Dr Eisenstat

5/18/22

1.  What we don’t use anymore: Spotlight on ancient vomiting sticks!, Ipecac syrup (no longer in use 2/2 aspiration risk), EWOL tube (large bore gastric tube), Potassium permanganate
2. Activated Charcoal: binds drugs in a 10:1 ratio.  The earlier the better (1-2 hours) and more efficacious with large, less polar molecules; dose 1-2g/kg (come in 50g tubes); CI with caustic ingestion, hydrocarbons, airway compromise, AMS
3. When to give multiple doses of AC
   1. SDAC: single dose AC, used predominately for salicylates
   1. MDAC: multiple doses AC, “gut dialysis”  for drugs to undergo enterohepatic recirculation; single bolus dose (1g/kg) and then q8 hours (.5g/kg); do not use w/ sorbitol (diarrhoea); does not reduce M&M but does reduce drug rate
      1. Carbamazepine
      1. Lamictal
      1. Colchicine
      1. Dapsone
      1. Phenytoin
      1. Phenobarbital
      1. Amatoxin
      1. Quinine (hypothetical with hydroxychloroquine)

•  Whole Bowel Irrigation (1-2L Go Lytly 1-2 hours) best used for things not well absorbed by AC; packers (drug mules), XR preparations.  Eg: Iron, Lithium, XR BB/CCB, bupropion.  Note that this is a cumbersome and messy endeavour.   
• Gastric lavage: used with colchicine or paraquat (pesticide)
• Take homes: AC best in the first 2 hours (but can argue to give beyond this), be familiar with MDAC, WBI for lithium and extended release substances

Lecture Points May 11, 2022

Zach Heppner, MD: Upper GI Bleed

1.  Most common aetiologies: PUD, erosive gastritis, oesophageal varices, malignancy, Mallory Weiss Tears
2. Initial management massive UGIB: ABC (secure airway, obtain access, blood to bedside), medical management (Rocephin, Protonix, Octreotide)
3. Balloon Tamponade
   1. Indications: tamponade that is unresponsive to endoscopic therapy or temporisation before definitive treatment
   1. No contraindications
   1. Complications: oesophageal rupture, rebleeding, aspiration, pain, cardiac arrythmias, pressure necrosis (x>48 hours of placement)
   1. Types of tubes
      1. Blakemore (3 ports)
      1. Minnesota (4 ports)
      1. Linton (2 ports, holds 700cc air)

Samantha Lucrezia, MD: Paediatric Haem/Onc Emergencies

1.  Closely examine: CVL sites, mucosal areas, skin/soft tissue
2. Workup: CBC, CMP, Blood (peripheral cultures are not routinely indicated)/urine cultures, CXR, LP if altered, Stool studies as needed based on symptoms
3. ALL: most common childhood malignancy; common presentation with fevers, lymphadenopathy, peteciae/purpura, hepatosplenomegaly, gingival hyperplasia, bone pain, hyperleukocytosis
4. Hyperleukocytosis: WCC>100k, high risk in infantile leukaemia, T cell ALL, AML, CML.  Manage with hydration (#1) and consider alkalinised fluids without addition of K.  Consider next adding Allopurinol and addition of Rasburicase (do not administer without consultation with haematology); avoid PRBC transfusion (increased risk of hyperviscosity)
5. Sickle Cell Anaemia: If pt presents with temp>35.5C, obtain CBC, blood/urine cultures, CXR, speak with haem/onc, antibiotics and admission of abnormal labs; can consider discharge if normal labs and OK with haem/onc/discussion with family/patient
   1. Acute chest syndrome: SSA, plus chest pain, fever, SOA/hypoxia, new infiltrate on CXR.  It is defined as a life-threatening lung infarction, common in 2-4 year olds, half of cases develop during hospitalisation and not at initial presentation.  It is the second most common cause of hospitalisation in children with SSA. 
      1. Acute management: fluids, antibiotics, transfusion as needed (maintain hgb 9-11g/dL) for anaemia or severe hypoxaemia

Jonathan Boland, MD: Hernias

1.  Reducible: soft, easy to replace; incarcerated: difficult to reduce, but retained blood flow; Strangulated: unable to be reduced, signs of ischaemia
2. Inguinal hernias are most common type of hernias; direct vs indirect
3. Femoral hernias: most common in women
4. Hernia management: if reducible> refer for outpatient management; if not reducible, CT and surgical consult.  USS may be helpful but CT for definitive imaging
5. Tips for reduction, per Dr Eisenstat: pain control, Trendelenburg, ice hernia prior to reduction

Kyle Stucker, MD: Cholecystitis, Cholangitis, Cholelithiasis

1.  Cholecystitis: more common in women, 8% prevalence in men, common with increasing age, bariatric surgery; vast majority asymptomatic
   1. Physical examination findings: Murphy’s sign (65% sens, 87% spec)
   1. Imaging: US modality of choice (81% sens, 83% spec)
   1. Gallstones + sonographic murphy’s sign: high PPV for acute cholecystitis
   1. If cholecystitis goes untreated, then gangrenous cholecystitis/perforation/emphysematous cholecystitis
   1. Treatment: fluids, Abx, pain control, admission, surgical consultation
   1. Acalculous cholecystitis: high occurrence with systemic, life-threatening disease
2. Biliary Colic: recurrent attacks of upper abdominal pain, associated with evening hours, lasts no more than a few hours; caused by stone moving in and out of obstructing position.  Treatment in the ER: pain control, outpatient surgery referral
3. Cholangitis: Charcot triad (fever, RUQ pain, Jaundice), +AMS, shock (Raynaud’s pentad)
   1. Tx with Abx, fluids, surgical consultation; ERCP for definitive management

Skyler Hill-Norby, DO: Hepatitis

1.  Aetiologies: viral, medication-induced, toxin induced, ischaemia
2. Clinical features: malaise, nausea/vomiting, fever, jaundice, hepatomegaly
3. Labs/imaging
   1. CMP: AST/ALT elevation, elevated Bilirubin, alk phos elevation
   1. LFTs: coags (PT/INR reflects synthetic function)
   1. Ammonia level
   1. RUQ US: may show acute liver pathology
   1. CT abdomen/pelvis
4.  Dispo: admission on case by case basis
5. Tylenol Toxicity          
   1. Suggested dose: 4g/day; toxic dose 150mg/kg
   1. Features of toxicity based on duration of ingestion
   1. Acute ingestion: Rumack Nomogram, NAC therapy
   1. Fulminant hepatic failure based on Cr, lactic acid, INR level
6.  Mushroom toxicity
   1. Amanita Phylloides
   1. Eary vs Late onset (early onset suggest benign course)
   1. Tx considerations: NAC, glucose monitoring, possible need for liver transplant
7.  Shock liver: very ill patients, treatment is to treat underlying causes of shock

Jessica Javed, MD: Palliative Care/Hospice Elective Follow Up

1.  Palliative Care: focused on symptom management, MDT, quality of life
2. Hospice: focused on patients who have less than 6 months to live, quality of life, pain management
3. Palliative care is available easily on an outpatient basis and can be arranged without admission
4. Hospice Takeaways: anyone can initiate a referral, inclusion criteria includes multiple ED visits for a chronic, unresolving medical issue, covered by most insurance, Hosparus is one of the only options for hospice in KY. 
5. Tips for breaking bad news
   1. Quiet setting
   1. Create IDT with chaplain/nurses
   1. Sit down if you can
   1. Start by asking what the families know and fill in knowledge from there
   1. Prepare family for bad news if appropriate
   1. Give family/patient time to process
6.  Tips for goals of care discussions
   1. Focus on what the patient would want
   1. Determine POA if patient is not decisional
   1. Do give your recommendations
   1. Don’t refer to full code as “doing everything”; this implies that everything else is not good/worthy
   1. Goals of care can change; be open to this
7.  Kentucky MOST form (Medical Orders for Scope of Treatment)
   1. Makes goals of care more algorithmic
   1. Usually used for hospice/palliative patients
   1. Kept in the home
   1. Can be used as a guide for caregivers/EMS (EMS must have original copy)/healthcare providers to direct what patient wants with regards to their care, especially in end of life situations
   1. Generally reviewed annually or after d/c from healthcare facility

Dr. Dan Fisher and Dr. Mitchell Weeman did an awesome job with their clinical pathway summarising ER management of both upper and lower GI bleeds. See brief lecture summary below and find their clinical pathway uploaded to the site for a more in-depth review.

1.  UGIB more common than LGIB; increased mortality with UGIB
2. GIB mimics: Pepto Bismol, Bismuth, Beets, red food colouring, bleeding from epistaxis/dental bleeding, red meat, iron supplements, vit C, horseradish, methylene blue
3. UGIB (proximal to ligament of Trietz; gastric>duodenal): most common aetioloy is PUD (NSAIDs, ETOH, ASA, Tobacco use), followed by erosive gastritis, oesophageal varices (high mortality) and Mallory Weiss tears; Risk stratification with Glasgow Blatchford Score
4. LGIB (distal to ligament of Treitz): most common aetiology haemorrhoids, diverticulosis/itis, aorto-enteric fistula (herald bleed), colitis, malignancy (ask about type B symptoms, Fhx), Meckels (in paediatric population)
5. ED workup: full history/physical, DRE, CBC, CMP (BUN:CR>36 w/o renal failure), type/screen, coags, guac stool test (if GIB can be pos for up to 2 weeks following), +/-lactic acid (risk stratification), +/- VBG (base deficit in acute setting), EKG (demand ischaemia), CT angio is test modality of choice for vascular cause of bleeding