Grand Rounds June 8th, 2016

• Toxicology: Mushroom Update
• M&M: ESRD, Renal Stones & Urosepsis
• Global Medicine mini-fellowship
• RSI Education mini-fellowship
• Health Policy Update
• Ultrasound Education mini-fellowship

---

Toxicology

Mushrooms are difficult to identify due to their changing shape with growth. Cyclopeptide amatonxin containing mushrooms are the most dangerous (Hepatotoxicity). Treatment includes activated charcoal to decontaminate the bowel, penicillin, and Silibinin (available from one company in California who will release medication). Patients develop nausea & vomiting approximately 6 hours after ingestion and the toxin destroys hepatic cells leading to liver failure.

M&M

ESRD

Patients on dialysis have a 5 year survival rate of 33%, and an 8x higher mortality rate than average. Patients are prone to arrhythmias due to structural changes and remodeling of the heart, as well as electrolyte shifts during dialysis. Sudden cardiac arrest is the most common cause of death, and more frequent during the weekend when the patient is not having dialysis, as well as when the patient is having large volumes dialyzed. Always have a high suspicion of pericardial effusion, hyperphosphatemia, and infectious etiologies.
Patients with renal failure may have elevated troponins due to LVH or decreased clearance, however patients should still be evaluated for ischemia.  

Renal Lithiasis & Pyelonephritis

Risk Factors for infection & sepsis with renal stones:

• Size & Location: Stones >5mm and stones in the proximal ureter are more likely to require surgical intervention or become infected
• Age: Risk increases with age, >75 years old and females are more likely to have urosepsis associated with stones
• Female: Women are more than 2 times more likely to have urosepsis or infection associated with kidney stones, although males are more likely to have stones.

ED Evaluation of renal lithiasis

• Urinary Analysis: To evaluate for infection, although will not always show infection as it is potentially proximal to the blockage. Many patients with renal stones will not have blood in urine.
• Urine Culture: Consideration should be made for urine culture. Predictors of a positive culture are pyuria, fever, and a WBC greater than 11.  “Urine cultures appear warranted in high-risk patients”
• Creatinine: Most patients are treated with NSAIDs, and a baseline creatinine is useful for those patients who may return with failure of outpatient treatment.
• Urology Consult: For intractable pain, obstructing stone with concerns for infection, and intractable nausea and emesis. 

RSI Education

RSI is a fundamental skill for EM physicians, however there is currently no curriculum in most medical schools regarding RSI.  4th year medical students were targeted for a curriculum of anatomy, intubation, and RSI with hands-on and didactic sessions. The curriculum was shown to statistically improve the students' ability to perform RSI. 

Health Policy Update

How to get involved in health policy: 

• ACEP Board: email the DC Chapter at dc.chapter@ACEP.org

Ultrasound Education Mini-fellowship

Working to update and increase intern ultrasound education and presentations.

• Podcasts
• Journal Articles
• Online sonography resources