- AP compression - Vertical shear Resuscitation essentials:
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 - Neonate in respiratory distress: remember NRP! - Neonate in respiratory distress with true unilateral absent breath sounds = Congenital Diaphragmatic Hernia??!!-> confirm with CXR Congenital Diaphragmatic Hernia (CDH) - Neonates likely have high risk for pulmonary hypertension! - Do not give PPV -> worsens GI distention/lung compression = worsening pulmonary HTN - In neonates intubate early to prevent hypoxia (hypoxia worsens pulmonary HTN) with low pressure vent settings - Maintain systemic BP to reduce right to left shunting - Older children with CDH, less likely to have significant pulmonary HTN, keep calm and try to avoid intubation - Persistent/worsening cyanotic neonate - think cyanotic congenital heart defect -> Start Prostaglandins - Remember Prostaglandins cause apnea, will likely need intubation - Neonate in extremis = call for back-up early!  
 * Our lizard brain -- addiction affects the most primitive structures using the mesolimbic dopaminergic system
* Try to hate the drugs, not the patient -- animal studies have repetitively shown that drug seeking behaviors are easily reproduced * May be self medication -- chemical coping for psychiatric disorder or pseudoaddiction * Yeah, I've heard that story -- behaviors more predictive of abuse are not that surprising. The more one has, the more likely it is opiate use disorder * "Nah, I don't want that" -- diversion patients will be uninterested in alternative therapies. People in actual pain will try anything just to feel relief (ketamine, nerve blocks, acupuncture) * We've all heard "avoid opioids for acute pain", but the chronic pain patient presents the greatest challenge * I want to relieve your pain, but... -- Have a script / set expectations with the patient -- there is little use in arguing if someone is in pain or not. * Hyperalgesia -- chronic pain can worsen not despite opioids but because of opioids creating new pain pathways * The emergency department is just a step in the process of recovery. We're not here to win the game for the patient to change but to at least get it started * Evidence is limited, but some suggest that PO Morphine less euphoric than oxycodone or hydrocodone with similar analgesic efficacy * Communicate! -- judging drug seeking behavior from a history is relatively unreliable, use the drug database, use past records, call pharmacies and send messages in Cerner  1. Intimate Partner Violence/Domestic Violence is the leading cause of injury in women aged 15-44. 2. 1 in 4 women will be victims of intimate partner violence. 3. Intimate Partner Violence is about control, not violence. 4. Women who leave a battering relationship are 75% more at risk of being murdered than those that stay. 5. US Preventative Services Task Force and JCAHO support universal screening of women for IPV in primary care settings and emergency departments. 6. Teen Dating Violence is an important risk factor for teen depression, suicidal ideation, drug and alcohol use, and pregnancy. 7. IPV can present without physical injuries, and can be related to multiple ED visits, anxiety and depression, chronic pain syndromes, and substance abuse. 8. As in child abuse, certain physical findings are important to recognize as non accidental and highly correlative to IPV injuries. These include bruises in multiple stages of healing, injuries not compatible with history, strangulation, bite marks, injuries to breast, abdomen, and perineal area. 9. Children in homes with IPV are at risk for neglect, emotional and physical abuse, and may become future perpetrators of IPV themselves. 10. It is important as ED physicians to develop supportive and non judgmental ways of screening all patients for IPV, and to maintain a high degree of suspicion with trauma victims, psychiatric patients, and patients with multiple ED visits. 11. Referrals to our Domestic Violence Healthcare Project WILL help victims gain access to services, provide counseling, and help with safety and discharge planning. Healthcare providers do NOT need patient consent to make a referral for DVHP services. 12. Physician documentation of physical abuse is the SINGLE MOST important correlate to successful prosecution of IPV cases in court. Remember to document patient history and injuries well. 
 • Myxedema coma can closely mimic cardiogenic shock
• TSH is an inexpensive screening tool to rule out myxedema coma • Management of myxedema coma includes airway management, IV levothyroxine, IV hydrocortisone, and supportive care • Greater than one half of patients presenting with sepsis syndrome will have negative blood cultures • Do not be falsely reassured by the presence of fever and leukocytosis • Always consider RUSH exam and reconsider differential diagnosis in complex hypotensive patients!  Key history & PE components for diagnosing viral exanthems:
- Hx: Where did it start, & where has it spread? Pruritic? Associated symptoms? - PE: Appearance? Confluence? Palms & soles? Oral lesions? Lymphadenopathy? Key clinical features: - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots - Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia - Roseola - Centripetal spread, fever defervesces before rash - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic - Mumps - Parotitis, orchitis - Coxsackie - Rash not just on hands, feet, & mouth - Mono - Rash not just after ampicillin - Nonspecific - MC viral exanthem  - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots
- Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia, fetal hydrops - Roseola - Centripetal spread, fever defervesces before rash - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic - Mumps - Parotitis, orchitis - Scarlet Fever - During strep throat, sandpaper rash, strawberry tongue, pastia's lines - Coxsackie - Not just on hands, feet, & mouth - Mono - Rash after ampicillin - Nonspecific - Most common viral exanthem we will see |
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