Grand Rounds November 9, 2023

Collagen Vascular Disease in the ED – Rebecca Jeanmonod, MD

– Collagen is everywhere= anywhere there is connective tissue

– Ehlers Danlos- loose skin, hypermobility,

– Dislocation, organ rupture, vascular rupture

– vascular subtype= bad

– Marfan Syndrome- tall, skinny, long fingers, wingspan relative to height

– aortic root issues

– lenses dislocations

– aortic disasters

-Osteogenesis imperfecta – blue sclarea, bendy, hearing loss, broken bones, valve problems, dissections, fractures in kids

– not all fractures= always child abuse

• Cricoarytenoid arthritis- ra
• Hypokalemic paralysis= Sjogren’s from RTAs
• Catastrophic antiphospholipid syndrome=lupus= clotting everywhere; massive bleeding and clotting
• Subglottic stenosis= Wegner’s
• Renal crisis= scleroderma
• Septic joints= RA
• Alveolar hemorrhage= lupus; Wegener’s
• Vertebrobasilar insufficiency= temporal arteritis
• Transverse myelitis= lupus
• Aa subluxation= RA, ankelosis spondylitis
• Aortitis= temportal arteritis
• Spinal fracgtures= ankylsosis spondylitis
• Vision loss= temporal arteritis
• Tamponade= lupus
• SCORING SYSTEMS DON’T Necessarily WORK on these patients; these populations weren’t included in the study’s aka heart score, perc score, syncope rules, psi, d dimer
• Always should consider it on your differential.
  • Weird vascular things = consider it
    • Systemic symptoms + organ system issues= consider collagen vascular issues
    • Call rheumatology if you have a suspicion.

9:30) Thyroid Emergencies – Holly Stankewicz, DO

• Thyroid storm: rare life threating
  • Hyperthermia, tachy, AMS
  • Symptoms: think everything is ramped up + big buggy eyes
  • Anything can be a precipitant.
  • Workup:
    • Tsh low or undetectable
    • Free t3/t4 elevated
    • Calcium may be elevated
    • Hyperglycemia common
    • Leukocytosis common
    • LFTs may be elevated
    • Cortisole level
    • EKG
    • R/o infection
  • Management:
    • Fever- don’t aggressively cool this can lead to vasoconstriction.
    • Ice packs, cooling blankets
    • Tylenol
      • Pearl avoid aspirin or NSAIDs because they can displace thyroid hormone
    • Dehydration/hypoglycemia
      • Fluids
    • Cardiac decompensation
      • Rate control, inotrops, diuretics as needed
    • Agitation
      • Benzos
    • Ptu = super sick patient
      • Blocks t4🡪t3 conversion
    • Methimazole-
      • Longer half life
      • Can’t use in first trimester pregnancy.
• 5 key steps to the management of thyroid storm
  • Inhibit hormone synthesis.
    • PTU/methimazole
  • Blocking of hormone release
    • iodine
  • Preventing peripheral conversion of T4 to T3
    • Steroids
  • Blocking peripheral effects of hormone
    • propranolol
  • Providing supportive care
    • ice packs cooling blankets, Tylenol
• Myxedema coma
  • Hypothyroidism + mental status change/coma + hypothermia + stressor
  • Symptoms: Everything is down + NONpitting edema
  • Slow function of multiple organs
    • Cold patient= degree of hypothermia proportional to mortality
    • Hypotensive, bradycardic, hypoventilation, hypoxia, ams
  • T4 levothyroixine first line therapy
    • 100-500 mcg followed by 75-100mcg IV
  • T3
    • 5-20mcg IV
  • Hydrocortisone 100mg IV q8hr
  • START PRESSORS IN THE HYPOTENSIVE PATIENT

10) Endocrine Cases – multiple faculty:

DKA, Hypercalcemia, Myxedema Coma, Thyroid storm

11) EM Case Presentation – Michael Murphy, DO

– Superglue in the eye

– ways to remove superglue

– antibiotic drops/ointments

– petroleum jelly

– acetone (not for eyes)

– WD40

– Peanut butter

– Oils

– 3% Sodium bicarb

11:30) TRIAGE – Chiefs

• Toxicology
  • 
• Radiology: TOA
  • 
• Integument
  • 
  • 
• Ancillary
  • 
• General Topic
  • Hyperpigmentation, hypotension, AMS, N/V- Addison’s adrenal crisis
  • Blunt ocular trauma, hyphemia, decreased VA- Globe rupture
  • 
  • HTN, HA, Palpitations, Diaphoresis- Pheochromocytoma
  • Night blindness and hyperkeratosis- Vitamin A deficiency
  • Retrograde amnesia, confabulations, nystagmus, ataxia- B1 thiamine deficiency- WKS
  • Vertigo, tinnitus, and hearing loss- Meniere’s Disease
• EKG

November 16, 2023. Lecture Room 2

8) Pediatric Endocrine Lecture – peds TBD

9) How to write and give a lecture – Rebecca Jeanmonod, MD

9:30) Dealing with the difficult patient – Eric Eustice, DO

10) Endocrine Jeopardy – Jason Becker, MD

11) Morbidity & Mortality Conference. David Pronchik, MD

12) EM Case Presentation – Dan Greco, DO

12:30) TRIAGE – chiefs