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

Thanks to Dr. Troha's diligent efforts, we will be initiating a new protocol to help streamline the decision making and coordination of care for patients with small PEs, Submassive PEs, and Massive PEs. 

Step 1: Risk stratification
- Obtain BNP, troponin, perform echo and assess vitals

Step 2: If massive or submassive, call out Code PE. Pull Code PE pack that contains treatment algorithm and lysis checklist

Step 3: Administer heparin

Step 4: Assess bleeding risk using lysis checklist

Step 5: If decision is made to give IV lysis, stop heparin drip during infusion

Step 6: If decision is made to administer catheter-based lysis, contact interventionalist on call

Common causes for acute ataxia in children are as follows:

• Acute cerebellar ataxia
  
• Drug ingestion
  
• Guillain- Barre syndrome

Life threatening causes are rare but should be excluded.  
They include:

• Vascular events
  
• Infection
  
• Processes leading to increase intra-cranial hypertension.

Acute cerebellar ataxia is a diagnosis of exclusion.
Ataxia management follows a stepwise algorithm.

Type & Screen 
- cheaper and doesn't hold blood and doesn't do whole cross match
- Consider in severe mechanisms, blood loss, tachycardia, concern for intraabdominal injury

Type & Cross 
- holds blood
- Consider in coagulopathy & severe trauma; significant mechanism with known blood loss; base deficit < -6, lactate > 4, low Hgb; +FAST

Serial H/H 
- not routinely used 
- consider in pelvic fractures (q1hr)

CBC 
- WBC rarely useful; 
- Consider to use to look at platelets (head trauma, liver disease, long bone Fx); 

PT/INR 
- For liver disease or anticoagulated; 
- Get coags for severe head trauma

Lactate 
- Strongly associated with blood loss and mortality in the setting of trauma

Urinalysis
- adult patient not in shock - gross hematuria matters; 
- microscopic hematuria - in stable patients don't worry; 
- in adult patients with shock - get CT scan - marker for intraabdominal injury; 
- in pediatric population with microscopic hematuria - need CT scan - marker for intraabdominal injury - most commonly splenic injury

Electrical injuries 
- CPK now and at 4 hrs 

Elderly 
- get PT/INR and lactate > 2 is concerning 

Pediatric 
- UA, LFT, lipase, Hgb

Spearing injuries
 - serial pancreatic enzymes 

Organophosphates

• DUMBBBELLS  - Diarrhea, Urination, Miosis, Bronchorrhea, Bronchospasm, Bradycardia, Excitation, Lacrimation, LOTS of Emesis, Salivation
• Can have persistant symptoms that can happen days after initial exposure 
• Intermediate syndrome - develop days after exposure
• Chronic symptoms - neuropsychiatric changes 
• Treatment - remove exposure!!!
• Muscarinic antagonist/ blockers; anticholinergics

- Atropine - MUCH higher doses than normal
- Valium
- Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion

When 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.

-        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).

-        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).

Always ask yourself:

1. Do I need more help?
2. Do I need more equipment?
3. Do I need a different plan?
4. Does the patient need additional resuscitation before proceeding!