• Anticoagulation in VTE (Dr. Daugherty, PharmD)
  • Heparin à no renal metabolism (helpful in patients with renal failure)
    • Thrombocytopenia, HIT, heparin resistance, hyperkalemia from aldosterone suppression
    • Half-life 30-60 minutes, immediate onset
    • IV administration for VTE, must be administered inpatient
    • Careful monitoring required
  • Enoxaparin (Lovenox, LMWH)
    • Derived from heparin
    • 3-5 hour onset, no monitoring required, patients may self-administer 
    • Similar outcomes compared to heparin with regards to recurrent VTEs, some data suggest lower bleeding risk
    • Renal clearance, avoid in renal dysfunction 
    • Similar precautions as heparin
    • Lower incidence of HIT, but still contraindicated in patients with HIT
    • Subcutaneous dose for VTE
  • Apixaban (Eliquis)
    • Factor Xa inhibitor
    • Half-life 9-14 hours, BID dosing
    • Renal clearance, caution in renal insufficiency
  • Rivaroxaban (Xarelto)
    • Factor Xa inhibitor
    • Half-life 5-19 hours, daily dosing
    • Must be taken with food to be effective
    • Renal clearance, caution in renal insufficiency
  • Dabigatran (Pradaxa)
    • Direct thrombin inhibitor
    • Half-life 12-14 hours
    • VTE dosing after 5 days of bridging, BID dosing
  • 2020 AHS Guidelines on Management of VTE suggests using DOACs over Warfarin
    • Does not apply to all patients
    • AMPLIFY à Eliquis non-inferior to standard therapy (Warfarin, LMWH), less bleeding complications
    • EINSTEIN DVT/PE à Xarelto non-inferior to standard therapy
    • Does not recommend one DOAC vs. another, recommend using patient specific factors to guide clinical decision making
    • Recommends home treatment for patients with uncomplicated DVT
    • 2020 AHS guidelines recommend considering home treatment for patients with low-risk PE (PESI Score risk stratification), conditional recommendation
  • Extremely important to counsel patients when being discharged on these high-risk medications, ensue follow-up and understanding of risks and return precautions

• Pneumomediastinum (Dr. Alia)
  • Presence of free air in the mediastinum
  • Spontaneous (idiopathic, tobacco use, recreational drug use) vs. secondary (i.e. traumatic, iatrogenic) etiologies
  • 30% have normal chest x-rays à CT Chest is preferred diagnostic modality
    • “Continuous diaphragm sign” on XR
  • Management:
    • Treat underlying cause
    • Supportive care à typically resolves spontaneously in 1-2 weeks
  • Disposition:
    • Primary à discharge with PCP follow-up
    • Secondary à management of underlying cause, typically will require admission

• Lung Abscess, Parapneumonic Effusion, Empyema or (Dr. Edwards)
  • Typically polymicrobial, affected tissue at risk for necrosis and cavitation
  • Diagnosed via CXR vs. CT Chest (also recommended following XR diagnosis)
    • Ultrasound helpful for evaluation of effusions and for procedure guidance
  • Obtain blood and sputum cultures (blood cultures frequently negative in empyema)
  • Treatment à empiric antibiotics with anaerobic coverage
    • Empyema, effusions require drainage
    • VATS for complicated effusions and empyema
  • Thoracentesis provides definitive diagnosis for empyema (distinguishes between effusion and empyema) à body fluid cultures and diagnostics must be obtained

• Pneumonia for EM Residents (Dr. Eisenstat)
  • CAP à everything not HAP or VAP
  • HAP à >48 hours from time of admission, previous admission within 90 days
    • Cover for pseudomonas and MRSA
  • VAP à >48 of intubation time, recent previous intubation  
    • Cover for pseudomonas and MRSA
  • Therapy tailored based on sensitivities and culture results
  • Normal vital signs and normal respiratory examination have good negative predictive value in most patients
  • Procalcitonin à good predictor of blood culture positivity
  • Hypoglycemia, lactate à predictors of 28-30 day mortality
  • 2-view chest XR recommended
  • Flu test patients with CAP during flu season
  • Give antibiotics to all patients clinically suspected to have CAP regardless of procalcitonin
  • Clinical judgement + decision tool is best (PSI > CURB-65)
  • Healthy, outpatient à amoxicillin vs. doxycycline vs. macrolide (if local resistance is <25%)
  • Comorbidities, outpatient à Augmentin vs. cephalosporin (cefpodoxime, cefuroxime) AND macrolide vs. doxycycline
    • Monotherapy with respiratory fluoroquinolone also acceptable, but consider risk factors
  • Inpatient treatment of CAP in adults without risk factors for MRSA or Pseudomonas
    • Combination therapy with Beta-lactam + macrolide or doxycycline
    • Monotherapy with respiratory fluoroquinolone
  • Inpatient treatment of severe CAP
    • Beta-lactam + macrolide (ex. Rocephin + azithromycin)
    • Beta-lactam + respiratory fluoroquinolone
  • Coverage of anaerobic pathogens not necessary in admitted patients who are suspected to have aspiration PNA
  • Inpatient treatment of patients with risk factors for MRSA and Pseudomonas à vancomycin or linezolid for MRSA, Zosyn/cefepime/meropenem for Pseudomonas
  • Corticosteroids are unnecessary unless used in patients persistently hypotensive despite IVF and vasopressors (i.e. surviving sepsis guidelines) but evidence is not conclusive
  • Give Tamiflu to patients with CPA who test positive for flu (regardless of inpatient vs. outpatient or duration of symptoms), give antibiotics regardless of flu positivity
  • Antibiotic treatment duration for outpatient treatment of CAP à 5-7 days
  • No follow-up CXR necessary in adults who are improving following treatment

• Pediatric Respiratory Distress (Dr. Poteh)
  • Bronchiolitis
    • <2 years (>2 years is referred to as WARI)
    • Leading cause of hospitalization in infants in the US
    • Symptoms often worsen on day 3-5 of illness and worse at night
    • Hypoxemia occurs from V/Q mismatch from mucus plugging
    • Pathophysiology à infection causes inflammation of the bronchiolar epithelium
    • Commonly causes by RSV, but also caused by other viruses and bacterial infections
    • Exam tricks:
      • Expose trunk
      • Count RR yourself for at least 30 seconds
      • Note signs of respiratory distress
      • Assess activity level (playful, fatigue, lethargic)
      • Assess hydration status (tears, saliva, capillary refill, wet diapers in 24 hours)
      • Check the ears (occasionally have coinfections)
      • Always do an abdominal examination to assess for hepatosplenomegaly
    • Management:
      • Suction! Suction! Suction!
      • CXR unnecessary unless concern for superinfection or clinical picture not consistent with typical bronchiolitis (prolonged symptoms, high fevers, persistent hypoxia) à atelectasis and peribronchial cuffing on CXR if obtained
      • Viral testing is not always necessary (exception: influenza, COVID-19, RSV <1 month causes apnea)
      • Respiratory support
      • Dexamethasone in patients <1yo with no history of wheezing did not demonstrate benefit
      • Albuterol has not been shown to benefit patients
    • Bronchiolitis Score is helpful with risk stratification
    • Discharge Criteria
      • O2 saturation >90% while awake
      • Adequate PO intake
      • Mild/moderate work of breathing
      • Reliable caretaker
      • Timely pediatrician follow-up in 1-2 days
    • Admission Criteria
      • Hypoxemia
      • Severe respiratory distress
      • Apnea
      • High-risk patients
      • Poor oral intake
      • Parents uncomfortable with discharge
    • Consider intubation if…
      • Recurrent apnea
      • Declining mental status
      • Not improving with respiratory support
  • Asthma Exacerbation    
    • Antibody binds antigen à release of histamine/leukotrienes à inflammation à bronchospasm
    • Pediatric Respiratory Assessment Measure (PRAM) is helpful for risk stratification
    • Timing of medications is key!
    • CXR is not required unless concern for complicating factors
    • Management:
      • Beta-2 agonists 
        • Albuterol à MDI vs. nebulizer
          • Always use a spacer!
          • Short vs. 1-hour long vs. continuous albuterol nebulizer
          • Discharge à take 4 puffs every 4 hours for the next 48 hours, then as needed after that
          • Remember to write for MDI with spacer if discharging with albuterol prescription
        • Terbutaline à IV vs. SQ
      • Corticosteroids à mainstay of treatment considering the pathophysiology
        • Dexamethasone
        • Prednisone/prednisolone
        • Methylprednisolone
      • Ipratropium nebulizer
        • Anticholinergic
        • Often used in conjunction with albuterol nebulizer
      • Magnesium sulfate
        • Smooth-muscle relaxer
        • Can cause smooth-muscle relaxation in the vasculature à hypotension (consider IVF bolus)
      • Epinephrine à anaphylaxis dosing
    • Admission Criteria
      • Requiring >1 1-hour long albuterol
      • Respiratory distress
      • Hypoxemia (O2 <92%)
      • Dehydration
  • Croup (laryngotracheobronchitis à upper airway)
    • Acute subglottic inflammation
      • Morbidity is greatest in 1^st year of life due to narrower subglottic airway
    • Affects children aged 6-36 months
    • Classically caused by parainfluenza virus, but also caused by many other viruses
    • Clinical presentation:
      • Barky cough
      • Inspiratory stridor (more concerning if occurring at rest)
      • Tachypnea
      • Suprasternal retractions (hypoxia, intercostal retractions, abnormal breath sounds, subcostal retractions are uncommon à croup is a disease of the upper airway, if hypoxia is present and lungs are clear to auscultation there should be high concern for impending upper airway compromise)
      • Low-grade fever
    • Management
      • Dexamethasone
      • Racemic epinephrine for resting stridor or respiratory distress (can repeat every 15-20 minutes)
      • Monitor for 3-4 hours prior to discharge if administering racemic epinephrine à admit for refractory stridor or if repeat dosing of racemic epinephrine is required
      • Consider Heliox for severe respiratory distress as it decreases turbulent flow

• Documentation Lecture (Ashley Chesman)
  • Critical Care Documentation
    • 7.2% of all ED visits reported to Medicare in 2019 were reported as critical care
    • Time at bedside, but also time spent engaged in work directly related to the patient’s care:
      • Reviewing test results and imaging studies
      • Consulting services
      • Placing orders
    • Procedures billed separately
    • Billings starts at 30 minutes à critical care time requests <30 minutes may not be compensated  
    • E/M and Critical Care Same Date of Service
      • Can now bill for E/M and Critical Care on the same date/visit
      • Documentation must support decompensation to a state requiring critical care
    • Remember to document critical care time beginning in residency!

• Subclavian Central Venous Lines (Drs. Nichols and Leavitt)
  • Contraindications
    • Overlying infection
    • Anatomic obstruction
    • Fracture of ipsilateral clavicle
    • Relative à coagulopathy (harder to compress and apply pressure to the subclavian site)
  • Complications
    • Arterial injury
    • Pneumothorax
    • Air embolism
    • Cardiac dysrhythmia
    • Infection
    • Bleeding
  • Supra- vs. Infraclavicular Subclavian Access
    • Infraclavicular
      • Utilizes short-axis ultrasound
      • Index finger on the sternal notch and thumb at the midpoint of the clavicle at the angle
      • Make contact with the clavicle and “walk-down” and pass under the clavicle vs. insert needle further laterally to avoid having to “walk-down” the clavicle
      • Ultrasound assisted technique utilizes short-axis
    • Supraclavicular
      • Well-defined landmarks (claviculo-SCM angle)
        • 1 cm superior and 1 cm lateral to the claviculo-SCM angle
        • 5-15 degrees above the coronal plane
        • Don’t advance past 3 cm
        • Ultrasound assisted technique utilizes long-axis as opposed to the short-axes
      • Shorter distance from skin to vein
      • Larger target area
      • Straighter path to the SVC
      • Less proximity to the lung
      • Fewer complications compared to infraclavicular
      • Found to be non-inferior to the infraclavicular approach

04/06/2022

• Lightning Lectures – Pulmonary Cases (Drs. Bishop and Slaven)
  • Tuberculosis
    • TB concern à NAAT + sputum cultures to assist with diagnosis (95% sensitive)
      • Negative pressure room with airborne precautions, PPE precautions for providers, HIV test if TB suspected  
    • Mycobacterium tuberculosis à aerobic rod, highly antigenic à can disseminate systemically if initial granuloma formation fails to contain the infection
    • Immunocompromised population at highest risk (2x)
    • bCG vaccine recipients all have positive TB skin tests (PPD)
    • Interferon test does not distinguish between latent and active TB
    • Active TB àINH, RIF, pyrizanimide, ethambutol x8 weeks à INH/RIF x18 weeks + B6
      • Hepatotoxicity
    • Latent TB à INH x9 months + B6
    • Must contact Public Health Department prior to discharge
  • Spontaneous Pneumothorax
    • Sudden pleuritic chest pain, increased work of breathing, hypoxia
    • DDx with examination + upright CXR
      • CT chest is very sensitive/specific but takes time to obtain
      • Consider US
    • Management:
      • Supplemental O2
      • Unstable à Decompression (treatment for tension PTX)
      • Stable, small à consider observation 4-6 hours, repeat CXR, must ensure follow-up within 24 hours à admit any recurrent or complicated PTX
      • Admit everything else and all PTX caused by comorbidities
• Inhaled Intoxicants (Dr. Eisenstat)
  • Huffing/bagging à toluene is intoxicating substance (higher in gold and silver paints)
    • Can cause NAGMA, renal tubular acidosis, hypokalemia, chronic encephalopathy
    • Sudden sniffing death syndrome à hydrocarbon (huffing) + high levels of catecholamine surge à death
      • Generally not recommended to use epinephrine/norepinephrine in patients suspected of hydrocarbon toxicity
  • Aluminum encephalopathy from black tar heroin use à basal ganglia lesions on MRI
  • High water solubility à chlorine, tear gases, ammonia (mucous membrane effects)
  • Low water solubility à phosgene, chloramine, nitrogen dioxide (delayed pulmonary edema)
  • Phosphine gas/aluminum phosphide à occurs when aluminum phosphide interacts with moisture à can expose providers during ventilation efforts/resuscitation
  • Nitrogen dioxide à silo fillers
  • Phosgene à choking agent, delayed pulmonary edema
  • Tear gases à OC spray AKA pepper spray AKA mace à capsaicin-based tear gas à causes severe burning and irritation, CS (military grade) is more potent
    • Treatment is irritation (consider Morgan lens for eye involvement)
  • Organophosphates à nerve agents àdecontamination, atropine, pralidoxime, supportive care
  • Asphyxiants à methane, propane, argon gas à sudden collapse, helper also collapses, etc.
  • Carbon monoxide à can be high in smokers (COHgb of 10) and large cities
    • Treatment is controversial à begins with O2 therapy (100% FiO2, NRBM)
    • Consider hyperbaric in COHgb levels >25 (15 in pregnant patients due to fetal Hgb affinity for CO) or signs of organ dysfunction (AMS, NSTEMI)
    • The reason for HBO therapy is to reduce long-term symptoms, which are often delayed (up to 6-8 weeks), not life-saving
  • Cyanide à combustion of nitriles in house fires à leads to unconsciousness and CV collapse à elevated lactate (>8 with ingestion, >10 in house fires) with high suspicion
    • Amyl nitrite (induces methemoglobinemia) vs. Hydroxocobalamin/Cyanokit (safer, colors urine organe/red) with levels >8 
  • Hydrogen sulfide à cellular asphyxiant similar to cyanide à rotten-egg smell in low concentrations (odorless in high concentrations), used in chemical suicide

• COPD and Asthma Cases (Dr. French)
  • COPD à titrate goal O2 to 88-92%
  • Patients need PPV
  • Antibiotics for COPD exacerbation à some evidence for reduced rate of readmission/representation
  • Remember to consider breath-stacking/auto-PEEP in MV
  • PRAM Score for asthma exacerbation à follow-up 3 hours with additional PRAM Score, can assist with disposition planning
    • PRAM >12 à marker of impending respiratory failure

• ED Management of Brain Aneurisms (Dr. Ding)
  • Unstable à repair
  • Stable à timely outpatient follow-up
  • 1/3 will die, 1/3 will be self-sufficient at discharge, 1/3 will have poor recovery
  • Surgery (clip) vs. endovascular (coiling)
    • Treatment modality depends on multiple factors à age, medical comorbidities, multiple aneurisms, location, size, symptoms
  • Which aneurisms will rupture à location (anterior communicating, posterior communicating aa. higher risk) vs. size of aneurism vs. risk factors vs. family history vs. connective tissue disease/AAA vs. stress vs. growth of aneurism  
  • Enlarging and symptomatic unruptured aneurisms should be treated
  • Before/after stent-coiling or flow diversion à DAPT
  • Consult NES for incidentally found aneurisms on imaging, both admitted and discharged
  • CTA/MRA for history of aneurism and symptoms
  • Consider SAH in post-coital headache 
  • Don’t forget about LP vs. MRI in patients suspicious for SAH with negative CT/CTA