Conference Notes 11-22-2011

Conference Notes 11-22-2011

CHANNON-PAQUETTE  ORAL BOARDS

Case1:  CO Poisoning with cardiac ischemia.  Treat with hyperbaric oxygen.  NTG for chest pain.   Also give ASA.

Case2: Hip Fracture

Case 3:Temporal Arteritis.  Consider DX in patient with headache over 50.  ESR is commonly over 50 with this diagnosis.   Treat with oral prednisone.

Test Taking Comments: Thorough ROS and Organized efficient Physical Exam.  Need to really push to get thru the three cases on time.  As the examinee, you have to take on a take charge demeanor.

CUMMINS   SHOULD PARAMEDICS INTUBATE?

Asking paramedics if they should be intubating in the field is viewed as an attack on their core skill.

Paramedics have been shown to be very competent in getting the ET tube in the trachea.  (@90-95% success rate)

However,  field intubations have been shown to increase mortality when compared to BVM.

Intubation is frequently followed by unintentional hyperventilation.   Which can worsen outcome.  Intubation may delay or interrupt chest compressions.

Average paramedic does  1-5 intubations per year.

If paramedics are going to intubate a patient with cardiac arrest in the field, they cannot interrupt chest compressions, they cannot miss an esophageal intubation, and they  cannot over-ventilate.  Those three things will worsen outcomes.

GIRZADAS  INTUBATING THE OBESE PATIENT

Obese patients desaturate more rapidly than normal weight patients

RAMPED Postion will improve oxygenation and laryngoscopic view.

Consider Ketamine sedated laryngoscopy prior to/in place of  RSI.

Bag-valve-mask ventillate using two handed/two person technique.  Also use CPAP valve on bag-valve-mask.

If you can't get the tube, try using an intubating LMA as your go-to rescue device.    ASA recommended.   

DR. SILVER   INITIAL CARE OF THE ACUTE CHF PATIENT

 The number of admissions for CHF a patient has is inversely proportional to life expectancy.

Approach to the CHF patient

Step 1:NYHA Functional Classification of CHF:   1=no symptoms,   4=symptoms at rest,  2 and 3 =somewhere in between.

Step 2: Assess  volume and perfusion.   Dry/wet   warm/cold

Step 3: Figure out their medications.  Diuretics for volume control.  Digoxin 0.125mg as a neuro hormonal depressor.   ACEI,  ARB’s

Step 4: Make an assessment of how sick they are.   Systolic BP/ CR/BUN are predictors of in-hospital mortality .   Seattle Heart Failure Risk is an iphone app.

Step 5: Integrate all the above info.

Be judicious with iv diuretics.   They can increase mortality/los.

NTG is a wonderful drug for CHF.  It lowers systemic and pulmonary vascular resistance.  Also lower wedge.  Gotta use enough of it.  Monitor patient and titrate up based on patient response.

Aldosterone antagonists are expected to be more commonly used.  A side effect is hyperkalemia.

In the hypotensive chf pt you need inotropes/diuretics.  Use milrinone for the tachycardic patient. Use dobutamine in the patient without tachycardia.

BNP can be not super high in copder’s and obese patients despite them being in decompensated chf.

Consider  ace-I’s in hypertensive chf patients.

No role for nesiritde in acute decompensated heart failure.

TOERNE   ACUTE ETOH WITHDRAWL

Brain responds to chronic etoh exposure  by altering receptors for glutamate and gaba.   The GABA related receptor affects Chloride influx into the cell.    Gaba receptor decrease and phenobarb receptors increase in the face of chronic etoh exposure.

Earliest withdrawl syndrome is Seizures.  Less than 3% of seizures result in status epilepticus.   30% of withdrawl seizures progress to DT’s.  

Next syndrome is uncomplicated withdrawl

Alcoholic hallucinosis is diagnosis of exclusion.  More likely is DT’s

Delerium Tremens occurs 2-7 days after stopping etoh.  Key is delirium.  They also have hyperadrenergic surge.   Risk factors are heavy daily eoth use, previus dt’s, older age, concurrent medical illness, abnormal liver function.

Proof is twice percentage of etoh.   151 rum is 75.5% etoh.  

Labs that suggest etohism: anemia with mcv around 105 which is a marker of folate deficiency.  Others are hyponatremia, thrombocytopenia.

Treat DT’s with large dose benzos and Phenobarbital.    Benzos increase the frequency of Chloride  channel opening and phenobarb increases the duration of channel opening. 

Give phenobarb 260mg slow ivp every 10-15 minute.  

Ketamine may be helpful to antagonize the glutamate receptor.

Conference Notes 11-15-2011

Conference Notes 11-15-2011

ANDREJ   ENVIRONMENTAL STUDY GUIDE

Altered mental status differentiates heat exhaustion from heat stroke.

Most effective way to cool patient is evaporative cooling.   Stop cooling once you have patient at 39 degrees.

Pricky heat: Sweat glands get blocked, histamine release, itchy rash.  Treat with antihistamines and talcum powder.

Acclimatization to heat: early onset of sweat production, increased plasma volume, decreased sweat electrolyte concentration, lower heart rate and increased stroke volume.

Most marathoners have a tropnin leak that is not prognostic of adverse outcome.  They can go home.

Dapsone may be effective in brown recluse spider bites.   Controversy about this.

Coral snake: red on yellow kill a fellow, red on black venom lack.  Elapid snake with neurotoxin venom.  Any bite gets antivenom for a coral snake.

Rattlesnakes: Crotalid snake,  triangular head, elliptical pupil, retractible fangs, pit anterior to eye.  Antivenom for spread(progression of localized symptoms)/bled (coagulopathy)/almost dead(abnormal vitals).

Antivenin is not contraindicated in pregnant patients.  It is not weight based.  Starting dose is 5 vials.  May need to redoes antivenin.

Spikey toxins use heat to deactivate toxins.   Slimey toxins use acetic acid.

Life threatening jelly fish are the box jelly fish and Portugese man-o-war.

Cold related EKG findings: Osborn waves, slow v-fib, bradycrdia,  t wave inversion, long pr and qt intervals,  afib,  muscle tremor artifact.

 Cerebral arterial gas embolus (CAGE).  Usually occurs within 10 min of surfacing. Vertigo, and altered mental  status are most common symptoms.   Recompression therapy is the only definitive treatment. Use saline to fill ET tube cuff when sending a patient to hyperbaric treatment.

Most common malady of scuba divers is ear squeeze (Barotitis).

Decompression sickness: Type 1  is joints/skin.             Type 2 is pulmonary, cv, neuro, vestibular.

Chillblain: inflammatory lesions of skin caused by long term intermittent exposure to damp, nonfreezing conditions.

Ophthalmia nodosa is a chronic ocular manifestation after exposure to tarantula spider hair

BADILLO/SINNOT   ACLS MEGA CODES

We covered the management of SVT, AFIB, WPW and Vtach, V-fib and Torsades.

DR. BERKLEHAMMER   VASCULAR DISEASES OF THE GUT

Mesenteric ischemia: Think about this in htn, smoking, dm, afib, post-mi.  You usually have double or triple vessel disease to have ischemia.  Check lactate. Diagnose with CTA. Tx with surgery or embolectomy.

Venous mesenteric ischemia has insidious onset.   Think about It in portal htn, hypercoaguable state, malignancy.  Dx with iv contrast CT. Tx with heparin.

Ischemic colitis: Sudden onset Abdominal pain with passage of mostly blood clots  per rectum. Usually will have lateral abdominal  tenderness.  You don’t need angio for colonic ischemia.  Only need angio for small ball ischemia.

Cholesterol  emboli following  cardiac cath can also cause mesenteric ischemia.

SAYGER/McGURK   ED CODING

For HPI you need 4 elements for a level  5.

For ROS you need 10 systems elevated for a level  5.

For PMH/SH/FH  you need 2 of 3 for a level  5.

Need 8 organ systems from physical exam for level 5.

Please make note of your medical decision making by noting test results, treatments and ekg/imaging interpretations.

Fortunate   (4-2-10-8) is the mnemonic for remembering what you need for  HPI-PMH/SH/FH-ROS-PE elements to get a level 5.

GROMIS and DRs. BAHN and AVULA  CURBSIDE CONSULT  AFIB

Get a  troponin on all new onset afib patients or any pt with afib and chest pain.

Important to start heparin or lovenox on all new afib patients in ER.

Consider d-dimer if  considering pe as cause of afib.   TSH should also be obtained in new afib patients.

Consider cardioversion for rhythm control for  young person with lone afib of less than 24 hours,  hemodynamically unstable afib,  patient with paroxysmal afib who is on Coumadin an comes in with afib.   

Any patient with rhythm conversion (chemical or electrical) requires warfarin for 4 weeks.

Rate control target is less than 110 beat per minute.

Ibutilide is best conversion drug.  Chemical cardioversion works better with afib less than 24 hours.

CHADS2 score.   (CHF 1, HTN 1, AGE >70 1, Diabetes 1 , Stroke or embolic phenomenon 2 )Less than 1 you don’t need warfarin and can use asa alone.  2 or more you need warfarin.  If score is 1 could be asa, plavix, dabagatrin, or warfarin based on physician judgment.

Ablation is 95% curative for a flutter.     

Conference Notes 11-08-2011

Conference Notes    11-8-2011

STEMI CONFERENCE

Some code 60’s are very tough calls.  

STUDY GUIDE  TOX   ANDREA CARLSON

Asymptomatic kids who ingested  sustained released verapamil need admission.

Eating a cigarette by a kid will not cause significant nicotine toxicity.  It will only cause vomiting.  Eating a tobacco plant is more likely to cause toxic nicotine levels.

NAC increases glutathione supply, detoxifies NAPQI and enhances microvascular function.   It can also scavenge free radicals.     

NAC is equally effective if given at any time in the first 8 hours after ingestion.   So you can give AC and wait until you get a 4 hour APAP level.

LSD gives you synesthesias which are you can taste sounds or feel  sights.    MDMA (ecstasy) causes bruxism.   Think of Ravers using pacifiers.

Glucagon increases CAMP to overcome beta blocker toxicity.

Things that cause wide QRS (quinidine effect): TCA’s, Carbamazepine, Propoxyphene, Benadryl, Cocaine 1a’s (PDQ: procainamide/disopyramide/quinidine), some 1c’s(encainide/flecanide).   All also have an an anticholinergic appearance to their toxidrome.

Avoid the interation between clarithromycin and digoxin.  Will increase risk of digoxin toxicity.

Intubation of patients with salicylate toxicity is fraught with hazard due to need for hyperventilation to maintain relatively normal ph.

Insulin in the setting of calcium channel blocker toxicity acts by providing glucose to myocytes for energy.

Glucagon causes emesis.

All antidotes work for CCB and Beta Blocker overdose: atropine, glucagon, high dose insulin.

Pepto Bismol contains asa.   Oil of wintergreen has a lot of asa (methyl salicylate)in it.  Ben Gay has oil of wintergreen in it.

Caffeine competes with adenosine at the adenosine receptor.   Also theophylline competes at the adenosine site.

ORAL BOARDS    RICCARDI  and KATIYAR

Case1:Splenic/renal  artery aneurysm rupture in a pregnant woman.  More common in multips due to repeated progesterone/estrogen fluxes in pregnancy.  Treat hemorrhagic shock.

Case2: ASIS avulsion.  Treat conservatively with pain control and crutches.

Case3: ASA toxicity.  Treat with fluids/bicarb drip/dialysis.   ABG with metabolic acidosis and respiratory alkalosis.    Important to give potassium when al

Comments on technique of examnee: Good pace.  Thorough exam.  Increase blood type and cross to 4-6 units.  Important to do a FAST at the bedside.  Once you identify intraperitoneal fluid you are going to OR.  Good to  Start transfusion.

Difficult cases.  Good rapid review of systems.  Good to ask about appearance of injured extremity.   Good nv exam of injured extremity.

PATIENT AUTONOMY      SHAYLA GARRET-HAUSER

Great read on medical ethics: The Immortal Life of Henrietta Lacks

Non malficience, justice, beneficence, patient autonomy are the pillars of Medical Ethics.    Hippocratic Oath only covers the first three pillars.

Voluntary consent to procedures did not become a medical concept until the Nuremburg Code post WW2.

Autonomy is a right to non-interference, not a right to every requested medical treatment . Doctors are not obligated to provide treatment they consider of no benefit.

There is a power/knowledge differential between doctor and patient.   Thus we control option that are offered to patients.   We need to understand patients values to know how to tailor their options.   

 Nothing trumps the MD in charge of a resuscitation.  If MD feels it is futile, the MD can stop resuscitation despite family wishes. 

Case discussion on should you perform drug testing on a 15yo patient who refuses test and parents demand it.     No one in auditorium will forcibly obtain urine from patient. But if patient voluntarily gives urine most would do test.    Same with pelvic exam or other evaluation.  The bright line for most MD’s in the room was if you have to forcibly restrain/sedate pt to get some evaluation done, they would not do it.

MED STUDENT REVIEW

Conference Notes 10-25-2011

Conference Notes 10-25-2011

EM-EDS JOINT CONFERENCE   MANAGEMENT OF HEMATOLOGIC  ILLNESSES

If patient has fever and clinically has acute chest syndrome  give ABX ASAP irregardless of CXR findings.  Antibiotics in a sick febrile patient with SCD can be lifesaving.

Acute Chest Syndrome: Dispo can be floor or PICU depending on clinical picture.  Transfusion is also dependent on clinical picture.  Decision should be made in concert with hematologist.

Supplemental oxygen should be given routinely in acute chest syndrome.   Supplemental oxygen does not need to be given routinely in painful crises.

TTP is rare in the pediatric population. 

ITP Management: Don’t give steroids without consulting hematologist.  There is controversy about steroids prior to bone marrow biopsy.  At ACMC hematologists rarely give steroids intially. Concern is that steroids may obscure diagnosis of leukemia.    IVIG is more commonly given by hematology.   Treat if mucosal bleeding.  These patients tend to have worse outcomes.  WinRho is similar to rhogam.  Can only give to Rh pos patients.  WinRho can’t be given in anemic patients.   Algorithm: If mucosal bleeding or platelets around 10-20K  give IVIG if there is a response that is confirmatory of ITP. In subsequent events give dexamethasone.    In a child with platelets less than 50K and head injury get CT.

Leukemia:  Check PT/PTT because APL versions of AML can cause DIC picture.  If leukemia presents with respiratory distress think T-cell or Burkett’s or Lymphoblastic.  There may be a mediastinal mass due to these.   IV fluids are critical to preserve renal function.  Be alert for tumor lysis syndrome with high potassium, uric acid and phosphate.   If febrile over 101 give abx for neutropenic fever.     Think leukemia in a child with bone pain, pallor,  splenomegaly, persistent lymphadenopathy, normocytic or macrocytic anemia, or any cytopenia.   Steroid use in a patient presenting with symptoms due to leukemia can delay diagnosis and it may alter the leukemia that requires a more toxic chemo regimine.

STUDY GUIDE  QUESTION SLAM TOXICOLOGY

Urinary alkalization for ASA and chlorpropamide.  3amps of NaHCO3 in 1L of D5W and run at 200ml/hr.  Shoot for a urinary ph of 7.5-8.5.   Monitor the K closely.

For TCA OD  Look at AVR on the EKG an look for a wide,tall  terminal R wave.  Treat seizures due to TCA’s with benzos and phenobarb.    TCA’s have sodium channel blockade,  alpha blockade, gaba antagonism,  and anticholinergic properties.   IV Sodium Bicarb for QRS widening or arrhythmia.

Most common finding in Serotonin Syndrome is myoclonus.   Tx: remove offending agents and give cyproheptadine.

MAOI  with severe hypertension tx with short acting antihypertensives.  There is risk of severe hypotension with long acting antihypertensives.   If ingested more than 1mg/kg, the patient should be admitted to ICU.   Beta Blockers  are contraindicated.

Tyramine reaction: severe occipital or temporal headache within 90 minutes of dietary amine ingestion in patient on MAOI. 

Neuroleptic Malignant Syndrome:  Magnesium for prolonged QT to avoid Torsades.  External cooling is indicated.  Benzo’s can help rigidity.   Use rocuronium for intubation instead of succinylcholine.  IV fluids and supportive management is indicated.  Dantrolene may be tried.

Lithium Overdose: Tx with saline and Kayexelate. Next step for severe overdose is dialysis (lithium >4, sustained release preps, increasing level, level not improving with saline and kayexelate).   EKG may show long QT, st depression and t wave inversion.   Treat seizures with benzos.  Don’t use phenytoin.

 Number 1 factor related to respiratory depression with a benzo is another coingestant.   Cirrhosis may also increase risk.

Isopropyl alchol: Fomepizole is not indicated because acetone is not more toxic than isopropanol.   Upper GI Bleed is classic finding.   Hemodialysis for severe overdose.

Naloxone drip rate for massive opioid overdose (body packer) is 2/3 of the initial effective bolus dose per hour.  Be prepared for a very agitated patient on waking.

Highest risk of ACS with cocaine use is in a chronic regular user.  (90% of cases).  Men more common.  ACS usually occurs within 3 hours of use.   Cocaine also increases athrogenesis.

MARK HINTON   TOXIC ALCOHOLS

Ethylene Glycol  is metabolized to toxin glycolic acid and oxalic acid (calcium oxylate crystals in kindey).

Osmolar Gap= 2X NA + Glucose/20 + BUN/3 +ETOH/5.  Should be less than 20.

Methanol Toxicity is metabolized to formic acid.  Formic acid causes acidosis and vision loss.

TX for EG and Methanol:  ETOH or Fomepizole.  Fomepizole has less side effects (less gi irritation, cns depression and hypoglycemia).   All patients should get dialyzed.   IV bicarb can be used for acidosis.  Folic acid supplement for methanol.   Pyridoxine for ethylene glycol.

Isopropanol:  Severe cns intoxication,  risk of gi bleed and hypotension.  Less toxic  than methanol and ethylene glycol.   Metabolized to acetone.   In kids check for hypoglycemia.   Elevated osmolar gap.  No severe acidosis.  “Ketosis without acidosis”  Treat with supportive care.

DAN NELSON  CHEST PAIN IN KIDS

Dangerous Causes: ACS, cardiomyopathy, arrhythmia, PE, pneumothorax, aortic dissection,  mediastinal mass, perforated esophagus,  perforated ulcer.

Ask about family history of sudden death or connective tissue disorders.

Benign early repolarization: Consider  in the following groups: young, male, African American.   ST-T segments are concave up.

Juvenile T wave pattern: females more common than males.  Normal up to 8yo, or into adolescence in athletes.  T wave inversions v1-3.

Sinus arrhythmia causes variation in HR with respiration.

Long QT syndrome: Can be related to certain meds.  500ms is definitely abnormal

Hypertrophic Cardiomyopathy: Consider when ekg shows lvh.  Big S waves anteriorly and Big R waves laterally.

WPW: Short pr interval with delta wave.   Orthodromic conduction has narrow complex.  Antidromic  conduction causes wide complex.

Brugada syndrome: Due to a genetic sodium channel abnormality.

CHRISTINE KULSTAD   FAST TRACK EMERGENCIES

Skin tears:  If skin will approximate use steristrips to close, and cover with non-adherent dressing. If there is more tissue loss try adaptic or hydrogel/duoderm.  Hydrogel or duoderm can stay in place for one week.    You can use tissue adhesive as well for wounds with little tissue loss.

Absesses: Give pre-procedure pain meds/sedation.   Give anesthesia twice.  Initially in skin on roof of abscess then make incision and relieve pressure. Then give anesthesia to remainder of abscess cavity.  No evidence that irrigation improves outcome.   Don’t need sterile gloves.  Probably safe to irrigate with tap water instead of saline.   Use U/S.    Needle aspiration is not effective.   Probably safe to not pack small abscess in otherwise healthy person.   Don’t need to pack abscess tightly.  Pack loosely.  Don’t need iodoform gauze.   Can use any type of ribbon gauze.   

DAB KAMAN-MALLABAN  PATIENT FALLS

Number of fall in ACMC 50-60 falls per month.

If we don’t  decrease our number of falls, we will lose reimbursement dollars.   It is important to work as a team to prevent falls.

Communicate with nurses, leave cart rails up, give patients opportunities to toilet, walk them to bathroom.  

If patients have a yellow wrist band they are a high fall risk. 

New Motto  “No one falls”

Injury Potential from Fall:  Age,  Bones (osteoporosis, cancer),  Coagulation (Coumadin, plavix)

Obviously it is important to make sure you have the correct patient and correct labeling of all specimens.

Do a time out before all procedures.   It is a Red Rule.  

DAVE BAROUNIS      THERAPUETIC HYPOTHERMIA PROTOCOL   ICEP PRESENTATION

Previous research has shown improved outcomes in cardiac arrest patients.

56 month period of study at ACMC.  

Inclusion: ROSC from any rhythm

Goal:  Get temp to 33 degrees C in 4 hours.  Cooled for 24 hours.

Results: 160 patients with ROSC.   73 with ROSC were excluded.   The most common rhythm was V-Fib.  Overall Mortality for patients treated with hypothermia was 70%.     Good Neuro  Outcome (CPC 1-2) of survivors treated with hypothermia  was 14%.    In patients treated with normothermia 71% died but good neuro outcome was  4%.   Various sub groups were analyzed.

Conclusion:  In unwitnessed arrest there was no benefit from hypothermia.  In witnessed V-Fib arrest there was survival and neurologic benefit from hypothermia.

Conference Notes 10-18-2011

Conference Notes 10-18-2011

ROHIT GUPTA/DAN BARTGEN  ORAL BOARDS

Case1:Retro/parapharyngeal abscess in a child.  Give ABX and consult ENT for I and D.

Case2:Iatrogenic Perforated Bowel.  Emergent surgical consultation.

Case3:COPD exacerbation complicated by a pneumothorax. Place chest tube.

JOAN COGLIN  STUDY GUIDE ENT

Most common source of bleeding in posterior nosebleed: sphenopalatine artery.

Complications of posterior nasal packing: hypoxia, cardiac arrest, obstructed airway, necrosis of collumella

Ludwig’s Angina is a complication of a dental infection.  Soft tissue swelling under tongue. Intubate early to protect airway.

Lemierre’s syndrome: Septic thrombophlebitis of IJ.  Severe sore throat, fever, and neck pain.  Patients can develop septic emboli to lungs. Fusobacterium species are most common cause.

Auricular burns need non-emergent referral to burn center.  Chondritis is common.  No silvadene above clavicles due to skin discoloration.

Floxin otic solution is the only FDA ototopical abx approved for use with perforated tm.  Floxin otic is very expensive.   Cortisporin otic suspension is second choice and is less expensive so more commonly used. 

Don’t use carbonic anhydrase inhibitors in sickle cell patients with hyphema.  CAI’s will lower ph in anterior chamber and increase sickling.  

 Malignant Otits Externa is most commonly due to pseudomonas.  Usually in adult diabetics.

CRAO: treat with digital massage, IOP lowering meds and paracentesis, Rebreathing to raise pco2 and vasodilate.

Aphthous stomatitis is due to allergic reaction to unidentified trigger.  Usually on labial or gingival mucosa.  Tx with steroid swishes.  Betamethasone syrup.

Orbital cellulitis: pain with eom, most common cause is sinusitis usually ethmoid,  most common cause is staph aureus and strep.

Optic Neuritis: Eye pain, altered vision, optic disc edema. Tx with iv steroids.   Think MS.

 Dental concussion: tooth is tender but not mobile

Subluxation: tooth is tender and mobile

Luxation: tooth is displaced

ANUG: acute necrotizing gingivitis treat with metronidazole and chlorhexidine rinses

Last ditch procedure to stop life threatening posterior epistaxis is lido/epi

DAVE BAROUNIS  VENTILATORS

Ideal Body Weight is almost always somewhere between 50 and 80 kg.

Tidal Volumes can be 6-8cc/kg. 

 In asthmatics start with a low respiratory rate of 8 to avoid stacking breaths.  Can be 12-16 in a normal patient.

Be sure to titrate your patients pAO2 to between 70 and 200max.   If pAO2 is  above 200 at 4 hours there is increased mortality

5 common causes of hypoxia: low fio2,  hypoventilation, impaired diffusion, shunting, V/Q mismatch such as pneumonia/pulmonary edema/ARDS

PEEP stents open the alveoli.   PEEP reduces preload and afterload in CHFer’s.

Peak airway pressure mostly dependent on resistance of airways because this is calculated to the power of 4.

Trouble shoot a patient with High Paw (level of bronchial tubes/trachea): disconnect the vent and evaluate how hard it is to bag.  If pt is hard to bag the airway not the machine is the cause.  Listen to patient, suction, get a CXR.   Next check Plateau Pressure (level of alveolus).  If no change then there is some type of obstruction such as aspiration or bronchospasm or secretions.  If PP increases could be due to abdominal distension or autopeep)

In asthmatics you have to use low rate, small tidal volumes, and prolonged time for expiration to avoid stacking breaths.  You are willing to tolerate a ph of 7.1-7.2 as long as oxygenation is ok. 

Similar strategies for COPD.  In addition only give enough fio2 to keep sats just over 90%.  Higher o2 sats will diminish COPDer’s respiratory drive.

There is an ARDS Network scale to Titrate FIO2 and PEEP.

ACMC has capability to use ECMO for both kids and adults.

Acidotic patients need A LOT of ventilation.   Pt’s can arrest peri-intubation if you don’t keep ventilating them during induction somehow.   Think bagging or bipap ventilation during sedation and paralysis.

PAARUL CHANDRA    TRAUMA LECTURE PELVIC FX’S AND GU TRAUMA

Pelvic fracture with shock has a 35-50% mortality rate

Single break is usually stable. Two or more breaks is unstable.

CT of abdomen/pelvis is considered GOLD STANDARD for  diagnosing pelvic fx’s.

Main issue with pelvic fx’s is hemorrhage control.  Resuscitate with generous blood products, stabilize the pelvis with sheet wrap.   If still unstable, next move may be angiography to embolize an arterial vessel.  If patient is unstable there is usually arterial bleeding.

Most common organs injured with pelvic fx are bladder and urethra.

When considering GU trauma, don’t place foley prior to urethrogram.  If foley already in place, leave it in place.

If urethral tear is partial, some contrast will get into bladder.  If complete, no contrast in bladder.

There is greater risk of bladder injury when trauma occurs with full bladder.

2 types of bladder rupture: intra and extraperitoneal.  Intraperitoneal are treated with surgery. Extraperitoneal are treated with foley catheter.  

Bladder injury symptoms: gross hematuria, inability to void, suprapubic pain.  DX with retrograde cystography.

Renal injuries are graded 1-5 with 5 being most severe (shattered kidney). Grade 1 0% go to surgery. Grade 2, 15% have surgery. Grade 3, 76% have surgery.   Grades 4 and 5  increase from there.   There is also renal pedicle injury. 

Conference Notes 10-11-2011

Conference Notes 10-11-2011

ELISE    STUDY GUIDE PEDS

Fifth’s disease: parvovirus B19, slapped cheeks, lacey rash, risk of complications in diabetics and sickle cell disease

Hemophilia A  is factor 8 deficiency.    For head injuries gotta give 50u/kg to get 100% activity.  For joints give 25u/kg for joint or other bleeds to get to 50% activity.  Give factor replacement prior to CT head.  Hemophilia causes an abnormal PTT.  Remember WEPT=warfarin/extrinsic/PT.   HIPTT=Heparin/Hemophilia/Intrinsic/PTT

Hydroxyurea used in SCD to increase the amount of fetal hgb production.  

Tx for VonWillibrands (most common congenital bleeding disorder) is DDAVP which increases the release of VWF from endothelial cells .  vWF;Factor 8 concentrate if not responsive to DDAVP

Impetigo (honey colored crusting is buzword)is strep or staph.  If bullous impetigo it is staph or MRSA.

Kerion= scalp mass from tinea.  Don’t I and D this!  Treat with griseofulvin or terbinafine po.  Topicals do not work.

Eczema Herpeticum: Diffuse herpes overlying eczema.  Cover staph and strep and add acyclovir.

In SCD although staph is most common cause of bone/joint infection, these patients are also at risk for Salmonella bone infection.   Dactylitis (swelling and painful fingers in little kids) may be presenting complaint for SCD.

Treatment for acute chest syndrome in a sickle cell patient is abx and  transfusion if PAO2 is less than 70.

 Scabies in infants has different presentation.  They will have scaly lesions on palms/soles and possibly wide spread rash.  Other family members may or may not be affected.

Typhlitis=neutropenic enterocolitis.   Think about in patient getting chemo with right lower abdominal pain. Treat with broad spectrum, big gun abx.  May need surgery.  Cecum usually involved.

Tumor lysis syndrome causes release of potassium, uric acid and phosphate.  Think sick puppy (Potasium-Uric acid-Phosphate-py).  Treat with iv fluids, bicarb, allopurinol or rasburicase.

Bone/joint pain due to Leukemia may not have way out of wack CBC.   CBC may show only nonspecific multiple mild abnormalities (anemia/low wbc count).

Roseola infantum= infant with high fever that breaks and rash develops.

ALISSA GOTTESMAN  TRAUMATIC BRAIN INJURIES TBI

Definition: impairment of brain function due to mechanical force

1/3 of trauma deaths due to TBI.

TBI: severe is 3-8, moderate 9-13, mild 13 and up.

GCS </=8  intubate.  Induce with etomidate.   Use C-spine precautions.   SZ prophylaxis with phenytoin for 7 days. Only hyperventilate when pt’s have signs of herniation.

High pressure bleeding with epidural hematoma from meningeal artery can cause herniation in 4 hours.  Underlying brain injury is small so surgery can be life and disability saving.  On CT bleeds appear with football shape appearance. Convex on medial surface.  Occurs in space between skull and dura.

Subdural hematomas usually due to injury to bridging veins in elderly or alcoholics.  Usually underlying brain injury is more severe than epidural.  On CT bleeds appear with concave surface medially.  Occurs in space between dura and pia mater.

SAH on CT shows blood in CSF.

Probably scan all Elderly patients with head trauma.

High risk criteria for scan: 8B’s  Brain dysfunction (seizure, amnesia, altered mental status, etc), Boney fx/step off, Banger (bad headache), Blow chow (vomiting), Bombed (intoxicated), Babies,  Boomers (over 60yo), Bleeders (coumadin or plavix use).

Cspine injury as high as 34% prevalence in the unconscious pt.

Jefferson burst fx oc C1 is unstable.

Hangman’s fx is due hyperextension injury of C2. Unstable

Teardrop Fracture due to severe flexion injury.  Unstable.Can get anterior cord injury.

Clay Shoveler’s is fx of spinous process of C7.  Stable.

When to scan Cspine?  Use Nexus or Canadian Rules.   If you can’t CT neck or want further eval, MRI of cervical spine is indicated.

If C-collar is to be on patient for more than 6 hours switch them to an Aspen Collar which is more comfortable and causes less skin breakdown.

ERIK KULSTAD  VARIATION IN MEDICAL PRACTICE

Research on Practice variation started about 40 years ago.   First study showed striking variation in tonsillectomies/hysterectomies/cholecystectomies in two Vermont towns.

The factor most important driving this variation is physician behavior and resource availability.

This type of finding has been replicated numerous times.

Dartmouth Health Atlas evaluates outcomes across the country in relation to intensity of care.

Health Care can be categorized as effective/necessary (15% of medicare spending), preference-sensitive care (influence by physician opinion and accounts for 25% of medicare spending), supply-sensitive care (includes referrals/consults/imaging/admission to ICU. Accounts for 60% of medicare spending)

Article in Science suggested that Variance is due to physician practice and there is risk of too much medical care   vs.  to too little care.

Medical Market Is in disequilibrium because excess supply pushes demand.  The assumption that more care is better, supplies are used up to exhaustion.

Unintended consequences of medical care make it possible that increased medical intensity leads to worse outcomes.

Informed patient choice has been shown to decrease utilization of healthcare usage.

PIKUL PATEL  LBBB AND AMI

7% of MI’s had LBB in National Registry of AMI.   Many did not get thrombolysis.

Most useful criteria: serial ekg changes, st elevation, abnormal q waves,

Cabrera’s sign is prominent notching in ascending limb of s wave in V3 or V4.  27% sensitive and 48% specific for AMI in LBB

Sgarbossa Criteria are  concordant st elevation 1mm, concordant depression 1mm, discordant st elevation of 5mm.

Smith Modified Sgarbossa Criteria: concordant ste 1mm or concordant  std 1mm, or discordant ste  with ratio of discordance of at least 0.2 ste/s wave depth

SHANNON LOVETT PEDIATRIC PROCEDURES

Peds airway differences: bigger head, bigger tongue, narrowest point is subglottic region -cricoid ring, epiglottis is bigger and more floppy and u shaped, larynx is more anterior and cephalad.

ETT tube size in kids: Use cuffed ET tube (age/4)+3.   Depth is ETT size x 3.   Use uncuffed tube in newborns (3.5 size ETT)

Needle cric for kids under 8yo.  Inspiratory/expiratory ration is ¼.  More time for passive expiration.  You will likely be stacking breaths somewhat.

Peds secretary has key to EZIO cabinet in PED.

Place IO in prox tibia just below tuberosity or medial maleolus.

Peds LP: keep bevel parallel to fibers of dura.  Neck flexion is unnecessary. 

Putting in a chest tube: between ribs 4,5, anterior to mid axillary line,  use finger and be cautious with hemostat.  Teens:28-32 french tube. Child:18french tube. Little kid: 8 French tube.  

Conference Notes 10-4-2011

Conference Notes 10-4-2011

ROHIT GUPTA   CLINICAL DECISION RULES

CDR’s should be clearly defined and address a clinically important outcome.

CDR needs to be Validated in a population different than the Derivation population.  The San Fran Syncope Rule did well in the derivation population but failed in the validation population.

A CDR then needs an Impact Analysis

Hieracrchy of rules: Level 4 needs further eval. Level 3 and 2 show increasing validity.  Level 1 CDR’s have been well validated and widely used.

The Pneumonia Severity Index CDR was reviewed.   This is a Level 1 CDR and can be used in our clinical practice.

The Glascow-Blatchford Bleeding Score for Upper GI Bleed was reviewed.  Score based on BUN,HGB,SBP, and a few other random factors.  This is a level 1 CDR also.   This rule can guide decisions on who can be discharged and who needs endoscopy.  Rohit advised that this CDR can be used in our own practice.

The PERC rule actually has not been well validated so far.

Harwood suggested MedEquations as an app for the iPhone for easy access to CDR’s.   Rohit also suggested MDCalc.com.

DAN GROMIS  and DR. OMI  CURBSIDE CONSULT TRAUMA ISSUES

Use your judgment on ACLS care and ACLS meds during trauma resuscitations.

End Tidal Co2 is less valuable in Trauma resuscitation because most of the time the patient is profoundly hypovolemic.

The lethal triad: hypothermia/acidotic/coagulopathic.

New research ongoing with cooling animals to 18C to see if that improves outcome.  Human trials are planned.

ECMO can be used but you have to be set up for it.  Requires heparinization. Data is lacking on efficacy.

Minimal Trauma Work UP for the Patient with no Vitals: Blunt Trauma: Airway/ chest tubes bilat/central catheter fluid infusion/FAST scan.  Penetrating Thoracic Trauma: consider thoracotomy

Who gets ED Thoracotomy?  Penetrating torso trauma.  The only thing likely to be fixed is Pericardial Tamponade.  If patient has lost vitals for more than 10-15 minutes or pt is asystole ED Thoracotomy is unlikely to provide benefit.

If patient has brain injury and they have been resuscitated with stable vitals consider Organ Donation. Determination of brain death takes about 24 hours so patient’s circulation needs to be maintained for that time period.

CHINTAN MISTRY  EMTALA

Anyone presenting to an ED must be provided with a timely medical screening exam to assess for an emergency medical condition.

If an emergency medical condition exists, the patient needs to be stabilized so they are unlikely to deteriorate prior to transfer.  If patient is in labor the infant and placenta need to be delivered.

If a patient presents to an outpt clinic at the hospital, EMTALA is triggered if the patient feels they have an emergent condition.

Who does the screening?  At ACMC it is an attending EP.

What is does screening consist of?   No one is totally sure.  Basically, do the right thing for the patient in the ED.

For legal purposes a discharge is a transfer.

For Trauma you have to accept from anywhere in the country.  Pt’s outside US have no claim to EMTALA.

EMTALA fines are not covered by malpractice insurance.  Hospitals can lose Medicare funding.

DAN NELSON  and CINDY CHAN ORAL BOARDS

Case 1: Ovarian Torsion.   U/S may show cysts and decreased blood flow to ovary.

Case2: Montaggia Fracture.  Check for compartment syndrome.  Consult Ortho for ORIF in adults. Kids can sometimes be tx’d with closed reduction.

Case3: DKA/NSTEMI  Treat with IV fluids, insulin, and potassium.   NSTEMI required asa, plavix, lovenox. Treatment.  No benefit to immediate cath.

JOE MASLAR   RADIATION INJURY

Radiation is the transfer of energy.   Wavelength effects properties and energy content.  Smaller wavelength has more energy.

Gamma rays can penetrate concrete and lead.  Xrays are less damaging and easier to shield.

Ionizing particles Alpha and Beta.  Because it is a charged particle it cannot penetrate skin/clothing.  It is only an issue if you ingest the particle.  Radon is a particle that emits radiation.

When energy from waves or particles hit atoms it ionizes the atoms.

Seiverts are the most important unit of measure for physicians because it measures the dose a patient received.  1 Seivert=1Gray=100Rads.   1Miligray=100 milirads

Avoid radiation exposure with time, distance, and shielding.

Ionizing radiation effects DNA.   DNA most susceptible during mitosis.  Radiation can also injure lysosomes and mitochondria.

  Most sensitive cells are blood forming cells, reproductive organs, digestive organs, and vascular system.

Cell damage and organ dysfunction lead to radiation sickness.

Radiation induced malformations in fetuses does not pass on to the next generation.  If the fetus survives it probably did not suffer catastrophic damage to the DNA blueprint.

Radiation sickness requires large dose of radiation from an external source, penetrating radition,  short time, whole body exposure.

If a patient has neuro symptoms they are going to die.  The nervous system is most resistant to radiation.

Three Radiation Syndromes: Hematologic, GI, CNS.  They are on a continuum of increasing radiation dose.   Anorexia/nausea/vomiting is the basic prodrome for all 3 syndromes.  Time to onset can be an indication of severity of radiation exposure.  If they are vomiting a lot at one hour they are at risk of dying.

24 hour lymphocyte count is the best marker for outcome. (Board alert) Rate of decline of lymphocytes is also used.

Risk to health care workers from radiation exposed patients is very low.  If possible removed patients clothing and wash them off with water and soap.  Do not delay care due to radioactive contamination of the patient.

Conference Notes 9-13-2011

Conference Notes 9-13-2011

GROMIS   ASOKEN   Use of Contrast for imaging studies

Most abdominal studies can be done without contrast.

Rectal contrast can save you time when doing a abdominal study.  Downsides are pt discomfort,  and pt having release of contrast from rectum. 

If the pt has some abdominal fat ct without contrast should be fine because the fat will outline the organs.

IV contrast is critical to opacify blood vessels example pe and aortic dissection. IV helps with inflammatory changes.   Looking for mets/tumor is aided by iv contrast. 

Oral contrast is much less likely to cause allergy compared with iv contrast.  IV contrast is iodine based so more allergic potential. Probably not a true allergy but more likely an idiosyncratic reaction.  

IV contrast is unpredictable in relation to causing an allergic reaction.  Patients with any type of allergy may be at increased risk.   Seafood allergy doesn't specifically mean a pt will be allergic to iodine based contrast.

GFR less than 30 is high risk for iv contrast.   GFR between 30 and 60 needs a risk/benefit analysis between radiologist and EM Doc.

IV or PO  hydration is the key to preventing increase in creatinine due to contrast. 

You probably don't need contrast for ct abd/pelvis for appy, obstruction, diverticulitis.

HINTON   CT ABD/PELVIS

Fat stranding is important marker of inflammation

Appendicitis shows an appendix greater than 6mm in width and associated inflammatory changes.   Start looking for the appendix at the cecum. 

U/S is better than CT for picking up gallstones.   Ct is better than U/S for identifying inflammatory changes around gallblader. 

Portal venous gas extends out to periphery of liver and is a poor prognostic marker.

Feces in the small bowel is a sign of bowel obstruction. 

SAWLANI   MANAGEMENT OF UTI

Who needs a urine culture?  If you decide to give antibiotics to a child up to 24 months for fever without clear source get a urine culture. 

Get urine for ua and culture by catheter or suprapubic tap. 

Risk factors for uti are fever equal/more than 39 and greater than 1 day of fever. Uncircumcised male is higher risk.  White girls and nonblack males are higher risk. 

If a ubag specimen urinalysis or dipstick is neg you are done. If it is positive you got to do a cath specimen.

A uti is diagnosed by a positive ua and culture of at least 50,000 cfu's. 

Uti and fever in kids under age 2 is considered pyelonephritis. 

ABX treatment for pyelo is omnicef.  it is covered by public aid as well. 

Febrile infants with first uti should get an ultrasound of urinary tract.  No VCUG unless u/s is abnormal.

Recurrent uti gets a VCUG.    Prophylaxis is not indicated.

HINTON AND CARLSON   ORAL BOARDS

Case 1 Methylene Chloride and Methanol.  Treat with oxygen and fomepizole. Consult hyperbaric chamber.  Always ask for co-oximetry.

Case 2 Pneumonia with adrenal crisis.   Give iv fluids, hydrocortisone, treat hypoglycemia, abx for pneumonia

Case 3  Measles.  Isolate patient, get confirmatory testing, arrange treatment of at risk contact (vaccinate or immunoglobulin), report case to health department.  Measles has cough/coryza/conjunctivits, rash moves head to toe, look for koplik's spots. 

WATTS   VAGINAL BLEEDING

menorrhagia  too much bleeding or too long or too frequent

metorrhagia   is off cycle

menormetorhagia is both of the above

4 stars on chicago flag is for chicago fire, fort dearborn, columbian exposition, century of progress exposition

Polycystic ovarian syndrome: high estrogen, low progesterone, endometrial hyperplasia.   Obesity, hirsuitism, anovulatory.

Over 35 with abnormal vaginal bleeding is cancer until proven otherwise.   They need follow up for u/s and biopsy. 

IV estrogen can help decrease bleeding in 5 hours in the unstable patient who then needs hysterectomy or embolization

PO estrogen  for stable vaginal bleeders.    3 tabs/day of orthocyclin for 7 days.   After that patients will have a heavy period.  The estrogen stabilizes the endometrium.      In young, non smoking pts not at risk for dvt/pe.  Patients over 35 are at some risk of cancer so probably don't give ocp's.

 

Conference Notes 8-30-2011

Conference Notes  8-30-2011

VISUAL DIAGNOSIS    SHANNON

Jones fracture is a linear fracture at the metaphysis of the the 5th MT.   Treatment is non weight bearing in cast for 6 weeks.    Fracture at the 5th MT tuberosity is called pseudo-jones and does not require casting.

Erythema Chronicum Migrans is target-like rash associated with  Lymes Disease. Treat with  doxycycline, rocephin or amox.  Erythro also acceptable on paper but Harwood says don't use erythro.

RMSF  treat with doxy in kids and adults.   Use choramphenicol in pregnant women.

HSV encephalitis shows bright temporal lobe on MRI

TEN/ Steven Johnson's associated with antibiotics like bactrim.   Transfer to burn unit.  Stop the drug needless to say.

Phlegmasia Cerulean Dolens is a severe dvt compromising venous outfow.  Leg is swollen and Purple

Phlegmasia Alba Dolens is a severe dvt with a white leg.  Arterial inflow is compromises

Pityriasis Rosea starts with a herald patch then becomes generalized.  Not contagious.  Thought to be viral.   Christmas tree pattern of rash on skin is key word for tests.

END TIDAL CO2  VIJAY

Colormetric Co2 detectors can falsely stay purple in the cardiac arrest patient.  The detectors need to see 4% co2 in exhaled breath and co2 may be less in the arrest patient.

End tidal   has close to 100% sensitivity for detecting tracheal intubation.

If you are in the trachea you will see a wave form on the capnograph. 

Capnography in the Cardiac Arrest Patient can guage effectiveness of CPR.  Your co2 with good cpr should be around 10.   If you see a sudden rise of 10 on the capnograph suggests ROSC.    Capnography can be used in place of pulse check.   If end tidal co2 is less than 10, 20 minutes out they are effectively dead.  This probably also applies to kids.  

Bicarb iv can falsely elevate entidal co2.

Capnography can demonstrate early apnea during procedural sedation

In copd and bronchospasm  the capnography wave form can demontrate breath stacking early. 

In patients with metabolic acidosis, ETCO2 will be high.   In DKA it will be low. 

CXR  DAN BARTGEN

Pneumomediastinum due to Macklin Effect in which alveolar air ruptures into interstitium and dissects toward hilum. Examples are asthmatics, scuba divers, smoking crack pipe etc.  If pneumomediastinum is not due to esophogeal rupture or tracheobronchial trauma it is benign.  If it is due to esophogeal rupture or trach-bronch trauma this is an emergency with high risk of mortality.  Requires surgery.

Mach Band can mimick a pneumediastinum.  The Mack band lacks a thin bright white line of the pleura.  This is very common.

Deep sulcus sign is a low/deep diaphragm and cp angle that indicates a pneumothorax.     The deep sulcus sign may be the only indication of a pneumothorax on CXR.  

TRANSFUSION MEDICINE     Dr. HAMILTON

Most common cause of fatal transfusion reaction is giving the wrong blood to patient and ABO incompatibility is present. 

Only use IV Saline with PRBC transfusion.  D5 can cause hemolysis. LR has CA which can cause clotting. 

O-pos blood can be used a an uncrossmatched resucitative transfusion instead of  O-neg in males and females over 50.

Blood transfusion requires a filter in the iv line. 

Transfuse as fast as tolerated.  If chf run it in slowly.   Gotta transfuse under 4 hours.   There may be some bacteria in the unit of blood or plasma and it is felt that transfusion under 4 hours limits the chance of increasing bacteria in blood. 

1 unit of PRBC's should raise hgb by 1.

1 unit of aphoresis platelets increases the platelet count by 20-40,000.

Criteria to transfuse for adults is hgb <8 or hgb 8-10 with symptoms or COPD/CAD/Other CV disease.  There is debate about the 8 hgb cut off.  Pt's with heart disease do better with blood.   Also transfuse pt's with acute blood loss >2% blood volume.

If pt has history of allerigic reaction to prbc/platelet transfusion, ask for washed or twice washed      

prbcs/platelets.

In patients with severe immunosuppression needs irradiated blood to prevent graft vs. host disease. 

GUNS AND MISSILES  KELLY WILLIAMSON

Tissue damage is mostly related to velocity based on the equation KE=1/2mass x (velocity squared)

Cavitation is movement of soft tissue as missile passes and severity is based on velocity.     

Handgun accuracy is low.  11% of perps and 25% of cops hit their intended target. 

High velocity is >2000 ft per second.

Wound care: irrigation, tetanus update, cover with gauze.   GSW's are not sterile but infection is rare.  If infection develops it is usually due to gram positives from skin flora.   Routine abx prophylaxis is not indicated. 

Indication for bullet removal: superficial and irritating, cosmetic reasons, joint space, globe of eye, in vessel lumen, nerve impingement, abscess, forensic investigation, elevated lead levels.

Do bullets set off metal detectors?  Yes

Missiles in joint spaces are most prone to cause lead poisoning.  Also bullets in bone are at risk. 

ACUTE STROKE   DR.  GRYSIEWICZ

Desmoteplase for strokes.  It is a plasminogen activator.  70% similar to TPA.

You can give up to 4.5-9 hours out. No neuro toxicity. More fibrin specific than TPA.  Half life is 4.5 hours.  Found naturally in the saliva of a vampire bat.  

 

Clinical equipose:  Genuine uncertainty as whether treatment in one arm of a clinical study has  benefit over treatment in the other arm. 

Intra-arterial thrombolysis (neurointerventional stuff) can be used 4-6 hours out from onset of stroke.

Studies have also looked at surgical recanulization out to 8 hours after onset of stroke. Clinical outcome data on these neurointerventional techniques are limited.

If you have a patient more than 3 hours out from onset of stroke, get a CTA in addition to CT.   Neuro will decide whether pt gets  Desmoteplase vs. Neurointervention.  No one knows if either helps patients.  

NARROW QRS COMPLEX  TACHYCARDIA    KUTKA

In afib,  F waves can look like p waves but have variable morphology. 

Aflutter should have very consistently symmetric flutter waves.  If they have differing morphology, then you have afib. 

Adenosine dosing thru central line is only 1-3 mg.   You might want to give sedation prior to giving Adenosine to lessen the feeling of impending doom/chest discomfort.

Heart rates 140-160 is usually aflutter with 2:1 conduction.

Retrograde P Waves should make you think AVNRT

You can't identify WPW in a narrow complex svt.   Orthodromic WPW SVT looks like any other narrow complex SVT.    Narrow complex tachycardia adenosine is ok.  Wide complex use procainamide. 

 

Conference Notes 8-23-11

Conference Notes 8-23-2011

ORAL BOARDS   ANDREJ and GROMIS

1.TTP

2.Orbital Cellulitis in an infant

3. Mastitis

TRAUMA   CHASTAIN

Hemorrhagic shock  class 1= 750ml, class 2=  750-1500ml, class 3=  1500-2000ml, class 4   =more than 2000ml

Lethal triad=acidosis, hypothermia,coagulopthy

Hemostatic Resuscitation  for penetrating trauma with short transport times get blood pressure to MAP of 65

Crystalloid only for keeping pt alive until they get blood. 

For large blood loss shoot for ratio of 1 unit prbc's:1 unit of ffp and possibly 1 unit of platelets.

Be extra thorough with trauma transfers and sign outs. 

Call for blood early

Fentanyl is a good analgesic choice for the hemodynamically unstable

AFIB CINDY CHAN

Agents for pharmacologic conversion of afib all lengthen the QT interval. So caution warranted.  Amio, Ibutalide, Propafenone.  Procainamide is another good choice. 

To reduce stroke  warfarin reduces risk  by 64%.   Asa instead of wrfarin is less effective but does reduce risk of stroke by itself.  Dabigatran (Pradaxa) is a direct thrombin inhibitor.  Expensive alternative to warfarin.  Indicated in non valavular/non renal/non liver disease related afib.  Anecdotal stories from audience relate experiences with severe bleeding.  

SAH and CEREBRAL VASOSPASM   LAURA

Blood sugar >200 increases risk of vasospasm

GCS can predict vasospasm.  The lower the score the hihger the risk of vaspasm.  SIRS also predicts vasospasm and overall poor outcome.   2 SIRS criteria gives you a 9.1 OR for vasospasm and poor outcome.  Elevated troponin also increases risk of mortality. 

LIFE  AFTER RESIDENCY   MIKE ANTONIS

Detorsion of testicular torsion can buy you time to pt to OR.

Groups in desirable cities like chicago/boston/denver will likely pay less than groups in less desirable cities. 

Hook Effect or Prozone Effect falsely low values on immunoassay due to extremely high levels of antigen.  Molar pregnancy was the example. Pt has a beta-hcg of greater than 1million and had a negative ucg.

Develop a track record with your group to allow you to negotiate from a position of strength on your contract.

STATS   Christine

Evaluating meta analyses;  Strict inclusion/exclusion criteria, include valid studies (RCT's best),   the included studies and their results should be similar, Funnel Plot make the results more trustworthy

Conference Notes 8-16-2011

Conference Notes 8-16-2011

DKA     JOELLEN CHANNON

Cerebral edema has unclear etiology.   Higher risk in kids less than 5yo, initial presentation, severe acidemia, dehydration,  serum sodium not rising as expected. 

Easy version of giving fluids is 1.5X maintenance.  

No insulin bolus.  Give insulin at 0.1 unit/kg.  Insulin supresses glucose and ketone production.

Give K if potassium is less than 5.5 and pt has made some urine.  Give 30meq of KCL in a liter of saline. 

Na should increase by 2.4 for every 100 decrease in glucose. 

Don't worry about phos unless it falls below 1. 

No bicarb unless cardiac arrest or ph is <6.9.

 If you suspect cerebral edema developing give mannitol or 3% saline (5ml/kg)

STUDY GUIDE   PEDIATRIC EMERGENCIES   ELISE

Electrolyte abnormalities causing seizures:    hyponatremia, hypocalcemia, hypomagnesium

Bilious emesis in the first year of life : volvulus due to malrotation diagnosed with upper gi series.   needs surgery

Complications of HSP: renal involvement, intussusception, gi bleed, hypertension, pseudotorsion, joint involvement.    HSP is an IGA vasculitis. 

MANTRELS for appy: migration, anorexia, nausea/vommit, tenderness in RLQ, rebound tenderness, elevated temperature, leukocytosis, shift of wbc's to left.   Score less than 5 makes appy unlikely,  score more than 8 is highly likely.

Life threats from nephrotic syndrome are infection and thromboembolism.  They have increased levels of thrombolytic inhibitors and increased viscosity. 

Post-strep glomerulonephritis: facial edema, hematuria/proteinuria/casts, tea colored urine, htn.  Restrict fluids, na restriction, lasix. Excellent prognosis. 

Diagnosing SCFE: Use Kline's Line.  A line along the lateral aspect of the femoral neck  should intersect the epiphysis in a symetric fashion bilat. 

SALTER HARRIS FX:  physis=1, metaphysis=2, epiphysis=3, metaphysis and epiphysis=4,  impacted=5

CRITOE= Capitellum 1yo, Radial head 3 yo, Internal Epicondyle 5yo, Trochlea 7yo, Olecranon 9 yo, External Epicondyl  11yo

Cardinal features of HUS are Microangiopthic Hemolytic Anemia, Uremia and Thrombocytopenia. 

CALCIUM CHANNEL BLOCKER OVERDOSE  ANDREA

Gastric lavage only with massive ingestion in the first hour with protected airway.

Whole bowel irrigation for sustained release preparations, early presentation, pills seen on xray.  Contraindicated for hypotension and decreased bowel sounds. 

Give charcoal up to 2 hours out.   

 Give calcium,  try glucagon,  and the main thing is Insulin and glucose to increase transmembrane calcium flux.  Insulin also has a pressor/inotrope effect.  Insulin also pushes glucose into the myocyte to feed the heart.   Insulin dosing is being ramped up by toxicologists.   High dose insulin is a first line therapy for CCB OD.  Insulin dose is 1u/kg bolus and then 0.5u/kg drip.   Give 1 amp glucose push then D10/.45ns at 80% maintenance.  Keep close eye on potassium.

IV fat emulsion can also be used. It acts as a lipid sink for lipid soluable drugs like local anesthetics and calcium channel blockers.  Also feeds the myocytes and opens calcium channels in myocytes.  Lipid  emulsion can mess up lab tests like measuring potassium.

Immediate release preps can dispo home after 6 hours on a monitor.  Sustained released preps or amlodipine admit for 24 hour monitoring. 

NEONATAL RESUSCITATION ALGORITHMS   BADILLO and SINNOTT

Escalating actions are the cornerstone of NALS.   Tactile stimuli and warming> bagging with room air for 90 seconds>  bagging with oxygen> intubation>  chest compressions>   iv epi 0.01mg/kg 1:10,000 iv/io/uvc. 

If meconimum present: child vigorous no suctioning; child not vigorous suction with et tube.

Conference Topics 8-9-2011

Conference Notes 8-9-2011

STEMI CONFERENCE

If pt has other issues such as endocarditis, fever, mental status changes in addition to STEMI, discuss with cardiologist prior to activating STEMI alert.   Going to cath lab is not always the best option for the complicated MI patient. 

Biphasic t waves V1-V3/4 identifies Wellen's Syndrome.   Which is a tight proximal LAD lesion.  Don't do a Stress Test in this case.   Consult cardiology for consideration of a cath. 

Think twice about activating STEMI when any of these Red Flags are present: Fever, Altered Mental Status, Severe Acidosis or Hyperkalemia, or Trauma.

ORAL  BOARDS   C. KULSTAD  vs.  BADILLO

Case #1   Pediatric SVT treated with Adenosine (0.1mg/kg up to 0.4mg/kg) and then Cardioversion with 0.5-2J/KG

Case#2 Posterior Shoulder Dislocation.  Xray shows lightbulb on a stick.  This is a rare dislocation.    Treat with traction/counter traction.

Case #3 Cyanide Poisoning from a house fire.   Pt with severe metabolic acidosis, nl SPO2, and had a CO level of 12.   Tx with Hydroxycobalamine or sodium thiosulfate or both.

CASE F/U  TESTICULAR PAIN   ANNA

Testicular torsion is complete when cord is twisted over 360 degrees.

Inadequated fixation of testes to tunia vaginalis allows twisting

Bell Clapper deformity is a transverse lie of testicle in scrotum.

Common ages are neonates and 12-18yo.  But can occur at any age. 

Torsed teste should have an absent cremasteric reflex but its not a perfect sign.

Salvage is 90% if you get to OR by 6 hours.   50% salvage at 12 hours.  0% salvage at 24 hours.   

To manually detorse, open the book motion.   End point is pain relief.  Problem is 30% are torsed laterally and opening the book will increase the torsion in these cases.

Patient will likely need pain control or mild sedation to make manual detorsion  possible. 

Epididymitis TX= Rocephin/Doxy for sexually active patients.  Flouroquinalone for those not at risk for STD.    Keflex for kids. 

Torsed appendix testes is the third ddx for the acute scrotum. 

TIPS FOR RESUSCITATION OF THE MEDICAL PATIENT  BAROUNIS

AABBCCDDEE and F

A=aorta (dissection or aaa) A=acidosis (6-8cc/kg TV with high rate maybe 18 for the severely acidotic patient),   B=bagging (watch for overventilation), 

Baby on board (think ectopic, displace uterus from ivc, defib is ok, avoid amio), C=chest compressions (100/min and minimize interruptions),  C=cooling,  D=defibrillation, D=dopes (dislodgement, obstruction, pneumothorax, equipent failure, stacking breaths), E=echo for effusion and embolism (t wave inversion inferior and anterior and tall terminal r wave in avr is  specific for pe), F= forget about it (bicarb, mag, amio, lido, atropine, trandelenburg, lido/defassiculating dose prior to intubation)

TIPS AND TRICKS   GROMIS

Car Buyers can ask the Dealer what their profit  margin is on the car. They are legally required to tell you.   Bottled water has a higher fecal content  than tap water.  

Getting to know how to minimally troubleshoot problems with the IV pumps improves your professionalism with your patients and with the nurses on the care team. 

Cannulate the basilic vein using u/s if you have a patient with poor iv access. Gotta use the long angiocaths.   You can also use u/s to identify veins in the antecubital fossa that can be cannulated. 

When doing IJ central line, pt should be in about 10 degrees of trandelenburg. Don't use too much suction with the syringe.  You can collapse the vessel around the needle.   If the wire gets hung up turn the bevel of the needle 180 degrees.

Bimanual intubation is a very effective way to improve your view of the larynx. 

Conference Topics 8-2-2011

8-2-2011  Conference Notes

Peds Study Guide  Bill Schroeder

Persistent unilateral nasal drainage, think nasal foreign body.

Unilateral air trapping on expiratory films points to an aspirated fb. 

Throat culture for strep has a 10% false negative rate.  Traditionally it is accepted that abx tx for strep throat shortens course of illness and prevents rheumatic fever.   (there is some debate about the significance of both these rationales)

Strep throat is uncommon under age 3 because kids at this age lack the necessary protein in the throat that binds strep. 

SIDS is due most frequently to an asphyxation event.  Basically child is suffocated by prone sleeping position or sleeping in bed with parents.

Diagnosis of acute otitis media depends on effusion (distortion of tm) and inflammation (injection).  Light reflex is not significant for diagnosis.  Insufflation is the best for diagnosing aom but is difficult. 

Crying infant think corneal abrasion

Conjunctivitis after erythromycin topically in infants think chlamydia and give oral erythro or azithro.

LIFE AFTER RESIDENCY   SUE NEDZA

50% of EP's are employees of a hospital

Additional career challenges other than clinical EM promote longevity in the specialty.

If you leave clinical medicine, it is hard to make equal or more money.  You are paid very highly for your clinical work. 

Invest in quality disability insurance.

When you look at a new group to join, ask how they are doing with their quality measures.  Do they use them to decide on your salary?

 Does the group have a good position in the hospital to get their share of bundled payments. 

More people are on medicaid then medicare. 

10,000 baby boomers enter medicare a day for the next 19 years with no added funds.

MEGA CODES

PEA :  Hypovolemia, Hypoxia, Hyper/Hypokalemia, Hypothermia, H+(acidosis)   Toxins, Tension Pneumo, Tamponade, Thrombosis (PE,AMI)

PEDIATRIC SKIN INFECTIONS   Beau

Keryon is a large boggy mass on scalp that is caused by tinea capitis.  Do not incise.  Treat with griseofulvin or diflucan po. 

I and D of pilonidal cyst stay just lateral to the midline for improved wound healing.

For Bartholin's Abscess, word catheter stays in for 4-6 weeks. 

Consider necrotizing fasciitis when pain is out of proportion to exam. 

Preseptal cellulitis: no impaired eom, no proptosis, no pain with eom, 

Augmentin or Clinda/bactrim or clinda/cipro for mammilian bites.

Id reaction: pt has a fungal infection on foot or hand and due to circulating antigen and  pt develops rash on a remote site of body.

ETHICS    SHAYLA 

Surogates Rank order: Guardian/ Spouse/ Adult Child/ Parent/ Adult Sibling/ Close Friend

Withdrawl of Care: Can't pull ET tube without being sure neuromuscular blockers and major sedatives are out of patient's system.

The LET form is important.  Fill it out please in the ED!  

 

Conference 7-26-11 Topics

7-26-11
DR. GOURINENI'S LECTURE
Iv Antibiotics are critical for open fractures.  Reduce fracture so bone is not exposed.  Don't use betadine dressings
After reducing a disolcation, put joint thru easy range of motion to assess the patients range of motion.  This is helpful info for the orthopedist.
Very few pediatric fractures have to be reduced in the ED.   If fracture is in plane of joint it will remodel very well even if there is diplacement and shortening
Supracondylar Fractures:  Admit all Gartland 3's (displaced fractures)
Pulselss but pink hand does not need emergent surgery.  Ischemic hand requires emergent surgery.
If there is varus angulation of elbow they need operative reduction within a week or they will have dformity for life.
When splinting elbow fractures don't splint with elbow flexed more than 90 degrees.   It decreases venous return.
If you are treating a pediatric elbow dislocation and on the f/u xray do not see the medial epicondyle, it may be stuck in the joint.
Femoral shaft fracture in kids under age 5 can go home in a splint from the rib cage to the lower leg.  Don't include the ankle in the splint.  Gotta rule out child abuse before they go home.  
Velcro splint is acceptable for a buckle fracture.
DR. HOYME'S LECTURE
Reducing paraphimosis: thumbs on glans and index middle fingers on parphimotic ring
Use absorbable sutures when repairing the genitalia
Any young adult with painful scrotum needs an u/s.  Testicular cancer can present in a myriad of ways.
Blue dot sign on scrotum signifies torsed appendix testes.  Appendix testes is the remnant of the mullerian duct.   The wolfian duct forms the vas deferens, epidymus and ejaculatory duct.
Strangulated hernia will obscure the spermatic cord.
Varicocoele is usually on the left side.   Varicocoele is more prominent when standing and can go away when laying down.  If it stays prominent when laying down you have to consider retroperitoneal neoplastic process.
Priapism stems from the god Priapis who is the protector of the male genitalia.  (Not sure if that is greek or roman god)  Many drugs can cause priapism. Treat priapism  with phenylepherine injection.   First aspirate the corpora cavernosum on one side 50ml of blood (the copora communicate) then inject phenylepherine 1ml Q3min for one hour.  If that fails, GU will have to do a shunting procedure.
Ureteral stones more common with increase BMI, sunny climate, males, caucasions.  Stones more likely to pass if <6mm and distal ureter.  If  a patient has a stone <10mm and symptoms controlled, pt can be discharged.   If stone >10mm they will need a procedure.   Stone and sepsis needs iv abx and urgent drainage (stent or nephrostomy)
ORAL BOARDS
Traumatic placental abruption
AFib RVR and WPW
Supracondylar Fracture
TONY'S LECTURE
ST segment elevation mi's
Look for R wave amplitude to decrease as mi evolves
Criteria for st elevation= 2mm in men, 1.5mm in women in precrodial leads, 1mm  for men and women in other leads
Inferior mi with st segment elevation of lead3>lead2  suggests right sided mi
Beware posterior mi with st depression and tall r wave in V1-V3 (carosel pony)
Code STEMI  requires attending to attending discussion
JOE LAVATO LECTURE
Vancomycin ominously has MIC creep with decreasing ability to treat MRSA. 42% has MIC of 1.
VRE already has 14% resistance to Linezolid
Gram neg can produce amp-C beta-lactamase which gives resistance to ceftriaxone and zosyn.
There is a new hyper toxin producing strain of c-diff (NAP-1 =60% of isolates at ACMC). Gotta use vanco.
Uncomplicated uti recommendations: 3 days bactrim, 7days of nitrofurantoin, or single dose 3g of phosphomycin (50bucks), or 3 days of a second generation cephalosporin.
Recommendation for community aquired cellulitis=ancef or nafcillin.  Early cellulitis in diabetic=unasyn.   severe diabetic foot infection=vanco/zosyn.
PARUUL'S LECTURE
Verapamil Sensitive V-Tach
Differentiating vtach from svt with abberrancy: concordance, fusion or capture beats, morpholgy that is not c/w classic lbbb or rbbb, pt with hx of heart disease, av dissociation, rbbb with left ear>right ear, v5,6 predominantly negative all point to vtach.
Idiopathic Vtach occur in young patients with no heart disease. Excellent prognosis. QRS duration is around 120ms, left axis deviation, rbbb.  Responds to iv verapamil 2.5mg.

Conference July 26, 2011

Dr. Gourineni:  Pediatric Orthopedics

1.  Remodeling:  Children have tremendous potential to remodel fractures, especially with boys <12, girls <10, often do not need to reduce fractures in younger children, especially in cases of distal radius and proximal humerus fractures, and when fracture in plane of movement of extremity.  On the other hand, valgus/varus displacements not tolerated (for example in supracondylar fx) and will more often need reduction/surgical repair.

2.  Buckle Fracture Treatment:  Literature to support minimal immobilization for simple buckle fractures (ace wrap!).  For Dr. Gourineni, velcro splint is fine.

Dr. Hoyme:  Urology Tips for the ER

1.  Hematuria:  DDx:  SHIT3.   Use large (24F) 3 way catheter for irrigation.  Manually irrigate clots out of bladder before hooking up CBI (Continuous Bladder Irrigation).

- Stone

- Hematologic (bleeding) diathesis

- Infection

- Trauma

- Tumor

- TURP

2.  Foley insertion:  use plenty of lubrication; Urojet is viscous lidocaine-extremely helpful.  Be very careful to have urine return before blowing up balloon (inflated balloon in urethra --> urethral stricture).

3.  Urethral stricture:  when suspected, try small (14F) catheter, or talk to your attending about using the Urology tray (in inventory).

4.  Varicocele:  if large and doesn't reduce at all when laying flat, consider retroperitoneal tumor (obstructing venous return).

5.  Stones:  AUA guidelines, if healthy non-pregnant pt with 2 kidneys and no infection, ok to discharge if stone <10 mm and pain/nausea controlled.  Use tamsulosin and urology f/up.  Outpatient KUB to track stone passage, may take one month to pass.

6.  Sepsis + Stone:  broad spectrum antibiotics and emergent stent or nephrostomy tube.  Nephrostomy tube preferred as larger tube, can monitor drainage to ensure patency, and do not need general anesthesia for placement.

Conference 7-19-2011

7-19-2011  Conference Highlights

STUDY GUIDE Tetanus shot  (td) safe in pregnancy.   Avoid Tdap in pregnancy.  Rapid sequence drugs are ok. Propofol and narcotics are ok if not near delivery.   Avoid NSAID's because it reduces uterine blood flow.

Highest radiation risk to fetus neuro development is 8-15 weeks post conception  Highest teratogenicity is 2-8 weeks as this is period of organogenesis.

Mastitis: staph most common organism, have mom continue breast feeding unless there is an abscess

Hydatidifrom mole:  presents with 1st or 2nd trimester bleed, hyperemesis, very high beta hcg.  Treatment with d and c.   Associated with choriocarcinoma.

Kleihauer Betke test is basically only for identifying large fetomaternal hemorrhage that would require extra rhogam. 

Mondor's Disease:sperficial phelbitis nar breast, benign and disappears spontanously

JOELLEN'S LECTURE  

Arachnoid Cyst:  Can present with headache or seizure.   Cysts can also occur in spine.   JoEllen's pt had cervical cord compression from the cyst.

In the fussy child always consider shaken baby or other types of abuse.   Look for incarcerated hernia, hair tourniquet, corneal abraision, torsion, cardiac disease etc.

Intussusception:  usually ileocolic junction.  6-36 month old child.  male:female ratio 4:1.   70% will be heme positive.  Atypical presentations include lethargy in 20%.   Child will progressively worsen.  

Diagnosis with ultrasound or barium enema. Recurrence rate of 30% usually in the first 48 hours. 

MICHELLE'S LECTURE

EKG Basics:  Systematic Approach is Rate,  rhythm, axis, conduction, s-t segments

wandering pacemaker=slowed down version of MAT 

Heart Block analogy of your significant other "stepping out on you" .  The relationship gets worse untile in third degree block,  the p and the QRS never see each other. 

Tachyarrythmias:  Break it down to Wide/Narrow and Regular/Irregular

V-tach has fusion and capture beats

Can't miss issues:brugada, wellen's,  long qt, wpw

EKG case presented with tachycardia and posterior ami findings

ORAL BOARDS

Vijay and Elise

Case #1=Lemierre's Syndrome (septic thrommbophlebitis of IJ) with septic emboli to lungs.  Lungs are most common secondary site.  Broad spectrum abx and consider anticoagulation.  Affects young patients.

Case#2=Multiple Trauma with flail chest/ pulmonary contusion and hemoperitoneum.    Hypoxia is max at 48 hours after pulmonary contusion.

Case#3=Ulnar Collateral ligament rupture of thumb.  Thumb spica Splint with outpt ortho follow up.

RICARRDI LECTURE

KILLER BABIES, HTN in pregnancy

Treatment of pre-existing htn: don't treat for less than 150/100.  po labetalol or methyl dopa

Gestational htn: no proteinuria

Pre-ecclampsia: BP=/>140/90, proteinuria, edema no longer in definition.  risk fractors: first kid, obesity,htn, dm.   Severe pre-ecclampsia is defined by signs of organ failure.  Definitive treatment is delivery. Treat BP with labetalol or hydralazine.  Get BP down to 130/80

Ecclampsia: seizures are self limited.  It can be ecclampsia even if BP is ok and there is no proteinuria.  Also consider other structural or metabolic causes of seizure in the patient without elevated BP or proteinuria.

Magnesium 6 grams bolus then 2gram/hour.  Can give IM magnesum 5gm in each buttock.   Calcium gluconate is antidote for magnesium toxicity.  

Preecclampsia/ecclampsia can occur up to 6 weeks after delivery.

THink HELLP Syndrome in pregnant patients with epigastric or ruq pain.

JIM JENSEN LECTURE

Intra-nasal administration of drugs: need low volume and high concentration of drug to use this route.   Can use this route for fentanyl, versed, narcan, flumazenil.     

Fentanyl dosing this route is 2micrograms/kg.  Morphine is 0.1mg/kg.  Versed is 0.2mg/kg.  Narcan is 1mg in each nostril.  Ref.  intransal.net

conference pearls 7-5-2011

• 7-05
• cool  heat stroke as fast as possible.  mist and fan technique probably easiest to get together quickly, also can use cool guard
• if nurse asks if there is anything else you want to do on oral boards, there is.
• be agressive on oral board cases, do everything now
• disciplined exam is critical on oral board cases
• pres syndrome   tx= calcium channel blockers
• preecclampsia  can test with  urine protein/ urine cr ratio,  serum uric acid
• air in ventricles from epidural anesthesia can cause headache. tx with 100%oxygen
• blood patch very effective for post lp or post epidural headache
• Systematic cxr eval  A=air and airway, B=breathing aka lungs and bones, C=cardiac and mediastinum,  D=devices, diaphragms, and data,  E=external to rib cage
• mediastinal hematoma caused by rupture of smaller vessels like azygos
• wide mediastinum is >8cm   on PA chest
• Overall incidence of SBI in kids is @10%,   meningitis is 1%.   
• Incidence in well appearing kids is @7%.
• SBI includes pneumonia, uti, bone/joint infection, meningitis, cellulitis, bacterial enteritis
•  Cautious simple approach to fever in kids:  up to 8 weeks of age do a full septic workup, give ceftriaxone and decide dispo with pediatrician
• 3-36 months  get urine in girls up to  24 months, uncircumcised boys up to 12 months,  circumcised boys up to 6 months
• RSV in kids less than 60 days old the risk of SBI is 7% and risk of meningitis is close to 0.  Consider getting urine and blood cultures in these kids. 
• Vaccination up to date in the 3-36 month kid lowers risk of SBI

7/5/11

Pneumocephalus is rare complication of epidural anesthesia. Usually characterized by acute onset of headache after procedure. +/- neuro deficits. Giving O2 speeds absorption of air. Can also be seen after trauma, cancer, otogenic infection. Prognosis based on cause, but generally good. Remember peripartum headache can be bad.

Joint Pediatric/EM conference 6.14.2011

Topic:  Infectious Disease (panelists Dr. Maryanne Collins, Dr. Bill Schroeder, Dr. Omar Sawlani, Dr. Surasek P.)

1.  Consensus of panel-avoid alternating acetaminophen and ibuprofen.  Using both increases medication errors, doesn't significantly improve fever control, and adds to fever phobia.  To mitigate concerns of "brain damage" from fever, explain that fever is the body's internal response to illness and will not cause harm.  This is in contrast to the potential dangers of external/environmental heat such as heat stroke.

2.  The pediatricians in the audience encourage the continued culturing of SSTI (skin and soft tissue infections/abscesses).  When a child shows up in the office with a worsening SSTI, it help the PMD to know the resistance pattern.  FYI, at ACMC, approximately 50% of SSTI are MRSA.  

3.  When to admit pediatric SSTI?  Per Dr. Collins, consider age of patient, site, size of infection, prior infections, followup, and toxicity of patient.

4.  Periorbital vs. Orbital cellulitis.  We rely on globe pain, restricted eye movements/pain with eye movements, high fever, proptosis, spread/amount of erythema/swelling, overall toxicity when distinguishing the two clinically.  Orbit CT is indicated if concerned about orbital cellulitis, but for the gray zone cases, no need to CT in the ED.  Initial management is IV antibiotics, and if poor response, the CT can happen the next day.  Treatment difference for the two conditions is twofold:  potential for surgery and longer duration of antibiotic treatment for orbital cellulitis.

5.  Fever 3-36 months in well appearing child:  There is a variety of acceptable work-ups, ranging from nothing to partial septic work-up.  Much depends on followup/where you see the patient:  more tests usually performed in ED, when doctor doesn't know family and there may not be great followup.  Remember, children need the first two sets of vaccines (2 and 4 months) to be considered "immunized"; after this, no testing usually necessary except for the consideration of a UA and urine culture (always send both in diaper wearing kiddos).  Urine may be deferred for happy kids with one day of fever, but need to warn parents that if fever continues for more than 2 days, UA/culture may be needed.