Annals of B-Pod: An Ocular Emergency

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Annals of B-Pod: An Ocular Emergency

A Case of Retrobulbar Hematoma

The patient is a female in her 60s who presents by EMS after a fall in a parking lot approximately one hour prior to arrival.  She fell forward and landed on her face.  She believes she simply tripped and fell, but she did lose consciousness and does not know how she ended up on the ground.  Per family, she is unsteady on her feet and falls frequently, requiring a cane at baseline.  She reports feeling “weak” but no other symptoms preceding her fall.  She presents with significant right-sided facial trauma and is unable to open her right eye. She has no complaints of blurry vision in her left eye.  She has no headache or other areas of pain or trauma.

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Dazed and Confused: The Approach to Altered Mental Status in the ED

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Dazed and Confused: The Approach to Altered Mental Status in the ED

We will all have the experience of taking care of a patient in the emergency department who is acting…different than they normally do.  Sometimes, the change can be subtle, maybe a family member will be the first to notice and bring the patient to be evaluated.  Sometimes the patient makes the change abundantly clear.  In either case it is essential to identify the underlying cause and treat any emergent conditions precipitating this dysfunction of the brain.  This month we hear from Dr. Erin McDonough on her approach to the patient with altered mental status (AMS). 

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Grand Rounds Recap 12/9/15

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Grand Rounds Recap 12/9/15

Glucose Emergencies

Remember the "I's" when looking for cause of DKA/HHS: Infection, Insulin lack, Infarction (MI, CVA, Ischemic gut), Indiscretion (EtOH, cocaine), Infant (pregnancy).

After 2L NS fluid bolus in the hemodynamically stable patient, the corrected sodium should guide fluid choice for further therapy.

Venous pH, HCO3 and base excess have sufficient agreement to be interchangeable with ABG in the ED.

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You've Been Blocked!

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You've Been Blocked!

Case 1

CC:  Laceration to Upper Lip

HPI:  23 year old male presents to the ED with laceration to his upper lip.  Patient states he was “Minding his own business” when all of the sudden the ground came up and hit him in the face.   His friend alcohol might have been there.  Patient states he now has a cut on his lip and a bruise on his pride.

Physical Exam:  Physical exam demonstrates a 2 centimeter full thickness laceration of the left upper lip that crosses the vermillion border.

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Grand Rounds Recap 12/2/15

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Grand Rounds Recap 12/2/15

Air Care Ground Rounds

Dr. Hinckley - Air Medical Resource Management

Familiarity and complacency can lead to mistakes. Stay uncomfortable. A policy for preflight walk-a-rounds will be released shortly. 

E-poc blood gas analyzer is now on AirCare. Think about using it for all patients, but particularly those who are intubated or may be in a state of shock.

Dr. Powell - Minnesota Tube is coming to AirCare

Everything you need will be in the Critical Care bag. You can bring all the gear with you into the hospital without having to gather supplies there. No football helmet required.

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CSF Evaluation in Subarachnoid Hemorrhage

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CSF Evaluation in Subarachnoid Hemorrhage

So, what constitutes a “positive” tap when evaluating for subarachnoid hemorrhage?

Traditional teaching is that a positive tap is Xanthochromia or blood in the CSF

What exactly is Xanthochromia?

The word xanthochromia is simply Greek for “yellow color.”  It refers to the yellow color that CSF can take in certain situations.  Some of these situations are listed below:

  • Elevated CSF protein            
  • Jaundice
  • Hypervitaminosis A
  • Rifampin Therapy
  • Elevated Bilirubin
  • Oxyhemoglobin

What we are especially interested in when evaluating for subarachnoid hemorrhage is bilirubin and oxyhemoglobin.

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Grand Rounds Recap - 11/18

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Grand Rounds Recap - 11/18

This week we recap the latest IOM recommendations on cardiac arrest management, evidence-based update on anaphylaxis management, management of the morbidly obese code and discuss the ins and outs of immunosuppressive agents.

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"Sepsis Under Fire" - Recap

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"Sepsis Under Fire" - Recap

This the recap of the 2nd of our 2 "Sepsis Smackdown" cases.  Several weeks back, we presented to you the case of Lucy, a 79 yo female resident of a nursing facility presenting to your busy community ED with reported altered mental status.  She's unable to provide you with a meaningful history but you piece together she's been acting abnormally at the nursing facility over the course of the past several days at the nursing facility and is now febrile, tachycardic, and hypotensive.  In your testing, you find her to have a UTI, begin her resuscitation and admit her to the hospitalist and MICU.  While waiting for a bed, she continues to be poorly responsive to your resuscitation...

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"Fighting the Bugs" - Recap

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"Fighting the Bugs" - Recap

Below you will find the recap of the 1st case in our Sepsis Smackdown case series.  Several weeks ago, we posed a clinical scenario followed by a series of questions.  As a refresher the case was that of Linda, a 79 yo female resident of a local nursing facility who arrives to your busy community ED with altered mental status, hypothermia, tachycardia, hypotension, and along history of multiple complicated UTI's. You begin your work up and find her to again have a likely UTI with a urine dipstick with large leukocyte esterase, pH 5.5, 20 protein, negative nitrite.

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Feeling "Dizzy"

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Feeling "Dizzy"

This month we have the pleasure of discussing the chief complaint of “dizziness” with Dr. William Knight.  In the attached podcast much of our discussion regarding this symptom focuses on stroke as a cause of this complaint.  Even so, it is important to remember that not all patients who present to the emergency department with dizziness are experiencing a stroke.  Quite the opposite; the majority of patients seeking care for feeling “dizzy” or “lightheaded” or “imbalanced” will have a cause other than restriction of blood flow to, or bleeding into, the posterior fossa. 

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Grand Rounds Recap 11/4

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Grand Rounds Recap 11/4

A Walk Down the Difficult Airway with Dr. Carleton

Case 1: Morbidly obese young female presents after overdose - tachycardic and unresponsive to sternal rub but maintaining saturations at 92% on a non-rebreather.

Difficulties in the morbidly obese and implications for airway management...

Use your rules for airway assessment

  • 2 fingers of mouth opening - remainder of 3-3-2 cannot be determined due to habitus
  • both MOANs for BVM and RODS for EGD predict difficulty with ventilation due to the restrictive physiology of her habitus
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Respiratory Monitoring - An Introduction to Pulse Ox and Capnography

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Respiratory Monitoring - An Introduction to Pulse Ox and Capnography

First a bit of physics....

Both pulse oximetry and capnometry rely on the Beer-Lambert Law. 

  • In 1760, Johann Heinreich Lambert proved that the absorbance of light through a material is proportional to the thickness of the material.  
  • In 1852, August Beer proved that the absorbance of light through a material is proportional to the concentration of the attenuating substance in the material.
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Grand Rounds Recap 10/21

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Grand Rounds Recap 10/21

Morbidity and Mortality Conference with Dr. Curry

Acute Coronary Syndrome in Pregnancy

Epidemiology

  • Incidence reported at about 6/100,000 deliveries
  • Maternal mortality is between 5-9%
  • 75% are STEMI
  • 2/3rds are anterior wall MI (LAD or LM as the culprit vessel)

Risk Factors

Many of these are typical ACS risk factors but are less prevalent in the pregnant population

  • Older age (>35 years old for pregnancy is considered older age....yikes)
  • Hypertension
  • Diabetes
  • Obesity
  • Smoking
  • Dyslipidemia
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Global Health Case Files #2

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Global Health Case Files #2

Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.

Case #5

32 yo M PMH HIV p/w LLE >RLE swelling & pain x 1 year.  Recent HIV+ and recently started ARVs.  CD4=40.  Pt denies trauma.  No history of DM or CHF.  No fevers, chills, N/V, abd pain, diarrhea.

PE:  37CHR-86BP-124/82RR-12

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