2020 AHA Guidelines (Dr. Price)

• Confirmation
  • CPR depth 2 to 2.4
  • CPR Rate 100 to 120
• New changes
  • Recommend lay rescuers initiate CPR for presumed cardiac arrest
  • Double sequential defibrillation for nonresponsive vfib/vtach not recommended anymore
  • Reasonable to attempt IV access prior to IO access first
  • Recommending epinephrine in non-shockable rhythms as soon as possible
  • Give epinephrine for shockable rhythm after defibrillation fails
  • Recommends against use of POCUS for prognostication, can be used to detect ROSC. 
  • Delay neuro-prognostication in coma for 72 hours
  • Should avoid excessive ventilation during cpr- causes harm
  • Amiodarone or lidocaine may be considered for CF/pVT unresponsive to defibrillation
  • Routine administration of Ca, NA bicarbinate, Magnesium not recommend in cardiac arrest
• Pediatric changes
  • 1 breath every 2-3 seconds (20-30 breaths per minute)
  • Reasonable to use Cuffed- ET tubes
  • Epinephrine may increase survival to discharge rates (unlike adults)
• Field termination rule
  • If patient had arrest not witnessed, no bystander CPR, No ROSC, No shock was delivered can consider stopping. 

Sickle cell disease in pediatrics (Amar Singh)

1. Vasocclusive pain crisis
   • Causes- sickling leads to occlusion leading to ischemia and pain. 
   • Dactylitis- sickling and infarction of hands. Usually first presentation in kids 6months to 2 years of age
   • Mgt: Fluids and pain control with NSAIDS/narcotics
2. Stroke- 300 fold increase risk . 
   • Tx is exchange transfusion and hydration. TPA not recommended. 
3. Acute chest syndrome
   • Pulmonary infiltrate and any respiratory symptom. Indicative of infection and or infiltrate. 
   • Mgt: 02, hydration, antibiotics, blood transfusion or exchange transfusion. 
4. Splenic sequestration
   • See acute hemoglobin drop at least 2 points with LUQ pain, splenomegaly
   • Tx: IVF with blood transfusion, find underling cause (Likely infection)
5. Sepsis
   • Streptococcus pneumonia- most common cause of sepsis in asplenic patient. 
   • Other encapsulated Strep, H.Flu, salmonella, ecoli.
   • Increased risk for salmonella osteomyelitis 
6. Aplastic Crisis 
   • Commonly caused by parvovirus b-19 with marked severe anemia with decreased reticulocyte count. 
   • Mgt- transfusion and IVIG to help clear parvovirus infection. 

Hyperglycemic emergencies (Dr. Mcgee)

1. DKA
   • Hyperglycemia >250mg/dl
   • Ketonemia- produced by excessive breakdown of fatty acids (includes acetoacetate, acetone, BHOB)
   • Acidosis pH <7.3
     • Can be normal 2/2 to compensation and contraction alkalosis, elevated anion gap may be only clues
   • Other types of ketoacidosis    
     • Alcoholic ketoacidosis, starvation ketoacidosis, isopropyl alcohol ingestion (ketonemia)
   • Mgt: focus should be on closing the gap. 
     • 1. Volume repletion most patients 3-6L down. When sugars < 250 include dextrose containing fluids. 
     • 2. Electrolyte repletion K<3.5 consider stopping insulin, K3.5 to 5.5, consider adding K to fluids 20-30meq/L. <5.5 no need to add potassium. Check Mg, Phos levels as well. 
     • Insulin drip >1units/kg dose. Switch to subQ after gap normalized and bicarbonate normalized. 
2. Hyperosmolar hyperglycemic state
   • Triad
     • Severe hyperglycemia (> 600 usually)
     • Elevated serum osmolality (>320 osm/kg)
     • Altered mental status 
   • Treat similarly to DKA, usually require more fluids as patients more dehydrated.  

Resuscitative Hysterotomy (Ben Turner and Harrison Brown)

1. Indications to do
   • Maternal cardiac arrest without ROSC within 4 minutes
   • Estimated gestational age of infant >20 weeks (fundus > 20 cm)
   • Not necessary to document FHT prior to procedure.      
2. Contraindications 
   • Known age < 20 weeks
   • ROSC within 4 minutes of arrest
3. Procedure
   • https://www.youtube.com/watch?v=IwDWv2iyAos

• Secrete meeting of the minds.

Pelvic inflammatory disease (Alaina Royalty)

• Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • Salpingitis, endometritis, myo/parametritis, and oophoritis
  • Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
  • Tubo-ovarian abscess is caused by direct extension
• Physical with pelvic with possible cervical motion tenderness Lower abdominal tendernes, Uterine and or adnexal tenderness, Mucopurulent discharge, Fever 
• DX: Sexually active women with lower abdominal pain without other cause found with PE with CMT, Adnexal tenderness, or uterine tenderness
• Tubo-ovarian Abscess
  • Dx via ct or US
  • Needs admission for IV antibiotics and OB/GYN Consult. Can have IR drainage. 
  • Predictors of failure of antibiotic treatment: WBC 16k or abscess > 5.2 cm 
• Outpatient management
  • Rocephin 250mg IM + Doxycyclin 100mg Po BID x 14 days with Metronidazole 500mg Po BID x 14 days
• Dispo
  • Admit of they have TOA, pregnant, cannot tolerate po, septic, failed outpatient antibiotics

Ovarian Torsion (Tyler Bayers)

• Ovary can rotate around suspensory ligaments or utero-ovarian ligament, compression of ovarian vein with leads to obstructed venous outflow leading to ischemia and necrosis
  • Risk factors mass >5cm, hx of cyst, ovarian malignancy, TOA, pregnancy
  • Presentation
    • 90% with pelvic pain, Adnexam mass, nausea and vomiting
    • Pearl- Right sided torsion more common due to presence of sigmoid colon on left  
  • Ultrasound- Evaluate for decreased venous/arterial flow
    • 2/3^rd might have normal flow
    • Can see enlarged unilateral ovarian volume
    • Lpelvic free fluid
    • Loss of echogenicitiy 
    • Whirlpool sign
  • CT
    • Can be used for evaluation of suspected torsoin, 
    • Sensitive for secondary findings in torsion
    • Can find ovarian enlargement, ovarian mass, distended pedical, lack of enhancement
  • Management
    • Pain and nausea control, transabdominal/transvaginal US, Emergent OBGYN consult
    • Definitive diagnosis by direct visualization

Bartholin Gland Cyst/Abscess (Dan Fischer)

• Ducts of the glands drain into posterior vestibule at 4 oclock and 8oclock positions. See mass near the posterior introitus medial to labia minora
• Usually sterile initially but can become infected
• Abscess- erythema, fluctuance, severely painful
• Dx- Clinical consider sti testing
• Tx: Word catheter placement 
  • Make small incision so that word catheter will not fall out
  • Drain abscess, explore wound
  • Place word catheter and inflate balloon with 2-4cc of water with blunt kneedle 
  • Keep in place for 4-6 weeks
  • Fllow up with gyn

HTN emergencies in Pregnancy (Joshua Sennets)

• Can occur from 20 weeks gestation to 6 weeks post partum
• Definition- new onset htn and proteinuria
• With severe features- new onset htn and signs of end organ dysnfucntion after 20 weeks gestation and up to 6 weeks gestation
  • Platlet <100,000, S CR >1.1, LFT >2X ULN, Palm edema, persistant headache, visual disturbance
• Labs: CBC, type and screen, Coags, Fibrinogen, CMP, LDH, Urine protein/creatine ratio, serum and urine tox
• Eclampsia- convulsive manifations of HTN in pregnancy
  • 60% antepartum, 20percent intrapartum, 20 percent post partum
• Manegement- ABCS, IV Magnesium, IV antihypertensvies, Fetal monitorinfg, 
• Magnesium
  • 4-6 gram in 15=20 min, repeat 2-4 gm LD PRN then 1-2/hr
  • Goal mag of 5-9 mg/dL
  • Monitor respiratory status and evaluate for decreased patellar reflexes
• BP control
  • Hydralzine, labetalol, nifedipine can all be used
  • 20mg IV labetalol, 10mg IV hydralazine, 10mg PO Nifedipine
  • Initiate for BP > 160mmhg

Cold Related Illness (MJ)

• Nonfreezing injury
  • Temp >32, wet exposure
  • Cold urticaicaria
    • Hypersensitivity to cold air/water
    • Treat like allergic reaction 
  • Paniculitis
    • Mild necrosis of subqutations fat
    • Seen more in kids, supportive care
  • Chilblains/pernio
    • Vasculitis causing tingling and numbness 12-24 hours post exposure with localized edema. After rewarming can see tender blue nodules. 
    • Supportive care, can use nifedipine for topical vasodilation, corticosteroids
  • Trenchfoot/Immersion Injury
    • Direct injury to the soft tissue from prolonged cold exposure
    • Stage 1 cold exposure-white
    • Stage 2 rewarming- mottled pale blue, pain and edema, can last  a few hours. 
    • Stage 3 hyperemia- severe burning pain, can last days to months. 
    • Rewarm slowely, can use vasodilators, cool if severe pain in hyperremia. 

Clinical Features

Classification

Visual determination of tissue viability is difficult in first few weeks; classify early injuries as superficial or deep

Biliary US (Dr. Baker)

• Tips
  • • Get sagittal view and transverse view 
    • X-7 technique- used phased aray probe and go 7 cm lateral to xiphiod process 
    • Have patient inspire, have them lay left lateral decubitus, can tilt feat down
  • Portal triad with common duct (normal <7cm you can have 1mm enlargement per decade of life), portal vein, hepatic artery
  • Cholelithiasis
    • See hyperechoic with posterior shadowing
    • Diagnosis cholecystitis: Gallstones, sonographic Murphy’s, Wall thickening >3mm, pericholecystic fluid

Emergency Delivery Small group (Aaron Kuzel)

A 26-year-old G1P0 38 weeks and 4 days female presents as a Code Green to the ambulance circle. The patient brought back to Room 9 for assessment. The patient states her “water broke” and it soaked through her pants. She is feeling contractions. Vitals are HR 120 BP 128/78 RR 24 SPO2 100% and T 97.6 F. On external vaginal exam you palpate a pulsating vessel in the vaginal canal and fetal head at 0 station.

●       What is the diagnosis? Umbilical cord prolapse

●       What is the most important next step in the management of this patient? Elevate presenting part to reduce compression and transport to OR for emergent c-section

●       What positions can you place the patient in to alleviate pressure on the protruding part? Knee to chest position, no pushing or Valsalva

A 27-year-old G1P0 at 37 weeks and 4 days is presenting in active labor to the emergency department. She is endorsing painful contractions that began within the last hour. Contractions are occurring every 2 minutes. Vitals are HR 106  BP 136/68 RR 18 SPO2 98% and T 98.8 F. Physical exam reveals fetal head crowning and bloody show. During delivery, you are able to advance the posterior shoulder, however as you attempt to advance the posterior shoulder the fetal head retracts. An episiotomy is made; however, you are still unable to advance the anterior shoulder.

●               What is the diagnosis? Shoulder dystocia

●               What is the most appropriate next course of action?HELPERR pneumonic. Chall for Help, Evaluate for episiotomy, Legs flex (Mcroberts maneuver), Pressure (suprapubic pressure), Entry maneuvers (Wood’s corkscrew or Rubin II maneuver, Remove posterior arm by sweaping it across chest, R Roll on all fours

●               What are some risk factors for this condition?Preterm labor, macrosomia, small materanal pelvis, prolonged labor

●               Failure to recognize this condition and correct it can have what damaging results? Fetal demise

●               Which of these three maneuvers is the most effective in relieving this condition? Roll on all four 

Case 3:

A 21 year-old G4P3 woman presents to your Rural Emergency Department in Ashland, KY in active labor and has a spontaneous vaginal delivery in the emergency department. Prenatal care was appropriate and the patient’s blood type is O-positive. The infant is full-term and well. An intact placenta passes shortly thereafter, followed by vaginal bleeding. There are no obvious lacerations to repair, and the bleeding appears to be originating from the cervical os. Vital signs are within normal limits. The patient continues to have oozing of blood from the vagina several minutes after birth.

What is the diagnosis? Post partum hemorrage

What is the most common cause of this diagnosis? Uterine atony

What is your next step in management? Bimanual massage,

What medications (and in what order) would you use to stop the bleeding? Pitocine 80units bolus IV or 10units IM, Misoprostol 600mcg SL or 1000mcg rectally

What is a rare complication of this diagnosis that results in high fetal and maternal death?Uterine rupture