LL

Dr. Pehle – Palpitations

• Unpleasant , alarming, painful, noticeable feeling in the chest. 
• Afib fairly common 13% diagnosis
  • Tachyarrhythmias
  • afibw/rvr, aflutter, svt, vfib, vtach, torsades
• H&P red flags
  • Chest Pain, exertional, triggers, syncope, AMS
  • Risk factors CAD, DM, CKD
  • Heart failure signs on exam jvd, BLE
• Holter monitor
  • Underlie structural heart disease
  • Fam hx of sudden cardiac death
  • Frequent palpitation that can reproduce their palpitations
• Smart watch?
  • Afib sens and specificity is pretty good
  • Will still miss stuff
• Metabolic/drug causes
  • Thyroid storm
    • Preceding symptoms, gi distress anxiety, trauma, pregnancy, constrast
    • Hyperthermia, tachycardia, AMS
    • Burch-wartofsky criteria – MD Calc likely hood of thyroid storm
  • Caffeine
  • Sympathomimetics
  • Electrolyte disturbances
  • EtOH
• PE and ACS cant miss

Dr. Graham – Back Pain

• DDx Musculoskeletal (DDD, spinal stenosis, herniation), ankylosiing spondylitis, sacroilliits, cauda equina/cona medulari, spinal epidural abscess, metastatic spinal disease, AAA
• Red flags
  • Recen infections, IV Drug use, recent spinal procedure, immunocompromised HIV/AIDs, immunosuppression, cancer, major trauma, weight loss, unremmitting pain / night pain, abdominal pain, fevers/chills, saddle anesthesia, bowel/bladder incontinence, retention
  • PE: motor strength, gait disturbance, BLE sensory loss, saddle anesthesia, DTR BLE, focal tenderness
• Workup – red flags – CT for fractures, CTA vessels, MRI for spinal cord and discs
• Treat NSAIDs, muscle relaxants
• Walking core strength

Dr. King – One Pill can kill

• Opioids
  • Narcan

• Calcium channel blockers, elevated blood glucose, decreased heart rate, can do high dose insulin, ionotropes
• Opiods, fix the airway before giving naloxone. Can give bolus of naloxone every hour instead of drip to expedite transport
• Salycilates
  • Oil of wintergreen 1 tsp = 7g
  • Tinnitus, vomiting, pulm edema, hallucinations, hyperpnea, agitation, delirium
  • NaBicarb, dialysis

– Sulfonylureas

– Need to observe 24hrs

– Octreotide and dextrose

– Clonidine / imidazolines (affrin)

– opioid toxidromes, bradycardia, decreased consciousness, respiratory depression

– tx naloxone, atropin

– IV fluids

– inotropes

Camphor

• Smells of moth balls

• The main route for toxicity is through ingestion. Onset of symptoms can occur as early as 15 minutes after ingestion ranging from sweating and agitation to seizures, cardiac arrhythmias, and cardiopulmonary arrest [1,2].
• Benzos, phenobarbital for seizures in camphor

Amitriptyline

• Na channel blockade, CNS, Cardiac, anticholinergic 
• Long QRS
• Na bicarb tx for cardiac dysrhythmias
• Benzos for seizure

Lomotil

• Imodium
  • Antimuscarinic and opioid symptoms

• Tx naloxone maybe gtt
• Need admission for 24hrs

Ethylene glycol

• Antifreeze degreaser engine coolants
• Oxalate binds with calcium and deposits causing hypocalcemia 
• Thiamine, pyridoxine,
• Tx: fomepizole, dialysis 

Dr. Platt – Syncope

• Reflex, orthostatic, cardiac
• Initial eval – detailed history: prodrome, extertional, position, family history, chest pain, palpitations, hypotension at triage
• Physical exam (cardiac, neuro, orthostatics
• EKG
• High Risk: syncope during exertion or while supine, abnormal cardiac exam, family history or sudden cardiac death, short/ absent prodrome
• RBBw/ LAFB syncope no prodrome and exertion needs admission. 
• Risk stratification tools
  • San francisco syncope rule: CHF, hct, ecg abnormal, sob, SPO2
  • CHESS risk factors 
  • Predicts 30 day serious outcome (arrhythmia death, cardiac event)
  • Scoring history, ekg findings, troponin, ED diagnosis 
• Canadian syncope risk score
  • 0- – 3 low, 1-3 medium, 4-7 very high
• Diagnostic yield – ekg highest at 5-15%

Dr. Harris – Shock small group

• Septic shock
• Pocus for shock, RUSH
• Cardiogenic shock
• Norepi frist line pressor for all shock

LL: Diplopia by Dr. Chady

• Binocular vs Monocular
• Bi – Double vision that resolves when the other eye is closed
  • DDx: Posterior circulation stroke, Cavernous Sinus Thrombosis, Compressive intracranial aneurysm, Botulism, MG

LL: Hematuria by Dr. Sawmiller

• DDx: microscopic vs macroscopic
• Micro : stones infection, viral illnesses, trauma, exercise, menstruation, renal disease, instrumentation
• Macroscopic: renal tumors, avm, aortocaval fistula, kidney stone, trauma, uti, STI
• Workup:
  • UA microscopy, CT urogram ( Ct A/P w/ and wo
  • MRI urography, noncon CT, US abd/pelvis, retrograde pyelogram
  • Cystoscopy
  • Asymptomatic hematuria – Cancer 
  • Trauma >50 RBC get ct scan to assess for injury
  • RUG in urethral injury or pelvic fractures

Ophthalmology Lecture

Vahid

• Visual acuity: near vision card, count fingers, hand motion (what direction is the hand moving), Light perception
• Pupils : Shape, size, direct response and consensual response
  • Anisocoria – CTA head/neck Horner syndrome (ptosis, miosis, anhidrosis), carotid dissection, pancoast tumor
  • Dark room, small pupil horner syndrome dissection pancoast
  • Bright room, large pupil, poor constriction of the big pupil
    • Wipes and plants vs 3rd nerve palsy
    • 3rd nerve palsy, MRI MRA

– EYE Pressure (IOP)

– eye drop pocket technique

– Tap central cornea, breath normally, normal below 22, ED 23-30 could be reasonable. 

– Hold eyelid against orbital rim

– Eye Movements

– entrapment – ischemia of the muscle

– Oculocardiac reflex – bradycardia n/v

– exotropia (outward), esotropia (inward) – call optho

– Amblyopia lazy eye – could be a brain problem

– Pain full eye

– corneal abrasion 

– flip upper eyelid if linear abrasions 

– Pinch eyelash, place cotton tip above the tarsal plate

– Tx: mechanism wood sticks, fingernail, contactlens – moxifloxacin 4x/day for 5 days

– Large, central moxifloxacin QID for 5 days

– Corneal foreign body – qtip preferred , 30 gauge needle bend to 75 degrees, bevel away from the eye, sweeping movement up and down not at the eye

– rust ring remove in the optho clinic – burr increases risk of scar

Cases

Nail glue on eye – erythromycin ointments 

Chemical injury

• Irrigate the eye
• Check pH and recheck pH
• pH should be 7.5

Corneal ulcer and hypopyon

• Infiltration, satellite lesions
• Acanthamoeba – swilling corneal ulcer

Blunt trauma

• Subconjunctival hemorrhage – resolves 2-3weeks
• Hyphema – traumatic rupture of iris blood vessel
  • High IOP – glaucoma and cornea staining 
  • African american patients with hyphema check for sickle cell at high risk of IOP
  • Needs close follow up Grade 1 & 2, call optho 3&4
  • IOP most important 
  • Ipressure lower drops

Traumatic Iritis 

• Happens 2 to 3 days after trauma 
• Traumatic mydriasis 
• Photophobia 

Retrobulbar hemorrhage 

• Orbital compartment syndrome – blood in the back of the eye 
• Needs lateral canthotomy and cantholysis (C&C)
• Proptotic , cant move, pupil big, vision blurry, chemosis
  • Lateral Canthotomy and cantholysis
    • Numb the eye, clamp cantho tendo with hemostat, hold eyelid with forcep and cut with iris or wescot scissors if you have
    • Inferior ramus of the lateral canthal tendon
    • Cut so the inferior eyelid can be pulled up to the limbus
    • Superior cantholysis (superior ramus) be careful to avoid lacrimal gland

Lacerations

• Simple- 
• Margin – optho does this repair 
• Canalicular laceration – laceration lateral near the medial punctum
  • Needs a stent oculplastics does

Globe rupture – penetrating trauma 

• No IOP, no fluorocene no drops
• CT w/o contrast
• Vanc and levaquin
• Tear drop pupil – iris protrudes
• Fly the eye place an eyeshield 

CRAO – central retinal artery occlusion

• Cherry red spot

• Activate code stroke
• < 8 hr activate code LVO
  • tPA intraarterial 

Giant Cell Arteritis 

• Anterior ischemic optic neuropathy
• Visual acuity RAPD Relative afferent pupillary defect , jaw claudication (do you get tired when chewing), proximal stiffness 
• ESR, CRP, CBC 
• High dose IV steroid

Chalazion (Stye)

• Warm compress
• Abx ointment 

Preseptal cellulitis and orbital 

• Orbital cellulitis – eye bulging, pupil changing, subperiosteal abscess 
• Risk factor – sinusitis 
• CT orbits with constrast

Conjectivits

• Viral vs bacterial 
• Allergic pataday eye drops
• Bacterial Purulent topical moxifloxacin 

Optic Neuritis 

• Color vision problems
• pixelated/static vision poorly reactive pupil 
• Painful eye movement up and inward
• MRI Brain/orbit

Acute Angle closure glaucoma

• pain , blurry, headache, n/v
• Mid dilated nonreactive to light
• IOP 30s/40s
• Recent nasal decongestant
• Tx: IOP lowering drops, IV diamox, IV mannitol 

Kids

• Red light reflex absent is bad
  • White reflex 
  • Urgent optho
  • Causes retinoblastoma, congenital cataract

• Eye hand book app

Slitlamp 

• Cell and flare
• 1mm , mag 1.6x, brightest light, 30degrees

Jimmy webb travels

• Angioedema 
• Trips abroad
  • Drake passage is where the pacific meets the atlantic 
  • World explorer is a big boat
  • No boat if you are on dialysis 
  • McGowan watches how people walk
    • She gives people fall risk bracelets
  • Cruise ship doc really good a sea sickness, diarrhea
  • Practicing emergency medicine physician expedition doctor – 3 to 4 weeks
  • Complicating factors that influence patient care
  • Jimmy organized 
  • Too much scopolamine causes naked running
  • Really good boot cleaning 
  • Really cool rocks in antarctica
  • Watch out for the bird flu
  • Really cool rocks in argentina 
  • Wilderness med education swiss alps put on by Utah
    • Chamonix
      • Mount Blanc highest mount in the Alps
        • There is a higher mountain western russian 
    • Rich Ingerstein wilderness med book 
    • Jimmy looks good in jorts
    • 2 french girls said there was a demon on the trail
      • It was an Ibex
    • Nex care tape is the best for blister
  • Lithuania
    • Formal global health elective