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 

Necrotizing Fasciitis: Dr. Lehnig, MD 
Diagnosis: Surgical Exploration CT 90% vs. MRI 86% sensitivityTreatment: “Early Surgical Debridement” Antibiotic Regimen: carbapenam or Zosyn +Vanc, dapto, or linezolid +clindamycin for antitoxin effects

Staphylococcal Scalded Skin Syndrome (SSSS): Dr. Edwards, MD 
Mostly less than 5 yo; if in adults typically immunocompromised Clinical Exam: +Nikolsky’s sign and will spare mucosal surfaces; + fever typically Diagnosis: Clinical Exam; look for other infections that precipitated the infection. Treatment and Disposition: Typically burn unit admission, Antibiotic Regimen: Typically MSSA but if there are risk factors for MRSA use coverage for MRSA. 

EMTALA : Dr. Royalty, MD 

Emergency Medical Treatment and Active Labor Act#1: Medical Screening Exam (Everyone gets this no questions asked)#2: If you ID an emergency condition, you must treat and stabilize this, if hospital can’t manage, must get accepting physician to transfer to higher level of care#3: If OSF needs to transfer patient because of lack of ability to care for patient, facility is required to accept patient despite ability to pay, etc. Transfers: All pertinent records and imaging should accompany patient or be sent electronically ASAP. 

Decisional Capacity: Dr. Yff, MD
Informed Consent: understand treatment, potential risks and benefits, and reasonable alternatives

4 Components: relevant info, appreciation of consequences (insight), reasoning of choice & 
communicating a choice.
Estimated, 48% of patients hospitalized are not capable of making decisions in a hospital setting MacCAT-T: decisional tool to evaluate capacity. 

Treatment of Non-Emergent Hyperglycemia in the ED: Sue McGowan, APRN 
Diagnosis: Glucose >126 fasting, a1c over 6.5%, and Random BG >200 + symptoms Targets for Diabetes: Premeal BG 80-130, post prandial <180, a1c <7Treatment: Diet and exercise-> Metformin if renal function adequate and no GI intolerance (500mg BID)-> a1c 8.5% (ADA recommends 2nd agent-> a1c 9% (see ADA guidelines)-> a1c Long Acting: 24 hour coverage “peak less”; glargine,basaglar, detemir, degludec (each vial has 30 days 300U)NPH/Intermed acting: onset 1-3 and peak 6-12 hours (NPH and 70:30 insulin very cheap) Rapid Acting: 5-10 min onset peaks1-2 hours (the “logs” and apidra and fiaspInitiating Insulin: basal or NPH 10U/day or 0.1-0.2 U/kg/day goal <130 before breakfast (titrate ever 3 days by increasing 2 U to hit morning goal)Glucose tabs=fastest method to correct hypoglycemia OOH (OTC and cheap)Send prescription for glucagon for 2ndary person to admin for rescue. Diabetes Supplies: glucometer, test strips, lancets, and needles for insulin. Diabetic NP: 10am-6:30pm ULH consult via cerner.

Electrical Injuries: Dr. Leavitt, MD 
Low voltage <600V (most household circuits around 120V)High Voltage 600V<Peds: chewing on electrical cords, must admit these, delayed necrosis of S. labial A. Lighting Injuries: Initiate CPR immediately if pulseless; ruptured TMs, A/C worse than D/C injuries