ED Operations Lecture 

Dr. A. Ross, MD 
POC Troponin will be leaving the ED
High Sensitivity Troponin (hsTnl): Less than 15ng/L in females and less than 20ng/L in males is interpreted as negative; anything above is considered positive.
-Reported in whole numbers-Significant delta is an increase in 15 ng/L (over 2 hours); note a fall greater than 15 is significant too. -Must Repeat in 2 hour intervals-Will take about 30-45 min to result. T2 Bacterial PCR: rapid diagnostic ecoli, s. aureus, klebsiella, pseudo, E. faecalis-TAT 3-5 hours Who: septic patients Benefit?: Deescalation of antibiotics once resulted.

Level 1 Activation Criteria: SBP <90mmHg, Resp compromise or impending, EP Discretion, Blood resuscitations to maintain VS in transport, GSW or severe penetrating trauma to neck, chest, or abdomen, GCS <9 with mechanism attributed to trauma.NOTE: GSWs to the head and going to SICU (call trauma on these) do not need to activate Level 1 on these. 
Shunt Series: power plan in cerner; rad VP shunt series (orders all plain films) 
TEG Stay Tuned
Continue to place Intend to Admit Order in Cerner on people you know will admit.

One Pill Can Kill 

Dr. R. Lund, MD 

CCB, TCA, Lamotil, Opiates/Opioids, Camphor, Clonidine, Antimalerials 
Opioids: Naloxone dosing peds: 2mg IV q3-5BB Tox: hypoglycemia and bradycardia; glucagon and or high insulin protocol (consult tox.)CCB: Dihydro and Non-Dihydro; Txt: supportive care; Poison Control ConsultationOil of Wintergreen: Salicylate Toxicity; Toxidrome: Nausea, Vomiting, Tinnitus, Txt: Urinary Alkalization Sulfonylureas: Admit for 24 hours, give either PO or IV. Txt: Octreotide infusion Clonidine/Imidazoles: A-2 agonist, high dose narcan and supportive care measures. symptoms: lethargy and or coma typically. Camphor: Txt: Benzos and Phenobarb for seizures; TCA: CNS, anticholinergic, and QRS prolongation; QRS 100ms< is pathologic; Tx: Benzos and Bicarbonate, Lamotil; loperamide +/- atropine; symptoms: anticholinergic and opiate toxidrome picture; txt: narcan Toxic Alcohols: Ethylene Glycol, Methanol, and Isopropyl Alcohol (rubbing etoh): Isopropyl: ketonuria; supportive care Methanol: de-icers, HA, Metabolic acidosis, breaks down into formic acid, give fomepizole or ETOH to compete out A. dehydrogenase Eth. glycol: txt: fomepizole, dialysis, and bicarb for acidosis. 

SJS/TEN 
Dr. Slaven, MD 

SJS <10%; TEN 30%<Hx physical exam key; Workup: CXR, CBC, CMP ESR/CRP SCORTEN Score predictor availableRemove inciting factor Pathogenesis: Sulfa drugs; typically first 8 weeks Consults: Optho, Uro, OBGYN 

Pemphigus Vulgaris & Bullous Pemphigoid

Dr. Martinez,MD 
PV: More common
Pemphigussssss is SSSSuperficial Age Range 40-60yo Autoimmune Dz; Ab to DSG 3&1+Nik sign; Flaccid bullae clinically, mucus membrane involvement <10% TBSA TxT: systemic steroids and rituximab IV; 2nd line: Dapsone, Mycophenolate and IVIG. Non-adhesive dressing application
BP: Pemphigoidddd is NOT Superficial Disease of elderly F>M 1.3-1autoimmune disorder vs. basement membraneTense blisters clinically; pruritic, tense bullaePruritus is more apparent clinicallyTxt: Topical steroids preferred; IVIG can be used as well per derm’s recs. 

Stress & Burnout: 

Dr. Huecker, MD 
Stress= perception of perceived threat. if perceived as negative, research says that this can have negative impacts on healthif perceived as positive=can have beneficial effects on personal potential Stress can impede performance, determined by the individual’s “appraisal” of the situation. Hormesis: phenomena of dose response relationships and over prolonged periods of time can have strengthening effects. Dose of poison a day will make us better. Connect with people daily: compassion does to deplete resourcesOptions to cope: exercise, therapeutic writing, gratitude recognition, thousands available