McGowan – Teaching series

Scaffolding – 

• Establish a baseline (Know your audience)
• Cues
• Leading qs vs reflective
• Breakdown tasks

Ex ) 

• SOAP notes
• ACGME milestones
• Certifying exam checklist
• Procedural skill learning
• Sim
• OSCE
• SLOE

• Consider graphic organizers for ddx
  • Gridded Charts
  • Flow charts 
  • Worksheets 

Final thoughts

• Assess learners baseline
  • Adjust level of intervention based on thiss

• Have clear objectives
• Short and sweet
• break down to smaller tasks
• Foster safe environment
• Failing is ok if you learn from it

Coffman – Question

Kelesis – RM9 Follow Up

27 F  w ho asthma, prior suicide attempt presents after unknown but large ingestion ibuprofen

• 5 large bottles 200mg ibuprofen empty

VBG 7.3/33.5/82/-9.5

CHEM8 139/3.6/108/143/1.14

Lactic 5.0

Intubated for aspiration risk w prop fent

CXR ok

CT head ok

C/f for lactic acidosis (AGMA), bleed, kidney injury

Rpt gas w ph 7.1, lactic to 8.3, Gap 19

HD placed, admitted to MICU underwent HD, still admitted to 3N

Reversible binding COX1/2 -> depletion of thromboxane = bleed

Peak plasma concentration 1-2hrs

Activated charcoal within 2 hrs of ingestion can be considered

Davenport – Shock US

I – indications

A – acquisition

I – interpretation

M – MDM

Pump – heart squeeze, beating, effusion

Pipe – IVC – plump, collapsable

Problem

Cardiogenic shock

• LV dysfunction w PLAX, PSAX
• IVC – plethoric
• EPSS on PLAX
  • Line on mitral valve
  • Measure peak of valve to septum
  • >7 = poor LVEF
• Lungs
  • Needs to be 15cm to be considered B line
  • Consider turning off tissue harmonics for brighter B line
  • 3 B lines per view for dx

Obstructive

• Tamponade
  • Speed of accumulation important 
  • Mitral valve inflow integral
    • Doppler at mitral valve outflow on A4C
    • Measure tallest expiration wave to lowest expiration wave
    • >25% = pulsus paradoxus
  • Plethoric IVC
• PE
  • D sign on PSAX, bc higher pressure in R heart
  • Mcconnel sign on A4C, bc RV free wall hypokinetic
  • Tricuspid annular plane systolic excursion
    • M node on  A4C on tricuspid
      • Measure peak to valley <16-17 = acute heart strain
• Tension ptx
  • Plethoric ivc
  • Heart could be hyperdynamic, flattening of R heart
  • Lung slide
    • Can mmode for barcode sign
    • US more sensitive than CXR
  • Lung point

Hypovolemic

• Hyperdynamic echo
• FAST
• Aorta – measure outer to outer, anterior to anterior

Distributive 

• Hyperdynamic echo
• Flat IVC
• RUQ
  • Pericholecystic fluid
  • Anterior wall thickening in short access
    • <3mm normal
  • Sonographic murpheys
  • CBD
    • Measure inner to inner

VEXUS (on icu pts s/p open heart sx)

• Measurement on venous congestion
• Organ perfusion pressure
• Determine modality of tx
• Prevent AKI, HF, pulm edema, poor wound healing

IVC widest diameter in subcostal view, >2cm moveone, less thant 2 = noncongestion

Hepatic vein w indicator towards pt head, find vein entering IVC

• Doppler

Portal vein w indicator towards back

• Doppler

Renal vein

Compare waveforms and grade

• High grade = diuretics

Obrien – Pituitary

Sheehan – pituitary grows in pregnancy but not blood supply, vulnerable to hypotension

• Tx w hydrocortisone

Pituitary apoplexy 

• Tx w hydrocortisone to address ACTH deficiency

Acromegaly – excess GH from pituitary adenoma

• Dx w serum insulin like growth factor level

SIADH – 

• Tx hypona sz with hypertonic, consider amps of bicarb
  • Aim to correct 4-6 meq/L
  • Beware of cerebral edema
  • Avoid isotonic fluids – makes them worse cause they hold onto free water

Congenital hypopituitary

• Hypoglycemia, sex organ weirdness, jaundice, midline deficits
• Tx glucose and hydrocortisone

Optic chiasma – pituitary masses compress this 

• Bitemporal hemianopsia
• Little = endocrine issues
• Big = mass effect

Prolactinoma – most common pituitary tumor

• Tx cabergoline to inhibit prolactin release

Zach; Vitamins

B1 Thiamine

• Deficiency
  • Early Beriberi (wet – cardiac) (dry- muscle wasting)
  • Late Wernicke- Korsakoff 
• Malnutrition, AIDS, Alcoholics
• Tx, replete 

B2 Riboflavin

• Erythematous lesions, ulceration, mucositis
• Breast fed children, skim milk, pregnant women
• Tx, replete

B3 Niacin

• Pellagra
  • 4ds
    • Diarrhea, dermatitis, dementia, death
• Alcoholics, aids, IBD, malnutrition

B5 Pantothenic Acid

• Fatigue, headache, muscle weakness, nausea
• Usually deficient with another b vitamin

B6 Pyridoxine

• Dermatologic, dental changes
• Consequence of medicines
  • INH,  valproic acid, phenytoin, hydralazine, carbamazepine
• Also decreased renal function, autoimmune disease, inborn metabolic errors

B7 Biotin

• Dermatologic and neurologic manifestation
• In pregnant women, IBD, isotretinoin, long term antiepileptics 

B9 Folate

• Megaloblastic anemia, glossitis
• Don’t confuse w B12
  • Normal MMA, elevated homocysteine
  • Elevated in both for B12
• Deficiency, pregnancy, burns, alcoholics

B12 Cobalamin

• Megaloblastic anemia, SCD, neuropathic symptoms
• Old people, vegans, IBD

C

• Scurvy
• Corkscrew hair, gingival hemorrhage, petechiae
• Malnutrition, alcoholics, pirates

Caroline; Hypoglycemia

• <70
• Symptoms generally develop <50-55
• More common in T1DM vs T2DM
• Whipple’s triad
  • Do you have low glucose
  • Do you have symptoms from low glucose
  • Do you get better with glucose
• Mechanisms against hypoglycemia
  • Glycogenolysis, gluconeogenesis
• S/Sx
  • Adrenergic; anxiety, diaphoresis, hangry, tremor
  • Neuroglycopenic; lethargy, confusion, seizures, agitation
• Most commonly in diabetics, usually overcorrection
• Nondiabetics; malnourishment, drugs/alcohol, insulinoma, critical illness, adrenal insufficiency, hypopituitary
• Workup
  • POC glucose
• Tx
  • Sugar
  • Glucagon
• D50 vs D10
  • Risk of overshooting w D50
  • D50 and be caustic
• Refractory?
  • D10 drip
  • Consider octreotide
• Has insulin pump?
  • Don’t dc pump
  • Supportive treatment 
  • Contact manufacturer to troubleshoot
• Pediatric hypoglycemia
  • Often asymptomatic until seizure
  • New onset T1DM
  • Maternal dm in neonates
  • Medicine ingestion; bb, ethanol, sulfonylurea
  • Glucose bolus 2ml/kg D10

Lyvers; pediatric endocrine

Hypoglycemia

• Causes
  • Fatty oxidation disorder
  • Insulin mediated
  • Ketotic hypoglycemia
  • Disorder of gluconeogenesis
• Other
  • Ingestion
  • Munchausen

– Obtain critical sample during hypoglycemic <50 episode

– for metabolic disorders

Fatty oxidation

• Can crump quick when glycogen depleted
• Test carnitine

Insulin mediated

Ketotic hypoglycemia

• Glycogen storage disorders
• Hormone deficiency
  • hypopit
• Idiopathic (kids grow out of this by 6-8)

Disorders of gluconeogenesis

• Glactosemia
• Fructose disorders

Tx – Rule of 50

• D10 = 5ml/kg
• D50 = 1ml/kg
• Consider steroid
• Glucagon?
  • Only helps with insulin mediated diseases bc they need preexisting hepatic stores of glycogen

Hyperglycemia

• DKA
  • New onset
    • p/w weight loss, polyuria, polydipsia, vomiting
    • Look for kussmaul  breaths
  • Glucose >200
  • pH <7.3
  • Ketones
• Tx
  • Correct acidosis, dehydration, glucose
  • Fluid resuscitation
    • Aggressive
    • 10-20 cc/kg bolus LR or NS
    • Add potassium due to shifts intracellularly
      • <3.5 = bolus
      • Defer if >5.5
        
    • Inulin 0.05 – 0.1 ug/kg
• Complications
  • Cerebral edema
  • Avoid bicarb
  • Could be from hypoperfusion from dehydration
  • Usually develops first 12hrs
  • Tx, mannitol

Shaw; Acid Base

Look at pH (primary disorder) >  check for compensation 

Respiratory

Metabolic

Metabolic acidosis is usually complicated by compensation

Winters = paCO2 = 1.5 (HCO3) + 8 +- 2

Anion gap = Na – Cl – HCO3

NAGMA = GI vs renal bicarb loss 

• Body takes in chloride

MUDPILES

Excess anion gap

• If change in anion gap > change in bicarb then too much bicarb = less acidotic
• AG – 12 + serum bicarb
  • >30  = 
  • <30 = underlying NAGMA (too  much Cl)

Use base deficit to predict resuscitation goals

VBG for people that don’t need exact pCO2, pulse ox accurate

ABG for people in shock

R acidosis – minute ventilation

R alkalosis – treat underlying cause

M alk – stop offending agent, consider CA inhibitor

M acidosis – treat underlying cause

Bicarb- need control or respirations to make sure co2 is blown off

• Otherwise benefits are primarily from Na and fluid replacemen t
• Na blocker overdose

Thomas; DKA/AKA

Gluconeogenesis/ glycogenolysis not as efficient glycolysis

Gluconeo breaks down fats and proteins

• Fat breakdown = ketones
• Happens in the liver primarily

Glyco

• No ketones
• Happens in muscle and liver

T1DM no insulin production

T2DM insulin resistance

Insulin = store

Glucagon = burn

T1DM more likely to have DKA

AKA

Wide gap acidosis in chronic drinkers

• Following a binge
• Abrupt stoppage of drinking prior to ED

Due to shift of carb metab due to malnutrition

Alcohol w no glucose

• Fasting state = glucagon secretion > gluconeogenesis (mainly lipolysis)
  • If functioning liver

S/Sx 

• N/V/abd pain
• Tachycardic, tachypnea

Labs 

• Etoh often negative
• Anion gap
• Usually w LFT abnormality

Does not need to be acidotic 

• 15% normal ph
  • compensation

Padget

Alcoholic ketoacidosis

Presents; n, v, dehydration, ams

Suspect in poor po + alcoholism

Alcohol increases NADH/NAD+ = higher ketones and lactic acidosis

• Malnutrition presents compensation
• p/w other metabolic derangements

Dx overlaps to some degree w starvation ketosis, DKA

• Correlate clinically

Tx

• Thiamine  (WK)
• Fluids
• D5LR preferred, thiamine before
• Can treat glucose >250 w insulin
• Supportive care otherwise
• Beware CIWA

If lactic >4 something else going on

Disposition; resolution in symptoms, acidosis = home

Rizzo; small group 

Case 1 – HyperK

• Ddx; medicines, renal disease, diet, rhabdo

• Ekg changes, spectrum, peaked t wave – prolonged qrs – sinusoidal 
• Tx, insulin, glucose, Ca, lasiks, albuterol, fluids, dialysis
  • Ca
    • Gluconate through PIV
    • Chloride in codes, central lines
  • Dialysis
    • K refractory to treatments

Case 2 – HypoK

• Ekg changes – U waves
• Ddx; diet, DM, GI loss, medicines
• Tx;
  • Mg, repletion
  • K repletion
    • 10meq = .1 increase

Case 3 – HypoNa

• Ddx; Polydipsia, SIADH, polypharm, CKD, aldosterone deficiency

• Tx; Replete w hypertonic 150mg / 10-20min
  • Can use x2-3 amps bicarb 
• <120 = ICU
• Don’t correct too quickly

Case 4 – HyperCa

• Ddx; exogenous, PTH, genetic disorder, bone resorption, addison, pagets, malignancy, polypharm
• Tx; Fluids, supportive, Ca binders, bisphos, dialysis
• EKG changes = osborne J wave, shortened QT

Case 5 – HypoMg

• Ddx; malnutrition, alcohol, gi loss, renal loss
• Ekg changes – prolonged qtc, risk for ventricular arrhythmia
• Tx; replete
  • Beware of rapid infusion – respiratory depression, hyporeflexia, hypotension

Ross; Small group

Case 1 – thyroid storms

• Precipitant; trauma, infection, contrast, medicines
• Burch and Wartofsky score to sound smart to endocrinology 

• Tx
  • Ptu vs methimazole (avoid in 1st trimester pregnancy)
  • Propranolol vs esmolol (beta selective)
  • Iodine, can substitute Li if allergic
  • Steroid
  • Cholestyramine
• Avoid, amio, asa

Hashimoto – low thyroid

Exogenous – dont need ptu, methimazole

Case 2 – HTN emergency (pheo)

• Ddx; pheochromocytoma, substance use, idiopathic, kidney disease, carcinoid, angina
• If pheo/cocaine avoid beta blockade
• Plasma metanephrines for pheo, urine catacholamines
• Tx;
  • Phentolamine
  • Oral doxazosin if stable
  • Cardine
  • Nitroprusside
• Imaging – CT scan w adrenal protocol
• Associated w MEN2, neurofibromatosis, von hippel lindau
• Reglan, TCA, steroids can exacerbate
• Common sx; palpitation, diaphoresis, HA

Case 3 – Myxedema coma

• Ddx; hypothermia, sepsis, chf, trauma, renal
• Tx;
  • Levothyroxine, consider T3 too (if TSH> 10)
    • T4 preferred in old people, significant CAD
  • Hydrocortisone if c/f concomitant adrenal insufficiency
  • Passive rewarm
  • Beware of pericardial effusion – low voltage ekg
    • Get an echo

Bequer/Baker; US

Fascia Iliaca Block

Blocks femoral/obturator/lateral cutaneous nerves

Indications 

•  femoral head/neck/trochanter fractures
• Anterior thigh lac/abscess

Careful on anticoagulated pts

Ropivicaine/bupivicaine preferred (longer acting)

Use linear probe

2 person procedure

• X2 syringe
• Threeway stopcock

Enter laterally between fascial planes

Sickle Cell pain treatment

Pain triggers

• inflammation
• hemolysis
• organ damage
• deoxygenation status
• dehydration
• infection
• stress

Diagnositc criteria

• pain onset within 10ndays of presentation lasting >2 hrs
• At least one: focal tenderness, focal pain w movement or regional pain causing decreased ROM,
• lab evidence of hemolysis
• pain not explained by another diagnosis

Management points:

• treat pain first: IN fentanyl if available, intranasal fentanyl instead of oral d/t bioavailability
• Individualized pain plan
• Explore social determinants
• If self-dc likely, plan oral step-down and follow-up within 48-72 hrs

Pharmacy lecture

• Renal colic
  • first line: ketorolac 15mgIV once, tyelnol 1000mg PO once
  • Second line: mag sulfate 2g IV, lidocaine 1.5mg/kg over 15 mins, ketamine
  • DC: ibuprofen 400mg PO Q4-6H, naproxen 500mg BID, ketorolac 10mg PO Q6H

Myasthenic Crisis

• anti-AChR auto antibodies
• ocular bulbar, limb symptoms, weakness worsens with muscle use
• Many meds can cause exacerbation i.e. macrolides, fluoroquinolones, levophed, laxatives etc.
• most on pyridostigmine at home
• infection/pregnancy common precipitants
• Bedside PFT, basic labs, tsh, hcg, cxr, r.o CVA
• 20-30-40 rule> FCV below 20, MIP below 30, MEP 40 consider intubation; NIF <30
• Will need increased dose of succinylcholine about double (depolarizing), less of roccuronium about half
• Treatment IvIG vs. plasmapharesis

Febrile seizure

• H and P
  • seizure characteristics
  • duration
  • recorded? video? can they act it out?
  • sick symptoms/contaqcts
  • PMHx, developmental hx IUTD, seizure hx
  • Fever causes that can be treated with ABX
• Seizure education/precautions
• Rescue meds> consider nasal vs rectal
• treat benzo x2> keppra load
• Consider intubation IF going on a drip

Pharmacology

• Status epilepticus
• SE neurocritical care society: 5 minutes or more of continuous clinical or electrical seizure activity or recurrent seizure without return to baseline
• refractory SE with highest mortality
• Treatment approach:
  • Consider levels
  • POC labs/EKG/Blood gas/valproate level/carbamazepime/phenytoin levels (all can run in house) keppra is a send out
  • Benzos: diazepam ( IV: 0.15-0.2 mg/kg max 10mg, Rectal: 0.2-0.5 mg/kg max 20mg, rapid onset, long half life, major hepatic clearance), lorazepam ( IV 0.1mg/kg max 4mg, may repeat once, fast onset, moderate half life, limited hepatic clearance) Midazolam ( IV 0.2mg/kg max 10mg can repeat once, IM 5mg, 10mg for >40kg, single dose, IN 5mg one nostril, may repeat once, rapid onset, very lipophilic)
  • IM midazolam non-inferior to IV lorazepam
  • lorazepam> faster seizure cessation
  • Midaz> faster time to administer
  • Sodium channel agonists: prevent further propagation for action potential between neurons, phenytoin ( max 50mg/min, need inline filter, high protein binding, cardio/hepato toxic, extrav (purple glove syndrome) and derm reactions) Fosphenytoin (converted to phenytoin w/in 15 min IV admin, 20mgPE/kg max 1500, infuse max 150mgPE/min no inline filter, decreased cardiotoxicity and extrav problems, still do therapeutic drug monitoring like phenytoin) valproic acid blocks na/ca/ channels, potentiates GABA( 40mg/kg max 3g, hepatotoxic, thrombocytopenia, hyperammonemia, derm reactions, dose dependent) Lacosamide (400mg single IV dose, arrhythmia, diplopia, derm reactions, renally excreted, EKG before administering)
  • Racatems (levetiracetam) Keppra blocks Ca and AMPA receptors, 60mg/kg max 4.5g, psych disturbances
  • Barbs: direct GABA-A agonists, some glutamate antagonism at high doses Phenobarbital (IV 15mg/kg, rapid onset, very long half life up to 120hrs, hepatic clearance avoid in liver pts) Pentobarbital ( 15mg/kg cumulative bolus, maintenance 0.5-5mg/kg/hr, drug monitoring, long half life, cardiac dysfunction,, hypotension, propylene glycol toxicity, severe ileus, hepatotoxicity)
• Tips: best agent is the one most readily available, consider avoiding phenytoin/phospheny, consider alternative from home reg, consider avoiding valproic acid and pheny/fospheny, avoid valproic acid in pregnancy, remember drug interactions.
• RSI considerations: ketamine/propofol for induction, succs is preferred d/t quick on and off, rocc not preferred d/t duration bc might suppress seizure activity
• Myasthenia Gravis
• RSI considerations: Succinylcholine 2mg/kg 2x normal dose, must overcome antibodies, rocuronium 0.6 mg/kg (about half), preferred for RSI since does not act on receptors.

Stroke prehospital

• should be dispatched high priority
• CSTAT- intended to identify LVO, Gaze Arm weakness, LOC
• Must determine LKN

TBI EMS

• EPIC study
• aggressively prevent and treat “three H bombs of TBI” hypoxemia, hypotension, hyperventilation
• EPIC studies showed increase survival in all groups

Central Venous thrombosis

• Female predominance/postpartum/pregnancy/OCP/thrombophilia
• HA/stroke like symptoms/N/V/Encephalopathy
• Most common in sup.sag. sinus> transverse sinus> sigmoid sinus
• Cord sign https://radiopaedia.org/articles/cord-sign-dural-sinus-thrombosis
• Triangle sign https://radiopaedia.org/articles/empty-delta-sign-dural-venous-sinus-thrombosis?lang=us
• Heparin? Yes please. Then OAc

Guillain- Barre

• Autoimmune mediated polyradiculoneuropathy
• Ascending symmetric, bilateral weakness
• Red flags: bulbar weakness/resp. distress/autonomic instability
• Preceded by recent illness/vaccination
• IVIg or plasmapheresis

Acute dizziness

• Must differentiate between pre-syncope and dizziness
• Vertiginous: Acute vestibular syndrome, triggered episodic vestibular syndrome, spontaneous vestibular syndrome, vestibular neuritis, BPPV
• Dangerous Ds: diplopia, dysarthria, dysphonia, dysphagia, dysmetria > r/o CVA
• Do a HINTS exam: head impulse test, nystagmus, test of skew
• HINTS https://www.youtube.com/watch?v=1q-VTKPweuk
• Dix hallpiike https://www.youtube.com/watch?v=Ey7TlLJUErY&pp=0gcJCfwAo7VqN5tD
• Epley maneuver https://www.youtube.com/watch?v=F_2GpR4HtkY

Functional Neurologic Disorder

• Functional neurologic abnormality without evidence of structural abnormality
• Always rule out structural causes i.e. CVA
• Can see abnormalities on fMRI
• Involuntary is a key aspect, absence of conscious secondary gain
• Hoover sign

Toxic Alcohols – Dr Eisestat

Ethylene glycol is a glycol and not an alcohol, however still included with methanol as the more toxic alcohols.

Isopropanol and ethanol can still be toxic but significantly less so than methanol and ethylene glycol.

Isopropanol

• Rubbing alcohol
• Metabolizes to acetone
• Can have GI irritation and severe intoxication from this
• Hemorrhagic gastritis can result

Methanol can be found in windshield washer fluid, solid cooking fuel, embalming fluid, and tainted beverages

• Formalin (used in cadaver labs) contains methanol and formaldehyde which is fatal in small mL doses.
• Moonshine called “white lightning” because it causes a white out of your vision with damage to the retina, much like the sensation of being struck by lightning.

Methanol

• Toxic metabolite is formate (formic acid)
• Can result in ocular toxicity, pancreatitis, basal ganglia damage

Ethylene Glycol

• Antifreeze
• Sweet taste (which is a problem for pets and small children)
• Breaks down to glyoxylic acid which involves the renal tubules which results in renal toxicity.
• Oxalate can cause hypocalcemia by precipitation as calcium oxalate.
• Oxalate crystal can form in the urine and can be examined with a wood’s lamp because antifreeze usually contains fluorescein.

Can be treated with ethanol and fomepizole

• Blood ethanol 100-105 mg/dL for treatment
• Children will often be hypoglycemic with treatment
• Adults will become “rowdy.”

Fomepizole

• Approx. $2,000 per dose
• 15mg/kg loading dose then 10mg/kg every 12 hours for 4 doses.
• Increase to 15mg/kg after that if therapy still necessary
• Administer more frequently in hemodialysis

Anyone who has acidosis, clinical symptoms, or concentration greater than 20mg/dL gets treatment.

Hemodialysis

• Half life of ethylene glycol 15 hours
• Half life of methanol 50 hours

https://www.extrip-workgroup.org/ contains a list of recommendations for hemodialysis.

Pancreas – Dr Huecker

The pancreas is retroperitoneal and may not always show signs of peritonitis until very advanced disease.

Lipase will generally have to be 3x upper limit of normal to diagnose pancreatitis

Amylase sensitivity is less than 80%. Lipase is a better test.

CT

• Sensitivity 70-80%
• On a non-contrast scan you are more likely to miss necrotizing pancreatitis

If CT is positive, the patient should be evaluated with ultrasound for concern of gallstone / biliary pathology.

Scorpions and autoimmune are rarer causes of pancreatitis

Management

• Initial 10mg/kg bolus and then 1.5 mL/kg/hr

Multiple scores such as BISAP and Marshall score can be used to risk-stratify

Most patients do not require antibiotics, however if there is extrahepatic infection or necrosis, it is necessary.

Imipenem and meropenem are specific antibiotics which can penetrate the biliary system well.

Abdominal hypertension is a potential very serious risk

Encourage early enteral feeding in mild cases

Pseudoscysts:

• Consider this diagnosis and obtain CT A/P
• If you don’t think about it, you wont diagnose it.
• Can be drained with IR or GI

Pancreatic Cancer:

• 7^th leading cause of death
• Painless jaundice is a big indicator.

Pediatric Lower GI Bleeds – Dr. Lyvers

Usually occur inferior to the ligament of Trietz

80-90/100,000 complaints of peds ED visits

• Most are self-limited, however can be more complicated if there is severe bleeding, lethargy, fever, pallor, etc.

Some cases of suspected GI bleeding are not blood

Red Brick Diaper Syndrome

• Caused by increased concentration of uric acid crystals in a newborn. Common and benign finding.

Cefdinir – Often a cause of red-purple stools

Some cases are blood but patients are not sick

Melena Neonatorum – Swallowed maternal blood during delivery or breast feeding, is the most common reasonof melena in a neonate. Can use the Apt test looking for HbF.

Anal Fissures

Some cases are a result of very concerning pathology

Midgut Volvulus – Occurs within the first month with bilious emesis and abdominal distention. Hematochezia is a late finding. Diagnosed by abdominal x-ray or upper GI series.

Nectrotizing Enterocolitis – Most commonly presents in pre-term infants in the NICU, however 13% occur in term neonates. Usually occur with underlying predisposition with sepsis or CHD. X-ray will show pneumatosis intestinalis or ileus in the early stages.

Hirschsprung’s Disease – Failure of neural crest cells to migrate during intestinal development resulting in aganglionic segments of bowel. Typically diagnosed as a failure to pass meconium in first 48 hours.

Hirschsprung’s Associated Enterocolitis – Can be seen 3 weeks to years after surgical repair. Abdominal distension, fever, vomiting, lethargy, foul smelling and bloody stools which can lead to shock. Provide with broad spectrum abx + metronidazole, as well as good resuscitation.

Meckel’s Diverticulum – Painless rectal bleeding caused by incomplete obliteration of the omphalomesenteric duct. Occurs from bleeding mucosal ulceration. Diagnosed by technetium-99 scan which collects dye in the gastric mucosa. 2x more common in males. 2 feet proximal to the ICV. 2 inches long. Symptoms occur before 2. 2% of patients develop complications.

Intussusception – Occur with currant jelly stool in later stages. Most common cause of obstruction 6 to 36 months. Diagnosed via ultrasound. Management initially with air enema and surgery if not successful.

Milk Allergy – Painless blood in stool in an exclusively breast fed infant occurring from 2 weeks to 1 year which resolves by 18 months. Can have a cross reactivity to soy protein. Can continue breast feeding if child is growing appropriately.

Infectious Colitis – Most common cause of hematochezia across all ages. Most common pathogen causing complications is HUS O157:H7 and other shiga toxin producing E Coli. Triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. 5-10 days of diarrhea in children < 5 years old. Early antibiotic administration may increase risk. 50% of kids who develop HUS require a period of dialysis.

Inflammatory Bowel Disease – Collection of diseases which include crohns disease, ulcerative colitis

Solitary rectal ulcer syndrome

GI Duplication Cysts

IgA Vasculitis (HSP)

Abdominal Pain – Dr. Thomas

Leading cause of ED visits 8.9% of cases

Up to 40% of patients may be discharged with a diagnosis of nonspecific abdominal pain

7% of all abdominal pain patients with life-threatening processes will present with NORMAL vital signs.

Risk is higher in elderly patients, especially with vascular causes.

History:

Abrupt onset is typically worse. Nausea / vomiting is more likely a surgical process.

Information on location and migration are useful.

Severity and description can vary greatly and has a low sensitivity and specificity.

Physical Exam:

Start in areas AWAY from where they localize the pain. Be complete.

Do not forget pelvic exam, rectal exam, or testicular exam, if required.

Imaging:

Abdominal x-rays are useful for obstruction, free air, or foreign body.

CT is often the most useful test, however is typically overused and comes with risk such as contrast reaction, cost, radiation, and difficulty managing care on a sick patient in the CT scanner.

High Risk Abdominal Pain

• Elderly
• Immunosuppressed
• Hepatology patients with ascites
• Post-op patients
• Traumatic patients

Visceral pain – occurs with stretching of the organs. Colicky and difficulty to localize. Ex: umbilical pain in early appendicitis

Somatic pain – Peripheral nerve pain from irritation, such as peritonitis. Better location with intense / constant pain. This is when pain associated with peritonitis or rebound pain can occur.

Referred pain – Any pain felt at a distance from the source

Elderly patients with presentation to the ED with abdominal pain have an approximately 10% mortality rate. 42% of these patients required surgery.

• Immune function decreases with age.
• Underlying conditions decrease immune function and reserve
  • Such as vascular, pulmonary disease, as well as DM.

Hysterectomy does not require pregnancy test, however a tubal ligation always does.

UTI / Pyelonephritis increases the risk of miscarriage, however PID is rare once pregnancy is established.

Pregnant patients may have the same etiology of pain as non-pregnant patients

• Biliary / appendix / gerd

Always have concern for SBP in a cirrhotic patient

• E Coli is present in 43% of isolates
• SBP usually is treat with a 3^rd generation cephalosporin, however always add vancomycin if they have a history of a staphylococcus aureus positive blood culture.

Paraplegic Patients

• Present a large risk when they are unable to feel a large majority of pain. May be only able to feel visceral pain or cramping.

Post-operative patients with shoulder pain may be peritonitic.

CT Abdomen / Pelvis -Dr. Elsaidy

Aorta

• Dissection / aneurysm

Thrombosis

• PE (right heart strain)

Air

• Emphysematous infection
• Free air
• Obstruction

Search Pattern

1. Air  in the lower chest (lung / heart / PE) then bowel
2. Bone (ribs, VBs, pelvis)
3. Circulatory (PE / dissection / aneurysm / active bleeding)
4. Solid organs
5. Feather (soft tissues)
6. Genitals

Respiratory Pharmacy Lecture – Zacharry Dougherty PharmD

Community Acquired Pneumonia (CAP)

• ATS/IDSA guidelines for treatment of adults with CAP
• Typical organisms include strep pneumoniae, H. Influenzae, M. pneumoniae
• Be aware if the patient has a history of MRSA / Pseudomonas colonization
• Risk stratify patients with a calculator such as Pneumonia Severity Index (PSI) to determine inpatient vs outpatient treatment.

Outpatient:

• With vs without comorbidities
• Without (Single agents): Amoxicillin 1000mg TID, Doxy 100mg BID, Azithromycin 500mg daily for 3 days.

Azithromycin monotherapy not recommended due to local S. pneumoniae resistance rates

• With: Augmentin 875mg BID plus doxy or azithromycin for 7 days
• Cefpodoxime 200mg BID or Cefuroxime 500mg BID plus doxy or azithromycin for 7 days
• Levofloxacin 750mg daily for 7 days

Clinical success is highest with cephalosporins.

Cefdinir technically has appropriate coverage, however some strains of these bacteria have resistance to this, and for this reason, it is not recommended by the ATS/IDSA

Multi Drug Resistant (MDR) Coverage:

• Doxycyline 100mg BID for MRSA coverage and Levofloxacin 750mg daily for p. aeruginosa

Always consult your hospital antibiogram

Inpatient (Nonsevere vs Severe CAP):

Nonsevere:

• Ceftriaxone 2g Daily + Azithromycin

If Prior culture, or recent hospitalization, add MRSA coverage with Vancomycin

If Prior culture, for pseudomonas change ceftriaxone to cefepime.

Severe:

• Cefepime 2g Q8 or Zosyn 4.5g Q6 (plus vancomycin and azithromycin)

Anaerobic Infections:

• Less common, however lung abscess, empyema, and necrotizing pneumonia make this more likely to occur.

Room 9 Follow-up – Madelyn Huttner MD

Age 60s F found down at home confused by family with black sputum. Hx of suspected IBS. Seen initially in room 9. HR 100, BP 100/60, 94% NRB, afebrile. GCS 14, pale, dried black emesis and stool covering her body.

Orders:

• CBC, CMP, Type and cross, Lipase, Coags, UA, CXR, ABG, Lactic Acid

Consider CTA A/P – was not obtained in this case

Medications:

• Protonix, Octreotide, Ceftriaxone, IV Fluids, Blood products

Consider reversal of anticoagulation

Procedures:

• Intubation, Central line, A line

Consider Minnesota tube

Anticipate significant blood in the airway

SALAD (Suction Assisted Laryngoscopy) Technique

ABG 7.3 / 29 / 45 / 14. Hgb 11.6

Na 130, K 3.2, Cl 96, BUN 46, Cr 2.2

Lactic 4.4

GI and MICU consulted from room 9. Patient found to have a history of excessive NSAID use.

Taken for emergent EGD with GI. Found to have significant esophagitis, diffusely ulcerated gastric mucosa and duodenitis.

Overview of Lithuanian Healthcare System – Simona and Deimante

Universal coverage throughout Lithuania. Patients can choose private insurance, however emergency care is fully covered. Private care is used for elective care, and faster access to care, but not common for emergency care. Can show your ID and have no-copay emergency care throughout Europe.

ED systems are based in public hospitals in major centers in Vilnius, Kaunas, and Klaipeda.

Country has a shortage of emergency medicine specialists. General practitioners are gatekeepers to other specialists.

Vilnius and Kaunas are tertiary care centers and trauma centers.

Gallbladder / Biliary Disease – Tim Price MD

30s Male with 4 days of abdominal pain. Pain is consistent and has been steadily worsening. Described as a dull pain. Located in the upper abdomen. If he lays on his back and holds his hands up, his pain is relieved. Has had regular bowel movements but has some nausea a small amount of emesis 3 days ago, as well as decreased appetite. Denies fevers or chills. Has taken hydrocodone which did help somewhat. Denies dysuria.

Differential: Cholecystitis, Choledocolithiasis, Biliary colic, Pancreatitis, Pyelonephritis, Nephrolithiasis, Hepatitis, ACS, Gastroenteritis, AAA, Cannabis hyperemesis

Labs: Elevated tbili on labs. Normal leukocyte count with neutrophil predominance

POCUS Gallbladder US: Gallstone present without pericholecystic fluid. No anterior gallbladder wall thickening. +Sonographic murphy sign.

CT – Significantly enlarged gallbladder wall

Disposition to Baptist for surgery

Rescue Task Force and Tactical Medicine – Dr. O’Brien

• Tactical Combat Casualty Care (TCCC) “cold zone” vs “warm zone” vs “hot zone”
• Rescue task force allows for a coordinated response to a situation which cannot be completely handled by a single first response agency
• (S)MARCH –(S.ecurity) M.assive hemorrhage, A.irway, R.espirations, C.irculation, H.ypothermia
• Hemostatic gauze: radiopaque, used when not able to apply tourniquet
• Care Under Fire Priority List
• Casualty Movement Rescue Plan
• “High and tight is always right” (for tourniquets)

ABEM Certifying Exam – Dr. Platt

• Steps
  • Program Director Approval
  • Apply (register May 9 – Oct 9. 
  • Qualifying exam November 3-12, 305 questions
  • Certifying Exam, brand new exam that assesses more competencies than oral exam. In Raleigh, NC. 
    • Half day sessions with 2 case types, clinical care cases and communication and procedures
    • Will be offered 9 times a year
    • Sample cases on ABEM website

• Central Venous Access – Drs. Stults and Wells
  • Locations: IJ (R 15cm, L 18cm), Subclavian(R 14cn, L 17cm), Femoral
  • Procedure SIM
• “To Pee or Not to Pee?” – Dr. Williams
  •  Rhabdomyolysis
    • Muscle breakdown – Meds, toxic ingestion, increased muscle activity
    • UA with positive heme/blood without RBCs
    • CK > 5000
    • Electrolyte abnormalities
    • McMahon Score
    • Treat by removing precipitating factors, Rehydrate as needed, treat electrolyte abnormalities, maybe dialysis
  • Acute Kidney Injury (AKI)
    • KIDGO Criteria
    • Staging (stage 1-> stage 3)
    • Pre-renal, Intra-renal, Post-renal
    • Screening/Labs: Electrolytes, CMP, BMP, CK, UA, Renal US, FENa
  • Uremic Encephalopathy
    • Cerebral dysfunction from accumulation of eremic toxins in acute or chronic renal failure
    • Delirium, fatigue, anorexia, nausea, asterixis/myoclonus, seizures
    • Often with GFR <15L/min
    • CMP/BMP. CBC, EEG, CT Head/MRI Brain
    • Treated with dialysis (must evaluate for other causes of delirium)
  • Hepatorenal Syndrome
    • Advanced cirrhosis causes systemic dilation, to compensate for low BP and SVR body releases endogenous catecholamines and activates RAAS
    • AKI
    • Diagnosis of exclusion (takes 2 days of albumin therapy to diagnose)
    • Treat with albumin
• US Image Review – Drs Baker and DiMeo
  • Vitreous detachment
  • Retinal Detachment
  • Nerve Block
• Introduction to Observation Medicine (OLOU) – Dr. Kuzel
  • Trial of therapy, Continued Diagnostic work up, risk stratification, Optimization before discharge home, assessment of acute psychosocial needs
  • Patient can be discharged within 24 hours
  • Specific inclusion and exclusion criteria, protocol based
  • NOT an ambiguity or continued decision unit
  • NOT an additional annex for ED holding patients
  • NOT for patients admitted to other services
  • Soft Launch of ULOU on Feb 3
    • Maximum number of 5 obs patients at a time

• Nephritis/Nephrosis – Dr. Samuels
  • Nephritic vs Nephrotic
    • Nephritic Syndromes
      • Hypertension
      • Decreased Urine Output
      • Proteinuria +/-
      • RBC casts
      • Examples:
        • PSGN
        • Rapidly Progressive Glomerulonephritis
        • IgA Nephropathy
    • Nephrotic
      • >3.5 grams protein excreted per 24h
      • Hypoalbuminemia >lipid formation
      • Edema/anasarca
      • Hypercoagulable state (loss of antithrombin III, protein C & S)
      • Examples:
        • FSGS (focal segmental glomerulosclerosis)
        • Membranous Nephropathy
        • Diabetic Nephropathy

• Urinary Infections – Dr. Stanforth
  • Urinary Tract Infections
    • Pathophys
      • Bacteria ascend through the urethra
      • Complicated vs uncomplicated
      • Relapse = recurrence of symptoms within 1 month despite treatment (typically same organism)
      • Reinfection = symptoms develop 1-6 months after treatment (typically different organs mim)
    • Risk factors
      • Anatomical abnormalities
      • Advanced age (men)
      • Nursing home residency
      • Neonatal
      • Diabetes, sickle cell disease
      • Pregnancy
      • Immunosuppression
      • Advanced neurologic disease
    • General workup
      • UA
        • WBC >5 w/ symptoms is diagnostic
      • Urine culture
      • Consider labs: CBC, CMP, lactic
      • Blood cultures not always indicated as cultured organsmi will typically match urine culture (97%)
    • Types
      • Renal
        • Pyelonephritis
          • Flank pain, fevers, chills, nausea, vomiting
            • CVA tenderness alone could be referred pain from cystitis
          • Complications
            • Bacterial Nephritis
            • Renal/perinephric abscess
            • Emphysematous pyelonephritis
      • Ureteral
        • Infected stone (8-15% of stones have co-infection)
        • Systemic symptoms: urology consult, close follow-up
        • Obstruction with infectious symptoms -> urologic emergency
        • Imaging considerations
      • Cystitis
        • Infection of bladder
        • Complicated
          • Symptoms >7 days
          • DM
          • UTI in previous 4 weeks
          • Men
          • > 65years old
          • Women using spermicides or diaphragm
          • Relapse
          • Pregnancy
        • Treatment
          • Refer to system/community based antibiogram
      • Urethritis
        • UA, Urine GC/Chlamydia, M. genitalium and trichomonas testing
        • Treatment: Empirically cover gonorrhea and chlamydia
        • Partner treatment
      • Prostatitis
        • E. coli makes up about 80% of cases
        • Enterococcus, Staph. N. gonorrhoeae, Chlamydia
        • Prostate manipulation: increased risk of pseudomonas infections
      • Management:
        • Prolonged antibiotic course
    • Asymptomatic bacteriuria
      • Do not treat unless immunocompromised or pregnant

• PEM: Renal Disorders – Dr. Lund
  • Pediatric Renal/GU
    • UTI
    • UTI: Diagnosis
      • Culture showing leukocyte esterase or pyuria AND …
        • 1,000 CFU SPA
        • 50,000 CFU catheterized specimen
        • 100,000 CFU clean catch
      • 2-24 months first febrile UTI or recurrent UTI in older child needs RBUS
    • UTI: Treatment
      • Cephalexin 25 mg/dose TID (max 1000mg/dose)
      • https://uticalc.pitt.edu/
  • PIGN
    • One of the most common causes of acute glomerulonephritis in children
    • PSGN: Clinical features
      • M>F
      • 4-14 y/o, rare before 2 y/o
      • Latency 1-2 weeks for pharyngeal infections and 3-5mfor skin infection
    • Acute nephritic syndrome
      • Hematuria
      • Hypertension
      • Edema
      • Oliguria
    • PSGN: Treatment
      • Treat underlying infection
      • Treat nephritic syndrome, if needed
        • Diuretics
        • Antihypertensives
        • RRT
  • Hemolytic Uremic Syndrome
    • Triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury
    • Many etiologies with most common being shiga-toxin producing E. coli (STEC)
    • Treatment
      • pRBC
      • Fluid/electrolyte anagment
      • Dialysis
      • Platelets
  • Henoch Schonlein purpura
    • IgA depositions in blood vessel walls – kidneys, GI tract, skin, joints
    • Clinical manifestation
      • Palpable purpura
      • Joint pain
      • GI complaints
      • Renal involvement
      • Cerebral vasculitis
      • Testicular hemorrhage
      • Interstitial pulmonary  hemorrhage
    • Pathogenesis
      • Preceding URI
      • IgA complexes deposit in the small vessels in the skin joints, kidneys and GI tract. 
    • Diagnosis
      • Mandatory criterium:
        • Purpura or petechiae with lower limb predominance
      • Minimum Criteria(1 of 4)
        • Diffuse abdominal pain with acute onset
        • Arthritis or arthralgia of acute onesie
        • Renal involvement in the form of proteinuria or hematuria
        • Histopathology showing leukocytoclastic vasculitis or proliferative glomerulonephritis, with predominant immunoglobulin A deposits
    • Treatment
      • Non renal involvement -> symptomatic treatment
      • No consensus on HSP nephritis/severe complications
        • Steroids
        • Cyclosporine, mycophenolate, cyclophosphamide, rituximab, dapsone 
    • Approach to Hematuria
      • Pathophysiology
        • Glomerular
          • Disruption of the glomerular basement membrane with leakage of RBS and protein
          • RBC casts 
          • Brown, smoky coca-cola colored
        • Non-glomerular
          • Renal papillae
          • Sickle cell disease, trait
          • Tubules are site inflammation caused by NSAIDs and antibiotics
          • Pink, bright red with ot without clots more likely lower in urinary tract
          • Increased vascularity from infection or chemical irritation
      • Evaluation
        • Confirm blood in urine
        • Detailed patient and family history
        • Life Threatening causes
          • Trauma
          • Acute glomerulonephritis
          • HUS
          • Renal stones with obstruction
          • Tumor
          • Hematologic disorders
          • toxin/xenobiotic
      • Trauma
        • Hematuria is “cardinal marker of renal injury, with magnitude of hematuria paralleling the severity of renal injury (except renal pedicle injuries, which may have no associated hematuria
        • Presence of gross hematuria or significant microscopic hematuria (>50 RBCs/HPF) along with mechanism point to emergent imaging

• Testicular Infections/STI – Dr. Scott
  • Sexually Transmitted Infections
    • Ulcerative
      • Painful Ulcers
        • HSV
          • HSV-2
            • Multiple painful lesions
            • Starts as blisters
            • Clinical Dx
            • Acyclovir 400 mg q8h x7-10 days or valacyclovir 1 g q12h x 7-10 days
        • Chancroid
          • H. ducreyi
          • Begins as chancre -> unilateral painful inguinal lymphadenopathy forms (buboes)
          • Can form abscess
          • Azithro 1 g PO x1 dose
      • Painless
        • Syphilis
          • Chancre painless
          • Secondary
            • Maculopapular ras on trunk and extremities
            • CSF involvement (40%) 
          • Late
            • Most commonly neuro, associated with HIV
            • Gummas
            • Cardiovascular
          • Diagnosis
            • RPR or VDRL -> antibody if reactive
            • Antibody test -> RPR or VDRL
          • Tx:
            • Penicillins
            • Doxycycline
            • Ceftriaxone if neurosyphilis
            • Jarish-Herxmeier reaction: fever. Chills, myalgias, headache
        • LGV
          • Chlamydia trachomatis
          • Associated with HIV
          • Primary: painless ulcer x2-3 days
          • Secondary: painful ulcer 2*6 weeks later
            • Fever, mylagia, malaise
        • Gonorrhea chlamydia/chlamydia
          • Arthritic, PID
          • Urine culture
          • Ceftriaxone/doxy
        • Epididymitis
          • <35, GC/chlamydia
          • >35 (or anal intercours): e. Coli, pseudomanas, TB, enterovacrer, syph
            • Scrotal elevation
            • Pain relief
            • GC/Chlamydia treatment
        • Orchitis
          • Testes inflammation
          • Most commonly mumps
          • GC, chlamydia, E. coli

• Torsion – Dr. Gosser
  • Ovarian torsion
    • Most common in reproductive-aged females but is found in females of any age
    • Risk factors
      • Ovary > 4cm
      • Pregnancy
      • Patients undergoing IVF, patients after tubal ligation
    • Mechanism: enlarged ovary rotates on the axis of its ligaments leading to twisting of the ligaments restricting lymphatic outflow, swelling that will inhibit venous return that in-turn compromises arterial blood flow. 
    • Requires emergent OB/Gyn consult for operative management
  • Testicular torsion
    • Bimodal incidence
      • Peaks in first year of life and in puberty
    • Risk Factors
      • Mechanical: exertional/exercise, trauma
      • Testicular masses
      • Undescended testicle
      • Bell-clapper deformity
    • Evaluation
      • Emergent urology consult
      • UA
      • US for equivocal cases
      • TWIST Score
    • Mechanism
      • Twisting of the testis on its blood supply
      • Tunica vaginalis is secured to the scrotal wall on the posterolateral side, prevents movement of the testis
        • If this attachment occurs too superiorly, this can lead to torsion
    • Treatment
      • Manual detorsion (temporizing measure)
        • Medial to lateral rotation (open book)
      • Urological consultation for detorsion and orchipexy
      • Salvage rates
        • 100% at 6 hours
        • 20% at 12 hours
        • Little to no salvageability at >24 hours
• ITE Tox Review – Dr. Eisenstat
  • Toxicology ITE Prep
    • self-review
• Renal Emergencies – Dr. Thomas
  • Hyperkalemia and Emergent Hemodialysis
    • Causes of hyperkalemia
      • The Kidney
        • Renal insufficiency
        • ARF
        • Addison’s Disease, Adrenal insufficiency
        • ACEs
        • ARBs
      • Intake
        • Excessive K+ supplementation
        • Excessive K+ in diet
        • Dehydration
          • Prerenal cause of insufficiency
          • Causes shift in electrolytes with more K+ now extracellular
      • Tissue Damage
      • Endocrine
      • The Lab/Phlebotomy
    • Hyperkalemia
      • Generally >5 or 5.5
      • The serum concentration of K+ is important
      • The rate of change in the concentration of serum K+ is MORE important
      • EKG changes
        • Mild 5.5-6.5  – Peaked T Waves and or Prolonged PR segment
        • Moderate 6.5-8 – Loss of P Wave, Prolonged QRS complex, ST-Segment elevation, Ectopic beats
        • Severe >8.0 – Progressive widening of the QRS, Sine wave morphology, V-fib, Asystole, axis deviations, BBB, Fascicular blocks
    • Therapy
      • Calcium
      • Insulin/dextrose
      • Albuterol
      • Bicarb
        • Only really worthy of consideration in setting of metabolic acidosis
      • Diuretics
      • GI elimination
        • NOT RAPID
        • NOT FOR EMERGENCY TREATMENT
      • Hemodialysis
    • Emergent Hemodialysis
      • AEIOU
        • Acidosis
          • pH ,7.1
        • Electrolytes
          • Refractory hyperkalemia
        • Intoxication/Ingestions
          • Toxic alcohols, salicylates, lithium, etc
        • Overload
          • Congestive Heart Failure
        • Uremia
          • Uremic pericarditis, uremic encephalopathy
      • I STUMBLED (Toxins removed by HD)
        • I – INH, Isopropyl alcohol
        • S – Salicylates
        • T – Theophylline, Tenormin (atenolol)
        • U – Uremia
        • M – Methanol
        • B – Barbiturates
        • L – Lithium
        • E – Ethylene glycol
        • D – Dabigatran, Depakote

• Lightning lectures Dr. Gosser, Dr. Angel, and Dr. Gronemeyer
  • Oral Abscesses
    • PTA       
      • uvula deviation, pain, fever, sore throat, trismus, muffled voice
      • CT w/ contrast
      • Strep/staph, anaerobes
      • I&D, clindamycin or augmentin outpatient, Unasyn inpatient
  • Dental abscess
    • Pain, tooth elevation, tenderness and swelling around tooth
    • CT if concerned for deeper abscess
    • Nsaids, opioids or local anesthetics, Dental follow up within 48 hrs, can do I&D
    • Augmentin, clindamycin, or Unasyn
  • Dacrocystitis
    • Infection of lacrimal sac due to blocked lacrimal duct
    • Swelling erythema and edema between medial canthus and nasal bridge
    • Manage with PO clindamycin, warm compresses, decongestants
  • Hordeolum (stye)
    • Blockage and infection of sebaceous/sweat glands of eye
    • Pustule with pain on eyelid
    • Treat with warm compresses
  • Blepharitis
    • Bacterial infection of meibomian gland
    • Swelling and erythema with pain and itching
    • Treat with hygiene, warm compresses, can use topical bacitracin
  • Prespetal and orbital cellulitis
    • Fever, Eyelid swelling and erythema with both
    • Orbital cellulitis will have visual defects, proptosis, and pain with EOM
    • Preseptal cellulitis is usually staph/strep, treat with Bactrim AND amoxicillin (or cefpodoxime or cefdinir)
    • Admit orbital cellulitis, treat with vanc/Unasyn (or vanc/zosyn), add ampho B for fungal infections if dm or immunocompromised
  • Herpes zoster ophthalmicus
    • Fever, headache, Hutchinson sign (vesicles on tip of nose)
    • Slit lamp
    • Artificial tears, topical abx to prevent secondary infection, antiviral
  • Gonorrheal conjunctivitis vs chlamydial conjunctivitis
    • 3-5 days post partum for gonorrheal, 5-12 days is chlamydial
    • Topical erythromycin
    • Adults treated with azithro/ceftriaxone
  • Temperomandibular disorder (TMJ)
    • Pain for 3+ months in TMJ
    • Managed with Nsaids, can use muscle relaxers, soft food diet
    • f/u with dentistry
  • mandibular dislocation
    • typically anterior, typically atraumatic
    • clinical diagnosis
    • CT face / IAC/temp bone if concerned for posterior dislocation especially if traumatic
    • Evaluate cranial nerves
    • Reduce by translating inferiorly and posteriorly
    • Can try syringe technique (97% success)
    • Discharge if uncomplicated otherwise
• Dr. Aiello and Dr. Kushner
  • Septal hematoma
    • Clinical diagnosis. Collection of blood will lead to infection, septal perforation, saddle nose deformity.
    • Use 4% lidocaine cotton balls (can use oxymetazolone) and plug both nares for 5-10 min
    • Incise vertically, stagger incision if bilateral
    • Pack with sponge/tampon
    • d/c with abx and analgesics, f/u with ENT in 2 days
  • Auricular Hematoma
    • Can lead to chronic ear deformity if not expressed/drained
    • Auricular block
    • Superficial incision
    • Pressure bandage to prevent reaccumulating

• Trachs, with Dr. Perling and Dr. Marks
  • Tracheostomy done for upper airway obstructions, or patients on prolonged mechanical ventilation.
  • 3-7 days for severe closed head injuries
  • Respiratory distress pathways and bleeding trachs
    • Most commonly trach fracture, displacement, obstruction, stenosis
    • Give O2 to stoma and mouth, remove inner canula, suction/confirm airway, confirm if trach patent or not. Bougie and re-trach, prepare to intubate from above
    • Tracheal infections = surgical consultation
    • Bleeding trach should raise concern, especially within 6 weeks
    • Beware sentinel bleeds
    • If bleeding; CUFFED tracheostomy
    • Manual compression if this fails.
    • CTA neck/chest
• Buprenoprhine with Dr. Eisenstat
  • X waiver -> now MATE
  • Methadone and other maintenance therapies reduce overdose, comorbidities of OUD
  • It is meant to be bridging, not long term alternative
  • Methadone = full agonist, long acting, but must go get it daily. Also QT prolonging  
  • Bazett formula for QTc : QT/ (sqrt of) RR interval
  • Buprenorphine = extremely competitive agonist, can precipitate withdrawal
  • Suboxone = buprenorphine with naloxone (to prevent abuse)

PEM: Orthopedic injuries and NAT- Dr. Warnick

1. 4 types of child abuse: physical, sexual, emotional, neglect
2. Consider developmental milestones: start to roll at 4 months, crawl at 9 months, taking steps at 12 months
3. TEN4FACES: bruises on torso, ears, neck, angle of jaw, cheeks, eyelids, subconj hemorrhage, frenulum tear; bruises on 4 months or younger; patterned bruising
4. Workup: trauma labs, skeletal survey (under age of 2), CT Head
   • UA > 50 RBC –> CT abd
   • ALT 3x upper limit –> CT abd
   • if low hgb –> look at context
5. Bucket handle fracture/corner fracture = concern for abuse
6. Posterior rib fractures
7. Spiral fracture vs toddler’s fracture
8. Social work, Law Enforcement, CPS report, Transfer to pediatric center

Hand injuries- Dr. Shaw

1. Perfusion: pulses, cap refill, most distal part of hand
2. Sensation: ulnar, median, radial, palmar/volar vs dorsal
3. Motor: “rock, paper, scissors, ok”; FDS vs FDP
4. Phalanx dislocation: frequently have ligamentous disruption, reduction with traction, splint with alumafoam to MCP
5. Nail avulsion: inspect for underlying laceration, repair as needed, suture/dermabond nail back in place
6. Fingertip avulsion injury: finger tourniquets
7. Subungal hematoma: assox with tuft fracture, trephination, abx if open fracture
8. Boxer’s fracture/metacarpal fracture with fight bite: closed reduction with 20-20-40 rule, hematoma block, ulnar/radial gutter splint
9. Scaphoid fracture: assess snuffbox, prone to malunion, thumb spica, follow up outpatient
10. Lunate dislocation: require emergent hand eval
11. Paronychia: I&D, abx if inflammation or abscess
12. Herpetic whitlow: topical acyclovir
13. Sporotrichosis: itraconazole 4-6 months
14. Felon: I&D lateral margin, bactrim
15. Flexor tenosynovitis: kanavel signs- sausage digit, pain with percussion of flexor sheath, held in passive flexion, pain with passive extension; hand consult, IV abx, OR
16. Water bath for ultrasound