EMS Prehospital US- Dr. Heppner

1. Pre hospital US began in the early 2000s
2. Advantages include possible early diagnosis of pneumothorax, intrabdominal hemorrhage, cardiac tamponade, and tube confirmation
3. Also, may improve triage process
4. Barriers include costs of equipment and training as well as operator dependence
5. Could also cause delay in transport times

Capstone- Dr. Davenport

1. Heterotopic pregnancy risk is 1/100,000
2. Consider this in patients with persistent symptoms despite IUP
3. Zebra diagnoses are rare but still must be considered if nothing else explains the diagnosis
4. Be cautious in pregnant patients if you are concerned with ectopic rupture, even in patients with stable vital signs

Hyponatremia- Dr. McGee

1. For hyponatremia consider history closely when deciding volume status.
2. Primary polydipsia is rare and requires huge amounts of water intake.
3. Doing a repeat confirmatory test on a hyponatremic patient with minimal symptoms is important.
4. Use serum osms to determine pseudohyponatremia
5. In true hyponatremia, sodium and osms are low
6. Low Urine Osms and low specific gravity point to ADH independent hyponatremia, high Osms and SG would suggest ADH dependent
7. Consider Uric Acid test which may be low in SIADH
8. Beware of elderly patients with mild hyponatremia because they are at much higher risks of falls
9. Goal of hypertonic saline is to raise sodium by 5 mEq or improve LOC

Room 9 Follow up- Dr. Thomas

1. 45 yof hx of obesity, HTN, DM, complaint of weakness and slurred speech with a GCS of 6
2. Intubation complicated by black emesis but achieved with reverse trendelenberg position.
3. Head up intubation increases time until desaturation.
4. Consider bougie for increased first pass success
5. Consider post intubation complications when selecting head up vs conventional intubation

Pediatric DKA- Dr. Patterson

1. Pediatric DKA can many varied presentations
2. Blood pressure is usually last thing to decompensate in pediatric shock
3. Don’t bolus insulin initially. Make sure patient is resuscitated and potassium is appropriate
4. 10-20 ml/kg fluid bolus is correct based on PECARN
5. Most new evidence suggest that cerebral edema may be less iatrogenic than initially thought

Lightning Lectures

Dr. Harmon-Thyroid Storm

1.Presentation is with thermoregulatory, CV, GI, or CNS disturbances. Symptoms can include hyperthermia, AMS, seizures, tachycardia, high output heartfailure, and GI symptoms.

2. Causes are systemic, endocrine, cardiovascular, obstetrical or idiopathic.

3.Treatment: Supportive care with slow cooling, benzodiazepines, beta blockers, PTU, Iodine, steroids, cholestyramine.

Dr. French- Cushing Syndrome/Disease

1. Cushing disease is caused by hypersecretion of ACTH. Cushing syndrome should be characterized by either ACTH dependence or independence.
2. Iatrogenic is the most common cause.
3. Symptoms: Weight gain, moon facies, buffalo hump, headache, HTN, Hyperglycemia, erectile dysfunction, irregular periods, central obesity.
4. Tx: mostly outpatient. ED management should focus on initial metabolic derangements. Don’t abruptly stop steroids.\

Dr. Sowers- Pheochromocytoma

1. tumor of adrenal medulla which releases catecholamines and metanephrines
2. Is associated with MEN, VHL, neurofibromatosis and famial paraganglioma
3. Diagnosis is made with plasma and urine metanephrines, chromagranin A and specialized imaging such as F-FDG PET scan
4. Treatment: Benzodiazepines, phentolamine. Avoid beta blockers and pay close attention to volume depletion.

MICU Follow UP- Dr. Cook

1. 29 year old female found down with V Tach arrest.
2. Etiology of Ventricular Tachycardia: Structural heart disease Ischemia, HOCM, Sarcoidosis, familial long QT, Brugada syndrome.
3. Therapeutic Hypothermia: Main benefit is reduction of neurologic sequelae
4. 2 studies in 2002 showed benefits of decreased mortality and improved neurologic outcomes at 30 days. Initial thought was lower temperature is better.
5. More recent Targeted Temperature Management study showed no differences in outcomes between 36 and 32 degrees Celsius cooling protocols.
6. Most institutions have hospital specific protocols.

CCU Follow up- Dr. Fisher

1. 82 yof fall at home with initial complaint of chest tightness. Also complained of 8-12 episodes of diarrhea daily for weeks and frequently takes loperamide.
2. Initially patient with elevated troponin and creatinine. EKG showed deep T wave inversions in the anterior leads.
3. After being admitted patient EKG showed widened QRS and ischemic changes. Cardiac catheterization revealed normal coronary arteries.
4. Pt was eventually discharged to hospice due in part to many comorbid conditions. Question if loperamide could have been the cause of the patients symptoms.
5. Loperamide toxicity: causes conduction disturbances which can persist for days. Includes widened QRS and prolonged QT.

Identity Theft- Dr. Bosse

1. Doctors are particularly vulnerable to identity theft
2. Claims can be disputed but it is a headache.
3. Pay close attention to accounts
4. Consider freezing credit scores or hiring credit monitoring companies.

Stroke Care in a Nonstroke Center- Dr. Remmel

1. Common mimics include seizure, drugs, metabolic derangement, hypertensive emergency, tumors, CNS infection, complex migraine, and functional
2. Know transfer options and stroke capabilities for any ER you work with.
3. LVO- aphasia or left neglect, eye deviation, weakness opposite of eye deviation.
4. Important exam elements: LOC, Visual fields, pupils, EOMs, sensation, facial motor, strength, speech and language, coordination, and extinction.
5. Consider using the Neuro Toolkit App
6. Consider tPA if 4.5 hours from symptoms onset.
7. Door to Needle time should be less than 30 minutes.
8. Know tPA exclusion criteria
9. tPA complications- angioedema, hemorrhage.
10. tPA dosing is 0.9 mg/kg with max of 90 mg. 10% is given as bolus. The rest is given over 1 hour.

Wellness- Dr. Huecker

1. Consider wellness daily. No one but you will advocate for your wellness once out of residency.
2. Eat a balanced diet.
3. Vitamin D is good, but not too much. Get sunshine.
4. Vitamin K2 is a sleeper vitamin. Warfarin can cause disruption causing many problems.
5. Magnesium is really, really good. Deficiency can cause cramps and headaches.
6. In general prefer natural foods over supplements.