Small Group Lecture: Bradycardia – Dr. Fisher
Case 1 – Symptomatic bradycardia. Initial management ABCs. GCS 8, however GCS score only validated for trauma patients. Would not intubate until after we attempt to resuscitate first: O2, monitor, x2 LBIV, check POC Gluc, Trop, Electrolytes, EKG. Start w/ 0.5 – 1.0 mg Atropine q3 min to 3 mg max. Consider Epi as well. Can transcutaneous pace. See transvenous pacing link: https://room9er.com/2020/08/13/transvenous-pacing/

Case 2 – Bradycardia w/ interior STEMI. Remember “MONA”. Recent studies have show increased in-hospital mortality w/ morphine, consider fentanyl. AVOID trial (no benefit in O2 w/ SaO2 > 94%). Give ASA. For Nitro, longstanding teaching to avoid NTG in inferior MI as it is preload dependent. However, there may be benefit to giving carefully.

Case 3 – Bradycardia in BB vs CCB OD. CCB poisoning usually causes hyperglycemia, whereas BB poisoning may cause hypoglycemia. Activated charcoal if ingestion w/i 1-2 hrs. Whole bowel irrigation should be considered for large ingestion of sustained-release medications, as these intoxications can outstrip all other therapeutic modalities. Early intubation. For patients with hypotension who require intubation, try to quickly achieve hemodynamic stability prior to intubation if possible. Treat w/ Glucagon, IV Calcium, Hyperinsulinemia euglycemia. Atropine rarely works.

Tick-born Diseases – Dr. Buchanan
Lyme Disease – Can present w/ erythema migrans, later followed w/ arthralgias, Bells’ Palsy or other neurologic sx, or heart blocks. Antibody panels usually negative during rash phase.

Rocky Mtn Spotted Fever – vasculitis w/ maculopapular rash, starts distally. Labs w/ thrombocytopenia and mild transaminitis.

Ehrlichiosis – similar labs to RMSF, but leukopenia. Lone star tick
Anaplasmosis – similar presentation to Ehrlichiosis, but carried by Deer tick/Blacklegged tick

Can treat all w/ doxy. Lyme disease CTX for neuro sx. Lyme dz alternative tx w/ Amoxil + cephalosporin.

Babesiosis – intracellular parasite. Fever, hemolytic anemia, DIC. Cells classically show “Maltese Cross”

Tularemia – wound w/ proximal LAD. Can also present w/ conjunctivitis, pharyngitis, PNA, or typhoidal sx.

Tick Borne PPx: Ixodes tick -> greater than 36 hrs or engorged tick -> w/i 72 hrs since removal -> they can take doxy -> Lyme dz is endemic

Clinical Pathway: Ectopic – Dr. Cook and Dr. French
~ 1:50 pregnancies in North America. 6% – 16% of patients that present to ED w/ 1st trimester bleeding or pelvic pain.

The discriminatory value is that level of hCG above which all normal intrauterine pregnancies should be seen: 1,500 for TVUS; 6,500 for TAUS.

IUP is gestational sac PLUS yolk sac and/or fetal pole. Gestational sac alone is not IUP

Pathway to be posted here: https://room9er.com/clinical-pathways/

Room 9: Follow up – Dr. Kuzel
Undifferentiated critically ill patient in status epilepticus, found down, wide complex irregularly irregular tachycardia, h/o a flutter on Eliquis. POC Gluc 55. Amp D50 given. Lactic 14, BCx and UCx obtained
1/2 BCx+
LP w/ elevated PMNs
Utilize Chem8+ in R9, D50 prn, AEDs
Status Epilepticus: IM/IO Versed > IV Versed/Ativan > IV Keppra & Fosphenytoin > Intubate (consider Propofol for induction/sedation)

https://room9er.com/wp-content/uploads/2021/06/Status-Epilepticus-Clinical-pathway-1.pdf

Intro to EMS: Part 1 – Dr. Orthober
Off line medical control – established protocols
On line medical control – calls into the ED for medical direction from EMS

Trauma radio: highest high, lowest low (i.e. highest HR, lowest BP), GCS, injuries
Stroke patient: Last known normal, anticoagulation, collateral info available