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  • Emergencies in Hemodialysis Patients

    ABSTRACT

    Audience:

    This classic team-based learning (cTBL) session is appropriate for medical students or emergency medicine residents.

    Introduction:

    Over 380,000 patients have renal failure in the United States and 90% of these patients are managed on hemodialysis. Hemodialysis patients have high rates of morbidity and mortality. Understanding the management of emergencies unique to these patients is essential for any emergency physician..

    Objectives:

    By the end of this session, the learner will: 1) describe primary dialysis complications; 2) construct a full differential for a dialysis patient presenting with complications; 3) formulate an appropriate treatment and resuscitation in an acutely ill dialysis patient; 4) plan appropriate disposition and utilization of consultants for dialysis complications.

    Methods:

    The format of this educational session is cTBL.

    Topics:

    Hemodialysis emergencies, TBL, team-based learning, dialysis, ESRD, renal disease.

  • A Faculty Development Session or Resident as Teacher Session for Clinical and Clinical Teaching Techniques; Part 2 of 2: Engaging Learners with Effective Clinical Teaching

    ABSTRACT

    Audience:

    This workshop is intended for faculty members in an emergency medicine (or other) residency program, but is also appropriate for chief residents and medical student clerkship educators.

    Introduction:

    Faculty development sessions are required by the Accreditation Council for Graduate Medical Education and enhance the learning environment within residency programs. Resident as   teacher   sessions   are   important   in   helping residents transition from junior learners to supervisors of medical students and junior residents. Part I of this two-part workshop introduces learners to effective techniques to engaging learners with clinical and bedside teaching.

    Objectives:

    By the end of this workshop, the learner will: 1) describe and implement nine new clinical teaching techniques; 2) implement clinical teaching techniques specific to junior and senior resident learners.

    Methods:

    This educational session is uses several blended   instructional  methods,   including   team- based learning (modified), the flipped classroom, audience response systems, pause procedures.

    Topics:

    Faculty development, clinical teaching, bedside teaching, one-minute preceptor, two-minute observership, teaching scripts, Aunt Minnie, SPIT, activated demonstration, teaching scripts.

  • Acute Pericarditis: Electrocardiogram

     

    HPI:

    A 22 year-old male presented to the emergency department with a chief complaint of retrosternal chest pain that started yesterday. He described the pain as a constant, sharp and pleuritic. The pain was worsened by lying flat, and improves with  leaning forward.  He  reported having a  sore throat and other cold symptoms earlier in the week. The patient’s exam was notable for a faint pericardial friction rub. A bedside echocardiogram demonstrated normal cardiac function without pericardial effusion. The patient’s ECG is shown.

    Significant findings:

    The ECG shows diffuse ST- elevation. The patient also has mild PR-depression, most notably in the inferior and lateral leads. The patient also has minimal PR elevation in lead aVR. The patient was diagnosed with acute pericarditis (ECG stage 1).

    Discussion:

    Pericarditis is inflammation or infection of the pericardial sac. There most common etiologies are viral or idiopathic1,2. While it is rarely fatal, acute pericarditis can cause severe, disabling pain2. Furthermore, concomitant myocarditis can cause significant morbidity and mortality. Classic ECG findings include diffuse ST-elevations and PR- segment depression, without reciprocal ST-segment depression (as shown in this image).   The ECG of pericarditis may move through various stages when followed over time1,2. These include stage 1: diffuse ST-elevations with concave-upwards contour, PR- depressions (most common in II, aVF, V4-6); stage 2: ST segments become isoelectric and T waves flatten; stage 3: symmetric T wave inversion throughout ECG; and stage 4: ECG normalization2. These ECG changes have variable sensitivity and specificity depending on the stage, with less than 50% of patients progressing through the classic stages2.

    Topics:

    Cardiology, Cards, ECG, ST elevation, acute pericarditis, abnormal ECG, PR depression

    References:

    1. Colletti JE, Tabas JA. Cardiovascular disorders in emergency medicine. In: Schofer JM, Mattu A, Kessler C, Lu LN, Parker T, Rogers R, et al. eds. A Focused Review of the Core Curriculum. 2nd Milwaukee, WI: American Academy of Emergency Medicine Resident and Student Association; 2015:237-242.
    2. Mattu A, Martinez JP. Pericarditis, pericardial tamponade, and myocarditis. In: Adams JG, Barton ED, Collings JL, DeBlieux PM, GIsondi MA, Nadel ES, eds. Emergency Medicine: Clinical Essentials. 2nd Philadelphia, PA: Elsevier; 2013:514-523.

  • Atrial Myxoma

    HPI:

    A 52-year-old female presented to the emergency department with lightheadedness and shortness of breath, which had gradually progressed over several months. She denied chest pain. Her only medical history was an atrial myxoma that had been previously removed. Her exam was notable for a “plopping” noise heard on cardiac auscultation.

    Significant findings:

    Bedside ultrasound revealed the presence of a left atrial mass that appeared to be tethered to the mitral valve. The mass was best viewed on ultrasound in the apical four-chamber window with the phased array probe placed over the patients’ point of maximal impact (PMI), with the patient in left lateral decubitus position.  

    Discussion:

    Primary cardiac tumors are rare, estimated to have an incidence of 0.0017 and 0.19 percent1. Approximately three quarters of primary cardiac tumors are benign, and nearly half of these are myxomas. Myxomas can occur in all age groups, however they are more prominent in the third to sixth decades of life. Approximately 75% originate in the left atrium, with the remaining 25% originating in the right atrium and the interatrial septum. Patients’ symptoms are directly related to the size and position of the myxoma. In cases of small tumors, patients maybe asymptomatic, while larger tumors may embolize causing cerebral vascular accidents, vision loss. Severe cases of embolized left ventricular myxomas can cause complete occlusion of the abdominal aorta. Myxomas can also cause intracardiac obstruction, leading to shortness of breath, heart failure, syncope, or more generalized symptoms such as fatigue, fevers, and weight loss. Surgical excision is the treatment of choice.  While CT and MRI may aid in diagnosis, transesophageal echocardiogram (TEE) remains the standard for diagnosis of atrial myxomas, with one study showing a sensitivity of 94% and specificity of 100%2.

    References/Suggestions for Further Reading:

    1. Reynen K. Cardiac myxomas. N Engl J Med. 1995:333(24);1610-1617. doi: 10.1056/NEJM199512143332407
    2. Goldman JH, Foster E. Transesophageal echocardiographic (TEE) evaluation of intracardiac and pericardial masses. Cardiol Clin. 2000;18(4):849-60.

  • Carbon Monoxide Poisoning

    ABSTRACT

    Audience:

    This oral boards case is appropriate for all emergency medicine learners (residents, interns, and medical students).

    Introduction:

    Carbon monoxide (CO) is a colorless and odorless gas that typically results from combustion. It binds hemoglobin, dissociating oxygen, causing headache, weakness, confusion and possible seizure or coma. Pulse oxygen levels may be falsely elevated. Practitioners should maintain a high index of suspicion for carbon monoxide poisoning. If caught early CO poisoning is reversible with oxygen or hyperbaric oxygen therapy.

    Objectives:

    By the end of this oral boards case, the learner will: 1) demonstrate ability to evaluate a patient with altered mental status and discuss the differential diagnosis of a patient with altered mental status and weakness, 2) recognize the signs and symptoms of carbon monoxide poisoning, 3) demonstrate the ability to manage treatment of a patient with carbon monoxide poisoning.

    Method:

    Oral boards case

    Topics:

    Carbon monoxide poisoning, toxicology, carboxyhemoglobin, altered mental status, oral boards, hypoxia, pulse oximetry.