ABEM

• ABEM exists to verify the abilities of physicians and to promote quality, trust, and responsibility.
• They aim to make our board certification more valuable by advocating for our value in hospitals
• See ABEM website for details about board certification and the exam
• Study for your exam!

Small Group: Nail bed Infections

• Flexor tenosynovitis
  • Hand emergency. Pt will often require OR washout with Hand surgery.
• Paronychia
  • Manage with warm compress and/or I&D
• Subungual hematoma
  • Ensure there is no underlying fracture
  • Trephination is generally reserved for symptomatic treatment within the first 24hrs

HIPAA: common scenarios and what is appropriate

• Family member: provider may disclose “directory info” (patient location and general health status) if caller identifies the patient by name.
  • The provider must first provide the patient with opportunity to agree or object
• Personal physician
  • Disclosures of PHI from one provider to another for treatment purposes are permissible without the patient’s authorization. Disclosing provider must use professional judgement to determine whether the requested PHI relates to the patient’s treatment by the requesting physician
• Press
  • Location and general health status can be disclosed if requestor identifies the patient by name, unless the patient has objected to such disclosures
  • Can’t just ask about the status of a GSW
• Test results
  • Provider must use their judgement to infer from the situation that a patient does or does not object
• Law Enforcement
  • Limited situations – PHI about a patient who is suspected to be a crime victim and the patient cannot agree to disclosure; the provider may disclose the PHI if (1) she/he determines that disclosures is in the patient’s best interest and the law enforcement officials represent that the PHI needed to determine whether another person violated the law. (2) The PHI is not intended to be used against the patient. (3) An immediate law enforcement activity depends on disclosure.

Small-bore Catheter (6-12 F) Thoracostomy Tube Placement

Small-bore catheter kit includes:

• Small-bore catheter (6-12 F)
• Trocar
• Finder needle with syringe
• Guide wire
• Heimlich flutter valve (one-directional)
• 11-blade scalpel
• Local anesthetic with additional needle and syringe
• Sterile drapes
• Sterilizing solution

Indications:

• Pneumothorax (especially stable, non-traumatic, spontaneous pneumothorax)
• Pleural effusion drainage in the unstable patient
  • Large-bore chest tubes are still recommended for more viscous effusions such as empyema or hemothorax  

Step-by-step Guide:

1. Prepare the chest tube atrium and ensure appropriate length tubing is available for low wall suctioning once the procedure is complete
2. Place the patient in either a lateral recumbent or supine body position with the head of the bed elevated to 30-45 degrees, or in a seated position with the patient leaning slightly forward for posterior tube placement (i.e. tube placement for drainage of pleural effusions, ultrasound guidance is recommended for posterior tube placement similar to with thoracentesis both to identify the location of the effusion and due to the increased presence of vascular structures between the rib spaces posteriorly)
3. Identify the location of insertion, usually the 4-5^th intercostal space at the mid-axillary line (similar to large-bore chest tube placement) at the level of the nipple. Remember the “safety triangle” bordered by the lateral edges of the pectoralis and latissimus dorsi muscles where there is a decreased risk for damage to underlying vascular, nervous, and organ structures
4. Sterilize the skin surrounding the site of insertion and drape the patient accordingly using the drape provided in the kit, or by using sterile towels if preferred (remember to leave the nipple exposed to assist with identifying landmarks during catheter placement)
5. Measure the small-bore catheter in front of the patient’s chest to determine the appropriate depth of insertion in a manner which ensures placement towards to superior aspect of the chest with all side ports within the pleural cavity (remember, the catheter can be withdrawn but not inserted further once the procedure is complete, similar to placing a central venous catheter)
6. Generously anesthetize the skin at the desired site of insertion, advancing your needle deeper over the superior aspect of the rib to minimize the risk of damage to the neurovascular bundle, withdrawing prior to injecting lidocaine as the needle progresses through the soft tissue. Be sure to anesthetize the parietal pleural during this process, as it is fine for the needle tip to pass into the chest cavity
7. Gently advance the finder needle over the superior aspect of the rib through the intercostal musculature similarly to the previous step while steadily drawing back against the syringe plunger as the needle tip advances. The plunger pressure will give way once access into the pleural cavity is achieved. Consider loading the finder needle syringe with several mL of sterile water for visualization of air bubbles in the syringe to assist with this step
8. Once access to the pleural space has been achieved remove the syringe from the finder needle and insert the guide wire into the back of the finder needle passing the wire into the pleural cavity in such a manner that leaves most of the wire hanging outside of the patient
9. Remove the needle from the patient and make a small incision in the skin at the base of the guide wire using the provided 11-blade scalpel
10. Pass the dilator over the guidewire and into the pleural space feeling it give-way once it has pierced the parietal pleura and entered the thoracic cavity. Be sure to visualize the guide wire exiting the back of the dilator prior to insertion to ensure the wire is not accidentally lost within the chest. The dilator may be removed once this step is complete
11.  Pass the small-bore catheter within its trocar over the guide wire and into the pleural space in a manner that ensures all side ports are within the space. Generally, the first black indicator line can be used for small and thin patients, the second black line for the average adult, and the third black line for large adults. Similarly to the above step, ensure the guide wire is visualized exiting the back of the trocar prior to insertion.

HD – Pigtail Chest Tube Insertion | EM:RAP (emrap.org)

ED Operations Lecture 

Dr. A. Ross, MD 
POC Troponin will be leaving the ED
High Sensitivity Troponin (hsTnl): Less than 15ng/L in females and less than 20ng/L in males is interpreted as negative; anything above is considered positive.
-Reported in whole numbers-Significant delta is an increase in 15 ng/L (over 2 hours); note a fall greater than 15 is significant too. -Must Repeat in 2 hour intervals-Will take about 30-45 min to result. T2 Bacterial PCR: rapid diagnostic ecoli, s. aureus, klebsiella, pseudo, E. faecalis-TAT 3-5 hours Who: septic patients Benefit?: Deescalation of antibiotics once resulted.

Level 1 Activation Criteria: SBP <90mmHg, Resp compromise or impending, EP Discretion, Blood resuscitations to maintain VS in transport, GSW or severe penetrating trauma to neck, chest, or abdomen, GCS <9 with mechanism attributed to trauma.NOTE: GSWs to the head and going to SICU (call trauma on these) do not need to activate Level 1 on these. 
Shunt Series: power plan in cerner; rad VP shunt series (orders all plain films) 
TEG Stay Tuned
Continue to place Intend to Admit Order in Cerner on people you know will admit.

One Pill Can Kill 

Dr. R. Lund, MD 

CCB, TCA, Lamotil, Opiates/Opioids, Camphor, Clonidine, Antimalerials 
Opioids: Naloxone dosing peds: 2mg IV q3-5BB Tox: hypoglycemia and bradycardia; glucagon and or high insulin protocol (consult tox.)CCB: Dihydro and Non-Dihydro; Txt: supportive care; Poison Control ConsultationOil of Wintergreen: Salicylate Toxicity; Toxidrome: Nausea, Vomiting, Tinnitus, Txt: Urinary Alkalization Sulfonylureas: Admit for 24 hours, give either PO or IV. Txt: Octreotide infusion Clonidine/Imidazoles: A-2 agonist, high dose narcan and supportive care measures. symptoms: lethargy and or coma typically. Camphor: Txt: Benzos and Phenobarb for seizures; TCA: CNS, anticholinergic, and QRS prolongation; QRS 100ms< is pathologic; Tx: Benzos and Bicarbonate, Lamotil; loperamide +/- atropine; symptoms: anticholinergic and opiate toxidrome picture; txt: narcan Toxic Alcohols: Ethylene Glycol, Methanol, and Isopropyl Alcohol (rubbing etoh): Isopropyl: ketonuria; supportive care Methanol: de-icers, HA, Metabolic acidosis, breaks down into formic acid, give fomepizole or ETOH to compete out A. dehydrogenase Eth. glycol: txt: fomepizole, dialysis, and bicarb for acidosis. 

SJS/TEN 
Dr. Slaven, MD 

SJS <10%; TEN 30%<Hx physical exam key; Workup: CXR, CBC, CMP ESR/CRP SCORTEN Score predictor availableRemove inciting factor Pathogenesis: Sulfa drugs; typically first 8 weeks Consults: Optho, Uro, OBGYN 

Pemphigus Vulgaris & Bullous Pemphigoid

Dr. Martinez,MD 
PV: More common
Pemphigussssss is SSSSuperficial Age Range 40-60yo Autoimmune Dz; Ab to DSG 3&1+Nik sign; Flaccid bullae clinically, mucus membrane involvement <10% TBSA TxT: systemic steroids and rituximab IV; 2nd line: Dapsone, Mycophenolate and IVIG. Non-adhesive dressing application
BP: Pemphigoidddd is NOT Superficial Disease of elderly F>M 1.3-1autoimmune disorder vs. basement membraneTense blisters clinically; pruritic, tense bullaePruritus is more apparent clinicallyTxt: Topical steroids preferred; IVIG can be used as well per derm’s recs. 

Stress & Burnout: 

Dr. Huecker, MD 
Stress= perception of perceived threat. if perceived as negative, research says that this can have negative impacts on healthif perceived as positive=can have beneficial effects on personal potential Stress can impede performance, determined by the individual’s “appraisal” of the situation. Hormesis: phenomena of dose response relationships and over prolonged periods of time can have strengthening effects. Dose of poison a day will make us better. Connect with people daily: compassion does to deplete resourcesOptions to cope: exercise, therapeutic writing, gratitude recognition, thousands available 

Necrotizing Fasciitis: Dr. Lehnig, MD 
Diagnosis: Surgical Exploration CT 90% vs. MRI 86% sensitivityTreatment: “Early Surgical Debridement” Antibiotic Regimen: carbapenam or Zosyn +Vanc, dapto, or linezolid +clindamycin for antitoxin effects

Staphylococcal Scalded Skin Syndrome (SSSS): Dr. Edwards, MD 
Mostly less than 5 yo; if in adults typically immunocompromised Clinical Exam: +Nikolsky’s sign and will spare mucosal surfaces; + fever typically Diagnosis: Clinical Exam; look for other infections that precipitated the infection. Treatment and Disposition: Typically burn unit admission, Antibiotic Regimen: Typically MSSA but if there are risk factors for MRSA use coverage for MRSA. 

EMTALA : Dr. Royalty, MD 

Emergency Medical Treatment and Active Labor Act#1: Medical Screening Exam (Everyone gets this no questions asked)#2: If you ID an emergency condition, you must treat and stabilize this, if hospital can’t manage, must get accepting physician to transfer to higher level of care#3: If OSF needs to transfer patient because of lack of ability to care for patient, facility is required to accept patient despite ability to pay, etc. Transfers: All pertinent records and imaging should accompany patient or be sent electronically ASAP. 

Decisional Capacity: Dr. Yff, MD
Informed Consent: understand treatment, potential risks and benefits, and reasonable alternatives

4 Components: relevant info, appreciation of consequences (insight), reasoning of choice & 
communicating a choice.
Estimated, 48% of patients hospitalized are not capable of making decisions in a hospital setting MacCAT-T: decisional tool to evaluate capacity. 

Treatment of Non-Emergent Hyperglycemia in the ED: Sue McGowan, APRN 
Diagnosis: Glucose >126 fasting, a1c over 6.5%, and Random BG >200 + symptoms Targets for Diabetes: Premeal BG 80-130, post prandial <180, a1c <7Treatment: Diet and exercise-> Metformin if renal function adequate and no GI intolerance (500mg BID)-> a1c 8.5% (ADA recommends 2nd agent-> a1c 9% (see ADA guidelines)-> a1c Long Acting: 24 hour coverage “peak less”; glargine,basaglar, detemir, degludec (each vial has 30 days 300U)NPH/Intermed acting: onset 1-3 and peak 6-12 hours (NPH and 70:30 insulin very cheap) Rapid Acting: 5-10 min onset peaks1-2 hours (the “logs” and apidra and fiaspInitiating Insulin: basal or NPH 10U/day or 0.1-0.2 U/kg/day goal <130 before breakfast (titrate ever 3 days by increasing 2 U to hit morning goal)Glucose tabs=fastest method to correct hypoglycemia OOH (OTC and cheap)Send prescription for glucagon for 2ndary person to admin for rescue. Diabetes Supplies: glucometer, test strips, lancets, and needles for insulin. Diabetic NP: 10am-6:30pm ULH consult via cerner.

Electrical Injuries: Dr. Leavitt, MD 
Low voltage <600V (most household circuits around 120V)High Voltage 600V<Peds: chewing on electrical cords, must admit these, delayed necrosis of S. labial A. Lighting Injuries: Initiate CPR immediately if pulseless; ruptured TMs, A/C worse than D/C injuries

Check out this very brief Amal Mattu article about that pesky ECG after ROSC. Bottom line: Wait at least 8 minutes to obtain the ECG if you obtain ROSC. This isn’t that wild of an idea, and often it takes a good 10 minutes to set up the machine and stop doing your other resus tasks. But don’t be compelled to get the ECG as fast as possible, as the delay of 8 minutes can reduce false + STEMI. Check out this long article he cites.

Think you need tick bite prophylaxis after that woodland hike? These are the indications.

Dr. Mallory shared this website with me, and I think it is a great reference for up-to-date stroke EBM. They break down stroke care by stage of care and share relevant translational knowledge of each topic. See link below.

https://www.strokejourney.com/

ACEP Advocacy from Dr. Cirillo

-Projected EM physician may have a job shortage of up to 9500 jobs by 2030
-Medicare data used to compile this projections
-Concern may be that we need to further specialized into things like substance abuse specialist, emergency psychiatric specialist, observation unit specialist.
-ACEP wants to protect jobs
-ACEP supports mental health for ER physicians
-support silence on ED violence in conjunction with the ENA

-Message overall: get involved if you want meaningful change/advocacy for our specialty

Tropical Diseases with Dr. Heppner

Dengue Fever

-AKA breakbone fever, that leads to myalgia and arthralgia. Labs leukopenia, transmitted be a mosquito, endemic to Southeast Asia in South America. Treatment is supportive care. Transfuse as needed. Diagnosed clinically.

Yellow Fever

-most notable symptoms lately have dysfunction with associated jaundice. The remainder are nonspecific symptoms. Trended to be mosquito. Endemic intensely here in Africa, treatment is supportive care.

West Nile Virus

-Transmitted via mosquito should perform an LP, symptoms are usually asymptomatic and most patients, but can include nonspecific in such as fever headache myalgias lymphadenopathy. Endemic in the Middle East Africa Southeast Asia, diagnosis clinical, can order a special CSF test which is an IV GM antibody. Treatment is supportive

Pharmacy ID Review with Dr. Senn

You should treat asymptomatic bacteriuria in pregnant patients, patients that have had a renal transplant within the last month, and patient is going for GU surgery in the next 72 hours.
Epididymitis if concern for E. coli should be treated with levofloxacin. In patients less than 30 consider STI coverage in these patients.
Meningitis/encephalitis: Patient is greater than 65 should have ampicillin added on for Listeria coverage, in addition she was treated with ceftriaxone and vancomycin. When covering for Pseudomonas picture you on cefepime. If concern for fungal encephalitis include amphotericin B plus flucytosine.
C. difficile: Treat with vancomycin p.o. that is first-line. IV vancomycin does not cross over into the gut.
Fournier’s gangrene make sure you could broad-spectrum antibiotic coverage with the addition of clindamycin for toxin neutralization.
Tick bite: Prophylax patient’s if a tick was document for greater than 36 hours and within 72 hours of it being removed. Doxycycline should be used.
Post-exposure prophylaxis for rabies bites if the patient has been previously vaccinated they receive the rabies vaccine on day 0 and 3 after the bite. If they have no prior rabies vaccine they get a rabies vaccine on day 0 3/7/14 after the bite.
Febrile neutropenia: Defined as ANC less than 500. Should have broad-spectrum antibiotic coverage. With the addition of vancomycin. No vancomycin as needed for suspected UTI.

ID Lightning Lectures with Drs. Royalty, Strohmaier, and Jordan

Flu: URI symptoms fevers and myalgias. Usually self-limited disease. Those extremities age are at high risk. In addition people with significant comorbidities pregnancy or BMI greater than 40 or high risk. High mortality associated with a secondary bacterial pneumonia. Treatment is supportive and Tamiflu. Tamiflu carry significant risk with it including nausea vomiting psychiatric issues including hallucinations and suicide attempts. Consider starting Tamiflu if patient has been admitted. For those that are low risk used shared decision-making with the patient explained risks and benefits.

TB:
Primary usually asymptomatic, unless immunocompromise then may have B symptoms. Reactivation TB can include pulmonary plus systemic symptoms. May have extrapulmonary findings including pericarditis peritonitis encephalitis or meningitis and right adrenal insufficiency. Latent TB can include nodular findings on chest x-ray, complex. Miliary TB has a high mortality rate. Small nodes found on chest x-ray. But can occur anywhere in the body. Treatment is right therapy rifampin isoniazid pyrazinamide and ethambutol. For treatment of latent TB can treat with rifampin or isoniazid plus B6 dependent on liver enzymes. Rifampin preferred in people with liver dysfunction.

Syphilis
Sexually transmitted. Can be spread to other organs if left untreated. Primary syphilis is painless chancre that developed with 30 to 90 days after exposure usually currently on mucosal membranes. Not noticed on limited the genitals. Secondary syphilis, lymphadenopathy rash on the palms and soles. Tertiary syphilis can have cardiovascular findings included a dilated aortic root, aortic valve dysfunction, thromboses or clot formation within coronary arteries, neurosyphilis or, syphilis.
Neurosyphilis is a poor prognostic indicator. Can have ocular symptoms meningitis or seizures. Late findings of neurosyphilis or paresis psychosis tabes dorsalis ataxia pain bladder dysfunction dementia death. Syphilis does cross the placenta, as such congenital syphilis can occur.
Testing VDRL RPR.
Treatment was with penicillin 2,400,000 units pen GIM. For length and latent syphilis should be treated with a 2,400,000 units pen G IM . All neurosyphilis patient should be admitted for IV penicillin G.

A couple cool articles in Academic Emergency Medicine and Training (AET)

1. One simply surveyed residency programs to see if we try to impart efficiency skills to our residents. Overall yes programs do try to educate on this topic. “Results: We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with “signifi- cant” or “moderate” priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: “individual data provided along with deidentified rank” (35%), “data provided only during private feedback meetings” (26%), and “no data or rank provided to residents” (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions.”

2. But the NEXT paper is much cooler. This one looked at what on shift behaviors actual correlate with improved efficiency of residents. Now the outcome metric they used was RVU/hour (they talk about using patients per hour but don’t really report the data in results). I am not sure if I would place your RVU per hour as a top priority. But in measuring efficiency and helping you in your job on graduation, I guess it is ok.

The results were interesting. Seven behaviors correlated with improved efficiency, three with worse efficiency, and a bunch with no difference. Now some of the more efficient ones were found to correlate with LESS efficiency in a study they did in community docs. And some of the less efficient ones were more efficient in community docs. So you have to read the discussion section of the paper.

But one major take home point that they wrote a whole paragraph about that you can do TODAY is “swarming.” This is when you go in with the nurse (and other staff) and take history with them while communicating your workup and treatment plan to the team. This improves your efficiency in seeing patients and everyone wins. I do this at Jewish, often at South the nurse wants to come in the room when the doc goes in. This communication helps and prevents the need to check back with the RN/Tech/RT to go over the plan. So today or on your next shift, try some swarming!

See below, as the variable increases, so does your RVU/hr. Makes sense on some, higher patient load means more RVU. But some cool ones like the more you use dictation, the more RVU. The more you use smartphone to communicate with people in the ED, the more RVU. Oddly, the more nonword tasks, the more RVU (might be that more efficient residents have leftover time to talk to people or do nonword tasks). Visiting the patient room multiple times meant less RVU per hour (but almost definitely happier patients!). Talking to the attending means less RVU (you aren’t billing patients when we talk), but likely more education for you. You see why using RVU/hour is a measure that does not equate to good patient care or even a good work experience for you. The business of medicine : /

More efficient: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour).

Less efficient: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour).

Check out this article by Louisville cardiologist John Mandrola. It is worth reading in full, just one and a half pages. Mandrola and coauthor Foy comment on an iatrogenic coronary dissection during a cath performed for a + troponin in SVT. Check out Table 1, very nice for conceptualizing Troponin elevation.

The TL;DR: carefully interpret troponin elevation when you do not suspect a type 1, acute coronary occlusion MI. As I always tell you guys, a very important binary to collapse in ED patients is, does this patient have an acute occlusion, or OMI.

If you are ordering a troponin in a patient with tachycardia from fever, SVT, afib, or even bradycardia, be prepared for an elevation. But unlike STEMI or STEMI equivalents (ie OMI), this troponin elevation may not require any specific treatment, especially cardiac cath. Treat the underlying condition, even if using troponin as a prognostic marker. This applies more for cardiologists, but we have a role as well. For instance, Amal Mattu says to not even obtain Trop in young healthy SVT patients (I agree).

Sepsis Review- Dr Shoff

What is sepsis? A systemic response to infection
Mortality reduction in sepsis? ANTIBIOTICS EARLY
SIRS- T 101F/90, RR >20, WBC >12k/10% bandemia with evidence of End Organ Dysfx
Severe sepsis += hypoperf despite adequate IVF resus.-30ml/kg crystalloid, or a drop in SBP drop by 40 mmhg, or any SBP <90mmHg
What do you do?
Within 3h of presentation get:
1. Lactic
2. Blood cx BEFORE abx
3. Broad spec abx coverage=zosyn, cefepime, meropenem, ceftriaxone, unasyn, amp, levofloxacin

Within 6h

Within 6h, rep lactic in first is >2h.
Pressor if ivf persist
If lac >4h rept vol status and tissue assessment
If hypotensive after ivf, repeat vol status and tissue assessment.

TIssue assessment/vol assessment?
Vs
Cardiopulm exam
Cap refill
Peripheral pulse eval
Skin exam

Exclusion crit
Comfort care
Death within 6h
Transfers from osh
Refusal to care

How do we do?
-90% bundle compliance

MCC of sepsis @UofL:
PNA
UTI
Skin/soft tissue

MEWS-used as a trend, if trending up=patient getting sick
Patient with BMI >30, can use Ideal Body Weight for fluid resuscitation

Things I wish I knew in residency-Dr. Gall

Eval where you want to work-shadow, see how RNs interact with staff
Less than 12h shifts are optimal
Overlap at shift change is beneficial
Nocturnists work less shifts, more $/hr
Negotiate your contract! -no malpractice without tail
$$- invest in broad index fund if you’re gonna play the market
Live below your means-work bc you want to, not because you have to
Keep studying
You will keep getting better
Fly or ground? >1h and critical (will need immediate intervention)= fly–but is dangerous
If issue with a consultant, have them come see the patient or admit patient for obs
Know what chain of command is before your have an issue with c/s
When pacing, consider use of u/s to ensure that you are actually getting capture.
Callback if concerned about a patient
Be nice to your patients
Review your patient prior to dc!
Take care of those you work with!
Apologize-to staff, patients
Books he likes -Rosen’s, EKGs for ER docs by Brady and Mattu, Roberts and Hedges procedure book

Panel

Things to learn before you finish residency-

TPA- talk to stroke team/follow pts whilst here because you’ll have to do it once done here
Chest tubes- percutaneous are more common outside of trauma centers
Ultrasound guided IVs, midlines
Lower acuity/urgent care style cases- we don’t see many here but you will later
It is normal for confidence to wax/wane right out of residency-but this gets better! Trust your training, you have been well trained
Don’t be afraid to call the children’s hospital for advice, not just for transfers
Follow up on patients you saw

Finances-
Pay quarterly taxes if IC
Read white coat investor
Live below your means

Just posting this article here to stimulate some discussion. Now that we sprinkle TXA on basically any body part, we need to be sure to maintain evidence based medicine. I would point out that there is very little downside to TXA. He mentions the HALT-IT trial that DID show a higher rate of VTE events in the treatment group. But most TXA studies have not shows risk of clotting. We also must be aware of the regression to the mean issue, which is probably what occurred in the most recent epistaxis study. For a book that covers this nicely, see this gem.

Again, I am a fan of TXA, and open to attempting treatment modalities with new, not yet gold standard of care evidence. But we must always practice non-maleficence, and must not be tempted by indication creep.

-Huecker

EMS Prehospital US- Dr. Heppner

1. Pre hospital US began in the early 2000s
2. Advantages include possible early diagnosis of pneumothorax, intrabdominal hemorrhage, cardiac tamponade, and tube confirmation
3. Also, may improve triage process
4. Barriers include costs of equipment and training as well as operator dependence
5. Could also cause delay in transport times

Capstone- Dr. Davenport

1. Heterotopic pregnancy risk is 1/100,000
2. Consider this in patients with persistent symptoms despite IUP
3. Zebra diagnoses are rare but still must be considered if nothing else explains the diagnosis
4. Be cautious in pregnant patients if you are concerned with ectopic rupture, even in patients with stable vital signs

Hyponatremia- Dr. McGee

1. For hyponatremia consider history closely when deciding volume status.
2. Primary polydipsia is rare and requires huge amounts of water intake.
3. Doing a repeat confirmatory test on a hyponatremic patient with minimal symptoms is important.
4. Use serum osms to determine pseudohyponatremia
5. In true hyponatremia, sodium and osms are low
6. Low Urine Osms and low specific gravity point to ADH independent hyponatremia, high Osms and SG would suggest ADH dependent
7. Consider Uric Acid test which may be low in SIADH
8. Beware of elderly patients with mild hyponatremia because they are at much higher risks of falls
9. Goal of hypertonic saline is to raise sodium by 5 mEq or improve LOC

Room 9 Follow up- Dr. Thomas

1. 45 yof hx of obesity, HTN, DM, complaint of weakness and slurred speech with a GCS of 6
2. Intubation complicated by black emesis but achieved with reverse trendelenberg position.
3. Head up intubation increases time until desaturation.
4. Consider bougie for increased first pass success
5. Consider post intubation complications when selecting head up vs conventional intubation

Pediatric DKA- Dr. Patterson

1. Pediatric DKA can many varied presentations
2. Blood pressure is usually last thing to decompensate in pediatric shock
3. Don’t bolus insulin initially. Make sure patient is resuscitated and potassium is appropriate
4. 10-20 ml/kg fluid bolus is correct based on PECARN
5. Most new evidence suggest that cerebral edema may be less iatrogenic than initially thought