1st Trimester Pelvic POCUS

• All patients who are suspected to be pregnant need a transabdominal US
• WHY? -> RULE IN UP 
• Trans Abd US POCUS
  • Full bladder
  • Sagittal view – scan through full anatomy (1st view – best idea of what the anatomy is going to look like)
  • Transverse view 
  • Measurements
    • M -Mode for FHR
    • CRL
  • Adnexa? Probably good practice
  • Linear probe for superficial uterus for better resolution
• TVUS
  • Hold probe with indicator on top (thumb on top)
  • When: Unable to confirm IUP on TAUS
  • Need EMPTY Bladder
  • Probe movements: Rock/Fan only
  • Start with placing probe into introitus, look at screen and then slowly advance probe with gentle pressure
• MUST HAVE at least a YOLK SAC to be confirmed as an IUP
• Do not use BhCG to determine if patient needs US
  • Ectopics can have BhCG level of 0 

Pleural Effusion and Opportunistic infections

• Evaluation
  • CXR, CT, US
    • Left lateral decubitus XR more sensitive than PA,  less fluid required
  • Pleural fluid tap
• Lights Criteria
  • Transudative vs Exudative 
• Treatment
  • Chest tube placement for drainage
  • Antibiotics
• Parapneumonic effusion/Empyema
  • Higher rates of morbidity and mortality
  • Higher risk in certain pops (IVDU, alcoholics, immunosuppressed, etc)
• Antibiotics
  • Pathogens MC – S pneumo > Anaerobes > S aureus > G- bacilli
  • Empiric Tx: Pip/Tazo + vanc (meropenem, cefepime, metronidazole if PCN allergy)
• Incomplete Drainage?
  • Fibrinolytics via thoracostomy tube
    • Alteplase + DNAse 
• PCP (P jiroveci) Pneumonia
  • HIV patients w. CD4 <200
  • SMX/TMP 15-20mg/kg divided into 3-4 doses daily
    • Dapsone, primaquine, atovaquone if need alternative
  • Steroids if PaO2<70 mmhg
• MAC (M avium)
  • HIV, CD4<50
  • Macrolide, ethambutol, rifampin 
• Histoplasmosis
  • Fungal infection endemic to central and south central USA
  • Amphotericin B preferred
  • Itraconazole alternative
• TB
  • RIPE therapy (rifampin, INH, pyrazinamide, pyridoxine, ethambutol) 
• Candidiasis
  • Very common in HIV w/ low CD4
  • Fluconazole best, can use itraconazole

The Analytical Evaluation of an Unwanted Outcome

• 50 yo M w/ CP/SOA while washing dog
• pmh HTN, HLD, hypothyroidism, TB use
• FH: brother died of MI in 40s
• Initial EKG w/ NSR, T wave inversion III, normal otherwise
• 2 prior ED admissions for similar symptoms w/ negative workup
• Trop 63, sent to Jewish via Lyft for Personal vehicle 
• Coded at Jewish in Vfib, Cath w/ 100% LAD and RCA, stented
• Things to think about
  • ALS vs BLS vs Lyft transfer
  • Should we have stricter rules to transfer to Jewish Cards Obs?
  • Should we call the fellow or attending on cards more often?

Pneumonia

• Severity classification for pna – differentiates what treatments to use
• No comorbidities = Monotherapy (Beta lactam, Doxycycline)
• Comorbidities= Beta lactam + Doxy or Azithro / or monotherapy w/ Levaquin
• Inpatient = IV ceftriaxone + Azithro or Doxy
• Prev hospitalization or IV abx in last 90d?  –> Vanc or Linezolid for MRSA coverage
• 5 days usually adequate if no comorbidities
• 7 days if Comorbid or MRSA/Pseudomonal coverage
• Procalcitonin essentially useless, Clinical criteria alone should be used
• Aspiration
  • Chemical pneumonitis – no abx required
    • Severe periodontal disease present – should be treated 
  • HAP / CAP = treat

Acute Bronchitis

• Rule out: Asthma, COPD, HF, pna
• Usually no fevers
• CXR indicated if tachycardic, tachypneic, rusty sputum, febrile
• Supportive care options
  • APAP, Ibuprofen, cetirizine/diphenhydramine, codeine, dextromethorphan (best results), benzonatate, guaifenesin (best data), albuterol (if wheezing or underlying asthma/copd)
• Educate patient on why Abx may not shorten illness, give supportive therapies, and expectations of illness/cough duration
• Bacterial
  • Sx> 10 d
  • Fever>102F w/ purulent nasal discharge/facial pain
  • Double worsening of symptoms
• Flu
  • Oseltamivir (Tamiflu) – within 48hrs of onset
    • Initial study – sx improvement only 16hrs earlier than placebo
    • 2023 meta analysis shows no benefit over placebo w/ primary outcome of hospitalization 
  • Who should get treated?
    • Hospitalized, immunocompromised, >2 yo or <65yo, pregnant

Research

• Think, Do, Write
• Research is fun, rewarding, and part of being a well rounded EM physician 
• Many conferences that you can go to (and Department will pay your way)