Ejection Fraction and Cardiac Imaging with Dr. Baker

• Normal EF findings on POCUS – wall thickening and symmetric contraction during systole, anterior leaflet of mitral valve slapping interventricular septum
• Ways to calculate EF using POCUS
• EPSS = End point septal separation
  • Less than 7 mm = normal
  • Greater than 10 mm = reduced EF
• Fractional shortening – measures LV in systole and diastole
• Fractional area change – uses RV volumes in end systole and end diastole to calculate EF
• Simpson Biplane method – US will calculate change in volume of the LV between end diastole and end systole

Lightning Lectures with Drs. Gellert and Wells

• Ludwig’s Angina
  • Rapidly progressive gangrenous cellulitis of the submandibular spaces
  • Polymicrobial
  • Clinical diagnosis, imaging not required
  • Management
    • Airway – preferred awake fiberoptic intubation
    • Antibiotics – Unasyn OR Rocephin + Vanc OR Clindamycin
    • Surgical – Tooth extraction, debridement
• Retropharyngeal Abscess
  • Abscess between posterior pharyngeal wall and prevertebral fascia
  • Late findings – stridor, respiratory distress, drooling, neck stiffness
  • Complications
    • Acute Necrotizing Mediastinitis (~25% mortality)
    • Sepsis
    • Aspiration
    • Lemierre’s syndrome – septic thrombophlebitis of IJ
  • Diagnose with CT neck w/contrast
  • Management
    • ENT consultation
    • Antibiotics – Cllindamycin 600-900 mg IV or Cefoxitin 2 mg IV or Augmentin 3 g IV
• Peritonsillar Abscess
  • Abscess between tonsillar capsule, superior constrictor muscles
  • Classic “hot potato voice”, uvula deviation
  • CT can help differentiate between cellulitis, RPA
  • Management
    • I&D or Needle Aspiration
      • For I&D use scalpel to incise 1 cm deep into abscess cavity
      • Use guard on scalpel to prevent deeper incision and vascular injury
    • Medications – Decadron 10 mg IV + Rocephin 2 g IV + Clindamycin 600 mg IV
    • Need ENT/PCP f/u in 24-48 hours if not admitted

Tracheostomy Complications with Drs. Lehnig and Nelson

• Approximately 1% of tracheostomies associated with major complications
  • 50% mortality with major complications
  • Usually occur after 1 week
• Emergent complications = decannulation, obstruction, hemorrhage
  • Decannulation
    • Replace ASAP as stoma will begin to close
    • If < 7 days old, recannulate under direct visualization with fiberoptics
    • If > 7 days, use direct visualization
  • Obstruction
    • Mucous plugs, blood clots, tube displacement
    • Remove inner cannula > suction trach > deflate cuff > remove trach > bag ventilate or intubate
  • Hemorrhage
    • If > 48 hours since placement, consider TI fistula, infection, coagulopathy, aggressive suctioning
    • Should be evaluated by surgeon
• Urgent complications = TE fistula, tracheal stenosis, infection, cutaneous fistula
• Tracheo-innominate artery fistula
  • Sentinel bleed occurs in 50% of patients
  • Management
    • External compression over sternal notch
    • Internal compression with hyperinflated cuff (up to 50 cc of air)
    • Remove trach > oral or stomal intubation > hyperinflate cuff
    • ET tube beyond fistula > digital compression of artery against manubrium

PEM Lecture – HEENT Problems with Dr. Lund

• Otitis media
  • Antibiotics duration by age
    • < 2 yrs – 10 days
    • 2-5 yrs – 7 days
    • > 6 yrs – 5 days
  • Antibiotics of choice
    • Amoxicillin high dose (90 mg/kg/day)
    • Augmentin – if amox in last 30 days or concurrent conjunctivitis
    • Ceftriaxone – IV or IM x3 days 50 mg/kg
    • Allergies – non-severe = cefdinir, cefpodoxime; severe = clindamycin
• Neck Masses
  • Thyroglossal Duct Cyst
    • Most common neck mass
    • Moves with swallowing
    • Can get infected – treated with clindamycin, augmentin, Keflex
  • Brachial Cleft
    • Treat the same as thyroglossal duct cyst > refer to ENT
  • Fibromatosis Coli
    • Result of neonatal torticollis causing shortening of SCM muscle
  • Lymphadenitis
    • Could be caused by bacterial infection of 1+ node, mycobacterium, cat scratch disease
• Post operative tonsillectomy bleeding
  • Management
    • Suction, IV placement
    • Lean forward
    • Direct pressure laterally with Magills or long clamp
    • Nebulized TXA
• Epiglottitis
  • Keep calm, avoid aggressive exam maneuvers
  • Inhalational anesthesia with no paralytics
  • Needle cric as temporizing measure
  • Antibiotics – cefotaxime or ceftriaxone AND clindamycin or vancomycin