal pain. Vital signs are within normal range for her age. Pelvic exam was unremarkable with no vaginal bleeding.

Bedside  US showed +IUP at about 14weeks with FHR at 130bpm

Labs: rh negative. no Rh antibodies.

Teaching Point: Indications for Rhogam.

Remember! The rh prefix is the name of a surface antigen on RBC’s. Rh negative means those RBCs do not have the antigen. Rh positive means they do. Thus, an Rh negative  person has anti-Rh antibodies! Now, in a pregnant female, this could potentially be a problem if they are pregnant with an Rh+ fetus as the anti-Rh antibodies from the mother could potentially cross the placental and destroy fetal RBC’s IF there is mixing of maternal and fetal blood!.

A woman can be sensitized any time the Rh–positive blood mixes with her blood. This can occur if an Rh–negative woman has once had: Vaginal bleeding during pregnancy, induced or spontaneous abortion, Ectopic pregnancy, chrionic villious sampling or trauma. Once sensitized, it takes approximately one month for Rh antibodies in the maternal circulation to equilibrate in the fetal circulation. In summary:

Rh NEGATIVE = BAD = Sensitization = possible death to current fetus plus issues with future pregnancy, therefore TREAT!

Treatment is Rhogam (anti-Rh IG) 50mcg IM if within the first 20wks or 300mcg IM otherwise.

 

Welcome!

In Uncategorized on June 28, 2011 at 1:03 am

Teaching Points officially welcomes all to a new academic year! it’s time for more fun learning and reading. The blog will be updated weekly (as long as the EM gods smile on me)! Please feel free to send any teaching cases to me at yvonne.ezeala@gmail.com!

‘help my baby!’

In Uncategorized on June 10, 2011 at 4:31 pm

A young mother runs into a small community ED screaming ‘Help my baby, i think she’s having seizures!’

The patient is a 15mo female with a hx of asthma. Per mum, patient had been having fevers up to 102.5 at home x1day. Patient had just woken up from sleep (10mins prior to arrival) when mum noticed generalized body stiffness, ‘eyes rolled back’ and general unresponsiveness to name calling. mother denies any trauma, falls, or any ingestions. No prior hx of seizures. No significant birth hx.

Patient is taken emergently to an ED room. IV, O2, Monitor.On exam

Vitals: T@103, 97% on room air, BP 140/60. Hr 120. heart, lungs, and abdominal are wnl. no visible signs of trauma. no rash. PERRL, Patient eyes open and staring into the distance, unresponsive to name calling and generalized body stiffness noted.

Patient was given tylenol PR, labs (cbc, bmp, ua, urine culture and blood cultures) were sent. After 2minutes with no change in the patients neurological status, 0.5mg IV of ativan. After 5mins,with still no change, another 0.5mg IV ativan was given and transport was arrange for the patient’s transferred to the nearby children’s hospital for further care.

Teaching Point: Identification and management of complex febrile seizures.

Usually, febrile seizures present to the ED without any ‘active’ seizures per say and as such, minimal intervention is required. Diagnosis is usually made from history and the patient with their caretakers are usually discharged home with careful instructions.

Definition: A febrile seizure is defined as seizures in the presence of a fever >38C without concurrent CNS infection or other identifiable cause such as electrolyte imbalance, neurologic illness or prior seizure disorder.

Simple febrile seizures are typically generalized, last < 15 min and do not recur within 24h while complex febrile seizures are prolonged, recur more than once in 24h, or are focal.

Complex febrile seizures usually warrant admission and a more extensive search for the cause of the seizure including infection, intracranial trauma and epilepsy.

What are your treatment options?! In peds, POP OUT THE BRASLOW TAPE! This will save you time in trying to figure out dosages!

First line: lorazepam(IV or IM; Ativan) – kids 0.05-0.1mg/kg every 3-5mins. Adult 0.02 -o.3mg/kg (about 2mg IV) every 3-5mins. Consider Diazepam(PR) if IV access is an issue.

Second line: Phenytoin 20mg/kg IV (Rem, IV phenytoin can cause hypotension) or Fosphenytoin 15-20PE/kg IV or Valproate 20-30mg/kg IV.

Third line: Phenobarbital ( its not called a ‘phenobarb coma’ for nothing. If you are getting to this point, the patient should be intubated for airway protection due to their chemically induced and physiologically depressed mental status)

 

Outcome: The child was transferred to the local children’s hospital. Complete workup including EEG, CT head, LP and all cultures were negative. Patient was discharged home in good condition about 3days later.

Radiology finds!

In Uncategorized on May 8, 2011 at 5:35 pm

Left Subdural Hemorrhage

Sternal Fracture

Subxiphoid view on US. LV-Left ventricle. LA-left atrium. RA-right atrium. The star(*) marks the effusion. The white arrows show how the effusion is causing RV-right ventricular collapse.

Intracranial Hemorrahge

Abdominal aortic aneurysm

?cardiomegaly

Intussusception

Subdural Hemorrhage

L large pneumothorax with lung collapse

Subdural Hemmorhage

Displaced maxillary fracture