ICCEM highlights

Recently went to ICCEM Malaysia 2015. Learnt tons which i will share some of the learning points here:

Topic: The nightmare of emergency presentation

  1. Tracheal rupture is a rare complication of emergency intubation. Think barotrauma first.
  2. The most common location of tracheal rupture is posterior part, in its membranous part which is not covered by cartilage.

Topic: The myocardia infarction that was shy but not silent

  1. In high and low pretest probability patients, troponin is not accurate in diagnosing MI.
  2. Troponin autoantibodies are present in 5-20 percent of patients, regardless of their health status. This could contribute to troponin that does not elevate during MI.

Topic: Unusual presentation and mimickers of dengue fever

  1. Fever + UGIB: remember to consider dengue fever.
  2. Dengue + abdominal pain: consider 2ndary diagnosis eg acalculous cholecystitis or hepatic abscess

Topic: Big arm, big problem

  1. Upper extremity DVT is not common but should be considered in a patient with persistent arm swelling.
  2. Paget-Shroetter disease: effort upper extremity DVT, related to strenuous activity and compressive anatomy of thoracic outlet causing venous stasis.
  3. Secondary upper extremity DVT could be due to in-dwelling CV catheter, so consider it when you see a patient with unilateral arm swelling on the same side as the CV catheter insertion site (right).

Topic: Beri-beri

  1. Consider malnutrition in prisoners, refugees and immigrants.
  2. Dry beri-beri: manifest by peripheral neuropathy (paresthesia, pain in the calf, muscular weakness, absent DTR and in severe case inability to work).
  3. Wet beri-beri: high CO failure.
  4. Infantile beri-beri: aphonia, absent DTR and CHF

Topic: Advancement and exciting tips on ECG in Chest Pain management

  1. Look out for hyperacute T wave (abnormally large and tall T wave) in patient with CP. Can be an early sign of STEMI.
  2. Benign early repol will have fish-hook sign (prominent J wave).
  3. Acute pericarditis will have diffuse ST elevation (not anatomically localized) and PR depression.
  4. ST segment should be compared to TP segment. ST in acute pericarditis is “up” because normally we compare to the depressed PR segment.
  5. Know De Winter T wave (J point depression with ascent into hyperacute T wave. There is usually avR ST elevation as well. De Winter T wave = proximal LAD occlusion.
  6. LMCA lesion = widespread ST depression and avR ST elevation.
  7. In LBBB, use Sgarbossa to dx STEMI. LBBB is NOT STEMI until proven otherwise anymore.
  8. Sgarbossa 1 and 2 are easy. Look for concordant changes (ST segment same direction to QRS direction). For criteria 3, use Smith’s formula (ST/S > 0.25 = STEMI).

Topic: Stroke Look Alike

  1. Not all hemiparesis are stroke.
  2. Consider aortic dissection if patient had/is having chest pain.
  3. Consider spinal cord lesion if the patient had/is having neck pain.

Topic: I Blew Up the Lung

  1. Staircase recruitment maneuvers have risk. Need to select the patients more carefully.
  2. From “Life in The Fast Lane” http://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/
    The evidence base for recruitment manoeuvres is conflicting. The ANZICS CTG’s PHARLAP study is currently in progress: a MCRCT looking at daily recruitment manoeuvres with protective ventilation strategy.

Topic: Cautionary Tale of Missed Perforated Viscus

  1. One diagnostic mistake can often lead another mistake. It is a viscious process. Always recheck and re-evaluate to avoid it !

Topic: Double Whammy On My Mummy

  1. STEMI can have aypical presentations. Always maintain a high degree of suspicion in a patient with SOB and chest pain even though the pain may not be typical.

Topic: Help Us, We Can’t Breathe

  1. PSP (paralytic shellfish poisoning) can be caused by consuming shellfish with saxitoxin.
  2. Saxitoxin is heat soluble, so cooking does not destroy it.
  3. Can progress to resp.muscles paralysis. Main treatment is supportive by provding ventilatory support.

Topic: Oh God! Please Give Me Back My Sight

  1. HTN in kids: > 95 percentile of the age.
  2. HTN in kids is commonly due to renal causes. So get a UFEME to look for glomerulonephritis.
  3. HTN in kids can lead to PRES which can cause cortical blindness. Not all blindness is due to brain SOL !

Topic: My Dad Almost Killed Me

  1. Heat stroke in children is not uncommon. Look for AMS, anhidrosis in a kid who has been exposed in hot environment for a few hours.
  2. Fever can be present/absent in heat stroke.
  3. High temperature causes uncoupling of oxidative phosphorylation, causing more energy wastage in the form of heat. Also with uncoupling of this process, acidosis occurs causing tachypnoea.Oxidative_phosphorylation
  4. Liver, brain and endothelial cells are susceptible to heat, creating with clinical picture of hypovolemic shock, AMS with acute liver failure. Liver enzymes may not be raised after 2-3 days.

Topic: Shock Me Baby One More Time:

  1. Hyperkalemia in children can happen. Avoid using neb salbutamol if the patient is in tachycardia.

Topic: The Blue Polka Dot Accident

  1. Fever + purpura, consider infectious origin (most common meningococcemia). Cover with B-lactam.
  2. Streptoccocal toxic shock syndrome (STSS) is rare but can happen. Superinfection of chickenpox vesicles (from child’s scratching) and use of ibuprofen are maybe the contributive factors.

Topic: An Unfortunate Turn of Events of a Powerpuff Girls

  1. Anaphylaxis to RSI drugs can happen. NM blockers are the most common, but it can happen to any RSI drugs.
  2. Fentanyl in small kids, even a small dose may cause chest wall stiffness and subglottic stenosis, causing difficult intubation.

Topic: Blue Bloom Flower

  1. Methemoglobinemia can present with skin discolouration (blue) in concentration 10-20 percent. But methylene blue is normally not needed if the metHb concentration is < 20 percent. This is important when the patient recovers and metHb level slowly comes down (skin discolouration may persist for a few days).
  2. Methylene blue in high dose can use hemolytic anemia. Also it may also be the cause of methemoglobinemia.
  3. Methylene blue is NOT FDA indicated for tx of methemoglobinemia.
  4. Nitrobenzene in pesticide can cause methemoglobinemia.

Topic: Fluids Management in Dengue vs DKA

  1. Diabetes can produce cytokines that destroy the glycocalyx, leading to more plasma leakage and more severe dengue.
  2. GB wall thickness > 5mm may predict a more severe dengue.
  3. Starch solution should not be used in dengue as it is linked with liver and renal failure.

Topic: 10 times unlucky from the cupid arrow

  1. Know the 3 neck zones. Vascular injuries happen the most in neck zone 1 trauma.

Topic: Finally He got his smile back

  1. Hx of taking SSRI + muscle stiffness = consider serotonin syndrome. Other symptoms include tremor, clonus and autonomic symptoms eg hyperthermia, hyper/hypotension, brady/tachycardia.
  2. Benzodiazepines are effective and rapidly reverse this syndrome.

Topic: Glucagon, a traditional pragmatic belief

  1. CCB and BB OD: use glucagon? Evidence is inconclusive. Alternative therapies eg HDI may work.

Topic: Muscarinic Toxicity after the consumption of mushrooms from genus inocybe

  1. Most mushrooms poisoning present with cholinergic toxidrome. So exact recognition of the sp is not needed before starting treatment.
  2. Know DUMBBELLS of cholinergic toxidrome: diarrhea, urination, miosis, bradycardia, bronchospasm, emesis, lacrimation, lethargy and salivation.
  3. Know that false morel mushroom maybe mistaken for morel mushroom (which is commonly eaten as delicacy in China and maybe brought back to Malaysia by Chinese population). False morel mushroom is fatal and causes acute liver dysfunction.

Topic: Langkau, the Sarawak Moonshine that may leave you in the darkness

  1. Homemade alcohols may produce toxic alcohols eg methanol and ethylene glycol.
  2. Visual blindness is the initial presentation in methanol poisoning.
  3. Ethylene glycol can lead to renal failure.
  4. Role of imaging in aiding toxic alcohols diagnosis still remains a ??

Topic: Anti-Dirrhoeal Nightmare

  1. Lomotil contains diphenoxylate (opioid derirative) and atropine, so poisoning may present with 2 types of symptoms (opioiod and anticholinergic toxidromes).
  2. Even a normal dose of lomotil maybe poisonous for a kid.
  3. Use of NG lavage is still controversial in lomotil poisoning.

Topic: One Bite and I Am Confused

  1. Dengue encephalitis is not uncommon and should be considered in a patient with positive dengue serology presents with altered mental status (confusion, seizure, coma)

Topic: untold history

  1. Consider asking for trauma history for every undifferentiated patient and you aren’t sure of the diagnosis. Patients may neglect the impact of trauma when their bodies do not have large external injuries.

These are all my take home messages. It has been a great conference and I thank you for all the members of the organizing comittee for such a great job !

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