• Central Venous Access – Drs. Stults and Wells
  • Locations: IJ (R 15cm, L 18cm), Subclavian(R 14cn, L 17cm), Femoral
  • Procedure SIM
• “To Pee or Not to Pee?” – Dr. Williams
  •  Rhabdomyolysis
    • Muscle breakdown – Meds, toxic ingestion, increased muscle activity
    • UA with positive heme/blood without RBCs
    • CK > 5000
    • Electrolyte abnormalities
    • McMahon Score
    • Treat by removing precipitating factors, Rehydrate as needed, treat electrolyte abnormalities, maybe dialysis
  • Acute Kidney Injury (AKI)
    • KIDGO Criteria
    • Staging (stage 1-> stage 3)
    • Pre-renal, Intra-renal, Post-renal
    • Screening/Labs: Electrolytes, CMP, BMP, CK, UA, Renal US, FENa
  • Uremic Encephalopathy
    • Cerebral dysfunction from accumulation of eremic toxins in acute or chronic renal failure
    • Delirium, fatigue, anorexia, nausea, asterixis/myoclonus, seizures
    • Often with GFR <15L/min
    • CMP/BMP. CBC, EEG, CT Head/MRI Brain
    • Treated with dialysis (must evaluate for other causes of delirium)
  • Hepatorenal Syndrome
    • Advanced cirrhosis causes systemic dilation, to compensate for low BP and SVR body releases endogenous catecholamines and activates RAAS
    • AKI
    • Diagnosis of exclusion (takes 2 days of albumin therapy to diagnose)
    • Treat with albumin
• US Image Review – Drs Baker and DiMeo
  • Vitreous detachment
  • Retinal Detachment
  • Nerve Block
• Introduction to Observation Medicine (OLOU) – Dr. Kuzel
  • Trial of therapy, Continued Diagnostic work up, risk stratification, Optimization before discharge home, assessment of acute psychosocial needs
  • Patient can be discharged within 24 hours
  • Specific inclusion and exclusion criteria, protocol based
  • NOT an ambiguity or continued decision unit
  • NOT an additional annex for ED holding patients
  • NOT for patients admitted to other services
  • Soft Launch of ULOU on Feb 3
    • Maximum number of 5 obs patients at a time

• Nephritis/Nephrosis – Dr. Samuels
  • Nephritic vs Nephrotic
    • Nephritic Syndromes
      • Hypertension
      • Decreased Urine Output
      • Proteinuria +/-
      • RBC casts
      • Examples:
        • PSGN
        • Rapidly Progressive Glomerulonephritis
        • IgA Nephropathy
    • Nephrotic
      • >3.5 grams protein excreted per 24h
      • Hypoalbuminemia >lipid formation
      • Edema/anasarca
      • Hypercoagulable state (loss of antithrombin III, protein C & S)
      • Examples:
        • FSGS (focal segmental glomerulosclerosis)
        • Membranous Nephropathy
        • Diabetic Nephropathy

• Urinary Infections – Dr. Stanforth
  • Urinary Tract Infections
    • Pathophys
      • Bacteria ascend through the urethra
      • Complicated vs uncomplicated
      • Relapse = recurrence of symptoms within 1 month despite treatment (typically same organism)
      • Reinfection = symptoms develop 1-6 months after treatment (typically different organs mim)
    • Risk factors
      • Anatomical abnormalities
      • Advanced age (men)
      • Nursing home residency
      • Neonatal
      • Diabetes, sickle cell disease
      • Pregnancy
      • Immunosuppression
      • Advanced neurologic disease
    • General workup
      • UA
        • WBC >5 w/ symptoms is diagnostic
      • Urine culture
      • Consider labs: CBC, CMP, lactic
      • Blood cultures not always indicated as cultured organsmi will typically match urine culture (97%)
    • Types
      • Renal
        • Pyelonephritis
          • Flank pain, fevers, chills, nausea, vomiting
            • CVA tenderness alone could be referred pain from cystitis
          • Complications
            • Bacterial Nephritis
            • Renal/perinephric abscess
            • Emphysematous pyelonephritis
      • Ureteral
        • Infected stone (8-15% of stones have co-infection)
        • Systemic symptoms: urology consult, close follow-up
        • Obstruction with infectious symptoms -> urologic emergency
        • Imaging considerations
      • Cystitis
        • Infection of bladder
        • Complicated
          • Symptoms >7 days
          • DM
          • UTI in previous 4 weeks
          • Men
          • > 65years old
          • Women using spermicides or diaphragm
          • Relapse
          • Pregnancy
        • Treatment
          • Refer to system/community based antibiogram
      • Urethritis
        • UA, Urine GC/Chlamydia, M. genitalium and trichomonas testing
        • Treatment: Empirically cover gonorrhea and chlamydia
        • Partner treatment
      • Prostatitis
        • E. coli makes up about 80% of cases
        • Enterococcus, Staph. N. gonorrhoeae, Chlamydia
        • Prostate manipulation: increased risk of pseudomonas infections
      • Management:
        • Prolonged antibiotic course
    • Asymptomatic bacteriuria
      • Do not treat unless immunocompromised or pregnant

• PEM: Renal Disorders – Dr. Lund
  • Pediatric Renal/GU
    • UTI
    • UTI: Diagnosis
      • Culture showing leukocyte esterase or pyuria AND …
        • 1,000 CFU SPA
        • 50,000 CFU catheterized specimen
        • 100,000 CFU clean catch
      • 2-24 months first febrile UTI or recurrent UTI in older child needs RBUS
    • UTI: Treatment
      • Cephalexin 25 mg/dose TID (max 1000mg/dose)
      • https://uticalc.pitt.edu/
  • PIGN
    • One of the most common causes of acute glomerulonephritis in children
    • PSGN: Clinical features
      • M>F
      • 4-14 y/o, rare before 2 y/o
      • Latency 1-2 weeks for pharyngeal infections and 3-5mfor skin infection
    • Acute nephritic syndrome
      • Hematuria
      • Hypertension
      • Edema
      • Oliguria
    • PSGN: Treatment
      • Treat underlying infection
      • Treat nephritic syndrome, if needed
        • Diuretics
        • Antihypertensives
        • RRT
  • Hemolytic Uremic Syndrome
    • Triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury
    • Many etiologies with most common being shiga-toxin producing E. coli (STEC)
    • Treatment
      • pRBC
      • Fluid/electrolyte anagment
      • Dialysis
      • Platelets
  • Henoch Schonlein purpura
    • IgA depositions in blood vessel walls – kidneys, GI tract, skin, joints
    • Clinical manifestation
      • Palpable purpura
      • Joint pain
      • GI complaints
      • Renal involvement
      • Cerebral vasculitis
      • Testicular hemorrhage
      • Interstitial pulmonary  hemorrhage
    • Pathogenesis
      • Preceding URI
      • IgA complexes deposit in the small vessels in the skin joints, kidneys and GI tract. 
    • Diagnosis
      • Mandatory criterium:
        • Purpura or petechiae with lower limb predominance
      • Minimum Criteria(1 of 4)
        • Diffuse abdominal pain with acute onset
        • Arthritis or arthralgia of acute onesie
        • Renal involvement in the form of proteinuria or hematuria
        • Histopathology showing leukocytoclastic vasculitis or proliferative glomerulonephritis, with predominant immunoglobulin A deposits
    • Treatment
      • Non renal involvement -> symptomatic treatment
      • No consensus on HSP nephritis/severe complications
        • Steroids
        • Cyclosporine, mycophenolate, cyclophosphamide, rituximab, dapsone 
    • Approach to Hematuria
      • Pathophysiology
        • Glomerular
          • Disruption of the glomerular basement membrane with leakage of RBS and protein
          • RBC casts 
          • Brown, smoky coca-cola colored
        • Non-glomerular
          • Renal papillae
          • Sickle cell disease, trait
          • Tubules are site inflammation caused by NSAIDs and antibiotics
          • Pink, bright red with ot without clots more likely lower in urinary tract
          • Increased vascularity from infection or chemical irritation
      • Evaluation
        • Confirm blood in urine
        • Detailed patient and family history
        • Life Threatening causes
          • Trauma
          • Acute glomerulonephritis
          • HUS
          • Renal stones with obstruction
          • Tumor
          • Hematologic disorders
          • toxin/xenobiotic
      • Trauma
        • Hematuria is “cardinal marker of renal injury, with magnitude of hematuria paralleling the severity of renal injury (except renal pedicle injuries, which may have no associated hematuria
        • Presence of gross hematuria or significant microscopic hematuria (>50 RBCs/HPF) along with mechanism point to emergent imaging

• Testicular Infections/STI – Dr. Scott
  • Sexually Transmitted Infections
    • Ulcerative
      • Painful Ulcers
        • HSV
          • HSV-2
            • Multiple painful lesions
            • Starts as blisters
            • Clinical Dx
            • Acyclovir 400 mg q8h x7-10 days or valacyclovir 1 g q12h x 7-10 days
        • Chancroid
          • H. ducreyi
          • Begins as chancre -> unilateral painful inguinal lymphadenopathy forms (buboes)
          • Can form abscess
          • Azithro 1 g PO x1 dose
      • Painless
        • Syphilis
          • Chancre painless
          • Secondary
            • Maculopapular ras on trunk and extremities
            • CSF involvement (40%) 
          • Late
            • Most commonly neuro, associated with HIV
            • Gummas
            • Cardiovascular
          • Diagnosis
            • RPR or VDRL -> antibody if reactive
            • Antibody test -> RPR or VDRL
          • Tx:
            • Penicillins
            • Doxycycline
            • Ceftriaxone if neurosyphilis
            • Jarish-Herxmeier reaction: fever. Chills, myalgias, headache
        • LGV
          • Chlamydia trachomatis
          • Associated with HIV
          • Primary: painless ulcer x2-3 days
          • Secondary: painful ulcer 2*6 weeks later
            • Fever, mylagia, malaise
        • Gonorrhea chlamydia/chlamydia
          • Arthritic, PID
          • Urine culture
          • Ceftriaxone/doxy
        • Epididymitis
          • <35, GC/chlamydia
          • >35 (or anal intercours): e. Coli, pseudomanas, TB, enterovacrer, syph
            • Scrotal elevation
            • Pain relief
            • GC/Chlamydia treatment
        • Orchitis
          • Testes inflammation
          • Most commonly mumps
          • GC, chlamydia, E. coli

• Torsion – Dr. Gosser
  • Ovarian torsion
    • Most common in reproductive-aged females but is found in females of any age
    • Risk factors
      • Ovary > 4cm
      • Pregnancy
      • Patients undergoing IVF, patients after tubal ligation
    • Mechanism: enlarged ovary rotates on the axis of its ligaments leading to twisting of the ligaments restricting lymphatic outflow, swelling that will inhibit venous return that in-turn compromises arterial blood flow. 
    • Requires emergent OB/Gyn consult for operative management
  • Testicular torsion
    • Bimodal incidence
      • Peaks in first year of life and in puberty
    • Risk Factors
      • Mechanical: exertional/exercise, trauma
      • Testicular masses
      • Undescended testicle
      • Bell-clapper deformity
    • Evaluation
      • Emergent urology consult
      • UA
      • US for equivocal cases
      • TWIST Score
    • Mechanism
      • Twisting of the testis on its blood supply
      • Tunica vaginalis is secured to the scrotal wall on the posterolateral side, prevents movement of the testis
        • If this attachment occurs too superiorly, this can lead to torsion
    • Treatment
      • Manual detorsion (temporizing measure)
        • Medial to lateral rotation (open book)
      • Urological consultation for detorsion and orchipexy
      • Salvage rates
        • 100% at 6 hours
        • 20% at 12 hours
        • Little to no salvageability at >24 hours
• ITE Tox Review – Dr. Eisenstat
  • Toxicology ITE Prep
    • self-review
• Renal Emergencies – Dr. Thomas
  • Hyperkalemia and Emergent Hemodialysis
    • Causes of hyperkalemia
      • The Kidney
        • Renal insufficiency
        • ARF
        • Addison’s Disease, Adrenal insufficiency
        • ACEs
        • ARBs
      • Intake
        • Excessive K+ supplementation
        • Excessive K+ in diet
        • Dehydration
          • Prerenal cause of insufficiency
          • Causes shift in electrolytes with more K+ now extracellular
      • Tissue Damage
      • Endocrine
      • The Lab/Phlebotomy
    • Hyperkalemia
      • Generally >5 or 5.5
      • The serum concentration of K+ is important
      • The rate of change in the concentration of serum K+ is MORE important
      • EKG changes
        • Mild 5.5-6.5  – Peaked T Waves and or Prolonged PR segment
        • Moderate 6.5-8 – Loss of P Wave, Prolonged QRS complex, ST-Segment elevation, Ectopic beats
        • Severe >8.0 – Progressive widening of the QRS, Sine wave morphology, V-fib, Asystole, axis deviations, BBB, Fascicular blocks
    • Therapy
      • Calcium
      • Insulin/dextrose
      • Albuterol
      • Bicarb
        • Only really worthy of consideration in setting of metabolic acidosis
      • Diuretics
      • GI elimination
        • NOT RAPID
        • NOT FOR EMERGENCY TREATMENT
      • Hemodialysis
    • Emergent Hemodialysis
      • AEIOU
        • Acidosis
          • pH ,7.1
        • Electrolytes
          • Refractory hyperkalemia
        • Intoxication/Ingestions
          • Toxic alcohols, salicylates, lithium, etc
        • Overload
          • Congestive Heart Failure
        • Uremia
          • Uremic pericarditis, uremic encephalopathy
      • I STUMBLED (Toxins removed by HD)
        • I – INH, Isopropyl alcohol
        • S – Salicylates
        • T – Theophylline, Tenormin (atenolol)
        • U – Uremia
        • M – Methanol
        • B – Barbiturates
        • L – Lithium
        • E – Ethylene glycol
        • D – Dabigatran, Depakote

• Lightning lectures Dr. Gosser, Dr. Angel, and Dr. Gronemeyer
  • Oral Abscesses
    • PTA       
      • uvula deviation, pain, fever, sore throat, trismus, muffled voice
      • CT w/ contrast
      • Strep/staph, anaerobes
      • I&D, clindamycin or augmentin outpatient, Unasyn inpatient
  • Dental abscess
    • Pain, tooth elevation, tenderness and swelling around tooth
    • CT if concerned for deeper abscess
    • Nsaids, opioids or local anesthetics, Dental follow up within 48 hrs, can do I&D
    • Augmentin, clindamycin, or Unasyn
  • Dacrocystitis
    • Infection of lacrimal sac due to blocked lacrimal duct
    • Swelling erythema and edema between medial canthus and nasal bridge
    • Manage with PO clindamycin, warm compresses, decongestants
  • Hordeolum (stye)
    • Blockage and infection of sebaceous/sweat glands of eye
    • Pustule with pain on eyelid
    • Treat with warm compresses
  • Blepharitis
    • Bacterial infection of meibomian gland
    • Swelling and erythema with pain and itching
    • Treat with hygiene, warm compresses, can use topical bacitracin
  • Prespetal and orbital cellulitis
    • Fever, Eyelid swelling and erythema with both
    • Orbital cellulitis will have visual defects, proptosis, and pain with EOM
    • Preseptal cellulitis is usually staph/strep, treat with Bactrim AND amoxicillin (or cefpodoxime or cefdinir)
    • Admit orbital cellulitis, treat with vanc/Unasyn (or vanc/zosyn), add ampho B for fungal infections if dm or immunocompromised
  • Herpes zoster ophthalmicus
    • Fever, headache, Hutchinson sign (vesicles on tip of nose)
    • Slit lamp
    • Artificial tears, topical abx to prevent secondary infection, antiviral
  • Gonorrheal conjunctivitis vs chlamydial conjunctivitis
    • 3-5 days post partum for gonorrheal, 5-12 days is chlamydial
    • Topical erythromycin
    • Adults treated with azithro/ceftriaxone
  • Temperomandibular disorder (TMJ)
    • Pain for 3+ months in TMJ
    • Managed with Nsaids, can use muscle relaxers, soft food diet
    • f/u with dentistry
  • mandibular dislocation
    • typically anterior, typically atraumatic
    • clinical diagnosis
    • CT face / IAC/temp bone if concerned for posterior dislocation especially if traumatic
    • Evaluate cranial nerves
    • Reduce by translating inferiorly and posteriorly
    • Can try syringe technique (97% success)
    • Discharge if uncomplicated otherwise
• Dr. Aiello and Dr. Kushner
  • Septal hematoma
    • Clinical diagnosis. Collection of blood will lead to infection, septal perforation, saddle nose deformity.
    • Use 4% lidocaine cotton balls (can use oxymetazolone) and plug both nares for 5-10 min
    • Incise vertically, stagger incision if bilateral
    • Pack with sponge/tampon
    • d/c with abx and analgesics, f/u with ENT in 2 days
  • Auricular Hematoma
    • Can lead to chronic ear deformity if not expressed/drained
    • Auricular block
    • Superficial incision
    • Pressure bandage to prevent reaccumulating

• Trachs, with Dr. Perling and Dr. Marks
  • Tracheostomy done for upper airway obstructions, or patients on prolonged mechanical ventilation.
  • 3-7 days for severe closed head injuries
  • Respiratory distress pathways and bleeding trachs
    • Most commonly trach fracture, displacement, obstruction, stenosis
    • Give O2 to stoma and mouth, remove inner canula, suction/confirm airway, confirm if trach patent or not. Bougie and re-trach, prepare to intubate from above
    • Tracheal infections = surgical consultation
    • Bleeding trach should raise concern, especially within 6 weeks
    • Beware sentinel bleeds
    • If bleeding; CUFFED tracheostomy
    • Manual compression if this fails.
    • CTA neck/chest
• Buprenoprhine with Dr. Eisenstat
  • X waiver -> now MATE
  • Methadone and other maintenance therapies reduce overdose, comorbidities of OUD
  • It is meant to be bridging, not long term alternative
  • Methadone = full agonist, long acting, but must go get it daily. Also QT prolonging  
  • Bazett formula for QTc : QT/ (sqrt of) RR interval
  • Buprenorphine = extremely competitive agonist, can precipitate withdrawal
  • Suboxone = buprenorphine with naloxone (to prevent abuse)

PEM: Orthopedic injuries and NAT- Dr. Warnick

1. 4 types of child abuse: physical, sexual, emotional, neglect
2. Consider developmental milestones: start to roll at 4 months, crawl at 9 months, taking steps at 12 months
3. TEN4FACES: bruises on torso, ears, neck, angle of jaw, cheeks, eyelids, subconj hemorrhage, frenulum tear; bruises on 4 months or younger; patterned bruising
4. Workup: trauma labs, skeletal survey (under age of 2), CT Head
   • UA > 50 RBC –> CT abd
   • ALT 3x upper limit –> CT abd
   • if low hgb –> look at context
5. Bucket handle fracture/corner fracture = concern for abuse
6. Posterior rib fractures
7. Spiral fracture vs toddler’s fracture
8. Social work, Law Enforcement, CPS report, Transfer to pediatric center

Hand injuries- Dr. Shaw

1. Perfusion: pulses, cap refill, most distal part of hand
2. Sensation: ulnar, median, radial, palmar/volar vs dorsal
3. Motor: “rock, paper, scissors, ok”; FDS vs FDP
4. Phalanx dislocation: frequently have ligamentous disruption, reduction with traction, splint with alumafoam to MCP
5. Nail avulsion: inspect for underlying laceration, repair as needed, suture/dermabond nail back in place
6. Fingertip avulsion injury: finger tourniquets
7. Subungal hematoma: assox with tuft fracture, trephination, abx if open fracture
8. Boxer’s fracture/metacarpal fracture with fight bite: closed reduction with 20-20-40 rule, hematoma block, ulnar/radial gutter splint
9. Scaphoid fracture: assess snuffbox, prone to malunion, thumb spica, follow up outpatient
10. Lunate dislocation: require emergent hand eval
11. Paronychia: I&D, abx if inflammation or abscess
12. Herpetic whitlow: topical acyclovir
13. Sporotrichosis: itraconazole 4-6 months
14. Felon: I&D lateral margin, bactrim
15. Flexor tenosynovitis: kanavel signs- sausage digit, pain with percussion of flexor sheath, held in passive flexion, pain with passive extension; hand consult, IV abx, OR
16. Water bath for ultrasound

Lightning Lectures: Swollen Joint- Dr. Scott

1. Septic arthritis: knee, hip, older- staph aureus, younger- gonorrhea
2. Gout: negatively birefringent, needle-shaped monosodium urate crystals, consider precipitants, tx: NSAIDs, colchicine, 90%. have positive uric acid
3. Pseudogout: positively birefringent
4. Post-strep
5. Traumatic
6. Avascular necrosis

Arthrotomy- Dr. Angel

1. Joint exploration, assess for extravasation of joint fluid (straw-colored)
2. X-ray to assess for open fracture, foreign body in joint, intra-articular air
3. Saline loading/methylene blue test vs CT scan
4. Also assess joints with range of motion
5. Tx: tdap, abx, ortho for washout in OR

Core US Topics- Dr. DiMeo, Dr. Nix

1. Abdominal Aortic US
2. Case: 72 yom h/o HTN, HLD, smoking presenting with left flank/lower back pain after lifting
3. Curvilinear probe
4. Orientation: find spine, aorta, and IVC
5. Obtain views in proximal, mid, and distal aorta in both short and long axis
6. Proximal aorta: celiac trunk with seagull sign
7. Mid aorta: left renal vein and SMA anterior to aorta
8. Distal aorta: bifurcation into iliac vessels
9. Pitfalls: intestinal gas, BMI
10. AAA: HTN, HLD, CAD, connective tissue disease; smoking (ever), age, sex (males)
11. 90% infrarenal
12. < 3 cm
13. > 5.5 cm = immediate call to vascular
14. Bladder US
15. Assess bladder volume, post-void residual, foley placement, renal failure
16. Landmark to pubic symphysis
17. Bladder volume- height x transverse depth x width x 0.7

R2 Pathway: Low Back Pain- Dr. Lyons and Dr. Mattingly

1. Consider red flag symptoms- trauma, age > 50, fever, immunocompromised, IVDU, recent surgery, epidural injection, urinary retention, abnormal reflexes, saddle anesthesia
2. Fracture: CT scan, spine consult
3. Malignacy: CBC, ESR, CRP, CT
4. Cauda equina: emergent MRI, PVR, 10 mg decadron, spine consult
5. Epidural abscess: CBC, ESR, CRP, Cultures, CT vs MRI; Vanc, flagyl, rocephin, spine consult
6. Transverse myelitis: MRI, LP (high protein), neuro consult, steroids +/- PLEX
7. Radicular back pain: no risk factors = no diagnostic imaging required
8. Nonspecific back pain: 85%, no labs required, can consider CBC, ESR, CRP, HCG
   • Imaging: CT better than XR, but does not assess spinal cord well, if concerned for spinal cord pathology > MRI; < 6 weeks of pain + no red flags = no immediate imaging
   • Treatment: heat/ice, remain active, light stretching
   • MMPC: NSAIDs, acetaminophen, lido patch, muscle relaxants
   • Trigger point injections

Open fractures– Dr. Gosser

1. Gustilo-Anderson classification: type 1-3
2. Management: if vascular compromise > attempt reduction, irrigate wound, immobilize in splint, abx, tdap, ortho consult
3. Antibiotics: cefazolin, add gentamycin for complex, add fluoroquinolones for fresh water, add doxy for salt water wounds
4. Complications: surgical site infection, osteomyelitis, surgical amputation, neurovascular injury, compartment syndrome

Splinting- Dr. Rizzo

1. Proximal humerus: cuff and collar
2. Supracondylar: posterior long arm
3. Distal radius and ulnar: sugar tong
4. Distal tibia: posterior short leg w or w/o stirrups
5. 5th metacarpal: ulnar gutter

Room 9 Follow up- Dr. Roberts

1. Aortic dissection
2. Symptoms: chest pain, abdo pain, syncope, stroke-like symptoms, paraplegia
3. Widened mediastinum on CXR in 40% of patients
4. Tx: BP control- short-acting beta blockers > long-acting, such as esmolol or labetalol; vasodilators such as nicardipine, clevidipine, nitroglycerine, nitroprusside
5. Ruptured aortic aneurysm
6. Symptoms: hypotensions, abdominal pain, pulsatile mass
7. Unstable > bedside ultrasound vs stable > CT w/ contrast
8. Tx: SBP 80-90, esmolol if HTN
9. Bowel perforation
10. Tx: fluids, NPO, abx, ppi, surgery consult, pain control
11. Decompensated cirrhosis
12. SBP tx: third gen cephalosporin, fluoroquinolone, carbapenem

Eponymous Fractures- Dr. Eisenstat

1. LeFort 1: horizontal maxillary, teeth from face
2. Lefort 2: pyramidal fracture, maxilla, orbital wall, nasal bone
3. LeFort 3: craniofacial disjunction, assox with CSF leak, temporalis muscle disruption
4. Chance: involves all 3 columns, assox with seat belt injury
5. Clay Shoveler: lower C spine process (usually C7), stable
6. Jefferson: C1 burst fx from axial loading (diving)
7. Bennett vs Rolando: 2 vs 3 fx fragments of 1st metacarpal > thumb spica
8. Bankart: glenohumeral avulsion with ant shoulder dislocation
9. Hill Sachs: humeral head depression fx
10. Monteggia: proximal ulna, dislocation of radial head; peds FOOSH
11. Galeazzi: distal radius fx with radio/ulnar dislocation
12. Boxer: distal metacarpal fx, no rotation accepted
13. Chauffer: radial styloid, direct blow to back of wrist
14. Colles: FOOSH, elderly women, distal radius, indication for DEXA scan
15. Smith: fall on flexed wrist
16. Game-keeper/Skier thumb: rupture of ulnar collateral ligament, caused by forced abduction, thumb spica > possible OR
17. Jones: base of 5th metatarsal, NWB 6-8 wks
18. Lisfranc: separation between tarsal bones, ligamentous injury in midfoot joint
19. Maisonneuve injury: tib/fib syndesmosis, proximal fib fracture
20. Pilon: comminuted distal tib
21. Segond: avulsion fracture assox with ACL tear
22. Weber classification of lateral malleolus fracture: A below, B @, C above syndesmosis
23. Salter harris classification of physeal fractures

• Secondary Trauma/Moral Injury¹

• Intro to EDH¹

• Room 9 Follow up with Dr. Whitford
  1. -Thyrotoxic Periodic Paralysis is an extremely uncommon but high mortality condition (80-100%) complication of thyrotoxicosis
  2. -Replete potassium aggressively. Avoid steroids if possible. Can give propanolol in conjunction for those patients refractory to potassium repletion
  3. VV ECMO for patients primarily with ARDS or inability to oxygenate/ventilate. VA ECMO for patients in acute cardiogenic shock

• Social Work in the ED

– Common misconceptions is that social work in the ED is able to find housing for homeless patients

– Social work is able to pay for some low cost medications for patients and help with some DME during business hours (things like ostomy supplies not covered)

– Also can help with transportation to substance use disorder clinics

• Survival Guide to the Peds ED

– Complete your notes on time (within 24 hours). Recognize sick vs not sick. Utilize complaint order sets to your advantage

-Heme/Onc, NES admit to themselves. Very select pediatricians will admit to themselves. Only fellows and attendings call to give report on PICU patients

-FiO2 50-60% and 2L/kg for HHFNC in kids is threshold for PICU

-Pay attention to vaccination status. Certain febrile neonates will automatically get an LP and septic workup compared to other kids

-White hot is a febrile chemo patient.Red hot is a febrile neonate

-Straining does not mean constipation in newborn population. Be careful about putting words toxic/lethargic/irritable in note unless you’re intubating, performing LP, or resuscitating. Describe in your note and paint picture of what kid looks like (high fiving, smiling, interactive, etc)

• Cardiac Pacing¹

-Indications: unstable bradycardia, SSS with frequent pauses

-Can do both transcutaneous and TVP. Start with TC pacing but prep for TV pacing. Can place pads anterolateral or anteriorposterior

-TC pacing: Select pacer function, select rate (typically around 70), set current and look for capture. Can increase current until you get capture by 10 mA equivalents. If youre getting to 120 mA without capture, consider replacing pads. Capture will look like QRS complexes on tele after each pacer spike. Make sure you have mechanical capture as well (palpable pulse, BSUS)

-TV pacing: Set up on generator has three knobs: rate, output, and sensitivity. 80/20/20 is typical initial set up for asynchronous pacing.

-TV pacing: First step is placing Cordis (preferably R IJ). put sterile sheath on pacer wire and have non-sterile assistant attach connecting cables to generate. insert the swan pos and neg pins then insert swan into cordis and go to about 20 cm and stop. then you inflate balloon, and advance until you get capture. once you get capture, decrease output until you lose capture and then incr to lowest effective output.

• How to Break Bad News²

– Be aware of the setting and perception of family members when you are delivering bad news. You want to know what they already know before you talk to them. Invite them to explain how much they want to know

-Don’t use medical jargon. Allow time for frequent pauses. Use chaplains and their services, they will typically tell you ahead of time who is in the room and what/how much they know

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Healthcare Disparities in the ED:

• -amongst persons experiencing homelessness (PEH), the rates of mental illness and substance used disorder is disproportionately higher compared to the non-PEH group
• – Implicit bias still affects medical care in the US today; black individuals are less likely to receive urgent triage score or to be admitted to the hospital for their complaints.
• – It has been well studied that patients receive better care and have better health outcomes when cared for by doctors who share similar identities in race or gender
• – Try to use preferred names and pronouns. Don’t ask intrusive questions or perform intrusive exams when not indicated. Be compassionate.
• – healthcare costs associated with undocumented immigrants (UI) largely felt by the ED. EMTALA applies to UI as well as documented immigrants.

• How to Give and Receive Checkout:
• – A TOC occurs when >2 providers exchange info about a pt. Happens more than you think
• -In a TOC, be clear, brief, timely and complete. Check your bias. Give the oncoming residents time to ask questions
• – Use IPASS mnemonic when transitioning care between providers
• – Check out your sickest patients first
• – Consult with a purpose and a specific request/question

I posted this paper and it’s revisited update on room9er about 3 years ago. July is always a good time for it!

Here is the original paper.

Here is the update.

The fundamentals do not change much!

Palliative care-

• Who- patients w/ end stage diseases, AIDs, malignancy, multi-organ failure, devastating injuries.
• Benefits to patients- improves quality of life, avoids undesired interventions.
• Benefits to providers- aids with burnout and staying focused on what patient would want.
• Symptom management- pain, dyspnea (opioids are first line, delirium, constipation.

DNR/DNI-

• Advanced directive indicating what patient would want from a care perspective.
• Otherwise consider POAs and next of kin.

Special Populations in the ED-

• Patient’s with intellectual disability: Consider barriers to health including physical, communicational, attitudinal, transportation, financial.
• Patient’s whose primary language is another language.
• Patient’s involved human trafficking.  Always be mindful of red flag signs.
• Elderly patient’s or those affected by dementia/cognitive decline.
• Patient’s affected by housing insecurity.

Systemic infections in children-

• Measles (Rubeola): symptom 10-14 days after exposure with cough, coryza, conuctivitis, Koplik spots.  Rash starts on face, spreading down, including palms and soles. First vaccine at 12 mo. Treatment = supportive.
• German measles (Rubella): symptoms include low grade fever, headache, sore throat and lymphadenopathy (post auricular). First vaccine 12 mo.  Treatment = supportive.
• Varicella: symptoms include fever, cough, rash with vesicular lesions at different stages of healing.  First vaccine at 12 mo. Treatment = supportive.
• Erythema infectiosum: nonspecific viral prodrome with slapped cheek rash caused by parvo. Treatment = supportive.  Most dangerous for sickle cell patients and pregnant patients.
• Roseola: characteristic pattern of high fever followed by rash, starting on trunk and spreading outward, caused by HHV6.  Treatment = supportive.
• Hand- foot- mouth disease: non specific viral symptoms with rash, caused by cocksackie.  Treatment = supportive.
• Papular acrodermatitis: immunologic response resulting in pruritic, popular rash in acral distribution often caused by EBV or hep B. Treatment = supportive.
• Scarlet Fever: sandpaper rash which is blanching and popular in the setting of Group A strep. Treatment = amoxicillin x 10 days.
• SSSS/TSS: peeling beefy red skin around moth, armpits, groin.
• Pediatic sepsis: consider the incredible ability to compensate in children.  Be wary of tachycardia not improved by bolus (up to 60 ml/kg of isotonic crystalloid).

Operations updates-

• East wing annex transitions to come May/June.
• Obs unit within the next year.
• 85% on sepsis compliance.

Restraints and Violent Patients:
• Agitation may be caused by a number of reasons including head trauma, hypoxia, infection, delirium, ingestion, psychiatric disorders. Always consider medical causes.
• Deescalating:
o Verbal- be honest and straightforward without be confrontational or threatening.
o Physical restraints- soft restraints, four-point, chest.
o Chemical sedation- offer voluntary administration with medications including IM ketamine, droperidol, haloperidol, midazolam and lorazepam.

Homelessness:
• Rates of homelessness are climbing within Louisville and the US.
• Patients experiencing homelessness are more likely to visit the emergency department.
• What can we offer? Respect, housing/shelter options, considerations to cost, complexity and availability of treatments


US Images:
• Chiari network: embryonic remnant of the sinus venosus which remains in the right atrium and is a benign finding.
• Use US for shoulder blocks with dislocations: palpate spine of scapula, marching out laterally to the acromion. After finding the posterior, inferior edge of the acromion, move two finger widths inferior and medially and inferiorly with injection directed forward towards to the coracoid process. Use 18 G spinal needle injecting 10-20 cc of lidocaine.
• Use US to confirm abscess before incision and drainage. Cellulitis is a clinical diagnosis but seeing a heterogenous collection on US.

Obesity in the ED:
• Obesity is a rising concern, especially in developed countries. Patients suffering from obesity are at increased risk of DM, CVD, HTN, HLD.
• BMI is a measuring tool which compares weight and height but may be lost to the favor of waist to hip ratio when describing obesity.
• Obesity in the ED:
o General interactions- ask permission to discuss weight, use “people first” language, consider bias, provide basic nutritional information, consider food insecurity and provide resources, referrals for physical activity and PCP.
o Airway- obesity creates different challenges regarding airway in the ED. Patients suffering from obesity have decreased respiratory reserve and decreased tolerance for apnea as well as increased airway pressure causing small ox reserve, increased work of breathing, higher risk of aspiration.
o Circulation- be sure blood pressure cuff is appropriately fitting and consider early arterial line. If venous access is difficult to obtain, consider using ultrasound guided lines as well as intraosseous lines.
o EKGs- findings more common in obesity include low voltages, longer QT intervals (not greater than 500), signs of LVH.
o Trauma considerations- more likely to have indeterminate FASTs, xrays are often underpenetrated, and CT scanners do have weight limits.

Tuberculosis by Dr. Marks

Incidence decreasing in the US

Latent TB infection approx. 5% in US. 25% in world

PPD screening:

If >5 mm PPD and immunocompromised = positive

If >10mm and been to high risk country, healthcare worker, or IVDU =positive

Otherwise >15mm = positive

Primary TB usually asymptomatic,

If suspect TB, isolate

Sputum PCR

Gold standard is cultures (6-8wk turnaround)

For latent TP rifampin+isoniazid +pyridoxine for 3 moths

For active TB:

RIPE therapy  8 weeks

Rifampin ,  (orange urine, CP450 induction)

isoniazid,  (B6 deficiency, seizures)

pyrazinamide (hepatotoxicity, hyperuricemia)

Ethambutol (optic neuritis)

Then rifampin/isoniazid for 18 more weeks

TB meningitis- RIPE + dexamethasone

Potts- RIPE + source control

Syphilis by Dr. Coffman

Incidence increasing since 1990.

Increasing in women. Congenital cases increasing.

Primary, Secondary, Tertiary

Painless ulcer on mucus membranes, rash involving hands and feet +nonspecific symptoms,

Jarisch Herxheimer reaction – treat symptoms with tylenol.

PEM: Endocrine by Dr. Magloire

DKA: defined by hyperglycemia, metabolic acidosis, and ketosis

30-40% are new onset T1DM

Risk factors include age <5, reduced access to medical care

Anorexia, N/V, abdominal pain, hyperventilation, dehydration

Often precipitated by missed insulin, acute illness, medications (steroids, antipsychotics)

Assume fluid deficit of 5-10%

Initial fluid bolus then 2 bag method over 24-48

Beware of cerebral edema. Treat with mannitol if developing

Avoid central lines due to increased risk of DVTs

Hypoglycemia:

Children and infants can have quicker shifts in glucose due to high metabolic demand and difference in gluconeogenesis.

If conscious, give 15 g of carbs (juice, glucose tabs etc)

IV D10 bolus if needed

If altered give 2-5ml/kg of D10 bolus, repeat and start infusion if needed

Adrenal Crisis:

Consider in known CAH, hypothalamic axis disorders, prolonged corticosteroid use, other autoimmune disorders, critically ill patients unresponsive to pressors, or neonates with atypical genitalia electrolyte abnormalities, hypoglycemia, hyperpigmentation, cushingoid features

Hyponatremia, hypoglycemia, hyperkalemia

Treat with hydrocortisone 50-100mg/m2 (25mg if <3yo, 50mg if 3-12 yo, 100mg if 12+yo)

Treat hyperkalemia if needed.

Tick-Borne Disease by Dr. Buchanan

Prevention is best

DEET and permethrin

DEET on skin, permethrin on clothes (last 6-8 weeks)

Combination of both decreased mosquito bites by 99%

Remove ticks >36hrs just use forceps.

Lyme – erythema migrans, vector is Ixodes, classic “target” rash. Disseminated disease in 60% if untreated

If bilateral bell’s palsy, treat for Lyme disease

If high clinical suspicion, can use IFA or EIA for testing

IgG +IgM if <1 month from exposure

Doxy+ceftriaxone  if neuro symptoms

STARI – southern tick associated rash illness

Causative organism unknown. Lone Star Tick

Probably best to treat as Lyme

Rocky Mountain Spotted Fever –

Maculopapular rash involving hands and palms. Flu like symptoms

Hyponatremia, transaminitis, thrombocytopenia

Rickettsia Rickettsii

Dermacentor sp. (wood tick or dog tick)

Clinical diagnosis, confirmed with IFA/EIA

Rickettsia Parkeri Rickettsiosis-

Inoculation eschar. Similar labs findings. Less severe disease. Gulf coast ticks

Erlichiosis-  Erlichia sp.

Lone star tick

Flu-like symtpoms

Leukopenia, hyponatremia, transaminitis

Whole blood PCR (most sensitive if <1week).

Otherwise IgG trending

Anaplasmosis –

Ixodes tick. More northeast than erlichiosis

Tick-borne relapsing Fever

Leukoytosis, thrombocytopenia, elevated bilirubin

recurring fevers. Every reccurence less and less severe

Borrelia sp.

Soft shell ticks are the vector. Western US.

Diagnoses with peripheral blood smear. Best checked during a fever.

Treatment for all the above is doxycycline

Babesiosis

Babesia microti. Vector is ixodes tick.

Fever, body aches, Scleral icterus, dark urine,

Transaminitis, anemia, thrombocytopenia, hyperbilirubinemia

Peripheral smear with intracellular organsisms, (maltese cross)

Treatment atovaquone +azithromycin OR Clindamycin + Quinnine

Tularemia

Franscisella tularensis

Vectors -Dermacentor and amblyomma spp.

Fevers, malaise, body aches.

Leukocytosis, thrombocytopenia, hyponatremia, transaminitis, sterile pyuria

Wound and glandular lymphadenopathy, conjunctivitis, oropharyngeal form. Pneumonic form, typhoidal form.

Confirmation by isolation of Tularensis (culture) or seroconversion (IgG/IgM) in paired sera

Treatment is streptomycin

Tick Bite prophylaxis

• Was it an ixodes tick? If no, no ppx
• Is it engorged or attached >36hr> if no, no ppx
• Has it been 72 hours since removal. If yes, no ppx
• Can they take doxy? If no, no ppx
• Is lyme endemic? If no, no ppx

Peds Pharm: PALS Drugs by Dr. Lucking

Bradycardia- atropine (min 0.1, max 0.5mg) epinephrine, treat as PEA if <60

Tachycardia-

• Sinus tach -treat underlying condition
• SVT- vagal maneuver, (ice to face), adenosine (proximal and fast) 0.1mg/kg
• Vtach- cardiovert, amio or procainamide
• Vfib- rare. Same as adults. Amio 5mg/kg

Epi spritzer

Used for brady/hypotension in a patient with a pulse to prevent cardiac arrest

Peri-intubation

0.001mg/kg (1/10 of a code dose)

RSI

If age <1 consider atropine as pre-medication

Historically, lidocaine was given for ICP, however this has fallen out of favor

Fentanyl 1mcg/kg max dose 100mct. Immediate onset, 30-60min duration

Midazolam 0.1mg/kg max 5mg. onset 3-5 mins. Duration <2 hours

Ketamine 2mg/kg. onset 30 seconds. Duration 5-10mins. Contraindicated in <3mo age

Etomidate 0.3mg/kg. does not provide analgesia. Can reduce sz threshold.

Propofol 1-2mg/kg.

Rocuronium 1mg/kg. duration 26-46 minutes

Succinylcholine 1-2mg/kg, hyperkalemia, malignant hypothermia

Endocrine Disorders (Kuzel)

• Hyperthyroidism:
• I.e. Graves Disease (most common), Toxic Multinodular goiter, Thyroiditis, Hashimotos (initially hyperthyroid, followed by hypothyroid) 
• Thyroid storm:
  • 15-50% mortality with tx (80-100% without) 
  • How they die: cardiac dysrhythmias, CHF, hepatic failure, hypotension, cardiovasc collapse
  • Tx: beta blocker (propranolol), thioamide (TPU/methimazole), steroid, iodide; avoid NSAIDs since they increase peripheral thyroid hormone conversion
  • PTU is Preferred because it has earlier onset and safe in Pregnancy 
• Hypothyroidism:
• Most commonly autoimmune, thyroiditis, iodine deficiency, post-ablation, panhypopituitarism 
• Euthyroid sick syndrome = low thyroxine syndrome w/ low or normal TSH, seen in critically ill pts
• Myxedema Coma:
  • 30-60% mortality
  • Often precipitated d/t sepsis, CHF, CVA, hypoxia, ACS
  • SLOW and SWOLE sx = bradycardia, hypotension, hypothermia, myxedema 
  • Tx: steroid, levothyroxine (be careful of dysrhythmias, ACS – give if hypotensive/altered)
• TSH can be helpful in NH patients w/ rapid decline and sx of hypothyroidism, & septic patients w/ refractory shock

Case Review (Loche, McGowan)

• AV fistula – most commonly in anterior forearm/upper arm, needs time to mature (6-12 mo) 
• Eval: should feel thrill; if you don’t feel thrill/pulse, assume thrombosis (get US/doppler) 
• AV fistula bleeding management:
  • Pinpoint pressure, can use bottle cap over bleed to let it clot off, use other adjuncts prn (surgicel, TXA, gelfoam)
  • Figure of 8 suture – DO NOT tie off vessel (damages fistula), just suture the superficial skin with non cutting suture 
  • If heavier bleeding, then do purse string suture 
  • If successful, have them move arm around, make sure it doesn’t rebleed, observe 1-2 hours
  • If you had to suture it or if any other major problems, you should give vascular surgery a call 
• Fistule thrombosis – loss of bruit/thrill, palpable clot
  • Management: Discuss with vascular, may or may not need emergent intervention, may get balloon angioplasty or thrombolysis 
• Pseudoaneurysm/aneurysm – bulging of vessel in outer wall (pseudo) or all layers (true) – get ultrasound, talk with vascular 
• Infection – much higher risk, especially if deeper infxn, need admission for IV abx, call vascular 

Supplements (Huecker) 

• Kefir should be first food of day – lots of good probiotics and vitamins 
• Daily supplement essentials: magnesium!, sunshine/VitD, vit K2, vit C, and iodine 
• Mag threonate is Huecker’s favorite form, oxide is trash; at least 200mg of elemental Mg/day 
• Labdoor.com is a good third party supplement tester
• Vitamin D: Most people need 3000-5000 IU in winter time, or 20 min in sun (if arms, legs, face exposed)
• Vitamin K2: helps prevent fractures, cancer incidence, neurocognitive fx 
• Fish oil: higher ratio of omega 3:6 is better, eating fish is best way to get it