Grand Rounds Recap - 6/29/2016

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Professionalism with Dr. Erin McDonough

Professionalism is a belief system.

 

  1. Things your colleagues/CORD consider unprofessional
    1. Lateness
    2. Not being ready to accept sign out
    3. Finishing charts late
    4. “Dumping” on fellow residents at turn over
    5. Disrespecting fellow medical staff
    6. Showing up to work intoxicated, sleep-deprived, or impaired.
  2. Tenants of professionalism
    1. Respect for your patient
    2. Respectfulness around your patient
    3. Respecting other team members
    4. Maintaining confidentiality
    5. Maintaining integrity
    6. Doing what’s best for the patients and patient care at all times.
    7. Be the best emergency physician you can be (know your limits, know your knowledge base, be accepting of feedback)
  3. Social Media
    1. “Don’t post anything you wouldn’t want your boss, patient, or mother to see."
    2. Remember to respect patient privacy at all times.

Discharge, Treat, or Transfer with Dr. Brian Stettler

Part I: Management of the Red Eye in the Community ED

 

Case #1: 28 year old male who was poked in the eye while wrestling. Small periorbital ecchymosis, conjunctival erythema, reactive pupils, consensual photophobia, fluorescein negative. Normal IOP bilaterally.

  1. Diagnosis: Traumatic Iritis/Anterior Uveitis - erythema, consensual photophobia, eye pain
  2. Management: 
    1. Cycloplegics and steroids
    2. Fluorescein exam (be sure they do not have a corneal abrasion)
  3. Follow up: 24-72 hours
  4. Complications: Glaucoma, synechiae (15% had glaucoma at 5 years) 
  5. Dispo: Treat and Discharge

Case #2: 62 year old male with abrupt onset of non-relenting eye pain. Conjunctival erythema, cloudy cornea, edematous anterior chamber, pupil fixed and mid-position. IOP affected eye 47, unaffected eye 18.

  1. Diagnosis: Acute angle closure glaucoma - erythema, severe eye pain, elevated IOP
  2. Management: 
    1. Timolol, Dorzolamide, Prednisone (whatever medications you can get that will not delay transfer)
    2. Goal is to decrease aqueous production and edema
    3. Definitive management is iridotomy by ophthalmology.
  3. Complications: Permanent vision loss
  4. Dispo: Treat and Transfer

Case #3: 38 year old male who is working on his car, felt something go into his eye and kept working. Wakes up the next day with foreign body sensation, eye pain, and redness. Conjunctival erythema, reactive pupil, foreign body noted, fluorescein negative.

  1. Diagnosis: Metallic foreign body
  2. Management:
    1. Topical anesthesia (numb the eye)
    2. Use a needle (or specialized tool) under slit lamp guidance to flick out the foreign body (not the rust ring)
    3. Needs follow up for removal of the rust ring, can be done 24 hours after by ophthalmology or in the ED. (The rust ring will soften in the first 24 hours after the FB is removed and then can usually be easily wiped away.)
  3. +/- antibiotics (There’s no robust data for this however they now essentially have a corneal abrasion so antibiotics should be considered.)
  4. Complications: endophthalmitis, scarring, perforation
  5. Dispo: Treat and Discharge (with follow up in 24 hours)

Case #4: 59 year old female with PMH of DM, HTN, arthritis with intense pain in R eye x 2 days. Associated with photophobia, nausea, and vomiting. Diffuse deep erythema to globe, pupil reactive, minimal photophobia, fluorescein negative, IOP 22 affected eye, IOP 18 other eye. Normal fundoscopic exam. Visual acuity 20/50 bilaterally. Normal anterior chamber.

  1. Diagnosis: Scleritis (scleral erythema (very red), pain out of proportion to exam)
    1. Cool diagnostic technique: 2 percent epinephrine drops (episcleritis redness will resolve, scleritis redness will not)
    2. Differential includes glaucoma but IOPs normal in this condition
  2. Management:
    1. Oral NSAIDs - 93% respond to oral NSAIDS
    2. Seek the cause:
      1. episcleritis - typically isolated problem
      2. scleritis - usually due to secondary cause such as arthritis or infection
  3. Complications: visual loss, systemic disease
  4. Dispo: Treat and Discharge

Case #5: Middle aged male with eye pain with erythematous papular/vesicular lesions on scalp, hemiface, and nose. No history of immunosuppression. Thinks he may have bug bites.

  1. Diagnosis: Herpes Zoster Ophthalmicus
    1. zoster lesions on face and nose
    2. corneal fluorescein uptake
  2. Management: oral antivirals (valacyclovir is at least as effective as acyclovir and is dosed less frequently so may be better for compliance)
  3. Complications: visual loss
  4. Dispo:
    1. Treat and Discharge if immunocompetent (but with follow-up in about a week or so)
    2. If immunocompromised: transfer for admission

Dr. Stettler's Ophthalmologic Soapbox: Dilate the eye if you need to in order to examine the fundus.

  1. Make sure they don’t have an APD first.
  2. Check for narrow anterior chamber. If you see a shadow on the opposite side of the chamber when shining a light source from the side across the anterior chamber this means the anterior chamber is narrow and you should not dilate the eye. You can safely dilate people who do not have a narrow anterior chamber (no cast shadow).
  3. Do not dilate patient’s eyes who have been surgically manipulated.

Tenants of Management of Eye Complaints

  1. If you don’t know what it is, it should be seen soon.
  2. If visual acuity is compromised, it should be seen now.
  3. Be less afraid of topical steroids and chemical mydriatrics.

Part II: Management of OBGYN Emergencies in a Community ED

Case #1: 22 yo F with abdominal cramping x 2 days. 8-9 weeks pregnant. TVUS without clear IUP and serum HCG within the indiscriminate zone.

  1. Diagnosis: Possible Ectopic Pregancy
  2. Management:
    1. Are they hemodynamically stable? Yes
    2. Non-diagnostic TVUS and serum bHCG < discriminatory zone: send home, repeat quant in 48 hours and return precautions
  3. Disposition: Discharge and follow up in 48 hours

Case #2: 34 yo F with abdominal pain, no vaginal bleeding, and copious vaginal discharge. Normal vitals, TTP LLQ, voluntary guarding, + cervical motion tenderness and TOA visualized on ultrasound.

  1. Diagnosis: PID with TOA
  2. Management: IV antibiotics. > 70% are managed with antibiotics alone, CT guided drainage is a second option.
  3. Disposition: Admit (possibly transfer depending on capabilities of institution)

Case #3; 34 yo F, MVC, restrained passenger at unknown rate of speed. 15 week pregnant by 12 week US. Pelvic cramping, no leakage of fluid or vaginal bleeding. Slight seatbelt sign visualize, negative FAST, benign abdominal exam.

  1. Management: Take care of mom. If you have a strong suspicion that there’s a serious injury, get the CT scan.
  2. If she’s pre-viable (<20 weeks): manage as you would any patient
  3. If viable: ALL patients get transferred to an OB capable center for monitoring.