Category Archives: Lectures

Respiratory Distress 102: The Land Between NC and ETT

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ABCs. Airway and breathing are two-thirds of that three letter dogma we etch into our brain. It should make sense then that as EM physicians we pride ourselves on managing them. We’ve probably all patted ourselves or our colleagues on the back for that difficult intubation. It is sometimes the tendencies of younger physicians to jump for the video scope and intubate that patient who seems to be struggling. While I think we do a wonderful job mastering this, the point of this post is to promote mastery in avoiding having to use this skill.

Simple Oxygen Delivery

“Simple” oxygen refers to non-invasive delivery of an increase in FiO2. This can mean anything from a nasal canula, to tents, masks, trach masks, and non-rebreathers. This should be your first choice for hypoxemia but likely won’t help much in someone who needs a little extra pressure support (ex. COPD exacerbation, CHF exacerbation, flash pulmonary edema). This means that while the oxygen being delivered is increased, the flow and pressure won’t be.

There are a few points to make note of when using simple oxygen. Generally speaking, “room air” is around 21% oxygen. With each liter of oxygen via NC, you add around 4%. I note this because some of our adjuncts provide 100% FiO2, which would require 20 L via NC to equate, which is impossible. If you move up the oxygen ladder to simple masks, they follow the same rules with one exception: you must maintain at least 5 L of flow to prevent rebreathing. Similarly, a non-rebreathing mask must maintain usually around 8 L, or at least enough to keep the bag inflated. There are other modes available and variable, but we will move on.

High Flow Nasal Cannula

High flow nasal cannula, or HFNC, is like simple oxygen’s big brother. Its primary use is again hypoxemic respiratory failure, but with the added benefit of flow. Contrary to simple oxygen, you set both an FiO2 and flow. The benefit of this is that for every 10 L/min of flow, you get approximately 1 mmHg of PEEP. This may not seem much, but considering that CPAP/BiPAP oftentimes start at 5 mmHg of PEEP, and that HFNC can max at 60 L, this can actually add up. Generally speaking, in adults we start at 0.5 L/kg/min to a max of 60 L, and start at 100% FiO2 and wean as able. In children, FiO2 starts at 40% and flow is based on weight.

A benefit of HFNC, apart from the oxygen, is that it affords a way of delivering pressure to someone who might either benefit from a small amount of support, or who could otherwise tolerate a more invasive way of delivering it (CPAP and BiPAP). It isn’t uncommon that patients who are in respiratory distress also do not want a tight mask over their face. While there are ways of easing this anxiety with verbal coaching or anxiolytics, it isn’t a guarantee that they’ll be able to tolerate the mask and this may be a more comfortable option.

CPAP/BIPAP

The final section in this short overview is CPAP/BPAP. Where HFNC provides a small amount of PEEP, CPAP and BPAP exist to provide pressure to aid in respiration. This helps to recruit alveoli, increase lung compliance, and increase oxygenation. It would explain why COPD/CHF exacerbations do well with it. It simply takes more pressure to overcome their disease process, but oftentimes with a little extra help the patient can do this without an ET tube. Studies have shown that CPAP/BPAP decrease both intubation and mortality in cardiogenic pulmonary edema and COPD exacerbation.

The best way of explaining the difference between the two is to look at the names. CPAP stands for continuous positive airway pressure. It would make sense then that you would set a pressure (the PEEP) and that would be the setting. Building on this, it would mean that this pressure is being delivered throughout the respiratory cycle, with no difference between inspiratory and expiratory. So, CPAP is beneficial for hypoxia in CHF exacerbation because this pressure works to stent open alveoli that pulmonary edema may have impacted, to improve oxygenation, but may not do much to help with work of breathing since there is no additional inspiratory pressure.

This is where BiPAP comes in. BiPAP stands for bilevel positive airway pressure. Bilevel insinuates two levels, which is exactly the benefit of BiPAP. Those two levels are IPAP (inspiratory pressure support) and EPAP (expiratory pressure support), which is PEEP. By convention these numbers are given as IPAP over EPAP, i.e. 10 over 5. The benefit of BiPAP is that it decreases work of breathing to increase ventilation in addition to oxygenation. It aids with inspiration and expiration, providing support throughout the respiratory cycle to aid in compensation while the underlying disease process is treated.

Conclusion

The emergency room is a place equipped to deal with any situation, filled with people equipped to deal with any situation. When it comes to respiratory distress, this should be no different. Intubation in the setting of respiratory distress should be last resort. Many of these patients have multiple medical comorbidities and may never come off of a ventilator. For as much as we strive for excellence in intubating, we should strive even more so to be experts, masters, in avoiding intubation.

March 9 Conference Notes

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Cranial nerve pathology, Dr. Nelson

  • Bell’s Palsy
    • Most common cause of unilateral facial paralysis
    • Presentation
      • Acute unilateral facial paralysis with involvement of the forehead
    • Most common cause is idiopathic but there is association with HSV
    • Must exclude
      • Ear infection
      • Stroke
        • Forehead spared in central causes except if you have ipsilateral pontine pathology you can have forehead involvement and peripheral nerve presentation however will usually have CN VI involvement (check EOM)
      • Ramsay-Hunt syndrome from Herpes Zoster
      • Lyme disease (MCC bilateral Bell’s Palsy)
    • Tx
      • Steroids
        • Reduces relative risk of incomplete recovery at 6-12 mo
        • Prednisone 60-80 mg qd x 1 week
        • Ideal to start within 72 hours of Sx
      • Antivirals controversial
      • Supportive care if they cannot completely close their eye too keep eye moist and avoid corneal ulcers
    • Prognosis
      • 15% can have permanent involvement
      • Follow up with ENT in 1 week
  • Trigeminal neuralgia
    • Paroxysms of severe unilateral pain lasting only seconds usually in the V2, V3 dermatome
    • 80-90% caused by compression from aberrant loop of artery/vein
      • Can also be 2/2 MS, malignancy, AVM
    • Tx
      • IV phenytoin/Fosphenytoin
        • Abortive Tx lasts 4 hr – 72 hr
      • Carbamazepine
        • First line outpatient Tx
        • High risk of side effects
      • Posterior fossa microvascular decompression surgery successful in 70% of patients

Temporal arteritis, Dr. Boland

  • Temporal arteritis
    • Giant cell arteritis 
      • Granulomatous, medium to large vessel vasculitis
      • Females 3x more likely
      • Rule of 50s
        • 50 years of age, ESR > 50, treated with 50 mg prednisone daily
      • Cain cause painless ischemic optic neuropathy and blindness
    • Usually presents as a headache 85% of the time, can have jaw claudication, polymyalgia rheumatica seen in 50%, transient vision loss
    • Dx is confirmed by biopsy but if suspected start high dose corticosteroids prior to biopsy
      • If vision at any point during Hx loss admit, start IV steroids (methylpred), and have optho see
      • If no vision loss start high dose steroids (PO prednisone) and have optho see as soon as possible outpatient and biopsy between 1-2 weeks
    • ESR doesn’t have to be elevated (about 15% of time its not)

Pediatric endocrinology, Dr. Kopp

  • DKA
    • Considerations regarding fluid administration and cerebral edema in peds
      • PECARN DKA Fluid Trial
        • Compared fast and slow infusions of normal and half normal saline (4 arms)
        • Afterwards performed bedside evaluation of neurologic status (this is a clinical Dx not radiologic)
          • Bimodal distribution for presentation of cerebral edema
            • 4 hours and 14 hours
        • 3.5% had GCS decline <14, 0.9% had clinically apparent brain injuries
        • *Conclusion: neither the rate of administration nor the sodium chloride content of the IVF had contribution to the neurologic outcomes
      • Fluid replacement calculations
        • Fast replacement
          • Assume 10% weight-based fluid deficit, give the 20 cc/kg bolus isotonic IVF and replace the remaining with 2x maintenance over 24h
          • Dr. Kopp’s opinion: 0.45 NaCl given as a fast replacement strategy is preferred method as there was a higher incidence of hyperchloremic metabolic acidosis in the normal saline group (not statistically significant but study was perhaps underpowered)
        • Slow replacement
          • Assume 5% deficit give the 10 cc/kg bolus isotonic IVF and replace the remaining with 1.5 x maintenance over 48h
      • Dextrose containing fluids to be added when glucose is 200-300 (i.e. ~250) or when there is > 100 drop in glucose between 1hr POC glucose checks
  • Hypoglycemia
    • Rule of 50
      • Google and review it, V important
    • Consider inborn errors of metabolism in the differential of children who are hypoglycemic 
      • Children with inborn errors of metabolism who present with acute illness, nausea, vomiting need prompt evaluation and immediate initiation of IV dextrose containing fluids and give them oral glucose immediately while IV access is being established. They can decompensate rapidly if kept in a catabolic state
  • Adrenal insufficiency + acute illness
    • Solucortef IV, IM
      • 0-3 years: 25 mg
      • 3-12 years: 50 mg
      • >12 years: 100 mg

March 2 Conference Notes

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  • Venous sinus thrombosis- Dr. Hill-Norby
    • 89% present with headache but can also present with altered mental status, focal neuro deficits, seizures, nuchal rigidity
    • Cavernous sinus
      • Ocular signs dominate d/t cranial enerve dysfunction
      • Cortical vein occlusions can present with motor and sensory dysfunction
    • Physical exam
      • Papilledema on fundoscopic or ultrasound
        • Ultrasound measurement is measured 3 mm posterior to the retina
    • Dx
      • CT/CTV
      • MRI/MRV
      • LP with opening pressure can be suggestive of Dx
    • Tx
      • Recanalize occlusion
      • Prevent propagation
      • Treat underlying cause
      • Standard care for elevated icp (HOB elevation to 30 degrees, etc.)
      • Seizure prophylaxis
  • PRES- Dr. McMurray
    • Sx usually will have posterior cortical deficits
    • 25% of people with PRES will not have HTN on presentation
    • Risk factors include renal disease, autoimmune conditions and immunosuppressive Tx
    • Pathogenesis
      • Autoregulatory failure, endothelial dysfunction, cortical dysfunction 
    • Tx
      • Target maximal reduction in MAP by 20-25% in the first hour
      • Reduce to 160/100 over next 2-6 hours
      • Then to normal over the next 24-48 hours
      • Medications
        • Labetalol, cardene, hydralazine, nitro
        • Seizure medications for seizures, if suspect eclampsia give Mg
  • Emergency management of individuals with brain tumors, a focus on steroids- Dr. Mistry
    • Focus of ER management
      • Control ICP (nonsurgically)
        • locally high ICP can progress to a generalized ICP problem
          • generalized will eventually involve the brainstem, also concerning is focal ICP that can compress the brain stem
        • signs of brain stem compression
          • imaging showing posterior fossa or supratentorial lesion/hydro
          • decreased mental status
          • bradycardia
          • hypertension (especially the diastolic pressure)
        • control
          • Delay MRI until after addressing ICP
          • Position
            • HOB > 30 degrees
              • Works by increasing venous return
            • Neck in anatomically free position
              • Want the jugular veins to actually be able to return blood
          • Vital interventions
            • Intubation
            • Hyperventilate (ETCO2 ~ 25 mmHg)
          • Drugs
            • Mannitol +/- furosemide
              • Will break down the blood brain barrier and will only work once
            • Hypertonic NaCl (>3%)
              • Preferred, can be given more than once and help control ICP
      • Control of tumor-related hemorrhage (ICP)
      • Control of neuroendocrine related shock
      • Control of seizures
        • Especially vulnerable are patients with temporal lobe lesions
    • Dexamethasone- “ a big problem”
      • Evidence for dex was initially based on case series work
      • However, there is NO evidence for dexamethasone, there is not even 1 study on dex that shows benefit
      • Dexamethasone is a very potent and long acting anti-inflammatory
        • Can be bad for people needing a stem-cell transplant 
        • Kills lymphocytes by apoptosis
          • *Pre-operative dexamethasone decreases diagnostic yield from surgical samples of primary CNS lymphoma*
      • Study in Brain 2016 showed that corticosteroids decreased survival in glioblastoma 
      • Pre-op dexamethasone in 2021 Hopkins study showed greatly decreased survival on Kaplan-Meyer survival curve
      • Dexamethasone thwarts immunotherapy
        • Combined corticosteroids plus immunotherapy has a higher hazard ratio than immunotherapy alone
      • Dexamethasone is standard of care and now we are in a battle with reversing this narrative
        • **dexamethasone does not decrease ICP emergently, it can take a week to see the ICP effects, use mannitol, Lasix, or hypertonic saline**
  • **there is one type of tumor to give steroids**
    • Pituitary apoplexy- a special hemorrhage
      • ER treatment is counter adrenal crisis (hydrocortisone 100 or 200 mg) and give fluids
        • Need to draw all endocrine labs before giving the hydrocortisone
      • Need a CTA immediately because there is an aneurysm that will mimic pituitary apoplexy, r/o aneurysm first before they can take to the OR
      • Consult
        • NES, ENT, optho, and endocrinology

Conference 07/14/2021

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RSI Pharmacology – Jade Daugherty, PharmD

Sedatives

Etomidate:
– Does not inhibit sympathetic tone or myocardial function. Minimal BP and HR changes|
– RSI: 0.3 mg/kg; Procedural sedation 0.1 – 0.2 mg/kg
– Onset 30 – 60 seconds; Peak 1 minute; Duration 3 – 5 minutes
– Can see myoclonus, dose dependent, can be blunted w/ opioids and benzos. Resolves upon paralysis. May cause difficulty w/ procedural sedation.
– Other adverse effects: N/V, lowers sz threshold, mild decrease in IOP and ICP, adrenal suppression (single dose can cause effects for 24 – 72 hrs)
– Consider avoiding Etomidate in Sepsis patients (see CORTICUS trial)

Ketamine:
– Analgesic and amnestic properties
– Nystagmus with amnestic doses
– RSI: 1 – 2 mg/kg
– Exerts sympathomimetic effects: increased HR, BP, CO by lessens reuptake of catecholamines. May not see this in catecholamine depleted patients
– Also causes bronchodilation and anticonvulsant effects

Propofol:
– Short acting sedative hypnotic that enhances GABA activity
– No analgesia; amnestic effects
– Onset 30 sec; Duration 3-10 min
– RSI 1 mg/kg
– Safer in pregnancy
– Adverse effects: hypotension
– Decreased cerebral O2, decrease in IOP and ICP, bronchodilation and anticonvulsant effects

Benzos:
– No analgesia. It does possess anxiolysis, anterograde amnesia, anti-convulsant properties
– Onset 2 – 3 min; Duration 45 – 60 min
– Midazolam preferred: RSI 0.1 – 0.3 mg/kg

Paralytics

Depolarizing Blockers – Succinylcholine:
– Be aware of hyperkalemia; therapeutic dose can raise serum potassium 0.5 – 1 mEq/L
– Consider avoiding in burns and crush injuries (delayed rise in serum K), as well as ESRD on HD, sepsis
– Small increase in ICP
** Special considerations: may require higher doses in Myasthenia gravis
** Pseudocholinesterase deficiency -> results in prolonged paralysis (several hours). NDMB (Roc/Vec) are safe for use

Rocuronium – non-depolarizing neuromuscular blocker:
– Dose 0.6 – 1.2 mg/kg (~1.0 mg/kg)
– Onset 60 – 90 seconds; Duration 30 – 60 minutes

Vecuronium – non-depolarizing neuromuscular blocker:
Needs to be reconstituted
– Dose 0.08 – 0.1 mg/kg (~ 0.1 mg/kg)
– Onset 2 – 3 minutes; Duration 25 – 45 minutes

If you use the longer acting paralytics, sedate appropriately

Guide to Pediatric ED – Dr. Penrod
– EPIC Order Sets: “Peds ED Treatment ____”
Examples: Neonatal Fever (0 – 7 d, 7 – 28 d, > 28 d), Sepsis, Status Epilepticus, Asthma, NAT, Trauma, DKA, more

– Discharge teachings: Get dot phrases from other attendings (i.e. Sandy Herr)

– Admission: bed request > .admitresidentnotification > TigerText (login: phys___@Norton) > ask admit resident when they call if it is ok to put in “ready for dispo” order

– Tylenol 15 mg/kg q6 hrs; Ibuprofen 10 mg/kg q 6 hrs – can alternate q3 hrs
– Versed: PO 1 mg/kg/dose, IN 0.2-0.3 mg/kg/dose, IV 0.1 mg/kg/dose
– CTX: Meningitis 50mg/kg/dose q12hrs, non-meningitis 75 mg/kg/dose daily
– Amox: 50 mg/kg/day, daily for GAS pharyngitis; 90 mg/kg/day divided BID for PNA and AOM

– IVF bolus: 22 cc/kg over 1 hr
– mIVF “4-2-1”: 4 cc/kg/hr for first 10 kg, 2 cc/kg/hr for second 10 kg, 1 cc/kg/hr for each additional kg

Abdominal Ultrasound – Dr. Baker
RUQ US: just below the R costal margin, or X minus 7 mm (7 mm to right of xiphoid process)
Maneuvers to assist: deep breath, left lateral decub
Portal triad (portal vein, hepatic artery, CBD < 7mm normal & > 10 mm + 1mm/decade life abn) makes an exclamation point w/ GB

Cholecystitis: gallstones, anterior* wall > 3mm, sonographic Murphy’s, pericholecystic fluid

Choledocolithiasis: “double barrel” sign

*important to measure anterior wall as posterior acoustic enhancement makes the posterior wall appear thicker due to fluid filled structure enhancing conduction of sound waves

SANE Lecture – Amanda Corzine, MSN, SANE-A
Assault exams/kits done within 96 hours/4 days, sometimes up to 5 days
All male/females 12 yrs and older

Center for Women and Familes (CWF) respond to SA and DV victims as an advocate

Patient may choose to report or not to police. Kit will be destroyed in 1 year if they choose to not report.

Dry swabs for wet surfaces, wet swabs for dry surfaces. Don’t package wet evidence, allow it to fully dry.

Place swab in envelope cotton part down. Do not lick envelope.

EMS Radio Calls Part 2: Dr. Orthober
– Discontinuing IV after Dextrose given: is patient now AAOx4, decisional, clear reason for hypoglycemia, have family members

Conference 07/07/2021

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Small Group Lecture: Bradycardia – Dr. Fisher
Case 1 – Symptomatic bradycardia. Initial management ABCs. GCS 8, however GCS score only validated for trauma patients. Would not intubate until after we attempt to resuscitate first: O2, monitor, x2 LBIV, check POC Gluc, Trop, Electrolytes, EKG. Start w/ 0.5 – 1.0 mg Atropine q3 min to 3 mg max. Consider Epi as well. Can transcutaneous pace. See transvenous pacing link: https://room9er.com/2020/08/13/transvenous-pacing/

Case 2 – Bradycardia w/ interior STEMI. Remember “MONA”. Recent studies have show increased in-hospital mortality w/ morphine, consider fentanyl. AVOID trial (no benefit in O2 w/ SaO2 > 94%). Give ASA. For Nitro, longstanding teaching to avoid NTG in inferior MI as it is preload dependent. However, there may be benefit to giving carefully.

Case 3 – Bradycardia in BB vs CCB OD. CCB poisoning usually causes hyperglycemia, whereas BB poisoning may cause hypoglycemia. Activated charcoal if ingestion w/i 1-2 hrs. Whole bowel irrigation should be considered for large ingestion of sustained-release medications, as these intoxications can outstrip all other therapeutic modalities. Early intubation. For patients with hypotension who require intubation, try to quickly achieve hemodynamic stability prior to intubation if possible. Treat w/ Glucagon, IV Calcium, Hyperinsulinemia euglycemia. Atropine rarely works.

Tick-born Diseases – Dr. Buchanan
Lyme Disease – Can present w/ erythema migrans, later followed w/ arthralgias, Bells’ Palsy or other neurologic sx, or heart blocks. Antibody panels usually negative during rash phase.

Rocky Mtn Spotted Fever – vasculitis w/ maculopapular rash, starts distally. Labs w/ thrombocytopenia and mild transaminitis.

Ehrlichiosis – similar labs to RMSF, but leukopenia. Lone star tick
Anaplasmosis – similar presentation to Ehrlichiosis, but carried by Deer tick/Blacklegged tick

Can treat all w/ doxy. Lyme disease CTX for neuro sx. Lyme dz alternative tx w/ Amoxil + cephalosporin.

Babesiosis – intracellular parasite. Fever, hemolytic anemia, DIC. Cells classically show “Maltese Cross”

Tularemia – wound w/ proximal LAD. Can also present w/ conjunctivitis, pharyngitis, PNA, or typhoidal sx.

Tick Borne PPx: Ixodes tick -> greater than 36 hrs or engorged tick -> w/i 72 hrs since removal -> they can take doxy -> Lyme dz is endemic

Clinical Pathway: Ectopic – Dr. Cook and Dr. French
~ 1:50 pregnancies in North America. 6% – 16% of patients that present to ED w/ 1st trimester bleeding or pelvic pain.

The discriminatory value is that level of hCG above which all normal intrauterine pregnancies should be seen: 1,500 for TVUS; 6,500 for TAUS.

IUP is gestational sac PLUS yolk sac and/or fetal pole. Gestational sac alone is not IUP

Pathway to be posted here: https://room9er.com/clinical-pathways/

Room 9: Follow up – Dr. Kuzel
Undifferentiated critically ill patient in status epilepticus, found down, wide complex irregularly irregular tachycardia, h/o a flutter on Eliquis. POC Gluc 55. Amp D50 given. Lactic 14, BCx and UCx obtained
1/2 BCx+
LP w/ elevated PMNs
Utilize Chem8+ in R9, D50 prn, AEDs
Status Epilepticus: IM/IO Versed > IV Versed/Ativan > IV Keppra & Fosphenytoin > Intubate (consider Propofol for induction/sedation)

https://room9er.com/wp-content/uploads/2021/06/Status-Epilepticus-Clinical-pathway-1.pdf

Intro to EMS: Part 1 – Dr. Orthober
Off line medical control – established protocols
On line medical control – calls into the ED for medical direction from EMS

Trauma radio: highest high, lowest low (i.e. highest HR, lowest BP), GCS, injuries
Stroke patient: Last known normal, anticoagulation, collateral info available

Lecture Notes from April 8th

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Notes from our conference on April 8th. If you have any corrections or comments please feel free to add!

Oncologic Emergencies

Neutropenic Fever

Definition: Fever (>101 F or >100.4 F for an hour) with ANC<500, typically avoid rectal temperatures (although no actual evidence of induced bacteremia)

Cause: Often caused by chemotherapy, WBC declines to nadir and then comes back up

  • Also myelodysplastic syndromes, post viral, medication side effect

Clinical Presentation: Often no typical signs of infection (due to lack of response)

Management: Cultures (including from any central access, sometimes fungal), +/-CSF studies, viral testing, typical infectious work-up

  • Reverse isolation, broad spectrum abx, otherwise typical therapy
  • Low threshold for hydrocortisone
  • Neutropenic enterocolitis: Typically presents with RLQ pain with neutropenia
  • Some clinical decision tools, varied validation, look up if interested

Hypercalcemia of Malignancy

General: up to 30%, most common with lung and breast cancers

Pathophysiology: Decreased GI motility, decreased muscular contractions

Mechanisms: PTH-related protein production, Vitamin D analog production, increased osteoclast activity

Treatment: Fluids, bisphosphonates, calcitonin, glucocorticoids, dialysis (for severe cases)

Tumor Lysis Syndrome

General: Typically after initiation of chemotherapy or during times of high cell turnover, found with hematologic malignancies

Clinical Presentation: Electrolyte abnormalities (hypocalcemia, hyperphosphatemia, hyperkalemia), elevated uric acid, acute renal injury, cardiac dysrhythmias, seizures

Treatment: Fluids, rasburicase, correct electrolyte abnormalities and treat as appropriate, dialysis for severe cases

-Correct calcium only if symptomatic to avoid crystallization with high phosphate load

Urinary Diversions

Types:

  • Ileal conduit: incontinent, portion of the bowel with ureters attached to one side and the other attached to skin, drains into urostomy bag
  • Indiana pouch: Similar to above with ileocecal valve making up the collecting pouch, ureters attached to onse side and the distal cecum attached to the skin, ileocecal valve functions as sphincter, urine drained by self-cath
  • Neobladder: Segment of bowel resected and made into a bladder-like sac, one side attached to ureters and the other attached to urethra, varying degrees of incontinence depending on preservation of nerves and sphincter tone, possible to urinate volitionally 

General: Since all of these diversions are made from bowel they are colonized with bacteria and will always have +UA, best practice is cleaning of skin site and catheter specimen sent for culture, diagnosis can also be made by stranding on CT

Clinical Presentation: More often nausea, vomiting, flank pain (different innervation than typical urinary system so will more closely approximate visceral/enteric nociceptor patterns)

Hypersensitivity Reactions

Types:

  • Type 1: Immediate, mediated by IgE (causes histamine release from mast cells)
    • Examples: classic allergic response, anaphylaxis
  • Type 2: Antibody mediated (autoimmune disease mediated by autoantibody against a self target)
    • Examples: Graves disease, Myasthenia, Autoimmune hemolytic anemia, Goodpasture’s 
  • Type 3: Immune complex mediated (autoimmune disease due to deposition of antibody/antigen complexes)
    • Examples: glomerulonephritis, SLE, RA, HSP
  • Type 4: T cell mediated
    • Examples: Tuberculin skin test, contact dermatitis, DM1, RA, IBD, MS

General: Should always be on the differential, often mimic infectious or traumatic pathologies. If you don’t think of them you won’t diagnose them

Lecture Notes from April 1st

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Here are some notes from our conference on April 1st for some spaced repetition. Topics included are Orthopedic emergencies, fracture pattern review, disorders of coagulation, and targeted temperature management after cardiac arrest. Please comment with any thoughts or corrections!

Orthopedics Review

Arthrotomy: Takes up to 155 cc for sensitive test, can sometimes substitute CT (institution dependent)

Injury Patterns by Anatomic Location:

Clavicle fracture: Medial can be complicated by vascular injury, up to 15% are complicated by nonunion, most common location is mid shaft

Shoulder dislocation: Anterior most common, posterior associated with seizure or electrical injury

Humerus: Posterior fat pad or anterior sail sign indicative of lipohemarthrosis, concern for occult injury (supracondylar in pediatrics, radial head in adults)

Forearm: Monteggia and Galleazzi (MUGR, Monteggia Ulnar fracture with radial head dislocation, Galleazzi Radius fracture with distal radioulnar dislocation)

Wrist: Colle’s (dinner fork) and Smith fracture (opposite), Lunate vs. perilunate dislocation (based on alignment of radius, lunate, and capitate) (https://radiopaedia.org/articles/lunate-dislocation?lang=us)

Hand: Boxer’s fracture (5th metacarpal)

Pelvis: mechanism of injury classification includes anterior compression, lateral compression, vertical shear injuries, binder to reduce pelvic volume for “open book” injuries typically associated with AC mechanism, posterior hip dislocation (early management reduces risk of avascular necrosis of femoral head)

Knee: posterior knee dislocation (high incidence of vascular injury, can often spontaneously reduce), tibial plateau fracture (often occult, can only see in lipohemarthrosis in some cases, low threshold for CT), tendon rupture (based on position of patella)

Ankle: Maisonneuve (due to syndesmosis conducting force to proximal fibula, sometimes associated with mortise widening), malleolar fractures, pilon fracture (through distal articular surface of tibia, increased likelihood of poor functional outcome)

Foot: LisFranc injury (dislocation at the Tarsometatarsal joint), Jones fracture (at the base of the 5th metatarsal, high rate of nonunion) (https://radiopaedia.org/articles/avulsion-fracture-of-the-5th-metatarsal-styloid?lang=us)

Infectious complications:

Septic arthritis- typically presents with pain with passive and active ROM at the joint, diagnosis is my arthrocentesis (WBC >50,000 for bacterial), polyarticular concerning for disseminated gonococcus

Felon/Paronychia- distal finger infections, involve the pulp space (felon) and the cuticle (paronychia)

Flexor tenosynovitis- Kanavel’s signs (pain with passive extension, flexor tenderness, circumferential swelling, held in flexion)

Compartment syndrome- Often clinical diagnosis diagnosis, more sensitive with compartment pressures (delta pressure <30, diastolic – compartment pressure or pressure >30), often associated with opioid use

Microangiopathic Hemolytic Anemias, vWF disease, and DIC

Thrombotic thrombocytopenic Purpura: 

General- Primary disorder, hereditary deficiency of or autoimmune response to ADAMSTS13 resulting in decreased cleavage of vWF polymers

-leads to consumptive coagulopathy with platelet destruction

Clinical Presentation- fever, AMS, thrombocytopenia, renal injury

Treatment- Plasmapheresis and steroids

Disseminated Intravascular Coagulation:

General- Secondary disorder, due to systemic inflammation leading to consumptive coagulopathy

Clinical presentation- bleeding, elevated D dimer, abnormal coagulation studies, low fibrinogen/platelets

Treatment- Aimed at underlying cause, can also transfuse as needed

Immune Thrombocytopenic Purpura:

General- Primary disorder, autoantibodies against platelets leading to platelet destruction and thrombocytopenia

-can be caused by infections (viral or bacterial,) autoimmune disease, or various medications

Clinical Presentation- asymptomatic thrombocytopenia

Treatment- glucocorticoids, IVIG if active bleeding

VonWillebrand Factor Disease

General- deficiency in vWF (either quantitative or qualitative) resulting in decreased activity/coagulation

Type 1- Decreased quantity

Type 2- Decreased activity

Type 3- Almost no vWF, most severe

Clinical Presentation- epistasis, mucosal bleeding, heavy menstrual cycles, increased bleeding during surgery

Treatment- When uncontrolled bleeding, desmopressin (for type I, causes vWF release), cryoprecipitate (for life threatening bleeding), recombinant vWF

Targeted Temperature Management

Indications: non traumatic cardiac arrest, earlier the better

Contraindications: DNR, already hypothermic, intoxicated/other cause for coma

General: Reduction in body temperature to 33-36 C for 24 hrs after arrest

-Main goal is to prevent hyperthermia which is associated with increased mortality and poor outcomes

Patients can take weeks to recover neurologic function after cardiac arrest; be careful about prognosticating too early.

Conference Lectures 1/2020

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Obstetrics and Gynecology Emergencies – Dr. Marques

Normal Vaginal Delivery Key Steps

  • Support the perineum to prevent tearing with delivery of the anterior shoulder
  • Upon delivery of the anterior shoulder, provide upward pressure to deliver the newborn
  • Pull only gentle traction when delivering the placenta, to avoid uterine inversion

Post-Partum Hemorrhage

  • Palpate the uterus to feel for inversion or retained products
  • Provide tone by providing suprapubic pressure with an external hand and uterine pressure with an intravaginal hand
  • Oxytocin can be given IM or IV to treat uterine atony

Shoulder Dystocia

  • Leg hyperflexion and abduction at the hips along with suprapubic pressure (McRobert’s Maneuver) can be done if the anterior shoulder cannot be delivered

Breech Delivery

  • This happens in 3-4% of all deliveries
  • Do not pull traction at any time, as this can lead to entrapment in a cervix that is not dilated
  • A pressure against the popliteal fossa can help flex the leg and deliver each leg

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Oral Boards: Sepsis Due to Spontaneous Bacterial Peritonitis – Hugh, Shoff, MD

  • The CMS Core Measures (SEP-1) provide quality measures for providers to follow in sepsis
  • Severe Sepsis is defined as Lactate >2 or organ dysfunction
  • Septic Shock is defined as severe sepsis with hypoperfusion despite fluid resuscitation or lactate>4
  • Within 3 hours of presentation, obtain a lactate, blood cultures prior to broad spectrum antibiotics, and 30cc/kg fluid resuscitation
  • Within 6 hours, lactate must be repeated if >2

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CCU Follow-Up – Phil Giddings, MD

Myocardial bridging- coronary arteries travel deep into myocardium as opposed to laying upon the muscle

The vessels are occluded but when there is demand ischemia it can look like a STEMI

Myocardial bridging is fairly common in the general population, but usually isn’t symptomatic or pathologic.

If it is symptomatic- you could do Ca2+ channel blockers, beta blockers, and even myotomy or CABG if you’re feeling wild.

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Urology Review- Isaac Shaw, MD

Priapism-

  • Normal tumescence- veins constrict so the corpus cavernosum engorges because blood flows in
  • Ischemic= low flow, less venous outflow, rigid, painful
  • Nonsichemic= high flow, more arterial inflow, half rigid
  • (Distinguish w/ a blood gas)
  • Treatment
  • anesthetize by blocking the dorsal nerve of the penis (2 & 10 o’clock) w/o epi
  • then aspirate at 3 or 9 o’clock from the corpus cavernosum
  • Use a phenylephrine stick from Room 9, 100mcg-500mcg Q1-5min

Fournier’s Gangrene

  • polymicrobial
  • assoc w/ DM
  • 22-40% mortality
  • empiric + clindamycin (clinda first because it’s addressing the toxins)

consult surgery before imaging

Paraphimosis

  • foreskin trapped proximal to glans so the tip can get ischemic
  • Treatment: manually reduce, dextrose, lube, may have to incise the dorsal foreskin

Phimosis

  • foreskin can’t be retracted over the glans 2/2 inflammation
  • Treatment in ED: topical steroids with urology follow-up

Urinary Retention

  • often have hesitancy, nocturia, frequency, urgency
  • >200cc PVR
  • d/c w/ Foley à Uro will keep that in for 2 weeks prior to void trial

Renal Stones

  • remember that 10-15% don’t have hematuria
  • CT w/o contrast is still the standard for diagnosis, but some emergent literature exists that US alone is sufficient in young, healthy patients
  • if <5mm, 90% pass; but if >8mm, 5% pass
  • admit for intractable vomiting, pain, urinary extravasation, infection & obstruction

Balanitis

  • Candida on the glans
  • Associated with DM or uncircumcised

Torsion

  • twisted around the spermatic cord
  • if actively torsed, you will NOT have a cremasteric reflex
  • ultrasound 88-100% sensitive because they can torse and untorse
  • consult before imaging

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Breaking Bad News– Frank Woggon, PhD

  • insensitive truth telling can have similar effects as lying
  • goals include gathering info, provide info, support patient, strategy for care
  • keep it simple, no jargon, talk slow, repeat PRN, use neutral language, be honest, allow emotions, consider cultural differences
  • “compassion is the willingness to let yourself be affected by the life and suffering of others”

SPIKES

  • Setting- privacy, sit down, eye contact, turn off pager
  • Perception- don’t combat denial at first, interpret first
  • Invitation- ask how much they want to know first
  • Knowledge- “what I’m about to say is not good,” be direct but not blunt, use their language
  • Empathize- ok to validate the emotions, silence is ok
  • Strategy & Summary- what comes next

GRIEV_ING Protocol

  • Gather the family
  • Resources- call for support
  • Identify yourself & staff, those in the room
  • Educate the family about what happened
  • Verify that the patient died by using that word
  • SPACE- silence is ok, let them have their gut reaction
  • Inquire whether they have questions
  • Nuts & bolts- organ donation, funeral arrangements, personal belongings, etc.
  • Give contact info for f/u questions

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STEMI Mimicks – Frank Shary, MD

OMI= occlusive MI

  • V2 & V3 2mm elev = STEMI; Everywhere else 1mm
  • Wellens: biphasic T wave, they recently had an OMI, symptoms may have gotten somewhat better by the time of the EKG, they need a cath
    • Deep T Wellens- deep and wide
  • LV aneurysm- deep Q wave w/ biphasic T wave, static
  • Sgarbossa criteria- OMI in the setting of LBBB and/or paced rhythm
    • look at vector of QRS and vector of ST segment
    • concordant elevation or depression greater than 1mm
    • discordant greater than 5mm
  • Hyperacute T waves- early into the ischemia, before ST elevation, cath soon because you have potential to save more myocardium, large area under the curve especially in proportion to the QRS complex
    • L circumflex is the vessel most likely to be silent
  • aVR- if it’s the only lead elevated and everywhere else is diffusely depressed, you might have diffuse subendocardial ischemia
    • could be bad triple vessel disease

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Managing the Bleeding Patient Without Blood Products – Chase, PharmD

There are 6 Jehovah’s Witness churches in Louisville

  • Plasma Derivatives are technically not Blood products… so whether or not a patient wants that is up to the individual
  • albumin, clotting factors, PCC, Immunoglobulins (including Rhogam and vaccines)
  • equine Ig and Crofab could also be iffy
  • ECMO, cardiopulmonary bypass, dialysis are allowed generally

Source Control

  • bone wax/putty- use in NES and long bone fx, high infection rate though
  • oxidized regenerated cellulose- ex. Surgicell, promotes rebuilding of proteins to heal & achieve hemostasis, like a mesh
  • gelatin matrix- ex. Floseal, more like a gel
  • there is a powder too but it’s $$$ and causes microemboli so don’t use
  • thombin- apply w/ 4×4’s
  • TXA- derivative of lysine THIS IS NOT A PLASMA DERIVATIVE SO THEY SHOULD BE OK WITH IT, 1g over 10min à another 1g over 8-10 hours
  • have a lower threshold to give TXA since there is a decrease in mortality, even if you wouldn’t have given TXA to a non-Jehovah’s witness

Usable Therapies:

  • Cell Saver
    • blood is collected, washed, centrifuged, returned to patient
    • example indications: AAA, TKA, THA, cardiac surgeries
  • Vitamin K
  • PCC- most efficacious
    • 4 factor is better than 3 factor, but if you try to give 3 factor and then just add Factor VII a la carte, more thromboembolic events
  • FFP- prep time is longer, tonzo volume
  • Adnexanet Alpha- new antidote for rivaroxaban and apixaban, we don’t have that
  • Novo7- directly activates Factor VIII, black box warning for thromboembolic events, no difference in mortality but there was a reduction in transfusions
  • Dabigatran reversal- idarucizumab, dialysis, charcoal
  • Antiplatelet reversal- ASA and Plavix are irreversible, but ticagrelor is reversible
    • DDAVP- indicated for DI, von Willebrand disease, uremic bleeding (renal failure), nocturnal enuresis
    • 0.4mcg/kg over 10min

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Pediatric Environmental Emergencies- Dr. Said

Drowning

  • fresh or salt water doesn’t matter, you’re ruining your surfactant
  • if you are anoxic you get brain damage in 4-6min, irreversible
  • cold temp is only helpful if it happens really quickly
  • outcomes depend on initial resuscitation, degree of pulmonary damage, time submerged
  • poor prognosis- coma, apnea, submersion >9min
  • can try vapotherm for positive pressure, albuterol can treat bronchospasm
  • steroids don’t help
  • goal warming 32C
  • if asymptomatic, obs for 8 hours! Oy vey
  • admit if prolonged submersion, respiratory or neuro symptoms, abnormal CXR

Electrical Injuries

  • lightning strikes carry 30% mortality risk, it causes asystole
  • doesn’t cause renal failure or burns/compartment syndrome
  • thicker tissue less damaged
  • tissue between entry and exit wounds could be more damaged interiorly than it appears
  • AC worse than DC because AC at low voltage causes tetany so you’re holding on longer
  • we use DC for defib, countershock, pacing but you get thrown off
  • oral electrical injury – monitor for progressive edema
  • could have delayed bleeding from labial artery

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EMTALA- Melissa Platt, MD

  • in court, all are case-by-case
  • we have to provide a medical screening exam and treat and stabilize an emergency medical condition
  • transferring physician assumes the risk if the patient crumps en route to accepting hospital

EMRA 6 minute Lecture Winners

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All,
As we have started to move towards shorter, more concise lectures I thought I would share these brief talks from EMRA. I encourage you to at least watch the first lecture (if not all three).
I want to point out how the first speaker uses essentially no bullet points, slides with minimal words, and images that cue him into what he’s talking about, cue the audience as well, but aren’t insanely distracting so that his audience is listening to him and not reading his slides. He also does a great job at the end of summarizing his talk (again with no bullet points).
I’d like you all to consider this when creating a talk, however big or small and if you have questions/need anything regarding talks fell free to ask me. I may try posting more tips/pages like this in the future if you find it helpful.

Enjoy the videos

Reub Strayer – Droperidol and the Dangerous Patient

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Every resident must listen to this podcast (or watch this video) at once. I finally listened to it and was pleased to find it a concise, evidence-based and accurate talk. I avoided watching because I thought he would talk about how much he loves his droperidol and that we should all use it, which would fill me with unbearable envy, since we have not had it in Louisville for years. I have been aware that no US company manufactures it but many EM / FOAMed docs still talk about it. Well Dr Strayer now has no access to the drug and shares his disappointment.

Take home points:

  1. Droperidol is a magical, wonderful drug and we need it back.
  2. The end

No but seriously many great points related to managing the combative patient. From the mildly disorganized schizophrenic, all the way to the truly medico legally dangerous excited delirium, Strayer gives inarguable advice. I love the “shove an O2 mask on the patient who is being restrained by 6 security guards.” He notes that this will often calm the patient, it will protect from spitting, and it will oxygenate the patient. Many other practical pearls here that you WILL USE pretty much every shift at UofL.

Post your favorite tips in the comments.

Approach to PE

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Hey all,
I got the privilege of going to ACEP last week in Boston. When I got the schedule one of the lectures that stood out to be was a PE lecture by Jeffrey Kline. Some of you may recognize the name but if not, he is an attending at IU with a special interest in thromboembolism. He is very active on twitter at @klinelab and wrote the Thromboembolism chapter in Tintinalli’s. After talking about PE last month and specifically approach to PE in the pregnant patient, I thought a summary of the key points would make for a worthwhile post.

The first question in the discussion of VTE should be ‘who actually needs to be tested?’ If someone comes in complaining of recent chest pain or dyspnea, PE needs to be included in the differential. If they are not complaining of those recently and have normal vitals (at all times) then you don’t need to go chasing down a clot that isn’t there. If the patient does complain of those then some sort of documentation is required to show you considered a PE. Even stating ‘I think PE is unlikely because of X, Y and Z’ would likely be enough. Now if your pretest probability is anything other than very low, some combination of wells, perc, Geneva should be applied. I like the following algorithm which I think Kline discussed on EMRap towards the end of last year.
algo

Following that algorithm helps cut down on the number of ct scans you’ll order, cuts down your false-positives, radiation exposure, and contrast induced nephropathy without increasing the number of significant PE’s that you miss.

As far as the pregnant patient, I think everyone knows to start with the lower extremity ultrasounds in hopes of an answer that would let you initiate treatment. However, when that is inevitably negative, there is also an algorithm for that scenario that incorporates a trimester adjusted d dimer.

algopreg

The other main takeaway from this talk was the disposition change on some of the low risk patients. Dr. Kline said he has sent about 70 patients home from the ED after being diagnosed with PE. To stratify who falls into low risk, you can apply the sPESI or HESTIA score as well as who is at low risk of bleeding.

–Simplified PESI-if any +, pt is NOT low risk:
age greater than 80
history of cancer
history of chronic cardiopulmonary disease
pulse greater than 100
BP less than 100
O2 sat less than 90

–Hestia-pt CAN BE considered low risk if
BP greater than 100
No thrombolysis needed
No active bleeding
02 sats greater than 90
Not already anticoagulated
No other medical or social reason for admission
Cr clearance greater than 30
not pregnant, no severe liver disease

For these people they’ll initiate rivaroxaban or apixaban in the ED and send them home with a prescription. The only failures they’ve experienced are people who returned requiring additional pain management. Has anyone done this or considered it? The majority of our patient population would not satisfy these requirements or, frankly, be reliable enough to consider outpatient management, but what about people working in the community with a different population?

Lastly, we all know to look for S1Q3T3 on the ekg to raise suspicion for PE but the odds ratio is only 2.06. Inverted T’s in V2 and V3 have odds ratios of 6.94 and 7.07 respectively, and are the most SPECIFIC ekg finding in pulmonary embolism

Dr. Smock’s Forensic GSW lecture 7/22/15

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Here are some highlights of Dr. Smock’s Forensic lecture. This will help remind me what to document in my next GSW pt. Here is a pfd version. Forensic GSW Documentation

 

Forensic GSW Documentation: 

Bullet causes… Abrasion collar
Unburned gunpowder causes… Tattooing aka. stippling (this lasts a few days, seen as punctate abrasions, DO NOT CALL THIS “GUN POWDER”)
Burned gunpowder causes… Soot
Flame causes… Seared skin
Injected gas causes… Triangular tears
Muzzle causes… Muzzle contusion

Distance from Weapon:

Indeterminate abrasion collar present
Intermediate < 40 in Tattooing & abrasion collar present
Close < 6 in Soot & abrasion collar present
Contact Seared skin, triangular shaped tears, & soot present