Conference Summary 8/4/21

August 4, 2021 , , ,
  • 7a: Mike Cyd – CCU/EKG lecture #2 / Mallory – Methadone Lecture
  • 8a: Resident lectures: Ivan / Robert (please send me your topics soon)
  • 9a: BREAK / Dr Jeong – Coney’s Complex Cases Review (Summer 2021)
  • 1030a: Dr Kindschuh + Geoff – M+M Case – Posterior Stroke (Admin block lecture)
  • 11a: Resident Meeting – Aug 2021 / Faculty Meeting Aug 2021 
  • GENERAL RESIDENCY UPDATES 
    • Link from Dr. Jeong: EMRAP Delta variant updates (8min podcast): LINK
    • Dr Kindschuh – some housekeeping stuff about the Breezy Point Community Outreach event (next week)
      • Replaces conference on Weds 08/11/2021
      • Will have transport from CIH (time TBA) to Breezy Point prior to the start
      • Dress Code: Business Casual
        • Guys: Collared shirt (polo shirt OK), NOT jeans, NOT shorts, avoid tennis shoes if possible, NO TIE
        • Girls: Probably whatever you want but who honestly knows (nice shirt, skirt/dress/pants, again no jeans)
    • 30 Rosh Review questions will be assigned to all residents every week starting this week to help with inservice scores.
  • 7a: Mike Cyd – CCU/EKG lecture #2
    • Case 46M 2 hours of pressure like chest pain, exertional pmhx HTN, smoker, COPD, rhythm strip NSR
      • ST depression V4-V6
    • Repeat ECG within 10-15min
      • Hyperacute T-waves, De Winter T-waves
      • Hyperacute (Ischemia) vs Peaked (HyperK)
        • Hyperacute = QRS can fit inside of the QRS (amal mattu)
      • De Winter T-wave pattern
        • STEMI equivalent: 2% of LAD occlusions
        • More STEMI equivalents: LINK
    • Next step:
      • Meds: ASA 324mg (+plavix or Brilinta)
      • Cath lab
      • 100% LAD occlusion
    • Peaked T wave differentials 
      • Prinzmetal angina (or MI)
      • Hyperkalemia
      • BER requirement (amal mattu)
        • S-wave or J-wave in V2 or V3 — must be present
      • De-Winter’s T waves (acute LAD occlusion)
    • Get serial EKGs (usually not more frequently than q10 mins!)
    • Dr. Steve Smith’s ECG Blog: Great reference for all things EKG & Emergency Department Cardiology
      • OMI (Occlusion MI) & NOMI (Non-Occlusion MI) INSTEAD of STEMI/NSTEMI
      • “STEMI criteria” missed ~30% of occlusion MIs
    • Link from Dr. Jeong: OMI vs NOMI review
  • Mallory – Methadone Lecture (addiction medicine lecture)
    • 18yoM w hx of psych d/o, drug abuse and anxiety took Methadone + mirtazapine and was admitted for aggressive behavior/agitation to psych, then found dead 48hrs later. 
    • Naloxone: 
      • IN: 4mg
      • IV 
        • 2mg if apneic
        • 0.4mg IV if opioid-naive w minimal respiratory depression
        • 0.05mg IV of opioid-dependent
      • Observation period
        • Heroin or other “typical” opiates (Oxy, Percocet, Norco, Heroin, etc)? Observe ~1-2 hours
          • HOUR Rule (when to discharge s/p narcan; NOT for Methadone OD)
        • Methadone? 12-24 hours
        • COWS score
      • Methadone MOA: mu receptor agonist; Dosing: 10-20mg/day, increased in 10mg increments until withdrawals sx’s are controlled 
        • 20mg daily MAX allowed to be given in ED (unless they have their ID cards)
        • If giving home dose, you MUST call the program & document the person who verified the dose… Otherwise, just give 20mg
        • May need to half dose if pt has not taken methadone
          • “A methadone dose of 10 mg intramuscularly or 20 mg orally significantly reduces the Clinical Opiate Withdrawal Scale score in ED patients with opioid withdrawal.” – Su M.K., Lopez J.H., Crossa A., et al. Low dose intramuscular methadone for acute mild to moderate opioid withdrawal syndrome. (Am J Emerg Med. 2018; 36: 1951-1956)
        • QTC prolongation → Torsades 💩… Give ALL the Magnesium!
          • Conservative definition of QTc prolongation: >470ms in men and >490ms in women
        • Observe for 12-24 hours
      • Buprenorphine (Suboxone) MOA: mu partial agonist + Narcan (pure antagonist)
        • Use COWS score! 🐮
  • Vivitrol (injectable naltrexone)
    • MOA: Full opioid antagonist
    • Will precipitate withdrawal symptoms if ANY opioids in system (No opiates at least 3-5 days, No Methadone for 7-14 days)
  • 8a: Resident lectures: Ivan – Alcohol
    • Alcoholics w trauma: low threshold to CT– ETOH causes brain shrinkage like old age, increased risk of bleeding.
    • ADH becomes saturated at low concentrations
    • CP 450-2Eq metabolism becomes more important at higher etoh concentrations or in chronic drinker
    • ETOH metabolism: 30mg/dL/h in tolerant drinkers; non-tolerant 15-20 mg/dL/h
    • Metabolic disorders
      • Hypoglycemia
        • ALWAYS GET A FS
        • More common in peds 2/2 less glycogen storage
      • HypoMag
        • Dietary deficiency
        • Malabsorption
        • Incr urine excretion
        • Ketosis
        • Prolonged QT
        • Vit D deficiency
        • Tx: EKG, Monitor, Magnesium repletion
      • HypoNa (Beer potomania) 
        • HypoNA Causes: beer potomania, pseudohyponatremia, SIADH, cardiomyopathy, cirrhosis, cerebral salt-wasting syndrome
        • Presentation: Neuro- AMS, FNDs, seizures
        • Dx: r/o other causes, BMP, beer drinking, low urine osm/low urine Na concentration
        • Tx: Water restriction, SLOW repletion, if seizing then hypertonic saline vs crash-cart hypertonic NA-bicarb
      • Alcoholic ketoacidosis (AKA)
        • Diff with DKA
          • AKA higher pH, lower potassium; 
          • BHB is primary anion in AKA
        • Tx: IVF, dextrose, thiamine, Folic Acid, Mg/K (dependent)
          • NOT insulin
      • Wernicke/Korsakoff
        • Wernicke Triad: confusion, ophthalmoplegia, ataxia
        • Korsakoff: IRREVERSIBLE amnesia, confabulation
        • Tx: IV Thiamine 500mg TID for 2-3 days followed by 250 for 3-5 days
  • Resident lectures: Robert – Alcohol Withdrawal
    • Fine while drinking / drunk
    • When EtOH goes away, CNS is PISSED
    • Tongue fasciculations = UMN issue; we should call them tongue TREMORS
    • SEIZURES: generalized tonic clonic
    • Hallucinations — but patient knows they are NOT real
    • Delirium tremens: 
      • onset after last drink: 48+ hrs
      • AMS defines DTs
      • No evidence of coma or other evolving neurocognitive disorder
      • Autonomic instability
    • CIWA score (serial-like a lab or vital sign)
      • <8 maybe discharge
      • >20 admit and may need MICU
    • RASS score–used in patients who are NOT speaking 
    • Treatment
      • Benzos
        • Benzo equivalency chart 
        • Valium (Diazepam) 
          • IV pushes q5-10min
          • 10mg x2 → 20mg x3 → 40mg x3 = 200mg TOTAL
        • Ativan (Lorezapam) –can cross BBB, metabolized outside the liver
        • Versed (Midazolam)
        • Librium (chlordiazepoxide)
        • IV BZDs for seizure – time to effect and duration:
      • Phenobarbital
      • Propofol – GABA agonist, for intubated patients generally
      • Dexmedetomidine – alpha 2 agonist, s/e hypotension + bradycardia
        • Does NOT treat etoh withdrawal, usually only adjunct therapy
        • Fixes vitals but not the cause,  NO GABA activity
      • Ketamine – NMDA receptor antagonist, NMDA receptors are NOT downregulated in chronic EtOH, chronic BZD use, prolonged seizures; 
        • s/e: tachy, HTN, laryngospasm, secretions
      • Thiamine –
        • Water soluble
        • Maximum body stores: , exist primarily in skeletal muscle, amount to ~30mg and can be depleted in as littel as 20 days in a patient inadequate intake, malabsorption or excess metabolic demand
        • TACHYCARDIA is earliest symptom of thiamine deficiency, can develop as early as 9 days after intake ceases
        • Give with the alcoholics (water soluble so it’s REALLY hard to overdose)
        • Prophylaxis 100mg IV
        • PO is unpredictable
        • Thiamine deficiency → unexplained high lactate 
  • Dr Jeong – Coney’s Complex Cases Review (Summer 2021)
    • CASE 1: 66 y/o hx of DM, HTN, smoking presenting w/ seizure vs syncope
      • Seizure = aura, post-ictal, lateral tongue biting, few hours, high CK
      • Syncope = flushed, hot/cold, 3-30 seconds, young age
      • JournalFeed 10/20 Seizure vs Syncope Rule
        • <10 jerks favor syncope
        • >20 jerks favor seizure
        • ST Elevation in aVR, Leads III, aVF; STD V4-V6, Lead I, aVL; T-Wave inversion vs biphasic in aVL
      • Case continued:
        • Sent emergently to Cath Lab (STEMI Code activated)
        • Cath report: 2 vessel disease (RCA with complex calcified lesion 95% occlusion, mid-LAD with 80% lesion with patent flow)
        • Due to complexity of RCA lesion and absence of overt culprit lesion, decision was made by Cardiology team to stage intervention, and pursue transfer to MMC vs BHC
        • While awaiting transfer overnight, patient had multiple episodes of polymorphic VT (Torsades), Pacemaker called overhead, CPR performed, and defibrillated back to NSR
        • Emergently transferred to MMC Interventional Cardiology extremely late at night ~0200
      • From Dr. Jeong: Convulsive syncope research link: Convulsive Syncope Induced by Ventricular Arrhythmia Masquerading as Epileptic Seizures: Case Report and Literature Review
      • Takeaway points:
        • Use objective findings (EKG, pmhx) vs subjective findings (chest pain description)
        • Worry about things that kill (MI more worrisome than new-onset seizure)
        • When in doubt (or conflicting statements from consultants), do the thing that will protect the patient
  • Dr Kindschuh + Geoff – M+M Case – Posterior Stroke (Admin block lecture)
    • *** EM:RAP – C3 – Approach to Dizziness ***
    • How to Not Miss Posterior Stroke — JournalFeed
    • 49M with headache, nausea, vomiting
    • FS 202, Istat K = 33, AG 22, LA 3.5
    • Meclizine, pepcid, valium, no response, CT head negative, MRI ordered, neuro consulted
    • PE: +horizontal nystagmus, +vomiting
    • Neuro consult: no tPA because time of onset unclear
    • MRI = cerebellar stroke
    • Discharged home 2 days later, modified Rankin = 0 
    • Problem? CT was done after 1 hour, should have been done immediately, delayed diagnosis
    • Gait testing is *super* important — best neuro test
    • HINTS exam
    • tPA within 3-4.5 hours of onset and absence of contraindications
    • Get a CT head non con but ALSO CTA head and neck for r/o LVO, MRI after if negative
    • MRI missed 10-20% of posterior strokes — consider tPA
  • 11a: Resident Meeting – Aug 2021

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