An interesting article worthy of a literature review was recently discussed at our Journal Club. Posted below is a description of the article and key takeaways from our discussion.

“Evaluating our progress with trauma transfer imaging: repeat CT scans, incomplete imaging, and delayed definitive care”

The research article was published in the journal Emergency Radiology. The study aimed to evaluate the progress made in trauma transfer imaging by investigating repeat CT scans, incomplete imaging, and delayed definitive care. The researchers conducted a retrospective review of all tier 1 trauma patients transferred to their trauma center between May 2018 and April 2019. They compared patients who underwent CT imaging at the initial hospital (IH) with those who did not. The study identified several imaging inadequacies, including repeat CT scans, C-spine inadequacies, incomplete chest-abdomen-pelvis (CAP) imaging, and CAP CT without IV contrast.

The results of the study showed that obtaining CT imaging at the IH led to significantly prolonged IH time. Among patients who had IH imaging, a considerable number required repeat CT scans, had C-spine inadequacies, incomplete CAP imaging, or one or more imaging inadequacies. Most patients with imaging at the IH returned to the CT scan at the trauma center. The study concluded that there are continuing issues with IH CT imaging, which result in delays in definitive care and increased radiation exposure for patients.

The most important takeaway from our discussion was the importance of following ATLS to manage your trauma patients. ATLS trained EM physicians know that a potentially critical trauma patient needs to be resuscitated, receive FAST examination, and receive chest/pelvic xrays where applicable. Once completed, these patients should be transferred to centers where definitive trauma management (ie surgery) is available. Spending time to obtain CT imaging usually leads to a delay in care for the patient.

Please use link below to access conference notes

https://docs.google.com/document/d/15_djB5-EtIzrueZ7b7sT1GAQjp80Mvj5-gyhTY2ADLU/edit?usp=sharing

Please access link below for full notes

https://docs.google.com/document/d/12mmZQoKA5VQpIw9IF8MXv9FB7tbrXiYgMEVcmH8ntkI/edit?usp=sharing

Oral Boards Review

• Always be reassessing the patient, especially after interventions are given
• Don’t be afraid to stand your ground when consults give pushback
• Think about what critical actions need to be taken for each patient
• Be thorough with your history taking, the examiner may not always be forthcoming with critical information

Cardiac Toxins

• When a pt presents with Bradycardia and hypotension, these medications should be on your differential
• Two different major categories: “Pump Killers” and “Electrical Disruptors”
  • Pump killers are your negative inotropes
  • In the setting of BB overdose, selective agents lose their selectivity and begin affecting both B1/B2 receptors
  • BBs in comparison to Ca channel blockers cause more profound AMS, classically cause hypoglycemia in contrast to Ca channel blockers which cause hyperglycemia
  • Early interventions include IVF, glucagon, atropine, and calcium. Consider placing a CVC early and gi decon
  • Bedside echo can be very valuable in helping guide management
    • If those interventions fail, move on to either Vasopressors or 1unit/kg insulin. End of the line is ECMO
    • In the setting of digoxin toxicity, potassium level is extremely valuable; One study found K+ >5.5 had a 100% mortality in those not given an antidote while <5.0 had 100% survival

EMS Radio Calls

• Main call-ins are for prearrival notification, requests for orders, requests to cease resuscitation or a patient refusing medical care
• There are strict guidelines for when we can vs cannot cease efforts in the field
• Often have to make critical decisions with very little information

Lightning Lectures

• -Average lifespan of the pulse generator is 6-10 years
  • -Leadless pacemakers are in the works. Can help reduce many of the risks associated with current pacemakers
• -Indications for pacemaker placement include Sinus Node dysfunction, high degree AV block or high risk to progress to high degree AV block
• -Magnet placement will revert any pacemaker back to the factory rate
• -Iphone 12s and newer models are known to be strong enough magnets to revert to factory settings
• -When a pacemaker is malfunctioning, interrogation is usually the first investigative step

• -AAAs that are symptomatic or > ~5cm require surgical repair
• -Most common complication of AAA: rupture
• -Risk Factors for AAA include Male gender, Smoking, HTN, age >50
• -Gold standard for diagnosis is CT, however, US can also be quite sensitive
• -Overall Tx goal is reducing shearing stress. Aggressively control pain, HR and BP

Using Self-Directed Learning Skills To Pass The Boards The First Time

• -Nationally across all specialties 20% of residents fail boards on the first attempt
• -Self directed learning has 4 main parts: Define a goal, identify the steps, choose the best strategy and asses
• -Important to try to identify gaps in knowledge; can help to ask yourself reflective questions
• -Try to create frameworks to organize your knowledge
• -How to read to gain knowledge: Ask yourself 1. What did I just read? 2. Why was it important? 3. How does it connect to something I already know?

PGY2 Clinical Pathway: Pulmonary Embolism

• -Helpful to divide acute vs subacute vs chronic. Stable vs unstable. Saddle vs segmental vs subsegmental
• -Wide variety of presentations ranging from asymptomatic to profound shock
• -ABG can sometimes be helpful (unexplained hypoxia should raise suspicion)
• -EKG abnormal in up to 70% of cases, however specific findings can vary widely
• -CTPE is 90% sensitive.
• -Treatment dependent on a number of factors including hemodynamic status and bleeding risk
• -Empirically anticoagulate those with low risk of bleed and high pre-test probability of PE

Short vs. Standard Course Outpatient Antibiotic Therapy for CAP in Children

• Clinical Question: Is a 5-day strategy of antibiotics superior to a 10-day strategy for the treatment of non-severe pneumonia in young children demonstrating early clinical response?
• Research Design: Randomized double-blind placebo-controlled superiority trial
  • Superiority trial = aims to show one treatment is clinically better than another
  • Non-inferiority trial = aims to show one treatment is not worse than active control tx
  • Intention to treat analysis = all participants who are randomized are included in the statistical analysis and analyzed according to the group they were originally assigned, regardless of what treatment (if any) they received
• Population: Eight US sites either outpatient clinic, urgent care, or ED
  • Inclusion: Children 6-71 months, diagnosed with uncomplicated CAP, prescribed with amoxicillin, amoxicillin-clavulanate, or cefdinir (IDSA recs), parental report of improvement (no fever, no tachypnea, no severe cough) by days 3-6
  • Exclusion: treatment with antibiotic before diagnosis of CAP, treatment outside of above antibiotic regimen, presence of severe CAP (significant pleural effusion, abscess, empyema, etc.), prior hospitalization during days 1-5 for CAP, history of pneumonia within past 6 months, history of asthma, history of underlying chronic medical condition
• Intervention: Short course antibiotic therapy -> 5 days antibiotics then 5 days of matching placebo  
• Control: Standard course antibiotic therapy -> 10 total days of prescribed antibiotic
• Primary Outcome: Response Adjusted for Duration of Antibiotic Risk (RADAR) measured at first outcome visit (OAV1) on days 6-10
  • RADAR determined by desirability of outcome ranking (DOOR) and ranked participants’ overall experiences
    • DOOR components: adequate clinical response, resolution of symptoms, presence and severity of antibiotic associated adverse effects
  • DOOR/RADAR helps assess the risks and benefits of new strategies to optimize antibiotic use
• Secondary Outcome: RADAR at OAV2 on days 19-25, antibiotic associated adverse effects, quantification of antibiotic resistance genes (sub-study)
• Results: 390 patients assessed, 385 patients enrolled (192 in short course and 193 in standard)
  • . Estimated probability of a more desirable RADAR for the short-course strategy of 0.69 (95% CI, 0.63-0.75)
  • RADAR at OAV2 clinically significant. The probability of a more desirable RADAR in the short-course strategy was 0.63 (95% CI, 0.57-0.69)
  • Antibiotic resistance genes were significantly lower in 5-day course than 10 days
• Conclusion: Shorter courses of antibiotics are superior in treating healthy, clinically improving children diagnosed with uncomplicated CAP
• Strengths: Clinically relevant patient-centered question, multicenter RCT so increases generalizability, placebo and antibiotics were matched for taste and appearance
• Limitations: Studied population is likely a convenience sample with selection bias (only 390 patients in 8 cities over 3 years), strict exclusion criteria, no standard definition or diagnostic criteria for CAP in this trial (viral pneumonia?), no information on diagnostic or radiographic testing (imbalanced testing frequency or imbalanced test results)

ED vs. OR Intubation of Patients Undergoing Hemorrhage Control Surgery

• Clinical Question: Does ED intubation increase the risk of death and major complication for patients undergoing urgent hemorrhage control surgery?
• Research Design: Retrospective cohort study
  • Cohort Study = outcome or disease-free study population is first identified by the exposure or event of interest and followed in time until the disease or outcome of interest occurs
• Population: National Trauma Data Bank
  • Inclusion: 16 years or older, underwent hemorrhage control surgery (received 1u blood in first 4 hours of arrival) at level 1 or 2 trauma centers, to the OR within 60 minutes of hospital arrival
  • Exclusion: suffered pre-hospital cardiac arrest, dead on arrival, non-survivable injuries, underwent ED thoracotomy, suffered severe head/face/neck injuries, presented with GCS <8, centers that performed <10 hemorrhage control surgeries
• Exposure: Endotracheal intubation performed in the ED
• Primary Outcome: in hospital mortality
• Secondary Outcome: total ED dwell time, units of blood transfused in the first 4 hours, major complications (in hospital cardiac arrest, AKI, ARDS, VAPs, severe sepsis)
• Results: 9,667 patients who underwent urgent hemorrhage control surgery at 253 levels 1 or 2 trauma centers in US/Canada
  • Most common procedure was laparotomy (68%), extremity (15%), and thoracotomy (6%)
  • ED intubation was performed in 1,972 patients (20%) and 877 (9%) died
  • • Also associated with longer ED dwell time, greater blood transfusion in first 4 hours, and higher risk of major complications (specifically inpatient cardiac arrest)
  • ED intubations significantly more likely to occur in blunt trauma with higher ISS because of severe injuries to the chest and extremities
  • Low ED intubation hospitals were significant more likely to be level 1, university affiliated trauma centers that perform higher levels of hemorrhage control surgery
• Conclusion: In patients who underwent urgent hemorrhage control at levels 1 and 2 trauma centers, ED intubation was associated with increased odds of mortality and major complications, specifically inpatient cardiac arrest
• Strengths: clinically relevant question, large patient population from multiple centers, reduced confounders by excluding patients with clear clinical indications for intubation such as those that were performed were more likely to be guided by physician discretion
• Weaknesses: reliability of some variables used in the study cannot be confirmed from the database, event-level information not available (may be other clinical indicators associated with mortality), timing of complications is unknown (no temporal association between intubation and cardiac arrest), not all hospitals have the same resources or protocols to maximize patient outcomes

7-19-23 Conference Notes

• Healthcare Quality and Safety Intro
  • Make sure you introduce yourself to patients
  • Ask “why” 5 times if you see something you want to improve – root cause analysis
  • Lean: removal of waste with an emphasis on work flow
  • Six-Sigma: eliminate defects and reduce variations in processes
• Traumacology: RSI and Pain Management
  • Intubation methods: RSI, delayed sequence (sedative first and then paralytic after appropriate oxygenation), drug assisted (sedative-only intubation)
  • RSI goals: facilitate first pass success, minimize aspiration
  • Pre-med: lidocaine (1.5mg/kg), fentanyl (2-3mcg/kg), atropine (0.02mg/kg), versed (2-4mg)
    • Lidocaine and fentanyl prevent increase in ICP by preventing cough/pain response
    • Atropine prevents bradycardia during airway manipulation (vagal response)
  • Etomidate: 0.3mg/kg (0.2mg/kg if >120kg). Adverse effects include myoclonus and protentional adrenal suppression
  • Ketamine: 1-2mg/kg. Adverse effects include tachycardia, hypertension, emesis, emergence reaction
  • Propofol: 1-1.5mg/kg. No analgesia. Adverse effects include hypotension
  • Succinylcholine: 1-2mg/kg. Adverse events include bradycardia, hypotension, hyperkalemia (severe burns >5 days old, crush injury, demyelinating disease, myasthenia gravis
  • Rocuronium: 0.6-1.2mg/kg. Emphasize higher dosing for faster onset. Duration 30-45mins
  • Vecuronium: 0.08-1mg/kg. Duration 30-60mins. Adverse events include prolonged action in hypothermia
  • Fentanyl 75-100x more potent than morphine, less histamine release
  • 1mg dilaudid is equivalent to 7mg morphine
• Transfer of Care
  • Consider EMTALA
    • Provide all patients with a medical screening examination
      • Helps uncover whether an emergency medical condition exists
    • Stabilize patients with an emergency medical condition
      • Make sure they can be transferred or discharged without clinical deterioration
    • Transfer or accept appropriate patients as needed
      • Transferring hospital should stabilize the patient to its fullest extent, provide care in route, contact the receiving hospital, and transfer the patient with copies of the medical records
• Tube Thoracostomy Simulation
  • Indications: pneumothorax, hemothorax, pleural effusion, empyemaRelative contraindications: pulmonary adhesions, coagulopathyPlacement: 4^th or 5^th intercostal space anterior to mid-axillary line above the rib to avoid the neurovascular bundle
  • Consider antibiotics (cefazolin most commonly) for infection prophylaxis

If you have the urge to order Mag for a patient, follow your intuition. But Mag might be even more important when replacing potassium.

When treating hypoK+, if the patient has an IV or will have one, I just order Mag 2g IV rapid infusion (never need to do it slowly, 20 minutes is great) along with 60meq oral K. If they are below 2.0 K+, I either give 2 K runs or if they need/can tolerate volume, a liter of D51/2NS with 20meqK (K runs which are painful and seem to take forever to get to the bedside). Of note, people with CHF very often Mag depleted from diuretics and other etiology.

If you give the Mag IV and K po a the same time, Mag is hitting them first. Tough ones are when you don’t have an IV, because Mag oxide is trash. Sometimes I still order it. But people with no IV are likely not very sick and probably have K above 3.

Something might happen when K gets below 3. So if below 3, I usually give some IV, some po.

Dr Harmon asked me about this before she graduated, and I went looking for a few papers on it. I did a little lit search and cant find a true RCT of K repletion VS K repletion WITH or AFTER Mag repletion. It would be expensive to do and lots of confounders and no one wants to spend $ on a Mag study because it’s an old, cheap medication. **(Although some press coverage now on a Magnesium L-Threonate [which I take] study that showed cognitive benefit in Alzheimers patients).

In the few relevant papers I found, authors just generally recommend Mag with K. But we should always be careful when doing something that is logical but isn’t proven empirically. Sometimes things that make sense in theory don’t pan out in studies (vitamin C in sepsis).

One study in ICU patients compared those getting lots of Mag vs those getting none, and looked at their K balance. They found an obvious benefit to Mag repletion for K balance. They cite lots of basic science research on the K-Mg interplay.

At the end of the day, most people are Mg deficient and people with low K maybe even more likely Mg deficient. Mag is awesome, no downside, patient might flush or get sleepy. Just watch out in those with renal failure.

• Not so e(FAST)
  • Do not bias yourself against doing an eFAST (especially if intoxicated and concerned for blunt trauma)
  • Novice scanners need around 600mL blood for FAST to be positive
  • Serial FAST can increase the sensitivity of the exam and decrease false negatives by 50%
  • Head injury and mild abdominal pain are associated with false negative FAST (be cautious with your FAST conclusions)
  • Caudal tip of the liver is the most common location for free fluid on RUQ view
  • A-lines originating from peritoneal stripes are suggestive of pneumoperitoneum
• Intro to Peds ED
  • “Peds ED T” lists of all ED order setsPrioritize PICU -> general floor -> discharge notes.edhighacuitytemplate and .edlowacuitytemplate are the pre-organized notes for residents.admitresidentnotification is the phrase for TigerText in note
  • Louisvillepemresources.wordpress.com
• Basics of EMS
  • Types of Providers
    • EMR (BLS): operate an emergency vehicle, BVM, OPA/NPA, Narcan, tourniquet, oxygen, CPR and AED
      • Not used in Jefferson County
    • EMT-B (BLS): 56 hours, Igels and LMAs, CPAP and BiPAP, blood glucose, EKG acquisition, LUCAS device, cannot start IV, can give ASA, glucose, IM epi, albuterol, Tylenol, ibuprofen
    • EMT-A (ALS): 228 hours, can start peripheral IV and IOs, can give D50, code dose IV epi, fentanyl, morphine, ketamine, nitro, zofran
    • Paramedic (ALS): 11 mo to 2 yrs, intubation, needle chest decompression, cricothyrotomy, interpret EKG, cardioversion, cardiac pacing, many drugs
      • None of the Jefferson County services have paralytics for RSI
  • Louisville Metro EMS and St. Matthews – Raymond Orthober, MD
  • Anchorage/Middletown EMS – Tim Price, MD
    • Uses Heads Up CPR, levophed for post ROSC, droperidol
  • Fern Creek EMS – Jeff Thurman, MD
  • Okolona EMS – Evan Kuhl, MD
  • Pleasure Ridge Park EMS – Dan O’Brien, MD
  • Patients can only decline transport if alert and oriented, not intoxicated, and decisional
  • Criteria to cease resuscitation: unresponsive, apnea, absence of palpable pulse at carotid, bilateral fixed and dilated, asystole in 2 leads (except in trauma or DNR)
    • Think twice before ceasing efforts for PEA in the field

• Room 9
  • Generally for “unstable” patients
  • Specific considerations
    • Trauma -> will need a man scan, intoxicated and difficult exam, open fractures
    • Stroke -> 10-minute goal door to CT time
    • Medical – > hypotension, hypoxia, AMS, seizure, shock
    • Sedations, procedures, cardioversion, etc.
  • PGY-1 roles
    • Help transfer from EMS stretcher to bed
    • ABCs, Exposure, Blankets
    • FAST exam -> use the barcode scanner, save clips, END EXAM, clean probe with grey wipe, interpret and sign in Qpath, /bedsideultrasound pulls interpretation into note
      • If penetrating, then start with cardiac view
      • If blunt, then start with RUQ view
  • PGY-2 and PGY-3 roles
    • Consider am I comfortable waiting several hours for their workup to start resulting?
    • Who to keep (trauma) -> man scan?, trustable exam?, vital sign derangements?, fracture/dislocation needing intervention?, elderly fall on thinner and isolated GSW to the extremities are common rollouts but do a thorough exam first
    • Who to keep (medical) -> hypotension, hypoxia, most respiratory intervention, intubated transfer patients are common rollouts
    • Who to keep (stroke) -> mostly keep all of these unless outside of window (>24 hours)
      • Get their last known normal, SBP, glucose, neuro exam, then call stroke attending
    • Level 1 criteria: confirmed SBP <90, respiratory compromise, blood products in route, GSW to the “box”, GCS <9 due to trauma, Emergency Physician discretion
      • Know the gender! Women receive O- blood. Men receive O+ blood
  • Room 9 Bay 1 -> has the most space, rigid stylet for VL intubations
  • Room 9 Bay 3 -> has chest tube and difficult airway cart
• Buprenorphine in the ED
  • Removal of X-waiver this past year via the MATE Act 2023
  • Opioids -> synthetic in nature like fentanyl
  • Opiates -> derived from poppy so opium, morphine, and codeine
  • Heroin synthesized in 1874 and thought to be safe and less addictive than morphine
  • Methadone
    • Invented in the 1940s and was created to help with opium and morphine shortage
    • Full opioid agonist. Started being used as maintenance therapy. Dispensed as a daily medication because it is a schedule two drug not covered under original DATA legislation, unlike suboxone which is a schedule three drug and is covered
    • Causes prolonged QT. End of T wave finishes greater than ½ the RR interval
  • Opiate Use Disorder (OUD)
    • Specific criteria from DSM-5
    • Withdrawal timeline: symptom peak at 72 hours (nausea/vomiting/diarrhea, etc.)
      • Start suboxone while they are already in withdrawal
      • Use the COWS score to grade withdrawal symptoms
        • Less than 13 is mild, 13-24 is moderate, 25-36 moderately severe, more than 36 is severe withdrawal
  • Buprenorphine
    • Partial agonist for the mu receptor
    • Ceiling effect for pain control, respiratory depression with minimal euphoria
    • Cannot be injected IV (due to naloxone)
    • Minimal side effects and contraindications (acute liver failure)
    • 2% bioavailability of naloxone when taken sublingually, so does not affect buprenorphine absorption
    • Trying to use opioids after taking suboxone is not particularly effective because buprenorphine is saturating receptors
  • Other MAT options
    • Buprenorphine/Naloxone (Suboxone)
    • Buprenorphine (Subutex)
    • Long-acting Naltrexone IM (Vivitrol)
    • Long-acting buprenorphine SQ (Sublocade)
  • Supportive Care for Opioid Withdrawal
    • Ibuprofen or Toradol (pain)
    • Loperamide (diarrhea), Bentyl (abdominal cramps), Zofran (nausea)
    • Clonidine (anxiety/tremors)
  • What dose???
    • Comes in 8mg (buprenorphine)/2mg (naloxone) and 2mg (buprenorphine)/0.5mg (naloxone)
    • Try to start with 8mg on day one, 16mg (8mg BID) day two, etc.
    • Can start at COWS of 8 (with objective signs) or 12 without
    • Can always start with test dose of 2mg. If they get worse, then likely used opioids more recently than they say or withdrawal is not severe enough. If they get better, then safe for higher dose
    • Precipitated withdrawal -> can either do supportive care or give higher doses of suboxone
• Air Methods
  • Benefits of an air ambulance -> saves time (most benefit when ground time is >1 hr), ability to give blood products, preserves “golden hour” of resuscitation
  • Tools: blood, antibiotics, RSI, TXA, tube thoracostomy, push dose pressors, dual providers
  • Other circumstances: GCS <8, dissecting AA, already on ECMO, LVADs, prone patients (think ARDS), IABP, organ transplant
  • Considerations: weight restrictions, cardiac arrest, combative patient, weather, decon
• Chaplaincy Services
  • Bad news: any news that adversely and negatively impacts their view of life
  • Basic steps
    • Gather information
    • Provide information
    • Support patient/family
    • Develop a strategy for treatment and care
  • SPIKES also a good mnemonic for breaking bad news, but meant for oncology patients
    • Setting (secure a quiet location)
    • Perception (determine what patient/family already knows)
    • Invitation (clarify information preferences)
    • Knowledge (give the information)
    • Empathy (respond to emotion)
    • Summary (next steps and follow up plan)

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 mentioned in conference recently, we have years of various studies on the use of Magnesium Sulfate in COPD and asthma. See below a Cochrane review on asthma.

But right after conference, I checked my email to find hot off the press in Annals of EM, a brief review on Mag in COPD.

Take-Home Message

Among patients with an acute exacerbation of chronic obstructive pulmonary disease, intravenous magnesium sulfate may be associated with fewer hospital admissions, reduced hospital length of stay, and improved dyspnea scores.

Here is the Cochrane review on Mag in Asthma. Authors’ conclusions: This review provides evidence that a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists and IV corticosteroids. Differences in the ways the trials were conducted made it difficult for the review authors to assess whether severity of the exacerbation or additional co-medications altered the treatment effect of IV MgSO4. Limited evidence was found for other measures of benefit and safety.Studies conducted in these populations should clearly define baseline severity parameters and systematically record adverse events. Studies recruiting participants with exacerbations of varying severity should consider subgrouping results on the basis of accepted severity classifications.