DED/72 Hr Return Learning highlights with Dr. Royalty

A patient is considered refractory after 3 or more defibrillators, 3 or more doses of epinephrine, AND 300 mg Amiodarone 

What therapies can you try?

-Hold additional epinephrine 

-Administer Esmolol for electrical storm: 500 mcg/kg bolus followed by infusion (50-100 mcg/kg/min)

-Dual-sequential Defibrillation: Place a second set of pads (R upper chest/left lateral and anterior/posterior), deliver 200J simultaneously from both defibrillators

Pediatric Cardiac Disease with Dr.Wadih

Cyanotic lesions: 5 T’s-Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, TAPVR

Truncus arteriosus: Associated with 22q11 deletion (DiGeorge), Primitive truncus does not divide into PA and aorta, Leads to significant pulmonary over circulation, Ductal independent 

Tetrology of Fallot: Large VSD, RVOT obstruction, RVH, overriding aorta. Tet spells= episodes of cyanosis usually triggered by crying. Treat tet spells by calming, knees to chest, supplemental O2, morphine, IN fentanyl or versed if no IV, IVF to increase preload. If these fail, move to beta blocker propranolol or esmolol, ECMO last resort. Degree of RVOT obstruction determines if lesion is ductal dependent. All require surgery

Total anomalous pulm venous return: Pulm vein do not return to L atrium, degree of illness depends on degree of obstruction of pulm venous return. Ductal independent. Must have ASD to survive 

Transposition of Great arteries: Must have large ASD , VSD, or PDA to survive. Usually presents within hours of birth. If not responding to prostin need a balloon atrial septostomy.

Tricuspid atresia: Absence of tricuspid valve w/ hypolastic RV. Relies on ASD 

L->R shunts: ASD, VSD, PDA, AV canal 

ASD: rarely symptomatic, usually close on their own. Typically close ASD around age 2-5 if becomes larger or persists. “fixed split S2” is a buzzword for ASD on exam 

AV canal (AV septal defect) commonly associated with trisomy 21. Spectrum of severity, all require repair 

VSD: Highly variable. Bigger VSD= more likely to cause heart failure, less likely to hear on exam. Smaller VSD= less likely to cause issues and may close on their own, louder murmur on exam. Over time will lead to increased PVR, increased RV pressure and RVH. May present at 4-8 weeks of life in heart failure, slightly later in trisomy 21

PDA: Machine like murmur at left upper sternal border. Persistence of ductus arteriosus. Ibuprofen used to encourage closure. More common in premature infants 

Ductal dependent lesions (depend on PDA): HLHS, critical aortic stenosis, critical coarctation of aorta, pulm atresia, +/- tet

These NEED PGEs. Prostaglandins cause apnea. Presents with murmur, cyanosis, heart failure on exam. Poor feeding with poor weight gain, sweating with feeds, irritability, tachypnea. W/u with pulse ox: R hand is pre ductal, >3% difference b/t pre and post ductal sats. Need CXR, EKG, Echo. Give prostaglandin .05-.1 mcg/kg/min, watch for apnea. Milrinone typically inotrope of choice due to vasodilation (doesn’t increase SVR). Consider epi for shock 

Coarctation of aorta: As PDA closes- hypoperfused lower extremities, hypertensive upper extremities, associated with turner’s. Present in shock as PDA closes. Coarct located pre-ductal is ductal dependent. Coarct other locations may not present until later in life 

HLHS:Hypoplasia of LV and ascending aorta, mitral valves with ASD and PDA. Cardiogenic shock when PDA closes. Mortality highest in 1^st year of life. Staged repair, first stage is Norwood(BT shunt connects PA and aorta) which is done during the 1^st few weeks of life. IF BT shunt clots they will die. 12% rate of clotting. Post op period is high risk. Listen for a shunt murmur

If you think shunt closed, bolus heparin and start drip. Consider ECMO, likely needs emergent surgery. Increase SVR with pressors (epi first choice), sedate and paralyze to reduce PVR( intubate). Once make it through staged repair survival rate is 90% at 30 years old. Atrial arrythmia is common comorbidity, also liver failure 

Ebstein’s anomaly- associated with maternal lithium use. R atrium enlargement, malformed tricuspid valve 

Eisenmenger syndrome: complications of uncorrected L->R shunt. Can occur in childhood or adulthood depending on the lesion. Cyanosis, syncope, dyspnea, fatigue, chest pain, sudden death. Increased pulm resistance, pulm HTN causes shunt to switch to R->L

Thoracic review with Dr. Baker 

Light’s criteria- if any one of the following is present the fluid is almost always an exudate: pleural fluid/serum protein ratio > 0.5, pleural fluid/serum LDH ratio > 0.6, pleural fluid LDH > 2/3 upper limit for serum LDH 

TB drug side effects: Ethambutol can cause optic neuritis.. starts with E and is eye pathology. Rifampin= orange body fluids. Isoniazid= peripheral neuropathy, seizures, B6

-Spontaneous PTX >20% needs chest tube. Smaller can be observed with oxygen administration 

-To prevent BPD in neonates: within one hour of birth give neonate surfactant, after an hour give caffeine. Risk factors are tobacco use, IUGR, preeclampsia

-Tracheoinonomate artery fistula. Overinflate cuff-> intubate-> remove trach-> digital compression of innominate artery 

-Pertussis buzz words: several weeks, eye sxs, post-tussive emesis 

-Coin position on xray: SAFE= sideways airway, frontal esophagus 

Most common symptom in PE: dyspnea

Most common sign in PE: tachypnea 

Tolerating secretions and toxic= tracheitis

Drooling and toxic= epiglottitis (Hib), thumbprint sign 

Spontaneous and stable Pneumomediastinum: dc with f/u. asthma most common trigger.. Hamman sign, pleuritic pain and neck pain. Usually self-resolving 

-Gram+ cocci in clusters= staph aureus 

-PNA+ bullous myringitis= Strep pneumo Phosgene smells like hay or cut grass 

CURB65: confusion, BUN>19, RR > 30, SBP <90 or DBP < 60, Age > 65

Berylliosis= Aerospace, fluorescent bulbs

Silicosis: glass, sand blasting, miners

Asbestosis: shipyard workers

Siderosis: arc welding (iron)

Most specific US finding for PTX: lung point sign 

Pneumocystis jirovecci: elevated LDH

Give prednisone if PaO2 less than 70 

Fat embolism: IVF and supplemental O2, may see petechial rash

Case Reviews with Dr. Weeman and Dr. McMurray

Meningitis

• Strep Pneumo most common pathogen, consider when recent sinusitis or OM
• N meningitis: group living, recent exposure, rash 
• S aureus: IVDU
• HIV/immunocompromised: also consider Listeria, cryptococcus, TB
• Perform CT prior to LP if any focal deficit, seizure, AMS,  hx tumor, age > 60, papilledema 
• Give steroids (10 mg IV dexamethasone) 20 min prior to Abx as part of your empiric coverage because it decreases mortality in S pneumo 

TTP 

TTP is decreased ADAMTS-13 which cleaves vWF, without it vWF forms multimers that lead to microthrombi 

Present with fever anemia thrombocytopenia, renal failure, AMS, only 20-30% of pts have the classic pentad 

Microthrombi result in end organ damage 

Dx with plt <20K, MAHA, schistocytes, elevated retic count, LDH, unconjugated bilirubin

Normal coags and normal fibrinogen

Tx: steroids, FFP, HD can temporize 

Gold standard is PLEX which removes autoantibodies and replaces ADAMTS-13

Avoid platelet transfusion-> provokes thrombosis

Caplacizumab is a monoclonal antibody against vWF to impede interaction with platelets, very expensive.. not prescribed if plts >30K. Prescribed for prevention but may also be used in inpatient management 

Tox Review with Dr. Eisenstat

-Contraindications to activated charcoal include aspiration risk (think of toxins with high risk of seizures, somnolence, vomiting, etc)

-GHB acts on GABA receptors. Short acting. Classic case is obtunded requiring intubation then later self extubates

-Organophosphate toxicity: Tx with atropine and pralidoxime 

-Serotonin syndrome: clonus, give cyproheptadine 

-NMS give bromocriptine, malignant hyperthermia give dantrolene

-Cyanide toxicity: house fire with lactic acidosis, hypotension, bradycardia. Gives hydroxycobalamin 

-Amatoxin containing mushroom-> NAC

-Digoxin toxicity-> Don’t give calcium. 

-Indications for hyperbaric for carbon monoxide: Carboxyhemoglobin level >25% or >15 if pregnant, also anyone with LOC or severe lactic acidosis 

ID Review with Dr. Shoff

-Flexor tensynovitis-> Kanavel’s signs: pain with passive extension, percussion tenderness, uniform swelling, flexion posture

-Most common septic arthritic: Staph aureus 

-Missisppi Valley-> histoplasmosis

-Southest US-> blastomycoisis 

-California-> coccidiomycosis 

Varicella: lesions in various stages

Smallpox: lesions in same stage 

Pertussis: treat close contacts

Rabies: PEP for any bat exposure. Vaccine day 0,3,7,14. Administer immune globulin around wound, any leftover goes IM

Lightning Lecture – Advance Directives
– Living Wills – May contain DNR but typically do not
– Health Care Proxy – legal document that establishes who makes decision on behalf of the patients
– DNR orders can vary by state
– There are different types of DNRs
– POLST/MOLST – Physician/Medical Orders for Life-Sustaining Treatments – Kentucky’s newest forms
– Be open, honest, and compassionate when it comes to discussing end-of-life care
– At ULH, we have 24/7 palliative care services which are available in the ED

Lightning Lecture – Steven-Johnson Syndrome
– Extreme immune reaction causing keratinocyte necrosis diffusely
– Causes – medications, infections (Mycoplasma pneumonia), malignancy, immunosupression (HIV)
– Onset 1-3 weeks
– Prodromal viral symptoms – headache, fevers, msk pain
– Macular rash with bull -> skin sloughing (+/- Nikosky sign)
– Genital lesions, GI necrosis, pneumonia, interstitial pneumonitis
– Workup – basic labs, inflammatory markers, CXR
– ScorTEN – scoring algorithm to assess overall mortality
– SJS <10% TBSA involvement
– SJS/TEN Between 10-30% TBSA involvement
– TEN > 30% TBSA involvement
– Treat it like a burn – stop suspected offending agent, give a significant amount of IVF, local wound care, pain management

Interesting/Important EKG Findings
– P waves best seen in V1 and lead II
– In lead II, SA node P waves should be upright
– In lead VI, SA node P waves should be biphasic
– P pulmonale – right atrial enlargement
– P mitrale – left atrial enlargement
– Q waves usually occurs in the setting of post-MI
– Not all Q waves are indicative of MI
– One small box wide and one small box deep inside the Q wave is more indicative of pathologic Q waves
– T Waves – predominately upright
– Usually when inverted they represent ischemia vs strain
– U waves are rare upright waves following T waves typically only seen in significant dysfunction and illness
– Normal QRS: 60-100msec
– Incomplete BBB: 100-120msec
– Complete BBB: >120msec
– Short QT (500) Syndromes exist
– R wave progression – R waves should slowly appear through the precordial leads
– Should at lest be present by lead V2
– R should be isoelectric around V2-V3
– R wave should peak by V4-V5
– Early RWP can be lead placement, RVH, PHTN, or RBBB
– Late RWP can be old infarct, lead placement, LBBB
– Bundle Branch Blocks
– Is the terminal QRS deflection (last deflection) positive in V1? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V6? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V1? then in is a LBBB
– Is the terminal QRS deflection (last deflection) positive in V6? then in is a LBBB
– Most of the time, a true new LBBB does not pass the “eye test” – i.e. they look terrible in person
– If higher STEMI in Lead II vs Lead III -> likely LCx lesion instead of RCA lesion
– aVR – care about it because it can represent a left main lesion
– Reciprocal changes help identify a posterior MI
– Sgarbossa Criteria
– Concordant ST elevation > 1mm in leads with a positive QRS complex (positive terminal deflection of QRS complex with elevation in the T wave)
– Concordant ST depression > 1mm in V1-V3 (negative terminal deflection of QRS complex with depression in the T wave)
– When to obtain a posterior EKG:
– If posterior heart is infracting, should have reciprocal changes in the anterior waves (V1-V3)
– Lead II, Lead III, Lead aVF all negative deflections – this makes it a LAFB – NOT a LBBB equivalent
– A flutter – rate around 300bpm, vent rate usually 2:1
– AVNRT is the most common form of SVT
– Brugada Algorithm exists
– 200j is a good idea for most everything
– Run a 12 lead rhythm strip if possible while defibrillating unstable arrhythmia
– Causes of cardiogenic syncope
– ARVC, QT Syndromes, Conduction Delays, Etc
– Short PR interval in the right setting is a sign of WPW
– Brugada has types?
– Brugada pattern is when EKG changes present without symptoms
– Brugada Syndrome – EKG changes with syncope, chest pain, heart failure symptoms
– Metoprolol has more significant breakthrough events with long QT syndrome so Propranolol and/or Nadolol are preferred
– T wave inversions present in V1-V3 with syncope is concerning ARVD – look for epsilon waves – notching immediately after QRS
– Arrhythmogenic Right Ventricular Dysplasia
– Fatty infiltrative disease of the right ventricular free wall

Brief Review of Statistics
– Normal Distribution – 68%, 95%, 99.7%
– P value is the probability that the observed effect within the study would have occurred by chance if, in reality, there was no true effect
– Confidence interval provides a range of values within a given confidence including the accurate value of the statistical constraint within a targeted population
– Type I Error – the result of the study is said to be statistically significant but in-reality it was not
– Type II Error – the result o the study is said to not be statistically significant but in-reality is was
– Closely associated with the power of the study
– Power – ability to correctly reject a null hypothesis that is indeed false
– Higher powered studies are better when evaluating high risk and/or life-threatening stuff?
– SPin and SNout
– PPV and NPV
– Higher prevalence, higher PPV and Lower NPV
– memorize the chart
– Prevalence – total existing cases/total population
– Incidence – new (over a certain time period) cases / total population
– Precision vs Accuracy
– Probability – event of interest / total events measured
– Odds – event of interest / not event of interest
– Risk Ratio – probability of one group / probability of another group
– Odds Ratio – odds/odds
Confidence intervals -> crosses 1 -> no difference
– Meta-analyses and Systemic Reviews are the best type of evidence based medicine
– High bias = low validity

IVC POCUS Lecture
– POCUS is just one data point
– How to perform an IVC View
– Start with the traditional subxiphoid view and rotate the probe 90 degrees (indicate to the head if abdominal probe, indicator to the toes if cardiac probe)
– How to measure the IVC
– Don’t use M Mode – the least right way to perform this study
– Use B Mode
– Measure 2cm from IVC/RA junction or 1cm from IVC/hepatic vein junction
– Freeze the image, use cine mode to find the maximum and minimum of the images
– Caval Index – (max – min)/max x 100
– Note, if the patient is vented, the change collapse is reduced
– If IVC appears small/collapsible or plethoric, that is when this US is very useful
– Different commonly used terms for these findings:
– Volume Status – poorly defined term
– Volume Responsiveness – better defined term
– Volume Tolerance – “Can the RV handle it? Can the LV use it?
– Note – CVP does not equal volume responsiveness

“What in the Baby is Going on Here”
– Thrush – can present on most surfaces in the oropharynx – treat with oral nystatin and need to sterilize all bottles/nipples
– Periodic Breathing – differentiate from apnea – concerning characteristics – pauses 20+ seconds, cyanosis, increased web – normal, resolves around 6 months of age
– Jaundice – breast fed vs formula fed? stool transitioned? birth weight? term vs preterm? any siblings needing phototherapy? ABO compatibility and/or other risk factors?
– Unconjugated Hyperbili – increased bilirubin production (hemolysis) vs decreased bilirubin clearance vs increased bilirubin circulation (breast mild jaundice) vs breast feeding jaundice (inadequate intake)
– Labs: total and diet bilirubin, CBC with Diff, reticent count, CMP, Coombs/DAT
– Start phototherapy and/or double up phototherapy
– Normal Saline bolus ( +encourage feeding if otherwise stable)
– Trend total bilirubin as an inpatient
– Neurotoxicity risk factors: GA < 38, albumin <3, isoimmune hemolytic disease, sepsis, concerning symptoms within 24 hours
– Omphalitis – different from umbilical granuloma
– Management: CBCd, Blood Culture
– Treatment: Admit for IV antibiotics: Vanc and Pip/Tazo
– Febrile Neonate
– CBC, CMP, CRP, Procal, Blood Culture, POC Glucose, UA with UCx, HSV Swabs, Lumbar Puncture for CSF Studies
– Treatment: IV Antibiotics and possibly antivirals (Ceftaz, Amp, Acyclovir)
– Hypothermic Neonate
– No clear consensus on management/workup at this time
– 96.5F is the partial consensus, WHO definition is <36.5C (97.7F)
– Bundling/skin-to-skin contact
– If well-appearing, try re-warming, if failed, then start a septic workup
– If ill-appearing, full septic workup and IV antibiotics
– Lethargy
– Ingestion, too, hypoglycemia, seizure, meningitis, sepsis, NAT/Head Trauma, intussusception, inborn error of metabolism, congenital adrenal hyperplasia, cardiac etiology

Opioid Use and ALTO Therapy
– Every week of opioids prescribed corresponds with an additional 20% increased risk of overdose and/or misuse
– Kentucky SOS (Statewide Opioid Stewardship)
– Reduce opioid prescribing by reducing opioid use
– ALTO – Alternatives To Opioid
– 600mg Ibuprofen and 1000mg Acetaminophen does the world good
– Toradol 15mg IV/IM has similar analgesia without additional side effects seen with higher doses
– IV Lidocaine 1.5mg/kg over 15 minutes (max 200mg) – use extremely cautiously due to side effects
– Do not use if pregnant, seizure history, severe cardiac disease, history of arrhythmia
– Ketamine 0.15mg/kg (max 20mg) over at least 5 minutes
– Magnesium 15mg/kg (approximately 1-2grams) over 15 minutes
– New Renal Colic PowerPlan has been created – ED Renal Colic PowerPlan
– Naproxen 500mg BID as a discharge med is probably the best NSAID for patients with complex cardiac histories

Campus Health Counseling 101
– Services are free, confidential, and do NOT impact your student/resident records
– Clinical services, couples counseling, psychiatric services, crisis services, case management and referrals
– Can call 502-852-6446 Campus Health to schedule an appointment – M-F 8-1630
– Currently there are two licensed counsellors but they are hoping to expand to four licensed counsellors shortly

Lightning Lecture – Necrotizing Fasciitis
– Fournier’s Gangrene – polymicrobial, associated with T2DM, if on SGLT2 inhibitor they are at higher risk
– If have any suspicion at all, consult surgery immediately
– Use broad spectrum ABx – vancomycin + Meropenum or Zosyn + Clindamycin
– Additional Therapies: IVF, Tdap booster, pRBCs if needed
– Hyperbarics and/or IVIG is controversial
– Factors that increase mortality – WBC>30000, Creatinine >2, Age >60, TSSS, Clostridial infection, Delay in surgery >24 hours

Lightning Lecture – Skin Cancers
– Basal Cell Carcinoma is the most common type and it is the least aggressive form
– Rarely metastasizes
– White skinned people are the most affected
– More common in older individuals and men
– Biggest risk factor is exposure to UV light, possibly more important in childhood years
– Nodular BCC is the most common type
– If noted in the ED, referred to dermatology
– Cutaneous Squamous Cell Carcinoma
– More malignant
– Affects white individuals more
– Same risk factors
– Cutaneous SCC in situ (Bowen’s Disease) is erythematous, well-demarcated scaly plaque
– Diagnosis based on skin exam and biopsy
– IF seen in the ED, refer to Dermatology
– Melanoma
– 5th most common cancer in men and women in the US
– Survival depends on when it is diagnosed
– ABCDE criteria
– Management – refer to dermatology
– LDH levels can be elevated if metastatic
– Most common site of mets = LN, skin, lung, liver, brain
– Karposi Sarcoma
– AIDS-defining illness
– Vascular tumor associated with HHV8
– Typically develops in those with CD4 counts less than 200
– Corticosteroid use increases the risk for development of KS undergoing organ transplant or those with lymph-proliferative disorders
– If noted in the ED, bigger concern is significant immunocompromised state

Discussion of Burn/Wound Care Dressings
– Adaptic – vaseline impregnated gauze – applied after a topical ointment
– Cuticerin is the same as adaptic but it is typically larger – impregnanted with aqua-phor
– Vaseline Gauze – larger sizes, impregnanted with more vaseline than adaptic
– Mepilex can be used for up to 7 days technically – silicone based dressing – great simple dressing for a smaller burn wound
– SSD is a sulfa drug and is oculo-toxic so it is not recommended for for face and/or hands, bacitracin is typically a safe option

Caustics Lecture
– Caustic = any xenobiotic that causes functional and histologic tissue damage
– Kids are more likely to be damaged with ingestions due to smaller areas of mucosa, so burns are relatively larger to body area
– Ophthalmic Exposure
– Irrigate, irrigate, irrigate
– Morgan lens vs taping a cut IV near the eyelids
– No intervention really reduces injury from a caustic ingestion
– Some evidence that steroids may help reduce GI strictures down the line but evidence is flimsy but may also harm
– Do not neutralize acids with a base due to exothermic reaction
– Prophylatic ABx is not warranted
– When to scope for ingestion – early but not too early
– <12 hours may be too quick for tissue injury to fully demarcate
– >72 hours may be too late because tissue is weakest at this time and iatrogenic injury is more likely
– The presence of oral injury does not correlate/indicate the degree of mucosal involvement further along in the GI tract
– If evidence of perforation – don’t call GI, call cardiothoracic surgery and/or general surgery
– Persistence of symptoms, intentional ingestions should normally be scoped
– If a kid with unintentional ingestion looks good, is tolerating po intake, and is observed for a few hours, can go home
– Hydrofluoric Acid is bad
– Systemically – drops concentration of calcium significantly – time of onset is inversely related to concentration
– Higher concentration is quicker
– Greater than 50% concentration will likely cause immediate injury
– Give calcium and magnesium as quickly as possible
– Place a central line for calcium chloride rather than gluconate
– Keep giving calcium until vtach and/or vfib resolves
– Start calcium and mag immediately
– Can reduce dermal absorption with calcium gluconate gel – if no gel, then can grind up tums in aquaphor and/or bacitracin
– If a hand, fill a glove with this calcium gel

PALS vs ACLS Lecture
– When to pick which one? if over 50 kilos, typically use adult dosing
– PALS – Bradycardia Pathway
– Causes – hypothermia, hypoxia, and/or medications
– Treatment – oxygenation, epinephrine, atropine
– Start CPR is HR is less than 60bpm in neonates/infants
– Young kids are heart rate dependent, cannot compensate as well
– Atropine max dose is reduced in PALS vs ACLS
– Weight Based dosing with adenosine (up to 6mg, 12mg, and/or possibly 18mg)
– Procainimide and/or amiodarone are also options for SVT as well
– PALS – pulseless arrhythmia – epi + shock
– 5mg/kg of Amiodarone for pediatric patients but no clear max per PALS algorithm
– Endotracheal epinephrine (max 2.5mg) due to lower rate of absorption – followed by 3-5 puffs of positive pressure ventilation
– Asystole/PEA pathway is the same
– Give Epi after a pulse check if it is due around time of pulse check for maximum effect
– Rapid Sequence Intubation
– Pre-mediation
– Atropine – children under the age of 1 year of age to prevent bradycardia
– Max dose of 0.5mg in child, 1mg in adolescent
– Dose is 0.02mg/kg
– Lidocaine – controversial and falling out of favor
– Dose is 1mg/kg
– Max dose is 100mg
– Adverse effects are bradycardia and hypotension so may be more harm than good
– Pain/Sedation Medications
– Midazolam – Gaba agonist
– Dose 0.1mg/kg
– Fentanyl – Mu opioid receptor
– Dose 1mcg/kg
– Max dose is 100mcg
– High Dose therapy is 5mcg/kg
– Should be given slowly over 2-5 minutes to prevent chest wall rigidity
– Ketamine
– Dose 0.5-3mg/kg – usually 2mg/kg for intubation
– Possible increase in ICP but more likely increases CCP rather than ICP
– Causes a lot of secretions when given to younger individuals
– No data in those less than 3 months of age
– Etomidate
– stimulates GABA receptors to block neuroexcitation
– Dose 0.2 – 0.6mg/kg – max dose 20mg
– Does cause some adrenal suppresion, so not perfect in those with sepsis
– Propofol
– GABA agonism and decreased glutamatergic activity via NMDA receptor blockade
– Rocuconium
– non-depolarizing blocker
– Dose 1mg/kg
– Half-life of 30-45 minutes
– Succinylcholine
– depolarizing neuromuscular blocker
– Dose 1-2 mg/kg (max 200mg)
– Increased ICP

Cocaine Lecture
– Amphetamines push out more neurotransmitters whereas cocaine blocks re-uptake
– Functions as a norepinephrine re-uptake blocker
– The only local anesthetic agent that is also a vasoconstrictor
– Cocaine can cause a brief transient bradycardia secondary to stimulation of the vagal nuclei followed by a quick tachycardia
– Microwave cocaine + baking powder = crack cocaine which can now be smoked
– Cocaine effects – persistent rhinitis, intra-nasal erosions, epistaxis, crack eye (ulceration from crack smoke)
– Increases body temperature – hyperthermia not a fever – worsened by psychomotor agitation and vasoconstriction at the skin
– Elevated core body temperature is directly linked to mortality
– Can develop seizures from cocaine – sympathomimetic effect and sodium blocking effect (same at TCAs)
– Cocaine increased risk of strokes, myocardial infarction (risk >24x in the hour after ingestion)
– Cocaine affects gestational birth weight, fetal growth, and the likelihood of a term delivery
– Also increases the risks of abruption, spontaneous abortions, and IUGR
– No real decon strategies for people with traditional use
– Decon strategy for a packer/stuffer – whole bowel irrigation to help move the packets along
– Do not use if any evidence of gut wall ischemia is present as this could lead to perforation
– If a packer has evidence of ruptured packet, needs to go to the OR stat
– No role for dantrolene if a patient is hyperthermic from cocaine overdose
– Start cooling around 105, stop around 101

Mycobacterium lightning lecture

• TB
  • 1/3 of world infected with TB
  • 2^nd leading cause of death
  • Symptoms
    • Cough
    • Hemoptysis
    • Night sweats
  • Management
    • Respiratory isolation
    • Contact health department
    • Isoniazid/rifampin/pyrazinamide/ethambutol
• Tuberculous Lymphadentis (scrofula)
  • Enlarging painless neck mass in child
  • Treated similarly as TB
• M. Leprae
  • Dry hypopigmented macules
  • Hair loss
• MAC
  • CD4 < 75
  • Fever/dyspnea/night sweats/cough
  • Azithromycin/erythromycin/ethambutol
• M. Marinum
  • Ascending lymphangitis in aquarium workers
  • Azithromycin or clarithromycin with ethambultol.
  • Treat for 25 weeks.

Rabies lightning lecture

• Acute progressive encephalitis
• Bats are #1 vector in the US.
• Management
  • Treatment is palliative in symptomatic patients
  • Postexposure prophylaxis is recommended if bite cannot be ruled out
    • Watch animal for 10 days if available
    • High risk animals – raccoons, skunks, foxes, bats
    • One dose of HRIG and 4 doses of rabies vaccine over a 14 day period. 5 of 28 days if immunocompromised
• Tetanus
  • Neuro illness from toxin created by clostridium tetani
  • Generalized – diffuse muscle spasms and rigidity
  • Cephalic – cranial nerve palseys
  • Neonatal- passed from unvaccinated mothers

Public Health Updates

• Restaurant inspections, STD tracking, vaccination tracking, septic systems
• Important to find niche outside of EM in your career, Public health could be a good option
• Covid
  • Significantly decreased level of acuity since onset.
  • Downtrending cases and deaths
• Yearly patterns
  • Upticks in November/December and right at start of school year
• Myocarditis
  • Can get from vaccine, but also from covid at an even higher rate

Lightning Lectures

• HIV
  • 1.2 million infected in US, 30-40,000 new cases per year
  • At risk populations
    • MSM 67%
    • Heterosexual contact 24%
    • IV drug use 6%
  • AIDS
    • CD4 count less than 200 or with AIDS defining illness
  • Considerations
    • Privacy when discussing matter with patient
    • Consider AIDS defining illnesses and contraction of rare illnesses
    • Low threshold to start antibiotics if ill appearing
  • History 
    • Does patient know CD4 count or viral load
    • Are they compliant with medications.
  • West Nile
    • Most common in US
  • Dengue
    • Most common worldwide
    • Can cause hem fever
  • Yellow Fever
    • Can cause hem fever
  • Chikungunya
    • Can cause hem fever

Sepsis Clinical Pathways

• Widespread inflammation and organ distress initiated by any type of microorganism
• Leading cause of hospital death 15-20% mortality overall, 50% if associated septic shock
• Defined:
  • Sepsis – suspected infection with SIRS+ or lab abnormalities
  • Septic shock – suspected or proven infection, signs of inflammation, signs of organ failure, + requiring pressors after fluid resuscitation. 
• qSOFA
  • AMS, RR>22, SBP<100
• SIRS
  • Temp < 96.4 or > 100.4
  • HR > 90
  • RR > 20
  • WBC > 12,000 or < 4,000
  • Meeting 2+ criteria is positive SIRS response
• Within 3 hours of patient presentation
  • Lactate measurement
  • Cultures > abx administration
  • 30ml/kg crystalloid fluid
  • repeat lactate before 6 hours
• Resuscitation
  • 20-30ml/kg LR if appropriate for patient
  • broad spectrum abx
  • If BP not responsive, vasopressors (norepinephrine) with target MAP 65 
• Abx
  • Vanc/zosyn or vanc/cefepime
    • Cefepime does not cover anaerobes

Multi-Drug Resistant Organisms: management overview

• MDRO – organism resistant to one or more classes of antibicrobial agents – CDC
  • Organisms of significant concern are resistant to MANY
    • VRE, ESBL, Carbapenemase producing organisms
  • Antibiogram available at pharmacy desk!!!
    • Use this when choosing your antibiotics please
  • VRE treatment
    • Daptomycin or linezolid
      • Both are equivalent 
  • ESBL treatment
    • Cystitis
      • Macrobid, Bactrim, fosfomycin
  • CRO treatment (consult ID)
    • Serine carbapenemase susceptibility
      • Ceftazidime/avibactam
      • Meropenem/vaborbactam
    • I mipenem/relebactam
    • Metallo-betalactamase susceptibility
      • Aztreonam+ceftazidime/avibactam

Documentation Changes

• Will Begin in January 2023
• MDM based
  • Number and complexity of problems addressed
  • Amount or complexity of data reviewed
  • Risk of complications
• Make sure you document all diagnoses considered in your workup.

Pericardiocentesis

• Perform if tamponade present
• Usually from penetrating trauma
• 2 techniques: parasternal and subxiphyoid
• 18guage spinal needle with angiocatheter
  • insert needle, aspirate during insertion until blood return, advance angiocath, draw off fluid until improvement, place stopcock.

Tick Born Disease

• prevention
  • insect repellant
  • Tick removal ASAP
    • Grab as close as possible to skin and pull straight off without twisting
• Lyme
  • B. burgdorefi
  • Ixodes tik
  • Erythema migrans (20% may not have rash)
  • Disseminated disease if untreated
    • Bells palsy – bilateral
    • Migratory arthritis
    • Heart block
• STARI – sourthern tick associated rash illness
  • Rash after being bit by tick
  • Lonestar tick – white dot on back
  • Does not cause severe disseminated disease
• RMSF
  • Macular/popular rash > Petechial Rash on extremities
  • Rickettsia rickettsi
  • Carried by Dog tick
  • Clinical diagnosis
• Erlichiosis
  • Carried by lonestar tick
• Anaplamosis
  • Ixodes tick
• Tick borne relapsing fever
  • Borrelia species
  • Soft shell tick
• Treat with docyycline for all

• Babesiosis (martha’s malaria)
  • Babesia microti
  • Peripheral smear with parasites (maltese cross)
  • Atovoqone and arythromycin
• Tularemia
  • Francisella tularensis
  • Lonestar tick and dog tick
  • Also in flies/contaminated meat
  • Conjuncitivis/ulcerative lesions, tonsillar exudate, typhoidal form
  • Treat if any antibody is +
    • Streptomycin 1g IM BID
• Tick Bite prophylaxis
  • Confirmed ixodes tick
  • Engorged or present graeter than 36 hours
  • Has it been 72 hours since removal
  • Can they take doxycycline
  • Is it a lyme endemic area? Ky is not.
  • IF all answers are yes – 1 dose of 200mg doxycycline

Check out this new essay in Annals EM. Well written. Our job is pretty amazing.

Wernicke Encephalopathy

• Encephalopathy, ophthalmoplegia, ataxia only present in 15% of cases
• Clinical Diagnosis
• Treatment
  • Start empiric thiamine, give with glucose
    • Prehospital though, give glucose first since thiamine not available for EMS
  • 500mg IV Thiamine TID for 2-3 days
• Ocular changes improve in 1 day
• Ataxia and confusion may take a week to improve

HHS

• Typically T2DM
• Mortality 10-20%
• Complications- cerebral edema
• Evaluation
  • Glucose (Typically >600)
  • Osmolarity >320
  • Bicarb relatively normal
  • pH relatively normal
  • Ketones (Low or negative)
• Treatment 
  • Fluids typically 8-12 L deficit
  • ICU admission

Operations- Ross

• Provide discharge instructions that coincide with chief complaints, as well as put chief complaints that are relevant. 
• If you have a code aorta (ascending aortic dissection) dial 8008 and select code aorta, don’t page cardiothoracic surgery etc. 
  • Descending aortic dissections managed by vascular here at ULH
• Cerner Camera Capture
  • 2 phones available (1 in room 9, 1 at attending desk)
  • Log into cerner on phone using “Cerner Camera Capture” app
  • Put in MRN
  • Put in location folder
  • Will find picture in multimedia manager on left hand menu list
• Code Green
  • Imminent Delivery
• Road Rash
  • If truly severe consider calling trauma and/or burn nurse to help get wound care managed
  • Can write for more than 3 days of opioid pain meds if medically justified
• New Kasper
  • When in patient chart click on ED provider view
  • Click on Kasper within white menu list on the left
• Dispo Times
  • NES if waiting for recommendations for multiple hours consider discussing with ED attending about escalating to NES attending.
  • Ortho should put in bedslip within approx. 2 hours

PEM Endocrine- Kopp

• DKA in Peds
  • 
  • 45kg child slow fluid resuscitation
    • 1.5x maintenance fluid rate
  • 45kg fast fluid resuscitation
    • 2x maintenance fluid rate
  • With resuscitation, if K is greater than 5 do not include K in initial fluid resuscitation
  • Add in dextrose when there is a decrease in glucose of >100 in 1 hour
    • Keep in mind to continue to check glucose every hour
  • Bicarb administration not recommended… except for life-threatening hyperkalemia or acidosis with pH <6.9 with evidence of compromised cardiac contractility
  • Avoid intubation
    • Increased CO2 > decreased pH CSF > cerebral vasodilation > cerebral edema
    • Make sure you match RR if you do intubate, and be quick to bag during RSI, 45 sec of apnea can be drastic
• Hypoglycemia
  • Rule of 50
    • 50/D50=1ml/kg
    • 50/D25=2ml/kg
    • 50/D10=5ml/kg
    • 50/D5=10ml/kg
  • Recommend D10 or D5 fluids for correcting hypoglycemia
    • D50/D25 > will blow small IVs which is most peripheral IVs in kids
• Inborn errors of metabolism
  • Most will have a cheat sheet
  • D10 45% NS with electrolytes run at 1.5x maintenance fluid
    • Dextrose fluids is mainstay
• Adrenal insufficiency
  • Stress dose steroids
    • 3x base dose steroids
  • Hydrocortisone (IV or IM)
    • 0-3: 25mg (Can pick kid up with 1 arm)
    • 3-12: 50mg (Can pick kid up with 2 arms)
    • >12: 100mg (Too big to pick up)
• Diabetes insipidus
  • DDAVP IN, IV, SubQ
  • Goal of lowering Na

Pharm Lectures

• Magnesium
  • Normal level 1.7-2.3
  • Hypomagnesia (<1.5)
    • Causes: poor nutrition chronic EtOH, excessive GI or renal loss, medications (thiazides etc.
    • Symptoms
      • Cramps
      • Fatigue
      • Vertical nystagmus
      • Ataxia
      • Seizures
      • Dysrhythmias, QTc prolongation
    • Tx: Mag oxide 300mg tablet, Mag sulfate 1-4G IV
    • Torsades de pointes> 2G IV over 15 min
    • V fib > Mag 2G IV over 2-5 min
  • Hypermagnesemia (>4)
    • Cause: overuse of mag supplements/laxatives
    • Symptoms
      • Muscle weakness
      • Absence of deep tendon reflexes
  • Mag Pearls
    • Predominantly intracellularà when serum levels are low= intracellular is likely very depleted​
    • Potassium and magnesium levels are linkedà if difficulty repleting potassium check a magnesium level and replace
• Potassium
  • Normal Range 3.5-5.0 (Cards patients 4.5 goal)
  • Physiologic function​
    • Action potential regulation​
    • Muscle contraction​
  • Hyperkalemia: K > 5.5 mEq/L​
    • Causes:​
      • Renal dysfunction (ESRD/AKI)/rhabdomyolysis; ​
      • Medications (ACE inhibitors, ARB’s, potassium sparing diuretics, immunosuppression (cyclosporine, tacrolimus), trimethoprim-sulfamethoxazole (Bactrim®)​
    • Symptoms: EKG changes, arrhythmias​
  • Hypokalemia: K < 3.5 mEq/L ​
    • Causes: GI losses, medications (diuretics, insulin, albuterol)​
    • Symptoms: Cramping, weakness, myalgias, malaise, arrhythmias​
  • EKG changes
    •  
  • Hyperkalemia treatment
    • Cardiac stabilization
      • Calcium gluconate
    • Shift K
      • Regular Insulin + Dextrose​, Albuterol
    • Targeted Elimination
      • Dialysis
      • Loop diuretics
      • Cation Exchange Resins/Polymer​
  • Hypokalemia treatment
    • Check and replete Mag
    • 3.2-3.5 mMol/L​
      • 40 mEq KCl PO or per tube​
      • KCl IV over 1 hour x 4 doses
    • 2.7-3.1 mMol/L
      • 40 mEq KCl PO or per tube x 2 doses 4 hours apart​
      • KCl IV over 1 hour x 4-8 doses
    • < 2.6 mMol/L
      • 10 mEq KCl over 1 hour x 8 doses
• Phosphorus
  • Normal: 2.5-4.5
  • Hypophosphatemia
    • Causes: Refeeding syndrome, chronic alcohol abuse, hyperparathyroidism, vitamin D deficiency, diabetic ketoacidosis (DKA) chronic diarrhea, antacids, hungry bone syndrome

• Symptoms: Loss of appetite, Bone pain/fragile bones, Irregular breathing, Irritability, Fatigue/Weakness, Encephalopathy, Seizures

• Hyperphosphatemia
  • Causes: Abnormal renal function (AKI/CKD), rhabdomyolysis, tumor lysis syndrome, hypoparathyroidism, hypothyroidism, phosphate containing laxatives, vitamin D toxicity, bisphosphonates, fosphenytoin.
  • Treatment:
    • Phosphate restricted diet (800 – 1000 mg/dL) ​
    • Fluid resuscitation to euvolemia​
    • Forced diuresis (acetazolamide +/- furosemide) ​
    • Phosphate binders: Bind phosphate in the gastrointestinal track (dosed 3 x daily with meals) à several drug interactions 
• Calcium
  • Normal:  8.8 – 10.4 mg/dl ​
    • 1.10-1.30 mmol/l (ionized)
  • Hypocalcemia
    • Muscular ​
      • Hyperflexia​
      • Fasciculations​
      • Cramping, myalgias
    • Neuro​
      • Anxiety, delirium, coma​
      • Paresthesias​
      • Seizure
    • Cardiovascular​
      • Hypotension​
      • Vtach​
      • Bradycardia, heart block
    • Indications for treatment:​
      • ​QT prolongation
      • ​Seizure, delirium, coma
      • Severe Muscle cramping ​
      • ​Pre-emptive in blood product transfusion
      • ​Caution: EG toxicity, severe increase in phosphate
  • Hypercalcemia
    • Signs and Symptoms​: Muscle weakness, hyporeflexia​, GI (constipation, ileus, n/v)​, hypertension​, Delirium, coma​, Paresthesia
    •  
    •  
• Sodium

• Hyponatremia
  • Treatment for Hypotonic Hyponatremia (Serum Na <135, Serum Osm (<280 mOsm/kg)
    • Hypervolemic
      • Fluid restriction
      • Diuresis
    • Euvolemic
      • Fluid restriction
      • Stop offending medication
    • Hypovolemic
      • Stop offending medication
      • Isotonic crystalloid (Saline)
    • Causative meds
      • SSRIs, TCAs, Antipsychotics, antineoplastics, NSAIDs, AEDs
  • Hypertonic Saline
    • Indications for hypertonic Saline
      • Seizure
      • Confusion (use with caution and consider other etiologies first)
      • Gait instability
      • Coma or cerebral herniation
    • Initial management
      • 3% NaCl infusion 2ml/kg over 5-10 min
      • If no clinical improvement > Repeat 3% bolus
      • Ensure correction does not exceed 6 mEq/L in 24 hours
      • What if no 3% NaCl at your facility?
        • Hypertonic sodium bicarb can be used
          • Push slow over 3-5 min, 2amps ~ 200 mL 3% Saline
  • Hypernatremia
    • Initial Labs
      • BMP​
      • Mg, Phos​
      • Urine Na​
      • Urine Osm and/or Urine SG​
    • Treatment
      • Hypovolemia with hypotension​
        • Isotonic fluids are recommended​
      • Normotensive Hypovolemia​
        • D5W or 0.45 % NaCl 
      • Na Correction​
        • Goal: restore sodium balance​
        • Lower Na:​ <10-12 mEq/L per 24hr​
      • Free Water Deficit​
        • Correct first half within 24 hours​
        • Correct remainder over 72 hours​
    • Diabetes insipidus
      • Labs
        • Serum Na > 145 mEq/L​
        • UOP > 200 mL/hr (sustained)​
        • Urine SG < 1.005​
        • Urine Osm < 300 mOsm/kg​
        • Serum Osm > 300 mOsm/kg
      • Treatment
        • Hemodynamically Stable:
          • DDAVP (desmopressin) 1 mcg IV q8hr​
            • May be administered subcutaneously*
        • Hemodynamically Unstable:​
          • Vasopressin continuous infusion​
        • Goal of Therapy:​
          • Maintain UOP < 200 mL/hr

Emma Ganshirt Cushing’s

• Presentation
  • Psychosis
  • Hypertensive emergency
  • Hypokalemia
  • Cardiomyopathy
• Broad Differential, consider it a risk factor for multiple etiologies
• Physical exam and Hx key

Dana Roberts Adrenal Crisis

• Adrenal crisis most common cause primary adrenal insufficiency
• Risk factors: 
  • History of adrenal crisis
  • On steroid therapy
  • Meds that increase cortisol (levothyroxine, phenytoin, phenobarbital, rifampin)
• Clinical manifestation
  • Volume depletion and hypotension not responsive to fluids (other: weakness, fatigue, weight loss, decreased appetite, hyperpigmentation, abdominal tenderness)
• Labs: 
  • Low Na, Glucose, aldosterone
  • High K, Ca, Creatinine (prerenal), ACTH, renin
  • Normocytic normochromic anemia
• Tx: 
  • Hydration, usually need 4-6L in first 24 hours, be mindful of likely low Na and don’t correct too quickly, steroids (100mg bolus IV or IM hydrocortisone with additional every 6-8 hours)
• Mortality: as high as 25%

Huecker Micronutrients/Supplements

• 5 Pillars of Wellness: Move, Rest, Nutrition (Micronutrients/Supplements), Wisdom, Community
• Deficiency avoidance vs Optimization (Daily % on box is minimum, not optimum)
  • Example 100% daily vitamin C is enough to not get scurvy, not to help build tendon etc. 
• For more reading: Perfect Health Diet, discusses ins and outs of a healthy diet in easy to read way
• Daily Supplements: Mag >200mg, Vit D (~2000IU), Vit K2 100mcg, Vit C (1G), Idodine
• Most important mineral: Mg 
  • Used in 800 bodily reactions
  • Deficiency Symptoms: Muscle cramps/HA arrythmia, tremor, reflux, mitochondrial decay, poor immune function, death
• PO mag oxide trash, best PO: mag threonate (Brain mag, Mag mind)
• Probiotics: Food > Pill
• Collagen: Glycine: Methionine ratio (Bone in meats better)
• Lab Door: Website that tests supplement products for authenticity

Huecker Handout

Daily Supplements

Ask yourself “Am I going take this pill or powder every day for the rest of my life?” One should decide to take a supplement only after thoughtful consideration of ability to maintain long-term compliance. Macro- and micronutrients should come from whole food sources as often as possible. The package of vitamins in foods has millions of years of evolution backing its design. Thus, infant formula makers continue to strive for the same profile and clinical benefits of breastmilk. 

The backbone of these recommendations comes from the book Perfect Health Diet. Written by PhD husband and wife, the book covers macronutrients and micronutrients, with focus on nutrient density of foods and avoidance of toxins. 

Nutrition should begin with regular consumption of nutrient-dense foods:

• 3 egg yolks daily (5 for pregnant or trying to become pregnant) for choline, folate, vitamin A.  

• Soup made with bone stock 3 days per week for calcium, phosphorus and collagen.

• Fermented vegetables (kimchi, sauerkraut, or fermented mixed vegetables) for nucleotides, probiotic bacteria, and vitamins K2 and B12. Add other vegetables such as tomato, avocado, potato, sweet potato, banana, green leafy vegetables, and seaweeds such as dulse, daily for potassium. 

• ¼ lb beef or lamb liver, weekly for copper, vitamin A, folate, choline. You can substitute ¼ lb chicken, duck, or goose liver weekly plus 30 g 85% dark chocolate daily. 

• Fish, shellfish, eggs, weekly (for selenium)

You want to supplement the nutrients from the foods on this list that you do not consume. Potential issues with food recommendations include the 3 eggs per day (saturated fat and cholesterol), the fermented food not mentioning fermented milk (ie. kefir or yogurt), and no mention of omega 3 fatty acid supplementation (should consider whole oil supplement depending on amount of fish in diet). If you are not eating some of these foods, consider supplementation, for instance collagen powder if you do not regularly eat bone broth. 

Other important food considerations include polyphenols, plant molecules that induce hormesis in our bodies that will lead to longer life. Common sources include coffee and tea, chocolate, mushrooms, colorful vegetables and fruits, nuts, herbs and spices, algae, wine, olive oil. 

DAILY Supplements

• Sunshine or vitamin D3 as needed to achieve serum 25OHD of 50-60 ng/ml

• Vitamin K2 100mcg

• Magnesium 200mg

• Iodine 200mcg

• Vitamin C 500mg 

• Activated vitamin B complex (see this formulation)

• Pantothenic acid (vitamin B-5) 500mg

OPTIONAL supplements, with some dietary caveats:

• Chromium, 200-400 mcg per week (not necessary if you cook in stainless steel pots)

• FOR PEOPLE WHO DO NOT EAT LIVER: Copper 2 mg per day, Vitamin A from cod liver oil, 50,000 IU/week

• Taurine 500 mg to 5000 mg per week (higher doses may be therapeutic for small intestinal or systemic infections)/(also helpful for blood pressure lowering)

• Selenium 200 mcg per week depending on selenium content of food (if food is produced in dry, flat areas = high selenium, no supplements; rainy, well-drained areas = 200 mcg/wk)

• Molybdenum 150 mcg per week

OTHER supplements depend on goals. The list above covers most of the supplements needed in the context of balanced, diverse diet. Individuals with restrictive diets should do research potential deficiencies. 

Special Considerations

Sleep – magnesium, glycine, L-theanine, vitamin D (in AM), resveratrol, LIGHT, rarely melatonin

Calorie Reduction/Weight Loss – sleep, chromium, high protein, creatine

Muscle Mass – sleep, creatine, omega 3, whey protein, collagen

Hormone Optimization – sleep, adaptogens (e.g., cordyceps, ashwagandha), Zinc, Vitamin D, B vitamins

Immunity – sleep, vitamin C, vitamin D, Zinc, garlic, elderberry, quercetin, probiotics

Recovery from Injury – sleep, glucosamine and chondroitin, hyaluronic acid, collagen

Hyperlipidemia – niacin, psyllium, phytosterols, red yeast rice

Nelson Thyroid Disorders

• Hyperthyroidism
  • Tachycardia, fever, exophthalmos, etc
  • Subclinical hyperthyroidism
    • TSH low, T3/T4 normal
  • Primary hyperthyroidism
    • TSH low, T3/T4 high
    • Graves Disease (85% of cases)
    • Thyrotoxicosis
    • Toxic nodular goiter
  • Secondary
    • TSH High, T3/T4 high
• Hypothyroidism
  • Subclinical hypothyroidism
    • TSH high, T3/T4 normal
  • Primary hypothyroidism
    • TSH high T3/T4 low
    • Hashimoto’s thyroiditis
    • Subacute painful thyroiditis
    • Subacute painless thyroiditis
    • Surgical/ablation
  • Secondary
    • Panhypopituitarism
    • Pituitary adenoma
    • CNS infection
• Thyroid Storm
  • Typically caused by stressor such as infection, recent surgery, trauma, PE, MI, DKA, med non-adherence
  • Triad: Hyperthermia (Usually >104F), tachycardia, AMS
  • Point Scale: Burch-Wartofsky Point Scale
  • Evaluation: Thyroid function panel, Tox, UDS, UA, CXR, EKG
    • Thyroid function: Low or undetectable TSH plus high free T3/T4
  • Treatment: Propranolol, Propylthiouracil or Methimazole, Cholestyramine, Fluids, Cool
    • Be careful wit B-blocker due to some patients having heart failure associated, can exacerbate and precipitate shock
    • PTU- Hepatotoxic
    • Methimazole- Avoid in pregnancy (can cause aplasia cutis)
    • Cholestyramine- Prevent free thyroid hormone reabsorption
• Myxedema Coma
  • Hypothyroidism, Altered mental status, Hypothermia/bradycardia
  • Precipitated by Sepsis, Medication nonadherence MI, heart failure, and cold exposure
  • Work-up
    • Thyroid panel: Elevated TSH, low T4 (Labs not correlated with severity)
    • Hyponatremia, hypoglycemia
    • Acidotic, retain CO2 and poor perfusion causing elevated lactate
    • Infectious work-up, Head CT, Possibly LP
  • Treatment
    • ABCs
    • Fluid resuscitation +/- vasopressors
    • Electrolyte replacement
    • Levothyroxine- 1^st line
      • Safe, give if suspected don’t wait for labs
    • Adrenal insufficiency cause > give steroids
• External Causes of  Hyperthyroidism
  • Amiodarone induced thyroiditis
    • Increased iodine load
    • Destructive thyroiditis- Thyrotoxic, can cause to release more thyroid hormone which then leads to hypothyroidism as thyroid
  • Other meds:
    • Lithium, HIV meds, immunotherapy, iodine, contrast
  • Munchhausen’s
  • Cancer
    • Struma ovarii, metastatic thyroid cancer

Shaw Acid/Base Disorders

• Anion Gap Acidosis
  • Decrease in HCO3, Increase in Gap
  • MUDPILES
    • Methanol
    • Uremia
    • Diabetic or alcoholic ketoacidosis
    • Paraldehyde (Tylenol)
    • Isoniazid/Iron
    • Lactic acidosis
    • Ethylene glycol
    • Salicylate
• Non Anion Gap Acidosis
  • Loss of HCO3 replaced by Cl ions
    • USEDCAR
      • Ureteroenterostomy
      • Saline Administration
      • Endocrine Disorder (Addison’s disease)
      • Diarrhea
      • Carbonic anhydrase
      • Ammonium Chloride
      • Renal tubular acidosis 
• How to Calculate Excess Anion Gap
  • Note in DKA (Don’t correct sodium to figure out gap)
  • Excess anion gap = Anion gap – 12 + HCO3
    • Sum >30: underlying metabolic alkalosis
      • Change in  AG > Change in HCO3
      • Less acidotic than should be
    • Sum <23: Underlying non-anion gap
      • Change in HCO3 > change in AG
      • More acidotic than should be
• Compensation in Metabolic Acidosis
  • Winters Formula
    • PaCO2=1.5 (HCO3) + 8 +/- 2
    • PaCO2 ~ last 2 digits of pH
• Treatment
  • Respiratory Acidosis
    • Correct ventilation problem
      • Example Opiate- Narcan
      • Anatomical- NPA, BiPAP, Vent
    • Two parameters to treat respiratory acidosis or increase minute ventilation
      • Respiratory rate
      • Tidal Volume (6-8 cc/kg)
  • Respiratory Alkalosis
  • Treat hyperventilation
    • Treat pain, Treat Toxidrome, Etc.
  • Metabolic alkalosis
    • Excessive loss of H+ through NG or vomiting > Zofran
    • Halt diuretics if contraction alkalosis
    • Stop Excess oral supplementation
    • Acetazolamide / Carbonic anhydrase
  • Metabolic Acidosis
    • Treat cause
    • Increased fixed metabolic acids? (Lactic acid, ketoacids, salicylic acid, toxic alcohols, etc.)
    • Uremic acidosis > Dialysis
    • Excess loss of HCO3 through kidneys of GI
    • Increased plasma Cl, limit Saline fluids
  • IV Bicarb?
    • Giving bicarb requires pt be able to blow off CO2 they will produce when HCO3 combines with free H+
    • If not able to compensate or when intubated RR is not matched to pre intubation RR can make acidosis worse
    • Cardiac arrest
      • Don’t use in MOST cardiac arrest
      • If cardiac arrest due to known TCA > consider it
    • Sepsis
      • Don’t use it, not helpful in improving hemodynamics or reducing vasopressor requirements
    • DKA
      • No benefit between pH of 6.9 to 7.1
      • Risk of hypokalemia, dereased O2 uptake, CSF acidosis, cerebral edema
      • No studies <6.9, so maybe
      • If pH < 6.9 Bicarb given 100mmol in 400mL sterile water with 20 mmol KCl at a rate of 100ml/h for 2 hours until pH greater than 7.0
    • Buffer pressors?
      • Theory: norepi needs to be converted to epi in vessels and if acidotic enzymes won’t work as well
      • What does data say: No evidence
    • Advantage
      • Provide fluid and sodium replacement
      • Increased arterial pH (does this matter, probably not)
      • ASA and TCA overdose, give it
    • Disadvantage
      • Na and water overload
      • Paradoxical CSF tissue acidosis
      • Cerebral edema
      • Hypokalemia
      • Decreases ionized Calcium
• Summary
  • Look at pH to discover primary disorder
  • AGMA is the accumulation of anions, NAGMA is a problem with GI or kidneys
  • If you have to calculate Winter’s formula on boards, it’s an ASA toxicity
  • VBG is okay if PCO2 not needed, pulse ox reading ok, not hypotensive

Prostatitis:

                   – E. coli in 80% of acute cases (chronic more common), others: STD pathogens

                   – Dx: DRE tender prostate, labs not always helpful

                                      – CT scan only if suspicion for prostate abscess

                   – Rx: 4 wk course of antibx with follow up with urology

Testicular Torsion:

                   – 2 types: Extra-vaginal torsion: neonates. Intravaginal torsion: adolescents

                   – Gold standard dx: surgery, scrotal Doppler US sensitivity about 86-92%

                   – Twist Score: helps determine high vs low risk for torsion

                   – Rx: Urology/OR, manual detorsion: open book 540-720 degrees

Chest Tube procedure sim:

                   – CT choices: 24F for viscous fluid and pigtail for uncomplicated PTX

                                      – Use own judgement

                   –  Can give 2g Ancef

                   – Go in about 10-12cm

GU Trauma: Dr. Huecker:

                   – 2019 model of clinical practice of emergency medicine

                   – Renal injury: Some injuries have no hematuria

                                      – gross hematuria, elderly, penetrating trauma

                                      – Injury classification >4 laceration into collection system go to surgery typically

                   – Ureter Injury: Iatrogenic 80%, penetrating trauma 18%

                   – Bladder: associated with pelvic fractures

                                      – needs CT cystography, RUG

                                      – Depends on intraperitoneal (needs surgery) vs extra (may not need surgery)

                   – Genitals: need good PE

                   – Pelvic injuries:

                                      – lateral compression, anterior/post, vertical shear

                                                         – binders with AP compression

Check out this great article about nurse intuition on acuity level of patients. Link posted by Sam Ghali, MD who you should follow on Twitter. TL;DR Listen to the nurses!

The study asked nurses in 2 medical and 2 surgical units in Rochester, MN to score patients based on a 5 point “Worry Factor.” Basically deciding sick or not sick. 31,000 shifts in 3551 hospital admissions. The Worry Factor was highly accurate, with a LR of ICU transfer of 17.8 for WF>2 and LR 40.4 for WF>3. Accuracy was higher for RNs with more experience. AUROC was 0.92 for ICU transfer in 24 hours. The article specifies that they couldn’t assert whether RNs used intuition or analytical skills (something our Gut Instinct study DID try to determine).

This paper reminds me of an article I wrote a few years ago about a teaching tool for the ED, asking EM residents to decide admit vs discharge (or try to guess diagnosis, etc,) the moment they see a patient.

The references for this article are fantastic as well. Multiple primary sources and reviews on the various scores MEWS, NEWS, EWS, etc that try to identify who will decompensate in the hospital. I like to think ER nurses and doctors are especially skilled here, although we should be better about following up on patients we admit. You called the ICU and they deflected to PCU: check the chart the next couple of days, were you right or wrong? That feedback is necessary to modify your mental models and learn. At least 5 of the references cover Nurse Worry, including one systematic literature review and one prospective trial in Denmark. The references also go into intuition, expertise, they even cite the book Thinking Fast and Slow, our inspiration for the Gut Instinct abstract that was presented by Carter and Giddings.

I have had this meme in my head for a while but don’t think I ever made it or saw it on the Internet. Maybe it will go nerd viral.

As I have lectured in didactics, a paradigm shift is taking place toward the OMI vs nonOMI, and perhaps moving away from STEMI vs nSTEMI.

The ACC may be getting on board with this change that began with ER docs, chiefly Stephen Smith at Hennepin. *Unstable Angina still exists.

Check out his tweet linking to the paper:

1/2 For first time, the Am Coll of Cardiology recognizes Occlusion MI in clinical guidelines (and references our first of many OMI/NOMI studies: Meyers HP, … Smith SW. Comparison of STEMI vs. NSTEMI & OMI vs. NOMI Paradigms of AMI. J Emerg Med 2020) https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

2/2 And also, for the first time in any Guideline (as far as I know), they recommend EKG criteria that were developed by an Emergency Physician (Smith Modified Sgarbossa Criteria). Page 7 of the pdf, references 10, 11, 21. https://jacc.org/doi/epdf/10.1016/j.jacc.2022.08.750

• Alaina: Room 9 M&M:
  • Symptomatic Bradycardia:
    • Atropine -> transcutaneous pacing -> Transvenous pacing
  • Bifascicular Block: extensive fibrosis of conducting system – if presenting with syncope high risk need to admit due to high risk of complete heart block
• Status Epilepticus in Peds:
  • Give kids a first pass for first seizure if unprovoked and simple and otherwise well-appearing child
  • Status Treatment: Def: >5 min or back to back without normal mental status between
    • 1st line meds:
      • Ativan: 0.1mg/kg max 4mg IV, takes about 2-5 min to work last 4-6 hours
      • Versed: 0.2mg/kg with max 10mg IM or 0.2mg/kg IN divided btwn both nostrils, stops seizures in less than 1 min
      • Diastat: 0.5mg/kg with max of 20mg rectally
      • Phenobarbital: 1st line in neonates (<1mo) 20mg/kg with max of 1000mg
    • If still seizing give 2nd dose after 5 min
    • 2nd line:
      • Keppra 60mg/kg IV with max 4500mg
      • Fosphenytoin 20mg/kg IV with max 1500mg
      • Valproic Acid: 40mg/kg IV with max of 3000mg
    • If still seizing 10 min after 1st and 2nd line then go 3rd line:
      • Pentobarbital 15mg/kg bolus with infusion of 5mg/kg/hr IV – will need to intubate patient/PICU
  • Pyridoxine for refractory seizures
  • Neonatal Seizures and infants less than 6mo: many are subclinical and not normal seizure activity
    • check glucose and electrolytes and septic workup (with LP) and antibx plus acyclovir
  • Febrile Seizures: 100.4 and above 6mo-5yo with normal neuro exam and have a seizure while febrile – not seizure then febrile afterwards
    • 30% chance of having another, 2-3% chance of developing epilepsy
    • Simple if <15min not recurrent/need to be vaccinated/GTC – give supportive care (tylenol/ibuprofen) – okay for DC home
    • Complex: >15min with more than 1 seizure in 24 hrs/focal seizure – admit
• Hyperkalemia/Hemodialysis
  • Causes: kidney/CKD, intake, tissue damage/leakage, endocrine (Addison’s/adrenal insuf)
  • Rate of change in potassium is more important than actual number
  • Treatment:
    • Calcium – 3g CaGlu or 1g CaCl stabilizes cardiac membrane/stabilizes voltage across membrane
    • Insulin – shifts potassium into cells through activation of ATPase 10 U plus 25g glucose decreases K by 1mEq/L
    • Albuterol: shifts potassium into cell by activation of ATPase decreases by about 0.5mEq/L – 15-20mg neb
    • Bicarb: Only use in Metabolic Acidosis otherwise do not give – doesn’t really decrease K until later in the course
    • Remove K: Lasix/Bumex, BInders/Lokelma renal likes – do not usually give in ED
    • Dialysis: Takes 60 min to decrease by 1 mEq/L
  • Succinylcholine: healthy people increases 0.5 per dose
  • Emergent Dialysis: A: acidosis, E: electrolytes, I: Ingestions/intoxicaitons, O: overload fluid, U: uremia (encephalopathy, pericarditis)
    • Chronic Dialysis Patient:
      • Electrolyte abnorm
      • Volume overload
      • Remove toxins/BUN/acidosis
    • Acute Renal Failure:
      • Electrolyte abnorm
    • Normal Renal Fxn:
      • Ingestions
  • Dialysis Basics:
    • Small molecule
    • Charged
    • Examples:
      • Toxic Alc: methanol and ethylene glycol
      • Lithium
      • ASA/Salicylates
      • Valproic Acid