Staph Aureus Infections - Hospital acquired infections relatively stable over the past 5 years - Community acquired infections on the rise - One ED visit increases risk 4-fold - Protect your patients! - Patients on hemodialysis have a 50-180 fold increased risk for developing infective endocarditis … be wary the vague presentation of endocarditis! Globe rupture: - Protect without pressure! - Prevent vomiting/valsalva - Don’t forget your tetanus - Avoid ultrasound (just don't tell Dr. Tayal) Hypocalcemia: - Potassium is not the only electrolyte that causes rhythm disturbances - When facing new EKG changes, consider magnesium and calcium
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Organophosphates
- Valium - Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion Case 1: Inferior shoulder dislocation and traumatic pneumothoraxWhen Evaluating Complex Patients: - Always regroup and reassess. It is okay to start over from scratch. - Ensure work up is complete for life threatening pathology before patient leaves the ED Inferior Shoulder Dislocation: - High incidence of vascular and nerve injury. You must document a thorough exam! - Reduction via hyperabduction with traction-counter traction or convert to anterior dislocation and then reduce. Occult Traumatic Pneumothorax (i.e. visible on Chest CT but not on supine CXR): - Supine CXR has sensitivity of ~50% - Supine Ultrasound has sensitivity of ~90%. We should be doing FAST with thoracic windows on all patients, especially those with no plans for CT Chest - Know/ Reference our trauma guidelines! - No hard and fast guidelines in regards to management. Needs a chest tube if progresses (visible on CXR or if patient has respiratory distress). - Most still feel positive pressure ventilation with occult PTX deserves a chest tube... although debated. Case 2: Black Dot Poison Ivy- Treat contact dermatitis with high potency topical steroid (ex. Clobetasol) for 2 weeks. - If treating with PO steroids remember needs tx for 2-3 weeks with taper. - Don’t forget adjuncts: Zanfel, Ivy Block (Research supports usage of both). Case 3: Hx of Devic disease with missed posterior circulation stroke- Know your limitations and don’t develop tunnel vision.
- A thorough CN II exam involves visual acuities, visual fields, light reflex and color testing. - Optic neuritis typically has pain with eye movement (92%) and impaired color vision (Red first). 1. Perceived conflicts of interest resulting in blind spot bias exist among stroke opinion leaders and the authors of the ACEP tPA Clinical Policy. 2. For Clinical Guidelines to be trustworthy, they must: 1) have transparent methodology, 2) manage conflicts of interest, 3) have a balanced guideline development group composition, and 4) have undergone adequate balanced external review. 3. It is unlikely that the revised ACEP tPA Clinical Policy will substantially impact current perspectives related to the use of IV tPA for stroke Hypercalcemia - Hypercalcemia relatively uncommon in the ED, but highly correlated with cancer and poor prognosis - 25% of cancer patients - 50% die within a month of hypercalcemia dx - Severe levels can be life threatening - Renal failure - Dysrhythmias - Coma - Death - Occurs due to increased bone resorption and release of calcium - Bony mets release cytokines that break down bone - Tumors secrete PTHrP and an active form of Vitamin D, causing bone breakdown - Who to suspect: - Elderly - Acute confusion/MS change - Unexplained weakness - History of cancer -- especially breast, lung, lymphoma, or multiple myeloma - What to look for: - Neuropsych, GI and MSK à vague symptoms - Evaluate with serum calcium (must account for serum albumin and correct) or ionized calcium - Consider the clinical context and order additional labs/tests as necessary, including EKG and CXR Treatment Mild
Moderate
Severe
- Pamidronate – 60-90 mg over 2-24 hrs
- >18mg/dL - Renal failure - CHF Central Cord Syndrome -Generally caused by hyperextension. Patients with history of central canal stenosis at risk -Upper extremities affected > lower extremities -Distal affected > proximal -Usually bladder dysfunction Opioid Induced Hearing Loss -Occurs <72 hours after use (seen in both acute and chronic users) -MCC is hydrocodone and heroin but seeing more with methadone lately -May be unilateral or bilateral -Most resolve within 72 hours but may be permanent -Treat with cessation of narcotics and possibly cochlear implants if permanent Rhabdomyolysis -Fluids, fluids, fluids as treatment -Diuretics (mannitol) and bicarb are controversial -Risk of AKI is lower when CK <5,000 but can be seen at CK levels of 1,000 -Urine dipstick + for blood with urinalysis - for blood has sensitivity of 80% for diagnosis Case 1 - Is that Tube in the Right Place?
Case 2 - Locked-In
Gastric Perforation 13 yr old female w/ abdominal pain - recent admission for abdominal pain with EGD (with biopsies taken). Became hypotensive, tachycardic, lactate 3.5 - surgery consulted & CT showed gastric perforation.
Hypotension - Beta Block Toxicity 49 y/o male from rehab - was found obtunded and hypotensive w/ BP 60/20 > ESRD dialysis patient > Hypothermic w/ temp of 93, pulse 59, BP 60/18; answering questions > Labs relatively unremarkable, EKG basically unchanged, CXR with pulmonary vascular congestion > List of meds reviewed - a LOT of antihypertensives including 1600 mg of labetolol in the past 24 hrs
Wernickes Encephalopathy 57 yr old "drunk" from medic > Normal vital signs, hx of COPD cirrhosis GERD and no meds > Wide based gait & tremulous & confused; while at rest normal neuro exam > Wernickes Encephalopathy - got thiamine and got better - Thiamine i500 mg iV over 30 minutes - At risk patients - anyone prone to malnutrition - Clinical diagnosis - consider with 2/4 nutritionally deficient, ocular findings, encephalopathy, ataxia Pt with Syncope... what should you do? 1. Obtain 12 lead EKGs on patients of all ages with history of syncope. (Level A Evidence) 2. According to ACEP Clinical Policy on Syncope, Laboratory testing and advanced investigative testing (such as ECHO and CT Head) need NOT be routinely performed unless guided by specific findings in the history or physical exam (Level C evidence). 3. There are multiple Risk Stratification Tools for syncope, including San Francisco, Rose, OESIL, EGSYS, and Boston, which have varying levels of sensitivity and specificity. The Boston Guidelines are the newest set of guidelines which have highest sensitivity at 100%. 4. ACEP's Clinical Policy of Syncope state the following four criteria for considering patients "high risk" following a syncopal event: 1. Older age with associated co-mordities, 2. Abnormal EKG, 3. Hct < 30, 4. History or presence of heart failure, CAD, structural heart disease HIGH YIELD CONCEPTS:
- Bifacet dislocation - Type II odontoid fracture - Hangmans fracture - distraction & rotation injury - posterior element of C2 gets fractured & spondylolisthesis of axis - Flexion Teardrop - most serious of all Cspine fractures |
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