Peer Perspective on Addiction, Dr. McMurray:

• Make an effort to attempt to treat those with Opioid Use like you would anyone else, connect with them, ask them about their families, hobbies, things that make them happy Disorder
• Louisville area addiction resources guide to be posted in EXI and able to handout to patients with updated information
• Buprenorphine: partial opioid agonist
  • Subutex: buprenorphine only
  • Suboxone: buprenorphine and naloxone (attempts to decrease misuse or diversion)
  • Ceiling effect for euphoria/pain relief
  • Use caution when other CNS depressants are on board or patient has liver impairment
• X wavier: free, takes 3-4 min to apply, must have DEA number
  • Use link to apply https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
  • Enter licensing state, medical license number, and DEA number
  • “starting at the 100 patient level” select “no” for both questions
  • Select “I wish to apply for the 30 patient level with exemption”
  • Recheck in ~1 week to make sure your application was approved
• 3 day rule is for those without an x-wavier
• Resources: California Bridge Buprenorphine Pathway, Clinical Pathway on room9er by Dr. Kuzel
• Dot phrase for resources: ,dcaddict
• Prescribe Narcan kit at discharge

Pharmacy- Eclampsia/Pre-E, Josh Senn, PharmD:

• Important to quickly identify and treat these patients in a timely manner
• Hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide
• 20-26% of eclampsia cases occur 48h-6weeks postpartum
  • 78% of these patients had no BP issues in pregnancy
• ACE-I and ARBS are contraindicated in pregnancy
• Preeclampsia: new onset hypertension and proteinuria
  • >160 systolic or >110 diastolic x1 or >140 and >90 x2 four hours apart
• Pre-e with severe features: new onset hypertension and signs of end organ dysfunction after 20 weeks gestation and up to 6 weeks postpartum
• Eclampsia: convulsive manifestation
  • Maintain airway, establish IV access, fetal monitoring and assessment, BP control, Mg therapy, obtaining pertinent labs
• Magnesium:
  • Do not wait on labs to initiate treatment with Mag!!
  • MOA possible cerebral vasodilation + blocking Ca entry + entry in neural cells and altering neurotransmission
  • Multiple studies validate use
  • Dosing: 4-6g IV over 15-20 min, repeat 2-4g loading dose PRN
  • Maintenance 1-2g/hr
  • **NO IV ACCESS: 5gm x2 IM in each buttock**
  • Monitoring: respiratory dive, patellar reflexes, for reversal can give Ca Gluconate 1g IV over 5-10 min, +/- 40mg Lasix (renal excretion of Mg)
• Blood pressure control otherwise: no difference in efficacy or safety in hydralazine, labetolol, nifedipine
• Initiate treatment for any SBP >160 or DBP >110
• Refractory HTN: nicardipine gtt (5-15 mg/hr) titrated to goal BP
• Stay up to date on ED protocol

Lightning Lectures:

• HELLP, Dr. Beard:
  • In pregnancy: multiple normal physiologic changes
  • HELLP 0.1-1% of all pregnancies
  • Questionably represents a severe form of pre-e
  • 15-20% do not have antecedent HTN or proteinuria
  • Pathogenesis: inadequate placental perfusion, induces platelet aggregation, endothelial dysfunction & arterial hypertension, fibrin released, microangiopathic hemolytic anemia
  • Risks: previous hx, multiparous women (>50%), COVID
  • Clinical manifestations: HTN, RUQ or epigastric pain, jaundice, nausea/vomiting, headaches, vision changes
  • Haptoglobin, LDH, coags in addition to other labs
  • Maternal stabilization and then prompt delivery if possible
  • Multiple pregnancy related disparities exist: black and Hispanic women are at significantly higher risk for pre-e and HELLP
• PID/TOA, Dr. Kushner:
  • PID: Proportion of cases caused by CT/GC is decreasing
    • Multiple other nontraditional organisms are surfacing and becoming more common
  • Risk factors: multiple partners, <25 yo, prior hx of PID or STI, partner with STI
  • Can occur acutely over several days or over weeks/months
  • S/s: lower abdominal or pelvic pain, pain with intercourse, abnormal uterine bleeding, urinary freq, vaginal discharge
  •  No single historical, physical or lab finding is both sensitive and specific
  • Special population: transgender patients- ask pronouns and ask about patient’s anatomy/organs
    • Very common (21%) for these patients to avoid ED care due to fear of discrimination
    • 4x higher rates of HIV, also higher rates of extreme poverty, sexual assault, sex work
    • Be cognizant of this
  • Maintain low threshold for clinical diagnosis of PID
    • Even mild or asymptomatic cases may be at risk of infertility
    • Presumptive treatment should be initiated for sexually active women: experiencing pelvic or abdominal pain, no other cause for illness can be identified or if one or more of the following criteria are present on pelvic exam: CMT, uterine tenderness, adnexal tenderness
  • Workup: pregnancy test, microscopy of vaginal discharge, HIV, syphilis, UA (in addition to other labs including inflammatory markers, CBC if more severe presentations)
  • Stay up to date on CDC guidelines
  • TOA: inflammatory mass involving fallopian tube, ovary, sometimes other adjacent organs like bowel/bladder
  • Not all are associated with PID
  • Pathophys: ascending lower genital tract infection
  • Not all have fever and acute abdominal pain
    • 23% have normal WBC count
  • CT > US if need to exclude GI tract involvement
  • Need at least 24h of inpatient observation

Research Updates, Dr. Huecker:

• Residents should understand how research is conducted, evaluated, explained to patients, and applied, participate in scholarly activity, have appropriate resources to accomplish these goals
•  ULDEM has a full time PhD faculty member who performs stats and also designs and serves as PI on studies: Dr. Jacob Shreffler

• Think, Do, Write
• Travel to conference is sponsored by the university if you are presenting
• Plan ahead, use available resources, expect delays, something you are passionate about

Suturing 101, Dr. Eisenstat:

• Resource: thelacerationcourse.com, also closing the gap
• “The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin” -Brian Lin
• Sizes and removal: please always discuss with patient and make sure to document in discharge instructions
• There is a difference between how long an absorbable suture supports the wound vs how long it actually stays in the skin
• Absorbable (fast gut) is completely appropriate for facial sutures in regards to scarring and patient satisfaction
• Utilize undermining when wound edges are too far apart to get good closure
• Vertical mattress sutures are good in high tension wounds: can make a big difference even with 1-2 placed in the middle of the wound
• Elderly, thinner skin: use steri-strips along edges and put sutures through steri strips