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!
- Protect without pressure!
- Prevent vomiting/valsalva
- Don’t forget your tetanus
- Avoid ultrasound (just don't tell Dr. Tayal)
- 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
1. Billing is fairly algorithmic and requires good communication to coders about the work done.
2. Documentation for coding is not always the same as documentation for good care.
3. Avoid all rubber stamp, Copy/Paste maneuvers, and “Dragonisms” if you can. Be thorough and vigilant!
4. Medical Decision Making drives the chart complexity and reflects the care you give.
** The New Code Cool is being launched across our system.
** Focus on: Cooling times, resuscitation, hemodynamic management, ventilator management.
** Literature supports cooling to either 33C or 36C; we will continue to cool to 33C pending additional ongoing studies.
1. Use new “Code Cool – Induction” order set.
2. Activate Code Cool via PCL line (essential for nursing resources, ICU bed allocation, and patient tracking).
3. Consult cardiology and intensivisits on all Code Cools.
4. Cool to 33C unless intolerance to cooling (dysrhythmia), sepsis, or bleeding, then cool to 36C.
5. Induce cooling with ice packs, cold fluids 30cc/kg, and long-acting neuromuscular blockade (vec 10 mg IV)
6. Goal MAP > 70 mmHg at all times (> 80 mmHg if chronic HTN)
7. Treat blood pressure aggressively with norepinephrine (not dopamine)
8. Titrate FIO2 on ventilator down to 40% if possible while maintaining O2 sat > 95%.
9. Code Cool/STEMI: Activate Code STEMI also with age < 75, downtime < 20 min; others discuss immediately with intensivisits; don’t delay cooling.
10. Don’t delay initiation of cooling for CT imaging. Recall, few VF/VT arrests (< 5%) are due to PE.
1. Papilledema is very specifically optic disk swelling in the presence of ICP.
2. Vomiting and abdominal distention should always worry you.
3. Bilious vomiting is a surgical emergency 40-60% of the time
4. Think non-typable haemophilus when you see conjunctivitis and otitis in tandem.
- See Conjunctivitis-Otitis Morsel
Common causes for acute ataxia in children are as follows:
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
- not routinely used
- consider in pelvic fractures (q1hr)
- WBC rarely useful;
- Consider to use to look at platelets (head trauma, liver disease, long bone Fx);
- For liver disease or anticoagulated;
- Get coags for severe head trauma
- Strongly associated with blood loss and mortality in the setting of trauma
- 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
Special Trauma COnsiderations
- CPK now and at 4 hrs
- get PT/INR and lactate > 2 is concerning
- UA, LFT, lipase, Hgb
- serial pancreatic enzymes
- Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion
Case 1: Inferior shoulder dislocation and traumatic pneumothorax
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.
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).
The stakes are high!
Stepwise Assessment Goals
Always ask yourself: