Short vs. Standard Course Outpatient Antibiotic Therapy for CAP in Children

• Clinical Question: Is a 5-day strategy of antibiotics superior to a 10-day strategy for the treatment of non-severe pneumonia in young children demonstrating early clinical response?
• Research Design: Randomized double-blind placebo-controlled superiority trial
  • Superiority trial = aims to show one treatment is clinically better than another
  • Non-inferiority trial = aims to show one treatment is not worse than active control tx
  • Intention to treat analysis = all participants who are randomized are included in the statistical analysis and analyzed according to the group they were originally assigned, regardless of what treatment (if any) they received
• Population: Eight US sites either outpatient clinic, urgent care, or ED
  • Inclusion: Children 6-71 months, diagnosed with uncomplicated CAP, prescribed with amoxicillin, amoxicillin-clavulanate, or cefdinir (IDSA recs), parental report of improvement (no fever, no tachypnea, no severe cough) by days 3-6
  • Exclusion: treatment with antibiotic before diagnosis of CAP, treatment outside of above antibiotic regimen, presence of severe CAP (significant pleural effusion, abscess, empyema, etc.), prior hospitalization during days 1-5 for CAP, history of pneumonia within past 6 months, history of asthma, history of underlying chronic medical condition
• Intervention: Short course antibiotic therapy -> 5 days antibiotics then 5 days of matching placebo  
• Control: Standard course antibiotic therapy -> 10 total days of prescribed antibiotic
• Primary Outcome: Response Adjusted for Duration of Antibiotic Risk (RADAR) measured at first outcome visit (OAV1) on days 6-10
  • RADAR determined by desirability of outcome ranking (DOOR) and ranked participants’ overall experiences
    • DOOR components: adequate clinical response, resolution of symptoms, presence and severity of antibiotic associated adverse effects
  • DOOR/RADAR helps assess the risks and benefits of new strategies to optimize antibiotic use
• Secondary Outcome: RADAR at OAV2 on days 19-25, antibiotic associated adverse effects, quantification of antibiotic resistance genes (sub-study)
• Results: 390 patients assessed, 385 patients enrolled (192 in short course and 193 in standard)
  • . Estimated probability of a more desirable RADAR for the short-course strategy of 0.69 (95% CI, 0.63-0.75)
  • RADAR at OAV2 clinically significant. The probability of a more desirable RADAR in the short-course strategy was 0.63 (95% CI, 0.57-0.69)
  • Antibiotic resistance genes were significantly lower in 5-day course than 10 days
• Conclusion: Shorter courses of antibiotics are superior in treating healthy, clinically improving children diagnosed with uncomplicated CAP
• Strengths: Clinically relevant patient-centered question, multicenter RCT so increases generalizability, placebo and antibiotics were matched for taste and appearance
• Limitations: Studied population is likely a convenience sample with selection bias (only 390 patients in 8 cities over 3 years), strict exclusion criteria, no standard definition or diagnostic criteria for CAP in this trial (viral pneumonia?), no information on diagnostic or radiographic testing (imbalanced testing frequency or imbalanced test results)

ED vs. OR Intubation of Patients Undergoing Hemorrhage Control Surgery

• Clinical Question: Does ED intubation increase the risk of death and major complication for patients undergoing urgent hemorrhage control surgery?
• Research Design: Retrospective cohort study
  • Cohort Study = outcome or disease-free study population is first identified by the exposure or event of interest and followed in time until the disease or outcome of interest occurs
• Population: National Trauma Data Bank
  • Inclusion: 16 years or older, underwent hemorrhage control surgery (received 1u blood in first 4 hours of arrival) at level 1 or 2 trauma centers, to the OR within 60 minutes of hospital arrival
  • Exclusion: suffered pre-hospital cardiac arrest, dead on arrival, non-survivable injuries, underwent ED thoracotomy, suffered severe head/face/neck injuries, presented with GCS <8, centers that performed <10 hemorrhage control surgeries
• Exposure: Endotracheal intubation performed in the ED
• Primary Outcome: in hospital mortality
• Secondary Outcome: total ED dwell time, units of blood transfused in the first 4 hours, major complications (in hospital cardiac arrest, AKI, ARDS, VAPs, severe sepsis)
• Results: 9,667 patients who underwent urgent hemorrhage control surgery at 253 levels 1 or 2 trauma centers in US/Canada
  • Most common procedure was laparotomy (68%), extremity (15%), and thoracotomy (6%)
  • ED intubation was performed in 1,972 patients (20%) and 877 (9%) died
  • • Also associated with longer ED dwell time, greater blood transfusion in first 4 hours, and higher risk of major complications (specifically inpatient cardiac arrest)
  • ED intubations significantly more likely to occur in blunt trauma with higher ISS because of severe injuries to the chest and extremities
  • Low ED intubation hospitals were significant more likely to be level 1, university affiliated trauma centers that perform higher levels of hemorrhage control surgery
• Conclusion: In patients who underwent urgent hemorrhage control at levels 1 and 2 trauma centers, ED intubation was associated with increased odds of mortality and major complications, specifically inpatient cardiac arrest
• Strengths: clinically relevant question, large patient population from multiple centers, reduced confounders by excluding patients with clear clinical indications for intubation such as those that were performed were more likely to be guided by physician discretion
• Weaknesses: reliability of some variables used in the study cannot be confirmed from the database, event-level information not available (may be other clinical indicators associated with mortality), timing of complications is unknown (no temporal association between intubation and cardiac arrest), not all hospitals have the same resources or protocols to maximize patient outcomes

7-19-23 Conference Notes

• Healthcare Quality and Safety Intro
  • Make sure you introduce yourself to patients
  • Ask “why” 5 times if you see something you want to improve – root cause analysis
  • Lean: removal of waste with an emphasis on work flow
  • Six-Sigma: eliminate defects and reduce variations in processes
• Traumacology: RSI and Pain Management
  • Intubation methods: RSI, delayed sequence (sedative first and then paralytic after appropriate oxygenation), drug assisted (sedative-only intubation)
  • RSI goals: facilitate first pass success, minimize aspiration
  • Pre-med: lidocaine (1.5mg/kg), fentanyl (2-3mcg/kg), atropine (0.02mg/kg), versed (2-4mg)
    • Lidocaine and fentanyl prevent increase in ICP by preventing cough/pain response
    • Atropine prevents bradycardia during airway manipulation (vagal response)
  • Etomidate: 0.3mg/kg (0.2mg/kg if >120kg). Adverse effects include myoclonus and protentional adrenal suppression
  • Ketamine: 1-2mg/kg. Adverse effects include tachycardia, hypertension, emesis, emergence reaction
  • Propofol: 1-1.5mg/kg. No analgesia. Adverse effects include hypotension
  • Succinylcholine: 1-2mg/kg. Adverse events include bradycardia, hypotension, hyperkalemia (severe burns >5 days old, crush injury, demyelinating disease, myasthenia gravis
  • Rocuronium: 0.6-1.2mg/kg. Emphasize higher dosing for faster onset. Duration 30-45mins
  • Vecuronium: 0.08-1mg/kg. Duration 30-60mins. Adverse events include prolonged action in hypothermia
  • Fentanyl 75-100x more potent than morphine, less histamine release
  • 1mg dilaudid is equivalent to 7mg morphine
• Transfer of Care
  • Consider EMTALA
    • Provide all patients with a medical screening examination
      • Helps uncover whether an emergency medical condition exists
    • Stabilize patients with an emergency medical condition
      • Make sure they can be transferred or discharged without clinical deterioration
    • Transfer or accept appropriate patients as needed
      • Transferring hospital should stabilize the patient to its fullest extent, provide care in route, contact the receiving hospital, and transfer the patient with copies of the medical records
• Tube Thoracostomy Simulation
  • Indications: pneumothorax, hemothorax, pleural effusion, empyemaRelative contraindications: pulmonary adhesions, coagulopathyPlacement: 4^th or 5^th intercostal space anterior to mid-axillary line above the rib to avoid the neurovascular bundle
  • Consider antibiotics (cefazolin most commonly) for infection prophylaxis

If you have the urge to order Mag for a patient, follow your intuition. But Mag might be even more important when replacing potassium.

When treating hypoK+, if the patient has an IV or will have one, I just order Mag 2g IV rapid infusion (never need to do it slowly, 20 minutes is great) along with 60meq oral K. If they are below 2.0 K+, I either give 2 K runs or if they need/can tolerate volume, a liter of D51/2NS with 20meqK (K runs which are painful and seem to take forever to get to the bedside). Of note, people with CHF very often Mag depleted from diuretics and other etiology.

If you give the Mag IV and K po a the same time, Mag is hitting them first. Tough ones are when you don’t have an IV, because Mag oxide is trash. Sometimes I still order it. But people with no IV are likely not very sick and probably have K above 3.

Something might happen when K gets below 3. So if below 3, I usually give some IV, some po.

Dr Harmon asked me about this before she graduated, and I went looking for a few papers on it. I did a little lit search and cant find a true RCT of K repletion VS K repletion WITH or AFTER Mag repletion. It would be expensive to do and lots of confounders and no one wants to spend $ on a Mag study because it’s an old, cheap medication. **(Although some press coverage now on a Magnesium L-Threonate [which I take] study that showed cognitive benefit in Alzheimers patients).

In the few relevant papers I found, authors just generally recommend Mag with K. But we should always be careful when doing something that is logical but isn’t proven empirically. Sometimes things that make sense in theory don’t pan out in studies (vitamin C in sepsis).

One study in ICU patients compared those getting lots of Mag vs those getting none, and looked at their K balance. They found an obvious benefit to Mag repletion for K balance. They cite lots of basic science research on the K-Mg interplay.

At the end of the day, most people are Mg deficient and people with low K maybe even more likely Mg deficient. Mag is awesome, no downside, patient might flush or get sleepy. Just watch out in those with renal failure.

• Not so e(FAST)
  • Do not bias yourself against doing an eFAST (especially if intoxicated and concerned for blunt trauma)
  • Novice scanners need around 600mL blood for FAST to be positive
  • Serial FAST can increase the sensitivity of the exam and decrease false negatives by 50%
  • Head injury and mild abdominal pain are associated with false negative FAST (be cautious with your FAST conclusions)
  • Caudal tip of the liver is the most common location for free fluid on RUQ view
  • A-lines originating from peritoneal stripes are suggestive of pneumoperitoneum
• Intro to Peds ED
  • “Peds ED T” lists of all ED order setsPrioritize PICU -> general floor -> discharge notes.edhighacuitytemplate and .edlowacuitytemplate are the pre-organized notes for residents.admitresidentnotification is the phrase for TigerText in note
  • Louisvillepemresources.wordpress.com
• Basics of EMS
  • Types of Providers
    • EMR (BLS): operate an emergency vehicle, BVM, OPA/NPA, Narcan, tourniquet, oxygen, CPR and AED
      • Not used in Jefferson County
    • EMT-B (BLS): 56 hours, Igels and LMAs, CPAP and BiPAP, blood glucose, EKG acquisition, LUCAS device, cannot start IV, can give ASA, glucose, IM epi, albuterol, Tylenol, ibuprofen
    • EMT-A (ALS): 228 hours, can start peripheral IV and IOs, can give D50, code dose IV epi, fentanyl, morphine, ketamine, nitro, zofran
    • Paramedic (ALS): 11 mo to 2 yrs, intubation, needle chest decompression, cricothyrotomy, interpret EKG, cardioversion, cardiac pacing, many drugs
      • None of the Jefferson County services have paralytics for RSI
  • Louisville Metro EMS and St. Matthews – Raymond Orthober, MD
  • Anchorage/Middletown EMS – Tim Price, MD
    • Uses Heads Up CPR, levophed for post ROSC, droperidol
  • Fern Creek EMS – Jeff Thurman, MD
  • Okolona EMS – Evan Kuhl, MD
  • Pleasure Ridge Park EMS – Dan O’Brien, MD
  • Patients can only decline transport if alert and oriented, not intoxicated, and decisional
  • Criteria to cease resuscitation: unresponsive, apnea, absence of palpable pulse at carotid, bilateral fixed and dilated, asystole in 2 leads (except in trauma or DNR)
    • Think twice before ceasing efforts for PEA in the field

• Room 9
  • Generally for “unstable” patients
  • Specific considerations
    • Trauma -> will need a man scan, intoxicated and difficult exam, open fractures
    • Stroke -> 10-minute goal door to CT time
    • Medical – > hypotension, hypoxia, AMS, seizure, shock
    • Sedations, procedures, cardioversion, etc.
  • PGY-1 roles
    • Help transfer from EMS stretcher to bed
    • ABCs, Exposure, Blankets
    • FAST exam -> use the barcode scanner, save clips, END EXAM, clean probe with grey wipe, interpret and sign in Qpath, /bedsideultrasound pulls interpretation into note
      • If penetrating, then start with cardiac view
      • If blunt, then start with RUQ view
  • PGY-2 and PGY-3 roles
    • Consider am I comfortable waiting several hours for their workup to start resulting?
    • Who to keep (trauma) -> man scan?, trustable exam?, vital sign derangements?, fracture/dislocation needing intervention?, elderly fall on thinner and isolated GSW to the extremities are common rollouts but do a thorough exam first
    • Who to keep (medical) -> hypotension, hypoxia, most respiratory intervention, intubated transfer patients are common rollouts
    • Who to keep (stroke) -> mostly keep all of these unless outside of window (>24 hours)
      • Get their last known normal, SBP, glucose, neuro exam, then call stroke attending
    • Level 1 criteria: confirmed SBP <90, respiratory compromise, blood products in route, GSW to the “box”, GCS <9 due to trauma, Emergency Physician discretion
      • Know the gender! Women receive O- blood. Men receive O+ blood
  • Room 9 Bay 1 -> has the most space, rigid stylet for VL intubations
  • Room 9 Bay 3 -> has chest tube and difficult airway cart
• Buprenorphine in the ED
  • Removal of X-waiver this past year via the MATE Act 2023
  • Opioids -> synthetic in nature like fentanyl
  • Opiates -> derived from poppy so opium, morphine, and codeine
  • Heroin synthesized in 1874 and thought to be safe and less addictive than morphine
  • Methadone
    • Invented in the 1940s and was created to help with opium and morphine shortage
    • Full opioid agonist. Started being used as maintenance therapy. Dispensed as a daily medication because it is a schedule two drug not covered under original DATA legislation, unlike suboxone which is a schedule three drug and is covered
    • Causes prolonged QT. End of T wave finishes greater than ½ the RR interval
  • Opiate Use Disorder (OUD)
    • Specific criteria from DSM-5
    • Withdrawal timeline: symptom peak at 72 hours (nausea/vomiting/diarrhea, etc.)
      • Start suboxone while they are already in withdrawal
      • Use the COWS score to grade withdrawal symptoms
        • Less than 13 is mild, 13-24 is moderate, 25-36 moderately severe, more than 36 is severe withdrawal
  • Buprenorphine
    • Partial agonist for the mu receptor
    • Ceiling effect for pain control, respiratory depression with minimal euphoria
    • Cannot be injected IV (due to naloxone)
    • Minimal side effects and contraindications (acute liver failure)
    • 2% bioavailability of naloxone when taken sublingually, so does not affect buprenorphine absorption
    • Trying to use opioids after taking suboxone is not particularly effective because buprenorphine is saturating receptors
  • Other MAT options
    • Buprenorphine/Naloxone (Suboxone)
    • Buprenorphine (Subutex)
    • Long-acting Naltrexone IM (Vivitrol)
    • Long-acting buprenorphine SQ (Sublocade)
  • Supportive Care for Opioid Withdrawal
    • Ibuprofen or Toradol (pain)
    • Loperamide (diarrhea), Bentyl (abdominal cramps), Zofran (nausea)
    • Clonidine (anxiety/tremors)
  • What dose???
    • Comes in 8mg (buprenorphine)/2mg (naloxone) and 2mg (buprenorphine)/0.5mg (naloxone)
    • Try to start with 8mg on day one, 16mg (8mg BID) day two, etc.
    • Can start at COWS of 8 (with objective signs) or 12 without
    • Can always start with test dose of 2mg. If they get worse, then likely used opioids more recently than they say or withdrawal is not severe enough. If they get better, then safe for higher dose
    • Precipitated withdrawal -> can either do supportive care or give higher doses of suboxone
• Air Methods
  • Benefits of an air ambulance -> saves time (most benefit when ground time is >1 hr), ability to give blood products, preserves “golden hour” of resuscitation
  • Tools: blood, antibiotics, RSI, TXA, tube thoracostomy, push dose pressors, dual providers
  • Other circumstances: GCS <8, dissecting AA, already on ECMO, LVADs, prone patients (think ARDS), IABP, organ transplant
  • Considerations: weight restrictions, cardiac arrest, combative patient, weather, decon
• Chaplaincy Services
  • Bad news: any news that adversely and negatively impacts their view of life
  • Basic steps
    • Gather information
    • Provide information
    • Support patient/family
    • Develop a strategy for treatment and care
  • SPIKES also a good mnemonic for breaking bad news, but meant for oncology patients
    • Setting (secure a quiet location)
    • Perception (determine what patient/family already knows)
    • Invitation (clarify information preferences)
    • Knowledge (give the information)
    • Empathy (respond to emotion)
    • Summary (next steps and follow up plan)

Lightning Lectures with Drs. Huttner and Loche

Foreign body aspiration
-	Presentation
o	Usually sudden onset coughing and choking
o	Can develop stridor, cyanosis, respiratory arrest
-	Diagnosis
o	CXR negative in > 50% of tracheal foreign bodies, 25% of bronchial foreign bodies
o	Bronchoscopy = gold standard
-	Treatment
o	If conscious, back blows, abdominal thrusts, chest thrusts
o	Laryngoscopy to remove with Magill forceps
o	Intubation can be used to push object into R mainstem bronchus and allow aeration of one lung

Mastoiditis
-	Usually results from untreated otitis media – mastoid air cells are continuous with middle ear
-	Most common cause is strep pneumoniae or strep pyogenes
-	Diagnosis
o	Clinical in most cases
o	Consider CT in toxic appearing children or if extracranial complications
-	Treatment
o	If not recurrent and no abx in 6 months > Unasyn q6h at 50 mg/kg
o	If recurrent or recent abx > Zosyn q6h 75 mg/kg
o	Add Vanc if septic
o	Treat 7-10 days IV, follow by 4 weeks of po antibiotics
o	Consult ENT
-	Complications – meningitis, CNS abscess, venous sinus thrombosis

Malignant Otitis Externa
-	Usually adults with diabetes
-	Caused by Pseudomonas in 95% of cases
-	Presentation – often have granulation tissue in the inferior EAC and purulent drainage
-	Initial treatment is with ciprofloxacin IV 400 mg q8h
-	Consider Zosyn for severe infection or immunocompromise 
-	Can lead to osteomyelitis of the skull base or TMJ

ENT Lecture with Dr. Vinh

Airway complications: Tracheostomy vs Laryngectomy
-	Tracheostomy: ask three questions
o	Why does patient have tracheostomy?
	Most common is failure to wean from vent > still able to intubate from above
	Anatomic obstruction from tumor, etc. > typically will be difficult to intubate from above
o	How long has trach been present?
	Takes at least 1 week for tract to mature
o	What type of trach is it? Cuffed or uncuffed?

-	Laryngectomy
o	Trachea is directly connected to skin
o	There is no airway from the nose and mouth
  cannot bag over mouth or intubate from above
o	Can use pediatric size BVM over stoma to bag

Complicated airways
-	Ludwig’s Angina – submandibular space infection which causes upper airway obstruction
o	Odontogenic infections account for ~70% of cases
o	Treatment with Unsyn and Vanc + surgical drainage and/or tooth extractions
-	Angioedema
o	Treatment
	Corticosteroids, antihistamines, epinephrine, stop ACE-Is
o	Always perform flexible laryngoscopy – laryngeal edema may be much worse than visible oropharyngeal edema
-	Peritonsillar abscess
o	Management – antibiotics (unasyn or augmentin), +/- steroids, +/- I&D or needle aspiration
o	Can have trismus (usually due to pain)
-	Epiglottitis 
o	Majority of cases caused by staph and strep – empiric antibiotics with Vanc and Unasyn
o	Swelling of the larynx causes disproportionate narrowing of the airway compared to other anatomic sites
-	Head and neck cancer

Securing the airway
-	Supportive measures
o	Treat underlying cause
o	Supplemental O2
o	Racemic epi – useful for laryngeal edema
o	Heliox 
-	Sedation/anesthesia?
o	Anesthesia causes airway obstruction due to loss of muscle tone, suppression of protective arousal responses and decrease in respiratory reserve
-	Make plan for intubation
o	Fiberoptics for oropharyngeal obstruction
o	Cricothyroidotomy for laryngeal obstruction
-	Fiberoptic intubation
o	Transoral vs transnasal
o	Local anesthesia is key if unable to sedate  atomizers and 4% lidocaine
o	Afrin and serial dilation with nasal trumpets

Transfer Center Lecture with Dr. Mallory

-	Similar to air traffic control – connects to physicians working clinically and directs patients to appropriate facilities
-	RNs and medical directors working in the transfer center have knowledge of which services are offered at which hospitals and are able to direct calls accordingly
-	Also have up to date information about specific bed availability at different facilities

Ophthalmology for the ED with Dr. Rashidi

-	Pupillary exam
o	Afferent pupillary defect – tested with swinging flashlight test
o	Test direct response and consensual response
o	Shape of pupil is important to check
-	Visual acuity
o	If unable to read letters/numbers, at least relay if patient can count fingers, detect light, etc.
-	Intraocular pressure
o	Up to 21 mmHg is normal

-	Corneal abrasions treatment
o	Smaller abrasions – erythromycin ointment 3-4x/day x4-5 days
o	Wood, ticks, fingernail – moxifloxacin drops 4x/day x4-5 days
o	Large, central, or concerning features – consult ophtho

-	Chemical burns
o	Use Morgan lens
o	Check pH before using any drops – normal 6.5 – 7.5 

-	Traumatic iritis/mydriasis
o	Treat with dilating drops (atropine or cyclopentolate 0.5 or 1%)

-	Hyphema 
o	Needs ophtho consult to check for posterior trauma

-	Retrobulbar hemorrhage
o	Causes orbital compartment syndrome – can result in irreversible vision loss
o	Needs lateral canthotomy and cantholysis

-	Eyelid laceration
o	Medial lacerations – concern for canaliculus injury

-	Acute angle closure glaucoma
o	IOP lowering drops – timolol, apraclonidine, latanoprost, pilocarpine
o	IV Diamox 500 mg
o	IV mannitol 1-2g/kg over 45 minutes

Ejection Fraction and Cardiac Imaging with Dr. Baker

• Normal EF findings on POCUS – wall thickening and symmetric contraction during systole, anterior leaflet of mitral valve slapping interventricular septum
• Ways to calculate EF using POCUS
• EPSS = End point septal separation
  • Less than 7 mm = normal
  • Greater than 10 mm = reduced EF
• Fractional shortening – measures LV in systole and diastole
• Fractional area change – uses RV volumes in end systole and end diastole to calculate EF
• Simpson Biplane method – US will calculate change in volume of the LV between end diastole and end systole

Lightning Lectures with Drs. Gellert and Wells

• Ludwig’s Angina
  • Rapidly progressive gangrenous cellulitis of the submandibular spaces
  • Polymicrobial
  • Clinical diagnosis, imaging not required
  • Management
    • Airway – preferred awake fiberoptic intubation
    • Antibiotics – Unasyn OR Rocephin + Vanc OR Clindamycin
    • Surgical – Tooth extraction, debridement
• Retropharyngeal Abscess
  • Abscess between posterior pharyngeal wall and prevertebral fascia
  • Late findings – stridor, respiratory distress, drooling, neck stiffness
  • Complications
    • Acute Necrotizing Mediastinitis (~25% mortality)
    • Sepsis
    • Aspiration
    • Lemierre’s syndrome – septic thrombophlebitis of IJ
  • Diagnose with CT neck w/contrast
  • Management
    • ENT consultation
    • Antibiotics – Cllindamycin 600-900 mg IV or Cefoxitin 2 mg IV or Augmentin 3 g IV
• Peritonsillar Abscess
  • Abscess between tonsillar capsule, superior constrictor muscles
  • Classic “hot potato voice”, uvula deviation
  • CT can help differentiate between cellulitis, RPA
  • Management
    • I&D or Needle Aspiration
      • For I&D use scalpel to incise 1 cm deep into abscess cavity
      • Use guard on scalpel to prevent deeper incision and vascular injury
    • Medications – Decadron 10 mg IV + Rocephin 2 g IV + Clindamycin 600 mg IV
    • Need ENT/PCP f/u in 24-48 hours if not admitted

Tracheostomy Complications with Drs. Lehnig and Nelson

• Approximately 1% of tracheostomies associated with major complications
  • 50% mortality with major complications
  • Usually occur after 1 week
• Emergent complications = decannulation, obstruction, hemorrhage
  • Decannulation
    • Replace ASAP as stoma will begin to close
    • If < 7 days old, recannulate under direct visualization with fiberoptics
    • If > 7 days, use direct visualization
  • Obstruction
    • Mucous plugs, blood clots, tube displacement
    • Remove inner cannula > suction trach > deflate cuff > remove trach > bag ventilate or intubate
  • Hemorrhage
    • If > 48 hours since placement, consider TI fistula, infection, coagulopathy, aggressive suctioning
    • Should be evaluated by surgeon
• Urgent complications = TE fistula, tracheal stenosis, infection, cutaneous fistula
• Tracheo-innominate artery fistula
  • Sentinel bleed occurs in 50% of patients
  • Management
    • External compression over sternal notch
    • Internal compression with hyperinflated cuff (up to 50 cc of air)
    • Remove trach > oral or stomal intubation > hyperinflate cuff
    • ET tube beyond fistula > digital compression of artery against manubrium

PEM Lecture – HEENT Problems with Dr. Lund

• Otitis media
  • Antibiotics duration by age
    • < 2 yrs – 10 days
    • 2-5 yrs – 7 days
    • > 6 yrs – 5 days
  • Antibiotics of choice
    • Amoxicillin high dose (90 mg/kg/day)
    • Augmentin – if amox in last 30 days or concurrent conjunctivitis
    • Ceftriaxone – IV or IM x3 days 50 mg/kg
    • Allergies – non-severe = cefdinir, cefpodoxime; severe = clindamycin
• Neck Masses
  • Thyroglossal Duct Cyst
    • Most common neck mass
    • Moves with swallowing
    • Can get infected – treated with clindamycin, augmentin, Keflex
  • Brachial Cleft
    • Treat the same as thyroglossal duct cyst > refer to ENT
  • Fibromatosis Coli
    • Result of neonatal torticollis causing shortening of SCM muscle
  • Lymphadenitis
    • Could be caused by bacterial infection of 1+ node, mycobacterium, cat scratch disease
• Post operative tonsillectomy bleeding
  • Management
    • Suction, IV placement
    • Lean forward
    • Direct pressure laterally with Magills or long clamp
    • Nebulized TXA
• Epiglottitis
  • Keep calm, avoid aggressive exam maneuvers
  • Inhalational anesthesia with no paralytics
  • Needle cric as temporizing measure
  • Antibiotics – cefotaxime or ceftriaxone AND clindamycin or vancomycin

As mentioned in conference recently, we have years of various studies on the use of Magnesium Sulfate in COPD and asthma. See below a Cochrane review on asthma.

But right after conference, I checked my email to find hot off the press in Annals of EM, a brief review on Mag in COPD.

Take-Home Message

Among patients with an acute exacerbation of chronic obstructive pulmonary disease, intravenous magnesium sulfate may be associated with fewer hospital admissions, reduced hospital length of stay, and improved dyspnea scores.

Here is the Cochrane review on Mag in Asthma. Authors’ conclusions: This review provides evidence that a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists and IV corticosteroids. Differences in the ways the trials were conducted made it difficult for the review authors to assess whether severity of the exacerbation or additional co-medications altered the treatment effect of IV MgSO4. Limited evidence was found for other measures of benefit and safety.Studies conducted in these populations should clearly define baseline severity parameters and systematically record adverse events. Studies recruiting participants with exacerbations of varying severity should consider subgrouping results on the basis of accepted severity classifications.

Lithuania

-training in Lithuania is 6 years and they graduate with a masters degree with ability to practice in EMS, ED and palliative care

-EMS services only carried out by EMS personnel, not fire or police

-Ambulance types: BLS, ALS, ALS intensive care

-BLS-minor traumas, cardiac arrest if nearest, transport, psychiatric emergencies, minor medical- Can start IV and apply supraglottic airway, no meds

-ALS- Nurse and driver-paramedic- can administer medications, can interpret EKG, supraglottic devices, intubation, procedural sedation, etc.

-ALS ICU- Doctor, nurse, driver-paramedic- US, terminating CPR, invasive and non-invasive ventilation- most critically sick patients

Riot Dispersal Agents and GSW Management

-Tear gas fall under chemical weapons- designed to be an irritant that leaves no lasting damage (not always the case)

-14 cases of death from these agents, but all have been from people getting struck with the cannister (in the US)

-In Israel have had cases of people dying from chemical itself when deployed in poorly ventilated areas

-No long term studies- there are concerns for long term toxicity

-Decontamination- removing from exposure

-Copious water irrigation

-Velocity of the GSW is what determines damage- high velocity causes worse disruption

-Two types of wounds: 1. Penetrating- enters but does not leave body 2. Perforating- enters and leaves body

-ABI for concern vascular injury- <.9 needs angiography, >.9 but less than 1.0 needs obs

-71% of those with arterial injury have concomitant nerve injury

EDH

-Introduction to Dr. Syed Shah

AAEM

-Est. 1993 to advocate for EM as a specialty

-Key Issues: Advocacy, Board Certification, Corporate practice of medicine, EMTALA, Due process

-AAEM has multiple resources and benefits to include scientific conferences, podcasts, help in establishing/finding democratic groups, etc

-When thinking about your finances, replace your “buts” with “ands”- for instance “I’m about to make 300k a year AND I don’t know what to do with it”, rather than saying “…but I don’t know what to do with it”

-Think about other streams of revenue. Examples: selling a product, content creation, renting room/property

-Take inventory of your life. What does your millionaire life look like? What kind of car do you want? House? What do you want to do with your time?

-Estimate the monthly costs of these. It is likely easier for you to “live your millionaire life” than you might think, and setting these goals and visualizing them can help you in determining your pathway to them.

Ortho tips and tricks for closed reductions

-Purpose- to restore length, alignment, rotation

-Helps with patient comfort, protecting cartilage, keep neurovascular structures away from stress, prevent skin/wound complications

-Also trial of non-operative management

-Needs pre-reduction XR

-Recreate the deformity to “unhinge”

-Consider your deforming forces- what structures at risk, what muscles/forces pulling fracture, what will open joint space, etc.

-Tourniquets can get in the way, so try and take down if possible

-Molding- holds your reduction in place, 3 point mold (never mold over bony prominence)

-Purpose of CT is to evaluate joint

-Rare to obtain CT prior to reduction unless there is a block of some kind

-Every time a joint gets dislocated it will need to stressed to assess for stability- this will determine need for operative management

-Unstable hip dislocations need traction pins

-Elbow test flex/extension + varus and valgus stress

-Unstable dislocations get ex-fix EVEN IF NO FRACTURE

-Joint dislocation is emergent in the ortho world

-Shoulder reduction

              -Do not try alone if there is an associated fracture, TSA or rTSA in place

              -Milch maneuver

              -Stability exam

              -Scapular Y XR and axillary views

-Elbow Reduction- typically associated with ligamentous damage

              -Simple- no fracture, complex- fracture

              -Terrible triad injury- LUCL, radial head, coronoid

              -Inline traction, supination, flexion

              -Stress the joint

              -Neurovascular exam

              -Monteggia- Proximal 1/3 ulna + radiocapitellar jt- make sure that radial head is reduced!!

                            -Blocks to reduction- annular ligament, biceps tendon

                           -Stress- especially pronation and supination- need to splint in whichever is more stable

-Hip- posterior wall fracture

              -often associated with acetabular fracture- if it isn’t try not to cause one

              -Captain Morgan reduction, East Baltimore Lift

              -Flexion, adduction, internal rotation (for posterior dislocation)- Stress exam

              -Make sure to get pre-reduction XR

              -When to ask for help- traction pin, peri-prosthetic

-Knee dislocation- often associated with neurovascular injury

              -First steps- physical exam, doppler, ABI’s?, CTA’s? (not super sensitive for intimal flaps)- typically keep these for obs for 24 hours

              -Vascular consult?

-Subtalar Dislocation

              -Difficult reduction- try and call ortho for this

              -Different than the tibiotalar dislocation (standard ankle dislocation

              -Dislocation of the talus and calcaneus

              -need to relax gastrocnemius muscle- flex the knee

              -Plantar flex the ankle

              -Is the talonavicular joint in place after reduction? Can see on post reduction lateral films

-Remember 3- point mold, and do not mold over bony prominence

-When does it not matter

              -certain fractures- humerus, femur shaft/ distal femur, both bone forearm, tibia +/- fibula

              -Just need to get to length

Lightning Lectures

Dr. Kushner- Kids with a limp

-fractures, muscle/tendon/ligament injury, insect bite, hemarthrosis, transient synovitis, cellulitis/abscess, plantar wart

-SCFE- type I Salter harris fracture

              -most common hip pathology in adolescents

              -Usually happens during periods of rapid growth

              -Risk factors: obesity, family history, endocrine/metabolic disorder, down syndrome

              -Stable- able to bear weight with crutches

              -Unstable- not able to bear any weight

              -Work-up: XR (AP and frog leg), MRI, possible workup for kidney disease or endocrine disorder

              -Non-weight bearing, consult to ortho

              -Unstable needs to be admitted

              -Complications: osteonecrosis, chondrolysis, femoroacetabular impingement

-Legg Calves Perthe- Osteonecrosis of femoral head- idiopathic

              -10-15% will be bilateral

              -Ages 2-12 with peak 4-9

              -Pain in hip, groin, thigh, knee

              -may wax and wane over weeks to months

              -Goals: pain relief, protect femoral head shape, restore hip mvmnt

              -Non-weight bearing, NSAIDS and consult to ortho

-Septic Arthritis- most commonly hematogenous spread

              -most common in hip, knee, ankle

              -Staph aureus, respiratory pathogens, kingella, e coli, salmonella

              -Need to rule out adjacent joint involvement

              -FABER position- Flexion, Abduction, External rotation

              -Workup: CBC, CRP/ESR, blood cultures- possible swabs if suspect gonorrhea

              -XR AP and frog leg

              ->50k WBC and >75% polymorphonuclear cells in synovial fluid suggestive of SA

              -Kochers criteria- fever, non-weight bearing, ESR >40, WBC >12k

              -Consider LP if septic joint caused by H. flu- high incidence of meningitis

              -Try and hold on abx until aspirate and cultures can be obtained

-Transient Synovitis

              -Etiology unclear but typically proceeded by URI, trauma, bacterial infection

              -Treatment NSAIDS, heating pads

              -Should resolve in 1 to 2 weeks- close follow up for resolution

Dr. Aiello- Conus medullaris and Cauda Equina Syndromes

-Conus medullaris syndrome- CM injury typically at L1-L2

              -Findings: Urinary incontinence, fecal incontinence, decreased rectal tone, erectile dysfunction, saddle anesthesia

              -What sets apart from cauda equina- muscle weakness typically bilateral, + upper motor neuron signs, loss of patellar reflexes

-Cauda equina syndrome

              -Begins at L2 and extends to sacral nerve roots

              -Can be asymmetric

              -Usually more painful than conus medullaris

-Management-

              -if neoplasm suspected- dexamethasone 10 mg IV?, MRI w/ contrast

              -Spine consult, likely surgery

R2 Clinical Pathway- Traumatic Injuries of the Spine- Drs. Bishop and Alia

-Up to 25% of SCI occurs after initial insult- extraction, transport, handling, early mobilization

-Spinal tracts:

              -Descending Motor tracts: Lateral corticospinal, ventral corticospinal

              -Ascending sensory tracts: Dorsal columns (fine touch, proprioception, vibration), Lateral spinothalamic (pain, temp), Anterior spinothalamic (course touch, pressure)

-High dose steroids not recommended in spinal cord injury

-Brown-Sequard Syndrome- transverse hemi-section or unilateral compression

              -ipsilateral spastic paresis, loss of proprioception/vibration

              -contralateral pain and temperature loss

-Central Cord syndrome- squeezing of the cord affecting inner portions

              -Quadriparesis worse in upper extremities

              -Cape like distribution

              -Sacral sparing

              -MRI, NES/Spine

-Anterior Cord Syndrome

              -Direct compression or ischemia of anterior 2/3 of spinal cord

                           -disc protrusion, AAA, hyperflexion, emboli

              -Symptoms:

                           -paraplegia below lesion

                           -loss of pain and temp

                           -Bowel/bladder dysfunction

                            -Dysautonomia

-Spinal Shock- injury resulting in transient global loss of function w/ temp flaccid paralysis, bowel/bladder dysfunction, anesthesia, loss of reflexes

              -Resolves in days to weeks

-Neurogenic Shock- injury to spinal column resulting in hypotension, bradycardia, and hypothermia

              -occurs in <20% of SCI patients

              -injury level:

                           -Above T1- full sympathetic denervation

                           -T1-L3: partial denervation

              -Management:

                           -Exclude other causes of vital sign abnormalities

                            -MAP goals- first line pressor (MAP goal 85-90)

                           -Levo first line, can add phenylephrine as second line pressor

                           -Atropine, temp probe, bair hugger

-Unstable fractures:

              -Jefferson Bit Off A Hangman’s Thumb

                           -Jeffersons Burst Fracture- C1 fracture of anterior/posterior arches

                           -Bilateral cervical facet dislocation

                           -Odontoid Fracture, type II (full odontoid fracture) or III (vertebral body involvement)

                           -Atlanto-occipital dissociation

                           -Hangmans fracture- bilateral C2 pedicle fractures- displaces C2 anteriorly onto C3

                           -(Flexion) Tear drop fracture- associated with anterior cervical cord syndrome

-Remember Canadian C-spine, NEXUS criteria for clearing C-spine

-R2 Pathway on room9er

Dr. Jacobs- Life after Residency

-Show up 15 minutes (at least) early for your shifts

-Get to know the people you work with and be friendly

-Avoid arguments

-Flow is important- order everything you think you might need (within reason) right out of the gate- will speed things up ultimately

-Ask for help if you need to- case management, colleagues, PT/OT, nurse manager, etc.

-Don’t vent your anger in public- beware of being recorded

-Temper patient expectations- don’t over-promise, do what you can do

-Don’t get locked into a diagnosis and refuse to budge- avoid confirmation bias

-Listen to your nurses, involve them in care- will help with building relationships

-Recognize your feelings- if you need a minute to decompress or vent, do so before your feelings boil over

-Get a lawyer/accountant/financial advisor onboard early in your career so you can maximize your pre-tax deductions, retirement accounts, etc.

Ortho ppx

-Open fracture classification Gustilo- Anderson

-Size lac, degree soft tissue injury, contamination, vasc comp

-I: lac < 1cm, clean

-II: lac >1cm w/o extensive soft tissue

-III: lac >10 cm w extensive soft tissue injury or amp

-III A, B C

-Open fractures w/ increased incidence of infx/ osteo, vasc injury, nerve injury, compartment syndrome, VTE

-Orthopedic Trauma Association Open Fracture Classification- emerging classification system due to poor interobserver classification- Skin, muscle, contamination, bone loss- score greater than 5 add gram neg

-Goal for abx ASAP, 1-3 hours post injury by EAST guidelines

-Type I and II, Gram + only- Cefazolin 2 g Q8H

-Pts > 120kg get 3 g

-Alt clindamycin 900 mg IV Q8H

-Duration 24 hrs after closure

-Type III Gram + and –

-Cefazolin + Gentamicin or tobramycin 5mg/kg 1 time dose

-Adverse effects of aminoglycosides- Nephrotoxic- make sure adequately hydrated- Ototoxic(irreversible)

-Soil/feces contamination- Clostridium species- 4-6 million units penicillin IV q 4-6h- alt metronidazole 500 mg q 8H

-Fresh water contamination- Aeromonas- Zosyn or cefepime

-If unable can use cipro or levofloxacin

-Salt water Vibrio- Zosyn/cefepime + doxycycline (alt is cipro/levo + doxycycline)

-GSW open fx- EAST guidelines recommend to consider type 3

-Reality- low velocity (handguns) similar management to closed

-High velocity- Rifles/shotguns- similar to type III

-Recs- treat like type I or II unless contamination present. If extensive tissue damage treat like type III

Peds: Ortho/ NAT

-Le fort fractures never occur in children less than 2 due to lack of pneumatization of the sinuses

-Children less than 8- susceptible to ligamentous and growth plate C spine fx that are higher up

-Older children lower C spine fractures more common

-Posterior displaced medial clavicle fx needs CT to ensure no compression of mediastinal vessels or trachea

-Salter Harris classification

-Gartland Classification supracondylar fx- type II and III likely to require surgery

-Galeazzi

-Monteggia-

-Toddler’s Fractures- 12-94 months, low energy trauma w/ rotational force

-Subtalar joints have poor blood supply making it prone to osteonecrosis

-Chopart- separates midfoot from hindfoot- important for pronation and supination

-NAT- TEN 4 FACES P

-torso including genitals, ears, neck, frenulum, angle of the mandible, cheek, eyelid, subconjunctival hemorrhage, patterned bruising

-4- any bruising in a child less than 4 months of age

-95.6% sensitive, 87.1% specific for NAT

-Point tenderness over an unfused epiphysis concern for non-displaced salter harris- need splinting and follow up

-Nursemaids elbow- mechanism is being pulled

-Reduced by hyper-pronation or supination/flexion

-pain is usually at wrist

Tactical Medicine

-Swat developed after the Texas tower incident Aug 1, 1966

-1989 to 1990 interest began in involving medical professionals with SWAT

-Officers to learn methods of self rescue and to provide basic medical care

-TCCC- Tactical Combat Casualty Care

-Hot zone- immediate area with perpetrator- shooting back, moving casualty out of hot zone are priority

-Warm zone- potential for hostile threat, not under direct fire- Immediate care can be performed here- tourniquet, Chest seal/decompress, airway

-Cold zone- No significant threat of danger- more definitive care

-They use (S)MARCH- security, massive hemorrhage, airway, circulation, hypothermia

Nailbed Injuries and Arthrocentesis

-Indication for trephination- less than 1-2 days old, 50% or more of nail bed

-Be careful with flammable alcohols and check for acrylic nails as these are also flammable

-Nail bed laceration- digital nerve block, remove nail, repair w/ 5-0 or 6-0 absorbable sutures, replace nail into fold

-Arthrocentesis- suspicion of septic arthritis, crytal arthropathies, unexplained arthritis W/ effusion, eval of jt capsule integrity in trauma, therapeutic relief of pain/ effusion

-Contraindications: No absolute but relative include overlying cellulitis, prosthetics

– >50k WBC, >90% PMN cells indicative of septic joint

Venous thromboembolism

• 90 day overall PE mortality rates were 17% in 1999, 16% in 2018
• Inari FLASH registry 30 day mortality rates for High and intermediate risk PE patients were 0.8%
• Nearly half of submassive 30 day mortality occurs outside of hospital
• Lightning Lectures:

Pelvic Fractures

-3 month mortality 3x higher in trauma patients with pelvic fractures

-Increased concern for bladder/urethra injury

-Sacral fractures -zone 1, 2, 3- 3 is worst prognostically

-APC 1 <2.5 cm pubic symph

-APC 2 >2.5 + anterior ligament

-APC 3 >2.5 + ant+ post

-Vertical sheer

-Pelvic binders: unstable and pelvic injury suspected. Over trochanters.

-Inlet/outlet films, judet AP and lateral decubitus position once stable

-FAST can help determine if needs lap (+ blood) or embolization

Compartment Syndrome

-1-10% of tibial fractures, ant compartment most common

-Normal compartment pressure < 10 mmHg

-<20 mmHg unlikely to cause damage

-CK, UA for myoglobin (rhabdo in 40%)

-Stryker- compartment >30 mmHg in one compartment

– Delta pressure: diastolic – pressure (30 or less is indication for fasciotomy)

-Fasciotomy w/in 6 hrs 100% recovery

-12 hr 66%

Ortho Plain Films

-Most often missed finding is the 2^nd finding

-More views are better

-Axillary view very helpful in glenohumeral joint evaluation

-Posterior shoulder dislocations- hard to see, patient can’t externally rotate (lightbulb sign), lack of crescent sign

-4 views at the elbow

-Monteggia fracture- Proximal ulnar fracture with dislocation of radiocapetallar joint (radial head dislocation)

-Galeazzi fracture- Mid to distal third of ulna with dislocation of distal radioulnar joint

-Maisonneuve- total disruption of interosseous membrane

Strangulation injuries are a tough chief complaint. We have many considerations in evaluating and managing these patients. Top priority is ABCs, and then ruling out other serious injuries in the patient.

We may tend to have too low a threshold for CTA in these patients. But they often end up in court proceedings and one could argue for the more aggressive imaging strategy for this reason. Of note, strangulation in the setting of domestic violence represents a VERY high risk mechanism to predict subsequent fatal injury in intimate partner violence.

I am not offering a clear cut answer on when to CTA and when not to. This should be a decision you make with the patient and your attending, considering patient age, injury severity, etc. But the two resources below can at least provide some context on evidence for imaging.

1. Check out this algorithm, authored by Dr. Bill Smock who was UL EM faculty for years and worked with the LMPD as the police surgeon for years. He writes the forensic medicine chapters in a few textbooks as well.

Imaging Recommendations for the Medical/Radiographic Evaluation of Acute Adult, Non-Fatal Strangulation

2. Also check out the paper below, authored by UL Emergency Radiology physicians including Dr. Jonathan Joshi.

https://pubmed.ncbi.nlm.nih.gov/31055673/

Pharm review with Jade 

DILI- can be from ABX, antiepileptics, Tylenol

FDA recommendation for Tylenol reduced to 3g for OTC safety however 4g daily is still safe to give 

Max tpa for stroke is 90 mg, otherwise .9 mg/kg. 10% over 1 min, remainder over 1 hour 

BP goal for tpa administration in stroke is 185/110

Criteria is same for alteplase and Tenecteplase 

Bactrim can cause hyperkalemia as an adverse effect 

Keppra load in status 40-60 mg/kg with a max of 4.5 g

Etomidate may lower seizure threshold- not ideal for status patients 

Rocuronium duration of action prolonged in renal and hepatic impairment, advanced age 

GI Review with Dr. Ross

IV glucagon first line for esophageal food bolus however low success rates

Second to adhesions, adenocarcinoma is most common cause of bowel obstruction 

Proctitis- sexually transmitted, treat with same empiric STI abx

Traveler’s diarrhea- give azithromycin if pregnant otherwise cipro is fine 

IBS- FODMAPS diet 

Esophageal candidiasis: if immunocompromised give systemic antifungal, otherwise topical 

Pyloric stenosis: hypochloremic hypokalemic metabolic alkalosis 

Pancreatic cancer- troussaeau syndrome aka thrombophlebitis 

HBsAg- active infection, anti- HBs is recovered or immunized

Sigmoid volvulus- flexible sigmoidoscopy 

Wilderness Review with Dr. McGowan 

Lightning strike triage is different- go to the coding pts 

Pulseless leg after lightening stroke- kerunoparalysis 

EKG finding in hypothermia- J wave/Osborn wave 

Mild hypothermia 90- 95. Shivering uncontrollably. Moderate hypothermia stop shivering 

Severe hypothermia- risk of dysrhythmia with movement 

Normal ACLS not beneficial with temp below 88-90. Reasonable to attempt 1 defib and 1 epi

K>12 is reason to cease efforts 

Rewarm frost bite with hot water immersion, do not warm if potential for refreezing 

AMS differentiates b/t heat exhaustion and heat stroke 

Air gas embolism occurs on surfacing-> hyperbarics

Nifedipine can be used to treat HAPE if unable to descend 

Immediate descent for HACE

OBGYN Review with Dr. Platt 

AUB= consider cancer in women over 45 yo F

US imaging of choice for genital tract pathology 

Ovarian cyst > 8cm, solid, multiloculate are worrisome for neoplasm, dermoid cysts, or endometriomas

An ovary > 4 cm in size is the most common US finding associated with torsion 

False labor= uterine contractions that don’t cause cervical changes 

Amniotic fluid changes nitrazine paper dark blue 

Sterile speculum exam, no digital exam if ROM suspected 

If vaginal bleeding during second half of pregnancy, perform US prior to speculum or digital exam