SANE, Amanda Corzine:

• Purpose: medical eval and treatment, evidence collection, documentation of injuries, male/female victims of sexual assault age >12, “rape kit” collection in <96h, sane room in back hallway has full shower and bathroom
• Benefits: detailed written and photo documentation, expedited visit, referrals to appropriate f/u care and community resources, integrated care with advocacy/law enforcement. SANEs can testify as expert witnesses in legal proceedings.
• Sexual assault nurse examiners: RN with specialized training in medical forensic exam
• Reporting may occur at time of exam or prior to arrival or victim may chose to have kit collected without reporting, kept for 1 year and then destroyed, only tested for DNA if report made
• Level of alertness required for exam, search warrant required for unconscious patients
• Can also see patients in EPS
• Neurobiology of trauma
  • Difficulty in recalling facts in linear format
  • Emotional presentation
  • Sometimes sensory memory is more well preserved
• Patient history guides the exam
• Important to write declined rather than refused
• SANEs will document bodily and genital injuries and obtain photographs as possible
• Will generally order prophylactic meds and notify physician
  • Specific protocol built for NPEP
• HIV risk by exposure:

Perimortem c-section, Drs. Royalty and Newcomb:

• Anatomic and physiologic changes in pregnancy
  • Airway: narrowing of upper aspect in third trimester, intubated using ETT 1 size smaller than usual
  • Breathing: elevation of diaphragm -> decrease in residual capacity, poor toleration of apnea. Give supplemental O2 rapidly.
  • Circulation: by 28w, blood volume and cardiac output increase by 30-40%, compression of IVC, displace uterus to L (rotate 15-30 degrees), aggressive fluid resuscitation.
• PRIMARY BENEFIT: MATERNAL RESUSITATION
  • Secondary benefit: fetal viability
• Indications:
  • Cardiac arrest- medical or trauma (ideally within 4 minutes, have been reports of saves up to 15 min post arrest)
  • >/= 24w or fundus is above umbilicus on your exam
• Contraindications:
  • ROSC within two cycles of compression
  • Gestational age <20 weeks
• ACLS considerations for pregnant patients:
  • Provider performing ACLS is separate from physician performing procedure
  • Fetal assessment should not be done.
  • Hand placement is the same as nonpregnant patients, same dose of meds. Cardioversion and defibrillation are not contraindicated
  • Continuous lateral uterine displacement while performing CPR with patient supine
• Need:
  • Bare minimum: scalpel, scissors, gloves. Chest tube kit can be a good start.
  • Other supplies: definitive airway, O2, two large bore IVs, end tidal CO2, c/s delivery kit/trauma lap kit, no 10 scalpel, hemostats, large scissors, gauze sponges/surgical towels, retractors, infant warmer, bulb suction, pediatric airway kit
• Very basic process

1. Large vertical incision from xyphoid process to pubic symphysis

2.  Expose uterus

3. Inferior small vertical incision (around 2 fingers size) to uterus, insert fingers and lift uterus away from fetus, use scissors to make incision directed superiorly

4. Deliver infant, pass infant to someone else

5. Pack uterus/abdomen,

• Complications:
  • Bladder/bowel injury, injury to fetus, arterial injury
• ROSC considerations:
  • Broad spectrum PRN or cephalosporin
  • Consider oxytocin, can cause arrhythmias and risk repeat arrest
  • Why did patient arrest?

Documentation update:

• Big changes coming in early 2023, stay aware and will have continued updates
• Make sure to document discussion with other physicians, brief summary
  • Radiology
• Any history obtained from someone other than patient
  • Friend/family, EMS, police, nursing home
  • Make sure to say “Per ___,”
• Review and summarization of old records
  • Cannot just copy and paste. Must make comment.
  • Try to say specifically what you reviewed, when/where that visit was, and what you took from it that was relevant.
  • Don’t just say- reviewed outside records. This does not add anything to the record.
• Conversation with other specialists, what you discussed, outcome/recommendations
• Document independent interpretation of imaging

Medical Mimickers of Psychotic Disorders: A Review of Secondary Psychosis, Drs. Reske and Marcellus:

• Condition affecting cognition and causing distorted perception or loss with reality
• Psychotic presentations are seen in many different syndromes/disease processes
• Primary psychiatric
  • Little/never develops over short period or in older patients, except potential for first break psychosis in post-menopausal women
  • Usually subacute, variable attention, generally alert, both episodic and chronic, episodes can resolve but repeated episodes can lead to chronic symptoms, in general cognition (orientation) should be intact
• Secondary psychosis
  • Mnemonic: TACTICS MDS USE
  • Substance intoxication: stimulants (symptoms can become permanent), hallucinogens, dissociants. Usually sudden onset, changes in vitals. Auditory, tactile hallucinations, paranoid delusions. Commonly with hyperkinetic body movements. Manage with benzos, antipsychotics, aggressive hydration.
  • Substance withdrawal:  GABAergics (benzos, barbs, baclofen, EtOH), opiates less frequently
  • Dementia with behavioral disturbance: in late stage, baseline psychosis is not uncommon. Consider frontotemporal dementia. Lewy Body Dementia and Parkinsons can have complex visual hallucinations. However, acute worsening of confusion or deviation from baseline should raise concern for underlying medical condition. Can be very distressing for patient but frequently can be calm and even soothed by these hallucinations, sometimes patients are aware that these perceptions are not real.
  • Infection: UTI most often, also meningitis, cerebritis, HIV, neurosyphilis
  • Delirium
  • What is atypical? Later onset, primarily confused/disoriented, visual/multimodal hallucinations.
  • Less common but can be easy to test: thyroid disease, b12/folate deficiency, hypo/hypernatremia, hypercarbia/hypoxic (can have visual hallucinations), calcium, hepatic encephalopathy (sometimes can present even before jaundice), infections (RPR, HIV), space occupying lesions, stroke, seizure
  • **Try to get a thorough history and physical**
• Primary vs secondary investigation:
  • Is presentation of psychosis atypical?
  • Is medical condition or substance use temporally related?
  • Is the psychosis not better explained by primary psychotic disorder or other mental illness?
  • Is psychosis a direct physiological consequence of a medical illness of substance use?
• Secondary: Treat underlying cause if known, avoid benzos if possible, can worsen delirium and disinhibition, avoid anticholinergic meds
• Primary: best to use antipsychotics if possible
  • Multiple medications exist in PO, IM forms with different MOA, onset times, etc