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Teaching Points for UF/Shands Jacksonville Emergency Medicine Residency

Teaching Points for UF/Shands Jacksonville Emergency Medicine Residency

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Teaching points Teaching points Presentation Transcript

  • Teaching Points Adrenal Crisis Angioedema
  • Adrenal Crisis Teaching Point
  • Adrenal InsufficiencyPrimary Adrenal Insufficiency Intrinsic adrenal dysfunction Low Cortisol and AldosteroneSecondary Adrenal Insufficiency Hypothalamic-pituitary dysfunction Low Cortisol, normal Aldosterone
  • Adrenal InsufficiencyCauses of Primary Infectious: HIV (MC in US), TB (MC worldwide) Autoimmune: along with DM, Thyroid, Hemorrhage, CAH, mets, sarcoidCauses of Secondary Withdrawal of long term steroids Head trauma, postpartum
  • Adrenal CrisisLife-threatening exacerbation of adrenalinsufficiency due to increased physiologic demand(e.g., infection) or decreased supply (e.g.,discontinuation of steroid therapy) of cortisol.Most common iatrogenic cause: rapid withdrawal ofsteroids in pts with adrenal atrophy secondary tolong-term steroid use
  • Adrenal CrisisHigh index of suspicion Unexplained hypotension in patients at risk HIV, chronic steroid, other autoimmune, physical signs (hyperpig), head traumaHypotension refractory to pressorsDehydration, weakness, delirium, acute pain/n/vPrimary: HypoNa, HyperKSecondary: HyperNa, HypoK
  • Adrenal CrisisTreatment IVF: D5-NSSteroids Hydrocortisone (100 mg) Dexamethasone (4 mg) for accurate stim testPressors Nor-epi, Dopamine, Phenylepherine
  • Done
  • Stent ThrombosisBare metal stents thrombosis usually in first 24-48 hours (80%) Uncommon after 1 month with DAT studies show 0.5-2.5% with ASA + Clop/Pras
  • Stent ThrombosisDrug Eluting Stents Most incidents occur within 30 days Study of 142 patients 33 who stopped DAT, mean time 7 days 15 who stopped clop without problem, then stopped ASA, mean time 7 days In all 48, 75% of cases occur within 10 days
  • Stent ThrombosisLong term overall risk up to one year is low for both as long as patients are continued on DAT
  • Stent ThrombosisMost cases of ST occur within the first 30 daysafter placement and rates similar for BMS and DESBMS: usually within first 24-48 hours or much lessoften within first month after placementEvents 30 days-1 year higher for BMSEvents after 1 year higher for DES
  • AppendicitisEarly: non specific, malaise, anorexia, indigestion Followed by periumbilical pain (visceral) Followed by nauseaMigration of pain --> RLQ McBurneys: 1/3 from ASIS to umbilicus Anatomic variation: flank, pelvis, LUQ Pregnant: may be RUQ
  • AppendicitisPelvic exam in females of child bearing ageIncreased WBC common with left shift No clear consensus on usefulnessUA: can show hematuria and pyuriaU/S: useful for preg and children Thickened, non-compressible > 6mm Limited by skill and anatomy
  • AppendicitisCT Sensitivity 96%, Specificity 96% Dilated appendix > 6mm with thick wall, fat stranding, and possible visualized stone Although IV/PO contrast often used, several studies show high sensitivity and specificity of unenhanced CT
  • AppendicitisAlvarado Score
  • Angioedema
  • AngioedemaBackground 15% of population 50% involve urticaria Common: periorbital, lips, tongue, ext, bowel Main cause of death: laryngeal edema
  • AngioedemaAllergic or IgE mediated Food or medicaitons Tx Antihistamine (Benadryl) H2 Blocker (Zantac) Glucocorticoid (Solu-medrol) Epinephrine (0.3 mg 1:1000 IM)
  • AngioedemaHereditary Angioedema C1q esterase inhibitor deficiency Causes: trauma (dental), anxiety, menstruation, infection, exercise, EtOH, stress Tx FFP (C1 inhibitor used in Europe/Canada) Epinephrine for airway edema
  • AngioedemaACE Inhibitor angioedema Up to 2.2% of pts taking ACE-i Elevated bradykinin Highest incidence during 1st month of use 5x more common in AA than caucasians Tx: epinephrine for airway edema, time (ETT) Usual IgE angioedema often given
  • AngioedemaMay still occur months after stopping ACE-iIn those with ACE-i angioedema, ARBs fairly safeFFP may also help with ACE-i angioedema Starting dose of 2 Units
  • Done
  • Cocaine Chest Pain
  • Cocaine Chest Pain