Conference Summary 8/25/21

by Ivan Ivanov, DO Conference Summaries

Dr. Kindschuh news and updates:

  • Dr. Gladstein gave tPA for a stroke in 24 minutes yesterday!
    • Coney goal is <30 minutes
  • Please clean your equipment (glidescopes, ultrasound, etc)
  • 7a: Chirag / Denise – resident lectures (please send your topics to me soon – 20min max)
  • 745a: Dan (rotating intern) – Syncope ED Pearls
  • 8a: Dr Misch – Managing Unstable GI bleeds (non-administrative)
  • 9a: Dr Viguri – Understanding Opioids
  • 10a: Dr Patel – EKGs
  • 11a: Dr Seeram – DKA/HHS — (not today)
  • Pancreatitis – Chirag
    • Pancreatitis dx, need ⅔
      • 1) Epigastric tenderness
      • 2) Lipase >3x normal
      • 3) CT evidence
    • Get triglyceride level
      • Hypertriglyceridimic pancreatitis is treated with IV insulin (M-ICU admission)
    • CT to look for complications, pseudocyst, necrotizing pancreatitis
    • Get RUQ US
      • Rule out gallstone pancreatitis
    • Ranson criteria 
      • Mortality of panc on initial vs 48hr lab values
    • BISAP: more specific than Ranson and APACHE II
    • Treatment:
      • LR > NS to prevent SIRS within first 24hrs
      • Pain control: opioids but avoid if possible as per APA
      • PO intake as tolerated
    • Causes of acute pancreatitis: I GET SMASHED


  • Valvular Disorders – resident lecture – Faseeh
    • treated with diltiazem
      • EKG with afib rate 140s, given Cardizem → new ekg shows NSR rate 75 (notched p-waves)
    • LAE can cause compression of esophagus, causing cough/hoarseness
    • CXR: showing enlarged LAE — loss of aortic knob:
    • LAE on POCUS (parasternal long and apical 4 chamber view)
    • Treatment in MR/MS in this pt
      • Treat underlying rhythm
      • If fluid overload: can use Dobutamine to increase inotropy; do not decrease preload
    • Internet Book of critical care
    • Think MI for MR or dissection for AR
    • Acute symptomatic valve regurgitation requires EMERGENCY SURGICAL REPAIR OR REPLACEMENT
      • Acute MR pts may benefit from an intra-aortic balloon pump if surgery is not immediately available
    • Crashing afib patient, Dr. Rizzo:
  • Dan (rotating intern) – Syncope ED Pearls
  • Dr Viguri – Understanding Opioids “What you should know when prescribing and available alternative”
    • MME = morphine milligram equivalents
    • ED Prescribing laws for opioids in NY
      • 7 day prescribing limit 
    • NJ law: must prescribe naloxone if prescribing >90 MME, or if opioid + benzo simultaneously
      • MME/day = dosage x doses per day x MME conversion factor
    • Dosages >50 MME/day x2 risk for OD
    • Alternatives:
      • NSAID, tylenol (975mg pain dose), topical (lidocaine, diclofenac), gabapentin, muscle relaxants, droperidol, ketamine (can cause increased myocardial demand: tachycardia +HTN)
      • Trigger point injections
      • PT, OMT, acupuncture, low dose antidepressants, CBT, pain management referral 
    • Migraine treatment
      • 1) Toradol, tylenol, reglan/zofran/compazine, IVF
      • 2) Mag, haldol, sumatriptan, ketamine
      • Droperidol > compazine
    • ED headache algorithm: ED Management of Headache Algorithm
    • Hyperemesis cannabinoid: 
      • (0.075%) Capsaicin can relieve discomfort (case studies)
  • 1100a: Dr Patel – EKGs
    • 69M hx of MG, hypothyroid, bipolar (on lithium) with generalized weakness, hypotension 60/40, brady 40s on arrival
    • EKG
      • 1st ECG: 1st degree AV block, bradycardia, RBBB, Q wave in III and aVF, hyperacute T wave aVF
    • CXR no PTx
    • Labs Cr. 2.9, Trop 0.9
      • 2nd ECG: Anterior ST depressions (concern for posterior MI), 2nd degree type 1 mobitz block: Wenckebach (No acute treatment for this block)
    • Becomes agitated, given 1 ativan → patient codes → ROSC
      • 3rd EKG: 3rd degree AV block, complete dissociation of p-waves and QRS complexes
    • V2-v4 depression, next step?
      • Get POSTERIOR EKG, may be POSTERIOR MI
    • DeWinters = STEMI equivalent
      • STD with hyperacute T-wave
      • 4th ECG: accelerated idioventricular 
    • Evolution of a STEMI:
    • Lithium toxicity
      • Processed renal, AKI → lithium toxicity
      • Lithium toxicity = indication for STAT DIALYSIS
    • Myasthenia crisis
      • Severe weakness? Intubate and MICU
      • Mild? Pyridostigmine
      • Steroids make it worse, useless in acute setting; take weeks for to take effect
      • Plasmapheresis: we can’t do at Coney, someone has to come in to do it from the city; we use IVIG
  • 1130a: Dr Patel – Clinical EKGs
    • A fib RVR 160s (hypertensive)
      • Tx: 
        • Cardizem (1st dose: 0.25mg/kg, 2nd dose 0.35mg/kg + chase with PO)  
        • Metoprolol 
        • High-dose Magnesium (4g)
        • Digoxin
        • Amiodarone
        • Procainamide
        • Shock
      • Metoprolol and cardizem:  AV node blockers
        • (Case reports of using BOTH cardizem and metoprolol can →  complete AV block)
    • A fib RVR 160s (relative hypotension 90/60)
      • Still treat with cardizem→ heart may need to slow down to return blood flow to heart and increase bp
    • A fib RVR 160s (severe hypotension 70/30)
      • Dig, amio, push dose epi, fluids, shock
    • Rate related stuff (Dr. Rizzo)
    • Atrial flutter
      • Usual rate: 300-150-100
    • SVT
      • Can use cardizem/metoprolol especially if you aren’t sure if SVT vs Aflutter.
      • Adenosine
      • Vagal maneuvers
    • Pericarditis vs STEMI (Amal Mattu)
    • T-wave inversions ddx
      • Ischemia
      • Brain bleed
      • PE (anterior-inferior)
      • HOCM w strain
      • LVH w strain
  • 11a: Dr Seeram – DKA/HHS
    • Moved to other date

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