While missing aortic dissection was considered "the standard" in the late 20th century, our understanding of the clinical diagnoses has improved considerably since the landmark International Registry of Aortic Dissection (IRAD) study in 2000. Nonetheless, aortic dissection remains difficult to diagnosis with 1 in 6 being missed at the initial ED visit. With the help of Dr. David Carr we’ll discuss how to pick up atypical presentations of aortic dissection without over-imaging as well as manage them like pros by reviewing: 1. The 5 Pain Pearls, 2. The concepts of CP +1 and 1+ CP, 3. Physical exam pearls, 4. CXR pearls and blood test pitfalls, and 5. The importance of the correct order and aggressive use of IV medications. So with these objectives in mind…
Anaphylaxis is the quintessential medical emergency. We own this one. While the vast majority of anaphylaxis is relatively benign, about 1% of these patients die from anaphylactic shock. And usually they die quickly. Observational data show that people who die from anaphylaxis and anaphylactic shock do so within about 5-30mins of onset, and in up to 40% there’s no identifiable trigger. The sad thing is that many of these deaths are because of two simple reasons: 1. The anaphylaxis was misdiagnosed and 2. Treatment of anaphylaxis and anaphylactic shock was inappropriate. So there’s still lots of room for improvement when it comes to anaphylaxis and anaphylactic shock management. With the help of Dr. David Carr of Carr's Cases fame, we’ll discuss how to pick up atypical presentations of anaphylaxis, how to manage the challenging situation of epinephrine-resistant anaphylactic shock, whether or not we should abandon steroids, a rare but ‘must know’ diagnosis related to anaphylaxis, and much more. Plus, we have a special guest apperance by George Kovacs, airway guru, to walk us through an approach to the impending airway obstruction we might face in anaphylaxis.
In this Part 2 of EM Cases' Highlights from Whistler's Update in EM Conference 2015 Dr. David Carr gives you his top 5 pearls and pitfalls on ED antibiotic use including when patients with sinusitis really require antibiotics, when oral antibiotics can replace IV antibiotics, how we should be dosing Vancomycin in the ED, the newest antibiotic regimens for gonorrhea and the mortality benefit associated with antibiotic use in patients with upper GI bleeds. Dr. Chris Hicks gives you his take on immediate PCI in post-cardiac arrest patients with a presumed cardiac cause and The Modified HEART Score to safely discharge patients with low risk chest pain.
In a previous Best Case Ever, 'Thinking Outside the Abdominal Box', Dr. Brian Steinhart reviewed some important can't-miss-diagnoses that can present elusively with abdominal pain. In this Carr's Cases Series on Inferior MI Presenting with Abdominal Pain, we continue in the theme of 'Thinking Outside the Abdominal Box' with David Carr explaining how he figured out that a man presenting with classic biliary colic was diagnosed with an inferior MI with right ventricular extension.
David Carr discusses his top 10 pearls on endocarditis and blood culture interpretation in this Carr's Cases Best Case Ever on EM Cases - Endocarditis and Blood Culture Interpretation. [wpfilebase tag=file id=560 tpl=emc-play /] [wpfilebase tag=file id=561 tpl=emc-mp3 /]
Dr. David Carr presents his third of EM Cases' Carr's Cases. This series features potentially debilitating diagnoses that may be thought of as 'zebras', but actually have a higher incidence then we might think - and if diagnosed early, can significantly effect patient outcomes. Dr. Carr tells the story of young woman with an MRSA supra pateller abscess who was put on trimethoprim sulfamethoxazole and presents looking very ill with a severe headache. Not only has trimethoprim sulfamethoxazole been implicated in aseptic meningitis, but NSAIDS, immunomodulators and antibiotics have also been implicated. The reason this is so important for ED practitioners to know, is that case reports of drug-induced aseptic meningitis have shown that symptoms will resolve completely within 24 hours, once the offending drug has been stopped. Not only that, but if the patient receives the drug again in the future, they are at risk for a more severe case of drug induced aseptic meningitis.
Dr. David Carr presents his second of Carr's Cases. This series features some potentially life-threatening diagnoses that may be perceived as zebras, but actually have a higher incidence then we might think - and if diagnosed early, can significantly effect patient outcomes. This Best Case Ever is about Anti-NMDA Receptor Encephalitis, a diagnosis that was only discovered in 2005, and has only recently been recognized by the Emergency Medicine community. Anti-NMDA Receptor Encephalitis may mimic a first presentation of schizophrenia or Neuraleptic Malignant Syndrome. It may present with seizure, altered mental status, autonomic instability or movement disorder in the absence of drug exposure. When you are faced with any of these presentations and no other diagnosis seems to fit, do an LP and send the CSF for anti-NMDA receptor antibodies. The time-sensitive treatment is IVIG and steroids. Anti-NMDA receptor Encephalitis is a must know diagnosis for all emergency medicine practitioners. Learn how to pick up this important diagnosis by listening to Dr. Carr's Best Case Ever and following the links to further resources.
In this episode on Whistler's Update in Emergency Medicine Conference 2014 Highlights we have... Chapter 1 with David Carr on his approach to Shock, including the RUSH protocol, followed by a discussion on Thrombolysis for Submassive Pulmonary Embolism.... Then in Chapter 2 Lisa Thurgur presents a series of Toxicology Cases packed with pearls, pitfalls and surprises and reviews the use of Lipid Emulsion Therapy in toxicology....Finally in Chapter 3 Joel Yaphe reviews the most important articles from 2013 including the Targeted Temperature Managment post-arrest paper, the use of Tranexamic Acid for epistaxis, return to play concussion guidelines and clinical decision rules for subarachnoid hemorrhage. Another Whistler's Update in Emergency Medicine Conference to remember.......
In the first of our series on Best Case Ever of 'Carr's Cases' we have, the legend himself, Dr. David Carr. This series will run on the theme of interesting diagnoses that we don't think of too often, but that are not as rare as we might think and can make a significant difference to your patient's outcome if you pick up on them early - and maybe even make you look as smart as David! Dr. Carr will be highlighted in our upcoming episode on Whistler's Update in EM Conference highlights 2014 when he will be speaking about his approach to the shocky patient as well as the controversial management of submassive pulmonary embolism. He will be featured along with Dr. Lisa Thurgur speaking about lipid emulsion therapy and other toxicologic goodies and Joel Yaphe will give us his take on the best of the EM literature from 2013 including the TTM trial, tranexamic acid for epistaxis, return to sport after concussion guidelines and more. Please go to the 'Next Time on EM Cases' page to submit your question about these topics.
Dr. David Carr, the past author of Tintinalli's chapter on occlusive arterial disease, tells us his Best Case Ever related to Aortic Dissection. In the related Episode 28: Aortic Dissection, Acute Limb Ischemia & Compartment Syndrome, we discuss the breadth of presentations and key diagnostic clues of Aortic Dissection. We review the value of ECG, CXR, biomarkers and the use of Transesophageal Echo and CTA in this sometime elusive diagnosis. We debate lots of clinical pearls and pitfalls when it comes to acute limb ischemia, and end with a discussion on the trials and tribulations of Compartment Syndrome. [wpfilebase tag=file id=398 tpl=emc-play /] [wpfilebase tag=file id=399 tpl=emc-mp3 /]