Wednesday Wrap Up – 3/22/17

Welcome to Wednesday Wrap Up! Here is a summary of what we learned in conference today:

 

Dr. Wiener on Pediatric Toxicology Pearls:

 

  • For a few toxins, one pill is potentially deadly in a child
  • Patients with ingestions of TCAs, camphor, and clonidine can often be discharged if asymptomatic (including normal ECG) in the ED.
  • Observe / Admit for: Atropine, MAO-I, opioid, calcium channel blocker, beta blocker, and sulfonurea exposure; these may have delayed onset of symptoms
  • Even for unintentional exposure of nontoxic substance, look for signs of abuse or neglect- especially if the child ≤ 6 months old
  • Mothballs can be distinguished by floatation in water
    • Camphor always floats
    • Paradichlorobenzene always sinks (and smells like a urinal cake)
    • Naphthalene sinks in fresh water and floats in salt water
  • Iron ingestions concerning if >15mg/kg ingested or serum level > 500mcg/dL (use deferoxamine)
  • Check a 48-hour coagulation panel after rat poison ingestion (super-warfarin)
  • Hydrocarbons cause aspiration pneumonitis (can be delayed 4-6 hours) and halogenated hydrocarbons can cause dysrhythmia

 

Dr. Moran on Abdominal Ultrasound

 

  • Use ultrasound as an extension of your physical exam (POCUS)
  • Sonographic small bowel obstruction – use curvilinear probe, lawnmower technique across abdomen
    • >2.5cm bowel loop
    • Decreased / absent peristalsis
    • Back/forth stool movement
    • Keyboard sign: finger-like projections that represent plicae circulares
    • Tanga sign (it’s a type of underwear?!)
  • Sonographic Appendicitis – use linear probe, or curvilinear in obese patients
    • Landmarks: Iliac crest (lateral), iliac artery (medial), psoas muscle (posterior)
    • Appendix > 6mm diameter (outer wall to outer wall)
    • Non-compressible tubular structure
    • “Ring of Fire”
    • No peristalsis
    • Edema and/or free fluid
  • Operator-dependent and high specificity but lower sensitivity (can rule in if positive but cannot rule out if negative)

 

Dr. Peralta on Task-Switching in the ED:

 

  • ED docs are distracted and interrupted A LOT
  • We are “task switchers” more than multi-taskers
  • Task switching takes more time, produces lower quality work, and increases workload (redundancy returning to initial task)
  • Short-term memory = Working memory is limited, unable to manage frequent, simultaneous, competing stimuli or information resulting in poorer performance
  • Develop effective task switching by recognizing risks, finding a role-model, debriefing, simulation, and graduated responsibility (i.e. junior role to senior role to pre-attending to attending)

 

Dr. Schnitzer on Critical Care - Thyroid Storm:

 

  • Always keep thyroid on your differential for tachycardic patients, especially in A-Fib
  • Treatment = Blockade
    • Beta blockade of symptoms
    • PTU or methimazole to block action thyroid hormone
    • Steroids to block conversion of hormone
    • Iodine (after an hour of other treatments) to block further thyroid production
  • “Hail Mary” treatments: plasmaphoresis, ECMO, or even surgery
  • Consider esmolol in the sick tachycardic patient for its rapid on/off effects
  • Consider cardioversion in the unstable a-fib patient for the extra atrial filling that may be needed

 

 

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Kylie Birnbaum

Emergency Medicine Resident at Kings County Hospital / SUNY Downstate

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