Operations- Ross

• Provide discharge instructions that coincide with chief complaints, as well as put chief complaints that are relevant. 
• If you have a code aorta (ascending aortic dissection) dial 8008 and select code aorta, don’t page cardiothoracic surgery etc. 
  • Descending aortic dissections managed by vascular here at ULH
• Cerner Camera Capture
  • 2 phones available (1 in room 9, 1 at attending desk)
  • Log into cerner on phone using “Cerner Camera Capture” app
  • Put in MRN
  • Put in location folder
  • Will find picture in multimedia manager on left hand menu list
• Code Green
  • Imminent Delivery
• Road Rash
  • If truly severe consider calling trauma and/or burn nurse to help get wound care managed
  • Can write for more than 3 days of opioid pain meds if medically justified
• New Kasper
  • When in patient chart click on ED provider view
  • Click on Kasper within white menu list on the left
• Dispo Times
  • NES if waiting for recommendations for multiple hours consider discussing with ED attending about escalating to NES attending.
  • Ortho should put in bedslip within approx. 2 hours

PEM Endocrine- Kopp

• DKA in Peds
  • 
  • 45kg child slow fluid resuscitation
    • 1.5x maintenance fluid rate
  • 45kg fast fluid resuscitation
    • 2x maintenance fluid rate
  • With resuscitation, if K is greater than 5 do not include K in initial fluid resuscitation
  • Add in dextrose when there is a decrease in glucose of >100 in 1 hour
    • Keep in mind to continue to check glucose every hour
  • Bicarb administration not recommended… except for life-threatening hyperkalemia or acidosis with pH <6.9 with evidence of compromised cardiac contractility
  • Avoid intubation
    • Increased CO2 > decreased pH CSF > cerebral vasodilation > cerebral edema
    • Make sure you match RR if you do intubate, and be quick to bag during RSI, 45 sec of apnea can be drastic
• Hypoglycemia
  • Rule of 50
    • 50/D50=1ml/kg
    • 50/D25=2ml/kg
    • 50/D10=5ml/kg
    • 50/D5=10ml/kg
  • Recommend D10 or D5 fluids for correcting hypoglycemia
    • D50/D25 > will blow small IVs which is most peripheral IVs in kids
• Inborn errors of metabolism
  • Most will have a cheat sheet
  • D10 45% NS with electrolytes run at 1.5x maintenance fluid
    • Dextrose fluids is mainstay
• Adrenal insufficiency
  • Stress dose steroids
    • 3x base dose steroids
  • Hydrocortisone (IV or IM)
    • 0-3: 25mg (Can pick kid up with 1 arm)
    • 3-12: 50mg (Can pick kid up with 2 arms)
    • >12: 100mg (Too big to pick up)
• Diabetes insipidus
  • DDAVP IN, IV, SubQ
  • Goal of lowering Na

Pharm Lectures

• Magnesium
  • Normal level 1.7-2.3
  • Hypomagnesia (<1.5)
    • Causes: poor nutrition chronic EtOH, excessive GI or renal loss, medications (thiazides etc.
    • Symptoms
      • Cramps
      • Fatigue
      • Vertical nystagmus
      • Ataxia
      • Seizures
      • Dysrhythmias, QTc prolongation
    • Tx: Mag oxide 300mg tablet, Mag sulfate 1-4G IV
    • Torsades de pointes> 2G IV over 15 min
    • V fib > Mag 2G IV over 2-5 min
  • Hypermagnesemia (>4)
    • Cause: overuse of mag supplements/laxatives
    • Symptoms
      • Muscle weakness
      • Absence of deep tendon reflexes
  • Mag Pearls
    • Predominantly intracellularà when serum levels are low= intracellular is likely very depleted​
    • Potassium and magnesium levels are linkedà if difficulty repleting potassium check a magnesium level and replace
• Potassium
  • Normal Range 3.5-5.0 (Cards patients 4.5 goal)
  • Physiologic function​
    • Action potential regulation​
    • Muscle contraction​
  • Hyperkalemia: K > 5.5 mEq/L​
    • Causes:​
      • Renal dysfunction (ESRD/AKI)/rhabdomyolysis; ​
      • Medications (ACE inhibitors, ARB’s, potassium sparing diuretics, immunosuppression (cyclosporine, tacrolimus), trimethoprim-sulfamethoxazole (Bactrim®)​
    • Symptoms: EKG changes, arrhythmias​
  • Hypokalemia: K < 3.5 mEq/L ​
    • Causes: GI losses, medications (diuretics, insulin, albuterol)​
    • Symptoms: Cramping, weakness, myalgias, malaise, arrhythmias​
  • EKG changes
    •  
  • Hyperkalemia treatment
    • Cardiac stabilization
      • Calcium gluconate
    • Shift K
      • Regular Insulin + Dextrose​, Albuterol
    • Targeted Elimination
      • Dialysis
      • Loop diuretics
      • Cation Exchange Resins/Polymer​
  • Hypokalemia treatment
    • Check and replete Mag
    • 3.2-3.5 mMol/L​
      • 40 mEq KCl PO or per tube​
      • KCl IV over 1 hour x 4 doses
    • 2.7-3.1 mMol/L
      • 40 mEq KCl PO or per tube x 2 doses 4 hours apart​
      • KCl IV over 1 hour x 4-8 doses
    • < 2.6 mMol/L
      • 10 mEq KCl over 1 hour x 8 doses
• Phosphorus
  • Normal: 2.5-4.5
  • Hypophosphatemia
    • Causes: Refeeding syndrome, chronic alcohol abuse, hyperparathyroidism, vitamin D deficiency, diabetic ketoacidosis (DKA) chronic diarrhea, antacids, hungry bone syndrome

• Symptoms: Loss of appetite, Bone pain/fragile bones, Irregular breathing, Irritability, Fatigue/Weakness, Encephalopathy, Seizures

• Hyperphosphatemia
  • Causes: Abnormal renal function (AKI/CKD), rhabdomyolysis, tumor lysis syndrome, hypoparathyroidism, hypothyroidism, phosphate containing laxatives, vitamin D toxicity, bisphosphonates, fosphenytoin.
  • Treatment:
    • Phosphate restricted diet (800 – 1000 mg/dL) ​
    • Fluid resuscitation to euvolemia​
    • Forced diuresis (acetazolamide +/- furosemide) ​
    • Phosphate binders: Bind phosphate in the gastrointestinal track (dosed 3 x daily with meals) à several drug interactions 
• Calcium
  • Normal:  8.8 – 10.4 mg/dl ​
    • 1.10-1.30 mmol/l (ionized)
  • Hypocalcemia
    • Muscular ​
      • Hyperflexia​
      • Fasciculations​
      • Cramping, myalgias
    • Neuro​
      • Anxiety, delirium, coma​
      • Paresthesias​
      • Seizure
    • Cardiovascular​
      • Hypotension​
      • Vtach​
      • Bradycardia, heart block
    • Indications for treatment:​
      • ​QT prolongation
      • ​Seizure, delirium, coma
      • Severe Muscle cramping ​
      • ​Pre-emptive in blood product transfusion
      • ​Caution: EG toxicity, severe increase in phosphate
  • Hypercalcemia
    • Signs and Symptoms​: Muscle weakness, hyporeflexia​, GI (constipation, ileus, n/v)​, hypertension​, Delirium, coma​, Paresthesia
    •  
    •  
• Sodium

• Hyponatremia
  • Treatment for Hypotonic Hyponatremia (Serum Na <135, Serum Osm (<280 mOsm/kg)
    • Hypervolemic
      • Fluid restriction
      • Diuresis
    • Euvolemic
      • Fluid restriction
      • Stop offending medication
    • Hypovolemic
      • Stop offending medication
      • Isotonic crystalloid (Saline)
    • Causative meds
      • SSRIs, TCAs, Antipsychotics, antineoplastics, NSAIDs, AEDs
  • Hypertonic Saline
    • Indications for hypertonic Saline
      • Seizure
      • Confusion (use with caution and consider other etiologies first)
      • Gait instability
      • Coma or cerebral herniation
    • Initial management
      • 3% NaCl infusion 2ml/kg over 5-10 min
      • If no clinical improvement > Repeat 3% bolus
      • Ensure correction does not exceed 6 mEq/L in 24 hours
      • What if no 3% NaCl at your facility?
        • Hypertonic sodium bicarb can be used
          • Push slow over 3-5 min, 2amps ~ 200 mL 3% Saline
  • Hypernatremia
    • Initial Labs
      • BMP​
      • Mg, Phos​
      • Urine Na​
      • Urine Osm and/or Urine SG​
    • Treatment
      • Hypovolemia with hypotension​
        • Isotonic fluids are recommended​
      • Normotensive Hypovolemia​
        • D5W or 0.45 % NaCl 
      • Na Correction​
        • Goal: restore sodium balance​
        • Lower Na:​ <10-12 mEq/L per 24hr​
      • Free Water Deficit​
        • Correct first half within 24 hours​
        • Correct remainder over 72 hours​
    • Diabetes insipidus
      • Labs
        • Serum Na > 145 mEq/L​
        • UOP > 200 mL/hr (sustained)​
        • Urine SG < 1.005​
        • Urine Osm < 300 mOsm/kg​
        • Serum Osm > 300 mOsm/kg
      • Treatment
        • Hemodynamically Stable:
          • DDAVP (desmopressin) 1 mcg IV q8hr​
            • May be administered subcutaneously*
        • Hemodynamically Unstable:​
          • Vasopressin continuous infusion​
        • Goal of Therapy:​
          • Maintain UOP < 200 mL/hr

Emma Ganshirt Cushing’s

• Presentation
  • Psychosis
  • Hypertensive emergency
  • Hypokalemia
  • Cardiomyopathy
• Broad Differential, consider it a risk factor for multiple etiologies
• Physical exam and Hx key

Dana Roberts Adrenal Crisis

• Adrenal crisis most common cause primary adrenal insufficiency
• Risk factors: 
  • History of adrenal crisis
  • On steroid therapy
  • Meds that increase cortisol (levothyroxine, phenytoin, phenobarbital, rifampin)
• Clinical manifestation
  • Volume depletion and hypotension not responsive to fluids (other: weakness, fatigue, weight loss, decreased appetite, hyperpigmentation, abdominal tenderness)
• Labs: 
  • Low Na, Glucose, aldosterone
  • High K, Ca, Creatinine (prerenal), ACTH, renin
  • Normocytic normochromic anemia
• Tx: 
  • Hydration, usually need 4-6L in first 24 hours, be mindful of likely low Na and don’t correct too quickly, steroids (100mg bolus IV or IM hydrocortisone with additional every 6-8 hours)
• Mortality: as high as 25%

Huecker Micronutrients/Supplements

• 5 Pillars of Wellness: Move, Rest, Nutrition (Micronutrients/Supplements), Wisdom, Community
• Deficiency avoidance vs Optimization (Daily % on box is minimum, not optimum)
  • Example 100% daily vitamin C is enough to not get scurvy, not to help build tendon etc. 
• For more reading: Perfect Health Diet, discusses ins and outs of a healthy diet in easy to read way
• Daily Supplements: Mag >200mg, Vit D (~2000IU), Vit K2 100mcg, Vit C (1G), Idodine
• Most important mineral: Mg 
  • Used in 800 bodily reactions
  • Deficiency Symptoms: Muscle cramps/HA arrythmia, tremor, reflux, mitochondrial decay, poor immune function, death
• PO mag oxide trash, best PO: mag threonate (Brain mag, Mag mind)
• Probiotics: Food > Pill
• Collagen: Glycine: Methionine ratio (Bone in meats better)
• Lab Door: Website that tests supplement products for authenticity

Huecker Handout

Daily Supplements

Ask yourself “Am I going take this pill or powder every day for the rest of my life?” One should decide to take a supplement only after thoughtful consideration of ability to maintain long-term compliance. Macro- and micronutrients should come from whole food sources as often as possible. The package of vitamins in foods has millions of years of evolution backing its design. Thus, infant formula makers continue to strive for the same profile and clinical benefits of breastmilk. 

The backbone of these recommendations comes from the book Perfect Health Diet. Written by PhD husband and wife, the book covers macronutrients and micronutrients, with focus on nutrient density of foods and avoidance of toxins. 

Nutrition should begin with regular consumption of nutrient-dense foods:

• 3 egg yolks daily (5 for pregnant or trying to become pregnant) for choline, folate, vitamin A.  

• Soup made with bone stock 3 days per week for calcium, phosphorus and collagen.

• Fermented vegetables (kimchi, sauerkraut, or fermented mixed vegetables) for nucleotides, probiotic bacteria, and vitamins K2 and B12. Add other vegetables such as tomato, avocado, potato, sweet potato, banana, green leafy vegetables, and seaweeds such as dulse, daily for potassium. 

• ¼ lb beef or lamb liver, weekly for copper, vitamin A, folate, choline. You can substitute ¼ lb chicken, duck, or goose liver weekly plus 30 g 85% dark chocolate daily. 

• Fish, shellfish, eggs, weekly (for selenium)

You want to supplement the nutrients from the foods on this list that you do not consume. Potential issues with food recommendations include the 3 eggs per day (saturated fat and cholesterol), the fermented food not mentioning fermented milk (ie. kefir or yogurt), and no mention of omega 3 fatty acid supplementation (should consider whole oil supplement depending on amount of fish in diet). If you are not eating some of these foods, consider supplementation, for instance collagen powder if you do not regularly eat bone broth. 

Other important food considerations include polyphenols, plant molecules that induce hormesis in our bodies that will lead to longer life. Common sources include coffee and tea, chocolate, mushrooms, colorful vegetables and fruits, nuts, herbs and spices, algae, wine, olive oil. 

DAILY Supplements

• Sunshine or vitamin D3 as needed to achieve serum 25OHD of 50-60 ng/ml

• Vitamin K2 100mcg

• Magnesium 200mg

• Iodine 200mcg

• Vitamin C 500mg 

• Activated vitamin B complex (see this formulation)

• Pantothenic acid (vitamin B-5) 500mg

OPTIONAL supplements, with some dietary caveats:

• Chromium, 200-400 mcg per week (not necessary if you cook in stainless steel pots)

• FOR PEOPLE WHO DO NOT EAT LIVER: Copper 2 mg per day, Vitamin A from cod liver oil, 50,000 IU/week

• Taurine 500 mg to 5000 mg per week (higher doses may be therapeutic for small intestinal or systemic infections)/(also helpful for blood pressure lowering)

• Selenium 200 mcg per week depending on selenium content of food (if food is produced in dry, flat areas = high selenium, no supplements; rainy, well-drained areas = 200 mcg/wk)

• Molybdenum 150 mcg per week

OTHER supplements depend on goals. The list above covers most of the supplements needed in the context of balanced, diverse diet. Individuals with restrictive diets should do research potential deficiencies. 

Special Considerations

Sleep – magnesium, glycine, L-theanine, vitamin D (in AM), resveratrol, LIGHT, rarely melatonin

Calorie Reduction/Weight Loss – sleep, chromium, high protein, creatine

Muscle Mass – sleep, creatine, omega 3, whey protein, collagen

Hormone Optimization – sleep, adaptogens (e.g., cordyceps, ashwagandha), Zinc, Vitamin D, B vitamins

Immunity – sleep, vitamin C, vitamin D, Zinc, garlic, elderberry, quercetin, probiotics

Recovery from Injury – sleep, glucosamine and chondroitin, hyaluronic acid, collagen

Hyperlipidemia – niacin, psyllium, phytosterols, red yeast rice

Nelson Thyroid Disorders

• Hyperthyroidism
  • Tachycardia, fever, exophthalmos, etc
  • Subclinical hyperthyroidism
    • TSH low, T3/T4 normal
  • Primary hyperthyroidism
    • TSH low, T3/T4 high
    • Graves Disease (85% of cases)
    • Thyrotoxicosis
    • Toxic nodular goiter
  • Secondary
    • TSH High, T3/T4 high
• Hypothyroidism
  • Subclinical hypothyroidism
    • TSH high, T3/T4 normal
  • Primary hypothyroidism
    • TSH high T3/T4 low
    • Hashimoto’s thyroiditis
    • Subacute painful thyroiditis
    • Subacute painless thyroiditis
    • Surgical/ablation
  • Secondary
    • Panhypopituitarism
    • Pituitary adenoma
    • CNS infection
• Thyroid Storm
  • Typically caused by stressor such as infection, recent surgery, trauma, PE, MI, DKA, med non-adherence
  • Triad: Hyperthermia (Usually >104F), tachycardia, AMS
  • Point Scale: Burch-Wartofsky Point Scale
  • Evaluation: Thyroid function panel, Tox, UDS, UA, CXR, EKG
    • Thyroid function: Low or undetectable TSH plus high free T3/T4
  • Treatment: Propranolol, Propylthiouracil or Methimazole, Cholestyramine, Fluids, Cool
    • Be careful wit B-blocker due to some patients having heart failure associated, can exacerbate and precipitate shock
    • PTU- Hepatotoxic
    • Methimazole- Avoid in pregnancy (can cause aplasia cutis)
    • Cholestyramine- Prevent free thyroid hormone reabsorption
• Myxedema Coma
  • Hypothyroidism, Altered mental status, Hypothermia/bradycardia
  • Precipitated by Sepsis, Medication nonadherence MI, heart failure, and cold exposure
  • Work-up
    • Thyroid panel: Elevated TSH, low T4 (Labs not correlated with severity)
    • Hyponatremia, hypoglycemia
    • Acidotic, retain CO2 and poor perfusion causing elevated lactate
    • Infectious work-up, Head CT, Possibly LP
  • Treatment
    • ABCs
    • Fluid resuscitation +/- vasopressors
    • Electrolyte replacement
    • Levothyroxine- 1^st line
      • Safe, give if suspected don’t wait for labs
    • Adrenal insufficiency cause > give steroids
• External Causes of  Hyperthyroidism
  • Amiodarone induced thyroiditis
    • Increased iodine load
    • Destructive thyroiditis- Thyrotoxic, can cause to release more thyroid hormone which then leads to hypothyroidism as thyroid
  • Other meds:
    • Lithium, HIV meds, immunotherapy, iodine, contrast
  • Munchhausen’s
  • Cancer
    • Struma ovarii, metastatic thyroid cancer

Shaw Acid/Base Disorders

• Anion Gap Acidosis
  • Decrease in HCO3, Increase in Gap
  • MUDPILES
    • Methanol
    • Uremia
    • Diabetic or alcoholic ketoacidosis
    • Paraldehyde (Tylenol)
    • Isoniazid/Iron
    • Lactic acidosis
    • Ethylene glycol
    • Salicylate
• Non Anion Gap Acidosis
  • Loss of HCO3 replaced by Cl ions
    • USEDCAR
      • Ureteroenterostomy
      • Saline Administration
      • Endocrine Disorder (Addison’s disease)
      • Diarrhea
      • Carbonic anhydrase
      • Ammonium Chloride
      • Renal tubular acidosis 
• How to Calculate Excess Anion Gap
  • Note in DKA (Don’t correct sodium to figure out gap)
  • Excess anion gap = Anion gap – 12 + HCO3
    • Sum >30: underlying metabolic alkalosis
      • Change in  AG > Change in HCO3
      • Less acidotic than should be
    • Sum <23: Underlying non-anion gap
      • Change in HCO3 > change in AG
      • More acidotic than should be
• Compensation in Metabolic Acidosis
  • Winters Formula
    • PaCO2=1.5 (HCO3) + 8 +/- 2
    • PaCO2 ~ last 2 digits of pH
• Treatment
  • Respiratory Acidosis
    • Correct ventilation problem
      • Example Opiate- Narcan
      • Anatomical- NPA, BiPAP, Vent
    • Two parameters to treat respiratory acidosis or increase minute ventilation
      • Respiratory rate
      • Tidal Volume (6-8 cc/kg)
  • Respiratory Alkalosis
  • Treat hyperventilation
    • Treat pain, Treat Toxidrome, Etc.
  • Metabolic alkalosis
    • Excessive loss of H+ through NG or vomiting > Zofran
    • Halt diuretics if contraction alkalosis
    • Stop Excess oral supplementation
    • Acetazolamide / Carbonic anhydrase
  • Metabolic Acidosis
    • Treat cause
    • Increased fixed metabolic acids? (Lactic acid, ketoacids, salicylic acid, toxic alcohols, etc.)
    • Uremic acidosis > Dialysis
    • Excess loss of HCO3 through kidneys of GI
    • Increased plasma Cl, limit Saline fluids
  • IV Bicarb?
    • Giving bicarb requires pt be able to blow off CO2 they will produce when HCO3 combines with free H+
    • If not able to compensate or when intubated RR is not matched to pre intubation RR can make acidosis worse
    • Cardiac arrest
      • Don’t use in MOST cardiac arrest
      • If cardiac arrest due to known TCA > consider it
    • Sepsis
      • Don’t use it, not helpful in improving hemodynamics or reducing vasopressor requirements
    • DKA
      • No benefit between pH of 6.9 to 7.1
      • Risk of hypokalemia, dereased O2 uptake, CSF acidosis, cerebral edema
      • No studies <6.9, so maybe
      • If pH < 6.9 Bicarb given 100mmol in 400mL sterile water with 20 mmol KCl at a rate of 100ml/h for 2 hours until pH greater than 7.0
    • Buffer pressors?
      • Theory: norepi needs to be converted to epi in vessels and if acidotic enzymes won’t work as well
      • What does data say: No evidence
    • Advantage
      • Provide fluid and sodium replacement
      • Increased arterial pH (does this matter, probably not)
      • ASA and TCA overdose, give it
    • Disadvantage
      • Na and water overload
      • Paradoxical CSF tissue acidosis
      • Cerebral edema
      • Hypokalemia
      • Decreases ionized Calcium
• Summary
  • Look at pH to discover primary disorder
  • AGMA is the accumulation of anions, NAGMA is a problem with GI or kidneys
  • If you have to calculate Winter’s formula on boards, it’s an ASA toxicity
  • VBG is okay if PCO2 not needed, pulse ox reading ok, not hypotensive

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

Check out this great article about nurse intuition on acuity level of patients. Link posted by Sam Ghali, MD who you should follow on Twitter. TL;DR Listen to the nurses!

The study asked nurses in 2 medical and 2 surgical units in Rochester, MN to score patients based on a 5 point “Worry Factor.” Basically deciding sick or not sick. 31,000 shifts in 3551 hospital admissions. The Worry Factor was highly accurate, with a LR of ICU transfer of 17.8 for WF>2 and LR 40.4 for WF>3. Accuracy was higher for RNs with more experience. AUROC was 0.92 for ICU transfer in 24 hours. The article specifies that they couldn’t assert whether RNs used intuition or analytical skills (something our Gut Instinct study DID try to determine).

This paper reminds me of an article I wrote a few years ago about a teaching tool for the ED, asking EM residents to decide admit vs discharge (or try to guess diagnosis, etc,) the moment they see a patient.

The references for this article are fantastic as well. Multiple primary sources and reviews on the various scores MEWS, NEWS, EWS, etc that try to identify who will decompensate in the hospital. I like to think ER nurses and doctors are especially skilled here, although we should be better about following up on patients we admit. You called the ICU and they deflected to PCU: check the chart the next couple of days, were you right or wrong? That feedback is necessary to modify your mental models and learn. At least 5 of the references cover Nurse Worry, including one systematic literature review and one prospective trial in Denmark. The references also go into intuition, expertise, they even cite the book Thinking Fast and Slow, our inspiration for the Gut Instinct abstract that was presented by Carter and Giddings.

I have had this meme in my head for a while but don’t think I ever made it or saw it on the Internet. Maybe it will go nerd viral.

As I have lectured in didactics, a paradigm shift is taking place toward the OMI vs nonOMI, and perhaps moving away from STEMI vs nSTEMI.

The ACC may be getting on board with this change that began with ER docs, chiefly Stephen Smith at Hennepin. *Unstable Angina still exists.

Check out his tweet linking to the paper:

1/2 For first time, the Am Coll of Cardiology recognizes Occlusion MI in clinical guidelines (and references our first of many OMI/NOMI studies: Meyers HP, … Smith SW. Comparison of STEMI vs. NSTEMI & OMI vs. NOMI Paradigms of AMI. J Emerg Med 2020) https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

2/2 And also, for the first time in any Guideline (as far as I know), they recommend EKG criteria that were developed by an Emergency Physician (Smith Modified Sgarbossa Criteria). Page 7 of the pdf, references 10, 11, 21. https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

• 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

Conference 09/28/22

Lightning Lectures

Carbon Monoxide poisoning

• Binds to Hgb, inhibits oxidative phosphorylation, decreased oxygen binding and delivery. 
• 137 cases per-million a year in US. Low SES, those without adequate heating/housing 

Clinically evaluate for risk of exposure to CO. based on presentation,  if concerned initiate 100% O2, especially if AMS is present. 

Indications for Hyperbaric

• decreased GCS/AMS
• any pregnant patient with >15% COHb 
• any patient with >25% regardless of presentation 

Clinical Pearl: The FiO2 delivered via NC is NOT adequate for CO toxicity. Consider NRB or other O2 delivery devices. 

Electrical Injuries

• Lightning strikes rare, but approx injuries in the US do occur yearly.
• 4 different mechanisms of injury by lighting strike depending on route of entry of electrical current. 
• Shockwave from rapidly heated air can cause concussive injuries. 

Injuries

• Neurological
  • Keraunoparalysis, Anisocoria/mydriasis, Seizures, increased risk of ICH
• HEENT: TM rupture is very common 
• CV: Any arrhythmia is possible, Coronary vasospasm, myocardial necrosis. 
• Resp: Apnea due to resp muscle paralysis. 
• Renal: rhabdo
• MSK: compartment syndrome/fractures
• Skin: any visible burn = high voltage, no correlation to surface injury with severity. Lichtenberg figures can be seen on skin. 

Treatment

• ABCs, c-spine immobilization if evidence of trauma, CBC, CMP, CK, troponin, EKG. 
• Dispo: Likely admission for observation/telemetry. 

Prolonged CPR/resuscitation may be required for lightning strike injuries as they may recover from Asystole arrest. 

Temperature related illnesses

4 types of thermoregulation 

• evaporation, radiation, convection, conduction. 
• evaporation is the human body’s primary means of heat dissipation

Thermoregulation failure

• high humidity >75%
• ambient temp > core body temp
• dehydration: for every 1% of body mass lost to dehydration, core temp increases 0.22 degrees C

Who is at risk? 

• athletes, firefighters, military, laborers, endurance athletes.

Still thousands of cases yearly in the US in young athletes. 

 Acclimatization 

• greatest risk of heat illness occurs during first 2 weeks of activity. 
• Body undergoes many physiologic changes to acclimatize to higher temperatures. (increased plasma volume, increased blood flow to skin, increased sweat production etc.) 

Categorizing heat illness

• Heat cramps
  • cramping of muscles associated with exercise. Does not require correlation with heat. 
  • Intense muscle pain and spasm. Rehydrate, treat symptomatically, rest. Consider further work up if unable to alleviate. 

• Heat Syncope  
  • Exercise associated syncope. 
  • Commonly occurs at the end of an event. Muscle contracture during exercise keeps blood pressure adequately elevated, end of exercise leads to drop. 
  • Benign/self limited. 
  • Clinical presentation similar to vasovagal syncope. 
  • Keep cardiac arrhythmia in differential 
  • Supportive care, hydrate and move to shade. 
• Heat exhaustion 
  • inability to maintain adequate CO due to physical activity and heat stress. 
  • temp often 101-104, but can occur without hyperthermia. 
  • Inability to continue with exertion
  • NO CNS dysfunction. 
  • symptomatic treatment, cool patient, if symptoms do not resolve in 1-2 hours, requires ED Evaluation 
• Heat Stroke
  • CNS dysfunction is the primary symptom. 
  • Core temp classically greater that 104. 
  • Cerebellar findings are usually the first notable symptoms. Other signs include disorientation/confusion, Seizures, coma. 

• Prognosis
  • worst when immediate cooling is not initiated, direct correlation with morbidity and mortality with duration of hyperthermia. 

• Cooling measures
  • ice water immersion is the quickest method for lowering core temperature. 
  • if ice water not available, room temperature water is adequate. 
  • When immersion not an option, douse with water as often as possible, put wet sheets around the patient with frequent rotation. ice directly to exposed skin.
  • Cool patient until they begin to shiver. 
• Cooling in the ED
  • ice packs to axilla/groin. 
  • douse water
  • fans
  • Continue to assess temp, vitals, mental state, administer fluids. 
  • Lab evaluation: all organ systems are sensitive to injury. CBC, CMP, CK, Coags, lactic acid. 
  • Treat other complications that arise: AMS/Seizures, Rhabdo, DIC, ARDS, Enteric ischemia/GI Bleed, MI
  • Medications will not treat hyperthermia (NSAIDS etc.) 
  • Dispo: admission for all heat strokes. 

Toxic Alcohols

Ethanol 

• AMS, hypoglycemia. 
• ethanol levels usually correlate with symptoms
• Hemodialysis is possible for severe ethanol toxicity. 

Isopropanol

• rubbing alcohol
• intoxication, GI irritation, NO metabolic acidosis. 
• converts to acetone 
• requires GC for actual identification of isopropanol, methanol and ethylene glycol. 
• treat supportively. 
• Can technically be dialyzed. 

Methanol

• windshield washer fluid, solid cooking fuel, embalming fluid, tainted beverages, tainted beverages. 
• toxic metabolite is formate/formic acid. 
• Clinical manifestations: CNS effects (not always), multiple hours until symptom onset due to toxic metabolite. 
  • metabolic acidosis with high anion gap. 
  • ocular toxicity (formate toxic to optic nerve)
  • pancreatitis
  • basal ganglia toxicity/effect. 

Ethylene Glycol

• sweet taste
• 4 metabolites of concern: oxalate, glycoaldehyde, glycolic acid, glyoxylic acid
• Clinical manifestations:  CNS effects, metabolic acidosis with AG, renal toxicity/failure, hypocalcemia from oxalate crystalizing into calcium oxalate crystals, basal ganglia toxicity. 
• if not at U of L consider getting lab samples transported ASAP. 
• Surrogate markers: calcium oxalate crystals, woods lamp (some antifreeze has fluorescein) elevated osmol gap (normal gap is around 10)
• Many factors affect osmol gap. 

Antidotes

• Ethanol: cheap, requires continuous infusion/administration, not as effected as fomepizole, requires frequent levels. If needed PO in encouraged over IV administration. 
• Fomepizole: preferred antidote, expensive, some GI irritation and transaminase elevation. 
• Both inhibit alcohol dehydrogenase. 
• Administer antidote if any signs or symptoms of ingestion is present. 
• Administer if methanol or EG levels are >20mg/%

Hemodialysis

fomepizole is very effective and may decrease need for dialysis.

consider with severe end organ damage, coma, seizure, renal failure.

Adjunct therapies: folic acid for methanol, thiamine and pyridoxine for EG. Sodium Bicarb for pH <7.20 according to Goldfrank’s.

Conference 09/14/22

Research “Life Cycle”

• complete required training courses
• develop a research project
• do a lit search
• Start plan/write protocol and IRB. 
• IRB submission. 
  • Must be approved by the IRB, takes time so plan accordingly. 
• Types of research
  • Human research
  • QI
  • Program eval
  • case report. 
• Collect data
• Data analysis (you don’t have to crunch numbers)
  • schedule something with Jacob, He’s awesome!
• Write the paper. Read papers. Learn the format and write it. 
• Publish: LONG process. 

Room 9 Follow up: Josh French

• 45 yo F presents via EMS after being found unresponsive. reports she fell earlier in the evening. “Oh btw she’s having a GI bleed” per EMS. 
• Unresponsive, ill appearing, GCS 3, severely hypotensive and requiring BVM for respiration. 
• Dark blood per rectum. 
• pH unreadable, hgb. unreadable, lactic acid greater than 20
• Triaged to CT with nonspecific findings of the abd/pelvis. 
• Upper vs Lower GI Bleed: Broad differential 
• Protip: BUN can be elevated from upper GI bleed due to absorption of blood through the upper GI tract. 
• Resuscitate, support pressures. get blood ASAP. 
• Needs a GI consultation for treatment of bleed through EGD/Colonoscopy. 
• MTP at U of L 
  • volume replaced exceeds patients estimated blood volume in a 24 hour period. 
  • 4 units RBC in 1 hour. 
  • 10 units of RBC, 10 units FFP/plasma, 2 units of platelets. 
• pmts who require significant blood products need calcium! Citrate as a preservative will bind the body’s calcium. 
• Resuscitate until normotensive. 

One Pill can Kill: Kaci Eastep, PEM. 

Incidence

• 70,000/year pediatric ingestions. 
• Peak incidence 1-3. 
• Most mild or clinically negligible. 

CCBs

• pediatric patients rely primarily on heart rate for cardiac output. 
• ingestion causes bradycardia, hypotension 
• Decon if able with charcoal. 
• ABC’s: atropine, pressers, fluids if needed. 
• Calcium, high dose insulin, glucagon, lipid infusion. 

Camphor (icy-hot, bengay, vics vapors)

• causes rapid GI distress in 10-20 minus. 
• delirium, restlessness, seizures
• coma, CNS depressant. 

Clonidine + Opioids

• clonidine has opioid receptor agonism and may look largely like opioid intoxication. used for ADHD treatment. 
• naloxone, higher doses required for clonidine. Up to 10mg. Start high dose. 
• Lomotil- diphenoxylate (opioid) + atropine
• Able to provide intranasal narcan for free upon discharge. 

TCAs

• leading cause of pediatric toxicities until 1993. 
• multiple areas of receptor interactions primarily norepinephrine and serotonin. 
• CNS depression, seizure, arrhythmia, anticholinergic toxicity. 
• treat with Bicarb. 1-2mEq/Kg. Alkalinize urine to expedite urinary secretion. 

Salicylates: peptobismol, oil of wintergreen, Aspirin

• minumum 150mg/kg for toxic dose.
• nausea, vomiting, diaphoresis, tinnitus(ototoxicity), pulm edema, hyperthermia, coma, death
• Mixed AG acidosis with resp alkalosis. 
• Alkalinize urine (bicarb). for severe ingestions hemodialysis. 

Sulfonylurea

• stimulate insulin release. 
• leads to profound hypoglycemia
• Treat with octreotide 1-2 microgram/kg/dose and dextrose as needed. 

Toxic Alcohols: ethylene glycol, windshield wiper fluid, rubbing alcohol. 

• Methanol: visual disturbances, AG acidosis, treat with 
• Ethylene Glycol: renal dysfunction, calcium oxalate crystals.  AG acidosis
• Isopropanol: no AG acidosis, increased osmolar gap. 
• toxic alcohols are broken down by alcohol dehydrogenase, which is targeted by fomepizole (used for methanol and EG) 
• Can technically use ethanol
• Hemodialysis for severe ingestions. 

Beta Blocker toxicity.

• One of the most commonly prescribed drugs.
• Onset of toxicity depends on type of beta blocker (instant vs extended release)
• Hypoglycemia is helpful in differentiating from calcium channel blocker overdose.
• Decon if possible with charcoal or whole bowel irrigation
• Stabilize with atropine for bradycardia, pressors for hypotension. Will require HIGH dose for pressors.
• Glucagon is gold standard: increases cardiac inotropy without beta agonism.
  • 5-10mg initial dose
  • Needs to be given early.
• Calcium to increase vascular tone
• High Dose insulin
  • 1u/kg/hr with D50 or dextrose containing fluids.
  • Takes 30-60 minutes to take effect so start early
• Intralipid
  • Theoretically works as “lipid sink” to absorb active drug
  • Only feasible with lipophilic drugs
• Dialysis,ECMO
• Dispo
  • Admit ALL sotalol ingestions due to long onset of action.

Calcium Channel Blocker Toxicity

• Very commonly prescribed drug
• Significant toxicity in overdose, especially in pediatric population. An extra dose of prescribed CCB can cause significant toxicity.
• Extended vs immediate release. Up to 16 hours in some formulations.
• Symptoms of toxicity range from dizziness to hemodynamic collapse. Non-DHPs present primarily with bradycardia.
• Can cause severe High anion gap metabolic acidosis.
• Hyperglycemia rather than hypo

• Treat hypotension and bradycardia aggressively with atropine/pressors or pacing if needed
• Decon if able
• Be cautious with fluids as decreased CO can lead to volume overload.
• IV calcium indicated, clinical response variable.
• High dose insulin therapy
  • 1-10u/kg/hr with dextrose containing fluid.
• Lipid emulsion
  • CCBs are lipophilic
• ECMO,LVAD

• Disposition

• Extended release toxicity should all be admitted for observation. 

Hypothermia and Cold Injuries

• Any core body temperature measurement less than 95º F or 35º C
• 4 methods of heat loss
  • Thermal radiation (lose most heat here!)
  • Convection
  • Conduction
  • Evaporation

• Non-freezing cold injuries
  • Trench Foot: prolonged foot immersion in cold water.
    • Dry and warm feet. Do not massage feet 
    • Do not submerge in warm water.
  • Chilblains: cold exposure injury without freezing of tissue. Paresthesias, erythematous tissues. 12+ hours after exposure.
    • Require treatment! Nifedipine 20mg TID, Pentoxifylline, Topical Steroids
• Frost Bite
  • 4 stages with advancing levels of tissue damage. IV being down to muscle.
  • Treat with warm circulating water. Local and superficial may be discharged. Treat supportively.
  • Do not rub extremities, allow to refreeze, or use dry heat for treatment.

• Hypothermia
  • Mild 92-95, moderate 82-90, severe 77-82.
  • CNS, Coagulopathy, Circulatory, Respiratory
    • CNS depression, amnesia, ataxia
    • Decreased clotting factors, decreased platelet functions.
    • Myocardial irritability
    • Oxygen demand decreased.
  • EKG Changes
    • J point elevation throughout (Osborne wave)
    • QT prolongation
    • Shortened PR interval.
  • Commonly decompensates into V. Fib arrest.
• Treatment
  • Mild: passive external warming. Blankets, warm rooms
  • Moderate: Active external. Bair Hugger, blankets
  • Severe: Active internal warming.
    • Warm fluids,
    • Bladder lavage
    • Chest lavage
    • Intubate, warmed O2.
  • When to cease resuscitation or NOT to initiate.
    • DNR if, obvious lethal injury,
    • Hyperkalemia greater than 12
    • Avalanche with ice/snow in airway >35 minutes.
    • AFTER rewarming, once pt is 89ºF and in asystole, may cease efforts.
  • CPR Pearls
    • ACLS code drugs DON’T WORK at low temps.
      • Multiple recommendations. Most recent recommends..
      • 1 defibrillation, 1 epi. Warm 5 degrees C and reattempt. Initiate full ACLS protocol at 30º C.
    • AVOID SUCCINYLCHOLINE. The temporary rise in K may lead to inappropriate cessation of efforts.
  • Running the code
    • ABCs
    • Warmed, humidified air.
    • Core body temp with rectal or bladder probe.
    • Femoral central line. AVOID IJ as irritating myocardium can lead to more arrhythmia.
    • 2 pigtail chest tubes bilaterally for warm thoracic lavage.

Bites and Stings

• Venomous snakes
  • 9000 snake envenomations a year in the US.
  • 2000 treated as such
  • 5-6 deaths annually.
  • 2 deadly snake families. Pit vipers, coral snakes.
• US pit vipers
  • 99% of all venomous bites in the US
  • Triangular head, elliptical pupil.
• Single row of anal plates more indicative of venomous snake.
• Slight chance of anaphylaxis associated with envenomation. Consider EPI if pressor requirement.

• Envenomation by pit vipers

• Venom varies among species.
  • Seriousness of envenomation varies based on several factors. Size, agitation of snake, age of victim, depth of wound etc.
  • Different venoms attack different systems (neurotoxin vs local destruction)
  • ¼ to 1/3 of bites are “dry bites”
  • Venom causes local tissue necrosis, severity of envenomation cannot be determined by initial symptoms.
• Minimal Envenomation
  • Swelling, ecchymosis, local pain
  • NO systemic signs.
• Moderate Envenomation
  • Swelling extends up extremity, severe pain
  • Mild systemic symptoms: nausea/vomiting, generalized weakness.
• Severe Envenomation
  • Significant soft tissue swelling
  • Severe pain
  • Resp. distress.
  • Vital sign instability, hypotension, shock
  • Coagulation abnormalities
  • RBC lysis
• Coral Snakes
  • Far less common envenomations
  • Neurotoxic component to venom.
  • Neurological symptoms, respiratory collapse.
  • NO ANTIVENOM produced. Limited supply.
  • Effect of bite may be delayed up to 12 hours. All require 24 hour surveillance in ICU.
  • Severe envenomation
    • Any systemic symptoms
    • Respiratory distress.
• Treatment
  • Look for wound. If no wound, very unlikely that envenomated by crotalid.
  • Get to hospital ASAP
  • Don’t chase a snake. Take pictures if possible.
  • Elevation of limb will diffuse cytotoxic venom and decrease local tissue damage.
  • DO NOT: torniquet, ice pack, suction, extrication kit.
  • Pressure wraps that obstruct lymphatic drainage may assist.
  • 2 antivenoms approved for US for pit viper envenomation.
    • Cro-Fab
    • ANAVIP
  • No pre-treatment necessary
  • Administer to all moderate to severe envenomations.
  • Send coral snake envenomations to Florida. Call tampa poison control center.
  • Antivenom Dosing (CroFab)
    • Initial dose:4-6 vials bolus and repeat that dose until symptoms are controlled.
    • 2 vials q6x3 for maintenance.
  • ANAVIP is cheaper, just as effective and does not require maintenance dosing.
  • We currently carry CroFab. Will switch to ANAVIP (allegedly)

• Copperhead envenomation
  • A small study has shown that administration of crofab only minimally decreases pain and disability in affected patient.

• Spider Bites
  • 3 dangerous spiders in US.
  • Brown recluse, brown recluse, hobo.
• Black Widow
  • Pain, anxiety, muscle cramps, paresthesia, may be some paralysis.
  • Can cause systemic symptoms.
  • Cool the area with ice or ice water.
  • Analgesia and anxiolysis
  • Antivenom: Merk; infrequently used (10% anaphylactic rate)
  • Give antivenom for uncontrollable pain, pregnancy with fetal distress, priapism
• Brown Recluse
  • Rare spider bite
  • Most bites in Midwest
  • Painless bites with 2-8 hours before symptom onset.
  • Systemic illness especially in pediatric cases.
  • No antivenom.

Toxicology small group

• Acetaminophen toxicity
  • Toxic dose: 150 mg/kg over 2 days. 10g in one dose or as calculated with Acetaminophen level and Rumack-Matthew Nomogram.
  • Rumack-Matthew Nomogram can be used to calculate toxicity. Can only be used in single oral exposure/acute toxicity.
  • Treatment, NAC indicated for known toxic dose
    • IV 150mg/kg over 1 hour>50mg/kg over 4 hours> 100mg/kg over 24 hours.
    • Admit all patients requiring treatment.
    • No data for pre 4 hour levels. Obtain 4 hour level. If highly suspicious for large ingestion then treat prior to 4 hour mark.
  • Tylenol PM
    • Co-ingestion with Benadryl
    • Bendryl theoretically slows gut absorption and gut motility.
    • Pts who were nontoxic initially may cross into toxic levels multiple hours later.
• TCA Toxicity
  • Multiple MOAs
    • Inhibits norepi and serotonin reuptake.
    • Anticholinergic
    • Sodium channel blockade
    • H1 properties
    • K channel blockade in myocytes
    • GABA blockade.
  • Narrow therapeutic index.
  • Toxic  dosing: 10 mg/kg moderate. 30mg/kg severe
  • Increased QRS, QT prolongation, tachycardia, agitation, AMS,
  • Can progress to torsades
  • Treat with 1-2meq/kg IV bolus of NaBicarb. Repeat until improvement or pH 7.5-7.55.
  • All other care is supportive.
  • Other treatments after bicarb
    • Lidocaine 1mg.kg
    • Hypertonic saline
    • Intralipid
    • ECMO
  • 6 hours minimum obs, admission if symptomatic.

• Salicylate toxicity
  • Salicylic acid can lead to profound acidosis.
  • Zero order kinetics in OD
  • Mild: <150 mg/kg.
    • Ototoxicity
    • GI irritation
    • AG metabolic acidosis.
  • Moderate 150-300 mg/kg
    • Resp alkalosis/hyperventilation
    • AMS
    • Fever
  • Treatment
    • ABCs
    • Fluids
    • Decon with charcoal
    • Bicarb for urine alkalization
    • Can be dialyzed if severe toxicity.
  • Disposition
    • DC: serial levels show decline, asymptomatic
    • Admit: any enteric coated ingestion with any symptomology and increasing levels.
    • Avoid intubation as long as possible. Intubating these people with profound acidosis will drop pH and cause arrest.

Ovarian Torsion, Garrett Stults D.O.:

• R > L ovary due to increased length of utero-ovarian ligament and no sigmoid colon to stabilize
• Incidence unknown, often missed, majority of cases in reproductive cases, peds cases around 15%
• Risk factors: previous torsion, ovary >4cm, 85% have ovarian mass
• Acute onset of moderate/severe pain, n/b, fever, mass, can have peritoneal signs but this should raise concern for adnexal necrosis
• CT noninferior to ultrasound, if CT is concerning then do not delay gyn consult for ultrasound
• Definitive diagnosis is made by direct visualization of ovary
  • Can de-torse or may have to do oophoropexy

Hyperemesis Gravidarum, Dominic Aiello, M.D.:

• Nausea/vomiting of pregnancy: normal vitals, normal physical, normal labs, 60-80% of pregnancies in first trimester
• Hyperemesis has increased incidence in lower socioeconomic class and non-Caucasian populations
• Complications: orthostatic hypotension, electrolyte abnormalities, transaminitis, Mallory Weiss tears, Wernicke encephalopathy, increased risk of pre-e, abruption, and low birth weight if in 2^nd trimester
• Treatment:
  • Nonpharmacologic: avoid triggers, small meals, avoid stress, ginger, P6 acupressure wristbands
  • Pharmacologic: pyridoxine, doxylamine. If persistent can add dimenhydrinate (Dramamine), Benadryl, prochlorperazine, promethazine,
  • No dehydration: metoclopramide, ondansetron, promethazine, trimethobenzamide
  • Dehydration: D5NS If ketonuria is present, can add in methylpred taper

Trauma in Pregnancy: the 2 for 1 plan, Melissa Platt, M.D.:

• Trauma is #1 cause of hospitalization for pregnant women (7-8% including falls)
  • MVA 2/3
• Respiratory changes:
  • Upper airway: mucosal edema, epistaxis, estrogen induced
  • Lungs: multiple changes related to capacity, increasing RR by 2-3 breaths/min
    • Oxygen consumption increased, respiratory alkalosis—pay attention if you get a gas
• Cardiovascular changes:
  • Cardiac output rises 30-50%
    • ½ of this occurs by 8w of pregnancy
    • Influenced by posture
  • Preload increased due to rise in blood volume, afterload reduced due to decline in SVR, HR increased by 15-20 BMP, EF remains unchanged (reliable indicator of LV function)
  • Appears enlarged on CXR, different projection/rotation
  • Apex at 4^th intercostal space instead of 5^th
  • EKG with LAD, ST depression, 28% PVC
  • BP typically falls but later returns to baseline
• Placenta
  • Low resistance circulation, no neuronal input
  • Vascular resistance is determined more by things like endothelin, NO, not epi
  • Placental flow 400-600cc/min
    • Blastocyst implants in innermost uterine wall, uterine blood supply is rich
• Other changes:
  • higher diaphragm
  • chest becomes more barrel shaped with increased diameter
  • slowed GI motility, slowed gastric emptying
  • normal to have small amounts of intraperitoneal fluid
  • widened symphysis pubic and sacroiliac joints
  • renal changes
• plasma volume expands, peaks at 28-34 weeks
• physiologic anemia with decreased blood viscosity
• Trauma general principles:
• Focus initially on ABCs, management dictated by severity initially geared toward maternal stabilization, what’s best for mom is going to be what’s best for baby
• Do not under diagnosis or under treat secondary to unfounded fears of fetal effects
• Place on O2 early due to decrease in FRC and increased O2 consumption
• Recognize shock early
• Four factors in maternal trauma/surgery that predict fetal morbidity/mortality: hypoxia, drug effects, infection, preterm labor
  • Decreased maternal hematocrit >50% or decreased MAP 20% or paO2 <60 à fetal hypoxia
  • Anesthesia-surgery is best between weeks 13-23
• Secondary survey:
  • Examine for non-obstetric injury, fetal heart tones, speculum exam to r/o SROM or VB
• Chest tubes need to be one intercostal space higher
• Weigh risk/harms of CT
• Shared decision making between Ob-Gyn, trauma, EP, and patient
• Most gestational ages: check fetal heart tones
• Continuous fetal monitoring is appropriate only if OB is willing to act on it (viable fetus)
• If heart tones are absent regardless of gestational age, no fetal resuscitation
• During acute phase, uterine contraction monitoring is appropriate
  • Remember you cannot r/o abruption with ultrasound (50% accurate or less)
• Abruption:
  • Can occur with no sign of injury externally
  • Maternal mortality 1-2%, fetal 20% +
  • VB, abdominal cramps, uterine tenderness, amniotic fluid leakage, change in FHT, maternal hypotension
• Labs:
  • Fibrinogen/KB test
  • Any patient who is Rh negative with abdominal trauma should receive Rhogam
• Utilize ultrasound, MRI as needed
• Penetrating trauma:
  • Remember intraabdominal organs change position
• Electrical burns: fetus has lack of resistance to current = high fetal mortality
• Other burns: silver sulfadiazine cream- used sparingly due to risk of kernicterus
• Pelvic fractures:
  • Increased risk of shock, bladder, urethra injuries
  • Fetal skull fracture, fat embolism, vaginal lacerations
  • Is pelvic fracture an absolute contraindication for vaginal delivery? NO, depends on severity/type and compromise of pelvic inlet
• Seat belt: lap belts alone increase abruption due to forward flexion and uterine compression, educate to wear low across pelvis

Pauline Thiemann, PharmD- Ketamine Music Trial Starting tomorrow, 9/1!!

EM Oral Boards, Jenny McGowan, M.D.:

• Randomly assigned to dates
• Format 7 cases, 15 min each, 2023 changing to 5 single patient, 2 structured interview
• Practice practice practice
  • Review books, courses, online resources and practice cases
• Structured interview: intended to assess clinical judgement and though process for decision making
  • Expect “why did you do xyz” question
  • What are you looking for
  • Interpret labs
• Initial case stimuli with brief history, vitals.
  • Take note of all abnormal vitals, must be addressed
• Labs
  • If certain lab is unavailable, move on
  • Should not be borderline
  • Occasionally may be given results you did not ask for, standardized results for all applicants, not that you missed something
• Imaging
  • Usually clear, not designed to be tricky/subtle
  • All static
  • If unavailable, may need to stabilize or find alternative means of diagnosis
• Talk to patient as if they are present
• Ask for whatever you need
  • Pharmacy, poison control, family, EMS, etc
• If someone says no or disagrees with you- you are allowed to argue
  • However, if you have tried to convince and they still refuse, you may be going down wrong path
• If you receive prompting of “anything else you would give/anyone else you would call?”, pause and reconsider
• Approach: HAVE A SYSTEM, if you don’t, you will skip steps and miss important findings
• HPI: generally, answers are direct enough that you can get a thorough history quickly
• Think level 5 charting: ask med, surgical, family, social hx. Ask meds. Ask allergies.
• Exam: head to toe on all cases, keep list, take notes, practice to move through efficiently
• Give orders clearly at a speed in which your examiner can keep up
• Be aware of scoring system, look at ABEM website
• ABC survey first in unstable patients, then interventions to stabilize, then secondary survey, gather more history to supplement along with additional medical info
• ABC interventions: accucheck, bil IV, cardiac monitor (supplemental O2 PRN, cont pulse ox, BP), draw rainbow of labs, EKG, family/EMS hang around, gown/expose, “hello” introduce to patient, immobilization/isolation
• You are provided with reference labs for normal ranges
• Level of care generally increased from typical clinical cases, patients rarely go home
  • If questioning, admit up a level

Substance Use Disorders in the ED, Richard Cales, M.D.

• Dependence- reliance on a substance to prevent withdrawal
  • Easily managed with medication, can be resolved with slow taper,
  • Not a unique property for many substances, but rather a normal and expected distraction from the real problem of addiction
• Addiction: unlike physical dependence, is abnormal and classified as a disease
  • Primary condition associated with uncontrollable cravings, inability to control use, compulsive use, continued use despite harm to self or others.
  • Currently characterized as substance use disorders
• Polysubstance use is the rule as opposed to exception for patients with severe substance use disorder (frequently nicotine and alcohol, also methamphetamines in this area)
  • Always think- what else are they taking?
• Diagnosis:
  • Severity groups based off of specific criteria associated with impaired control, social impairment, risky use, drug dependence
• POC urine drug testing has been used widely and remains appropriate for screening low risk populations (workplace, schools, military, etc).
  • Massive number of false positives, negatives
  • Should not be used for management, use as red flag to refer/obtain additional testing such as mass spectrometry
• ED options for OUD:
  • New term is MOUD (medication for opioid use disorder) rather than MAT (medication assisted treatment)
  • Buprenorphine slowly replacing methadone as standard of care
    • Available as daily sublingual tablets/films or monthly depot injections
  • Most common ED presentations:
    • Overdose requiring admission- managed with Narcan, admission, eventual referral
    • Overdose not requiring admission: managed with symptomatic treatment and referral
    • OUD patient in withdrawal: managed with buprenorphine induction and referral
    • OUD patient not in withdrawal seeking treatment: managed with referral only
• Vulnerability to addiction is 50% genetic (derived from twin studies)
• Addiction (defined as severe SUD) is chronic
  • Subject to acute exacerbation, similar to severe COPD, CHF
  • Requires lifelong treatment (as opposed to tapering, which is often used for mild SUD)

SANE, Amanda Corzine:

• Purpose: medical eval and treatment, evidence collection, documentation of injuries, male/female victims of sexual assault age >12, “rape kit” collection in <96h, sane room in back hallway has full shower and bathroom
• Benefits: detailed written and photo documentation, expedited visit, referrals to appropriate f/u care and community resources, integrated care with advocacy/law enforcement. SANEs can testify as expert witnesses in legal proceedings.
• Sexual assault nurse examiners: RN with specialized training in medical forensic exam
• Reporting may occur at time of exam or prior to arrival or victim may chose to have kit collected without reporting, kept for 1 year and then destroyed, only tested for DNA if report made
• Level of alertness required for exam, search warrant required for unconscious patients
• Can also see patients in EPS
• Neurobiology of trauma
  • Difficulty in recalling facts in linear format
  • Emotional presentation
  • Sometimes sensory memory is more well preserved
• Patient history guides the exam
• Important to write declined rather than refused
• SANEs will document bodily and genital injuries and obtain photographs as possible
• Will generally order prophylactic meds and notify physician
  • Specific protocol built for NPEP
• HIV risk by exposure:

Perimortem c-section, Drs. Royalty and Newcomb:

• Anatomic and physiologic changes in pregnancy
  • Airway: narrowing of upper aspect in third trimester, intubated using ETT 1 size smaller than usual
  • Breathing: elevation of diaphragm -> decrease in residual capacity, poor toleration of apnea. Give supplemental O2 rapidly.
  • Circulation: by 28w, blood volume and cardiac output increase by 30-40%, compression of IVC, displace uterus to L (rotate 15-30 degrees), aggressive fluid resuscitation.
• PRIMARY BENEFIT: MATERNAL RESUSITATION
  • Secondary benefit: fetal viability
• Indications:
  • Cardiac arrest- medical or trauma (ideally within 4 minutes, have been reports of saves up to 15 min post arrest)
  • >/= 24w or fundus is above umbilicus on your exam
• Contraindications:
  • ROSC within two cycles of compression
  • Gestational age <20 weeks
• ACLS considerations for pregnant patients:
  • Provider performing ACLS is separate from physician performing procedure
  • Fetal assessment should not be done.
  • Hand placement is the same as nonpregnant patients, same dose of meds. Cardioversion and defibrillation are not contraindicated
  • Continuous lateral uterine displacement while performing CPR with patient supine
• Need:
  • Bare minimum: scalpel, scissors, gloves. Chest tube kit can be a good start.
  • Other supplies: definitive airway, O2, two large bore IVs, end tidal CO2, c/s delivery kit/trauma lap kit, no 10 scalpel, hemostats, large scissors, gauze sponges/surgical towels, retractors, infant warmer, bulb suction, pediatric airway kit
• Very basic process

1. Large vertical incision from xyphoid process to pubic symphysis

2.  Expose uterus

3. Inferior small vertical incision (around 2 fingers size) to uterus, insert fingers and lift uterus away from fetus, use scissors to make incision directed superiorly

4. Deliver infant, pass infant to someone else

5. Pack uterus/abdomen,

• Complications:
  • Bladder/bowel injury, injury to fetus, arterial injury
• ROSC considerations:
  • Broad spectrum PRN or cephalosporin
  • Consider oxytocin, can cause arrhythmias and risk repeat arrest
  • Why did patient arrest?

Documentation update:

• Big changes coming in early 2023, stay aware and will have continued updates
• Make sure to document discussion with other physicians, brief summary
  • Radiology
• Any history obtained from someone other than patient
  • Friend/family, EMS, police, nursing home
  • Make sure to say “Per ___,”
• Review and summarization of old records
  • Cannot just copy and paste. Must make comment.
  • Try to say specifically what you reviewed, when/where that visit was, and what you took from it that was relevant.
  • Don’t just say- reviewed outside records. This does not add anything to the record.
• Conversation with other specialists, what you discussed, outcome/recommendations
• Document independent interpretation of imaging

Medical Mimickers of Psychotic Disorders: A Review of Secondary Psychosis, Drs. Reske and Marcellus:

• Condition affecting cognition and causing distorted perception or loss with reality
• Psychotic presentations are seen in many different syndromes/disease processes
• Primary psychiatric
  • Little/never develops over short period or in older patients, except potential for first break psychosis in post-menopausal women
  • Usually subacute, variable attention, generally alert, both episodic and chronic, episodes can resolve but repeated episodes can lead to chronic symptoms, in general cognition (orientation) should be intact
• Secondary psychosis
  • Mnemonic: TACTICS MDS USE
  • Substance intoxication: stimulants (symptoms can become permanent), hallucinogens, dissociants. Usually sudden onset, changes in vitals. Auditory, tactile hallucinations, paranoid delusions. Commonly with hyperkinetic body movements. Manage with benzos, antipsychotics, aggressive hydration.
  • Substance withdrawal:  GABAergics (benzos, barbs, baclofen, EtOH), opiates less frequently
  • Dementia with behavioral disturbance: in late stage, baseline psychosis is not uncommon. Consider frontotemporal dementia. Lewy Body Dementia and Parkinsons can have complex visual hallucinations. However, acute worsening of confusion or deviation from baseline should raise concern for underlying medical condition. Can be very distressing for patient but frequently can be calm and even soothed by these hallucinations, sometimes patients are aware that these perceptions are not real.
  • Infection: UTI most often, also meningitis, cerebritis, HIV, neurosyphilis
  • Delirium
  • What is atypical? Later onset, primarily confused/disoriented, visual/multimodal hallucinations.
  • Less common but can be easy to test: thyroid disease, b12/folate deficiency, hypo/hypernatremia, hypercarbia/hypoxic (can have visual hallucinations), calcium, hepatic encephalopathy (sometimes can present even before jaundice), infections (RPR, HIV), space occupying lesions, stroke, seizure
  • **Try to get a thorough history and physical**
• Primary vs secondary investigation:
  • Is presentation of psychosis atypical?
  • Is medical condition or substance use temporally related?
  • Is the psychosis not better explained by primary psychotic disorder or other mental illness?
  • Is psychosis a direct physiological consequence of a medical illness of substance use?
• Secondary: Treat underlying cause if known, avoid benzos if possible, can worsen delirium and disinhibition, avoid anticholinergic meds
• Primary: best to use antipsychotics if possible
  • Multiple medications exist in PO, IM forms with different MOA, onset times, etc

Sepsis Update, Marianne Kreuger

• RN can initiate triage-initiated sepsis alert if patient has 2+ SIRS criteria and suspected/confirmed infection with or without organ dysfunction
  • Patient can flag for sepsis while in waiting room- time zero is triage
• Multiple sepsis power plans exist
• Three hour bundle and six hour bundle have different requirements.
  • 3h: IV abx, fluid bolus, lactic with reflex
  • 6h: repeat lactic if initial was >2, vasopressors if not responsive to IV fluids, tissue perfusion reassessment (echo, cap refill, periph pulses eval, etc)
• 30cc/kg bolus required when patient has two or more hypotensive episodes or lactic >4
  • If withholding full sepsis fluids, please document reason why
• .sepsisreassessment is helpful dot phrase in cerner
• Effort is being made to track patients in the waiting room to help meet compliance and goals
• Also: new hyperkalemia power plan exists specifically for insulin/dextrose treatment
  • Protocol for repeat poc glucose afterward for 6 hours, BMP Q1h x4

Pediatric Trauma, Dr. Klensch:

• Trauma Stat (generally more severe) vs Trauma Alert
• Trauma Role assignments: team leader, airway, assessor, procedure physicians
  • Specific roles prior to arrival and then after arrival
• Airway considerations:
  • Small mouth, larger tongue, large adenoid, floppy epiglottis
  • Larynx more cephalad and anterior
  • Increased vagal response, use atropine PRN
  • ET Tube: (age/4)+4
  • Depth: ETT x3
• Breathing:
  • Compliant ribcage makes fracture less likely
  • Pulm contusion is most common ped thoracic injury
  • Mobile mediastinum: less aortic disruption, more tracheobronchial injuries, earlier compromise from tension ptx
• Circulation
  • Long bone fracture generally won’t have as much blood loss as adults
    • Ex: if hypotensive with femur fx, should look into chest, abdomen, etc for other causes
  • ICH with open fontanelle can contain large amount of blood
  • No sternal IO in kids <12yo
  • Hypotension: 70 + (2x age)
  • Pay close attention to mentation in evaluating shock
• Disability:
  • Modified GCS exists for infants and children
  • Prevent secondary injury in TBI: avoid hypoxia, hypercapnia, hyperthermia, hyponatremia
  • Linear skull fracture are typically benign unless depression exists, overlying vascular channel, a diastatic fracture, or over area of MMA
  • Closed head injury: PECARN <2
• Exposure:
  • Expose entirely to eval for other injuries
  • At risk for hypothermia, keep exposure time brief
    • Due to large BSA, thin skin, minimal fat
• NAT:
  • KY has highest child abuse rate in the country
    • ~20/1000 kids in the state
  • IN has highest child abuse death rate nation wide
  • Up to 25% of severe child abuse cases have previous sentinel injuries
  • Red flags:
    • No hx of trauma, mechanism does not fit, history inconsistent with age/development, history changes, delay in seeking care
  • Use TEN-4-FACESp for bruising clinical decision rule for children <4
• Cervical Spine:
  • Generally uncommon, 1-2% of all trauma admissions
  • High risk: Down Syndrome, Ehlers Danlos, NAT
  • Most common site of fracture varies with age
  • Why not CT?
    • More expensive, more radiation
    • Less likely to define injury in infants and small children with only ligamentous injury
  • Ok to clear clinically in low risk (no distracting injury, normal neuro exam, etc), also make sure to examine for tenderness/ROM
  • Conscious, not meeting low risk criteria: okay to get plain XR, CT if XR unclear or high suspicion for injury
  • Unconscious or obtunded, obtain CT head and c spine
  • SCIWORA: neuro deficits or symptoms that may be transient w/ normal imaging, get MRI and NES consult, admit, can be delayed up to 30min-4days
• FAST
  • Data mixed
  • Several studies demonstrate lower sensitivity than for adults

Clinical Pathway- Complicated Delivery, Drs. Boland and Hill-Norby:

• ED deliveries higher risk than those on labor floor
  • Often little or no prenatal care
  • Higher perinatal mortality
  • Need to expect the unexpected
• Shoulder dystocia:
  • Clinical diagnosis when gentle traction is insufficient to deliver shoulders after delivery of head
  • General Mgmt: stop pushing, align buttocks flush with edge of bed to provide optimal access, cath bladder for decompression, suprapubic pressure
  • HELPERR (Ob, empty bladder, legs flexed (McRoberts), pressure to suprapubic area, enter vagina (Rubin or Woods), remove posterior arm (Barnum), roll to all 4s (Gaskin))
    • Pressure should be applied just above pubic symphysis, not fundal
    • Rubin, Woods, and Barnum generally all require adequate anesthesia, making their use more challenging in ED deliveries
  • Maneuvers of last resort:
    • Fracture of fetal clavicle
    • Zavanelli maneuver requires immediate availability of surgeon and anesthesiologist: push fetal head back up into pelvis and c/s performed
  • Breech presentation
    • 4% of live births
    • Prone to problems with cervical dilation and umbilical cord prolapse
    • Frank, complete, incomplete breech
    • Call for help, if fetus not yet emerged, tell mom not to push
    • Consider uterine relaxants
    • Allow spontaneous delivery, support fetus but do not apply traction
    • Fetus should be delivered within 10 min as cord will be compressed causing acidosis
    • Mauriceau-Smellie-Veit maneuver
  • Umbilical Cord Prolapse
    • 50% are associated with malpresentations
    • OB should be called, prep for c/s but if delivery is imminent facilitate as possible
    • Cord manipulation can induce vasospasm and hypoxia
    • Position mom in knee chest position
    • Any presenting parts should be manually elevated with provider’s hand to reduce pressure
  • CODE GREEN: imminent delivery
  • *** See Clinical Pathway Section for Malpositions Complicating Precipitous Delivery Flowchart***

The Clench Test, Dr. Martinez:

• Nerve innervations and why the clench test is useless in assessing for true spinal cord injury
• Glutes are innervated by L5-S2 where ankle flexion is innervated by S1-2 meaning if they can plantar flex, their buttcheeks can squeeze
• S3-4 control bowel and bladder function
• Pudendal nerve supports rectal tone, urethral and anal sphincters, made up of nerve fibers from S2-S4
• Trauma neuro exam
  • GCS/pupils/mentation, gross sensory, gross motor (PF and DF ankles), digital rectal exam
• Isolated damage to S1-5 can happen with sacral fractures depending on location, more medial fractures are higher risk for neurologic injury mostly involving bowel, bladder, and sexual dysfunction
• Reasons to do a proper DRE in trauma: clued in early to severe sacral fractures, blood, high riding prostate
• Always make sure to notify patient prior to DRE

Postpartum Hemorrhage, Dr. Shaw:

• Definition: >1000cc of blood loss or any blood loss with systemic signs of hypovolemia
  • Up to 24h postpartum
• Leading cause of maternal death worldwide, 1-5% of US deliveries
• Uterine atony most likely cause also laceration, retained POC
• DDx: tone, trauma, tissue, thrombin
  • Use physical exam to differentiate
    • Fundus should be below umbilicus
    • Inspect perineum for lacs
    • Uterine sweep for retained tissue, use ultrasound, look at placenta to verify that it appears intact
    • Coagulopathy: CBC, CMP, PT, PTT< fibrinogen, dimer, type/screen
• Bimanual uterine massage: one hand compresses fundus, one hand intravaginally compressing body of uterus
• Oxytocin first line
  • 10U IM, or 10-40U per 500-1000cc bag of saline as continuous infusion wide open
• Misoprostol: PO sublingual, rectal
• Uterine inversion:
  • Risks/causes: excessive cord traction, short umbilical cord, uterine relaxants during labor, previous inversion, placental attachment
  • Management: requires reduction of uterus
    • Provide adequate analgesia, likely procedural sedation
    • Nitroglycerine is potent uterine relaxant, onset 30 seconds, dose 50-100mcg bolus over 1-2 min, half life 2.5 minutes
• Retained Products of Conception
  • Eval with ultrasound for normal endometria stripe, inspect placenta, manual removal
  • Hemorrhagic shock: blood products ASAP
    • 1g bolus TXA = decreased risk of death by bleeding, evidence based practice
  • Tamponade with uterine packing, or Bakari balloon if available
    • Other options: Blakemore, condom cath

Peer Perspective on Addiction, Dr. McMurray:

• Make an effort to attempt to treat those with Opioid Use like you would anyone else, connect with them, ask them about their families, hobbies, things that make them happy Disorder
• Louisville area addiction resources guide to be posted in EXI and able to handout to patients with updated information
• Buprenorphine: partial opioid agonist
  • Subutex: buprenorphine only
  • Suboxone: buprenorphine and naloxone (attempts to decrease misuse or diversion)
  • Ceiling effect for euphoria/pain relief
  • Use caution when other CNS depressants are on board or patient has liver impairment
• X wavier: free, takes 3-4 min to apply, must have DEA number
  • Use link to apply https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
  • Enter licensing state, medical license number, and DEA number
  • “starting at the 100 patient level” select “no” for both questions
  • Select “I wish to apply for the 30 patient level with exemption”
  • Recheck in ~1 week to make sure your application was approved
• 3 day rule is for those without an x-wavier
• Resources: California Bridge Buprenorphine Pathway, Clinical Pathway on room9er by Dr. Kuzel
• Dot phrase for resources: ,dcaddict
• Prescribe Narcan kit at discharge

Pharmacy- Eclampsia/Pre-E, Josh Senn, PharmD:

• Important to quickly identify and treat these patients in a timely manner
• Hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide
• 20-26% of eclampsia cases occur 48h-6weeks postpartum
  • 78% of these patients had no BP issues in pregnancy
• ACE-I and ARBS are contraindicated in pregnancy
• Preeclampsia: new onset hypertension and proteinuria
  • >160 systolic or >110 diastolic x1 or >140 and >90 x2 four hours apart
• Pre-e with severe features: new onset hypertension and signs of end organ dysfunction after 20 weeks gestation and up to 6 weeks postpartum
• Eclampsia: convulsive manifestation
  • Maintain airway, establish IV access, fetal monitoring and assessment, BP control, Mg therapy, obtaining pertinent labs
• Magnesium:
  • Do not wait on labs to initiate treatment with Mag!!
  • MOA possible cerebral vasodilation + blocking Ca entry + entry in neural cells and altering neurotransmission
  • Multiple studies validate use
  • Dosing: 4-6g IV over 15-20 min, repeat 2-4g loading dose PRN
  • Maintenance 1-2g/hr
  • **NO IV ACCESS: 5gm x2 IM in each buttock**
  • Monitoring: respiratory dive, patellar reflexes, for reversal can give Ca Gluconate 1g IV over 5-10 min, +/- 40mg Lasix (renal excretion of Mg)
• Blood pressure control otherwise: no difference in efficacy or safety in hydralazine, labetolol, nifedipine
• Initiate treatment for any SBP >160 or DBP >110
• Refractory HTN: nicardipine gtt (5-15 mg/hr) titrated to goal BP
• Stay up to date on ED protocol

Lightning Lectures:

• HELLP, Dr. Beard:
  • In pregnancy: multiple normal physiologic changes
  • HELLP 0.1-1% of all pregnancies
  • Questionably represents a severe form of pre-e
  • 15-20% do not have antecedent HTN or proteinuria
  • Pathogenesis: inadequate placental perfusion, induces platelet aggregation, endothelial dysfunction & arterial hypertension, fibrin released, microangiopathic hemolytic anemia
  • Risks: previous hx, multiparous women (>50%), COVID
  • Clinical manifestations: HTN, RUQ or epigastric pain, jaundice, nausea/vomiting, headaches, vision changes
  • Haptoglobin, LDH, coags in addition to other labs
  • Maternal stabilization and then prompt delivery if possible
  • Multiple pregnancy related disparities exist: black and Hispanic women are at significantly higher risk for pre-e and HELLP
• PID/TOA, Dr. Kushner:
  • PID: Proportion of cases caused by CT/GC is decreasing
    • Multiple other nontraditional organisms are surfacing and becoming more common
  • Risk factors: multiple partners, <25 yo, prior hx of PID or STI, partner with STI
  • Can occur acutely over several days or over weeks/months
  • S/s: lower abdominal or pelvic pain, pain with intercourse, abnormal uterine bleeding, urinary freq, vaginal discharge
  •  No single historical, physical or lab finding is both sensitive and specific
  • Special population: transgender patients- ask pronouns and ask about patient’s anatomy/organs
    • Very common (21%) for these patients to avoid ED care due to fear of discrimination
    • 4x higher rates of HIV, also higher rates of extreme poverty, sexual assault, sex work
    • Be cognizant of this
  • Maintain low threshold for clinical diagnosis of PID
    • Even mild or asymptomatic cases may be at risk of infertility
    • Presumptive treatment should be initiated for sexually active women: experiencing pelvic or abdominal pain, no other cause for illness can be identified or if one or more of the following criteria are present on pelvic exam: CMT, uterine tenderness, adnexal tenderness
  • Workup: pregnancy test, microscopy of vaginal discharge, HIV, syphilis, UA (in addition to other labs including inflammatory markers, CBC if more severe presentations)
  • Stay up to date on CDC guidelines
  • TOA: inflammatory mass involving fallopian tube, ovary, sometimes other adjacent organs like bowel/bladder
  • Not all are associated with PID
  • Pathophys: ascending lower genital tract infection
  • Not all have fever and acute abdominal pain
    • 23% have normal WBC count
  • CT > US if need to exclude GI tract involvement
  • Need at least 24h of inpatient observation

Research Updates, Dr. Huecker:

• Residents should understand how research is conducted, evaluated, explained to patients, and applied, participate in scholarly activity, have appropriate resources to accomplish these goals
•  ULDEM has a full time PhD faculty member who performs stats and also designs and serves as PI on studies: Dr. Jacob Shreffler

• Think, Do, Write
• Travel to conference is sponsored by the university if you are presenting
• Plan ahead, use available resources, expect delays, something you are passionate about

Suturing 101, Dr. Eisenstat:

• Resource: thelacerationcourse.com, also closing the gap
• “The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin” -Brian Lin
• Sizes and removal: please always discuss with patient and make sure to document in discharge instructions
• There is a difference between how long an absorbable suture supports the wound vs how long it actually stays in the skin
• Absorbable (fast gut) is completely appropriate for facial sutures in regards to scarring and patient satisfaction
• Utilize undermining when wound edges are too far apart to get good closure
• Vertical mattress sutures are good in high tension wounds: can make a big difference even with 1-2 placed in the middle of the wound
• Elderly, thinner skin: use steri-strips along edges and put sutures through steri strips

Dr.Baker- Knobology

ALARA- As Low As Reasonably Achievable

High Frequency Probe- Good for superficial structures, High Resolution

Low Frequency Probe-Good for deeper structures, Low Resolution

Gain- Brightness

Depth

Zoom

Use these three to make your image clearer

Hyperechoic- Brighter (More echogenicity) than surrounding area

Hypoechoic- Darker (Less echogenicity) than surrounding area

Isoechoic-Same color (Same echogenicity) as surrounding area

Anechoic- Black. No color at all (No echogenicity)

Dr.Neal, PharmD- Sepsis  and Antibiotics

Sepsis- Life threatening organ dysfunction secondary to unregulated host response to infection

SIRS- hypo or hyperthermic, tachypnea, tachycardia, leukocytosis

Septic shock- Infection requiring vasopressors despite adequate fluid resuscitation

Good empiric choice should cover 80% of the bug you’re suspecting, based on local antibiogram

Give bacterial meningitis patients steroids to help reduce risk of side effects of infection (deafness, etc.)

Use source to guide your empiric antibiotic therapy

Dr.Howell, PharmD- Fluids and Vasopressors in Septic Shock

Maintain MAP > 65

30cc/kg bolus of fluids if hypotensive or lactate greater than 4.

Must document why if you give less

If fluids don’t maintain pressure, start vasopressors

Hypotension is due to decrease in systemic vascular resistance, use pressors that increase SVR

Norepinephrine is safe to start peripherally

Norepi is 1^st line for septic shock

Vasopressin is 2^nd line

Epi vs phenylephrine is 3^rd/ 4^th line, depending on scenario

Dr. Senn, PharmD- Rapid Sequence Intubation

Etomidate- GABA receptors, .3mg/kg, onset 30-60secs, duration 5-1min, minimal side effects of hemodynamics, may cause myoclonus. May cause some adrenal suppression but clinical relevance unclear

Propofol- GABA receptors, 1-1.5mg/kg, onset 10-30secs, duration 3-10min, may cause hypotension

Ketamine- NMDA receptors, 1-2mg/kg IV, onset 30-60sec, Duration 5-15min, Sympathomimetic and may cause hypersalivation

Succinylcholine- Depolarizing agent, 1-2mg/kg, onset 45-60secs (look for fasciculations), Duration 10-15min, may cause hypotension, causes hyperkalemia about .5-1 mEq rise transiently, may also cause malignant hyperthermia, use with care in peds due to underlying muscular dystrophy

Rocuronium- Nondepolarizing agent, .6-1.2mg/kg, onset 60-120s, Duration 30-45min

Vecuronium- Nondepolarizing agent,.08-.1mg/kg, onset 2-3min, Duration30-50min, may cause hypothermia

Have post-intubation sedation meds ready when asking for intubation drugs, do not want patient paralyzed but not sedated