Case Conference Summary, August 16, 2017

Thanks to Dr. Daniel Francescon for putting together the following summary of Rapid Fire Case Conference, August 16th:

Dr. Schirm presents a case of a 47F with the common complaint of elbow pain. It has been worsening for the past three weeks and is exacerbated by movement, especially when lifting objects at her job. She denies any fevers or trauma to the area. Physical exam is significant for point tenderness over the lateral epicondyle with full range of motion. She is neurovascularly intact distally. Dr. Schrim forgoes an X-ray and diagnoses the patient with lateral epicondylitis (tennis elbow).

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Case Conference Summary, August 9, 2017

Case Conference Summary, August 9, 2017

This week in Rapid Fire Case Conference we had a number of great clinical cases and educational pearls.

Dr. Patrick Sylvester presented a case of an elderly gentleman who presented with complaints of fatigue. On arrival he was noted to be hypotensive and diaphoretic. Physical examination revealed JVD and muffled heart sounds. He astutely used bedside ultrasound and saw this:

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Cardiogenic Shock and Peri-Intubation Arrest – It Happens

By Zach Adams MD, OSUEM PGY2 // Edited by Michael Barrie MD, OSU EM Assistant Professor

A 65 year-old patient presents with a history of ischemic cardiomyopathy and multiple medical co-morbidities. Initial triage vital signs show a BP of 83/40 with a pulse of 120 and oxygen saturation of 92%.  He appears in extremis.

On initial evaluation, the patient is mentating well but complaining of shortness of breath. Heart sounds are distant and lungs are otherwise clear.  You note mottled peripheral extremities, which appear cyanotic and are cold to touch.  He tells you that he was recently hospitalized, but does not know what and whether or not he is still being treated.

While obtaining initial lab studies and getting the patient hooked up to the monitor, you perform a RUSH exam and note extremely poor systolic function of the left ventricle and the IVC is distended without respiratory variation.  You suspect this is cardiogenic shock.  What is cardiogenic shock?  What are your next steps in management?

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Tricyclic Toxicity – Key Points

By Dr. Zach Adams, OSU EM PGY1 // Edited by Dr. Michael Barrie, OSU EM Assistant Professor

Pertinent to the previous post – I was working a shift at East the other day with Dr. Southerland and, low and behold, a TCA overdose came rolling through the doors. The patient had taken an unknown quantity of amitriptyline an hour before arrival. The patient was solemn but easily aroused. Vital signs showed sinus tachycardia with declining systolic BPs in the low 100s. Activated charcoal 1 g/kg was administered via an NGT (as the patient refused to drink the activated charcoal). Poison control was called and even though the QRS duration was less than 100 ms, we gave 2 mg/kg of sodium bicarb for the following:

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Anticholinergic toxicity and physostigmine – what’s the data?

By Dr. Zach Adams, OSU EM PGY1 // Edited by Dr. Michael Barrie, OSU EM Assistant Professor

A 21 year-old male presents via EMS from a rock and roll festival to the ED with agitation, hyperthermia, and confusion. On exam the patient has large pupils, and skin is dry to the touch. Multiple staff members are trying to keep the patient restrained in the bed to start the medical workup, when the nurse ask you a “B-52” and leather restraints. After just listening to April’s EM:RAP Episode, you consider a diagnostic trial of physostigmine, but you also hear the voice of your local toxicologist in the back of your mind saying “giving physostigmine will cause seizures and death!” What should you do?

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