Pleural Effusion (Dr. Lyons)
• Any abnormal amt of fluid in pleural space
• Exudative (parapneumonic, malignancy) vs Transudative (CHF)
• Broad differential for Effusions
• Workup
○ CBC (leukocytosis, anemia), CMP (renal dysfxn, liver disease)
○ Individualized based on presentation n
• Positioning impt for CXR
○ Left lateral decubitus has very high sensitivity (only need 5-10mL of fluid)
○ Supine = 67% sensitivity
• Imaging
○ Pleural US
○ CT chest if necessary based on presentation
• Diagnostics
○ Thoracentesis (if you need further investigation to determine etiology)
§ Lights criteria
• Management
○ Treat underlying cause
○ Lateral decubitus positioning with good lung to ground (improved VQ mismatch)
• Disposition
○ Discharge home if clinically stable without systemic illness/infection
○ Admit
§ Parapneumonic, increased O2 requirement
Tuberculosis (Dr. Webb)
• M tuberculosis, 1/3 of worlds pop affected, 8300 cases in US in 2022
• Most exposed do not get infected (70%)
• Infected individuals –> Primary TB
○ Most infected (90%) cause immune activation and granuloma formation
• S/Sx: Cough, Hemoptysis, effusion, fever, night sweats, weight loss
• Highest Risk of exposure
○ Healthcare workers
○ Immigrants
○ Prisoners
○ Homeless
○ IV drug users
• Worse Disease in:
○ Immunosuppressed
○ Transplant
○ Malnourishment
○ Pediatric/Geriatric
• Primary TB
○ Most asymptomatic
○ Granuloma formation ‘Ghon complex’
• Latent TB
○ Most asymptomatic
○ Ranke complex (calcifications)
○ If immunosuppressed –> becomes Active TB with upper lobe spread / Cavitation (fibrocaseous necrosis)
• Active TB
○ Miliary
○ Invasion of body tissues with a variety of patholigies (Miliary TB, Scrofula, Addisions, Potts Disease, etc)
• DX
○ PPD (BCG – older or europeans, false positives)
§ >5mm wheel for immunocompromised
§ >10mm for healthcare workers
§ >15mm if no known risk factors
○ QuantiFERON Gold
• TX:
○ Airborne isolation
○ Contact health department
○ Med not started in ED typically (RIPE, rifampin, isoniazid, pyrazinamide, ethambutol)
○ Health department will contact these individuals

Health Care Disparities (Dr. Eisenstat)
• Equity vs Equality
• Black patients 10% less likely to receive urgent ESI scores and 1.26x more likely to die in the ED / Hospital
• Hispanic patients with no sig difference on admission
• Asian patients more likely to be admitted than white
• Persons Experiencing homelessness (PEH)
○ 27% considered chronically homeless
○ Most go in and out of homelessness
○ 25-30 unoccupied houses for every PEH in US
○ Higher rates of mental health diagnosis, substance use disorder, worse health conditions
• Gender differences
○ Females have higher risk of MI and CVA
§ Drug eluting stents and GDMT less likely to be used in Females
§ Less likely to get tPA as a female
§ Less likely to be in a leadership position in Academic Medicine as a Female
• Medicine and Race
○ Father of OBGYN experimented on slaves to develop surgical procedures
○ Tuskegee experiment used poor black sharecroppers to observe long term outcomes of Syphilis and did not treat them with PCN for 15 years after it became standard of care
○ Hispanic/American Indian/Alaskan native/Black were among the highest death rates during COVID 19 pandemic
• Sex identity
○ Transgender individuals more likely to experience discriminatory treatment, believe they would be refused services because of their sex identity
§ Trans patients have high suicidality and death
§ More likely to work in “underground economy”, be incarcerated, and use alcohol/illicit substances
§ 4x more likely to be infected w/ HIV
○ Sex (biologic) vs Gender (social)
○ DSM V – gender dysphoria as a diagnosis
• Inclusive language
○ Try to avoid implicit and explicit bias
○ Bias leads to barriers
§ Barriers leads to poor outcomes
• Be cognizant of standardizing language and assessment of applicants in the coming interview season



Room 9 Follow Up (Dr. Bishop)
• Case info
○ 49 year old female, MVA, driver, ?restraint, head trauma with LOC, complaint of 10/10 left wrist pain
• Room 9 Course
○ CXR negative, left forearm with left distal radius fracture
○ Valium given per patient request
○ Ketamine sedation, with systolic pressures in 200s during procedure
○ Patient became agitated, altered, hypoxic after sedation completion
○ Given 1 mg versed for agitation. BVM initiated with NPA, OPA in place
○ CXR repeat with bilateral pulmonary edema
• EKG: tachycardic, peaked T waves with TWI in lead I. Diffusely abnormal.
• Room 9 Course continued
○ Refractory hypoxia with BVM, intubated with etomidate, succinylcholine
○ CXR confirmed tube, propofol started
○ Transfer to CT, became agitated, fentanyl and versed gtt initiated
• Case continued
○ CBC normal, CMP with K 6.1, glucose 319, Cr 1.5
○ Trop 1860
○ CT scan concerning for ARDS
• Hospital Course
○ Hypotensive before admission, requiring levophed
○ HyperK with peaked T waves
○ Rhinovirus on RPP
○ Echo 32% (65% in 7/18), read as Takotsubo cardiomyopathy
○ Trop peaked 3160, downtrended, ACS heparin
○ LHC with improved EF, normal coronaries
○ ORIF day 5, discharged day 7
• Procedural Sedation and Analgesia
○ Should I be sedating?
§ Consider ASA class, age, comorbidities, allergies, and alternatives
○ Setup is key
§ IV, monitor, oxygen, EtCO2, airway equipment
○ Pre-oxygenation and positioning
§ NC with end tidal –> longer safe apnea time
§ 45 degree angle –> improves lung compliance
○ HFNC has some potential benefits
○ Goal sedation levels
○ Medication options
§ Ketamine
§ Midazolam
§ Fentanyl
§ Etomidate
§ Propofol
○ Adverse Events in PSA
§ Highest in fentanyl, lowest in ketamine