I posted this paper and it’s revisited update on room9er about 3 years ago. July is always a good time for it!
The fundamentals do not change much!
I posted this paper and it’s revisited update on room9er about 3 years ago. July is always a good time for it!
The fundamentals do not change much!
Palliative care-
DNR/DNI-
Special Populations in the ED-
Systemic infections in children-
Operations updates-
Tuberculosis by Dr. Marks
Incidence decreasing in the US
Latent TB infection approx. 5% in US. 25% in world
PPD screening:
If >5 mm PPD and immunocompromised = positive
If >10mm and been to high risk country, healthcare worker, or IVDU =positive
Otherwise >15mm = positive
Primary TB usually asymptomatic,
If suspect TB, isolate
Sputum PCR
Gold standard is cultures (6-8wk turnaround)
For latent TP rifampin+isoniazid +pyridoxine for 3 moths
For active TB:
RIPE therapy 8 weeks
Rifampin , (orange urine, CP450 induction)
isoniazid, (B6 deficiency, seizures)
pyrazinamide (hepatotoxicity, hyperuricemia)
Ethambutol (optic neuritis)
Then rifampin/isoniazid for 18 more weeks
TB meningitis- RIPE + dexamethasone
Potts- RIPE + source control
Syphilis by Dr. Coffman
Incidence increasing since 1990.
Increasing in women. Congenital cases increasing.
Primary, Secondary, Tertiary
Painless ulcer on mucus membranes, rash involving hands and feet +nonspecific symptoms,
Jarisch Herxheimer reaction – treat symptoms with tylenol.
PEM: Endocrine by Dr. Magloire
DKA: defined by hyperglycemia, metabolic acidosis, and ketosis
30-40% are new onset T1DM
Risk factors include age <5, reduced access to medical care
Anorexia, N/V, abdominal pain, hyperventilation, dehydration
Often precipitated by missed insulin, acute illness, medications (steroids, antipsychotics)
Assume fluid deficit of 5-10%
Initial fluid bolus then 2 bag method over 24-48
Beware of cerebral edema. Treat with mannitol if developing
Avoid central lines due to increased risk of DVTs
Hypoglycemia:
Children and infants can have quicker shifts in glucose due to high metabolic demand and difference in gluconeogenesis.
If conscious, give 15 g of carbs (juice, glucose tabs etc)
IV D10 bolus if needed
If altered give 2-5ml/kg of D10 bolus, repeat and start infusion if needed
Adrenal Crisis:
Consider in known CAH, hypothalamic axis disorders, prolonged corticosteroid use, other autoimmune disorders, critically ill patients unresponsive to pressors, or neonates with atypical genitalia electrolyte abnormalities, hypoglycemia, hyperpigmentation, cushingoid features
Hyponatremia, hypoglycemia, hyperkalemia
Treat with hydrocortisone 50-100mg/m2 (25mg if <3yo, 50mg if 3-12 yo, 100mg if 12+yo)
Treat hyperkalemia if needed.
Tick-Borne Disease by Dr. Buchanan
Prevention is best
DEET and permethrin
DEET on skin, permethrin on clothes (last 6-8 weeks)
Combination of both decreased mosquito bites by 99%
Remove ticks >36hrs just use forceps.
Lyme – erythema migrans, vector is Ixodes, classic “target” rash. Disseminated disease in 60% if untreated
If bilateral bell’s palsy, treat for Lyme disease
If high clinical suspicion, can use IFA or EIA for testing
IgG +IgM if <1 month from exposure
Doxy+ceftriaxone if neuro symptoms
STARI – southern tick associated rash illness
Causative organism unknown. Lone Star Tick
Probably best to treat as Lyme
Rocky Mountain Spotted Fever –
Maculopapular rash involving hands and palms. Flu like symptoms
Hyponatremia, transaminitis, thrombocytopenia
Rickettsia Rickettsii
Dermacentor sp. (wood tick or dog tick)
Clinical diagnosis, confirmed with IFA/EIA
Rickettsia Parkeri Rickettsiosis-
Inoculation eschar. Similar labs findings. Less severe disease. Gulf coast ticks
Erlichiosis- Erlichia sp.
Lone star tick
Flu-like symtpoms
Leukopenia, hyponatremia, transaminitis
Whole blood PCR (most sensitive if <1week).
Otherwise IgG trending
Anaplasmosis –
Ixodes tick. More northeast than erlichiosis
Tick-borne relapsing Fever
Leukoytosis, thrombocytopenia, elevated bilirubin
recurring fevers. Every reccurence less and less severe
Borrelia sp.
Soft shell ticks are the vector. Western US.
Diagnoses with peripheral blood smear. Best checked during a fever.
Treatment for all the above is doxycycline
Babesiosis
Babesia microti. Vector is ixodes tick.
Fever, body aches, Scleral icterus, dark urine,
Transaminitis, anemia, thrombocytopenia, hyperbilirubinemia
Peripheral smear with intracellular organsisms, (maltese cross)
Treatment atovaquone +azithromycin OR Clindamycin + Quinnine
Tularemia
Franscisella tularensis
Vectors -Dermacentor and amblyomma spp.
Fevers, malaise, body aches.
Leukocytosis, thrombocytopenia, hyponatremia, transaminitis, sterile pyuria
Wound and glandular lymphadenopathy, conjunctivitis, oropharyngeal form. Pneumonic form, typhoidal form.
Confirmation by isolation of Tularensis (culture) or seroconversion (IgG/IgM) in paired sera
Treatment is streptomycin
Tick Bite prophylaxis
Peds Pharm: PALS Drugs by Dr. Lucking
Bradycardia- atropine (min 0.1, max 0.5mg) epinephrine, treat as PEA if <60
Tachycardia-
Epi spritzer
Used for brady/hypotension in a patient with a pulse to prevent cardiac arrest
Peri-intubation
0.001mg/kg (1/10 of a code dose)
RSI
If age <1 consider atropine as pre-medication
Historically, lidocaine was given for ICP, however this has fallen out of favor
Fentanyl 1mcg/kg max dose 100mct. Immediate onset, 30-60min duration
Midazolam 0.1mg/kg max 5mg. onset 3-5 mins. Duration <2 hours
Ketamine 2mg/kg. onset 30 seconds. Duration 5-10mins. Contraindicated in <3mo age
Etomidate 0.3mg/kg. does not provide analgesia. Can reduce sz threshold.
Propofol 1-2mg/kg.
Rocuronium 1mg/kg. duration 26-46 minutes
Succinylcholine 1-2mg/kg, hyperkalemia, malignant hypothermia
Endocrine Disorders (Kuzel)
Case Review (Loche, McGowan)
Supplements (Huecker)
Wernicke/Korsakoff (Blair)
Pheochromocytoma (Mattingly)
Pharmacology in Hyperglycemic Crisis (Loudermilk)
Pediatric Seizures (Isacoff)
Diabetic Emergencies (Kuhl)
R1 Lightning Lecture – Thyroid Storm (Dr. Perling):
R1 Lightning Lecture – Addison’s and Cushing’s disease (Dr. Hudson)
R2 Small Group Cases (Dr. Beard)
R3 Case Review (Dr. Hill-Norby)
Diagnosis of exclusion
Keep in your differential
Treat for hypertension, consider MRI
3 associated conditions – INO, optic neuritis, dysautonomia
Anterior cord – hyperflexion
Central cord – hyperextension, elderly
Brown sequard – stab in the back classic
Bilateral, highly associated with MS
High dose steroids and plasma exchange
Botulism – presynaptic acetylcholine receptor
Myasthenia gravis – post synaptic acetylcholine receptor
Lambert Eaton -presynaptic ca channel
NIF is the negative inspiratory force, strength of inhale. 0- -20 is weak, needs intubation
Steroids worsen mortality
Ascending weakness
Miller fisher variant
Albuminocytologic disassociation
Peripheral cause of facial weakness
Does not spare the forehead
Steroids
Acyclovir if presents within time frame
Artificial tears
Zoster
Vesicles of the ear
Steroids
Acyclovir
Contraindications – Cellulitis, Fracture, Epidural abscess
Platelet must be atleast 50k
Head CT before LP , r/o increased icp
L3-4 or l4-5
20 gauge is good, decreased spinal headache
Traumatic and larger needles have higher chance of LP headache
Lateral decubitus position (if you want pressure) versus sitting position
Demyelinating CNS disease
INO
Optic neuritis – pulfrich test (feels something is coming at them when its not), red saturation test (changes to pink on affected eye)
MRI gold standard
Oligoclonal bands in CSF highy suggestive of MS
High dose steroids is treatment
Short PR
Delta Wave
SVT is high yield test question, will need procaimaide If wider QRS
Bipashic T wave in anterior leads
Chest pain usually resolved
Needs urgent catheterization
Needs AICD
Downsloping ST segment
Typically infrarenal
When ruptured – need blood, but allow for permissive hypotension – call for your aorta team
Mobitz Type II and 3rd degree block need AICD/pacer
Vagal maneuver —> Adenosine (6, 12, 12) if hemodynamically stable
If unstable, synchronized cardioversion
3 types
Type III may have CSF rhinorrhea
Avoid NG tube placement
1500cc of output right away (~20cc/kg)
200 cc an hour for 3 hours (~3 cc/kg)
Hammans crunch
Massive vomiting or iatrogenic (most common)
Broad spectrum antibiotics
Slow, steady pressure
Sugar as pre treatment
Avoid if toxic appearing or nectroic appearing
First attempt to overinflate the cuff
Next try manually compressing against the sternum through the trash
Most common sign is tachypnea
Most common symptom is dyspnea
Most common EKG finding is sinus tachycardia
Most specific finding on EKG Is S1Q3T3, T wave inversions in the anterior leads
Benzo first
Midazolam (can be given IM or intransal (great option for patient who doesn’t have access))
Lorazepam, Diazepam
Keppra (40-60 mg/kg IV. (Max dose of 4500 mg)), Fosphenytoin
Lacosamide or Valproic acid
Fosphenytoin and Valproic acid cannot be used together
Intubate with Propofol, Ketamine, or Versed as induction agents as these have anti-epileptic properties
Need continuous EEG to r/o subclinical seizures and further monitoring
GOODLUCK on ITE
Maryland pearls post about a recent paper in JEM about patients coming in with uncertain head trauma.
While the unknown patients had a lower % of positive head CT, it was not negligible. See the description below:
In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%, 1.2% and 0.7% respectively). The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.
Turchiaro ML Jr, Solano JJ, Clayton LM, Hughes PG, Shih RD, Alter SM. Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma. J Emerg Med. 2023 Dec;65(6):e511-e516. doi: 10.1016/j.jemermed.2023.07.009. Epub 2023 Jul 26. PMID: 37838489.
Brief but informative post from the Canadian Medical Protective Association (CMPA). They apparently do have lawsuit risk in Canada with as many as 24% of EM physicians named in a case in 5 years.
Check out our UL DEM 2018 article* that appeared in ABEM’s LLSA list. Many of the same diagnoses remain high risk today: Fractures, Lacs/wounds, Stroke, ACS, Appendicitis (And other GI), and less commonly seen in other reviews, respiratory system infections.
*Brian Ferguson, Justin Geralds, Jessica Petrey, Martin Huecker. Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider. J Emerg Med. 2018 Nov;55(5):659-665.
The following risk management considerations have been identified for physicians providing care in the emergency department:
Arsenic (Aiello)
Toxicology Oral Boards Prep (Eisenstat)
Environmental Tox (McGowen)
Lightning (Perling)
Toxic Mushrooms (Webb)
Peds Toxicology (Graff)
Salicylates (Adams)
TCA Toxicity (Marks)
Salicylate Toxicity (Hudson)
Heavy Metals (Eisenstat)
Iron
Answers to Know for Poison Control Center Consult
Lead
Altitude Sickness (Ganshirt)
Spectrum of diseases caused by too rapid of ascension, inadequate time to adjust to changes in O2 and atmospheric pressures
Acute Mountain Sickness
HACE- High altitude cerebral edema
HAPE- High Altitude Pulmonary Edema
Decompression Illness
Hypothermic Cardiac Arrest (Edwards)
Passive External- Remove wet clothes, heated room, blankets
Active External- Heated blankets, bair hugger/ arctic sun, warm humidified air/02
Active Internal- Heated IVF, Bladder and thoracic lavage, ECMO, peritoneal lavage (not here)
ACLS
Termination of CPR
Outcomes
*Screenshots of charts taken from WikiEM.*
Conference notes 12/6
Conference 12/13
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 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, 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.
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.
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.