Conference Summary 10/13/21

by Dimitri Livshits, DO Conference Summaries

Residency/Department Updates

  • Next week’s 10/20 conference will be over Zoom
  • 10/27 conference will be a reverse conference day
    • Princess shift 7am-1pm
    • Conference will be in person around the Coney Island board, full schedule will be e-emailed soon.
  • 7a: Dr Jeong / Dr Rizzo / Peds EM faculty: CCA GI Bleed
  • 830a: Peds EM faculty: CCA GI Bleed
  • 930a: Resident Lectures: Ivan / Jessica
  • 1030a: Faseeh – EKG/CCU #3 / Jessica – Toxicology Lecture (or Ultrasound)
  • 1130a: Kaiser Permanente Physician – Job Searches and CV writing w/ Q+A (There will be food)

Resources for GI Bleed ‘Core Clinical Application’ discussion:

EMRAP C3

EMCases

EMCrit

Dr Jeong / Dr Rizzo / Peds EM faculty: CCA GI Bleed

Peds EM faculty: CCA GI Bleed

  • 15% of circulating blood volume may be lost prior to changes in vital signs

Upper GI Bleed

  • Case 1—NOT SICK
    • ROS: rash, weight loss, FTT, wet diapers
    • Meds: ASA, phenytoin, phenobarb, abx, iron
    • Trauma
    • BH: Location of birth, cephalohematoma, etc.
  • Case 2–-SICK
  • Neonatal Upper GI Bleed
    • Swallowed maternal blood
      • Allow feeding in the ED
      • Apt test: put blood in alkaline solution, neonatal blood will remain bright red (mom’s goes brown – denature)
      • Hx of painful nursing
    • Gastritis / Peptic Ulcer
      • Prolonged hospital / NICU stay
    • Vitamin K deficiency
      • Parents refused or home delivery
  • Infancy Upper GI Bleed
    • Gastritis
    • Mallory-Weiss tears
  • School age/adolescence upper GI
    • Epistaxis
    • Esophageal/gastric varices (2/2 portal vein thrombosis 2/2 umbilical catheterization)
    • Mallory weiss
    • PUD
    • Foreign body
    • Caustic ingestion

Lower GI Bleed

  • Case 3–-SICK
    • Imaging: abdominal x-ray
      • Pneumatosis  intestinalis–air and gas in bowel wall
  • Case 4–Not sick–passed polyp
  • Neonatal Lower GI Bleed
    • Necrotizing enterocolitis (NEC)
      • Premature (Birth complications eg maternal cocaine use, IUGR, heart complications etc), feeding intolerance, abdominal distension
    • Hirschsprung
      • Delayed passage of meconium
      • Consider partial Hirschcprungs
      • Hirschsprung enterocolitis3 (kinda like toxic megacolon) – can be fatal, can happen years after repair
  • Infancy Lower GI Bleed
    • Anal fissure–MOST COMMON CAUSE of lower gi bleeding in first 2 years of age (rosh question)
      • Can cause chronic fissures (skin tags, chronic constipation, GI f/u)
      • Bloody, not mucoid
    • Polyps
      • Painless rectal bleeding
      • Juvenile polyps, > 5 through GI, 10-15% malignancy chance, f/u w/ GI
    • Intussusception
      • Telescoping of intestine
      • Sausage mass in RUQ/”Currant Jelly” stools (late finding), both actually in <15% of patients
      • Tx: Air enema
    • Meckel’s diverticulum
      • Remnant of vitelline duct
      • Gastric mucosa or pancreatic tissue
      • 2% of population, usually 2 types of tissues, 2 inches from ileocecal junction, 2 year olds
    • Colitis
      • Infectious, cows milk protein allergy, FPIES (food protein-induced enterocolitis-SEVERE)
      • Hypovolemic shock + colitis = FPIES
  • School age/adolescent LOWER GI Bleed
    • Polyps
    • IBD
    • HUS
    • HSP
    • Angiodysplasia – rare, usually small bowel, massive hemorrhage
    • Vascular lesions
  • MANAGEMENT
    • Guaiac?
      • Lots of false positive/negatives, not sensitive/specific
    • NG lavage
    • Imaging
    • Antibiotics?
      • Salmonella? 
        • If <3months of age TREAT; or if septic, or if systematic (joints) –give rocephin (except if first month right due to kernicterus?)
  • Blood or not blood game – Very hard to know the difference
  • Take home points:
    • Is it really blood?
    • Causes: upper lower, age, severity
    • Management varies, stabilize first
  • Differential diagnosis by age summarized
  • Normal vitals by age

Ivan – Resident Lecture—Cyanide/CO poisoning

  • Cyanide
    • Rapidly increase lactic acid 
    • Can → early parkinson’s (damage to basal ganglia)
    • Sources:
      • NaCN (gold mining) 
      • KCN (jewelry cleaner/buffer)
      • CACN
      • Cyanogens include cyanide glycosides (food or “natural) e.g amygdalin
  • Tangent 1: How much nitroprusside to kill your patient?
    • 10-15mcg/kg/min for >1 hour
    • Half life 11 minutes
    • 0.3 mic/minute -starting rate
  • Symptoms 
    • TRIAD: AMS, Hypotension, Elevated lactate (BOARDS Q!)
    • Non-reactive mydriasis
    • Smell = bitter almonds (BOARDS Q!)
  • Diagnostics–
    • PULL LABS PRIOR TO GIVING CYANOKIT
    • Cyanide level (takes too long, just treat)
    • Lactate
    • Carboxyhemoglobin
    • ABG vs VBG (<10% difference, may be a myth?)
    • Pulse ox 
      • CO false readings
      • Cyanohemoglobin is another one of those “myths”  ~~ usually normal pulse ox read
  • Treatment
    • ABC, Airway, O2
    • Cyanokit (Hydroxycobaline)
      • May turn urine bright red
      • Case report of interfering with hemodialysis
    • Lilly kit (CAK)
      • Amyl nitrite (poppers), sodium nitrite, sodium thiosulfate
  • Side effects: 
    • Methemoglobinemia
  • Tangent two:
    • Hydrogen sulfide
    • ‘Ten dead people in a sewer’ = HS 
  • Carbon monoxide 
    • Metabolic acidosis
    • CO level is important for consideration for hyperbaric treatment
    • Hyperbarics:
      • Pregnancy with CO hemoglobin level >15%
        • Fetal Hb tends to bind more CO
      • Blood level >25%

Jessica – Resident Lecture – Case Presentation 

  • Sign out from previous team: 34F with RUQ TTP, pending labs and US
    • From Pakistan, in US for 10 years
    • PMH eye problem with discharge, hearing loss
    • Sx: back, hip, leg pain, generalized weakness; 2w n/v/d; 6 months purulent eye drainage
    • LMP 1 month ago
    • Incontinent of urine–was too weak to get up on exam.
    • Increase in eye discharge on re-examination
    • So what’s going on??
      • Hearing loss, eye problem (6months), 2 weeks n/v/d, weakness
      • DDx includes Guillain-Barre Syndrome
      • CRP elevated
      • Dx: Wegener’s (Granulmatossi with Polyangiitis)
      • Symptoms: respiratory, kidney, lung
        • Strokes, reduced vision/hearing, small vessel occlusions everywhere/hemorrhage-alveolar hemorrhage
      • Tx: IV steroids

Jessica – Ultrasound

  • Core Ultrasound 
  • Parasternal long view
  • Parasternal short
  • Apical 4 chamber
  • Subxiphoid view
  • Ultrasound case reviewed
  • EPSS (to estimate EF)
  • Pericardial effusion
  • Pulmonary embolism
    • D-sign 
    • Right heart strain / RV dilation
    • Thrombi visualization
    • McConnell sign
      • Regional RV wall motion abnormalities
  • Lung exam
    • 3+ B-lines, LR 12 for CHF
  • Case 1 – cardiac effusion
  • Case 2 – pneumonia w/ B-lines
  • Case 3 – CCB ingestion → poor contractility + ventricle dilation = cardiogenic shock
    • Tx: charcoal, insulin, pressorsb

Faseeh – EKG/CCU #3

  • Postponed to next week

Kaiser Permanente Physician Southern California (SCPMG) – Job Searches and CV writing w/ Q+A

  • Kaiser located: California, Virginia, DC, Washington state
  • Physician started and run 
  • SCPMG (for profit entity):
    • Insurer + hospitals + medical group
    • Pre-authorization is not needed for visits
  • SCPMG partnership tract
    • Eligible after 3 years of full-time employment 
  • Benefits:
    • Lots of specifics, please see website
    • Relocation up to $10,000 to Southern California
    • Retirement plan: Retire at 30years of service get 50% of your salary back per year (other year options as well)
  • San Diego EM market–very hard to get into
  • Things to put on CV:

  • Questions: 
    • Fellowships: Ultrasound
    • Does emergency medicine have “office hours/time” like other specialties in kaiser? 
      • Four hours/week to finish charts
    • How easy is it to relocate within the group? 
      • Moving from southern california to washington –VERY DOABLE
      • San Francisco to Los Angeles — VERY DOABLE
      • Bakersfield to San Diego — NOT DOABLE
    • What does full time mean in Kaiser?
      • Each franchise runs differently: 
        • San Diego shifts: 8h, 10h, 12h
        • Full time: 1650 hours/year (national average 1640/year)
    • How do new grads get treated in the ED first six months?
      • Get extra help with note writing, don’t get paired with students/residents.
      • Never on shift alone right away. 
  • CV how to stand out: write a cover letter
  • Contacts:

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