Prostatitis:

                   – E. coli in 80% of acute cases (chronic more common), others: STD pathogens

                   – Dx: DRE tender prostate, labs not always helpful

                                      – CT scan only if suspicion for prostate abscess

                   – Rx: 4 wk course of antibx with follow up with urology

Testicular Torsion:

                   – 2 types: Extra-vaginal torsion: neonates. Intravaginal torsion: adolescents

                   – Gold standard dx: surgery, scrotal Doppler US sensitivity about 86-92%

                   – Twist Score: helps determine high vs low risk for torsion

                   – Rx: Urology/OR, manual detorsion: open book 540-720 degrees

Chest Tube procedure sim:

                   – CT choices: 24F for viscous fluid and pigtail for uncomplicated PTX

                                      – Use own judgement

                   –  Can give 2g Ancef

                   – Go in about 10-12cm

GU Trauma: Dr. Huecker:

                   – 2019 model of clinical practice of emergency medicine

                   – Renal injury: Some injuries have no hematuria

                                      – gross hematuria, elderly, penetrating trauma

                                      – Injury classification >4 laceration into collection system go to surgery typically

                   – Ureter Injury: Iatrogenic 80%, penetrating trauma 18%

                   – Bladder: associated with pelvic fractures

                                      – needs CT cystography, RUG

                                      – Depends on intraperitoneal (needs surgery) vs extra (may not need surgery)

                   – Genitals: need good PE

                   – Pelvic injuries:

                                      – lateral compression, anterior/post, vertical shear

                                                         – binders with AP compression

Check out this great article about nurse intuition on acuity level of patients. Link posted by Sam Ghali, MD who you should follow on Twitter. TL;DR Listen to the nurses!

The study asked nurses in 2 medical and 2 surgical units in Rochester, MN to score patients based on a 5 point “Worry Factor.” Basically deciding sick or not sick. 31,000 shifts in 3551 hospital admissions. The Worry Factor was highly accurate, with a LR of ICU transfer of 17.8 for WF>2 and LR 40.4 for WF>3. Accuracy was higher for RNs with more experience. AUROC was 0.92 for ICU transfer in 24 hours. The article specifies that they couldn’t assert whether RNs used intuition or analytical skills (something our Gut Instinct study DID try to determine).

This paper reminds me of an article I wrote a few years ago about a teaching tool for the ED, asking EM residents to decide admit vs discharge (or try to guess diagnosis, etc,) the moment they see a patient.

The references for this article are fantastic as well. Multiple primary sources and reviews on the various scores MEWS, NEWS, EWS, etc that try to identify who will decompensate in the hospital. I like to think ER nurses and doctors are especially skilled here, although we should be better about following up on patients we admit. You called the ICU and they deflected to PCU: check the chart the next couple of days, were you right or wrong? That feedback is necessary to modify your mental models and learn. At least 5 of the references cover Nurse Worry, including one systematic literature review and one prospective trial in Denmark. The references also go into intuition, expertise, they even cite the book Thinking Fast and Slow, our inspiration for the Gut Instinct abstract that was presented by Carter and Giddings.

I have had this meme in my head for a while but don’t think I ever made it or saw it on the Internet. Maybe it will go nerd viral.

As I have lectured in didactics, a paradigm shift is taking place toward the OMI vs nonOMI, and perhaps moving away from STEMI vs nSTEMI.

The ACC may be getting on board with this change that began with ER docs, chiefly Stephen Smith at Hennepin. *Unstable Angina still exists.

Check out his tweet linking to the paper:

1/2 For first time, the Am Coll of Cardiology recognizes Occlusion MI in clinical guidelines (and references our first of many OMI/NOMI studies: Meyers HP, … Smith SW. Comparison of STEMI vs. NSTEMI & OMI vs. NOMI Paradigms of AMI. J Emerg Med 2020) https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

2/2 And also, for the first time in any Guideline (as far as I know), they recommend EKG criteria that were developed by an Emergency Physician (Smith Modified Sgarbossa Criteria). Page 7 of the pdf, references 10, 11, 21. https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

• Alaina: Room 9 M&M:
  • Symptomatic Bradycardia:
    • Atropine -> transcutaneous pacing -> Transvenous pacing
  • Bifascicular Block: extensive fibrosis of conducting system – if presenting with syncope high risk need to admit due to high risk of complete heart block
• Status Epilepticus in Peds:
  • Give kids a first pass for first seizure if unprovoked and simple and otherwise well-appearing child
  • Status Treatment: Def: >5 min or back to back without normal mental status between
    • 1st line meds:
      • Ativan: 0.1mg/kg max 4mg IV, takes about 2-5 min to work last 4-6 hours
      • Versed: 0.2mg/kg with max 10mg IM or 0.2mg/kg IN divided btwn both nostrils, stops seizures in less than 1 min
      • Diastat: 0.5mg/kg with max of 20mg rectally
      • Phenobarbital: 1st line in neonates (<1mo) 20mg/kg with max of 1000mg
    • If still seizing give 2nd dose after 5 min
    • 2nd line:
      • Keppra 60mg/kg IV with max 4500mg
      • Fosphenytoin 20mg/kg IV with max 1500mg
      • Valproic Acid: 40mg/kg IV with max of 3000mg
    • If still seizing 10 min after 1st and 2nd line then go 3rd line:
      • Pentobarbital 15mg/kg bolus with infusion of 5mg/kg/hr IV – will need to intubate patient/PICU
  • Pyridoxine for refractory seizures
  • Neonatal Seizures and infants less than 6mo: many are subclinical and not normal seizure activity
    • check glucose and electrolytes and septic workup (with LP) and antibx plus acyclovir
  • Febrile Seizures: 100.4 and above 6mo-5yo with normal neuro exam and have a seizure while febrile – not seizure then febrile afterwards
    • 30% chance of having another, 2-3% chance of developing epilepsy
    • Simple if <15min not recurrent/need to be vaccinated/GTC – give supportive care (tylenol/ibuprofen) – okay for DC home
    • Complex: >15min with more than 1 seizure in 24 hrs/focal seizure – admit
• Hyperkalemia/Hemodialysis
  • Causes: kidney/CKD, intake, tissue damage/leakage, endocrine (Addison’s/adrenal insuf)
  • Rate of change in potassium is more important than actual number
  • Treatment:
    • Calcium – 3g CaGlu or 1g CaCl stabilizes cardiac membrane/stabilizes voltage across membrane
    • Insulin – shifts potassium into cells through activation of ATPase 10 U plus 25g glucose decreases K by 1mEq/L
    • Albuterol: shifts potassium into cell by activation of ATPase decreases by about 0.5mEq/L – 15-20mg neb
    • Bicarb: Only use in Metabolic Acidosis otherwise do not give – doesn’t really decrease K until later in the course
    • Remove K: Lasix/Bumex, BInders/Lokelma renal likes – do not usually give in ED
    • Dialysis: Takes 60 min to decrease by 1 mEq/L
  • Succinylcholine: healthy people increases 0.5 per dose
  • Emergent Dialysis: A: acidosis, E: electrolytes, I: Ingestions/intoxicaitons, O: overload fluid, U: uremia (encephalopathy, pericarditis)
    • Chronic Dialysis Patient:
      • Electrolyte abnorm
      • Volume overload
      • Remove toxins/BUN/acidosis
    • Acute Renal Failure:
      • Electrolyte abnorm
    • Normal Renal Fxn:
      • Ingestions
  • Dialysis Basics:
    • Small molecule
    • Charged
    • Examples:
      • Toxic Alc: methanol and ethylene glycol
      • Lithium
      • ASA/Salicylates
      • Valproic Acid

Conference Notes:

Lightning Lectures:

– Priapism: 3 types Ischemic (emergent and most common), non ischemic (trauma/fistula/congenital), stuttering. Common causes: adult medications, children SCD. Dx with PE/blood aspiration/US. Tx: phenylephrine/aspiration.

– Epididymitis: Causes are mostly STI organisms and E. coli. Acute less than 6 weeks. Orchitis: usually with epididymitis. Dx: US to rule-out torsion if suspected, gram stain, MB, GV, UA. TX: Ceftriaxone, Doxy if enteric organisms suspected Ceftriaxone and Levofloxacin. Can be associated with nec fasc. Chronic greater than 6 weeks: most common cause TB will need urology consult.

Dr. Eisenstat Lecture:

– Med Safety: PD vs PK – ADME absorption (bioavailability: IV is 100%, not affected by age, mostly by route and other drugs/diseases), distribution (volume of distribution less than 1 = more in serum, elderly have less water and more fat and less albumin which increases volume of distribution and free drug respectively), metabolism (enzymes), elimination (liver vs renal). T1/2: half life, time which is required to for initial concentration to decrease by 0.5 (changed by metabolism or elimination). Elderly high risk for adversed drug events ADE. Beers List: opioids, SSRI, TCA, anti-cholinergics, anticoags, benzos, anti-pysch, others.

Dr. Price Lecture:

– Is that your final Answer?: paramedics are trained in determining death on scene.

– Urolithiasis: Imaging: CT vs US: looking for hydronephrosis or hydroureter on US, non-con CT most sens and spec for stones. Who to image: no hx of stones, older age, complications (fever, infection on UA, transplanted kidney/solitary kidney, AKI), Management: pain ctr, labs, imaging, medical expulsion therapy. Look for other causes of symptoms.

Cystitis and Pyelonephritis:

– Cystitis: signs and symptoms: hematuria, CVA, back pain, freq, dysuria (in males think prostatitis). Urine dipstick: nitrites very spec not sens, leukocyte esterase most sens not spec, for a dipstick test when both are negative post-test prob at 5% . Asympto bacteriuria: no need to rx unless preg/urologic surgeries/transplant kidney.

– Pyelonephritis: UTI plus CVA/fevers/N/V – will need urine cultures drawn and antibx coverage. Most can be DC home unless unable to tolerate PO or septic

– Rx: uncomplicated: Macrobid, TMP-SMX, fosfomycin, cephalexin. Complicated: Cipro, Levo, TMP-SMX plus all these should get 1 dose of IV antibx (usually ceftriaxone)

Flow chart to be posted in Room9er