Palliative care-

• Who- patients w/ end stage diseases, AIDs, malignancy, multi-organ failure, devastating injuries.
• Benefits to patients- improves quality of life, avoids undesired interventions.
• Benefits to providers- aids with burnout and staying focused on what patient would want.
• Symptom management- pain, dyspnea (opioids are first line, delirium, constipation.

DNR/DNI-

• Advanced directive indicating what patient would want from a care perspective.
• Otherwise consider POAs and next of kin.

Special Populations in the ED-

• Patient’s with intellectual disability: Consider barriers to health including physical, communicational, attitudinal, transportation, financial.
• Patient’s whose primary language is another language.
• Patient’s involved human trafficking.  Always be mindful of red flag signs.
• Elderly patient’s or those affected by dementia/cognitive decline.
• Patient’s affected by housing insecurity.

Systemic infections in children-

• Measles (Rubeola): symptom 10-14 days after exposure with cough, coryza, conuctivitis, Koplik spots.  Rash starts on face, spreading down, including palms and soles. First vaccine at 12 mo. Treatment = supportive.
• German measles (Rubella): symptoms include low grade fever, headache, sore throat and lymphadenopathy (post auricular). First vaccine 12 mo.  Treatment = supportive.
• Varicella: symptoms include fever, cough, rash with vesicular lesions at different stages of healing.  First vaccine at 12 mo. Treatment = supportive.
• Erythema infectiosum: nonspecific viral prodrome with slapped cheek rash caused by parvo. Treatment = supportive.  Most dangerous for sickle cell patients and pregnant patients.
• Roseola: characteristic pattern of high fever followed by rash, starting on trunk and spreading outward, caused by HHV6.  Treatment = supportive.
• Hand- foot- mouth disease: non specific viral symptoms with rash, caused by cocksackie.  Treatment = supportive.
• Papular acrodermatitis: immunologic response resulting in pruritic, popular rash in acral distribution often caused by EBV or hep B. Treatment = supportive.
• Scarlet Fever: sandpaper rash which is blanching and popular in the setting of Group A strep. Treatment = amoxicillin x 10 days.
• SSSS/TSS: peeling beefy red skin around moth, armpits, groin.
• Pediatic sepsis: consider the incredible ability to compensate in children.  Be wary of tachycardia not improved by bolus (up to 60 ml/kg of isotonic crystalloid).

Operations updates-

• East wing annex transitions to come May/June.
• Obs unit within the next year.
• 85% on sepsis compliance.

Restraints and Violent Patients:
• Agitation may be caused by a number of reasons including head trauma, hypoxia, infection, delirium, ingestion, psychiatric disorders. Always consider medical causes.
• Deescalating:
o Verbal- be honest and straightforward without be confrontational or threatening.
o Physical restraints- soft restraints, four-point, chest.
o Chemical sedation- offer voluntary administration with medications including IM ketamine, droperidol, haloperidol, midazolam and lorazepam.

Homelessness:
• Rates of homelessness are climbing within Louisville and the US.
• Patients experiencing homelessness are more likely to visit the emergency department.
• What can we offer? Respect, housing/shelter options, considerations to cost, complexity and availability of treatments


US Images:
• Chiari network: embryonic remnant of the sinus venosus which remains in the right atrium and is a benign finding.
• Use US for shoulder blocks with dislocations: palpate spine of scapula, marching out laterally to the acromion. After finding the posterior, inferior edge of the acromion, move two finger widths inferior and medially and inferiorly with injection directed forward towards to the coracoid process. Use 18 G spinal needle injecting 10-20 cc of lidocaine.
• Use US to confirm abscess before incision and drainage. Cellulitis is a clinical diagnosis but seeing a heterogenous collection on US.

Obesity in the ED:
• Obesity is a rising concern, especially in developed countries. Patients suffering from obesity are at increased risk of DM, CVD, HTN, HLD.
• BMI is a measuring tool which compares weight and height but may be lost to the favor of waist to hip ratio when describing obesity.
• Obesity in the ED:
o General interactions- ask permission to discuss weight, use “people first” language, consider bias, provide basic nutritional information, consider food insecurity and provide resources, referrals for physical activity and PCP.
o Airway- obesity creates different challenges regarding airway in the ED. Patients suffering from obesity have decreased respiratory reserve and decreased tolerance for apnea as well as increased airway pressure causing small ox reserve, increased work of breathing, higher risk of aspiration.
o Circulation- be sure blood pressure cuff is appropriately fitting and consider early arterial line. If venous access is difficult to obtain, consider using ultrasound guided lines as well as intraosseous lines.
o EKGs- findings more common in obesity include low voltages, longer QT intervals (not greater than 500), signs of LVH.
o Trauma considerations- more likely to have indeterminate FASTs, xrays are often underpenetrated, and CT scanners do have weight limits.