Restraints and Violent Patients:
• Agitation may be caused by a number of reasons including head trauma, hypoxia, infection, delirium, ingestion, psychiatric disorders. Always consider medical causes.
• Deescalating:
o Verbal- be honest and straightforward without be confrontational or threatening.
o Physical restraints- soft restraints, four-point, chest.
o Chemical sedation- offer voluntary administration with medications including IM ketamine, droperidol, haloperidol, midazolam and lorazepam.

Homelessness:
• Rates of homelessness are climbing within Louisville and the US.
• Patients experiencing homelessness are more likely to visit the emergency department.
• What can we offer? Respect, housing/shelter options, considerations to cost, complexity and availability of treatments


US Images:
• Chiari network: embryonic remnant of the sinus venosus which remains in the right atrium and is a benign finding.
• Use US for shoulder blocks with dislocations: palpate spine of scapula, marching out laterally to the acromion. After finding the posterior, inferior edge of the acromion, move two finger widths inferior and medially and inferiorly with injection directed forward towards to the coracoid process. Use 18 G spinal needle injecting 10-20 cc of lidocaine.
• Use US to confirm abscess before incision and drainage. Cellulitis is a clinical diagnosis but seeing a heterogenous collection on US.

Obesity in the ED:
• Obesity is a rising concern, especially in developed countries. Patients suffering from obesity are at increased risk of DM, CVD, HTN, HLD.
• BMI is a measuring tool which compares weight and height but may be lost to the favor of waist to hip ratio when describing obesity.
• Obesity in the ED:
o General interactions- ask permission to discuss weight, use “people first” language, consider bias, provide basic nutritional information, consider food insecurity and provide resources, referrals for physical activity and PCP.
o Airway- obesity creates different challenges regarding airway in the ED. Patients suffering from obesity have decreased respiratory reserve and decreased tolerance for apnea as well as increased airway pressure causing small ox reserve, increased work of breathing, higher risk of aspiration.
o Circulation- be sure blood pressure cuff is appropriately fitting and consider early arterial line. If venous access is difficult to obtain, consider using ultrasound guided lines as well as intraosseous lines.
o EKGs- findings more common in obesity include low voltages, longer QT intervals (not greater than 500), signs of LVH.
o Trauma considerations- more likely to have indeterminate FASTs, xrays are often underpenetrated, and CT scanners do have weight limits.