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.

Think you need tick bite prophylaxis after that woodland hike? These are the indications.

Dr. Mallory shared this website with me, and I think it is a great reference for up-to-date stroke EBM. They break down stroke care by stage of care and share relevant translational knowledge of each topic. See link below.

https://www.strokejourney.com/

ACEP Advocacy from Dr. Cirillo

-Projected EM physician may have a job shortage of up to 9500 jobs by 2030
-Medicare data used to compile this projections
-Concern may be that we need to further specialized into things like substance abuse specialist, emergency psychiatric specialist, observation unit specialist.
-ACEP wants to protect jobs
-ACEP supports mental health for ER physicians
-support silence on ED violence in conjunction with the ENA

-Message overall: get involved if you want meaningful change/advocacy for our specialty

Tropical Diseases with Dr. Heppner

Dengue Fever

-AKA breakbone fever, that leads to myalgia and arthralgia. Labs leukopenia, transmitted be a mosquito, endemic to Southeast Asia in South America. Treatment is supportive care. Transfuse as needed. Diagnosed clinically.

Yellow Fever

-most notable symptoms lately have dysfunction with associated jaundice. The remainder are nonspecific symptoms. Trended to be mosquito. Endemic intensely here in Africa, treatment is supportive care.

West Nile Virus

-Transmitted via mosquito should perform an LP, symptoms are usually asymptomatic and most patients, but can include nonspecific in such as fever headache myalgias lymphadenopathy. Endemic in the Middle East Africa Southeast Asia, diagnosis clinical, can order a special CSF test which is an IV GM antibody. Treatment is supportive

Pharmacy ID Review with Dr. Senn

You should treat asymptomatic bacteriuria in pregnant patients, patients that have had a renal transplant within the last month, and patient is going for GU surgery in the next 72 hours.
Epididymitis if concern for E. coli should be treated with levofloxacin. In patients less than 30 consider STI coverage in these patients.
Meningitis/encephalitis: Patient is greater than 65 should have ampicillin added on for Listeria coverage, in addition she was treated with ceftriaxone and vancomycin. When covering for Pseudomonas picture you on cefepime. If concern for fungal encephalitis include amphotericin B plus flucytosine.
C. difficile: Treat with vancomycin p.o. that is first-line. IV vancomycin does not cross over into the gut.
Fournier’s gangrene make sure you could broad-spectrum antibiotic coverage with the addition of clindamycin for toxin neutralization.
Tick bite: Prophylax patient’s if a tick was document for greater than 36 hours and within 72 hours of it being removed. Doxycycline should be used.
Post-exposure prophylaxis for rabies bites if the patient has been previously vaccinated they receive the rabies vaccine on day 0 and 3 after the bite. If they have no prior rabies vaccine they get a rabies vaccine on day 0 3/7/14 after the bite.
Febrile neutropenia: Defined as ANC less than 500. Should have broad-spectrum antibiotic coverage. With the addition of vancomycin. No vancomycin as needed for suspected UTI.

ID Lightning Lectures with Drs. Royalty, Strohmaier, and Jordan

Flu: URI symptoms fevers and myalgias. Usually self-limited disease. Those extremities age are at high risk. In addition people with significant comorbidities pregnancy or BMI greater than 40 or high risk. High mortality associated with a secondary bacterial pneumonia. Treatment is supportive and Tamiflu. Tamiflu carry significant risk with it including nausea vomiting psychiatric issues including hallucinations and suicide attempts. Consider starting Tamiflu if patient has been admitted. For those that are low risk used shared decision-making with the patient explained risks and benefits.

TB:
Primary usually asymptomatic, unless immunocompromise then may have B symptoms. Reactivation TB can include pulmonary plus systemic symptoms. May have extrapulmonary findings including pericarditis peritonitis encephalitis or meningitis and right adrenal insufficiency. Latent TB can include nodular findings on chest x-ray, complex. Miliary TB has a high mortality rate. Small nodes found on chest x-ray. But can occur anywhere in the body. Treatment is right therapy rifampin isoniazid pyrazinamide and ethambutol. For treatment of latent TB can treat with rifampin or isoniazid plus B6 dependent on liver enzymes. Rifampin preferred in people with liver dysfunction.

Syphilis
Sexually transmitted. Can be spread to other organs if left untreated. Primary syphilis is painless chancre that developed with 30 to 90 days after exposure usually currently on mucosal membranes. Not noticed on limited the genitals. Secondary syphilis, lymphadenopathy rash on the palms and soles. Tertiary syphilis can have cardiovascular findings included a dilated aortic root, aortic valve dysfunction, thromboses or clot formation within coronary arteries, neurosyphilis or, syphilis.
Neurosyphilis is a poor prognostic indicator. Can have ocular symptoms meningitis or seizures. Late findings of neurosyphilis or paresis psychosis tabes dorsalis ataxia pain bladder dysfunction dementia death. Syphilis does cross the placenta, as such congenital syphilis can occur.
Testing VDRL RPR.
Treatment was with penicillin 2,400,000 units pen GIM. For length and latent syphilis should be treated with a 2,400,000 units pen G IM . All neurosyphilis patient should be admitted for IV penicillin G.

A couple cool articles in Academic Emergency Medicine and Training (AET)

1. One simply surveyed residency programs to see if we try to impart efficiency skills to our residents. Overall yes programs do try to educate on this topic. “Results: We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with “signifi- cant” or “moderate” priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: “individual data provided along with deidentified rank” (35%), “data provided only during private feedback meetings” (26%), and “no data or rank provided to residents” (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions.”

2. But the NEXT paper is much cooler. This one looked at what on shift behaviors actual correlate with improved efficiency of residents. Now the outcome metric they used was RVU/hour (they talk about using patients per hour but don’t really report the data in results). I am not sure if I would place your RVU per hour as a top priority. But in measuring efficiency and helping you in your job on graduation, I guess it is ok.

The results were interesting. Seven behaviors correlated with improved efficiency, three with worse efficiency, and a bunch with no difference. Now some of the more efficient ones were found to correlate with LESS efficiency in a study they did in community docs. And some of the less efficient ones were more efficient in community docs. So you have to read the discussion section of the paper.

But one major take home point that they wrote a whole paragraph about that you can do TODAY is “swarming.” This is when you go in with the nurse (and other staff) and take history with them while communicating your workup and treatment plan to the team. This improves your efficiency in seeing patients and everyone wins. I do this at Jewish, often at South the nurse wants to come in the room when the doc goes in. This communication helps and prevents the need to check back with the RN/Tech/RT to go over the plan. So today or on your next shift, try some swarming!

See below, as the variable increases, so does your RVU/hr. Makes sense on some, higher patient load means more RVU. But some cool ones like the more you use dictation, the more RVU. The more you use smartphone to communicate with people in the ED, the more RVU. Oddly, the more nonword tasks, the more RVU (might be that more efficient residents have leftover time to talk to people or do nonword tasks). Visiting the patient room multiple times meant less RVU per hour (but almost definitely happier patients!). Talking to the attending means less RVU (you aren’t billing patients when we talk), but likely more education for you. You see why using RVU/hour is a measure that does not equate to good patient care or even a good work experience for you. The business of medicine : /

More efficient: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour).

Less efficient: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour).

Check out this article by Louisville cardiologist John Mandrola. It is worth reading in full, just one and a half pages. Mandrola and coauthor Foy comment on an iatrogenic coronary dissection during a cath performed for a + troponin in SVT. Check out Table 1, very nice for conceptualizing Troponin elevation.

The TL;DR: carefully interpret troponin elevation when you do not suspect a type 1, acute coronary occlusion MI. As I always tell you guys, a very important binary to collapse in ED patients is, does this patient have an acute occlusion, or OMI.

If you are ordering a troponin in a patient with tachycardia from fever, SVT, afib, or even bradycardia, be prepared for an elevation. But unlike STEMI or STEMI equivalents (ie OMI), this troponin elevation may not require any specific treatment, especially cardiac cath. Treat the underlying condition, even if using troponin as a prognostic marker. This applies more for cardiologists, but we have a role as well. For instance, Amal Mattu says to not even obtain Trop in young healthy SVT patients (I agree).

Sepsis Review- Dr Shoff

What is sepsis? A systemic response to infection
Mortality reduction in sepsis? ANTIBIOTICS EARLY
SIRS- T 101F/90, RR >20, WBC >12k/10% bandemia with evidence of End Organ Dysfx
Severe sepsis += hypoperf despite adequate IVF resus.-30ml/kg crystalloid, or a drop in SBP drop by 40 mmhg, or any SBP <90mmHg
What do you do?
Within 3h of presentation get:
1. Lactic
2. Blood cx BEFORE abx
3. Broad spec abx coverage=zosyn, cefepime, meropenem, ceftriaxone, unasyn, amp, levofloxacin

Within 6h

Within 6h, rep lactic in first is >2h.
Pressor if ivf persist
If lac >4h rept vol status and tissue assessment
If hypotensive after ivf, repeat vol status and tissue assessment.

TIssue assessment/vol assessment?
Vs
Cardiopulm exam
Cap refill
Peripheral pulse eval
Skin exam

Exclusion crit
Comfort care
Death within 6h
Transfers from osh
Refusal to care

How do we do?
-90% bundle compliance

MCC of sepsis @UofL:
PNA
UTI
Skin/soft tissue

MEWS-used as a trend, if trending up=patient getting sick
Patient with BMI >30, can use Ideal Body Weight for fluid resuscitation

Things I wish I knew in residency-Dr. Gall

Eval where you want to work-shadow, see how RNs interact with staff
Less than 12h shifts are optimal
Overlap at shift change is beneficial
Nocturnists work less shifts, more $/hr
Negotiate your contract! -no malpractice without tail
$$- invest in broad index fund if you’re gonna play the market
Live below your means-work bc you want to, not because you have to
Keep studying
You will keep getting better
Fly or ground? >1h and critical (will need immediate intervention)= fly–but is dangerous
If issue with a consultant, have them come see the patient or admit patient for obs
Know what chain of command is before your have an issue with c/s
When pacing, consider use of u/s to ensure that you are actually getting capture.
Callback if concerned about a patient
Be nice to your patients
Review your patient prior to dc!
Take care of those you work with!
Apologize-to staff, patients
Books he likes -Rosen’s, EKGs for ER docs by Brady and Mattu, Roberts and Hedges procedure book

Panel

Things to learn before you finish residency-

TPA- talk to stroke team/follow pts whilst here because you’ll have to do it once done here
Chest tubes- percutaneous are more common outside of trauma centers
Ultrasound guided IVs, midlines
Lower acuity/urgent care style cases- we don’t see many here but you will later
It is normal for confidence to wax/wane right out of residency-but this gets better! Trust your training, you have been well trained
Don’t be afraid to call the children’s hospital for advice, not just for transfers
Follow up on patients you saw

Finances-
Pay quarterly taxes if IC
Read white coat investor
Live below your means

Just posting this article here to stimulate some discussion. Now that we sprinkle TXA on basically any body part, we need to be sure to maintain evidence based medicine. I would point out that there is very little downside to TXA. He mentions the HALT-IT trial that DID show a higher rate of VTE events in the treatment group. But most TXA studies have not shows risk of clotting. We also must be aware of the regression to the mean issue, which is probably what occurred in the most recent epistaxis study. For a book that covers this nicely, see this gem.

Again, I am a fan of TXA, and open to attempting treatment modalities with new, not yet gold standard of care evidence. But we must always practice non-maleficence, and must not be tempted by indication creep.

-Huecker

EMS Prehospital US- Dr. Heppner

1. Pre hospital US began in the early 2000s
2. Advantages include possible early diagnosis of pneumothorax, intrabdominal hemorrhage, cardiac tamponade, and tube confirmation
3. Also, may improve triage process
4. Barriers include costs of equipment and training as well as operator dependence
5. Could also cause delay in transport times

Capstone- Dr. Davenport

1. Heterotopic pregnancy risk is 1/100,000
2. Consider this in patients with persistent symptoms despite IUP
3. Zebra diagnoses are rare but still must be considered if nothing else explains the diagnosis
4. Be cautious in pregnant patients if you are concerned with ectopic rupture, even in patients with stable vital signs

Hyponatremia- Dr. McGee

1. For hyponatremia consider history closely when deciding volume status.
2. Primary polydipsia is rare and requires huge amounts of water intake.
3. Doing a repeat confirmatory test on a hyponatremic patient with minimal symptoms is important.
4. Use serum osms to determine pseudohyponatremia
5. In true hyponatremia, sodium and osms are low
6. Low Urine Osms and low specific gravity point to ADH independent hyponatremia, high Osms and SG would suggest ADH dependent
7. Consider Uric Acid test which may be low in SIADH
8. Beware of elderly patients with mild hyponatremia because they are at much higher risks of falls
9. Goal of hypertonic saline is to raise sodium by 5 mEq or improve LOC

Room 9 Follow up- Dr. Thomas

1. 45 yof hx of obesity, HTN, DM, complaint of weakness and slurred speech with a GCS of 6
2. Intubation complicated by black emesis but achieved with reverse trendelenberg position.
3. Head up intubation increases time until desaturation.
4. Consider bougie for increased first pass success
5. Consider post intubation complications when selecting head up vs conventional intubation

Pediatric DKA- Dr. Patterson

1. Pediatric DKA can many varied presentations
2. Blood pressure is usually last thing to decompensate in pediatric shock
3. Don’t bolus insulin initially. Make sure patient is resuscitated and potassium is appropriate
4. 10-20 ml/kg fluid bolus is correct based on PECARN
5. Most new evidence suggest that cerebral edema may be less iatrogenic than initially thought

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department

Intimate Partner Violence

“Such violence is more prevalent during a woman’s lifetime than conditions such as diabetes, depression, or breast cancer, yet it often remains unrecognized by health professionals.” 

Pelvic Inflammatory Disease

“A large body of evidence suggests that infec- tion and inflammation in the upper genital tract can occur and lead to long-term reproductive com- plications in the absence of symptoms, a condi- tion often called subclinical pelvic inflammatory disease.”

“However, of note, in one study involving infertile women without a history of diagnosed pelvic inflamma- tory disease, 60% of the women with tubal-factor infertility, as compared with only 19% of those without tubal-factor infertility, reported health care visits for abdominal pain38; this suggests that many cases of pelvic inflammatory disease are missed and that clinicians should have a low threshold for considering the diagnosis.”

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy:  A Systematic Review

Lightning Lectures

Dr. Harmon-Thyroid Storm

1.Presentation is with thermoregulatory, CV, GI, or CNS disturbances. Symptoms can include hyperthermia, AMS, seizures, tachycardia, high output heartfailure, and GI symptoms.

2. Causes are systemic, endocrine, cardiovascular, obstetrical or idiopathic.

3.Treatment: Supportive care with slow cooling, benzodiazepines, beta blockers, PTU, Iodine, steroids, cholestyramine.

Dr. French- Cushing Syndrome/Disease

1. Cushing disease is caused by hypersecretion of ACTH. Cushing syndrome should be characterized by either ACTH dependence or independence.
2. Iatrogenic is the most common cause.
3. Symptoms: Weight gain, moon facies, buffalo hump, headache, HTN, Hyperglycemia, erectile dysfunction, irregular periods, central obesity.
4. Tx: mostly outpatient. ED management should focus on initial metabolic derangements. Don’t abruptly stop steroids.\

Dr. Sowers- Pheochromocytoma

1. tumor of adrenal medulla which releases catecholamines and metanephrines
2. Is associated with MEN, VHL, neurofibromatosis and famial paraganglioma
3. Diagnosis is made with plasma and urine metanephrines, chromagranin A and specialized imaging such as F-FDG PET scan
4. Treatment: Benzodiazepines, phentolamine. Avoid beta blockers and pay close attention to volume depletion.

MICU Follow UP- Dr. Cook

1. 29 year old female found down with V Tach arrest.
2. Etiology of Ventricular Tachycardia: Structural heart disease Ischemia, HOCM, Sarcoidosis, familial long QT, Brugada syndrome.
3. Therapeutic Hypothermia: Main benefit is reduction of neurologic sequelae
4. 2 studies in 2002 showed benefits of decreased mortality and improved neurologic outcomes at 30 days. Initial thought was lower temperature is better.
5. More recent Targeted Temperature Management study showed no differences in outcomes between 36 and 32 degrees Celsius cooling protocols.
6. Most institutions have hospital specific protocols.

CCU Follow up- Dr. Fisher

1. 82 yof fall at home with initial complaint of chest tightness. Also complained of 8-12 episodes of diarrhea daily for weeks and frequently takes loperamide.
2. Initially patient with elevated troponin and creatinine. EKG showed deep T wave inversions in the anterior leads.
3. After being admitted patient EKG showed widened QRS and ischemic changes. Cardiac catheterization revealed normal coronary arteries.
4. Pt was eventually discharged to hospice due in part to many comorbid conditions. Question if loperamide could have been the cause of the patients symptoms.
5. Loperamide toxicity: causes conduction disturbances which can persist for days. Includes widened QRS and prolonged QT.

Identity Theft- Dr. Bosse

1. Doctors are particularly vulnerable to identity theft
2. Claims can be disputed but it is a headache.
3. Pay close attention to accounts
4. Consider freezing credit scores or hiring credit monitoring companies.

Stroke Care in a Nonstroke Center- Dr. Remmel

1. Common mimics include seizure, drugs, metabolic derangement, hypertensive emergency, tumors, CNS infection, complex migraine, and functional
2. Know transfer options and stroke capabilities for any ER you work with.
3. LVO- aphasia or left neglect, eye deviation, weakness opposite of eye deviation.
4. Important exam elements: LOC, Visual fields, pupils, EOMs, sensation, facial motor, strength, speech and language, coordination, and extinction.
5. Consider using the Neuro Toolkit App
6. Consider tPA if 4.5 hours from symptoms onset.
7. Door to Needle time should be less than 30 minutes.
8. Know tPA exclusion criteria
9. tPA complications- angioedema, hemorrhage.
10. tPA dosing is 0.9 mg/kg with max of 90 mg. 10% is given as bolus. The rest is given over 1 hour.

Wellness- Dr. Huecker

1. Consider wellness daily. No one but you will advocate for your wellness once out of residency.
2. Eat a balanced diet.
3. Vitamin D is good, but not too much. Get sunshine.
4. Vitamin K2 is a sleeper vitamin. Warfarin can cause disruption causing many problems.
5. Magnesium is really, really good. Deficiency can cause cramps and headaches.
6. In general prefer natural foods over supplements.

Lightning Lectures – Guillain Barre, Myasthenia Gravis, Botulism

Guillain Barre – Dr. Tyler Bayers

-Immune system attacks myelin sheath causing ascending paralysis

-Progressive, mostly symmetric muscle weakness with absent or decreased DTRs

-Clinical diagnosis with CSF support showing albuminocytologic dissociation (increased CSF protein with normal CSF WBC)

-Monitor for signs of respiratory failure

-Treatment with IVIG; can also do plasma exchange

Myasthenia Gravis – Dr. Blaine Jordan

-Autoimmune NMJ disorder of postsynaptic Acetylcholine receptors causing fluctuating skeletal muscle weakness/true muscle fatigue.

-Highly associated with thymus disorders (thymoma); consider chest CT

-Often presents with ocular myasthenia, but can be weakness of any muscle group, often see ptosis, expressionless face

-Avoid drugs that can worsen MG – ex. fluoroquinolones, macrolides, aminoglycosides, beta blockers

-Infection, pregnancy can cause MG crisis – look for them

-In MG crisis, initiate steroids in ED; consider intubation as meds for crisis take days to work and could worsen prior to meds taking effect

Botulism – Dr. Avery Newcomb

-Clostridium bacteria with botulinum neurotoxin blocking presynaptic Acetylcholine release causing symmetric and descending flaccid paralysis

-Different types: Infant botulism involves ingestion of spores that colonize GI tract and release toxin produced in vivo; food borne botulism occurs after ingestion of food contaminated with preformed botulinum toxin; wound botulism with in vivo production of neurotoxin.

-Sxs may range from minor cranial nerve palsies associated with symmetric descending weakness to rapid respiratory arrest.

-Clinical diagnosis – tests take days to result. Botulinum antitoxin should be given as soon as suspected for age > 1 year. Botulinum immune globulin (BabyBIG) for infants <1 year of age.

Procedure Sim: LPs Dr. Mary Jane Schumacher and Dr. Dhruv Patel

-LP either left or right lateral decubitus position or sitting up

-Landmarks midline of spinous processes and anterior iliac crests = L4; go a space above or below (L3-L4, L4-L5 interspace). Ultrasound can assist in identifying landmarks. Prep and drape the patient. Use local anesthesia. Prepare manometer and collection tubes. 20-22 g spinal needle with stylet, aim towards umbilicus. Bevel edge should be parallel to the ligament fibers (bevel up when patient on side, to right or left when sitting up). Once in Subarachnoid space, obtain pressure then collect 1 cc of fluid in tubes.

-Layers needle goes through: skin, subcutaneous tissues, supraspinous ligament, interspinous ligament, ligamentum flavum.

-Tubes: 1) cell count and differential, 2) gram stain, cultures 3) glucose, protein, 4) cell count and differential; tube 3 and 4 can be used for special tests or additional cultures

tPA pharmacy lecture – Dr. Jade Daugherty

-Alteplase FDA approved for acute PE, acute ischemic stroke, STEMI (not preferred agent), central line thrombosis; several other off label indications

-Half life ~5 min. Fibrinolytic activity persists for up to 1 hour after administration

-Adverse effects: bleeding (notably ICH), hypersensitivity and angioedema

-Stroke dosing: 0.9 mg/kg IV (max 90 mg). 10% as IV bolus over 1 min, 90% as continuous IV infusion over 1 hour. Different dosing for different indications, look up dosing.

-Before giving tPA: know BG (<50 or >400 then correct and re-assess), blood pressure (<185/110 prior to tPA, <180/105 after administration), CT head without contrast, last known normal, and a good story.

-Several contraindications – use MD calc to go through list

-Excellent resource: AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke

-“Blood thinners” – antiplatelets are ok, warfarin with INR < 1.7 ok, prophylactic AC is ok, Direct Thrombin inhibitors and Xa inhibitors: check labs (INR, aPTT, platelet, TT, and anti Xa level) if last dose >48 hours and normal renal function then ok for tPA otherwise likely not. Glycoprotein IIb/IIIa inhibitors also not ok.

-Trials over the years: NINDS-II and ECASS-III showed disability benefit but after re-adjusting for baseline imbalances, no benefit showed.

-Wake Up Trial: in patients who awake with stroke sxs or have unclear time of onset >4.5 hours from LKN, MRI to identify diffusion positive FLAIR negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.

-If ICH after tPA administration: stop tPA infusion, emergent CT head, Labs including CBC, PT, INR, aPTT, fibrinogen level, type and cross. Cryoprecipitate: 10 U infused over 10-30 min, administer additional dose if fibrinogen level <150 mg/dL. TXA 1000 mg IV infused over 10 min.

Neuro Exam – Dr. Jeremy Thomas

-If neuro complaint, fever, sxs that don’t make sense, need full neuro exam. Lots of info below, some of the highlights included.

-GCS score in setting of trauma: Eyes 4, Verbal 5, Motor 6

-Low GCS: Do the DON’T: D: Dextrose, O: Oxygen, N: Narcan, T: Thiamine

-Pupillary response: reactive (no brainstem involvement), fixed and dilated (anoxic encephalopathy, exclude anticholinergics), one dilated (herniation with CN III compression or nerve lesion). Small and reactive – usually metabolic or toxic causes; consider thalamic or pontine infarcts

-Testable pupil findings:

Argyll Robertson Pupil (tertiary syphillis, selective damage to pathways from retina to edinger-westphal nucleus) “Prostitute pupil” – accommodates but does not react. Light near dissociation.

Marcus Gunn (total lesion of optic nerve/CN II). De-afferented eye. no response to direct light, constricts to light stimulus in other eye.

Horner’s syndrome (sympathetic denervation), ptosis, miosis, anhydrous. Trauma, stroke, carotid dissection/aneurysm.

Central Lesions – cause contralateral deficits of face and body (ex classic MCA stroke) and produce negative symptoms (ex. decreased sensation, decreased ability to speak); but cerebellar lesions can cause positive symptoms such as nausea/vomiting, nystagmus.

Midbrain Lesions: contralateral hemiplegia, ipsilateral CN III and IV findings

CN III: Oculomotor nerve, pupil size, raising eyelid, most movement of eye

CN IV: Trochlear nerve, movement of eye (superior oblique)

Eye innervation: LR6(SO4)AO3: Lateral Rectus CN VI, Superior Oblique CN IV, All Others CN III

Pons Lesions: contralateral hemiplegia, ipsilateral CN V, VI, VII, VIII findings

CN V: trigeminal nerve, sensation of face and muscles of mastication

CN VI: abducens nerve, lateral rectus as above

CN VII: facial nerve, movement of facial muscles and taste on anterior 2/3 of tongue

CN VIII: vestibulocochlear nerve, hearing and balance

Medulla Lesions: Contralateral hemiplegia, ipsilateral CN IX, X, XI, XII

CN IX: Glossopharyngeal nerve – taste on back 1/3 of tongue

CN X: Vagus nerve – ability to swallow, gag, some taste and part of speech

CN XI: Accessory nerve – move shoulders and neck, turn head from side to side/shrug shoulders

CN XII: Hypoglossal nerve: move the tongue

Cauda Equina: Compression of nerve roots in lumbar spine; loss of bowel or bladder control, saddle anesthesia, pain or weakness in lower extremities

DTRs – can help localize a lesion: Biceps C5/C6, Triceps C7/C8, Abdominal T8-T12, Patella L2/3/4, Achilles L5, Babinski S1/S2.

Grading: DTRs (0 absent, 1 decreased but present, 2 normal, 3 brisk and excessive, 4 with clonus). Strength (0 no movement, 1 flicker, 2 movement, 3 movement against gravity, 4 movement against resistance but weak, 5 normal).

Cerebellum: influences movement of voluntary movement, balance and equilibrium, muscle tone. Eyes open tests cerebellar. Eyes closed tests proprioception.