Lightning Lecture – Necrotizing Fasciitis
– Fournier’s Gangrene – polymicrobial, associated with T2DM, if on SGLT2 inhibitor they are at higher risk
– If have any suspicion at all, consult surgery immediately
– Use broad spectrum ABx – vancomycin + Meropenum or Zosyn + Clindamycin
– Additional Therapies: IVF, Tdap booster, pRBCs if needed
– Hyperbarics and/or IVIG is controversial
– Factors that increase mortality – WBC>30000, Creatinine >2, Age >60, TSSS, Clostridial infection, Delay in surgery >24 hours

Lightning Lecture – Skin Cancers
– Basal Cell Carcinoma is the most common type and it is the least aggressive form
– Rarely metastasizes
– White skinned people are the most affected
– More common in older individuals and men
– Biggest risk factor is exposure to UV light, possibly more important in childhood years
– Nodular BCC is the most common type
– If noted in the ED, referred to dermatology
– Cutaneous Squamous Cell Carcinoma
– More malignant
– Affects white individuals more
– Same risk factors
– Cutaneous SCC in situ (Bowen’s Disease) is erythematous, well-demarcated scaly plaque
– Diagnosis based on skin exam and biopsy
– IF seen in the ED, refer to Dermatology
– Melanoma
– 5th most common cancer in men and women in the US
– Survival depends on when it is diagnosed
– ABCDE criteria
– Management – refer to dermatology
– LDH levels can be elevated if metastatic
– Most common site of mets = LN, skin, lung, liver, brain
– Karposi Sarcoma
– AIDS-defining illness
– Vascular tumor associated with HHV8
– Typically develops in those with CD4 counts less than 200
– Corticosteroid use increases the risk for development of KS undergoing organ transplant or those with lymph-proliferative disorders
– If noted in the ED, bigger concern is significant immunocompromised state

Discussion of Burn/Wound Care Dressings
– Adaptic – vaseline impregnated gauze – applied after a topical ointment
– Cuticerin is the same as adaptic but it is typically larger – impregnanted with aqua-phor
– Vaseline Gauze – larger sizes, impregnanted with more vaseline than adaptic
– Mepilex can be used for up to 7 days technically – silicone based dressing – great simple dressing for a smaller burn wound
– SSD is a sulfa drug and is oculo-toxic so it is not recommended for for face and/or hands, bacitracin is typically a safe option

Caustics Lecture
– Caustic = any xenobiotic that causes functional and histologic tissue damage
– Kids are more likely to be damaged with ingestions due to smaller areas of mucosa, so burns are relatively larger to body area
– Ophthalmic Exposure
– Irrigate, irrigate, irrigate
– Morgan lens vs taping a cut IV near the eyelids
– No intervention really reduces injury from a caustic ingestion
– Some evidence that steroids may help reduce GI strictures down the line but evidence is flimsy but may also harm
– Do not neutralize acids with a base due to exothermic reaction
– Prophylatic ABx is not warranted
– When to scope for ingestion – early but not too early
– <12 hours may be too quick for tissue injury to fully demarcate
– >72 hours may be too late because tissue is weakest at this time and iatrogenic injury is more likely
– The presence of oral injury does not correlate/indicate the degree of mucosal involvement further along in the GI tract
– If evidence of perforation – don’t call GI, call cardiothoracic surgery and/or general surgery
– Persistence of symptoms, intentional ingestions should normally be scoped
– If a kid with unintentional ingestion looks good, is tolerating po intake, and is observed for a few hours, can go home
– Hydrofluoric Acid is bad
– Systemically – drops concentration of calcium significantly – time of onset is inversely related to concentration
– Higher concentration is quicker
– Greater than 50% concentration will likely cause immediate injury
– Give calcium and magnesium as quickly as possible
– Place a central line for calcium chloride rather than gluconate
– Keep giving calcium until vtach and/or vfib resolves
– Start calcium and mag immediately
– Can reduce dermal absorption with calcium gluconate gel – if no gel, then can grind up tums in aquaphor and/or bacitracin
– If a hand, fill a glove with this calcium gel

PALS vs ACLS Lecture
– When to pick which one? if over 50 kilos, typically use adult dosing
– PALS – Bradycardia Pathway
– Causes – hypothermia, hypoxia, and/or medications
– Treatment – oxygenation, epinephrine, atropine
– Start CPR is HR is less than 60bpm in neonates/infants
– Young kids are heart rate dependent, cannot compensate as well
– Atropine max dose is reduced in PALS vs ACLS
– Weight Based dosing with adenosine (up to 6mg, 12mg, and/or possibly 18mg)
– Procainimide and/or amiodarone are also options for SVT as well
– PALS – pulseless arrhythmia – epi + shock
– 5mg/kg of Amiodarone for pediatric patients but no clear max per PALS algorithm
– Endotracheal epinephrine (max 2.5mg) due to lower rate of absorption – followed by 3-5 puffs of positive pressure ventilation
– Asystole/PEA pathway is the same
– Give Epi after a pulse check if it is due around time of pulse check for maximum effect
– Rapid Sequence Intubation
– Pre-mediation
– Atropine – children under the age of 1 year of age to prevent bradycardia
– Max dose of 0.5mg in child, 1mg in adolescent
– Dose is 0.02mg/kg
– Lidocaine – controversial and falling out of favor
– Dose is 1mg/kg
– Max dose is 100mg
– Adverse effects are bradycardia and hypotension so may be more harm than good
– Pain/Sedation Medications
– Midazolam – Gaba agonist
– Dose 0.1mg/kg
– Fentanyl – Mu opioid receptor
– Dose 1mcg/kg
– Max dose is 100mcg
– High Dose therapy is 5mcg/kg
– Should be given slowly over 2-5 minutes to prevent chest wall rigidity
– Ketamine
– Dose 0.5-3mg/kg – usually 2mg/kg for intubation
– Possible increase in ICP but more likely increases CCP rather than ICP
– Causes a lot of secretions when given to younger individuals
– No data in those less than 3 months of age
– Etomidate
– stimulates GABA receptors to block neuroexcitation
– Dose 0.2 – 0.6mg/kg – max dose 20mg
– Does cause some adrenal suppresion, so not perfect in those with sepsis
– Propofol
– GABA agonism and decreased glutamatergic activity via NMDA receptor blockade
– Rocuconium
– non-depolarizing blocker
– Dose 1mg/kg
– Half-life of 30-45 minutes
– Succinylcholine
– depolarizing neuromuscular blocker
– Dose 1-2 mg/kg (max 200mg)
– Increased ICP

Cocaine Lecture
– Amphetamines push out more neurotransmitters whereas cocaine blocks re-uptake
– Functions as a norepinephrine re-uptake blocker
– The only local anesthetic agent that is also a vasoconstrictor
– Cocaine can cause a brief transient bradycardia secondary to stimulation of the vagal nuclei followed by a quick tachycardia
– Microwave cocaine + baking powder = crack cocaine which can now be smoked
– Cocaine effects – persistent rhinitis, intra-nasal erosions, epistaxis, crack eye (ulceration from crack smoke)
– Increases body temperature – hyperthermia not a fever – worsened by psychomotor agitation and vasoconstriction at the skin
– Elevated core body temperature is directly linked to mortality
– Can develop seizures from cocaine – sympathomimetic effect and sodium blocking effect (same at TCAs)
– Cocaine increased risk of strokes, myocardial infarction (risk >24x in the hour after ingestion)
– Cocaine affects gestational birth weight, fetal growth, and the likelihood of a term delivery
– Also increases the risks of abruption, spontaneous abortions, and IUGR
– No real decon strategies for people with traditional use
– Decon strategy for a packer/stuffer – whole bowel irrigation to help move the packets along
– Do not use if any evidence of gut wall ischemia is present as this could lead to perforation
– If a packer has evidence of ruptured packet, needs to go to the OR stat
– No role for dantrolene if a patient is hyperthermic from cocaine overdose
– Start cooling around 105, stop around 101