Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department

Intimate Partner Violence

“Such violence is more prevalent during a woman’s lifetime than conditions such as diabetes, depression, or breast cancer, yet it often remains unrecognized by health professionals.” 

Pelvic Inflammatory Disease

“A large body of evidence suggests that infec- tion and inflammation in the upper genital tract can occur and lead to long-term reproductive com- plications in the absence of symptoms, a condi- tion often called subclinical pelvic inflammatory disease.”

“However, of note, in one study involving infertile women without a history of diagnosed pelvic inflamma- tory disease, 60% of the women with tubal-factor infertility, as compared with only 19% of those without tubal-factor infertility, reported health care visits for abdominal pain38; this suggests that many cases of pelvic inflammatory disease are missed and that clinicians should have a low threshold for considering the diagnosis.”

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy:  A Systematic Review

Lightning Lectures

Dr. Harmon-Thyroid Storm

1.Presentation is with thermoregulatory, CV, GI, or CNS disturbances. Symptoms can include hyperthermia, AMS, seizures, tachycardia, high output heartfailure, and GI symptoms.

2. Causes are systemic, endocrine, cardiovascular, obstetrical or idiopathic.

3.Treatment: Supportive care with slow cooling, benzodiazepines, beta blockers, PTU, Iodine, steroids, cholestyramine.

Dr. French- Cushing Syndrome/Disease

1. Cushing disease is caused by hypersecretion of ACTH. Cushing syndrome should be characterized by either ACTH dependence or independence.
2. Iatrogenic is the most common cause.
3. Symptoms: Weight gain, moon facies, buffalo hump, headache, HTN, Hyperglycemia, erectile dysfunction, irregular periods, central obesity.
4. Tx: mostly outpatient. ED management should focus on initial metabolic derangements. Don’t abruptly stop steroids.\

Dr. Sowers- Pheochromocytoma

1. tumor of adrenal medulla which releases catecholamines and metanephrines
2. Is associated with MEN, VHL, neurofibromatosis and famial paraganglioma
3. Diagnosis is made with plasma and urine metanephrines, chromagranin A and specialized imaging such as F-FDG PET scan
4. Treatment: Benzodiazepines, phentolamine. Avoid beta blockers and pay close attention to volume depletion.

MICU Follow UP- Dr. Cook

1. 29 year old female found down with V Tach arrest.
2. Etiology of Ventricular Tachycardia: Structural heart disease Ischemia, HOCM, Sarcoidosis, familial long QT, Brugada syndrome.
3. Therapeutic Hypothermia: Main benefit is reduction of neurologic sequelae
4. 2 studies in 2002 showed benefits of decreased mortality and improved neurologic outcomes at 30 days. Initial thought was lower temperature is better.
5. More recent Targeted Temperature Management study showed no differences in outcomes between 36 and 32 degrees Celsius cooling protocols.
6. Most institutions have hospital specific protocols.

CCU Follow up- Dr. Fisher

1. 82 yof fall at home with initial complaint of chest tightness. Also complained of 8-12 episodes of diarrhea daily for weeks and frequently takes loperamide.
2. Initially patient with elevated troponin and creatinine. EKG showed deep T wave inversions in the anterior leads.
3. After being admitted patient EKG showed widened QRS and ischemic changes. Cardiac catheterization revealed normal coronary arteries.
4. Pt was eventually discharged to hospice due in part to many comorbid conditions. Question if loperamide could have been the cause of the patients symptoms.
5. Loperamide toxicity: causes conduction disturbances which can persist for days. Includes widened QRS and prolonged QT.

Identity Theft- Dr. Bosse

1. Doctors are particularly vulnerable to identity theft
2. Claims can be disputed but it is a headache.
3. Pay close attention to accounts
4. Consider freezing credit scores or hiring credit monitoring companies.

Stroke Care in a Nonstroke Center- Dr. Remmel

1. Common mimics include seizure, drugs, metabolic derangement, hypertensive emergency, tumors, CNS infection, complex migraine, and functional
2. Know transfer options and stroke capabilities for any ER you work with.
3. LVO- aphasia or left neglect, eye deviation, weakness opposite of eye deviation.
4. Important exam elements: LOC, Visual fields, pupils, EOMs, sensation, facial motor, strength, speech and language, coordination, and extinction.
5. Consider using the Neuro Toolkit App
6. Consider tPA if 4.5 hours from symptoms onset.
7. Door to Needle time should be less than 30 minutes.
8. Know tPA exclusion criteria
9. tPA complications- angioedema, hemorrhage.
10. tPA dosing is 0.9 mg/kg with max of 90 mg. 10% is given as bolus. The rest is given over 1 hour.

Wellness- Dr. Huecker

1. Consider wellness daily. No one but you will advocate for your wellness once out of residency.
2. Eat a balanced diet.
3. Vitamin D is good, but not too much. Get sunshine.
4. Vitamin K2 is a sleeper vitamin. Warfarin can cause disruption causing many problems.
5. Magnesium is really, really good. Deficiency can cause cramps and headaches.
6. In general prefer natural foods over supplements.

Lightning Lectures – Guillain Barre, Myasthenia Gravis, Botulism

Guillain Barre – Dr. Tyler Bayers

-Immune system attacks myelin sheath causing ascending paralysis

-Progressive, mostly symmetric muscle weakness with absent or decreased DTRs

-Clinical diagnosis with CSF support showing albuminocytologic dissociation (increased CSF protein with normal CSF WBC)

-Monitor for signs of respiratory failure

-Treatment with IVIG; can also do plasma exchange

Myasthenia Gravis – Dr. Blaine Jordan

-Autoimmune NMJ disorder of postsynaptic Acetylcholine receptors causing fluctuating skeletal muscle weakness/true muscle fatigue.

-Highly associated with thymus disorders (thymoma); consider chest CT

-Often presents with ocular myasthenia, but can be weakness of any muscle group, often see ptosis, expressionless face

-Avoid drugs that can worsen MG – ex. fluoroquinolones, macrolides, aminoglycosides, beta blockers

-Infection, pregnancy can cause MG crisis – look for them

-In MG crisis, initiate steroids in ED; consider intubation as meds for crisis take days to work and could worsen prior to meds taking effect

Botulism – Dr. Avery Newcomb

-Clostridium bacteria with botulinum neurotoxin blocking presynaptic Acetylcholine release causing symmetric and descending flaccid paralysis

-Different types: Infant botulism involves ingestion of spores that colonize GI tract and release toxin produced in vivo; food borne botulism occurs after ingestion of food contaminated with preformed botulinum toxin; wound botulism with in vivo production of neurotoxin.

-Sxs may range from minor cranial nerve palsies associated with symmetric descending weakness to rapid respiratory arrest.

-Clinical diagnosis – tests take days to result. Botulinum antitoxin should be given as soon as suspected for age > 1 year. Botulinum immune globulin (BabyBIG) for infants <1 year of age.

Procedure Sim: LPs Dr. Mary Jane Schumacher and Dr. Dhruv Patel

-LP either left or right lateral decubitus position or sitting up

-Landmarks midline of spinous processes and anterior iliac crests = L4; go a space above or below (L3-L4, L4-L5 interspace). Ultrasound can assist in identifying landmarks. Prep and drape the patient. Use local anesthesia. Prepare manometer and collection tubes. 20-22 g spinal needle with stylet, aim towards umbilicus. Bevel edge should be parallel to the ligament fibers (bevel up when patient on side, to right or left when sitting up). Once in Subarachnoid space, obtain pressure then collect 1 cc of fluid in tubes.

-Layers needle goes through: skin, subcutaneous tissues, supraspinous ligament, interspinous ligament, ligamentum flavum.

-Tubes: 1) cell count and differential, 2) gram stain, cultures 3) glucose, protein, 4) cell count and differential; tube 3 and 4 can be used for special tests or additional cultures

tPA pharmacy lecture – Dr. Jade Daugherty

-Alteplase FDA approved for acute PE, acute ischemic stroke, STEMI (not preferred agent), central line thrombosis; several other off label indications

-Half life ~5 min. Fibrinolytic activity persists for up to 1 hour after administration

-Adverse effects: bleeding (notably ICH), hypersensitivity and angioedema

-Stroke dosing: 0.9 mg/kg IV (max 90 mg). 10% as IV bolus over 1 min, 90% as continuous IV infusion over 1 hour. Different dosing for different indications, look up dosing.

-Before giving tPA: know BG (<50 or >400 then correct and re-assess), blood pressure (<185/110 prior to tPA, <180/105 after administration), CT head without contrast, last known normal, and a good story.

-Several contraindications – use MD calc to go through list

-Excellent resource: AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke

-“Blood thinners” – antiplatelets are ok, warfarin with INR < 1.7 ok, prophylactic AC is ok, Direct Thrombin inhibitors and Xa inhibitors: check labs (INR, aPTT, platelet, TT, and anti Xa level) if last dose >48 hours and normal renal function then ok for tPA otherwise likely not. Glycoprotein IIb/IIIa inhibitors also not ok.

-Trials over the years: NINDS-II and ECASS-III showed disability benefit but after re-adjusting for baseline imbalances, no benefit showed.

-Wake Up Trial: in patients who awake with stroke sxs or have unclear time of onset >4.5 hours from LKN, MRI to identify diffusion positive FLAIR negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.

-If ICH after tPA administration: stop tPA infusion, emergent CT head, Labs including CBC, PT, INR, aPTT, fibrinogen level, type and cross. Cryoprecipitate: 10 U infused over 10-30 min, administer additional dose if fibrinogen level <150 mg/dL. TXA 1000 mg IV infused over 10 min.

Neuro Exam – Dr. Jeremy Thomas

-If neuro complaint, fever, sxs that don’t make sense, need full neuro exam. Lots of info below, some of the highlights included.

-GCS score in setting of trauma: Eyes 4, Verbal 5, Motor 6

-Low GCS: Do the DON’T: D: Dextrose, O: Oxygen, N: Narcan, T: Thiamine

-Pupillary response: reactive (no brainstem involvement), fixed and dilated (anoxic encephalopathy, exclude anticholinergics), one dilated (herniation with CN III compression or nerve lesion). Small and reactive – usually metabolic or toxic causes; consider thalamic or pontine infarcts

-Testable pupil findings:

Argyll Robertson Pupil (tertiary syphillis, selective damage to pathways from retina to edinger-westphal nucleus) “Prostitute pupil” – accommodates but does not react. Light near dissociation.

Marcus Gunn (total lesion of optic nerve/CN II). De-afferented eye. no response to direct light, constricts to light stimulus in other eye.

Horner’s syndrome (sympathetic denervation), ptosis, miosis, anhydrous. Trauma, stroke, carotid dissection/aneurysm.

Central Lesions – cause contralateral deficits of face and body (ex classic MCA stroke) and produce negative symptoms (ex. decreased sensation, decreased ability to speak); but cerebellar lesions can cause positive symptoms such as nausea/vomiting, nystagmus.

Midbrain Lesions: contralateral hemiplegia, ipsilateral CN III and IV findings

CN III: Oculomotor nerve, pupil size, raising eyelid, most movement of eye

CN IV: Trochlear nerve, movement of eye (superior oblique)

Eye innervation: LR6(SO4)AO3: Lateral Rectus CN VI, Superior Oblique CN IV, All Others CN III

Pons Lesions: contralateral hemiplegia, ipsilateral CN V, VI, VII, VIII findings

CN V: trigeminal nerve, sensation of face and muscles of mastication

CN VI: abducens nerve, lateral rectus as above

CN VII: facial nerve, movement of facial muscles and taste on anterior 2/3 of tongue

CN VIII: vestibulocochlear nerve, hearing and balance

Medulla Lesions: Contralateral hemiplegia, ipsilateral CN IX, X, XI, XII

CN IX: Glossopharyngeal nerve – taste on back 1/3 of tongue

CN X: Vagus nerve – ability to swallow, gag, some taste and part of speech

CN XI: Accessory nerve – move shoulders and neck, turn head from side to side/shrug shoulders

CN XII: Hypoglossal nerve: move the tongue

Cauda Equina: Compression of nerve roots in lumbar spine; loss of bowel or bladder control, saddle anesthesia, pain or weakness in lower extremities

DTRs – can help localize a lesion: Biceps C5/C6, Triceps C7/C8, Abdominal T8-T12, Patella L2/3/4, Achilles L5, Babinski S1/S2.

Grading: DTRs (0 absent, 1 decreased but present, 2 normal, 3 brisk and excessive, 4 with clonus). Strength (0 no movement, 1 flicker, 2 movement, 3 movement against gravity, 4 movement against resistance but weak, 5 normal).

Cerebellum: influences movement of voluntary movement, balance and equilibrium, muscle tone. Eyes open tests cerebellar. Eyes closed tests proprioception.

1. Position statements from four different organizations on Thrombolytic Use in PE, Submassive vs Massive

2. What do you do in the case of massive hemorrhage from a tracheostomy? Check your heart rate, consider tracheoinominate fistula, , and then follow this algorithm.

3. Managing suicidal patients in the ED. Risk level, interventions.

4. Elder abuse: Don’t forget the many ancillary staff / professionals you can lean on for assistance.

Clinical Pathways for Status Epilepticus – Dr. Kuzel and Dr. McKinney

In First 5 minutes:

-ABCDEFG (ABC’s, Don’t Ever Forget Glucose).

-Airway considerations: lateral decubitus, nasal trumpets, O2, suction

-Obtain IV access and search for reversible causes, can consider initiation of first line tx with benzos prior to waiting 5 minutes; be aggressive early

5-10 minutes:

First Line Agents: IV Lorazepam 4 mg and up to 0.1 mg/kg, may repeat Q5min or Midazolam 10 mg IM once if no IV access, or IV Diazepam 10-20 mg. Go big or go home. Get the seizures to stop sooner rather than later as more likely to have respiratory depression from status than with benzos.

Second Line Agents: Levetiracetam 60 mg/kg IV (max 4500 mg) or Fosphenytoin or Phenytoin 20 mg/kg IV (max 1500 mg) or Valproate 40 mg/kg IV (max 3000 mg)

Consider intubation if needed.

10-30 minutes:

Medications in refractory status epilepticus: Propofol 2-5 mg/kg IV, then infusion of 2-10 mg/kg/hr. Midazolam 0.2 mg/kg IV, then infusion of 0.05-2 mg/kg/hr. Ketamine 0.5-3 mg/kg IV, then infusion of 0.3-4 mg/kg/hr. Phenobarbital 15-20 mg/kg IV at 70-75 mg/min.

Advanced airway management: RSI. Preoxygenation. Induction: Propofol or Ketamine. Paralytics: Succinylcholine or Rocuronium (however consider status not being seen). When to intubate: when predicted course of seizures will necessitate high dose of respiratory depressing drugs.

–Special considerations: Consider nonconvulsive status epilepticus in known epileptic patient without return to baseline (emergent EEG, consider benzos). Always consider tox causes (avoid Phenytoin of Fosphenytoin in undifferentiated tox patient or drug withdrawal. Also avoid if this is a home medication due to concern of cardiotoxicity). Give Thiamine 100 mg if alcoholic. In isoniazid overdose, give pyridoxine 70 mg/kg, Max 5 gm.

–Pediatric considerations: Access usually a problem. Intranasal Midazolam 5 mg/mL solution dosed at 0.2 mg/kg divided into each nostril. Lorazepam 0.1 mg/kg IV, max 4 mg. See CHOP status epilepticus

Oral Boards – Dr. Shoff

-What do I see when I walk in room? If AMS, get POC glucose early on

-IV access, heart monitor, O2 monitor

-If a vital sign is missing, ask for it, likely will be abnormal

-If vitals are abnormal, start addressing immediately. Can always request “if this intervention changes a vital sign, will you let me know?”

-Always ask allergies before giving meds

-Get history from whoever you can: paramedics, family. Don’t forget social, surgery, family hx

-When to order things: right when you walk in, after history, after physical (can whenever but these are the 3 best times)

-If you ask specifics in regards to exam, they will answer yes/no, don’t want to be too broad but don’t forget to ask things either.

Geriatrics Lecture – Mobility

-Find out who lives at home, steps at home, assistive devices?

-Walk the patient in the ED and see how they do

-Could request PT/OT eval; may be hard from ED but could admit for these services.

-If thinking needs rehab/admit and not obs because they need a 3 day stay for insurance purposes

-If discharging, make sure home health eval can occur. If discharging with pain meds, do only half a pill.

-If patient is falling, consider that this is #1 morbidity/mortality for elderly

Meningitis – Dr. Platt

–Important higher level questions to ask: exposure to recent meningitis, current sinusitis/OM, recent antibiotic use, travel such as to Hajj and Umrah, recent IVDA, progressive rash, recent or remote head trauma, HIV infection, immunocompromised, recent drug use including OTC, age, vaccination status

-Screening CT not necessary if none of these apply: immunocompromised state (HIV, immunosuppressive therapy, solid organ or hematopoietic cell transplant), Hx of CNS disease (mass lesion, stroke, or focal infection), New onset seizure within 1 week of presentation, papilledema, abnormal level of consciousness, focal neurological deficit.

-LP: try to get blood cultures first and quickly do LP before antimicrobial therapy. If there will be a delay, blood cultures, abx.

-Drug that cause aseptic meningitis: NSAIDS!, antimicrobials (Bactrim, Amoxicillin, Isoniazid) most common but others include Muromonab-CD3 (Orthoclase OKT3), Azathioprine, IVIG, Intrathecal methotrexate or cystine arabinoside.

-CSF studies: normal glucose is about 2/3 concentration of blood. Glucose may decrease with bacteria, WBCs, or cells shed by tumors. Small amount of protein is normal in CSF but increases commonly seen with meningitis and brain abscess, brain or spinal cord tumors, MS, GB, syphillis. Don’t forget to order specifics for what you want.

-Don’t forget Dexamethasone prior to/same time as antibiotics

-Antibiotics based on age: <1 month (Ampicillin + Cefotaxime or aminoglycoside), 1 month to 50 years (Vanc + ceftriaxone +/- Rifampin if dexamethasone given), >50 years (Vanc + Ampicillin + Ceftriaxone +/- Rifampin if dexamethasone given).

Journal Club – Dr. Mary Jane Schumacher

-Compression therapy for prevention of recurrent cellulitis of the leg – do it

-TXA vs oxymetazoline for hemostasis in epistaxis: need a better study, would still try Affrin first but remember TXA as another option as this review shows it could be clinically beneficial and may prevent need for nasal packing

72 hour returns/Deaths in ED/Deaths within 24 hours – Dr. Mary Jane Schumacher

-Great job on care of patients and documentation

–For documentation: remember to take out the things that are saved in every note but do not apply. For ex. a patient dies in the ED, do not have in your note: discussed plan and all of their questions were answered or follow up with primary care physician upon discharge

-Important patient care points:

Remember to think of social situation and set patients up for success if going to discharge. Are they going to go home and fall and break a hip/get a brain bleed? Do they have a PCP to follow up with?

If vitals or clinical change on a trauma patient – repeat FAST.

Seizure patients – monitor in ED for a period of time, give their seizure meds/keppra load if they have definitely missed doses and discharging but be cautious of restarting Lamotrigine for risk of SJS if they haven’t been taking it. People coming back with recurrent seizures – neuro consult.

Alcohol withdrawal – really pay attention to these people, they can become sick very quickly. Symptoms can range from mild to severe. Recognize the symptoms from tremors/tachycardia to hallucinations/delusions and seizures. If alcoholic and reported seizure at home and don’t look well, consider admission. If they look well, can give phenobarbital 260 IM if discharging as it has a long half life and can prevent decompensation. You can also give phenobarbital IV if admitting for sxs.

Cirrhotics – use ideal body weight, use LR for resuscitation. Don’t forget considerations of Albumin in SBP, HRS, etc.

Morbidity and Mortality Case – Dr. Caleb Webb

-HIV/AIDS: AIDS when CD4 count <200

-AIDS defining illnesses: Several; discussed cryptococcosis, MAC, PCP

-Cryptococcal Meningitis: HA, fever, neck pain, n/v, photophobia. Will see increased ICP on lumbar puncture. Need to specifically order crypto testing on CSF fluids. Treatment is induction therapy with Amphotericin B and Flucytosine.

-MAC: most likely when CD4 count <50. Disseminated MAC: fever, night sweats, abd pain, diarrhea, weight loss. Diagnosis via isolation of MAC from the blood.

-PCP: diffuse, bilateral interstitial infiltrates. Induced sputum sample. Consider ordering LDH as often elevated.

Electrolytes – Capstone Dr. Dan Grace

Hyperkalemia

Causes: #1 cause hemolysis followed by renal failure, acidosis, cell death, drugs (ACE/ARBS)

Sxs: Abd pain, diarrhea, chest pain, muscle weakness/numbness, n/v, palpitations

EKG changes: variable depending on K; peaked T waves then P flattens and PR lengthens, conduction abnormalities and bradycardia – prolonged QRS up to sine wave, then cardiac arrest

Treatment: stabilize cardiac membrane with calcium gluconate, shift K into cells via 5-10 U regular insulin with 1-2 D50 amps, albuterol neb, sodium bicarb (esp if acidotic), Get rid of K via lasix if properly hydrated, dialysis.

Hypokalemia

Causes: chronic ETOH, malnutrition, diuretics, vom/diarrhea, hyperventilating, alkalosis

Sxs: cramping, weakness

EKG changes: U waves, flattening/loss of T waves, tornadoes, AV block, brady, PVCs

Deficit: For every 0.3 meq/L below 3.5, 100 meq deficit, replace with KCl PO if can, or IV; also have Effer-K, K phos at no more than 60 meq at at time

Hypernatremia

Causes: unreplaced water losses, decreased water intake or excessive Na intake

Sxs: HA, n/v, confusion/AMS, seizure, coma

Treatment: Depends on sxs, mild symptomatic (if euvolemic consider 1/2NS), severe with seizure/coma (D5W), Free water deficit on MDCalc [(serum Na – 140)/140] x 0.6body weight in kg. Don’t correct more than 0.5/hr.

Hyponatremia

Causes: vomiting, diarrhea, diuretics, drinking too much water, dehydration, heart/kidney/liver problems, inadequate salt intake – generally classified into hypovolemic, euvolemic, or hypervolemic

Sxs: dizziness, fatigue, HA, confusion, nausea, seizures

Repletion: no more than 0.5 meq/hr and 8meq/day to avoid osmotic demyelination syndrome. Give hypertonic saline 3% for seizure, coma 100 -150 cc over 10 min, can repeat x 1

Other electrolytes important in ED

Hypercalcemia: bones, stones, groans, psychiatric overtones; Tx if 12-14 with sxs or >14; fluid resuscitate, lasix if fluid overload, calcitonin is faster than bisphosphonates

Hypophosphatemia: anemia, bruising, seizure, coma, constipation, muscle weakness; usually caused by DKA, refeeding, malabsorption, ETOH; tx with NaPhos or KPhos PO or IV

Environmental Kahoot – Dr. Dan Grace

-Killerbees more likely to swarm and sting multiple times

-Acute Mountain Sickness – descend; Acetazolamide works by causing primary metabolic acidosis

-Ruptured TM following ascent from scuba diving – antibiotic drops and ear precautions

-Difference b/t heat stroke/exhaustion = neuro sxs

-Iguana bite – cipro

-ARDS after wet drowning due to water washing away surfactant

Toxic Smoothie – Dr. Bosse

-Digoxin toxicity is only time you do not want to use calcium for hyperkalemia

-Cyanide toxicity: lactate level. Tx with hydroxycobalamin. Other tx: nitrite (causes methemoglobinemia which then scavenges cyanide); thiosulfate, cyanokit (amyl nitrite, sodium nitrite, sodium thiosulfate)

-Antihypertensive overdose: hypotension possible but not common with ACE-I OD

-Few toxins cleared by HD: lithium, toxic alcohols, salicylates, theophylline

Geriatrics Lecture – Mentation

-Normal aging: slowed, need more time.

-Confusion, problems with judgement not normal

-Dementia progresses over years vs delirium acute change in things like attention, falling asleep, disorganized thinking or altered level of consciousness

-Delirum causes – several, but think of infection, meds, seizures, intracranial bleed, NPH

-Can use ADEPT Tool to assess change in mental status

-Use smaller doses of medications for elderly

-If need meds for agitation ex: Haldol 0.5 mg (IV,IM,PO), Seroquel 12.5 mg, Olanzapine 2.5-5 mg, Risperidone 0.25-0.5 mg

Decompensated Cirrhosis – Dr. McGee

-Have high index of suspicion for cirrhosis – use clues from exam and labs

-Search for underlying etiology of portosystemic encephalopathy, GIB, etc.

-Diagnose and treat SBP: diagnostic paracentesis with >250 PMNs, Ceftriaxone 2g Q24 hrs, Alubmin 1.5g/kg on day 1 reduces mortality

-GIB: early GI consult; varies 15-30% risk of death. 2 large bore IVs, cultures, ceftriaxone (or broader), keep Hb around 7. correcting INR with FFP not recommended, transfuse if plt <50 K, cryo for fibrinogen <100. Protonix, octreotide. Blakemore tube if needed.

-Hepatorenal Syndrome: High index of suspicion, Cirrhosis and Cr >1.5. If cirrhotic with AKI, use albumin 5% if hypovolemic, 25% if euvolemic/hypervolemic, non ICU midodrine and octreotide; if ICU levo with MAP >85.

-Medications to AVOID: Never NSAIDs, if opiates needed then fentanyl > Hydromorphone > morphine, avoid benzos as much as possible; can give Tylenol up to 2 g/day

MICU Follow Up – Hypothermia

-ECMO (if available) may be best way to rewarm, 7-10 ⁰C /hr

-Thoracic lavage up to 6 ⁰C/hr

-If coding, can attempt defibrillation x 3; rewarm to at least 86 ⁰ F

-Try to avoid stimulating heart, if need central access, fem line is best

-Rewarming complications include several electrolyte/coag abnormalities; check frequently

-Goal rewarm temp is 86-89 ⁰F

Neuro Cases

1. Stroke in Sickle Cell

-Neuro/hem consults early

-Exchange transfusion as treatment

-Can use upper motor neuron/lower motor neuron signs to help delineate where problem is

ex. UMN: +Babinski, spasticity, hyperreflexia ; LMK: Fasciculations, hypotonia, hypo/areflexia

2. Posterior Circulation Strokes

-Several symptoms: vertigo/dizziness, imbalance, unilateral limb weakness, dysarthria, diplopia, nystagmus, n/v, dysphagia

-HINTS exam can be used if symptomatic (Head Impulse, Nystagmus, Test of Skew)

-Subclavian Steal Syndrome: suspect in a patient with vertebrobasilar territory neuro sxs, arm claudication (exercise-induced arm pain or fatigue; coolness or paresthesias in extremity)

3) tPA

-BP goals for tPA administration <180/110 – may use Labetalol/Nicardipine for BP control

-Know some of the absolute contraindications; ex: any hx of intracranial hemorrhage, BP >180/110, known bleeding diathesis (platelet count <100,000; use of warfarin with INR > 1.7, use of DOACs) Can use MDCALC to run absolute/relative contraindications

-tPA symptom onset < 4.5 hours (prefer <3 hours esp in those >80 years)

Geriatrics Lecture

4 M’s for the ED: Medications

-Medications/polypharmacy should be high on differential for acute change in elderly

-1/3 of elderly patients lose independence in at least 1 activity when admitted

-Several meds are problematic; warfarin, ASA, plavix, digoxin, metformin and other diabetic medications, antibiotics

Room 9 Follow Up Case – Massive Hemoptysis

-Massive hemoptysis, no clear consensus definition. 100-1,000 mL/24 hours or >50 mL in a single event – really any bleed that is life threatening due to airway obstruction, hypotension, or blood loss

-Usually arises from bronchial circulation; MCC usually TB, bronchiectasis, lung abscess, bronchogenic carcinomas

-Airway protection: if having difficulty clearing airway or hypoxic/dyspneic, prepare for difficult intubation; intubation of mainstem of the good lung; can do this via going past the cords and turning ET 90 degrees; have patient lay on side of the bad lung

-TXA: nebulized TXA with 1 g TXA in 10 cc saline. Can also do 500 mg TID. Systemic route also an option, 1gm load in 100 mL NS over 10 minutes and 1 gm over 8 hours.

-Bronchoscopy and CT; CTA may help identify source; consults to consider early: Pulm, IR or CT surgery

EMS Lecture- PreHospital Stroke

-Several scoring systems (RACE, Stroke VAN, FAST-ED, CSTAT, LAMS) to help guide pre-arrival notification and transport to comprehensive stroke center

-CSTAT: Cincinnati Stroke Triage Assessment Tool, Screen for Large Occlusion Strokes >/= 2 is positive

Conjugate Gaze Deviation 2 points

Incorrectly Answers Age or Month and Does not follow at least one command (close your eyes, open and close your hand) 1 point

Arm (right, left or both) falls to the bed within 10 seconds 1 point

-Mobile stroke units – can decrease time to stroke tx by 50%, 20 units worldwide, CT scanner in back; tremendous expense without great improvement in outcomes

-tPA goal 60 minutes door to drug.

Hey I was going over some articles with a friend for Board Prep. Check out a few valuable figures from the papers:

• TIA Management. Think about the mimics. High risk for stroke if true TIA.

Edlow JA. Managing patients with transient ischemic attack. Ann Emerg Med 2018 Mar;71(3):409-15.

• Cord Compression Diagnosis and Treatment. Steroids only for malignancy. Keep BP up, ABx when indicated, and call the surgeon!

Ropper AE, Ropper AH. Acute spinal cord compression. N Engl J Med 2017 Apr;376(14):1358-69.

• Algorithm approach for New Onset Seizure. Anticonvulsants recommended even for first time IF epilepsy diagnosed.

Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA 2016 Dec;316(24):2657-68

• Outcomes with Endovascular stroke therapy in hours 6-16. This is why we room 9 strokes outside of the tPA window.

DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018 Feb;378(8):708-18

Trauma Conference – Amanda Corzine

• Domestic violence underreported in Louisville and nationally
• SANE and CWF are important resources to use here
• Have increased concern for women that present intoxicated on alcohol with no prior history of intoxications – be informed about domestic violence; Dr. Coleman has done research looking at the coincidence of domestic violence in this patient population

MICU Case Review – Royalty

• Patient with AMS, seizure-like activity. PMH of COPD on home O2, HFpEF, HTN, T2DM, Afib on AC, intubated prior to ICU
  • Subsequently COVID+ on floor transfer; sent back to MICU
  • Intubated again. Started on Remdesivir, Dexamethasone. Code during intubation.
  • Ultimately complicated course of Afib management and thrombocytopenia
  • +trop in trending labs q48h in COVID patient; cards consulted.

DED/72H Returns – Staben

• Remember to get labs in hypothermic patients who have arrested – it can lead to more appropriate prognostication and cessation of futile codes. K>12 means further resuscitative efforts are futile.
• Reviewed Brain Trauma Foundation guidelines regarding surgical management of acute SDH
• Remember to do indicated procedures like bilateral chest tubes or finger thoracostomy in blunt traumatic arrest even in seemingly futile cardiac arrest as these patients can have occult injury.

2-10-2020 Conference Notes

GME disability discussion – Calvin Rasey

• Endorsed by UofL
• COVID long term effects “long haulers.”

Pediatric Fractures – Elizabeth Lehto

• Torus fracture
• Plastic deformation, kids < 4
  • Generally associated fractures
  • >20 degrees of angulation require reduction
• Greenstick, kids < 10
  • Convex surface fracture
• Complete fractures
• Salter-Harris Fracture – SALTER vs know your MEME
  • I – Straight through the growth plate, may be radiographically absent
  • II – Above, through the growth plate and above into the metaphysis
  • III – Lower, fracture through growth plate and epiphysis
  • IV – Through both epiphysis, growth plate, and metaphysis
  • V – Rammed, growth plate crush injury
• Name that fracture game
• Elbow fractures
  • Capitellum – age 1
  • Radial head – age 3
  • Internal  epicondyle – age 5
  • Trochlea – age 7
  • Olecranon – age 9
  • External epicondyle – age 11
  • Need true 90 degree flexion X-rays – don’t get lazy with them.
    • Anterior fat pad – normal
      • Big sail sign = lipohemearthrosis
    • Posterior fat pad – pathological
    • Radiocapitellar Line
    • Anterior humeral line
  • Supracondylar fractures
    • Volkman’s Contracture if neurovascular injury
    • Anterior interosseous syndrome – normal if a good “okay sign”
  • Nursemaid’s elbow
• Non-accidental trauma
  • Torso, ears, neck, 4 years or younger
  • Watch out for kids that aren’t pulling up or walking – they should not have any bruises.
  • High specificity fractures
    • Metaphyseal fractures
      • Corner fractures – oblique avulsions of the metaphysis
      • Bucket handle fractures – horizontal avulsions of metaphysis
    • Rib fractures
      • Posterior more specific; CPR causes anterior rib fractures
    • Skull fractures
      • Non-parietal, cross suture lines, depressed
    • Scapular fractures
    • Sternal fractures
    • Spinous process fractures
• Leg fractures
  • Tibial fractures
    • High risk for compartment syndrome
      • Tibial shaft fractures requiring reduction tend to be admitted
    • Toddler’s fracture – distal shaft spiral/oblique fracture between 9-3 years
  • Juvenile Tillaux fracture – SH III
    • May require CT to evaluate closed vs open reduction, <2mm can be reduced
  • Triplane fracture, distal SH IV  – requires CT
• Hand fractures
  • Carpal fractures
    • Scaphoid fracture, think FOOSH, snuffbox tenderness
  • Distal phalanx fractures
    • Tuft fractures, splinted in DIP extension
    • Nailbed associated fractures – give abx
    • Seymour fracture – displaced SH II fracture, generally open, and requires reduction.
• Hip fractures
  • SCFE
    • Fat teens presenting with knee pain
    • Surgical pinning and NWB
  • Avascular necrosis – Legg-Calve-Perthes Disease
    • Preteen, insidious onset, antalgic gait

GI Review Game – Dr. Shaw

• NEC – new babies, mostly premature, pre-E, cocaine use in pregnancy
  • Amp/Gent, bowel rest
• Giardia – treat with flagyl
• Boerhaave – L pleural effusion, CXR with pneumomediastinum
• Esophageal foreign bodies
  • Esophageal bodies align in coronal plane
  • Sharp objects, objects > 6cm in length require surgical removal, then 24h trial of passage
  • All EFB require GI f/u to rule-out structural abnormalities
• AAA
  • >5.5cm = OR, include the mural thrombus
• Hernias
  • Indirect vs direct vs femoral hernias
    • Indirect follows inguinal canal

Ventilator Management Lecture – Obrien

• Check out Scott Weingart’s post on EMcrit regarding mastering the vent.
• PRVC or VC is preferred
• Remember ARDSNet

Intern Lightning Lectures – Schutzman, French, Strohmaier

• Positively electrifying.
• Acid-Base Status
  • Bicarb vs respiration vs buffers control pH
  • Delta gap in context of AGMA  – (AG-12) – (24-Bicarb)
    • Normal -6 to +6
    • Can indicate AGMA +NAGMA superimposed or vice versa.
• Unstable C-spine fractures
  • Denis Column Concept
    • Anterior column – always stable
    • Middle column – sometimes stable
    • Posterior column – always unstable
  • Jefferson’s Fracture
    • Consider vertebral artery injury
  • Bilateral Facet Dislocation
    • Consider CTA C-spine, MRI may be warranted as SCI strongly associated
  • Odontoid Fracture
    • Types I, II, III
  • Atlanto-Occipital Dissociation
    • Calculate that Power’s ratio, folks.
  • Atlanto-Axial Dislocation
    • Remember increased likelihood in some populations; Trisomy 21, OI, Marfan, NF1, SLE, AS, psoriasis, RA
  • Hangman’s Fracture
    • C2 fx with anterior displacement
  • Flexion Teardrop
    • Can disrupt posterior longitudinal ligament, high association with anterior cord syndrome
• DRESS vs SJS vs TEN
  • DRESS – drug rash with eosinophilia – morbilliform rash
    • Remember herpes reactivation
  • SJS/TEN
    • Mucosal involvement

Can’t Miss EKG Review – Huecker

• Didn’t miss a beat.
• Read Amal Mattu. If you don’t, you won’t understand EKGs very well
• He’ll send out his presentation

Test Taking Strategies – Shreffler

• 225 multiple choice questions, 4.5 hours to complete
• Feel okay to change answers after you re-read questions; you will likely have more insight later on.
• He will send out his presentation

Headaches in Small Groups – Nichols

• HA1
  • Temporal Arteritis
    • Get ESR, can do US vs MRI, will require temporal artery biopsy
    • Ophtho involvement means a larger burst x3 days of methylprednisolone, likely requires admission
• HA2
  • CO poisoning
    • Need ABG with co-oximetry
    • Consider EKG and troponin
    • Remember fetal Hb binds CO much more preferentially than maternal Hb, so lower threshold to treat with hyperbarics.
• HA3
  • Epidural hematoma
    • Consider BP goals, mannitol/3%, elevate HOB, hyperventilate

Procedural Review – Baker

• Excellent multiple choice questions.
• SBP
  • Remember albumin, get abx early
  • Low thresholds for diagnosis with cell count greater than or equal to 100 in peritoneal dialysis
  • We need to do more paracentesis
• LP
  • Watch that bevel
  • Platelets > 20/25, INR >=1.5
• Pacemakers
  • RIJ
  • Transvenous: 80 BPM, 20mA, 20cm
• Thoracotomy
  • >1500 initial output, >200mL over first 3 hours
  • 5^th intercostal space
• Yolk sac + gestational sac required for confirming IUP earliest.

Check out this article on the 10 commandments of our specialty. This is a revision of the original 10, which was published 30 years ago. Not much has changed on these bedrock principles. Check it out.

• Termination of resuscitation (Nichols)
  • When to stop resuscitation in out of hospital arrest
    • DNR order
    • No chance of saving them–safety, signs of irreversible death
    • Nothing left to do–unwitnessed arrest, no shockable rhythm, ROSC does not return in the out of hospital setting
  • Stop CPR if:
    • No ROSC
    • No shocks
    • Unwitnessed
• CCU follow up (French)
  • Arrhythmogenic RV dysplasia
    • 2nd MCC sudden cardiac death in young patients
    • Greek or Italian descent
    • Male:Female= 3:1
    • Presentation
      • Asymptomatic
      • Palpitations
      • Syncope
      • Ventricular dysrhythmias/cardiac arrest
      • FH of unexplained syncope/sudden death
      • RV failure
    • Cards consult–>admission
    • Arrhythmogenic RV dysplasia EKG: V1-V3 T wave inversions, epsilon wave
    • HOCM EKG changes: high voltage, LVH, lAD, tall R wave V1
• MICU follow up (Schutzman)
  • Myxedema coma
    • Hypotension
    • Bradycardia
    • Electrolyte derangements
    • Altered mental status
    • Give levothyroxine
• Jeopardy (Daughtery)
  • Activated Charcoal
    • Adsorbs toxins and inhibits GI absorption
    • Must be given in 1-2 hours, but still consider if ingested drug is extended release
    • Contraindications: GI perforation, need for endoscopic procedures
    • Concerns: emesis, CNS depression and aspiration risks
    • Consider risk vs benefit of administration
  • Deferoxamine
    • MOA: complexes with trivalent ions (ferric ions) to form ferrioxamine which is eliminated in urine by the kidneys
    • Indications: iron level >500, metabolic acidosis, lethargy/coma, shock, toxic appearance
    • Can cause urticaria, flushing of skin, hypotension, shock with rapid IV administration, ARDS
  • Itralipids (lipid emulsion)
    • Reversal of local anesthetic systemic toxicity
    • Consider for severe hemodynamic compromise of lipophilic xenobiotics or drugs with significant neurological or CV toxicity–last line
    • 20% emulsion solution
  • Phentolamine
    • MOA: competitively blocking alpha adrenergic receptors
    • Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation
    • Concerns: hypotension, medication safety
  • Levocarnitine
    • Antidote to valproic acid
    • Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity
  • Naloxone for clonidine reversal
    • Big doses- 10mg
    • Consider for reversal of CNS depression 
    • Fluids and vasopressors may also be required
  • Benzodiazepines
    • Midazolam: IV onset of action 2 min
    • Lorazepam: onset of action 5-20 minutes
  • Physostigmine 
    • Reversal of anticholinergic toxicity
    • Primarily for agitation and delirium reversal
    • MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine
    • Have physician and atropine at bedside
    • No significant risk of seizures
    • Low dose, push slow
  • Flumazenil
    • Benzodiazepine overdose or reversal only
    • Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex
    • Not effective on other medications that affect GABA
    • Concerns
      • Could precipitate withdrawal seizures if patient regularly uses benzos
      • Seizure history outside of withdrawal seizures
      • Risk vs benefit–goal of therapy
• Project ECHO
  • Optimal Aging Clinic will be added to discharge follow up options
  • Have a “what matters” conversation
  • Advance Directives
    • Living will
    • POA
    • POLST/MOST
    • EMS DNR
  • Advanced care planning–ICD code, must spend 16 minutes to bill
  • MOST form
    • A physician’s order
    • Must be honored by all KY healthcare providers in all KY settings
  • State of KY Hierarchy of Decision making authority if no advance directives
    • Court appointed guardian
    • Healthcare surrogate
    • Spouse
    • Adult children
    • Parents
    • Adult siblings
    • Closest living relative
• ECMO (Ritchie)
  • Components
    • Motor/pump
    • Filter/oxygenator
    • Blender
    • Ventilation–to increase, go up on gas flow aka sweep
    • Oxygenation–to increase, go up on blood flow aka flow
    • Cannulas (single vs double)
    • Circuits
      • Vein-Vein ECMO
        • Is the heart still able to pump
      • Vein-Artery ECMO
        • Heart pump function not ideal
      • Vein-Artery-Vein ECMO
  • VV ECMO 
    • Indications
      • Hypoxic respiratory failure, 50% mortality risk consider ECMO
      • Hypoxic respiratory failure, 80% mortality risk, put on ECMO
      • CO2 retention on mechanical ventilation despite high Pplat
      • Severe air leak syndromes
      • Need for intubation in a patient on lung transplant list
      • Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)
      • Anytime patient is on dangerous vent settings
    • Murray Score: conventional ventilation or ECMO for severe adult respiratory failure 
      • Score of 3–consider transfer to ECMO center
      • Score of 4– ECMO indicated
    • Contraindications
      • No absolute contraindications
        • Mechanical ventilation at high settings for 7 days or more
        • Major pharmacologic immunosuppression
        • CNS hemorrhage that is recent or expanding
        • Non-recoverable co-morbidity
    • When making the decision to begin ECMO
      • Is this condition reversible?
      • Is it a bridge to transplant?
      • RESP score (estimated survival once on VV ECMO)
    • ARDS
    • Ventilator trauma
      • Volutrauma
      • Barotrauma
      • Atelectrauma
      • Biotrauma (cytokine storm, inflammation)
      • Energytrauma (goal for driving pressure 15 or less)
    • Settings once cannulation successful
      • Set flow: 4L
      • Set Sweep: 4L
      • Lung rest settings while on ECMO
      • PC 10/10/10/40%
      • Goals
        • Sat >85%
        • MvO2 >65%
  • VA ECMO
    • Indications
      • Heart failure bridge to recovery, heart transplantation, VAD
      • Cardiogenic shock
      • Myocarditis
      • ECPR
      • Right heart failure
      • PE
      • Medication overdose
    • SAVE score
  • Trans pulmonary pressure
    • Consider in morbidly obese patients
    • May have higher PEEP requirements given pressure from chest wall/abdomen
    • When intubated, they lose the ability to autopeep
  • Page Jewish thoracic or cardiac surgery –consult early

• ITE- grab bag (E Thomas)
  • Spider bite, necrotic wound>brown recluse
  • MCC erythema multiforme> HSV
  • Strawberry cervix>trich
  • Pre-E, less than 24 weeks>mole pregnancy
  • Abdominal pain after sex>ovarian torsion
  • Most common personality disorder>borderline
  • Patient intentionally fakes symptoms>malingering
  • Sudden paralysis after traumatic event>conversion
  • Discriminatory zone for TVUS>1500
  • PID/RUQ pain/shoulder pain>Fitz Hugh Curtis
  • MCC postpartum hemorrhage>uterine atony
  • Pizza pie fundus>CMV
  • Corneal dendrites>HSV keratitis
  • Tachycardia out of proportion to fever>thyroid storm
  • Alcohol, AMS, ataxia, nystagmus>wernicke
  • Stingray wound>hot water
  • Beta blocker OD>hypoglycemia
• One Pill Can Kill (Lund)
  • Ingestions–fatal in small doses
    • CCB
    • Cyclic antidepressants
    • Lomotil
    • Opiates
    • Salicylates
    • Toxic alcohols
    • Sulfonylureas
    • Camphor
    • Clonidine
    • Antimalarials
  • CCB OD
    • Hypotension, bradycardia, bradydysrhythmias, hyperglycemia
    • Tx: charcoal, fluids, atropine, calcium, intralipid
  • Salicylates
    • Oil of wintergreen, ASA, pepto-bismol
    • n/v, tinnitus, delirium, hallucinations, pulmonary edema, cerebral edema, mixed anion gap metabolic acidosis with respiratory alkalosis
  • Sulfonylureas
    • Hypoglycemia, lethargy, irritability, confusion, HA, seizures
    • Tx: observation x24 hrs
    • Dextrose bolus, then consider infusion
    • Can give octreotide (inhibits secretion of insulin)
  • Clonidine
    • Alpha 2 agonist, (afrin, visine)
    • Opioid syndrome: lethargy, coma, miosis, respiratory depression
    • Tx: naloxone, atropine, IV fluids, inotropes
  • Camphor
    • Campho-phenique, vicks vaporub
    • GI distress, generalized warmth, CNS hyperactivity, CNS depression, n/v, oropharyngeal irritation/burning/stinging
    • Tx: benzos, phenobarb
  • Amitriptyline
    • CNS depression, seizures, cardiac conduction abnormalities (QRS prolongation), hypotension, mydriasis, flushing, dry mucous membranes, hallucinations, hyperthermia
    • Tx: benzos for seizures, sodium bicarb for QRS widening >100ms
  • Lomotil
    • Opioid receptor agonist +/-atropine
    • Classically biphasic, with anticholinergic symptoms 2-3 hours s/p ingestion followed by opioid symptoms
    • Tx: naloxone
    • Dispo: admit
• Toxic Alcohols (Bosse)
  • Ethanol
    • Can cause hypoglycemia
    • Is dialyzable
  • Isopropanol
    • Rubbing alcohol
    • Metabolized to acetones
    • No metabolic acidosis
    • Supportive treatment, can be dialyzed
  • Methanol
    • Windshield washer fluids, solid cooking fuel, embaling fluid, tainted beverages
    • Toxic metabolite is formate (formic acid)
    • CNS effects, visual effects, pancreatitis, symptoms delayed in onset
    • Metabolic acidosis with elevated anion gap
  • Ethylene glycol
    • Antifreeze (sweet taste)
    • Toxic metabolites: oxalate, glycolaldehyde, glycolic acid, glyoxylic acid
    • CNS effects, metabolic acidosis, renal toxicity, myocardial dysfunction
    • Oxalate can cause hypocalcemia by calcium oxalate precipitation
    • Oxalate crystals in urine
    • Wood’s lamp to urine, antifreeze products may contain fluorescein, not a great test
  • Osmol gap
    • Difference between measured serum osmolality and calculated serum osmolarity
    • Normal serum osmolality: 275-295 mOsm/kg
  • Antidotes
    • Ethanol, fomepizole
    • Competitive inhibitors of alcohol dehydrogenase
    • If ethanol must be used, give orally. Keep blood level >100mg/dL
    • Treat if methanol or ethylene glycol level >20mg/dL
    • Can be stopped once level less than 20mg/dL
    • Dialysis
      • Consider if patient has end organ manifestations (even if levels undetectable)
    • Folic acid for methanol
    • Thiamine and pyridoxine for ethylene glycol
  • Send methanol and ethylene glycol levels ASAP