Tumor Lysis Syndrome – Dr. Aher

typically occurs within days after chemotherapy.

Findings of: Hyperkalemia, Hyperuricemia, Hyperphosphatemia, HYPOcalcemia (2/2 phosphate binding Calcium

Dialysis indications: Potassium >6, Cr. >10, Uric Acid >10, symptomatic hypocalcemia, Phos >10, Volume overload

Methemoglobinemia – Dr. Norby-Hill

Can happen with dapsone overdose

Dissociation between SPaO2 and PaO2

Acquired cases from medications and environment, commonly dapsone, local anesthetics, nitrites, h202

50% is fatal

Features: refractory to supplemental o2, color of blood, cyanosis, respiratory depression

Tx: methylene blue (Not in G6PD or those on SSRIs as MB is MAOI), ASCORBIC ACID, EXCHANGE TRANSFUSION

Pediatric Surgical Emergencies – Dr. Robin Lund

Early blood tinged emesis – cracked nipples

Pyloric stenosis: M>F 4:1, 3 to 5 weeks, veracious eaters, NBNB projectile every feed, dehydration, malnutrition

Appy’s usually missed the younger they are

Intuss – 6 mo to 3 yo; ddx Meckels and hsp. 

Features: colicky severe, 20 min, emesis, sausage mass

NEC: sudden feeding intolerance, distention, tenderness, bilious vomiting, diarrhea, rectal bleeding

Malrotation: <1* vomiting, sick, abd distension, peritonitis.

Heme emergencies – Dr. McGee

1 single unit of donor platelets raises plts by 30k

Transfusion indications: <10k (20k if febrile or septic), <50k active bleeding, <100k CNS bleeding or neuraxial surgery

-vwb dz tx for minor bleeding is ddavp

Post transfusion purpura: alloantigen on transfused plts: t penia, purport, clinically significant bleeding. Tx IVIG

Don’t forget about HIIT if recent inpatient stint

MAHAs – non immune HA.

TMAs: microvascular hemolysis; tap, has, drug, complement, pregnancy, htn emergency

High Sensitivity Troponin – Dr. Adam Ross

6 or above reported. Anything less than 20 nl in males; <15 normal in females

>88 MI

15 or greater (change in either direction) increase is clinically significant (2 hours)

TBD if there will be poc trop in R9

Single trop undetectable with >3 hours of symptoms

Hemophilia Lecture

A is Factor VIII deficiency

B is Factor IX

Both are 

VWD: VWf “chaperones” Factor VIII and facilitates its efficacy

Emicizumab: bispecific mab. Helps factor 9 and 10 work. Subcutaneous injection prophylactically.

Meds ending in -ate are for VIII deficiency.

Transfusion Reaction – Dr. Bayers

1. TRALI vs TACO
   1. TRALI more often febrile, more often low BP
   2. TACO very consistent with CHF exacerbation, likely preceding CHF.
2. Other Transfusion Reactions on the Differential
   1. Anaphylaxis
   2. Sepsis – Transfusion Transmitted
   3. Urticaria
   4. FNHTR
   5. AHTR – usually secondary to ABO incompatibility: send Coombs, recheck T&S, DIC, Haptoglobin

If Fever and no other symptoms: stop transfusion, give antipyretic, wait 30 minutes and continue transfusion

Research Overview – Dr. Huecker

Think Do Write

Be passionate

Research Louisville September

ACEP October

CORD March

AAEM April

SAEM May

IRB submission typically takes one month

Common IRB approved research:

-human subjects research

-quality improvement

-program evaluation

Utilize Jacob

-plan stats, charts, graphs, that you want back in a timely fashion. Give him time to complete

Tuberculosis – Dr. Matthew Keller

Most common symptom is cough

8 weeks for exposure testing

2-4 weeks of treatment of active TB before non-infectious

Active TB:

Symptomatic +ppd, +qfg, abnormal cxr, +sputum or culture -> RIPE

Latent TB Isoniazid x9 months

Don’t treat CAP with quinolone (especially) if TB is on ddx

Case Follow Up: Hyperviscosity syndrome – Dr. Slaven

Hyperviscosity syndrome

Features: fever, fatigue, headache, blurred vision, dyspnea, chest pain. polycythemia, thrombocytosis.

Mgt: Give IV fluids Consider phlebotomy.

Causes of fever other than obvious: Infection/Iatrogenic, Mets, AI, Drugs, Endocrine, Clots. (IMADEClots)

Case Follow Up: Febrile Neutropenia – Dr. Ferko

ANC <500 + fever

More than 80% hematologic malignancies. Often currently receiving chemo

Blunted immune response; not necessarily SIRS

COPD places into high risk category.

To be low risk category, everything needs to look good, including transportation and likelihood to follow up

Consider using MASCC Risk score

Admit: Cover pseudomonas, not necessary to start MRSA coverage unless:

Pneumonia

Not HDS

If MRSA suspected

Catheter or skin and soft tissue infection

PECARN Pediatric Head Injury/Trauma Algorithm

Presenter: Dr. Tara Kopp, Pediatric EM

• SNOUT – sensitivity = rule out
• SPIN – specificity = rule in
• PECARN = cohort of 20+ large academic institutions that combine to produce academic research studies
• ciTBI = clinically important traumatic brain injury
• Want to have high sensitivity = screening test = rule out ciTBI and need for CT scan

PECARN Criteria:

• Age: <2 yo or >2 yo
• GCS ≤14 or signs of basilar skull fracture or signs of AMS
  • AMS = Agitation, somnolence, repetitive questioning, or slow response to verbal communication
• History of LOC or history of vomiting or severe headache or severe mechanism of injury
  • Small children = severe fall > 3 ft
  • Older children = severe fall > 5ft

Observation vs CT scan

• Observation usually 4-6 hours; may take into account time from injury
• Children with no PECARN criteria ciTBI predictors = lots of head CTs which could be avoided
• Recommend repeat physical exam prior to discharge if observation

Conclusion:

• Severe injury mechanism
  • Children with isolated severe injury mechanism are at low risk of ciTBI, and many do not require imaging.
• Scalp hematoma
  • Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to determine need for imaging in otherwise asymptomatic children.
• VP shunt
  • Children with VP shunts had higher CT use but similar rates of ciTBI compared with children w/o VP shunts. (limited sample size)

Peritonsillar abscess

Presenter: Dr. Brett Nelson

• Most common deep space infection of head and neck
• Predisposed by previous/recurrent tonsilitis or pharyngitis

Symptoms:

• Odynophagia, drooling, voice change

Evaluation:

• Edematous tonsil, pillars, or soft palate
• Uvula deviation
• Ultrasound
  • Intraoral US with endocavitary probe
  • Submandibular US with linear probe
• CT head/neck w/ contrast

Treatment:

• Needle aspiration – start near superior tonsillar pole, cut needle guard to protect
• Incision and drainage – cut scalpel guard to protect
• Antibiotics alone – Augmentin +/- Clindamycin
• “Quinsy Tonsillectomy” – performed by ENT in severe cases of airway obstruction

Disposition: Usually discharge with ENT follow-up

Sialolithiasis and Suppurative Parotitis

Presenter: Dr. Kyle Stucker

Sialolithiasis:

• Calcium carbonate or phosphate stones of salivary gland in stagnant duct
• Mechanism: Duct stasis, bacterial migrations alter salivary gland pH, altered duct electrolyte concentrations
• 80% occur in submandibular gland
• Usually 5mm; >10-15 mm = “megalith”

Diagnosis:

• Facial swelling, pain, discomfort
• Clinical – stone may be palpated
• CT scan
• Ultrasound

Treatment:

• <5 mm stone
  • Conservative
  • Outpatient therapy and analgesia
  • Gland massage
  • Sialogogues, such as lemon drops
  • Antibiotics if concern for infection
  • ENT referral
• > 5mm
  • Consider ENT consult

Suppurative Parotitis

• Duct infection or infected stone
• Evaluated with CT or US
• Collect cultures if visible purulent discharge

Treatment:

• Augmentin or clindamycin if penicillin allergy
• Admit for IV abx (Unasyn) if concern for sepsis, signs of trismus or airway compromise

Small Group Lecture: ENT Foreign Bodies

Present: Dr. Taylor Strohmaier

Ear foreign body:

• Lidocaine, mineral oil, hydrogen peroxide – anesthesia and kill insect

Removal techniques:

• Irrigation – may utilize IV catheter; contraindicated in TM perforation and button battery
• Forceps – flat or alligator, right angle tool, currette (lighted if available)
• Dermabond + Q-tip – allow glue to become tacky
• Snake pediatric NG tube/foley past to attempt to drag out

Consider otic drops if TM perforation or significant EAC trauma

• Cipro-dex drops
• Dry ear precautions

Consult ENT:

• Unable to remove FB
• Patient requires sedation

Eye foreign body:

Eye exam: EOM, pupils, visual acuity, fluorescein stain, Woods lamp, slit-lamp exam, tonometry, ultrasound, CT scan (may be helpful if concern for metallic FB)

Removal techniques: irrigation, moist Q-tip or cotton swab, 18 g needle on slit-lamp exam, eye burr

Complication of metallic FB: rust ring or corneal perforation (open globe)

• Rust rings can form within only a few hours
• Update Tdap
• Consult ophthalmology

Antibiotic:

• Moxifloxacin (Vigamox), ofloxacin, ciprofloxacin drops
  • Require pseudomonal coverage for contact len wearers
• Erythromycin ointment

Consult ophthalmology if unable to remove FB, visual deficit, concern for open globe, or rust ring

Follow-up with optho – 24-48 hrs

Nasal Foreign Body:

Removal Techniques:

• Mother’s Kiss Technique
• Suctioning
• Forceps with nasal speculum
• Dermabond on Q-tip
• Foley catheter, Fogarty catheter or Katz extractor

Complications:

• Soft tissue injury – epistaxis, septal injury/hematoma, nasopharyngeal trauma
• Barotrauma
• Displacement of FB into airway

Disposition:

• Discharge home following FB removal in uncomplicated cases
• Antibiotics if concern for infection
• ENT consult if unable to remove FB or persistent epistaxis

Here are four papers on ovarian torsion. If you suspect torsion clinically, do NOT be reassured by normal flow on USN. Only the last paper (12 years old) showed a high sensitivity of ultrasound doppler flow for torsion. The other findings matter!

Diagnostic Efficacy of Sonography for Diagnosis of Ovarian Torsion (2014)

323 subjects. The ultrasound correctly diagnosed 72.1% of ovarian torsion and missed 27.9% of them (false negatives)

Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department (2014)

20 cases, 20 controls. Pelvic US for ovarian torsion was 80.0% sensitive (95% CI, 58.4-91.9%) and 95.0% specific (95% CI, 76.4-99.1%) for reader 1, while 80.0% sensitive (95% CI, 58.4-91.9%) and 85.0% specific (95% CI, 64.0-95.0%) for reader 2.

Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler? (2018)

55 cases of surgically proven torsion, 48 controls. Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Presence of ovarian cysts was significantly associated with torsion. Sensitivity of ultrasound was 70% and specificity was 87%.

Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion (2009)

One hundred and ninety-nine patients presented with adnexal mass and intermittent lower abdominal pain. Sensitivity and specificity of tissue edema, absence of intra-ovarian vascularity, absence of arterial flow, and absence or abnormal venous flow in the diagnosis of adnexal torsion were: 21% and 100%, 52% and 91%, 76% and 99%, and 100% and 97%, respectively. All patients with adnexal torsion had absent flow or abnormal flow pattern in the ovarian vein. In 13 patients, the only abnormality was absent or abnormal ovarian venous flow with normal gray-scale US appearance and normal arterial blood flow. Of these 13 patients, 8 (62%) had adnexal torsion or subtorsion.

TL;DR

1. Ovarian Torsion is a clinical diagnosis. Ultrasound is NOT 100% sensitive.

2. Read the USN report, Just like a cardiac cath*, normal must really mean normal. If you can’t visualize one ovary, or have normal ovarian flow but a large cyst, or have edema, etc, that is NOT a normal pelvic ultrasound.

* A cath report that has 50% blockage in 2 vessels is not “normal” or “clean”! Caths with absence of a lesion that requires PCI (stent) can still have abnormalities that are very important. Remember, the 50% coronary plaques are the most likely to be unstable and rupture.

Pharmacy Lecture

Presenter: Nicholas Cottrell, Pharm.D

Intranasal Meds:

Adv:

• Ease of use
• Rapidly effective
• Relatively safe

Metabolism:

• Metabolized by liver
• Nasal meds bypass liver metabolism
• Optimizing drug intranasal:
  • 0.2-0.3 ml, Never more than 1 mlà will cause post nasal drip
  • Remove blood and mucous from the nose
  • Use both nostrils
  • Use atomized delivery system

Go to Treatment for Headache:

• Sphenopalatine Ganglion Nerve Block:
  • Associated with trigeminal nerve
  • Seen in migraine and cluster HA
  • How to perform Sphenopalatine Ganglion Nerve Block
    • 10 cm cotton tip applicator
    • Anesthetic 1% lido
    • 5 cc syringe with large bore needle to draw up anesthetic

Angioedema:

• Hereditary
  • Recurrent attacks
  • C1 esterase inhibitor deficiency
  • Allergic reaction meds are ineffective
• Acquired Angioedema
  • Rare
• Treatment:
  • Green Zone: Minimal edema
    • Observation
  • Yellow: Moderate
    • Watch, meds
  • Red Zone: Immediate need for intubation
    • Stridor
    • Dyspnea
    • Progressive deterioration

Intubations Hazards:

• Airway manipulation may worsen swelling
• Laryngeal edema will preclude use of LMA

TXA:

• TXA can work on bradykinin mediated angioedema
• 1 g IV push over 10 minutes, q4h PRN
  • ADE: Thrombosis
• C1 esterase deficiency angioedema:
  • 2 units of FFP initially, 2 units PRN
  • Other meds:
    • Icatibant and Ecallentide
      • Take longer to work
      • Not always available
      • EXPENSIVE

Management of Obligate Neck Breathers

Presenter: Dr. Shawn Jones, Otolaryngology PGY-2

• Tracheostomy:
  • Exteriorizes trachea to skin of neck for permanent gas exchange:
    • Why:
      • Severe OSA
      • Head and neck cancers or masses
      • Subglottic stenosis
      • Ludwig’s angina
      • Paralysis of vocal cords
      • Prolonged ventilator support
    • Benefits:
      • Reducing need for sedation
      • Improve patient comfort
      • Reduce ventilator pneumonia
    • Risks:
      • Infections
      • Bleeding
      • Fistula
      • Granulation tissue and scarring
      • Tracheal occlusion:
        • Mucus plugging
        • Accidental decannulation

Tracheostomy and Respiratory Distress:

1. Remove trach cap

2. Attempt to pass suction catheter to assess patency

3. Provide supplemental O2 (trach collar, BiPAP, bagging)

4. Replace uncuff trach tube with cuffed trach tube or cuffed ET Tube to provide PPV

Image Source: https://aneskey.com/what-is-a-tracheostomy-what-is-a-laryngectomy/

Laryngectomy

• Larynx is surgically removed
• Upper airway no longer connects to trachea
• Trachea is fixed to skin to create permanent stoma

Indication:

• Cancer of head and neck
• Chronic aspiration

TEP = transesophageal prothesis – may be placed after laryngectomy to allow for speech

Image Source: https://sinaiem.org/dont-fear-the-tracheostomy/

Laryngectomy and respiratory distress:

• Provide supplemental O2: trach-collar, BiPAP, bagging
• Must place cuffed ET tube to provide PPV (lary tubes are uncuffed)

Image source: https://www.pinterest.com/pin/117586240255365772/

Pediatric Heme/Onc Emergencies

Dr. Julie Klensch, Pediatric EM Fellow

Hemorrhagic Disease of Newborn

• Vit K deficiency causes severe bleeding
• Onset usually during 1^st week of life
• ICH, intrathoracic or intracranial bleeding, oozing from mucous membranes

Treatment:

• Vit K and FFP
• Transfuse for Hgb<7
• pRBC 10-15 ml/kg given over 2-4 hrs
• 10 ml/kg should increase Hgb by ~2

Hemolytic anemia

• Pallor, jaundice, dark urine, fatigue, dizziness
• Intrinsic vs extrinsic
• Evaluation: CBC, CMP, LDH, haptoglobin, direct/indirect bilirubin , Comb’s test in newborns

Sickle Cell disease

• Vascular occlusion
• Infection
• End organ damage
• Tx: analgesia and hydration
• Salmonella + sick cell patient = osteomyelitis

Dactylitis

• Vaso-occlusive crises of hands and feet; often initial presenting sign of SS disease

Splenic Sequestration

• Splenomegaly, thrombocytopenia, LUQ pain

Acute chest syndrome

• Infiltrate of CXR, chest pain, hypoxia
• Tx: ceftriaxone and azithromycin, IVFs, consider pRBC transfusion if respiratory support required

Stroke

• Management: CT, MRI, exchange transfusion

Avascular necrosis:

• Leg/hip pain, inability to bear weight
• Tx: analgesia and orthopedics consult

Infection

• Hyposplenia leaves patient at risk from encapsulated organism, specifically S. Pneumoniae
• Children < 5yo should be on prophylactic penicillin.

Thrombocytopenia

• Plt transfusion 5-10 ml/kg, rate dependent on urgency
• 1 U increase 5,000-10,000

Immune thrombocytopenia (ITP)

• Well appearing child, unexplained petechiae and bruising, isolated thrombocytopenia following viral infection
• Tx: IVIG, don’t transfuse plt

Neutropenia

• ANC<1500, severe ANC<500
• Fever + Neutropenia = septic work-up with administration of broad-spectrum antibiotics

Tumor Lysis Syndrome

• Initiation of chemotherapy; most common in leukemia or lymphoma (high cell turnover)
• Hyperkalemia, hyperphosphatemia, and elevated uric acid
• Tx: Allopurinol and hydration, Rasburicase for severe cases but expensive

Lateral Canthotomy – Procedure SIM

Presenter: Dr. Michael Carter and Dr. Ross Sizemore

Indication for lateral canthotomy: Ocular compartment Syndrome

• Most commonly due to blunt trauma
  • Retrobulbar hematoma/hemorrhage
  • Infection, orbital emphysema, FB (less common)
• Eye Pain, proptosis, difficulty open eyelids, pain/difficulty with EOM
• Perform pupillary exam, visual acuity, and tonometry (IOP>40)
• Order CT but do not delay treatment
• Irreversible vision loss may occur within 60-100 min if not treated

Globe rupture: contraindication to the procedure

Medical management:

• Elevate HOB, analgesia, and BP control, antiemetics
• IV acetazolamide
• Timolol eye drops
• IV mannitol

Pitfalls:

• Lack of early recognition and ophthalmology consultation
• Iatrogenic injury
• Incomplete resolution

Equipment:

• Chlorhexadine
• Lidocaine w/ epi
• Needle and syringe for lidocaine injection
• Straight mosquito hemostat
• Iris scissors
• Forceps

Procedure Tips:

• Angle sharps away from eye during procedure
• Recheck IOP after procedure
• Be aware of lacrimal gland if cutting superior tendon.

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

Ceasing Resuscitation in the Pre-Hospital Setting

Presenter: Dr. Raymond Orthober

Termination of out of hospital cardiac arrest (OHCA)

• Non-traumatic patients
• 0.6% survival rate in those with ROSC >25 min CPR
• In most situations, ACLS initial resuscitation on scene is equivalent to ACLS offered in-hospital
• Goal: Gain ROSC and obtain good neurological outcome

Load-and-Go vs Stay-and-Play

• Trauma = Load-and-Go
• Medical = Stay-and-Play

Withholding resuscitation efforts: Evaluate life status

• Cold and stiff in warm environment
• Rigor Mortis
• Lividity
• Obvious mortal wounds
• Obvious signs of decomposition
• Valid DNR

Determination of death:

• Pupils fixed and dilated
• Apnea
• Pulseless
• Asystole in 2 leads

Exceptions to cease resuscitation in the field: cold water drowning, electrical injury, hypothermia

CPR underway & request to cease resuscitation:

• No bystander CPR
• No witnessed arrest
• No response after >6 min high quality CPR
• No shockable rhythm
• Asystole in 2 leads
• No ROSC at anytime
• 20-25 min CPR prior to request to cease resuscitation

EtCO2

• EtCO2 > 20 is a sign of life
• EtCO2 < 10 may be used to support termination of CPR
• Technical difficulties may lead to inaccurate EtCO2
• Use as complementary value in bigger picture of patient

Radio call – Questions to ask

1. Valid DNR or MOST form?
2. Witnessed arrest and/or bystander CPR?
3. Definitive airway? iGel, LMA, ETT
4. Any shocks delivered?
5. ROSC at any point?
6. Asystole at time of call?
7. 20-25 min CPR?
8. EtCO2<10

Termination of Resuscitation in Trauma

• Trauma = Load-and-Go
• All trauma patients should be transported except in rare circumstance of obvious mortal wound, no signs of life, and prolonged downtime

Thromboelastography (TEG)

Presenter: Dr. Isaac Shaw

Utilize to guide your blood product resuscitation.

Trauma patients or severe UGI bleed presenting in hemorrhagic shock and requiring MTP in the ED.

Image Source: https://www.tamingthesru.com/blog/grand-rounds/teg

• Prolonged R-time –> administer FFP
• Decreased Alpha angle –> administer cryoprecipitate
• Decreased MA –> administer platelets
• Increased LY30 –> administer TXA

TEG turn-around time: Final result in ~30 minutes

Room 9 computer has TEG software – can begin to see graph form in 5-10 minutes.

Oral Boards Case

Presenter: Dr. Isaac Shaw

28 year-old male presents for hemoptysis in the setting of recent tracheostomy placement.

Differential diagnosis for bleeding tracheostomy site:

• Tracheoinnominate fistula
• Tracheal irritation
• Bacterial Tracheitis
• Surgical site bleeding or infection
• Pulmonary Embolism
• Diffuse Alveolar Hemorrhage

Sentinel bleed: small bleed prior to large volume hemorrhage due to tracheoinominate fistula formation

It takes ~1 week for tracheostomy tract to mature

Image Source: http://emdaily.cooperhealth.org/content/emconf-tracheoinnominate-fistula

Management:

1. Hyperinflate tracheostomy cuff (~40-50cc)

2. Consider replacing trach with standard ET tube and then hyperinflate ET tube cuff (may help if bleed is further down)

3. Insert fingers in trach site and apply pressure anteriorly against back of sternum

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Lighting Lectures:

Presenter: Dr. Jordan Martinez and Dr. Adam Lehnig

Retropharyngeal Abscess

• Age: 2-4 years old most common
• Often presents after an infection, usually URI
• May be precipitated by trauma, dental procedure, intubation, etc
• Polymicrobial infection

Management:

• Evaluate for airway compromise –> ABCs
• Obtain CT soft tissue neck W (historically lateral neck X-ray was used)
• Antibiotics: IV Unasyn or IV Clindamycin
• Consult: ENT

Image Source: https://www.slideserve.com/derora/deep-neck-infections

Image Source: https://www.wikidoc.org/index.php/Retropharyngeal_abscess

Ludwig’s Angina:

• Bilateral infection of submandibular space
• Dental source = most common cause
• “Hardening of floor of mouth”
• Tongue swelling and elevation; neck swelling

Management:

• Evaluate for signs of respiratory distress: drooling, dyspnea, dysphonia, dysphagia
• Fiberoptic nasal intubation if necessary
• Consider CT imaging
• Antibiotics: IV Unasyn – first line
• Polymicrobial infection – consider broad spectrum if known MRSA or pseudomonal exposure
• ENT consult

Room 9 Follow-Up:

Presenter: Dr. Dylan Nichols

Two patient cases discussed. Both patients with bradycardia in the setting of acute renal failure and severe hyperkalemia. Both patients demonstrated transient bradycardia which eventually resolved.

BRASH Syndrome:

• Bradycardia
• Renal Failure
• AV blockade
• Shock
• Hyperkalemia

Consider in: Elderly patients with cardiac disease on BB/CCB

Trigger: hypovolemia or AKI

Image Source: https://litfl.com/brash-syndrome/

Epistaxis

Presenter: Dr. Matthew Eisenstat

Anterior Bleed (90%): comes from Kiesselbach’s plexus

Posterior Bleed: (10%): higher concern severe bleeding or arterial bleed (sphenopalentine artery)

May use nasal speculum for better visualization.

Image Source: https://www.aafp.org/afp/2018/0815/p240.html

Management:

1. Direct pressure (consider taping together tongue depressors)
2. Oxymetazoline (Afrin) spray – have patient blow nose to remove clots prior to application
   1. May also consider lidocaine w/ epinephrine or phenylephrine spray
3. Chemical cauterization with silver nitrate stick – do not apply bilaterally due to decrease flow to nasal septum
4. TXA soaked gauze/pledget or Surgicel gauze
5. Traditional nasal packing with Vaseline gauze
6. Nasal Tampon Device (Merocel) – expands when exposed with liquid, tape string to patient’s face
7. Nasal balloon device (Rhino-Rockets) – inflatable device applies direct pressure

Image Source: https://www.capesmedical.co.nz/medical-products/woundcare/epistaxis-control/epistaxis-rapid-rhino-device-unilateral-airway

Disposition:

• Admit posterior bleeds and severe anterior bleeds requiring nasal packing
• Consider admission in patients with multiple comorbidities or on anti-coagulation
• No definitive recommendation on blood pressure management in epistaxis
• If discharging recommend removal of nasal packing in 48-72 hours to avoid development of toxic shock syndrome

Nasal fracture:

• No imaging required in isolated injury
• Immediate reduction or reduction at follow up in:
  • Children: 2-4 days
  • Adult 6-10 days
• Nasal septal hematoma: requires immediate drainage followed by bilateral nasal packing and ENT follow-up within 24 hours
• Children + epistaxis: evaluate for foreign body

Ophthalmology for the ED Provider

Presenter: Dr. Sanket Shah, Ophthalmology PGY-4

Image Source: https://www.allaboutvision.com/resources/anatomy.htm

Eyelid lacerations

• Laceration involving eyelid border = ophthalmology consult
• Laceration to medial canthus = concern for disruption of lacrimal duct = ophthalmology consult

Visual acuity

• Check each eye individually
• With glasses on or utilize pin hole in patient >40 y/o
• Counting fingers, hand motion, light perception if patient unable to read eye chart

Pupillary exam

• Size, shape, response to light

IOP

• Utilize anesthetic drops and Tonopen
• Normal is up to ~21 mmHg; in the ED up to 30 mmHg is reasonable
• Ensure no pressure on the eye from hands; patient no holding their breath during exam

Subconjunctival hemorrhage

• may follow-up in clinic

Subconjunctival hemorrhage + chemosis

• depends on severity and percent of chemosis; consider ophthalmology consult in severe cases

Corneal abrasion

• Evert eyelids and exam – utilize cotton tip
• Evaluate with fluorescein staining
• Small, normal vision
  • erythromycin ointment QID 4-5 days
• In setting of wood, sticks, fingernail, contacts
  • moxifloxacin eye drops
  • avoid ciprofloxacin drops due eye toxicity
• Large, central, concern for corneal ulcer:
  • Immediate ophthalmology consult
  • Antibiotic drops

*Never discharge patients with anesthetic eye drops (tetracaine or proparacaine); Toradol drops are a safe option

Foreign body removal

1. damp cotton swab
2. 18g needle
3. Eye burr – recommend ophthalmology consult prior to trying this

Chemical burns

• Check pH prior to application of any drops
• Irrigate copiously and recheck pH
• Consider Morgan Lens

Corneal Ulcer

Staining corneal ulcer = Ophthalmology emergency and immediate consult

Traumatic Iritis

• Blunt trauma
• Visual deficit = ophthalmology consult
• Tx: dilating drops (cyclopentolate); Ophthalmology may start steroids

Hyphema

• >50% consider ophthalmology consult

• Consult ophthalmology in all sickle cell patients

Orbital Fracture

• Ophthalmology requests full eye exam prior to consult
• Entrapment higher concern in pediatric population

Retrobulbar hemorrhage

• Ophthalmology Emergency – Immediate consult
• Check IOP
• Consider lateral canthotomy if increased IOP, decreased visual acuity, or proptosis present

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

Ruptured Globe

• Ophthalmology Emergency – Immediate consult
• Apply eye shield
• Obtain CT Orbits WO
• Update Tdap
• Broad Spectrum Antibiotics: Prefer Vancomycin and Levaquin

Painful Vision Loss:

• Acute angle closure glaucoma
  • IOP lowering drops

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/b-pod-case/angle-closure-glaucoma

• Optic neuritis
  • MRI Brain/Orbit W&WO
  • Neurology consult
• Uveitis
• Endophthalmitis
• Corneal hydrops

Painless Vison Loss:

• Giant Cell Arteritis (GCA)
• Central Retinal Artery Occlusion (CRAO)
• Central Retinal Vein Occlusion (CRVO)
• Retinal Detachment
  • Utilize ultrasound for evaluation

Image Source: https://jetem.org/retinal_detachment/

• Vitreous Hemorrhage
• Amaurosis Fugax

Chronic Eye Disease:

• Cataracts
• Open angle glaucoma
• Dry eye
• Diabetic retinopathy
• Macular degeneration

US for Shoulder Dislocation and Reduction

Complications of the Foot by Dr. Ford

• Osteomyelitis
  • High risk groups: Substance abusers, Diabetics, open fractures
  • Bone biopsy is gold standard for diagnosis
  • Get a deep culture (with a piece of tissue or bone) before initiating abx
  • Bone mineral loss of 30% is required for changes to be visible on X-ray
• Charcot neuroarthropathy
  • Progressive noninfectious condition
  • 2 etiologies: neurovascular and neurotraumatic (microfractures)
    • Neurovascular: massive amounts of blood flow “water log” the bones. Caused by autonomic dysfunction
  • Initial phases can look like cellulitis but erythema is DEPENDENT (resolves with 10min of elevation)
  • Consolidation (chronic) phase = rocker bottom foot. Mid foot bony deformity
  • DISCHARGE if no WBC or open wound. Normal to have elevated ESR, CRP, temperature.
  • ADMIT if open wound present to r/o infection with biopsy
  • Treatment is offloading with total-contact cast
• Gout
  • Gouty arthritis can break down bone and mimic osteo. Differentiate with history.
  • Uric acid level will be elevated

Lightning Lectures

Gout

• Monosodium urate crystal deposition
• Elevated uric acid levels
• Monoarthritis often involving first MTP or knee joint
• US can demonstrate “double contour sign”
• Treatment options: NSAIDs, Prednisone, Colchicine

Septic Arthritis

• <35yo: N gonorrhea; >35yo: S. aureus
• Pain with ROM
• Arthrocentesis with synovial fluid analysis is diagnostic

Pharmacology in Open Fractures and Reductions

• In antibiotic selection in open fractures consider Gustilo Classification and environmental exposures.
• Grade I & II fractures: gram positive coverage w/ Cefazolin
• Grade III fracture: gram positive and negative coverage w/ cefazoline and gentamicin

I have recently seen many patients sent to the ED from urgent care centers and PCP offices for evaluation of hypertension. While true hypertensive emergency often leads to straight forward disposition, this condition is rare and much more commonly patients present with severe asymptomatic hypertension (sometimes referred to as hypertensive urgency). I will discuss an approach to management of these conditions below.

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Common causes of hypertension:

• Medication noncompliance
• Pain
• High-salt diet
• Amphetamine or stimulant use
• Alcohol withdrawal or drug withdrawal

Less common causes of hypertension:

• Pheochromocytoma
• Thyroid Storm
• Intracranial hemorrhage
• Preeclampsia/Eclampsia

Special considerations in hypertension:

• Ischemic/hemorrhagic stroke
• Aortic Dissection

Hypertensive Emergency: Severe hypertension, commonly defined as BP > 180/120, with signs of end-organ damage.

End-organ damage:

• Neurological: intractable headache, vision changes, ischemic or hemorrhagic stroke, hypertensive encephalopathy or PRES
• Cardiac: chest pain, EKG changes or elevated cardiac biomarkers indicative of cardiac stress
• Pulmonary: dyspnea, pulmonary edema
• GI: abdominal pain, nausea/vomiting, transaminitis
• Renal: AKI, proteinuria, electrolyte abnormalities

Image Source: https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis

Work-up:

• CBC
• CMP
• EKG
• Troponin
• Chest X-ray
• Urinalysis
• β-hCG in females
• Consider Head CT if neurological symptoms

Management:

Treatment with IV anti-hypertensives and admission to appropriate service, usually medicine or cardiology.

Common IV anti-hypertensives:

• labetalol IV push (5-20 mg)
• hydralazine IV push (10-20 mg)
• nicardipine drip (start at 5 mg/hr and titrate to goal BP)
• nitroglycerin drip – specifically for acute pulmonary edema (see SCAPE management for dosing)

BP Goal: reduction in MAP by 10-20% in the first hour followed by gradual reduction in MAP by ~25% over the first 24 hours.  Commonly a goal BP of ~160/100 achieves goal of 10-20% reduction.

*There is increased risk of cerebral and cardiac ischemia if lowering BP too rapidly

Exceptions:

• Hemorrhagic CVA and aortic dissection have specific guidelines for BP goals and rapid lowering
• Ischemic CVA allow for permissive hypertension

*Beta-blocker contraindicated in amphetamine intoxication and pheochromocytoma

• amphetamine intoxication – use benzodiazepine
• pheochromocytoma – use alpha-blockers (phentolamine)

Severe asymptomatic hypertension (hypertensive urgency): Severe hypertension, commonly defined as BP > 180/120, with no signs of end-organ damage.

*Some physicians strongly dislike the term “hypertensive urgency” and ACEP utilizes the term “asymptomatic severely elevated blood pressure”.

This is a diagnosis of exclusion. As an ED physician it is your job to first rule out hypertensive emergency.

Management of severe asymptomatic hypertension:

* The first 3 steps below should apply to any patient presenting for hypertension.

1. Place patient in a quiet and relaxing environment (when possible)
2. Administer patient’s home PO anti-hypertensives if not taken today
3. Control patient’s pain and treat any underlying causes
4. Consider additional PO or IV anti-hypertensives
   1. PO anti-hypertensives
      1. Captopril (6.25-50 mg)
      1. Enalapril (2.5-20 mg)
      1. Clonidine (0.1-0.2 mg) *Would avoid due to variable response
   1. IV anti-hypertensives
      1. labetalol IV push (5-20 mg)
      1. hydralazine IV push (10-20 mg)
5. BP reassessment following administration

Goal BP prior to discharge:

• Ideally BP ~160/100
• In a completely asymptomatic patient, BP ~180/110 or even higher may be acceptable with appropriate follow-up
• No definitive recommendation exists for a blood pressure cut-off for which an asymptomatic patient must be acutely treated
• Many physicians have personal practice patterns and different comfort levels with this

Discharge Medications:

• If initiating home PO anti-hypertensives common medications include:
  • Amlodipine (5-10 mg)
  • Hydrochlorothiazide (HCTZ 12.5-25 mg)
• May considering increasing current home anti-hypertensive dose but would avoid this in most circumstances
• Once again, many physicians have personal practice patterns and different comfort levels with initiating or increasing doses of antihypertensives from the ED

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Follow-up:

• All patients should be provided resources for appropriate outpatient management
• Recommend repeat BP check within several days
• Recommend repeat renal function testing within 1 week if initiating anti-hypertensive therapy or increasing ACE or ARB

References:

1. UpToDate: Evaluation and treatment of hypertensive emergencies in adults
2. UpToDate: Management of severe asymptomatic hypertension (hypertensive urgencies) in adults
3. TamingTheSRU: Clinical Practice Guidelines: Hypertension
4. https://epmonthly.com/article/dont-let-hypertension-stress/
5. https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis

Upper and Lower Extremity Nerve Palsies

Pediatric Ortho

• Always consider non-accidental trauma in children
• Occult fractures are more common in peds
• If in doubt, splint and follow-up with ortho
• Presence of fat pads can indicate underlying fracture
  • Posterior is always pathologic.
  • A thin anterior fat pad is normal, but a “sail sign” is pathologic
• Management of common fractures
  • Monteggia fracture – urgent ortho consult for ORIF
  • Seymour fracture – physeal fracture of distal phalanx with associated nailbed injury. High risk for soft tissue entrapment. Requires Hand consult for likely ORIF
  • Tufts fracture w/ nailbed injury – antibiotics not required. Follow-up in 7-10 days with Hand
  • Common avulsion fractures (e.g. ASIS, lesser troch, iliac crest apophysis avulsion) should be NWB on affected extremity and f/u with ortho.
  • Torus fracture – splint with short arm cock-up splint
  • Greenstick fracture – unstable, requires splinting
  • Bowing deformity – treat it like a fracture and splint it
  • Mid and proximal humerus fracture – sling and swathe OR coaptation splint, sling, ortho f/u

Drug Rashes

• Common drug-induced rashes
  • Exanthematous drug eruption (EDE) – maculopapular
  • Urticaria w/o anaphylaxis
  • Vancomycin flushing syndrome (“Red man”)
• Uncommon and severe drug-induced rashes
  • Fixed drug eruptions
  • angioedema
  • acute generalized exanthematous pustulosis
  • DRESS
  • SJS and TEN
• DRESS can occur up to 8 weeks from drug exposure
• EDE (T-cell related) vs Urticaria (histamine) – draw an image on patient’s skin. If it appears red and/or raised after 10 min, it is urticaria
• Antihistamines: First gen (sedating): diphenhydramine, hydroxyzine; Second gen (less sedating): cetirizine, loratadine
• Topical corticosteroids – medium to high potency preferred for short course

ABEM

• ABEM exists to verify the abilities of physicians and to promote quality, trust, and responsibility.
• They aim to make our board certification more valuable by advocating for our value in hospitals
• See ABEM website for details about board certification and the exam
• Study for your exam!

Small Group: Nail bed Infections

• Flexor tenosynovitis
  • Hand emergency. Pt will often require OR washout with Hand surgery.
• Paronychia
  • Manage with warm compress and/or I&D
• Subungual hematoma
  • Ensure there is no underlying fracture
  • Trephination is generally reserved for symptomatic treatment within the first 24hrs

HIPAA: common scenarios and what is appropriate

• Family member: provider may disclose “directory info” (patient location and general health status) if caller identifies the patient by name.
  • The provider must first provide the patient with opportunity to agree or object
• Personal physician
  • Disclosures of PHI from one provider to another for treatment purposes are permissible without the patient’s authorization. Disclosing provider must use professional judgement to determine whether the requested PHI relates to the patient’s treatment by the requesting physician
• Press
  • Location and general health status can be disclosed if requestor identifies the patient by name, unless the patient has objected to such disclosures
  • Can’t just ask about the status of a GSW
• Test results
  • Provider must use their judgement to infer from the situation that a patient does or does not object
• Law Enforcement
  • Limited situations – PHI about a patient who is suspected to be a crime victim and the patient cannot agree to disclosure; the provider may disclose the PHI if (1) she/he determines that disclosures is in the patient’s best interest and the law enforcement officials represent that the PHI needed to determine whether another person violated the law. (2) The PHI is not intended to be used against the patient. (3) An immediate law enforcement activity depends on disclosure.

Small-bore Catheter (6-12 F) Thoracostomy Tube Placement

Small-bore catheter kit includes:

• Small-bore catheter (6-12 F)
• Trocar
• Finder needle with syringe
• Guide wire
• Heimlich flutter valve (one-directional)
• 11-blade scalpel
• Local anesthetic with additional needle and syringe
• Sterile drapes
• Sterilizing solution

Indications:

• Pneumothorax (especially stable, non-traumatic, spontaneous pneumothorax)
• Pleural effusion drainage in the unstable patient
  • Large-bore chest tubes are still recommended for more viscous effusions such as empyema or hemothorax  

Step-by-step Guide:

1. Prepare the chest tube atrium and ensure appropriate length tubing is available for low wall suctioning once the procedure is complete
2. Place the patient in either a lateral recumbent or supine body position with the head of the bed elevated to 30-45 degrees, or in a seated position with the patient leaning slightly forward for posterior tube placement (i.e. tube placement for drainage of pleural effusions, ultrasound guidance is recommended for posterior tube placement similar to with thoracentesis both to identify the location of the effusion and due to the increased presence of vascular structures between the rib spaces posteriorly)
3. Identify the location of insertion, usually the 4-5^th intercostal space at the mid-axillary line (similar to large-bore chest tube placement) at the level of the nipple. Remember the “safety triangle” bordered by the lateral edges of the pectoralis and latissimus dorsi muscles where there is a decreased risk for damage to underlying vascular, nervous, and organ structures
4. Sterilize the skin surrounding the site of insertion and drape the patient accordingly using the drape provided in the kit, or by using sterile towels if preferred (remember to leave the nipple exposed to assist with identifying landmarks during catheter placement)
5. Measure the small-bore catheter in front of the patient’s chest to determine the appropriate depth of insertion in a manner which ensures placement towards to superior aspect of the chest with all side ports within the pleural cavity (remember, the catheter can be withdrawn but not inserted further once the procedure is complete, similar to placing a central venous catheter)
6. Generously anesthetize the skin at the desired site of insertion, advancing your needle deeper over the superior aspect of the rib to minimize the risk of damage to the neurovascular bundle, withdrawing prior to injecting lidocaine as the needle progresses through the soft tissue. Be sure to anesthetize the parietal pleural during this process, as it is fine for the needle tip to pass into the chest cavity
7. Gently advance the finder needle over the superior aspect of the rib through the intercostal musculature similarly to the previous step while steadily drawing back against the syringe plunger as the needle tip advances. The plunger pressure will give way once access into the pleural cavity is achieved. Consider loading the finder needle syringe with several mL of sterile water for visualization of air bubbles in the syringe to assist with this step
8. Once access to the pleural space has been achieved remove the syringe from the finder needle and insert the guide wire into the back of the finder needle passing the wire into the pleural cavity in such a manner that leaves most of the wire hanging outside of the patient
9. Remove the needle from the patient and make a small incision in the skin at the base of the guide wire using the provided 11-blade scalpel
10. Pass the dilator over the guidewire and into the pleural space feeling it give-way once it has pierced the parietal pleura and entered the thoracic cavity. Be sure to visualize the guide wire exiting the back of the dilator prior to insertion to ensure the wire is not accidentally lost within the chest. The dilator may be removed once this step is complete
11.  Pass the small-bore catheter within its trocar over the guide wire and into the pleural space in a manner that ensures all side ports are within the space. Generally, the first black indicator line can be used for small and thin patients, the second black line for the average adult, and the third black line for large adults. Similarly to the above step, ensure the guide wire is visualized exiting the back of the trocar prior to insertion.

HD – Pigtail Chest Tube Insertion | EM:RAP (emrap.org)

ED Operations Lecture 

Dr. A. Ross, MD 
POC Troponin will be leaving the ED
High Sensitivity Troponin (hsTnl): Less than 15ng/L in females and less than 20ng/L in males is interpreted as negative; anything above is considered positive.
-Reported in whole numbers-Significant delta is an increase in 15 ng/L (over 2 hours); note a fall greater than 15 is significant too. -Must Repeat in 2 hour intervals-Will take about 30-45 min to result. T2 Bacterial PCR: rapid diagnostic ecoli, s. aureus, klebsiella, pseudo, E. faecalis-TAT 3-5 hours Who: septic patients Benefit?: Deescalation of antibiotics once resulted.

Level 1 Activation Criteria: SBP <90mmHg, Resp compromise or impending, EP Discretion, Blood resuscitations to maintain VS in transport, GSW or severe penetrating trauma to neck, chest, or abdomen, GCS <9 with mechanism attributed to trauma.NOTE: GSWs to the head and going to SICU (call trauma on these) do not need to activate Level 1 on these. 
Shunt Series: power plan in cerner; rad VP shunt series (orders all plain films) 
TEG Stay Tuned
Continue to place Intend to Admit Order in Cerner on people you know will admit.

One Pill Can Kill 

Dr. R. Lund, MD 

CCB, TCA, Lamotil, Opiates/Opioids, Camphor, Clonidine, Antimalerials 
Opioids: Naloxone dosing peds: 2mg IV q3-5BB Tox: hypoglycemia and bradycardia; glucagon and or high insulin protocol (consult tox.)CCB: Dihydro and Non-Dihydro; Txt: supportive care; Poison Control ConsultationOil of Wintergreen: Salicylate Toxicity; Toxidrome: Nausea, Vomiting, Tinnitus, Txt: Urinary Alkalization Sulfonylureas: Admit for 24 hours, give either PO or IV. Txt: Octreotide infusion Clonidine/Imidazoles: A-2 agonist, high dose narcan and supportive care measures. symptoms: lethargy and or coma typically. Camphor: Txt: Benzos and Phenobarb for seizures; TCA: CNS, anticholinergic, and QRS prolongation; QRS 100ms< is pathologic; Tx: Benzos and Bicarbonate, Lamotil; loperamide +/- atropine; symptoms: anticholinergic and opiate toxidrome picture; txt: narcan Toxic Alcohols: Ethylene Glycol, Methanol, and Isopropyl Alcohol (rubbing etoh): Isopropyl: ketonuria; supportive care Methanol: de-icers, HA, Metabolic acidosis, breaks down into formic acid, give fomepizole or ETOH to compete out A. dehydrogenase Eth. glycol: txt: fomepizole, dialysis, and bicarb for acidosis. 

SJS/TEN 
Dr. Slaven, MD 

SJS <10%; TEN 30%<Hx physical exam key; Workup: CXR, CBC, CMP ESR/CRP SCORTEN Score predictor availableRemove inciting factor Pathogenesis: Sulfa drugs; typically first 8 weeks Consults: Optho, Uro, OBGYN 

Pemphigus Vulgaris & Bullous Pemphigoid

Dr. Martinez,MD 
PV: More common
Pemphigussssss is SSSSuperficial Age Range 40-60yo Autoimmune Dz; Ab to DSG 3&1+Nik sign; Flaccid bullae clinically, mucus membrane involvement <10% TBSA TxT: systemic steroids and rituximab IV; 2nd line: Dapsone, Mycophenolate and IVIG. Non-adhesive dressing application
BP: Pemphigoidddd is NOT Superficial Disease of elderly F>M 1.3-1autoimmune disorder vs. basement membraneTense blisters clinically; pruritic, tense bullaePruritus is more apparent clinicallyTxt: Topical steroids preferred; IVIG can be used as well per derm’s recs. 

Stress & Burnout: 

Dr. Huecker, MD 
Stress= perception of perceived threat. if perceived as negative, research says that this can have negative impacts on healthif perceived as positive=can have beneficial effects on personal potential Stress can impede performance, determined by the individual’s “appraisal” of the situation. Hormesis: phenomena of dose response relationships and over prolonged periods of time can have strengthening effects. Dose of poison a day will make us better. Connect with people daily: compassion does to deplete resourcesOptions to cope: exercise, therapeutic writing, gratitude recognition, thousands available 

Necrotizing Fasciitis: Dr. Lehnig, MD 
Diagnosis: Surgical Exploration CT 90% vs. MRI 86% sensitivityTreatment: “Early Surgical Debridement” Antibiotic Regimen: carbapenam or Zosyn +Vanc, dapto, or linezolid +clindamycin for antitoxin effects

Staphylococcal Scalded Skin Syndrome (SSSS): Dr. Edwards, MD 
Mostly less than 5 yo; if in adults typically immunocompromised Clinical Exam: +Nikolsky’s sign and will spare mucosal surfaces; + fever typically Diagnosis: Clinical Exam; look for other infections that precipitated the infection. Treatment and Disposition: Typically burn unit admission, Antibiotic Regimen: Typically MSSA but if there are risk factors for MRSA use coverage for MRSA. 

EMTALA : Dr. Royalty, MD 

Emergency Medical Treatment and Active Labor Act#1: Medical Screening Exam (Everyone gets this no questions asked)#2: If you ID an emergency condition, you must treat and stabilize this, if hospital can’t manage, must get accepting physician to transfer to higher level of care#3: If OSF needs to transfer patient because of lack of ability to care for patient, facility is required to accept patient despite ability to pay, etc. Transfers: All pertinent records and imaging should accompany patient or be sent electronically ASAP. 

Decisional Capacity: Dr. Yff, MD
Informed Consent: understand treatment, potential risks and benefits, and reasonable alternatives

4 Components: relevant info, appreciation of consequences (insight), reasoning of choice & 
communicating a choice.
Estimated, 48% of patients hospitalized are not capable of making decisions in a hospital setting MacCAT-T: decisional tool to evaluate capacity. 

Treatment of Non-Emergent Hyperglycemia in the ED: Sue McGowan, APRN 
Diagnosis: Glucose >126 fasting, a1c over 6.5%, and Random BG >200 + symptoms Targets for Diabetes: Premeal BG 80-130, post prandial <180, a1c <7Treatment: Diet and exercise-> Metformin if renal function adequate and no GI intolerance (500mg BID)-> a1c 8.5% (ADA recommends 2nd agent-> a1c 9% (see ADA guidelines)-> a1c Long Acting: 24 hour coverage “peak less”; glargine,basaglar, detemir, degludec (each vial has 30 days 300U)NPH/Intermed acting: onset 1-3 and peak 6-12 hours (NPH and 70:30 insulin very cheap) Rapid Acting: 5-10 min onset peaks1-2 hours (the “logs” and apidra and fiaspInitiating Insulin: basal or NPH 10U/day or 0.1-0.2 U/kg/day goal <130 before breakfast (titrate ever 3 days by increasing 2 U to hit morning goal)Glucose tabs=fastest method to correct hypoglycemia OOH (OTC and cheap)Send prescription for glucagon for 2ndary person to admin for rescue. Diabetes Supplies: glucometer, test strips, lancets, and needles for insulin. Diabetic NP: 10am-6:30pm ULH consult via cerner.

Electrical Injuries: Dr. Leavitt, MD 
Low voltage <600V (most household circuits around 120V)High Voltage 600V<Peds: chewing on electrical cords, must admit these, delayed necrosis of S. labial A. Lighting Injuries: Initiate CPR immediately if pulseless; ruptured TMs, A/C worse than D/C injuries

Check out this very brief Amal Mattu article about that pesky ECG after ROSC. Bottom line: Wait at least 8 minutes to obtain the ECG if you obtain ROSC. This isn’t that wild of an idea, and often it takes a good 10 minutes to set up the machine and stop doing your other resus tasks. But don’t be compelled to get the ECG as fast as possible, as the delay of 8 minutes can reduce false + STEMI. Check out this long article he cites.