Lightning Lectures with Drs. Huttner and Loche

Foreign body aspiration
-	Presentation
o	Usually sudden onset coughing and choking
o	Can develop stridor, cyanosis, respiratory arrest
-	Diagnosis
o	CXR negative in > 50% of tracheal foreign bodies, 25% of bronchial foreign bodies
o	Bronchoscopy = gold standard
-	Treatment
o	If conscious, back blows, abdominal thrusts, chest thrusts
o	Laryngoscopy to remove with Magill forceps
o	Intubation can be used to push object into R mainstem bronchus and allow aeration of one lung

Mastoiditis
-	Usually results from untreated otitis media – mastoid air cells are continuous with middle ear
-	Most common cause is strep pneumoniae or strep pyogenes
-	Diagnosis
o	Clinical in most cases
o	Consider CT in toxic appearing children or if extracranial complications
-	Treatment
o	If not recurrent and no abx in 6 months > Unasyn q6h at 50 mg/kg
o	If recurrent or recent abx > Zosyn q6h 75 mg/kg
o	Add Vanc if septic
o	Treat 7-10 days IV, follow by 4 weeks of po antibiotics
o	Consult ENT
-	Complications – meningitis, CNS abscess, venous sinus thrombosis

Malignant Otitis Externa
-	Usually adults with diabetes
-	Caused by Pseudomonas in 95% of cases
-	Presentation – often have granulation tissue in the inferior EAC and purulent drainage
-	Initial treatment is with ciprofloxacin IV 400 mg q8h
-	Consider Zosyn for severe infection or immunocompromise 
-	Can lead to osteomyelitis of the skull base or TMJ

ENT Lecture with Dr. Vinh

Airway complications: Tracheostomy vs Laryngectomy
-	Tracheostomy: ask three questions
o	Why does patient have tracheostomy?
	Most common is failure to wean from vent > still able to intubate from above
	Anatomic obstruction from tumor, etc. > typically will be difficult to intubate from above
o	How long has trach been present?
	Takes at least 1 week for tract to mature
o	What type of trach is it? Cuffed or uncuffed?

-	Laryngectomy
o	Trachea is directly connected to skin
o	There is no airway from the nose and mouth
  cannot bag over mouth or intubate from above
o	Can use pediatric size BVM over stoma to bag

Complicated airways
-	Ludwig’s Angina – submandibular space infection which causes upper airway obstruction
o	Odontogenic infections account for ~70% of cases
o	Treatment with Unsyn and Vanc + surgical drainage and/or tooth extractions
-	Angioedema
o	Treatment
	Corticosteroids, antihistamines, epinephrine, stop ACE-Is
o	Always perform flexible laryngoscopy – laryngeal edema may be much worse than visible oropharyngeal edema
-	Peritonsillar abscess
o	Management – antibiotics (unasyn or augmentin), +/- steroids, +/- I&D or needle aspiration
o	Can have trismus (usually due to pain)
-	Epiglottitis 
o	Majority of cases caused by staph and strep – empiric antibiotics with Vanc and Unasyn
o	Swelling of the larynx causes disproportionate narrowing of the airway compared to other anatomic sites
-	Head and neck cancer

Securing the airway
-	Supportive measures
o	Treat underlying cause
o	Supplemental O2
o	Racemic epi – useful for laryngeal edema
o	Heliox 
-	Sedation/anesthesia?
o	Anesthesia causes airway obstruction due to loss of muscle tone, suppression of protective arousal responses and decrease in respiratory reserve
-	Make plan for intubation
o	Fiberoptics for oropharyngeal obstruction
o	Cricothyroidotomy for laryngeal obstruction
-	Fiberoptic intubation
o	Transoral vs transnasal
o	Local anesthesia is key if unable to sedate  atomizers and 4% lidocaine
o	Afrin and serial dilation with nasal trumpets

Transfer Center Lecture with Dr. Mallory

-	Similar to air traffic control – connects to physicians working clinically and directs patients to appropriate facilities
-	RNs and medical directors working in the transfer center have knowledge of which services are offered at which hospitals and are able to direct calls accordingly
-	Also have up to date information about specific bed availability at different facilities

Ophthalmology for the ED with Dr. Rashidi

-	Pupillary exam
o	Afferent pupillary defect – tested with swinging flashlight test
o	Test direct response and consensual response
o	Shape of pupil is important to check
-	Visual acuity
o	If unable to read letters/numbers, at least relay if patient can count fingers, detect light, etc.
-	Intraocular pressure
o	Up to 21 mmHg is normal

-	Corneal abrasions treatment
o	Smaller abrasions – erythromycin ointment 3-4x/day x4-5 days
o	Wood, ticks, fingernail – moxifloxacin drops 4x/day x4-5 days
o	Large, central, or concerning features – consult ophtho

-	Chemical burns
o	Use Morgan lens
o	Check pH before using any drops – normal 6.5 – 7.5 

-	Traumatic iritis/mydriasis
o	Treat with dilating drops (atropine or cyclopentolate 0.5 or 1%)

-	Hyphema 
o	Needs ophtho consult to check for posterior trauma

-	Retrobulbar hemorrhage
o	Causes orbital compartment syndrome – can result in irreversible vision loss
o	Needs lateral canthotomy and cantholysis

-	Eyelid laceration
o	Medial lacerations – concern for canaliculus injury

-	Acute angle closure glaucoma
o	IOP lowering drops – timolol, apraclonidine, latanoprost, pilocarpine
o	IV Diamox 500 mg
o	IV mannitol 1-2g/kg over 45 minutes

Ejection Fraction and Cardiac Imaging with Dr. Baker

• Normal EF findings on POCUS – wall thickening and symmetric contraction during systole, anterior leaflet of mitral valve slapping interventricular septum
• Ways to calculate EF using POCUS
• EPSS = End point septal separation
  • Less than 7 mm = normal
  • Greater than 10 mm = reduced EF
• Fractional shortening – measures LV in systole and diastole
• Fractional area change – uses RV volumes in end systole and end diastole to calculate EF
• Simpson Biplane method – US will calculate change in volume of the LV between end diastole and end systole

Lightning Lectures with Drs. Gellert and Wells

• Ludwig’s Angina
  • Rapidly progressive gangrenous cellulitis of the submandibular spaces
  • Polymicrobial
  • Clinical diagnosis, imaging not required
  • Management
    • Airway – preferred awake fiberoptic intubation
    • Antibiotics – Unasyn OR Rocephin + Vanc OR Clindamycin
    • Surgical – Tooth extraction, debridement
• Retropharyngeal Abscess
  • Abscess between posterior pharyngeal wall and prevertebral fascia
  • Late findings – stridor, respiratory distress, drooling, neck stiffness
  • Complications
    • Acute Necrotizing Mediastinitis (~25% mortality)
    • Sepsis
    • Aspiration
    • Lemierre’s syndrome – septic thrombophlebitis of IJ
  • Diagnose with CT neck w/contrast
  • Management
    • ENT consultation
    • Antibiotics – Cllindamycin 600-900 mg IV or Cefoxitin 2 mg IV or Augmentin 3 g IV
• Peritonsillar Abscess
  • Abscess between tonsillar capsule, superior constrictor muscles
  • Classic “hot potato voice”, uvula deviation
  • CT can help differentiate between cellulitis, RPA
  • Management
    • I&D or Needle Aspiration
      • For I&D use scalpel to incise 1 cm deep into abscess cavity
      • Use guard on scalpel to prevent deeper incision and vascular injury
    • Medications – Decadron 10 mg IV + Rocephin 2 g IV + Clindamycin 600 mg IV
    • Need ENT/PCP f/u in 24-48 hours if not admitted

Tracheostomy Complications with Drs. Lehnig and Nelson

• Approximately 1% of tracheostomies associated with major complications
  • 50% mortality with major complications
  • Usually occur after 1 week
• Emergent complications = decannulation, obstruction, hemorrhage
  • Decannulation
    • Replace ASAP as stoma will begin to close
    • If < 7 days old, recannulate under direct visualization with fiberoptics
    • If > 7 days, use direct visualization
  • Obstruction
    • Mucous plugs, blood clots, tube displacement
    • Remove inner cannula > suction trach > deflate cuff > remove trach > bag ventilate or intubate
  • Hemorrhage
    • If > 48 hours since placement, consider TI fistula, infection, coagulopathy, aggressive suctioning
    • Should be evaluated by surgeon
• Urgent complications = TE fistula, tracheal stenosis, infection, cutaneous fistula
• Tracheo-innominate artery fistula
  • Sentinel bleed occurs in 50% of patients
  • Management
    • External compression over sternal notch
    • Internal compression with hyperinflated cuff (up to 50 cc of air)
    • Remove trach > oral or stomal intubation > hyperinflate cuff
    • ET tube beyond fistula > digital compression of artery against manubrium

PEM Lecture – HEENT Problems with Dr. Lund

• Otitis media
  • Antibiotics duration by age
    • < 2 yrs – 10 days
    • 2-5 yrs – 7 days
    • > 6 yrs – 5 days
  • Antibiotics of choice
    • Amoxicillin high dose (90 mg/kg/day)
    • Augmentin – if amox in last 30 days or concurrent conjunctivitis
    • Ceftriaxone – IV or IM x3 days 50 mg/kg
    • Allergies – non-severe = cefdinir, cefpodoxime; severe = clindamycin
• Neck Masses
  • Thyroglossal Duct Cyst
    • Most common neck mass
    • Moves with swallowing
    • Can get infected – treated with clindamycin, augmentin, Keflex
  • Brachial Cleft
    • Treat the same as thyroglossal duct cyst > refer to ENT
  • Fibromatosis Coli
    • Result of neonatal torticollis causing shortening of SCM muscle
  • Lymphadenitis
    • Could be caused by bacterial infection of 1+ node, mycobacterium, cat scratch disease
• Post operative tonsillectomy bleeding
  • Management
    • Suction, IV placement
    • Lean forward
    • Direct pressure laterally with Magills or long clamp
    • Nebulized TXA
• Epiglottitis
  • Keep calm, avoid aggressive exam maneuvers
  • Inhalational anesthesia with no paralytics
  • Needle cric as temporizing measure
  • Antibiotics – cefotaxime or ceftriaxone AND clindamycin or vancomycin

As we know, point-of-care ultrasound has become an extremely useful tool in the ED, allowing providers to glean disposition-altering information from a quick and non-invasive bedside study.  On my ultrasound month, I helped out with a patient who presented with shortness of air for 2-3 days.  The patient was a fairly poor historian, but she reported progressive dyspnea on exertion for several weeks along with cough and orthopnea.  She had no formal diagnosis of COPD or CHF, but she had an extensive smoking history.  I was asked to perform a bedside echo to help narrow down the differentials. The images I obtained demonstrated some classic findings of right heart strain, and I felt like this would be a good opportunity to review some of them.

1. RV dilatation

In a normal heart, the LV should be fairly circular in the parasternal short axis view, and the RV will appear more crescent-shaped. Additionally, the walls surrounding the LV should move inward equally during systole. In the setting of elevated RV pressures, you can often see the interventricular septum bowing in towards the LV, creating a “D” shaped left ventricle, as seen in the clip above. Interestingly, there are different variants of the so-called “D sign”, helping to distinguish between right ventricular pressure vs. volume overload. In pressure overload, the RV presses on the septum during systole AND diastole. Conversely, in volume overload, the septal bowing is much more pronounced in diastole compared to systole. Our patient has a D-shaped LV throughout the cardiac cycle, suggesting RV pressure overload.

4. McConnell’s Sign

This finding refers to RV wall hypokinesis with apical sparing. As you can see in the video above, the apex of the RV appears to bounce up and down while the rest of the RV remains stationary. In the right clinical setting, McConnell’s sign is considered highly specific for acute pulmonary embolism. Disclaimer: this clip came from one of Dr. Nichols’s patients who was later found to have an extensive saddle embolus.

5. Lack of respiratory variation in the inferior vena cava

The normal IVC diameter is less than 1.7 cm and there is a 50% decrease in the diameter during inspiration when the RA pressure is normal (0-5 mmHg). When the inspiratory collapse is less than 50%, the RA pressure is usually between 10-15 mmHg. If there is no collapse with respirations in a spontaneously breathing patient, this suggests markedly increased RA pressure > 15 mmHg. This is usually best evaluated using M mode, measuring the diameter of the IVC during inspiration and comparing to its diameter during expiration. Our patient has an enlarged IVC with almost no collapsibility throughout the respiratory cycle.

Conclusion

If you identify any of these findings on a patient in the emergency department, you should consider common causes of RV failure and strain, such as PE, pulmonary hypertension, left heart failure, ARDS, severe tricuspid regurgitation, volume overload, etc. Our patient received a CT PE in the ED, which was negative. She was subsequently admitted to the cardiology service, where right heart catheterization found evidence of severe pre-capillary pulmonary hypertension. After a few days of monitoring, she was subsequently discharged back into the world with a prescription for diuretics and follow up in the pulmonary clinic.