November 1st Conference Pearls

Brought to you by Molly Bourke and Priya Ghelani

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EKG of the Block (Dr. Barrett):

• Only a type 1 Brugada pattern (coved ST elevation in V1-2 followed by negative T wave) is diagnostic of Brugada syndrome, if the history corresponds (syncope, family history of sudden death, etc)
• Type 2 or type 3 Brugada patterns in the right clinical context should be worked up by cardiology
  • Diagnosis depends on provoking a type 1 pattern with class 1 antiarrhythmics (not in the ER)
• Short QT syndrome if QTc <330ms, or <360ms with history of sudden death, syncope, etc
• Early repolarization ECG characteristics:
  • J wave
  • Slurred terminal QRS complex
  • ST elevation
• J wave differential includes:
  • Hypothermia
  • Hypercalcemia
  • Intracranial hypertension/subarachnoid hemorrhage/head injury
  • Early repolarization

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Ultrasound of the Block (Dr. Bourke):

• Lung US can be a useful tool in assessing the febrile, coughing child
• Lung US found to be 96% sensitivity, 93% specific
• How it’s done:
  • Warm gel (when available)
  • Recruit the parents to have them hold the child (hugging or sitting on the lap)
  • 6 scanning points:
    • anterior (bilateral)
    • lateral (bilateral)
    • posterior (bilateral)
  • Scan in 2 orientations: transverse and sagittal planes
  • Scan from top until you visualize the diaphragm
• LUS can decrease need for CXR
• Video with scanning protocol, normal lung and pneumonia

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Sim Case: COPD with Pneumothorax (Dr. Restivo):

• Remember to keep your differential wide and don’t anchor!
• DDx for SOB in a COPD patient (the short list):
  • COPD exacerbation
  • Pneumonia
  • Pleural Effusion
  • Ruptured Bleb
  • PE
• Positive pressure ventilation (CPAP and mechanical ventilation) can make a pneumothorax worse into a tension PTX
• Review of Chest Tube placement:
  • 7/12 Conference Pearls
  • Life in the Fast Lane: Own the chest tube
  • EMRAP review: Chest tubes in the obese 
• EMRAP: How to set up a chest tube drain
• Complications:
  • Most common complication: malposition,
    • But remember: if it ain’t broke (if its doing its job), don’t fix it.
  • If its a traumatic tube, don’t forget to give antibiotics to prevent empyema
  • Troubleshooting Chest Tube Complications
• Size may matter… when choosing your chest tube
  • Review article
  • Prospective Analysis in Traumatic Chest Tubes
• EMCases Review of management of spontaneous PTX