Grand Rounds Recap 5.10.2017

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Oral Boards with Drs. Stettler and McDonough

Case 1:
Young male reports that he was out with his buddies drinking last night and comes in to the ED feeling palpitations and lightheadedness. Vitals are 70/30, HR 170, RR 40, 37 C, 88% O2 Sat on room air. He complains also of chest pain and shortness of breath.

PMH: GERD
PSH: Appendectomy
Meds: PPI for GERD
Social EtOH and Marijuana Use, + Tobacco use

Physical Exam: Tachycardia, clear lungs, otherwise normal

EKG shows Afib with RVR

Patient is electrically cardioverted using etomidate with return to NSR and improvement in vital signs.

How this case is scored:

  • Rapidly obtain EKG
  • Make appropriate pre-sedation assessment and verbalize
  • Must give a plan for safe sedation to facilitate cardioversion including assembly of proper airway equipment

Case 2: 
Middle aged female who presents with three days of progressive altered mental status and one day of nausea/vomiting. She is agitated and writhing around which her husband states began today. She has been using cocaine daily for the last several days. Her husband reports she has a history of a "gland problem" for which she used to take medication but she hasn't been able to afford it for months.

Vitals: HR 140, BP 185/95, Temp 38.9 C, 96% on RA

Exam reveals: exophthalmos, enlarged thyroid consistent with goiter, hot/flushed skin and dry mucous membranes, non-focal neurologic examination

Labs reveal T4 of 100, TSH < 0.01, otherwise unremarkable
EKG: A fib with RVR

Treatment: IV fluids 2L, treatment for Afib with RVR however Beta Blockers in the setting of recent cocaine use will cause the patient's BP to elevated significantly in this oral boards case so should be avoided, PTU/Methimazole

Takeaway: Remember that historical toxic substance use in an oral boards setting still applies in the management of the patient.

Triple Encounter

Patient 1:

39M with fatigue, epigastric pain/vomiting from Football game by EMS
87/52, P85, 96% on RA, 36.2C
PE: cold, clammy, diaphoretic, B/L pitting edema

Quickly decompensated into pulseless wide complex tachycardia:

  • 2 rounds ACLS protocol
  • Regains pulse: P 28, BP 70/30
  • Push dose epi, trans-cutaneous pacing: P 60, BP 80/30
  • Airway established, interventional cardiology c/s
  • Amio bolus gtt, Levophed gtt, Heparin gtt, ASA
  • To cath lab

Initial EKG: Wide complex tachycardia w/ Anterior ST elevation
Post ROSC EKG: Bradycardic, wide complex junctional

Patient 2:

R Hand pain after punching friend yesterday
PE: R hand dorsal swelling and ecchymosis, TTP over 4/5th MCP. Skin intact
XR R hand: Boxers fracture
Management:

  • Hematoma block, closed reduction, splint in ulnar gutter
  • Ortho follow up

Patient 3:

Generalized weakness x 1 week, worsening
Double vision at night

PMH: HTN/DM/CAD
Meds: ASA/Bblocker/Glyburide/HCTZ
Exam: 

  • mild tachycardia
  • b/l pitting edema, trace
  • b/l ptosis, normal EOM, proximal>distal muscle weakness, DTR (-)

CXR: unremarkable
EKG: Sinus Tach
Labs: Cr 1.9
CT head: negative

Management:

  • IcePack Test: complete resolution of ptosis
  • NIF/VC
  • Neurology Consult
  • Admit for further workup - Myasthenia Gravis

What We Talk About When We Talk About Global Health with Dr. Bryant

Global Health: a mix of clinical medicine, public health, international health

Official definitions have included: “The are of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants and solutions: it involves many disciplines and promotes inter-disciplinary collaboration, and is a synthesis of population based prevention and individual level care.”

Who are the players in this field?

  • WHO - World Health Organization 
  • UNICEF/UNFPA - United Nations International Children’s Education Fund/United Nations Population Fund
  • UNAIDS
  • World Bank

Public-Private Partnerships:

  • The Global Fund (To fight AIDS, TB, and Malaria)
  • UNITAID
  • Gavi - The Vaccine Alliance
  • Human Rights Watch

Private Organizations:

  • BMGF - Bill and Melinda Gates Foundation 
  • NGOs: Many.

Why does this matter to us as emergency physicians?

Your patients are travelers, immigrants, and can be nearly anywhere on earth in 24 hours

Some clinical pearls:

What weight for height Z score qualifies as severe, acute malnutrition?

  • -3 (represents standard deviation from the mean)

What CBC findings are characteristic of dengue fever?

  • Thrombocytopenia!

What is the antibiotic of choice if you acquire typhoid while traveling in Asia?

  • Ceftriaxone

R2 Case Follow-up with Dr. Brittney Bernardoni

71 yo M w/ PMH HTN, CAD s/p stunting x 2, Diabetes presenting with hyperglycemia. For the past few days he has only been taking his HTN medication because he doesn't like how the other medicines make him feel. Has not taken insulin for the past three days. He has not taken his anti platelet agents.

Labs: pH 6.9, BMP remarkable for potassium 7, elevated glucose, Na 117 with anion gap, Creatinine 4.0 (new)
EKG shows hyper acute T waves

Hyperkalemia:

  • Cardiac instability is related to absolute value of the potassium and also the rate of rise
  • Always treat a potassium greater than 6.5
  • There are not always EKG changes before arrhythmia develop

Take home points: