Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


LVADs & Tetanus

Adam Brunfeldt, MD

- involve the helper and the instructional trifold early! (both of these are always with the patient)
- Doppler BP is normally 70-80 mmHg, and pulses can be intermittent (normal)
- check clinical perfusion, coags, and alarms upon arrival... then switch power source (batteries or power module).
- prophylaxis dose is 250 units of tetanus immunoglobuin IM for dirty wounds, unvaccinated patient
- treatment dose is 6000 units (3000 if peds) IM, surgical consult for debridement, flagyl, and tons of valium.

Shock and AAwe

Angela Fusaro, MD

  • Presentation of neurogenic shock: disruption of descending sympathetic fibers causes unopposed vagal stimulation: bradycardia, hypotension, with vasodilated & warm extremities.
  • 50% of thoracic aortic aneurysms are ascending, and chest X-ray reveals an abnormality 80-90% of the time.

Neutropenic Fever & Sickle Cell

  • Defined with a temp of >38C and an ANC of <500.  Shotgun cultures and cover with broad-spectrum antibiotics + vancomycin.
  • Peak ages for acute chest syndrome are between 2-4 years of age.  Often not present on initial ED evaluation; develops days later in hospital.  Have a high suspicion for any fever in sicklers.

Hyperkalemia, Marine Envenomations, and SBO

  • In addition to the 1st line treatments of calcium, insulin-d10, bicarbonate and dialysis, effective treatment of hyperkalemia involves β2-agonists; 20mg albuterol nebulized over 10 minutes or terbutaline 0.5mg IV quickly drives potassium intracellularly.
  • Proper treatment of most marine envenomations, catfish being the most common, is hot water soaks for 30-90 minutes with good wound care and a quinolone or augmentin for 5 days.
  • CT abd/pelvis is only 92% sensitive for small bowel obstruction.  Keep an open mind if you have strong clinical suspicion.
    • Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. J Am Soc Nephrol. 1995;6(4):1134.
    • Allon M, Copkney C. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int. 1990;38(5):869.
    • Carrette TJ, Cullen M, et al. 2002. Temperature effects on box jellyfish venom, a possible treatment for envenomated patients? Med J Aust. 177: 654.
    • Glenister KM, Corke CF. Infarcted intestine: a diagnostic void. Journal of Surgery 2004. 74:260

Endocarditis and Compartment Syndrome

  • The sensitivity of 1 set of blood cultures is 65%, while 2 sets is >95%. Always get 2!
  • Staph and Strep are common causes of endocarditis - always cover with vancomycin empirically.
  • Compartment syndrome of the leg is most common with tibial fractures, and commonly involves the anterior compartment or the deep posterior compartment.
  • A key physical exam finding in the diagnosis of compartment syndrome is pain upon passive motion of the big toe.

Hyponatremia and SAH

  • 3% normal saline often corrects hyponatremia too quickly and may cause central pontine myelinolysis; reserve it for seizures, severe AMS, and coma.
  • Subarachnoid hemorrhage may still respond to compazine.  In the patient that refuses LP, consider CTA of the head to find small aneurysms.