Dr.Baker- Knobology

ALARA- As Low As Reasonably Achievable

High Frequency Probe- Good for superficial structures, High Resolution

Low Frequency Probe-Good for deeper structures, Low Resolution

Gain- Brightness

Depth

Zoom

Use these three to make your image clearer

Hyperechoic- Brighter (More echogenicity) than surrounding area

Hypoechoic- Darker (Less echogenicity) than surrounding area

Isoechoic-Same color (Same echogenicity) as surrounding area

Anechoic- Black. No color at all (No echogenicity)

Dr.Neal, PharmD- Sepsis  and Antibiotics

Sepsis- Life threatening organ dysfunction secondary to unregulated host response to infection

SIRS- hypo or hyperthermic, tachypnea, tachycardia, leukocytosis

Septic shock- Infection requiring vasopressors despite adequate fluid resuscitation

Good empiric choice should cover 80% of the bug you’re suspecting, based on local antibiogram

Give bacterial meningitis patients steroids to help reduce risk of side effects of infection (deafness, etc.)

Use source to guide your empiric antibiotic therapy

Dr.Howell, PharmD- Fluids and Vasopressors in Septic Shock

Maintain MAP > 65

30cc/kg bolus of fluids if hypotensive or lactate greater than 4.

Must document why if you give less

If fluids don’t maintain pressure, start vasopressors

Hypotension is due to decrease in systemic vascular resistance, use pressors that increase SVR

Norepinephrine is safe to start peripherally

Norepi is 1^st line for septic shock

Vasopressin is 2^nd line

Epi vs phenylephrine is 3^rd/ 4^th line, depending on scenario

Dr. Senn, PharmD- Rapid Sequence Intubation

Etomidate- GABA receptors, .3mg/kg, onset 30-60secs, duration 5-1min, minimal side effects of hemodynamics, may cause myoclonus. May cause some adrenal suppression but clinical relevance unclear

Propofol- GABA receptors, 1-1.5mg/kg, onset 10-30secs, duration 3-10min, may cause hypotension

Ketamine- NMDA receptors, 1-2mg/kg IV, onset 30-60sec, Duration 5-15min, Sympathomimetic and may cause hypersalivation

Succinylcholine- Depolarizing agent, 1-2mg/kg, onset 45-60secs (look for fasciculations), Duration 10-15min, may cause hypotension, causes hyperkalemia about .5-1 mEq rise transiently, may also cause malignant hyperthermia, use with care in peds due to underlying muscular dystrophy

Rocuronium- Nondepolarizing agent, .6-1.2mg/kg, onset 60-120s, Duration 30-45min

Vecuronium- Nondepolarizing agent,.08-.1mg/kg, onset 2-3min, Duration30-50min, may cause hypothermia

Have post-intubation sedation meds ready when asking for intubation drugs, do not want patient paralyzed but not sedated

Dr. Cook- Room 9 Follow Up

AMS in young person – Concern for toxidrome. But keep wide differential.

Prolonged QTc. Look at T-wave as it related to QRS complexes, if greater than halfway between two QRS complexes, think prolonged.

Serotonin Syndrome- Nystagmus, Sustained Clonus, elevated BP, HR, Respiratory Rate, Hyperthermia, Altered Mental Status, Diaphoresis.

Hunter’s Criteria to help diagnose.

Treatment = Stop offending medication, supportive care, Benzos

In TCA overdose, treatment for EKG changes is bicarb. Serial EKG’s to monitor following bicarb administration.

Dr. Lund- Peds ED

See sicker patients first

Lots of order sets for specific cases (neonatal fever, DKA, Asthma, etc.)

Vaccine status very important

Finish notes within 24 hours

All medical subspecialties aside from heme/onc admit to JFK (medicine)

Newborns eat 2oz every 2 hours on average

1 month oz, 4oz every 4 hours on average

Newborns may poop once a week or multiple times a day

Ibuprofen/Tylenol 10mg/kg every 6 hours, Ibuprofen > 3 months, Tylenol any age

Versed PO dose 1mg/kg, IV .1mg/kg, IN .2-.3mg/kg

Morphine .1mg/kg

Fentanyl 1mcg/kg

Need high dose amox to kill strep pneumo (pneumonia, AOM)

Bolus = 20cc/kg

Sepsis= 60cc/kg in first hour

Dr. Ferko- Shock

Shock = Hypoperfusion

Signs of shock – hypotension, tachycardia, decreased urine output, altered mental status

Types of shock- cardiogenic, obstructive, distributive, hypovolemic

Distributive shock- Example is sepsis. Inappropriate vasodilation.

Use lactic and blood pressure to determine severity of sepsis. Severe sepsis needs 30cc/kg bolus

Norepinephrine is first line. Vasopressin 2^nd line. Then epinephrine or phenylephrine.

Cardiogenic shock- Most likely caused by acute MI. Severe decrease in cardiac output.

Norepinephrine is first line pressor again (pretty much first line for all shocks)

Distributive shock- Another example is distributive shock. Again, inappropriate vasodilation. Also classically involves no appropriate increase in cardiac output

Hypovolemic shock- In trauma, number one cause of shock. Treatment is blood or fluids, depending on cause of hypovolemia

Obstructive shock- Example is cardiac tamponade or tension pneumothorax. Decrease in cardiac output secondary to physical obstruction. Treatment is to relieve the obstruction.

Dr. Danzl- Law and Emergency Medicine

Document everything you do

When in doubt, treat the patient

Be kind and compassionate to your patients

Do everything you can to prevent patients leaving AMA. Give them the best chance to succeed if leaving AMA (give follow up, antibiotics as needed, etc.)

Take x-rays of all foreign bodies

Be sure patient can walk prior to discharge if they can normally walk

Always get a pregnancy test in women of childbearing age

Room 9 Introduction by Dr. Harmon

Interns- Expose patient. ABC handled by upper level this early in year. Don’t cut clothes if you don’t have to

EFAST- Save lots of clips. Ask for help. Diagnostic exams can be pulled into chart. Educational can’t.

Cardiac view first in penetrating trauma. RUQ in blunt trauma.

If you don’t know where stuff is in room 9, ask

PGY2- Do they need a man scan? Vital signs? Open fracture? All reasons to keep in room 9

Stroke- Get last known normal. 10min to get to CT. Expedite neuro exam. Stroke attending will want BP, glucose, hx of stroke, blood thinners.

EMS Introduction / Radio Calls by Dr. Orthober

Types of EMS/EMS providers. EMT (no procedures) vs Paramedic (procedures)

Taking calls – Get Vitals. Decide triage vs room 9 vs see in room 9 and decide

Answering helicopter calls, speaker vs phone call

Be professional on calls

3 types of “death” that must be transported. Hypothermia, Cold water drowning, Electrical

Transfer of Care by Dr. Platt

Happens all the time during a patient’s stay

Be professional

IPASS

When receiving, try to dictate ToC note yourself

Try to avoid doing ICU care to get patient to medical service

Sign out AMR patients

Be aware of patients coming from EPS. If you take call from EPS, you find patient on cerner and put your name on it

Healthcare Disparities by Dr. Eisenstat

Equality vs equity. Similar opportunities vs Similar outcomes.

People come from different walks of life and it affects your healthcare

Most people experiencing homelessness are temporary. 27% are “chronically homeless”

People experiencing homelessness have life expectancy 10-15 years less than their non-homeless counterparts

Tuskegee Experiments went on from the 1930’s until 1972. We knew penicillin could treat at the beginning.

Think about bias in triage patients

Be compassionate