Teaching points

389 views

Published on

Teaching Points for UF/Shands Jacksonville Emergency Medicine Residency

Published in: Education
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
389
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
5
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • Teaching points

    1. 1. Teaching Points Adrenal Crisis Angioedema
    2. 2. Adrenal Crisis Teaching Point
    3. 3. Adrenal InsufficiencyPrimary Adrenal Insufficiency Intrinsic adrenal dysfunction Low Cortisol and AldosteroneSecondary Adrenal Insufficiency Hypothalamic-pituitary dysfunction Low Cortisol, normal Aldosterone
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. Adrenal CrisisTreatment IVF: D5-NSSteroids Hydrocortisone (100 mg) Dexamethasone (4 mg) for accurate stim testPressors Nor-epi, Dopamine, Phenylepherine
    8. 8. Done
    9. 9. 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
    10. 10. 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
    11. 11. Stent ThrombosisLong term overall risk up to one year is low for both as long as patients are continued on DAT
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. AppendicitisAlvarado Score
    17. 17. Angioedema
    18. 18. AngioedemaBackground 15% of population 50% involve urticaria Common: periorbital, lips, tongue, ext, bowel Main cause of death: laryngeal edema
    19. 19. AngioedemaAllergic or IgE mediated Food or medicaitons Tx Antihistamine (Benadryl) H2 Blocker (Zantac) Glucocorticoid (Solu-medrol) Epinephrine (0.3 mg 1:1000 IM)
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. Done
    24. 24. Cocaine Chest Pain
    25. 25. Cocaine Chest Pain

    ×