1. Position statements from four different organizations on Thrombolytic Use in PE, Submassive vs Massive

2. What do you do in the case of massive hemorrhage from a tracheostomy? Check your heart rate, consider tracheoinominate fistula, , and then follow this algorithm.

3. Managing suicidal patients in the ED. Risk level, interventions.

4. Elder abuse: Don’t forget the many ancillary staff / professionals you can lean on for assistance.

Clinical Pathways for Status Epilepticus – Dr. Kuzel and Dr. McKinney

In First 5 minutes:

-ABCDEFG (ABC’s, Don’t Ever Forget Glucose).

-Airway considerations: lateral decubitus, nasal trumpets, O2, suction

-Obtain IV access and search for reversible causes, can consider initiation of first line tx with benzos prior to waiting 5 minutes; be aggressive early

5-10 minutes:

First Line Agents: IV Lorazepam 4 mg and up to 0.1 mg/kg, may repeat Q5min or Midazolam 10 mg IM once if no IV access, or IV Diazepam 10-20 mg. Go big or go home. Get the seizures to stop sooner rather than later as more likely to have respiratory depression from status than with benzos.

Second Line Agents: Levetiracetam 60 mg/kg IV (max 4500 mg) or Fosphenytoin or Phenytoin 20 mg/kg IV (max 1500 mg) or Valproate 40 mg/kg IV (max 3000 mg)

Consider intubation if needed.

10-30 minutes:

Medications in refractory status epilepticus: Propofol 2-5 mg/kg IV, then infusion of 2-10 mg/kg/hr. Midazolam 0.2 mg/kg IV, then infusion of 0.05-2 mg/kg/hr. Ketamine 0.5-3 mg/kg IV, then infusion of 0.3-4 mg/kg/hr. Phenobarbital 15-20 mg/kg IV at 70-75 mg/min.

Advanced airway management: RSI. Preoxygenation. Induction: Propofol or Ketamine. Paralytics: Succinylcholine or Rocuronium (however consider status not being seen). When to intubate: when predicted course of seizures will necessitate high dose of respiratory depressing drugs.

–Special considerations: Consider nonconvulsive status epilepticus in known epileptic patient without return to baseline (emergent EEG, consider benzos). Always consider tox causes (avoid Phenytoin of Fosphenytoin in undifferentiated tox patient or drug withdrawal. Also avoid if this is a home medication due to concern of cardiotoxicity). Give Thiamine 100 mg if alcoholic. In isoniazid overdose, give pyridoxine 70 mg/kg, Max 5 gm.

–Pediatric considerations: Access usually a problem. Intranasal Midazolam 5 mg/mL solution dosed at 0.2 mg/kg divided into each nostril. Lorazepam 0.1 mg/kg IV, max 4 mg. See CHOP status epilepticus

Oral Boards – Dr. Shoff

-What do I see when I walk in room? If AMS, get POC glucose early on

-IV access, heart monitor, O2 monitor

-If a vital sign is missing, ask for it, likely will be abnormal

-If vitals are abnormal, start addressing immediately. Can always request “if this intervention changes a vital sign, will you let me know?”

-Always ask allergies before giving meds

-Get history from whoever you can: paramedics, family. Don’t forget social, surgery, family hx

-When to order things: right when you walk in, after history, after physical (can whenever but these are the 3 best times)

-If you ask specifics in regards to exam, they will answer yes/no, don’t want to be too broad but don’t forget to ask things either.

Geriatrics Lecture – Mobility

-Find out who lives at home, steps at home, assistive devices?

-Walk the patient in the ED and see how they do

-Could request PT/OT eval; may be hard from ED but could admit for these services.

-If thinking needs rehab/admit and not obs because they need a 3 day stay for insurance purposes

-If discharging, make sure home health eval can occur. If discharging with pain meds, do only half a pill.

-If patient is falling, consider that this is #1 morbidity/mortality for elderly

Meningitis – Dr. Platt

–Important higher level questions to ask: exposure to recent meningitis, current sinusitis/OM, recent antibiotic use, travel such as to Hajj and Umrah, recent IVDA, progressive rash, recent or remote head trauma, HIV infection, immunocompromised, recent drug use including OTC, age, vaccination status

-Screening CT not necessary if none of these apply: immunocompromised state (HIV, immunosuppressive therapy, solid organ or hematopoietic cell transplant), Hx of CNS disease (mass lesion, stroke, or focal infection), New onset seizure within 1 week of presentation, papilledema, abnormal level of consciousness, focal neurological deficit.

-LP: try to get blood cultures first and quickly do LP before antimicrobial therapy. If there will be a delay, blood cultures, abx.

-Drug that cause aseptic meningitis: NSAIDS!, antimicrobials (Bactrim, Amoxicillin, Isoniazid) most common but others include Muromonab-CD3 (Orthoclase OKT3), Azathioprine, IVIG, Intrathecal methotrexate or cystine arabinoside.

-CSF studies: normal glucose is about 2/3 concentration of blood. Glucose may decrease with bacteria, WBCs, or cells shed by tumors. Small amount of protein is normal in CSF but increases commonly seen with meningitis and brain abscess, brain or spinal cord tumors, MS, GB, syphillis. Don’t forget to order specifics for what you want.

-Don’t forget Dexamethasone prior to/same time as antibiotics

-Antibiotics based on age: <1 month (Ampicillin + Cefotaxime or aminoglycoside), 1 month to 50 years (Vanc + ceftriaxone +/- Rifampin if dexamethasone given), >50 years (Vanc + Ampicillin + Ceftriaxone +/- Rifampin if dexamethasone given).

Journal Club – Dr. Mary Jane Schumacher

-Compression therapy for prevention of recurrent cellulitis of the leg – do it

-TXA vs oxymetazoline for hemostasis in epistaxis: need a better study, would still try Affrin first but remember TXA as another option as this review shows it could be clinically beneficial and may prevent need for nasal packing

72 hour returns/Deaths in ED/Deaths within 24 hours – Dr. Mary Jane Schumacher

-Great job on care of patients and documentation

–For documentation: remember to take out the things that are saved in every note but do not apply. For ex. a patient dies in the ED, do not have in your note: discussed plan and all of their questions were answered or follow up with primary care physician upon discharge

-Important patient care points:

Remember to think of social situation and set patients up for success if going to discharge. Are they going to go home and fall and break a hip/get a brain bleed? Do they have a PCP to follow up with?

If vitals or clinical change on a trauma patient – repeat FAST.

Seizure patients – monitor in ED for a period of time, give their seizure meds/keppra load if they have definitely missed doses and discharging but be cautious of restarting Lamotrigine for risk of SJS if they haven’t been taking it. People coming back with recurrent seizures – neuro consult.

Alcohol withdrawal – really pay attention to these people, they can become sick very quickly. Symptoms can range from mild to severe. Recognize the symptoms from tremors/tachycardia to hallucinations/delusions and seizures. If alcoholic and reported seizure at home and don’t look well, consider admission. If they look well, can give phenobarbital 260 IM if discharging as it has a long half life and can prevent decompensation. You can also give phenobarbital IV if admitting for sxs.

Cirrhotics – use ideal body weight, use LR for resuscitation. Don’t forget considerations of Albumin in SBP, HRS, etc.

Morbidity and Mortality Case – Dr. Caleb Webb

-HIV/AIDS: AIDS when CD4 count <200

-AIDS defining illnesses: Several; discussed cryptococcosis, MAC, PCP

-Cryptococcal Meningitis: HA, fever, neck pain, n/v, photophobia. Will see increased ICP on lumbar puncture. Need to specifically order crypto testing on CSF fluids. Treatment is induction therapy with Amphotericin B and Flucytosine.

-MAC: most likely when CD4 count <50. Disseminated MAC: fever, night sweats, abd pain, diarrhea, weight loss. Diagnosis via isolation of MAC from the blood.

-PCP: diffuse, bilateral interstitial infiltrates. Induced sputum sample. Consider ordering LDH as often elevated.

Electrolytes – Capstone Dr. Dan Grace

Hyperkalemia

Causes: #1 cause hemolysis followed by renal failure, acidosis, cell death, drugs (ACE/ARBS)

Sxs: Abd pain, diarrhea, chest pain, muscle weakness/numbness, n/v, palpitations

EKG changes: variable depending on K; peaked T waves then P flattens and PR lengthens, conduction abnormalities and bradycardia – prolonged QRS up to sine wave, then cardiac arrest

Treatment: stabilize cardiac membrane with calcium gluconate, shift K into cells via 5-10 U regular insulin with 1-2 D50 amps, albuterol neb, sodium bicarb (esp if acidotic), Get rid of K via lasix if properly hydrated, dialysis.

Hypokalemia

Causes: chronic ETOH, malnutrition, diuretics, vom/diarrhea, hyperventilating, alkalosis

Sxs: cramping, weakness

EKG changes: U waves, flattening/loss of T waves, tornadoes, AV block, brady, PVCs

Deficit: For every 0.3 meq/L below 3.5, 100 meq deficit, replace with KCl PO if can, or IV; also have Effer-K, K phos at no more than 60 meq at at time

Hypernatremia

Causes: unreplaced water losses, decreased water intake or excessive Na intake

Sxs: HA, n/v, confusion/AMS, seizure, coma

Treatment: Depends on sxs, mild symptomatic (if euvolemic consider 1/2NS), severe with seizure/coma (D5W), Free water deficit on MDCalc [(serum Na – 140)/140] x 0.6body weight in kg. Don’t correct more than 0.5/hr.

Hyponatremia

Causes: vomiting, diarrhea, diuretics, drinking too much water, dehydration, heart/kidney/liver problems, inadequate salt intake – generally classified into hypovolemic, euvolemic, or hypervolemic

Sxs: dizziness, fatigue, HA, confusion, nausea, seizures

Repletion: no more than 0.5 meq/hr and 8meq/day to avoid osmotic demyelination syndrome. Give hypertonic saline 3% for seizure, coma 100 -150 cc over 10 min, can repeat x 1

Other electrolytes important in ED

Hypercalcemia: bones, stones, groans, psychiatric overtones; Tx if 12-14 with sxs or >14; fluid resuscitate, lasix if fluid overload, calcitonin is faster than bisphosphonates

Hypophosphatemia: anemia, bruising, seizure, coma, constipation, muscle weakness; usually caused by DKA, refeeding, malabsorption, ETOH; tx with NaPhos or KPhos PO or IV

Environmental Kahoot – Dr. Dan Grace

-Killerbees more likely to swarm and sting multiple times

-Acute Mountain Sickness – descend; Acetazolamide works by causing primary metabolic acidosis

-Ruptured TM following ascent from scuba diving – antibiotic drops and ear precautions

-Difference b/t heat stroke/exhaustion = neuro sxs

-Iguana bite – cipro

-ARDS after wet drowning due to water washing away surfactant

Toxic Smoothie – Dr. Bosse

-Digoxin toxicity is only time you do not want to use calcium for hyperkalemia

-Cyanide toxicity: lactate level. Tx with hydroxycobalamin. Other tx: nitrite (causes methemoglobinemia which then scavenges cyanide); thiosulfate, cyanokit (amyl nitrite, sodium nitrite, sodium thiosulfate)

-Antihypertensive overdose: hypotension possible but not common with ACE-I OD

-Few toxins cleared by HD: lithium, toxic alcohols, salicylates, theophylline

Geriatrics Lecture – Mentation

-Normal aging: slowed, need more time.

-Confusion, problems with judgement not normal

-Dementia progresses over years vs delirium acute change in things like attention, falling asleep, disorganized thinking or altered level of consciousness

-Delirum causes – several, but think of infection, meds, seizures, intracranial bleed, NPH

-Can use ADEPT Tool to assess change in mental status

-Use smaller doses of medications for elderly

-If need meds for agitation ex: Haldol 0.5 mg (IV,IM,PO), Seroquel 12.5 mg, Olanzapine 2.5-5 mg, Risperidone 0.25-0.5 mg

Decompensated Cirrhosis – Dr. McGee

-Have high index of suspicion for cirrhosis – use clues from exam and labs

-Search for underlying etiology of portosystemic encephalopathy, GIB, etc.

-Diagnose and treat SBP: diagnostic paracentesis with >250 PMNs, Ceftriaxone 2g Q24 hrs, Alubmin 1.5g/kg on day 1 reduces mortality

-GIB: early GI consult; varies 15-30% risk of death. 2 large bore IVs, cultures, ceftriaxone (or broader), keep Hb around 7. correcting INR with FFP not recommended, transfuse if plt <50 K, cryo for fibrinogen <100. Protonix, octreotide. Blakemore tube if needed.

-Hepatorenal Syndrome: High index of suspicion, Cirrhosis and Cr >1.5. If cirrhotic with AKI, use albumin 5% if hypovolemic, 25% if euvolemic/hypervolemic, non ICU midodrine and octreotide; if ICU levo with MAP >85.

-Medications to AVOID: Never NSAIDs, if opiates needed then fentanyl > Hydromorphone > morphine, avoid benzos as much as possible; can give Tylenol up to 2 g/day

MICU Follow Up – Hypothermia

-ECMO (if available) may be best way to rewarm, 7-10 ⁰C /hr

-Thoracic lavage up to 6 ⁰C/hr

-If coding, can attempt defibrillation x 3; rewarm to at least 86 ⁰ F

-Try to avoid stimulating heart, if need central access, fem line is best

-Rewarming complications include several electrolyte/coag abnormalities; check frequently

-Goal rewarm temp is 86-89 ⁰F

Neuro Cases

1. Stroke in Sickle Cell

-Neuro/hem consults early

-Exchange transfusion as treatment

-Can use upper motor neuron/lower motor neuron signs to help delineate where problem is

ex. UMN: +Babinski, spasticity, hyperreflexia ; LMK: Fasciculations, hypotonia, hypo/areflexia

2. Posterior Circulation Strokes

-Several symptoms: vertigo/dizziness, imbalance, unilateral limb weakness, dysarthria, diplopia, nystagmus, n/v, dysphagia

-HINTS exam can be used if symptomatic (Head Impulse, Nystagmus, Test of Skew)

-Subclavian Steal Syndrome: suspect in a patient with vertebrobasilar territory neuro sxs, arm claudication (exercise-induced arm pain or fatigue; coolness or paresthesias in extremity)

3) tPA

-BP goals for tPA administration <180/110 – may use Labetalol/Nicardipine for BP control

-Know some of the absolute contraindications; ex: any hx of intracranial hemorrhage, BP >180/110, known bleeding diathesis (platelet count <100,000; use of warfarin with INR > 1.7, use of DOACs) Can use MDCALC to run absolute/relative contraindications

-tPA symptom onset < 4.5 hours (prefer <3 hours esp in those >80 years)

Geriatrics Lecture

4 M’s for the ED: Medications

-Medications/polypharmacy should be high on differential for acute change in elderly

-1/3 of elderly patients lose independence in at least 1 activity when admitted

-Several meds are problematic; warfarin, ASA, plavix, digoxin, metformin and other diabetic medications, antibiotics

Room 9 Follow Up Case – Massive Hemoptysis

-Massive hemoptysis, no clear consensus definition. 100-1,000 mL/24 hours or >50 mL in a single event – really any bleed that is life threatening due to airway obstruction, hypotension, or blood loss

-Usually arises from bronchial circulation; MCC usually TB, bronchiectasis, lung abscess, bronchogenic carcinomas

-Airway protection: if having difficulty clearing airway or hypoxic/dyspneic, prepare for difficult intubation; intubation of mainstem of the good lung; can do this via going past the cords and turning ET 90 degrees; have patient lay on side of the bad lung

-TXA: nebulized TXA with 1 g TXA in 10 cc saline. Can also do 500 mg TID. Systemic route also an option, 1gm load in 100 mL NS over 10 minutes and 1 gm over 8 hours.

-Bronchoscopy and CT; CTA may help identify source; consults to consider early: Pulm, IR or CT surgery

EMS Lecture- PreHospital Stroke

-Several scoring systems (RACE, Stroke VAN, FAST-ED, CSTAT, LAMS) to help guide pre-arrival notification and transport to comprehensive stroke center

-CSTAT: Cincinnati Stroke Triage Assessment Tool, Screen for Large Occlusion Strokes >/= 2 is positive

Conjugate Gaze Deviation 2 points

Incorrectly Answers Age or Month and Does not follow at least one command (close your eyes, open and close your hand) 1 point

Arm (right, left or both) falls to the bed within 10 seconds 1 point

-Mobile stroke units – can decrease time to stroke tx by 50%, 20 units worldwide, CT scanner in back; tremendous expense without great improvement in outcomes

-tPA goal 60 minutes door to drug.

Hey I was going over some articles with a friend for Board Prep. Check out a few valuable figures from the papers:

• TIA Management. Think about the mimics. High risk for stroke if true TIA.

Edlow JA. Managing patients with transient ischemic attack. Ann Emerg Med 2018 Mar;71(3):409-15.

• Cord Compression Diagnosis and Treatment. Steroids only for malignancy. Keep BP up, ABx when indicated, and call the surgeon!

Ropper AE, Ropper AH. Acute spinal cord compression. N Engl J Med 2017 Apr;376(14):1358-69.

• Algorithm approach for New Onset Seizure. Anticonvulsants recommended even for first time IF epilepsy diagnosed.

Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA 2016 Dec;316(24):2657-68

• Outcomes with Endovascular stroke therapy in hours 6-16. This is why we room 9 strokes outside of the tPA window.

DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018 Feb;378(8):708-18

Trauma Conference – Amanda Corzine

• Domestic violence underreported in Louisville and nationally
• SANE and CWF are important resources to use here
• Have increased concern for women that present intoxicated on alcohol with no prior history of intoxications – be informed about domestic violence; Dr. Coleman has done research looking at the coincidence of domestic violence in this patient population

MICU Case Review – Royalty

• Patient with AMS, seizure-like activity. PMH of COPD on home O2, HFpEF, HTN, T2DM, Afib on AC, intubated prior to ICU
  • Subsequently COVID+ on floor transfer; sent back to MICU
  • Intubated again. Started on Remdesivir, Dexamethasone. Code during intubation.
  • Ultimately complicated course of Afib management and thrombocytopenia
  • +trop in trending labs q48h in COVID patient; cards consulted.

DED/72H Returns – Staben

• Remember to get labs in hypothermic patients who have arrested – it can lead to more appropriate prognostication and cessation of futile codes. K>12 means further resuscitative efforts are futile.
• Reviewed Brain Trauma Foundation guidelines regarding surgical management of acute SDH
• Remember to do indicated procedures like bilateral chest tubes or finger thoracostomy in blunt traumatic arrest even in seemingly futile cardiac arrest as these patients can have occult injury.

2-10-2020 Conference Notes

GME disability discussion – Calvin Rasey

• Endorsed by UofL
• COVID long term effects “long haulers.”

Pediatric Fractures – Elizabeth Lehto

• Torus fracture
• Plastic deformation, kids < 4
  • Generally associated fractures
  • >20 degrees of angulation require reduction
• Greenstick, kids < 10
  • Convex surface fracture
• Complete fractures
• Salter-Harris Fracture – SALTER vs know your MEME
  • I – Straight through the growth plate, may be radiographically absent
  • II – Above, through the growth plate and above into the metaphysis
  • III – Lower, fracture through growth plate and epiphysis
  • IV – Through both epiphysis, growth plate, and metaphysis
  • V – Rammed, growth plate crush injury
• Name that fracture game
• Elbow fractures
  • Capitellum – age 1
  • Radial head – age 3
  • Internal  epicondyle – age 5
  • Trochlea – age 7
  • Olecranon – age 9
  • External epicondyle – age 11
  • Need true 90 degree flexion X-rays – don’t get lazy with them.
    • Anterior fat pad – normal
      • Big sail sign = lipohemearthrosis
    • Posterior fat pad – pathological
    • Radiocapitellar Line
    • Anterior humeral line
  • Supracondylar fractures
    • Volkman’s Contracture if neurovascular injury
    • Anterior interosseous syndrome – normal if a good “okay sign”
  • Nursemaid’s elbow
• Non-accidental trauma
  • Torso, ears, neck, 4 years or younger
  • Watch out for kids that aren’t pulling up or walking – they should not have any bruises.
  • High specificity fractures
    • Metaphyseal fractures
      • Corner fractures – oblique avulsions of the metaphysis
      • Bucket handle fractures – horizontal avulsions of metaphysis
    • Rib fractures
      • Posterior more specific; CPR causes anterior rib fractures
    • Skull fractures
      • Non-parietal, cross suture lines, depressed
    • Scapular fractures
    • Sternal fractures
    • Spinous process fractures
• Leg fractures
  • Tibial fractures
    • High risk for compartment syndrome
      • Tibial shaft fractures requiring reduction tend to be admitted
    • Toddler’s fracture – distal shaft spiral/oblique fracture between 9-3 years
  • Juvenile Tillaux fracture – SH III
    • May require CT to evaluate closed vs open reduction, <2mm can be reduced
  • Triplane fracture, distal SH IV  – requires CT
• Hand fractures
  • Carpal fractures
    • Scaphoid fracture, think FOOSH, snuffbox tenderness
  • Distal phalanx fractures
    • Tuft fractures, splinted in DIP extension
    • Nailbed associated fractures – give abx
    • Seymour fracture – displaced SH II fracture, generally open, and requires reduction.
• Hip fractures
  • SCFE
    • Fat teens presenting with knee pain
    • Surgical pinning and NWB
  • Avascular necrosis – Legg-Calve-Perthes Disease
    • Preteen, insidious onset, antalgic gait

GI Review Game – Dr. Shaw

• NEC – new babies, mostly premature, pre-E, cocaine use in pregnancy
  • Amp/Gent, bowel rest
• Giardia – treat with flagyl
• Boerhaave – L pleural effusion, CXR with pneumomediastinum
• Esophageal foreign bodies
  • Esophageal bodies align in coronal plane
  • Sharp objects, objects > 6cm in length require surgical removal, then 24h trial of passage
  • All EFB require GI f/u to rule-out structural abnormalities
• AAA
  • >5.5cm = OR, include the mural thrombus
• Hernias
  • Indirect vs direct vs femoral hernias
    • Indirect follows inguinal canal

Ventilator Management Lecture – Obrien

• Check out Scott Weingart’s post on EMcrit regarding mastering the vent.
• PRVC or VC is preferred
• Remember ARDSNet

Intern Lightning Lectures – Schutzman, French, Strohmaier

• Positively electrifying.
• Acid-Base Status
  • Bicarb vs respiration vs buffers control pH
  • Delta gap in context of AGMA  – (AG-12) – (24-Bicarb)
    • Normal -6 to +6
    • Can indicate AGMA +NAGMA superimposed or vice versa.
• Unstable C-spine fractures
  • Denis Column Concept
    • Anterior column – always stable
    • Middle column – sometimes stable
    • Posterior column – always unstable
  • Jefferson’s Fracture
    • Consider vertebral artery injury
  • Bilateral Facet Dislocation
    • Consider CTA C-spine, MRI may be warranted as SCI strongly associated
  • Odontoid Fracture
    • Types I, II, III
  • Atlanto-Occipital Dissociation
    • Calculate that Power’s ratio, folks.
  • Atlanto-Axial Dislocation
    • Remember increased likelihood in some populations; Trisomy 21, OI, Marfan, NF1, SLE, AS, psoriasis, RA
  • Hangman’s Fracture
    • C2 fx with anterior displacement
  • Flexion Teardrop
    • Can disrupt posterior longitudinal ligament, high association with anterior cord syndrome
• DRESS vs SJS vs TEN
  • DRESS – drug rash with eosinophilia – morbilliform rash
    • Remember herpes reactivation
  • SJS/TEN
    • Mucosal involvement

Can’t Miss EKG Review – Huecker

• Didn’t miss a beat.
• Read Amal Mattu. If you don’t, you won’t understand EKGs very well
• He’ll send out his presentation

Test Taking Strategies – Shreffler

• 225 multiple choice questions, 4.5 hours to complete
• Feel okay to change answers after you re-read questions; you will likely have more insight later on.
• He will send out his presentation

Headaches in Small Groups – Nichols

• HA1
  • Temporal Arteritis
    • Get ESR, can do US vs MRI, will require temporal artery biopsy
    • Ophtho involvement means a larger burst x3 days of methylprednisolone, likely requires admission
• HA2
  • CO poisoning
    • Need ABG with co-oximetry
    • Consider EKG and troponin
    • Remember fetal Hb binds CO much more preferentially than maternal Hb, so lower threshold to treat with hyperbarics.
• HA3
  • Epidural hematoma
    • Consider BP goals, mannitol/3%, elevate HOB, hyperventilate

Procedural Review – Baker

• Excellent multiple choice questions.
• SBP
  • Remember albumin, get abx early
  • Low thresholds for diagnosis with cell count greater than or equal to 100 in peritoneal dialysis
  • We need to do more paracentesis
• LP
  • Watch that bevel
  • Platelets > 20/25, INR >=1.5
• Pacemakers
  • RIJ
  • Transvenous: 80 BPM, 20mA, 20cm
• Thoracotomy
  • >1500 initial output, >200mL over first 3 hours
  • 5^th intercostal space
• Yolk sac + gestational sac required for confirming IUP earliest.

Check out this article on the 10 commandments of our specialty. This is a revision of the original 10, which was published 30 years ago. Not much has changed on these bedrock principles. Check it out.

• Termination of resuscitation (Nichols)
  • When to stop resuscitation in out of hospital arrest
    • DNR order
    • No chance of saving them–safety, signs of irreversible death
    • Nothing left to do–unwitnessed arrest, no shockable rhythm, ROSC does not return in the out of hospital setting
  • Stop CPR if:
    • No ROSC
    • No shocks
    • Unwitnessed
• CCU follow up (French)
  • Arrhythmogenic RV dysplasia
    • 2nd MCC sudden cardiac death in young patients
    • Greek or Italian descent
    • Male:Female= 3:1
    • Presentation
      • Asymptomatic
      • Palpitations
      • Syncope
      • Ventricular dysrhythmias/cardiac arrest
      • FH of unexplained syncope/sudden death
      • RV failure
    • Cards consult–>admission
    • Arrhythmogenic RV dysplasia EKG: V1-V3 T wave inversions, epsilon wave
    • HOCM EKG changes: high voltage, LVH, lAD, tall R wave V1
• MICU follow up (Schutzman)
  • Myxedema coma
    • Hypotension
    • Bradycardia
    • Electrolyte derangements
    • Altered mental status
    • Give levothyroxine
• Jeopardy (Daughtery)
  • Activated Charcoal
    • Adsorbs toxins and inhibits GI absorption
    • Must be given in 1-2 hours, but still consider if ingested drug is extended release
    • Contraindications: GI perforation, need for endoscopic procedures
    • Concerns: emesis, CNS depression and aspiration risks
    • Consider risk vs benefit of administration
  • Deferoxamine
    • MOA: complexes with trivalent ions (ferric ions) to form ferrioxamine which is eliminated in urine by the kidneys
    • Indications: iron level >500, metabolic acidosis, lethargy/coma, shock, toxic appearance
    • Can cause urticaria, flushing of skin, hypotension, shock with rapid IV administration, ARDS
  • Itralipids (lipid emulsion)
    • Reversal of local anesthetic systemic toxicity
    • Consider for severe hemodynamic compromise of lipophilic xenobiotics or drugs with significant neurological or CV toxicity–last line
    • 20% emulsion solution
  • Phentolamine
    • MOA: competitively blocking alpha adrenergic receptors
    • Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation
    • Concerns: hypotension, medication safety
  • Levocarnitine
    • Antidote to valproic acid
    • Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity
  • Naloxone for clonidine reversal
    • Big doses- 10mg
    • Consider for reversal of CNS depression 
    • Fluids and vasopressors may also be required
  • Benzodiazepines
    • Midazolam: IV onset of action 2 min
    • Lorazepam: onset of action 5-20 minutes
  • Physostigmine 
    • Reversal of anticholinergic toxicity
    • Primarily for agitation and delirium reversal
    • MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine
    • Have physician and atropine at bedside
    • No significant risk of seizures
    • Low dose, push slow
  • Flumazenil
    • Benzodiazepine overdose or reversal only
    • Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex
    • Not effective on other medications that affect GABA
    • Concerns
      • Could precipitate withdrawal seizures if patient regularly uses benzos
      • Seizure history outside of withdrawal seizures
      • Risk vs benefit–goal of therapy
• Project ECHO
  • Optimal Aging Clinic will be added to discharge follow up options
  • Have a “what matters” conversation
  • Advance Directives
    • Living will
    • POA
    • POLST/MOST
    • EMS DNR
  • Advanced care planning–ICD code, must spend 16 minutes to bill
  • MOST form
    • A physician’s order
    • Must be honored by all KY healthcare providers in all KY settings
  • State of KY Hierarchy of Decision making authority if no advance directives
    • Court appointed guardian
    • Healthcare surrogate
    • Spouse
    • Adult children
    • Parents
    • Adult siblings
    • Closest living relative
• ECMO (Ritchie)
  • Components
    • Motor/pump
    • Filter/oxygenator
    • Blender
    • Ventilation–to increase, go up on gas flow aka sweep
    • Oxygenation–to increase, go up on blood flow aka flow
    • Cannulas (single vs double)
    • Circuits
      • Vein-Vein ECMO
        • Is the heart still able to pump
      • Vein-Artery ECMO
        • Heart pump function not ideal
      • Vein-Artery-Vein ECMO
  • VV ECMO 
    • Indications
      • Hypoxic respiratory failure, 50% mortality risk consider ECMO
      • Hypoxic respiratory failure, 80% mortality risk, put on ECMO
      • CO2 retention on mechanical ventilation despite high Pplat
      • Severe air leak syndromes
      • Need for intubation in a patient on lung transplant list
      • Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)
      • Anytime patient is on dangerous vent settings
    • Murray Score: conventional ventilation or ECMO for severe adult respiratory failure 
      • Score of 3–consider transfer to ECMO center
      • Score of 4– ECMO indicated
    • Contraindications
      • No absolute contraindications
        • Mechanical ventilation at high settings for 7 days or more
        • Major pharmacologic immunosuppression
        • CNS hemorrhage that is recent or expanding
        • Non-recoverable co-morbidity
    • When making the decision to begin ECMO
      • Is this condition reversible?
      • Is it a bridge to transplant?
      • RESP score (estimated survival once on VV ECMO)
    • ARDS
    • Ventilator trauma
      • Volutrauma
      • Barotrauma
      • Atelectrauma
      • Biotrauma (cytokine storm, inflammation)
      • Energytrauma (goal for driving pressure 15 or less)
    • Settings once cannulation successful
      • Set flow: 4L
      • Set Sweep: 4L
      • Lung rest settings while on ECMO
      • PC 10/10/10/40%
      • Goals
        • Sat >85%
        • MvO2 >65%
  • VA ECMO
    • Indications
      • Heart failure bridge to recovery, heart transplantation, VAD
      • Cardiogenic shock
      • Myocarditis
      • ECPR
      • Right heart failure
      • PE
      • Medication overdose
    • SAVE score
  • Trans pulmonary pressure
    • Consider in morbidly obese patients
    • May have higher PEEP requirements given pressure from chest wall/abdomen
    • When intubated, they lose the ability to autopeep
  • Page Jewish thoracic or cardiac surgery –consult early

• ITE- grab bag (E Thomas)
  • Spider bite, necrotic wound>brown recluse
  • MCC erythema multiforme> HSV
  • Strawberry cervix>trich
  • Pre-E, less than 24 weeks>mole pregnancy
  • Abdominal pain after sex>ovarian torsion
  • Most common personality disorder>borderline
  • Patient intentionally fakes symptoms>malingering
  • Sudden paralysis after traumatic event>conversion
  • Discriminatory zone for TVUS>1500
  • PID/RUQ pain/shoulder pain>Fitz Hugh Curtis
  • MCC postpartum hemorrhage>uterine atony
  • Pizza pie fundus>CMV
  • Corneal dendrites>HSV keratitis
  • Tachycardia out of proportion to fever>thyroid storm
  • Alcohol, AMS, ataxia, nystagmus>wernicke
  • Stingray wound>hot water
  • Beta blocker OD>hypoglycemia
• One Pill Can Kill (Lund)
  • Ingestions–fatal in small doses
    • CCB
    • Cyclic antidepressants
    • Lomotil
    • Opiates
    • Salicylates
    • Toxic alcohols
    • Sulfonylureas
    • Camphor
    • Clonidine
    • Antimalarials
  • CCB OD
    • Hypotension, bradycardia, bradydysrhythmias, hyperglycemia
    • Tx: charcoal, fluids, atropine, calcium, intralipid
  • Salicylates
    • Oil of wintergreen, ASA, pepto-bismol
    • n/v, tinnitus, delirium, hallucinations, pulmonary edema, cerebral edema, mixed anion gap metabolic acidosis with respiratory alkalosis
  • Sulfonylureas
    • Hypoglycemia, lethargy, irritability, confusion, HA, seizures
    • Tx: observation x24 hrs
    • Dextrose bolus, then consider infusion
    • Can give octreotide (inhibits secretion of insulin)
  • Clonidine
    • Alpha 2 agonist, (afrin, visine)
    • Opioid syndrome: lethargy, coma, miosis, respiratory depression
    • Tx: naloxone, atropine, IV fluids, inotropes
  • Camphor
    • Campho-phenique, vicks vaporub
    • GI distress, generalized warmth, CNS hyperactivity, CNS depression, n/v, oropharyngeal irritation/burning/stinging
    • Tx: benzos, phenobarb
  • Amitriptyline
    • CNS depression, seizures, cardiac conduction abnormalities (QRS prolongation), hypotension, mydriasis, flushing, dry mucous membranes, hallucinations, hyperthermia
    • Tx: benzos for seizures, sodium bicarb for QRS widening >100ms
  • Lomotil
    • Opioid receptor agonist +/-atropine
    • Classically biphasic, with anticholinergic symptoms 2-3 hours s/p ingestion followed by opioid symptoms
    • Tx: naloxone
    • Dispo: admit
• Toxic Alcohols (Bosse)
  • Ethanol
    • Can cause hypoglycemia
    • Is dialyzable
  • Isopropanol
    • Rubbing alcohol
    • Metabolized to acetones
    • No metabolic acidosis
    • Supportive treatment, can be dialyzed
  • Methanol
    • Windshield washer fluids, solid cooking fuel, embaling fluid, tainted beverages
    • Toxic metabolite is formate (formic acid)
    • CNS effects, visual effects, pancreatitis, symptoms delayed in onset
    • Metabolic acidosis with elevated anion gap
  • Ethylene glycol
    • Antifreeze (sweet taste)
    • Toxic metabolites: oxalate, glycolaldehyde, glycolic acid, glyoxylic acid
    • CNS effects, metabolic acidosis, renal toxicity, myocardial dysfunction
    • Oxalate can cause hypocalcemia by calcium oxalate precipitation
    • Oxalate crystals in urine
    • Wood’s lamp to urine, antifreeze products may contain fluorescein, not a great test
  • Osmol gap
    • Difference between measured serum osmolality and calculated serum osmolarity
    • Normal serum osmolality: 275-295 mOsm/kg
  • Antidotes
    • Ethanol, fomepizole
    • Competitive inhibitors of alcohol dehydrogenase
    • If ethanol must be used, give orally. Keep blood level >100mg/dL
    • Treat if methanol or ethylene glycol level >20mg/dL
    • Can be stopped once level less than 20mg/dL
    • Dialysis
      • Consider if patient has end organ manifestations (even if levels undetectable)
    • Folic acid for methanol
    • Thiamine and pyridoxine for ethylene glycol
  • Send methanol and ethylene glycol levels ASAP

• Aspirin Toxicity (Harmon)
  • Sources of salicylates
    • Aspirin
    • Oil of Wintergreen
    • Pepto-Bismol
    • Bengay
    • Alka-Seltzer
    • Skincare products
  • Mechanism of toxicity
    • Fatal dose 10-30 g in adults
    • Dose dependent
    • Acute vs chronic
    • Increases respiratory center sensitivity, uncouples oxidative phosphorylation, inhibits TCA cycle/amino acid metabolism, stimulates chemoreceptor/trigger zone
  • signs/symptoms
    • Tinnitus, nausea, vomiting, dizziness, fever
    • Ataxia, anxiety, lethargy, AMS, seizure, arrhythmias, seizure
  • Evaluation in ED
    • Serum salicylate concentration and trend
    • ABG
    • CBC, CMP, coags, EKG, UA, tox
  • Management
    • Gastric decontamination (ingestion w/in past 1-2 hours)
    • Sodium bicarb (consider if level >40)
    • Avoid intubation as long as possible
    • Fluids
    • HD
    • Poison Control
• Acetaminophen Toxicity (Cook)
  • Signs/Symptoms
    • Stage I: anorexia, n/v, elevated transaminases
    • Stage II: RUQ pain, elevated transaminases
    • Stage III: hepatic failure, acidosis, renal failure, pancreatitis, peak transaminase levels
    • Stage IV: multi-organ failure vs resolution
  • Lab Assessment
    • APAP levels
      • Within 1-4 hrs of ingestion, used to exclude ingestion
      • Obtain 4 hour level to get estimated peak absorption
    • CBC, CMP, ABG
  • Rumack Matthew Nomogram
    • Treatment line 
      • begins at 4 hr mark
      • If above line, treat
  • Treatment
    • Activated charcoal
    • N-Acetyl Cysteine
      • Replenishes glutathione stores to conjugate NAPQI to limit hepatocyte injury and promote renal excretion
• TCAs (Weeman)
  • MOA
    • SSRI/SNRI, antihistamine, alpha antagonist, anti-muscarinic 
  • Symptoms
    • Early: anticholinergic effects, HTN, AMS
    • Late: myocardial suppression, QRS widening, seizures, ventricular dysrhythmia, hypotension
  • Mimics: diphenhydramine, carbamazepine, sympathomimetic toxicity, serotonin syndrome
  • Assessment
    • EKG, UDS, TCA level (does not correlate with severity)
  • Management
    • Activated charcoal if within 1 hour of ingestion
    • Do not treat early HTN as patients will likely develop hypotension as they progress, treat hypotension with normal saline
    • Sodium bicarbonate
      • IV push if QRS exceeds 100 msec
      • Infusion to maintain pH 7.5-7.55
    • If seizing, use IV benzos or phenobarbital if refractory
• Clinical Pathway Opioid Overdose (Leavitt, Sizemore)
  • Duration:
    • Heroin half life: 3-8 min, metabolites ~3hrs
    • Fentanyl half life: 2-4 hrs
    • Oral opioid half life: 3 or more hours
  • Narcan
    • Opioid antagonist
    • In general, don’t exceed ~5-10 mg, but can titrate to effect
    • Route
      • IN/IM/SC: slower onset, longer duration
      • Intranasal can last ~3hrs
      • IV
      • Infusion: 
        • Mix 4mg naloxone in 100 mL D5W
        • Infusion rate at ⅔ of effective dose that initially reversed the patient
    • Can repeat dosing every 3 minutes 
  • St. Paul’s Early Discharge Rule
  • HOUR Study
  • Clinical Pathway to be posted soon
• Envenomation (Giddings)
  • Ciguatera
    • Heat stable toxin
    • Barracuda, red snapper, mostly reef/tropical fish
    • GI symptoms, paresthesias, hot/cold reversal, bradycardia
    • Treatment: antiemetics, atropine, mannitol
    • Mechanism: increases permeability of sodium channels inducing membrane depolarization
  • Scombroid
    • Caused by improperly stored fish, heat stable toxin
    • Symptoms: flushing, warmth, urticarial rash, palpitations, itching
    • Causes histamine release
    • Tx: antihistamine
  • Coral Snake (Elapidae)
    • Presentation: minimal local symptoms, severe systemic symptoms, respiratory paralysis, AMS, CN palsies
    • Complications: hypovolemic shock, DIC
    • Work up: CBC, CMP, coags, fibrinogen, d-dimer
    • Treatment: anti-venom, aggressive supportive care
    • Dispo: Admit, concern for neurotoxic effects including respiratory failure, can have delayed presentation
    • Mechanism: cholinergic
  • Crotaline (Pit Vipers)
    • Presentation: Local pain/tissue damage, fang marks, coagulopathy, weakness, n/v
    • Complications: swelling, compartment syndrome, DIC, hypotension
    • Treatment: CroFab (give if bad systemic symptoms, abnormal labs, AMS, significant swelling)
  • Black Widow
    • Presentation: Pinprick bite, pain to whole extremity, muscle cramps, tachycardia, hypertensive, can mimic appendicitis
    • Management: supportive care, antivenin for severe symptoms
  • Tarantula
    • Barbed hair, can penetrate cornea, may need ophthalmology consult
    • Supportive care
  • Brown Recluse
    • Painless bite, local tissue necrosis
    • Systemic effects are rare
    • Treatment: supportive
• High Altitude Medicine (Thurman)
  • Physiology
    • High Altitude: 1500m, Very High: 3500m, Extreme: 5500m
    • Begin to see altitude illness at around 2500m/8000ft
    • As altitude increases, percentage of oxygen available decreases
  • Acclimatization
    • Respiratory compensation by increasing minute ventilation, which decreases PaCO2
    • Renal compensation by increasing excretion of bicarbonate
      • Associated diuresis can exacerbate altitude illness and increase dehydration
  • Acute Mountain Sickness
    • Headache, GI symptoms, fatigue/weakness, dizziness/light-headedness
    • Prevention (ideally start 1 day before trip, continue 1-2 days after patient is at highest altitude)
      • Acetazolamide 125 mg q12hr
      • Dexamethasone 2mg q6hr or 4mg q12hr
      • Gradual ascent
      • Ibuprofen 600 mg q8hr
    • Treatment
      • Halt ascent until symptom free
      • Only need to descend for severe symptoms
      • Supplemental oxygen, dexamethasone, acetazolamide
  • High Altitude Cerebral Edema
    • Acute mountain sickness + mental status change, ataxia
    • Treatment
      • Immediate descent/evacuation
      • Supplemental oxygen
      • Dexamethasone
      • Portable hyperbaric chamber
      • Acetazolamide 
  • High Altitude Pulmonary Edema
    • Non-cardiogenic pulmonary edema
    • Symptoms (need at least 2)
      • Dyspnea at rest
      • Cough
      • Chest tightness/congestion
      • Weakness/decreased exercise tolerance
    • Signs (need at least 2)
      • Crackles or wheeze
      • Central cyanosis
      • Tachypnea
      • Tachycardia
    • Prevention
      • Gradual ascent
      • Nifedipine 30 mg q12hr or 20 mg q8hr
      • Tadalafil/Sildenafil
    • Treatment:
      • Immediate descent
      • Supplemental oxygen
      • Nifedipine
      • Portable hyperbaric chamber
      • tadalafil/sildenafil
      • CPAP
• COVID (Brown)
  • Symptoms
    • Typical of most viral syndromes
  • Lab abnormalities
    • Elevated WBC, LDH, d dimer, ferritin, ESR/CRP, procal, ALT/AST, t bili, troponin, CK
    • Low lymphocyte count, albumin, platelet count, hemoglobin
  • Imaging
    • Normal vs bilateral pulmonary opacities
  • Airway management
    • Pre-oxygenate with NRB or HFNC
    • Consider supraglottic airway with viral filter
    • Video laryngoscopy
    • Trial HFNC or non-invasive ventilation prior to taking airway
    • Low tidal volumes, permissive hypercapnia, ARDSNet protocol
    • Consider proning
  • Treatment
    • Supportive treatment
    • Bamlanibimab
    • Dexamethasone
    • Remdesivir
    • DVT ppx if hospitalized
  • Disposition
    • Walking O2 test
    • 4C mortality score
• Pacemakers (D. Thomas)
  • Prevent HR from falling below set limit
    • Pacing
    • Sensing
  • Malfunction
    • Failure to capture
      • Low battery
      • Inflammation
      • Loose or displaced lead
    • Sensing issues
      • Undersensing
      • Oversensing 
  • Management
    • Typical bradycardia management
    • Atropine, epinephrine, transcutaneous pacing, transvenous pacing
  • Magnet placement
    • Opens Reed switch with breaches sensing circuit and will pace regardless of intrinsic cardiac activity 

2020 AHA Guidelines (Dr. Price)

• Confirmation
  • CPR depth 2 to 2.4
  • CPR Rate 100 to 120
• New changes
  • Recommend lay rescuers initiate CPR for presumed cardiac arrest
  • Double sequential defibrillation for nonresponsive vfib/vtach not recommended anymore
  • Reasonable to attempt IV access prior to IO access first
  • Recommending epinephrine in non-shockable rhythms as soon as possible
  • Give epinephrine for shockable rhythm after defibrillation fails
  • Recommends against use of POCUS for prognostication, can be used to detect ROSC. 
  • Delay neuro-prognostication in coma for 72 hours
  • Should avoid excessive ventilation during cpr- causes harm
  • Amiodarone or lidocaine may be considered for CF/pVT unresponsive to defibrillation
  • Routine administration of Ca, NA bicarbinate, Magnesium not recommend in cardiac arrest
• Pediatric changes
  • 1 breath every 2-3 seconds (20-30 breaths per minute)
  • Reasonable to use Cuffed- ET tubes
  • Epinephrine may increase survival to discharge rates (unlike adults)
• Field termination rule
  • If patient had arrest not witnessed, no bystander CPR, No ROSC, No shock was delivered can consider stopping. 

Sickle cell disease in pediatrics (Amar Singh)

1. Vasocclusive pain crisis
   • Causes- sickling leads to occlusion leading to ischemia and pain. 
   • Dactylitis- sickling and infarction of hands. Usually first presentation in kids 6months to 2 years of age
   • Mgt: Fluids and pain control with NSAIDS/narcotics
2. Stroke- 300 fold increase risk . 
   • Tx is exchange transfusion and hydration. TPA not recommended. 
3. Acute chest syndrome
   • Pulmonary infiltrate and any respiratory symptom. Indicative of infection and or infiltrate. 
   • Mgt: 02, hydration, antibiotics, blood transfusion or exchange transfusion. 
4. Splenic sequestration
   • See acute hemoglobin drop at least 2 points with LUQ pain, splenomegaly
   • Tx: IVF with blood transfusion, find underling cause (Likely infection)
5. Sepsis
   • Streptococcus pneumonia- most common cause of sepsis in asplenic patient. 
   • Other encapsulated Strep, H.Flu, salmonella, ecoli.
   • Increased risk for salmonella osteomyelitis 
6. Aplastic Crisis 
   • Commonly caused by parvovirus b-19 with marked severe anemia with decreased reticulocyte count. 
   • Mgt- transfusion and IVIG to help clear parvovirus infection. 

Hyperglycemic emergencies (Dr. Mcgee)

1. DKA
   • Hyperglycemia >250mg/dl
   • Ketonemia- produced by excessive breakdown of fatty acids (includes acetoacetate, acetone, BHOB)
   • Acidosis pH <7.3
     • Can be normal 2/2 to compensation and contraction alkalosis, elevated anion gap may be only clues
   • Other types of ketoacidosis    
     • Alcoholic ketoacidosis, starvation ketoacidosis, isopropyl alcohol ingestion (ketonemia)
   • Mgt: focus should be on closing the gap. 
     • 1. Volume repletion most patients 3-6L down. When sugars < 250 include dextrose containing fluids. 
     • 2. Electrolyte repletion K<3.5 consider stopping insulin, K3.5 to 5.5, consider adding K to fluids 20-30meq/L. <5.5 no need to add potassium. Check Mg, Phos levels as well. 
     • Insulin drip >1units/kg dose. Switch to subQ after gap normalized and bicarbonate normalized. 
2. Hyperosmolar hyperglycemic state
   • Triad
     • Severe hyperglycemia (> 600 usually)
     • Elevated serum osmolality (>320 osm/kg)
     • Altered mental status 
   • Treat similarly to DKA, usually require more fluids as patients more dehydrated.  

Resuscitative Hysterotomy (Ben Turner and Harrison Brown)

1. Indications to do
   • Maternal cardiac arrest without ROSC within 4 minutes
   • Estimated gestational age of infant >20 weeks (fundus > 20 cm)
   • Not necessary to document FHT prior to procedure.      
2. Contraindications 
   • Known age < 20 weeks
   • ROSC within 4 minutes of arrest
3. Procedure
   • https://www.youtube.com/watch?v=IwDWv2iyAos

• Secrete meeting of the minds.

Pelvic inflammatory disease (Alaina Royalty)

• Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • Salpingitis, endometritis, myo/parametritis, and oophoritis
  • Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
  • Tubo-ovarian abscess is caused by direct extension
• Physical with pelvic with possible cervical motion tenderness Lower abdominal tendernes, Uterine and or adnexal tenderness, Mucopurulent discharge, Fever 
• DX: Sexually active women with lower abdominal pain without other cause found with PE with CMT, Adnexal tenderness, or uterine tenderness
• Tubo-ovarian Abscess
  • Dx via ct or US
  • Needs admission for IV antibiotics and OB/GYN Consult. Can have IR drainage. 
  • Predictors of failure of antibiotic treatment: WBC 16k or abscess > 5.2 cm 
• Outpatient management
  • Rocephin 250mg IM + Doxycyclin 100mg Po BID x 14 days with Metronidazole 500mg Po BID x 14 days
• Dispo
  • Admit of they have TOA, pregnant, cannot tolerate po, septic, failed outpatient antibiotics

Ovarian Torsion (Tyler Bayers)

• Ovary can rotate around suspensory ligaments or utero-ovarian ligament, compression of ovarian vein with leads to obstructed venous outflow leading to ischemia and necrosis
  • Risk factors mass >5cm, hx of cyst, ovarian malignancy, TOA, pregnancy
  • Presentation
    • 90% with pelvic pain, Adnexam mass, nausea and vomiting
    • Pearl- Right sided torsion more common due to presence of sigmoid colon on left  
  • Ultrasound- Evaluate for decreased venous/arterial flow
    • 2/3^rd might have normal flow
    • Can see enlarged unilateral ovarian volume
    • Lpelvic free fluid
    • Loss of echogenicitiy 
    • Whirlpool sign
  • CT
    • Can be used for evaluation of suspected torsoin, 
    • Sensitive for secondary findings in torsion
    • Can find ovarian enlargement, ovarian mass, distended pedical, lack of enhancement
  • Management
    • Pain and nausea control, transabdominal/transvaginal US, Emergent OBGYN consult
    • Definitive diagnosis by direct visualization

Bartholin Gland Cyst/Abscess (Dan Fischer)

• Ducts of the glands drain into posterior vestibule at 4 oclock and 8oclock positions. See mass near the posterior introitus medial to labia minora
• Usually sterile initially but can become infected
• Abscess- erythema, fluctuance, severely painful
• Dx- Clinical consider sti testing
• Tx: Word catheter placement 
  • Make small incision so that word catheter will not fall out
  • Drain abscess, explore wound
  • Place word catheter and inflate balloon with 2-4cc of water with blunt kneedle 
  • Keep in place for 4-6 weeks
  • Fllow up with gyn

HTN emergencies in Pregnancy (Joshua Sennets)

• Can occur from 20 weeks gestation to 6 weeks post partum
• Definition- new onset htn and proteinuria
• With severe features- new onset htn and signs of end organ dysnfucntion after 20 weeks gestation and up to 6 weeks gestation
  • Platlet <100,000, S CR >1.1, LFT >2X ULN, Palm edema, persistant headache, visual disturbance
• Labs: CBC, type and screen, Coags, Fibrinogen, CMP, LDH, Urine protein/creatine ratio, serum and urine tox
• Eclampsia- convulsive manifations of HTN in pregnancy
  • 60% antepartum, 20percent intrapartum, 20 percent post partum
• Manegement- ABCS, IV Magnesium, IV antihypertensvies, Fetal monitorinfg, 
• Magnesium
  • 4-6 gram in 15=20 min, repeat 2-4 gm LD PRN then 1-2/hr
  • Goal mag of 5-9 mg/dL
  • Monitor respiratory status and evaluate for decreased patellar reflexes
• BP control
  • Hydralzine, labetalol, nifedipine can all be used
  • 20mg IV labetalol, 10mg IV hydralazine, 10mg PO Nifedipine
  • Initiate for BP > 160mmhg

Cold Related Illness (MJ)

• Nonfreezing injury
  • Temp >32, wet exposure
  • Cold urticaicaria
    • Hypersensitivity to cold air/water
    • Treat like allergic reaction 
  • Paniculitis
    • Mild necrosis of subqutations fat
    • Seen more in kids, supportive care
  • Chilblains/pernio
    • Vasculitis causing tingling and numbness 12-24 hours post exposure with localized edema. After rewarming can see tender blue nodules. 
    • Supportive care, can use nifedipine for topical vasodilation, corticosteroids
  • Trenchfoot/Immersion Injury
    • Direct injury to the soft tissue from prolonged cold exposure
    • Stage 1 cold exposure-white
    • Stage 2 rewarming- mottled pale blue, pain and edema, can last  a few hours. 
    • Stage 3 hyperemia- severe burning pain, can last days to months. 
    • Rewarm slowely, can use vasodilators, cool if severe pain in hyperremia. 

Clinical Features

Classification

Visual determination of tissue viability is difficult in first few weeks; classify early injuries as superficial or deep

Biliary US (Dr. Baker)

• Tips
  • • Get sagittal view and transverse view 
    • X-7 technique- used phased aray probe and go 7 cm lateral to xiphiod process 
    • Have patient inspire, have them lay left lateral decubitus, can tilt feat down
  • Portal triad with common duct (normal <7cm you can have 1mm enlargement per decade of life), portal vein, hepatic artery
  • Cholelithiasis
    • See hyperechoic with posterior shadowing
    • Diagnosis cholecystitis: Gallstones, sonographic Murphy’s, Wall thickening >3mm, pericholecystic fluid

Emergency Delivery Small group (Aaron Kuzel)

A 26-year-old G1P0 38 weeks and 4 days female presents as a Code Green to the ambulance circle. The patient brought back to Room 9 for assessment. The patient states her “water broke” and it soaked through her pants. She is feeling contractions. Vitals are HR 120 BP 128/78 RR 24 SPO2 100% and T 97.6 F. On external vaginal exam you palpate a pulsating vessel in the vaginal canal and fetal head at 0 station.

●       What is the diagnosis? Umbilical cord prolapse

●       What is the most important next step in the management of this patient? Elevate presenting part to reduce compression and transport to OR for emergent c-section

●       What positions can you place the patient in to alleviate pressure on the protruding part? Knee to chest position, no pushing or Valsalva

A 27-year-old G1P0 at 37 weeks and 4 days is presenting in active labor to the emergency department. She is endorsing painful contractions that began within the last hour. Contractions are occurring every 2 minutes. Vitals are HR 106  BP 136/68 RR 18 SPO2 98% and T 98.8 F. Physical exam reveals fetal head crowning and bloody show. During delivery, you are able to advance the posterior shoulder, however as you attempt to advance the posterior shoulder the fetal head retracts. An episiotomy is made; however, you are still unable to advance the anterior shoulder.

●               What is the diagnosis? Shoulder dystocia

●               What is the most appropriate next course of action?HELPERR pneumonic. Chall for Help, Evaluate for episiotomy, Legs flex (Mcroberts maneuver), Pressure (suprapubic pressure), Entry maneuvers (Wood’s corkscrew or Rubin II maneuver, Remove posterior arm by sweaping it across chest, R Roll on all fours

●               What are some risk factors for this condition?Preterm labor, macrosomia, small materanal pelvis, prolonged labor

●               Failure to recognize this condition and correct it can have what damaging results? Fetal demise

●               Which of these three maneuvers is the most effective in relieving this condition? Roll on all four 

Case 3:

A 21 year-old G4P3 woman presents to your Rural Emergency Department in Ashland, KY in active labor and has a spontaneous vaginal delivery in the emergency department. Prenatal care was appropriate and the patient’s blood type is O-positive. The infant is full-term and well. An intact placenta passes shortly thereafter, followed by vaginal bleeding. There are no obvious lacerations to repair, and the bleeding appears to be originating from the cervical os. Vital signs are within normal limits. The patient continues to have oozing of blood from the vagina several minutes after birth.

What is the diagnosis? Post partum hemorrage

What is the most common cause of this diagnosis? Uterine atony

What is your next step in management? Bimanual massage,

What medications (and in what order) would you use to stop the bleeding? Pitocine 80units bolus IV or 10units IM, Misoprostol 600mcg SL or 1000mcg rectally

What is a rare complication of this diagnosis that results in high fetal and maternal death?Uterine rupture