Prostatitis:

                   – E. coli in 80% of acute cases (chronic more common), others: STD pathogens

                   – Dx: DRE tender prostate, labs not always helpful

                                      – CT scan only if suspicion for prostate abscess

                   – Rx: 4 wk course of antibx with follow up with urology

Testicular Torsion:

                   – 2 types: Extra-vaginal torsion: neonates. Intravaginal torsion: adolescents

                   – Gold standard dx: surgery, scrotal Doppler US sensitivity about 86-92%

                   – Twist Score: helps determine high vs low risk for torsion

                   – Rx: Urology/OR, manual detorsion: open book 540-720 degrees

Chest Tube procedure sim:

                   – CT choices: 24F for viscous fluid and pigtail for uncomplicated PTX

                                      – Use own judgement

                   –  Can give 2g Ancef

                   – Go in about 10-12cm

GU Trauma: Dr. Huecker:

                   – 2019 model of clinical practice of emergency medicine

                   – Renal injury: Some injuries have no hematuria

                                      – gross hematuria, elderly, penetrating trauma

                                      – Injury classification >4 laceration into collection system go to surgery typically

                   – Ureter Injury: Iatrogenic 80%, penetrating trauma 18%

                   – Bladder: associated with pelvic fractures

                                      – needs CT cystography, RUG

                                      – Depends on intraperitoneal (needs surgery) vs extra (may not need surgery)

                   – Genitals: need good PE

                   – Pelvic injuries:

                                      – lateral compression, anterior/post, vertical shear

                                                         – binders with AP compression

• Alaina: Room 9 M&M:
  • Symptomatic Bradycardia:
    • Atropine -> transcutaneous pacing -> Transvenous pacing
  • Bifascicular Block: extensive fibrosis of conducting system – if presenting with syncope high risk need to admit due to high risk of complete heart block
• Status Epilepticus in Peds:
  • Give kids a first pass for first seizure if unprovoked and simple and otherwise well-appearing child
  • Status Treatment: Def: >5 min or back to back without normal mental status between
    • 1st line meds:
      • Ativan: 0.1mg/kg max 4mg IV, takes about 2-5 min to work last 4-6 hours
      • Versed: 0.2mg/kg with max 10mg IM or 0.2mg/kg IN divided btwn both nostrils, stops seizures in less than 1 min
      • Diastat: 0.5mg/kg with max of 20mg rectally
      • Phenobarbital: 1st line in neonates (<1mo) 20mg/kg with max of 1000mg
    • If still seizing give 2nd dose after 5 min
    • 2nd line:
      • Keppra 60mg/kg IV with max 4500mg
      • Fosphenytoin 20mg/kg IV with max 1500mg
      • Valproic Acid: 40mg/kg IV with max of 3000mg
    • If still seizing 10 min after 1st and 2nd line then go 3rd line:
      • Pentobarbital 15mg/kg bolus with infusion of 5mg/kg/hr IV – will need to intubate patient/PICU
  • Pyridoxine for refractory seizures
  • Neonatal Seizures and infants less than 6mo: many are subclinical and not normal seizure activity
    • check glucose and electrolytes and septic workup (with LP) and antibx plus acyclovir
  • Febrile Seizures: 100.4 and above 6mo-5yo with normal neuro exam and have a seizure while febrile – not seizure then febrile afterwards
    • 30% chance of having another, 2-3% chance of developing epilepsy
    • Simple if <15min not recurrent/need to be vaccinated/GTC – give supportive care (tylenol/ibuprofen) – okay for DC home
    • Complex: >15min with more than 1 seizure in 24 hrs/focal seizure – admit
• Hyperkalemia/Hemodialysis
  • Causes: kidney/CKD, intake, tissue damage/leakage, endocrine (Addison’s/adrenal insuf)
  • Rate of change in potassium is more important than actual number
  • Treatment:
    • Calcium – 3g CaGlu or 1g CaCl stabilizes cardiac membrane/stabilizes voltage across membrane
    • Insulin – shifts potassium into cells through activation of ATPase 10 U plus 25g glucose decreases K by 1mEq/L
    • Albuterol: shifts potassium into cell by activation of ATPase decreases by about 0.5mEq/L – 15-20mg neb
    • Bicarb: Only use in Metabolic Acidosis otherwise do not give – doesn’t really decrease K until later in the course
    • Remove K: Lasix/Bumex, BInders/Lokelma renal likes – do not usually give in ED
    • Dialysis: Takes 60 min to decrease by 1 mEq/L
  • Succinylcholine: healthy people increases 0.5 per dose
  • Emergent Dialysis: A: acidosis, E: electrolytes, I: Ingestions/intoxicaitons, O: overload fluid, U: uremia (encephalopathy, pericarditis)
    • Chronic Dialysis Patient:
      • Electrolyte abnorm
      • Volume overload
      • Remove toxins/BUN/acidosis
    • Acute Renal Failure:
      • Electrolyte abnorm
    • Normal Renal Fxn:
      • Ingestions
  • Dialysis Basics:
    • Small molecule
    • Charged
    • Examples:
      • Toxic Alc: methanol and ethylene glycol
      • Lithium
      • ASA/Salicylates
      • Valproic Acid

Conference Notes:

Lightning Lectures:

– Priapism: 3 types Ischemic (emergent and most common), non ischemic (trauma/fistula/congenital), stuttering. Common causes: adult medications, children SCD. Dx with PE/blood aspiration/US. Tx: phenylephrine/aspiration.

– Epididymitis: Causes are mostly STI organisms and E. coli. Acute less than 6 weeks. Orchitis: usually with epididymitis. Dx: US to rule-out torsion if suspected, gram stain, MB, GV, UA. TX: Ceftriaxone, Doxy if enteric organisms suspected Ceftriaxone and Levofloxacin. Can be associated with nec fasc. Chronic greater than 6 weeks: most common cause TB will need urology consult.

Dr. Eisenstat Lecture:

– Med Safety: PD vs PK – ADME absorption (bioavailability: IV is 100%, not affected by age, mostly by route and other drugs/diseases), distribution (volume of distribution less than 1 = more in serum, elderly have less water and more fat and less albumin which increases volume of distribution and free drug respectively), metabolism (enzymes), elimination (liver vs renal). T1/2: half life, time which is required to for initial concentration to decrease by 0.5 (changed by metabolism or elimination). Elderly high risk for adversed drug events ADE. Beers List: opioids, SSRI, TCA, anti-cholinergics, anticoags, benzos, anti-pysch, others.

Dr. Price Lecture:

– Is that your final Answer?: paramedics are trained in determining death on scene.

– Urolithiasis: Imaging: CT vs US: looking for hydronephrosis or hydroureter on US, non-con CT most sens and spec for stones. Who to image: no hx of stones, older age, complications (fever, infection on UA, transplanted kidney/solitary kidney, AKI), Management: pain ctr, labs, imaging, medical expulsion therapy. Look for other causes of symptoms.

Cystitis and Pyelonephritis:

– Cystitis: signs and symptoms: hematuria, CVA, back pain, freq, dysuria (in males think prostatitis). Urine dipstick: nitrites very spec not sens, leukocyte esterase most sens not spec, for a dipstick test when both are negative post-test prob at 5% . Asympto bacteriuria: no need to rx unless preg/urologic surgeries/transplant kidney.

– Pyelonephritis: UTI plus CVA/fevers/N/V – will need urine cultures drawn and antibx coverage. Most can be DC home unless unable to tolerate PO or septic

– Rx: uncomplicated: Macrobid, TMP-SMX, fosfomycin, cephalexin. Complicated: Cipro, Levo, TMP-SMX plus all these should get 1 dose of IV antibx (usually ceftriaxone)

Flow chart to be posted in Room9er