THE CENTER FOR

MEDICAL EDUCATION
Sponsored by
 TABLE OF CONTENTS
EMERGENCY MEDICINE BOOTCAMP

PAGE
Accreditation Information and Faculty Disclosures ......................................................................................I-VI

Introduction to the Emergency Medicine Boot Camp ...................................................................................1-4

How to Stay Connected During the Conference ............................................................................................5-8

Taking it to the Next Level: Medical Apps ...................................................................................................9-20

Approach to the ED Patient ..........................................................................................................................21-28

Vital Signs: Keys to Risk Avoidance ............................................................................................................29-34

Head Trauma ..................................................................................................................................................35-46

Essential Charting Concepts .........................................................................................................................47-56

Pediatric Rashes ............................................................................................................................................57-68

TIAs and Strokes: State of the Art ................................................................................................................69-86

Thriving, Not Just Surviving: Wellness and Self-Care ..................................................................................87-98

Ear Disorders .................................................................................................................................................99-114

Neuropsychiatric Disorders ...........................................................................................................................115-128

What You Must Know to Avoid Being Sued ................................................................................................129-134

Hypertension and Syncope ............................................................................................................................135-144

Sinus, Nose and Tooth Ailments ..................................................................................................................145-150

STIs: Diagnosis and Treatment ......................................................................................................................151-160

Knee Disorders...............................................................................................................................................161-170

Cutting Edge Medicolegal Issues...................................................................................................................171-176

Headaches: Don’t Miss the Serious Ones .....................................................................................................177-182

Endocrine and Acid-Base Disorders .............................................................................................................183-202

Hips and Pelvis Disorders .............................................................................................................................203-212

Elbow and Forearm Complaints ...................................................................................................................213-220

Essential Pediatrics .......................................................................................................................................221-226

Hand and Wrist Problems .............................................................................................................................227-238

Congestive Heart Failure, Myocarditis and Pericarditis ...............................................................................239-250

Environmental Disorders ..............................................................................................................................251-258

Electrolyte Disorders .....................................................................................................................................259-270

Shoulder Disorders.........................................................................................................................................271-282

Lower Abdominal Disorders..........................................................................................................................283-294

Adult Chest Disorders, Part 1 ........................................................................................................................295-304

Ankle and Foot Disorders .............................................................................................................................305-316

Eyes: Essential Diagnosis and Treatment .....................................................................................................317-324

Cardiac Dysrhythmias ....................................................................................................................................325-336

Cervical Spine Disorders ...............................................................................................................................337-350

Clinician Collaboration in the Emergency Department .................................................................................351-356

Adult Chest Disorders: Part 2 ........................................................................................................................357-370

Acute Coronary Syndrome ............................................................................................................................371-384

Upper Abdominal Disorders .........................................................................................................................385-392

Asthma and Chronic Obstructive Pulmonary Disease ...................................................................................393-408

Colds and Influenza: Not So Straightforward ................................................................................................409-420

Pediatric Infections ........................................................................................................................................421-432

Back Disorders: Don’t Miss the Red Flags....................................................................................................433-442

Urology: Rapid Assessment and Treatment ..................................................................................................443-454

Soft Tissue Infections and Sepsis ..................................................................................................................455-464

Soft Tissue Injuries: Optimized Care .............................................................................................................465-478

Oropharyngeal and Neck Disorders ...............................................................................................................479-486

Analgesics and Procedural Sedation .............................................................................................................487-494

Dermatology: Rashes to Anaphylaxis ...........................................................................................................495-510

Odds and Ends in EM: THE LAST LECTURE ...........................................................................................511-520

 EMERGENCY MEDICINE BOOT CAMP
SPONSORS

The Center for Medical Education

Since 1977, the Center for Medical Education, through its publications and courses, has been providing emergency medicine and primary care providers with
evidence-based educational content focusing on evidence-based, state-of-the-art care. In 2011, over 5,000 physicians, PAs and NPs attended courses produced by
the Center or its affiliates and over 9,000 providers subscribed to its various affiliated monthly publications. Please visit CCME.org for more information.

The Center for Emergency Medical Education

The Center for Emergency Medical Education is a producer and accreditor (Accreditation Council for Continuing Medical Education) of educational programs
primarily focused on evidence-based emergency medicine. It is the co-producer of the largest board review course in the field of emergency medicine and also
produces courses in pediatric emergency medicine and the risk management aspects of emergency medicine. Please visit CEME.org for more information.

ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical
Education through the joint sponsorship of the Center for Emergency Medical Education (CEME) and the Center for Medical Education, Inc.

The Center for Emergency Medical Education (CEME) is accredited by the ACCME to provide continuing medical education for physicians.

The Center for Emergency Medical Education (CEME) designates this Live activity for a maximum of 26.5 AMA PRA Category 1 Credits™. Physicians should
claim only the credit commensurate with the extent of their participation in the activity.

Approved by the American College of Emergency Physicians for a maximum of 26.00 hour(s) of ACEP Category I credit.

Approved by the American Osteopathic Association for 26.5 credits of AOA Category 2-A credits.

ACCME-approved credit is classified as preapproved CME Category 1 credit by the National Commission on Certification of Physician Assistants (NCCPA).

The Center for Medical Education, Inc., is an approved provider by the California Board of Registered Nursing, Provider No. CEP 12345.

TARGET AUDIENCE
The Emergency Medicine - An Intensive Boot Camp course is intended for Physician Assistants, Nurse Practitioners and Primary Care Physicians who want an
intensive, evidence-based course focusing on the provision of efficient, safe and medically appropriate care to a wide variety of patients with emergent or urgent
complaints.

I
LEARNING OBJECTIVES
After attending this course, participants should be able to:
 Incorporate strategies into practice to reduce the likelihood of misdiagnosis in common emergencies
 Identify historical, physical and testing strategies to consistently provide evidence-based care to a large variety of ED and urgent care patients
 Enhance clinical skills with regard to the day-to-day care of emergency department and urgent care patients
 Enhance clinical skills for the delivery of care to patients with emergent or urgent complaints in a variety of ambulatory care settings

FACULTY
W. Richard Bukata, MD - Dr. Bukata has been the Medical Director of a community emergency department for 25 years and the Founder and
Medical Director of the Center for Medical Education. Dr. Bukata has personally developed over 35 courses in emergency medicine and primary
care and has served as faculty in over 300 courses. In addition, he is a Clinical Professor of Emergency Medicine at the Keck, University of
Southern California, School of Medicine, and based on his educational achievements, was the 1993 recipient of the Education Award of the
American College of Emergency Physicians.
Disclosure: Dr. Bukata has stated that he is the President of The Center for Medical Education, Inc. The Center publishes a variety of emergency
medicine and primary care-related databases as well as provides CME courses pertinent to these specialties. This relationship will not impact his
ability to provide an unbiased presentation.

Diane Birnbaumer, MD - Dr. Birnbaumer is Senior Faculty in the Department of Emergency Medicine at the Harbor-UCLA Medical Center in
Los Angeles and is nationally and internationally known for her educational endeavors. She was Associate Program Director for the department's
emergency medicine residency from 1991-2011 where she was directly involved in the education of over 300 resident physicians. Doctor
Birnbaumer was the 2003 recipient of the Education Award of the American College of Emergency Physicians and has also received ACEP's
Outstanding Speaker of the Year award.
Disclosure: Dr. Birnbaumer has stated that she has no relevant financial interest or relationships with any commercial interests to disclose.

Michael Gooch, DNP ACNP, FNP - Mr. Gooch is an instructor at the Vanderbilt University School of Nursing in their Acute Care and
Emergency Nurse Practitioner programs. In addition, he practices in the ED of Maury Regional Medical Center in Columbia, TN, where he also
serves as a preceptor for nurse practitioner students. Mr. Gooch is a flight nurse for Vanderbilt University Medical Center's LifeFlight program and
a paramedic. He is the recipient of the Founder's Medal from the Vanderbilt University School of Nursing and has extensive experience in lecturing
on emergency medicine topics throughout North America.
Disclosure: Mr. Gooch has stated that he has no relevant financial interest or relationships with any commercial interests to disclose.

II
Chip Lang, PA – Mr. Lang is an adjunct professor at Missouri State University. He is also the CEO of Practical POCUS, an ultrasound education
company. His academic work includes original research, being published in JAAPA, and speaking across the country in various conferences. Mr.
Lange started his medical career in EMS and continues to actively be involved in prehospital medicine along with his local community emergency
department.
Disclosure: Mr. Lang has stated that he receives a salary as CEO, speaker and presenter for Practical POCUS. This will not impact his ability to
provide an unbiased presentation.

Wm. Kenneth Milne, MD – Dr. Milne is a staff physician at Middlesex Hospital Alliance, Ontario, Canada and associate professor, Division of
EM, Schulich School of Medicine. He is also the creator of The Skeptics Guide to Emergency Medicine Blog.
Disclosure: Dr. Milne has stated that he has a patent pending on a pediatric resuscitation device. This will not impact his ability to provide an
unbiased presentation.

Martha A. Roberts, MSN, ACNP, PNP-AC/PC - Ms. Roberts is an Emergency, Critical Care and Urgent Adult and Pediatric Nurse Practitioner
at Zuckerberg San Francisco General Hospital & Trauma Center. She is an Associate Professor, Samuel Merritt College of Nursing. Ms. Roberts is
also on the Editorial board for Emergency Medicine News and editor for Clinical Procedures in Emergency Medicine for PAs/NPs.
Disclosure: Ms. Roberts has stated that she has no relevant financial interest or relationships with any commercial interests to disclose.

Michael A. Sharma, PA-C – Mr. Sharma is a practicing emergency medicine and urgent care PA at Medical City Lewisville in Lewisville, Texas.
He previously served as a PA with the U.S. Army, during which time he deployed to Afghanistan and led trauma teams providing resuscitative care
at a NATO Role 1 aid station. He is also lead instructor for CME4Life, preparing Pas for their national certification and recertification
(PANCE/PANRE) exams. For the past several years, he has lectured and taught hands-on workshops on emergency medicine subjects throughout
the country to a variety of clinicians.
Disclosure: Mr. Sharma has stated the he has no relevant financial interest or relationships with any commercial interests to disclose.

Jan Shoenberger, MD - Dr. Shoenberger is Vice Chair of Operations and Clinical Education and former Residency Program Director for the
Department of Emergency Medicine at the Los Angeles County / USC Medical Center. She is boarded in hospice and palliative care medicine and
the recipient of the 2018 Cal/ACEP Education Award.
Disclosure: Dr. Shoenberger has stated that she has no relevant financial interest or relationships with any commercial interests to disclose.

III
 Jessie Werner, MD – Dr. Werner is a clinical instructor of Emergency Medicine, University of California San Francisco at Fresno and assistant
medical clerkship director, Community Regional Medical Center, Fresno, California. She is on the Physician Editorial Staff for EM:RAP.
Disclosure: Dr. Werner has stated that she has no relevant financial interest or relationships with any commercial interest to disclose.

FACULTY DISCLOSURE
It is the policy of The Center for Medical Education, Inc., to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational
activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that
the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the
Accreditation Council for Continuing Medical Education (ACCME), The Center for Medical Education require resolution of all faculty conflicts of interest to
ensure CME activities are free of commercial bias. All individuals in a position to control the content of this CME activity have indicated that he/she has no
relevant financial relationships, which, in the context of this CME activity, could be perceived as a potential conflict of interest. Complete disclosure of relevant
(or no) financial relationships will be made to learners prior to the beginning of the CME activity.

CONTACT INFORMATION
The Center for Medical Education, Inc.
P.O. Box 600
Creamery, PA 19430
800-458-4779
support@ccme.org

PRIVACY POLICY
The Center for Medical Education (CME) is committed to protecting your privacy while using the CME website. You can, in general, visit our website without
identifying yourself or disclosing any personal information. Any personal information you choose to provide will not be shared with third parties without
permission. When you submit online registration, the information you provide is confidential. At no point do we now, or will we ever sell, rent or lease
information we collect to any outside individual or organization.

The CME website contains links to other sites. CME is not responsible for the privacy practices or the content of such websites.

IV
COPYRIGHT NOTICE
These materials are protected by copyright laws and may not be reproduced, modified, displayed, transmitted, or otherwise published without the prior written
consent of The Center for Medical Education (CME).

DISCLAIMER
These materials are provided for general medical education purposes only and are not meant to be applied rigidly and followed in all cases. Use of this information
in a particular situation remains the professional responsibility of the practitioner. In no event will CME be liable for any decision made or action taken in reliance
upon the information provided.

Copyright © 2022 The Center for Medical Education, Inc. All Rights Reserved

V

Introduction to the
Emergency Medicine
Boot Camp
The Goals of the Course
• To help optimize the
experience of our patients
from both a clinical and
service perspective
• To increase your confidence
in the quality of care you are
providing
• To stoke your passion for the challenging
specialty of emergency medicine
• To make you feel great about what you do

The Course Manual The Rules of Engagement

• Covers the vast majority of
ED visits
• Contains more material
than we can cover in the
lectures
• To optimize the course’s
outcome, focus on
retaining what you don’t
currently know
• Actively participate – listen,
look, underline, take notes –
the more you engage the
more you will retain
3 4
• All cell phones on vibrate
• Hold all questions or comments
until the Q & A sessions or
ask questions on Slido
• We have physicians, PAs, and
NPs participating – we will try
to be sensitive regarding
terminology
• We may be taking some
photographs during the course
and will appreciate your allowing
use of your images

1
 The Faculty
5 6
Michael Gooch, DNP, ENP
• Faculty, Vanderbilt University
Acute Care and Emergency NP
Programs & Middle Tennessee
School of Anesthesia
• Emergency Flight NP,
Vanderbilt University Medical
Center
• Emergency NP, TeamHealth
• Regional Director, American
Academy of Emergency NPs
7 8
2
Diane Birnbaumer, MD
• Associate Director, EM Boot
Camp Courses
• Senior Faculty, ED, Harbor
UCLA Medical Center
• Emeritus Professor, David Geffen
School of Medicine at UCLA
• Recipient, ACEP Outstanding
Contribution in Education Award
• Recipient, ACEP Outstanding
Speaker of the Year Award
Chip Lange, PA C
• Emergency Department Physician
Assistant, Phelps Health,
Rolla, Missouri
• CEO, Practical POCUS, Ultrasound
Educational Courses
• Host, TOTAL EM, an online blog
and podcast
• Adjunct Professor, Department of
Physician Assistant Studies,
Missouri State University
 Wm. Kenneth Milne, MD
• Associate Professor of
Emergency Medicine, Schulich
School of Medicine and
Dentistry, Western University
• Creator of The Skeptics Guide
to Emergency Medicine Blog
• Recipient, 2013 CAEP Teacher
of the Year Award
• Recipient, 2019 ACEP
Education Award
Michael A. Sharma, PA C
• Emergency Department PA,
Medical City Lewisville,
Lewisville, Texas
• Instructor, Envision Dallas/Fort
Worth EM APP Internship
• Co host of The 2 View: EM PAs
& NPs podcast
• Former U.S. Army Captain with
Service as NATO Role 1 Trauma
Team Leader, Afghanistan
Martha Roberts, RN, ACNP, PNP, MSN
• Adult & Pediatric Emergency
Medicine & Critical Care
Nurse Practitioner
• PA, Zuckerberg San Francisco
General Hospital & Trauma
Center
• Associate Professor, Samuel
Merritt College of Nursing
• Co host of The 2 View: EM
PAs & NPs podcast
9 10
Jan Shoenberger, MD
• Vice Chair of Operations and
Clinical Education and Former
Residency Program Director,
(80 Residents),
Los Angeles County / USC
Medical Center
• Boarded in Hospice and
Palliative Care Medicine, 2010
• Recipient, 2018 Cal/ACEP
@michaelsharma Education Award
11 12
3
 Jessie Werner, MD
• Clinical Instructor of Emergency
Medicine, University of California
San Francisco at Fresno
• Assistant Medical Clerkship
Director, Community Regional
Medical Center, Fresno
• The Dean’s Excellence in Teaching
Award, The Warren Alpert Medical
School of Brown University, Providence, RI
• Medical Education Fellowship, UCSF Fresno
• Physician Editorial Staff, EMRAP
13
Thank You!
4
Richard Bukata, MD
• Director, EM Boot Camp Courses
• Former Medical Director, ED,
San Gabriel Valley Medical Center,
Los Angeles, 25 years
• Adjunct Clinical Professor, EM,
LAC/USC Medical Center
• Recipient, the ACEP Outstanding
Contribution in Education Award
• Medical Director, The Center for Medical Education
14
 No Financial Disclosures
#EMBootcamp
How to Stay Connected
During the Conference

#EMBootcamp
2

Facebook, Twitter, Instagram Growing Group on Facebook

• Top trending social media accounts • The Center for Continuing
• Free, popular, easy to use Medical Education’s new
• Great for personal accounts and FOAM group “CCME Members”
on Facebook.
• Discussion group. Stay
connected with new
friends, course updates,
announcements.

https://www.facebook.com/CenterForMedicalEducation/
https://twitter.com/CCMECOURSES 3 4

5
 5 6

Sli.do Sli.do
• Join our interactive question and answer live • Question and Answer threads
chat on Sli.do • Immediate answers to your questions (faculty)
• Participate in REAL TIME during the conference – The wizards behind the
curtain
• Ask questions and provide feedback
• Direct specific concerns to dedicated faculty • Crowdsource
– Polls
– Topic discussion ideas

7 8

6
 Download the Application Event Code #EMBootcamp

• Go to the App store on your mobile device

• Download Sli.Do application
– Open the application
– Create a profile name or remain anonymous
– Start asking questions, look for announcements,
feedback
• Also available for laptop computer
– https://www.slido.com

9 10

Fact Check Table Expert Faculty Available

11 12

7
Here we go!

13

8
 Follow us! Facebook, Twitter, Instagram

Taking It to the Next Level: • FREE top trending social media accounts
• Great for personal accounts and FOAM
Medical Applications

https://www.facebook.com/CenterForMedicalEducation/
https://twitter.com/CCMECOURSES
https://twitter.com/proceduralistEM
2

The 2 View: Brand New CCME Podcast I’d give my right kidney….
• Monthly podcast featuring Subscribe
Apple Podcasts
Martha Roberts NP and Spotify
Michael Sharma PA. Google Podcasts
Fireside
– Discusses hot topics in EM and
urgent care for advanced practice
providers.
– Literature reviews, procedures,
case studies, controversial topics,
interviews, and innovative
approaches to the emergent and
urgent care patient.
www.TheProceduralist.org
SUBSCRIBE https://2view.fireside.fm/ 3 4

9
 Benefits of Medical Applications Benefits of Medical Applications
• Phone/tablet applications may help you: • Many are free, easy to download
– Assist clinical decision making – Some $$$$  $
– Look up, dose and calculate medications • Easy to use and navigate
– Data Integration • Some require annual fees
– Assist with interpretation of findings – You may have free access if you are already a member
– Carry entire medical textbooks on your phone of a particular organization i.e. Emergency Medical
– Enhance your EBP repertoire Abstracts, EM:Rap, Inkling etc.
– Catch up on latest news or FOAM (Free Open Access • Your hospital may even have free membership
“Meducation”) abilities
– Up to Date, Epocrates etc.
• Evidence based studies:
– Paging apps like Tigertext,
– Improve patient outcomes Nuntio, Spok mobile and Amion
– Improve quality of care
5 6

First, Get Connected Taste the Rainbow

Tip: If you can, use the same username So many to try!

for medical apps / tagging social media
and logins
Examples: @proceduralistEM or #EMBootcamp
7 8

10
 $$$$ or Free
$$$$ or Free
Up to Date Up to Date
• Medical knowledge to answer all clinical questions
evidence based practice citations
• Cost: $559/year individual (group rates vary)
• CME: 0.5 credits for each article read
• Features
– Thousands of disease processes
– Encyclopedia of knowledge
– Case studies
– Highlights HPI and physical exam findings
– Treatment options
– Organized, easy navigable
– Clickable links throughout text
– References all listed
– Charts, graphs, algorithms, photos http://www.uptodate.com
http://www.uptodate.com
– “Basics” for patient discharge 9 10

$$$
PEPID ACEP APPROVED
$$$
PEPID
• Extremely interactive medical app
• Peer reviewed
• Can earn CME while using it
• Cost: ~$20/month (subscription)
• Features
– Diagnosis and treatment options
– Drug interactions
– Dosing suggestions
– Disease information
– Reference videos, procedures
– “Push” notifications
– “Share” notes / Cloud capability
– Drug approvals, black box warnings http://www.pepid.com/
– AAEM/ACEP affiliated http://www.pepid.com/
11 12

11
$$$
Epocrates $$$
Epocrates
• “Gold Standard” of medical apps.
• Cost: $159/year
• Features
– Drugs, interactions, pill look up
– 40+ EBP Guidelines
– Disease information
– Suggested workups /treatments
– Tables and algorithms
– Notifications/text alerts/EBP
– Lab interpretation
– Calculations
– Drug chain pricing Target/Walmart
– Alt Medications
http://www.epocrates.com/
– BJM affiliated http://www.epocrates.com/
13 14

Free$$$$$
Em:Rap Em:Rap Core Pendium
• Emergency Medicine Reviews • The revolutionary online Emergency Medicine
and Perspectives (EM:RAP) textbook by EM:RAP
http://emrap.org/ – Cutting edge literature, world renowned EM authors
• Membership: $195 495/year
• “Netflix” of Emergency Medicine • Searchable, continuously updated daily
• View and listen to podcasts, videos, case • Videos, disease processes, diagnosis, workup
presentations, free live stream events • Critical care, EKGs, X rays, visual media
• Free broadcasts and lectures are available • Available 24/7, in the palm of your hand
– Comes with the EM:RAP subscription
• CME included
• EM:RAP GO – International outreach

15 16

12
$$$ $14.99
Emergency Medicine Abstracts Bedside EM
• EM Abstracts: The first podcaster and pioneer Dr.
Rick Bukata, created an online database of • Top‐ranked EM app contains a wide
variety of content on applicable
evidence based practice
topics ranging from:
• Monthly audio publication providing analysis and – Toxicology to trauma
perspective on the latest EM Literature – Intubation & sedation
– Now merged with EM:RAP – Medications, imaging, procedures and
more.
• Highest quality information
• Many professionals also like the
• Search the database decision‐making rules in the ERres
• Cost: Included with EM:Rap app. (i.e. integrating PERC rules,
http://emrap.org/ Heart Score etc. within the ap itself)
17 18

Bedside EM Bedside EM

19 20

13
 $48.99
Free  $$ / 39.99

Emergency Medicine Flashcards Emergency Medicine Flashcards

• Contains 264 full colored
flashcards of clinical
presentations that occur
commonly in an emergency
medicine setting
• Can help improve your visual
diagnostic skills
• Based on the content in The
Atlas of Emergency Medicine
Flashcards from McGraw Hill 21 22

Free$$$$$
Variable $

HIPPO Education / ERcast Apps Honorable Mentions

• Multiple podcasts and categories
• ERcast (weekly updates)
• Monthly Audio Programs & CME i.e. Peds
Rap, Urgent Care Rap and Primary Care Rap
• “Essentials of EM” conference (EEM)
• PediStat (Pediatric guide)
– Quickly calculate/dose medications
– Broselow tape included
– Resuscitation guidelines ($5.49)
• EMRA PressorDex (Pressor guide)
– Adult and Pediatric
– Vasoactive drugs
– critical care medications ($16.99)

https://www.hippoed.com/ 23 24

14
Variable $

Honorable Mentions MdCalc

• Infectious disease / antibiotic
• Sanford Antibiotic Guide ($29.99)
• EMRA Antibiotic Guide ($9.99)
• CDC STD Tx Guide Mobile (Free)
• Psych
• Diagnostic and Statistical Manual of
Mental Disorders (DSM 5)
Mobile app ($119)
https://www.sanfordguide.com
https://www.emra.org 25 Evidence based decision making tools 26

Medscape Fig. 1
• News, alerts
• Drugs
• Diseases
• Videos
• Editorial pieces
• CME and Education
• Unlimited access, free
but must register

27 28

15
 Free (if purchased text) Free

Inkling Inkling
• Library book on your phone, stores all your
textbooks
• Features: Full version of the text, photos, videos,
supplemental items (other textbooks)
• Top Texts include (not limited to)
– Ferri’s Clinical Advisor, Handbook of fractures,
Harrison’s Internal Medicine, Roberts and Hedges
Clinical Procedures in EM, Rosen’s Emergency
Medicine, Pocket Medicine books…
https://www.inkling.com/store/

https://www.inkling.com/store/ 29 30

Useful ED Reference Texts GoodRx

• 5 Minute Consult Texts (various authors) • Compare prices of prescriptions
– Clinical Consult, Emergency Medicine, Pediatrics
• Roberts and Hedges Clinical Procedures in Emergency • Get coupons
Medicine
• Netter’s Atlas of Human Anatomy
• Ferri’s Clinical Advisor
• Tintinalli's Emergency Medicine
• Trott’s Wound and Lacerations
• Any ultrasound book YOU feel comfortable using
• Handbook of Fractures
• Merck Manual of Patient Symptoms
• Marino’s The ICU Book

These are all available as APP’s on your phone/ipad/laptop 32

16
Free Free

Eye Chart Newspapers

• Portable Snellen eye chart

• Cost: Free
• Features
– Handheld vision screening
– Portable / quick / accurate
– Color blind test
– Multiple styles

www.EM‐NEWS.com www.EPMonthly.com
33 34

Free Free

MediCalc Dermatome Man

35 36

17
 Do you use EPIC? Google Translate
• NOT a medicine specific app, may be invaluable
in the ED for dealing with critically ill or injured
patients and their families who speak a
different language.
• It can translate between English and 100+ other
languages… but…
• By law, your hospital MUST have interpreter
line/phone or person! USE THEM!
• GT is not defendable in a court of law.
38

Free Networking Phone/Tablet Gadgets

• Doximity (jobs) • Butterfly Ultrasound Wand
• Indeed (jobs) • Apple watch
• Ziprecruiter (jobs) • EKG (Kardia)
• Locumtenens (jobs) • Portable handheld otoscopes
• PanOptic Ophthalmoscope (Welch Allyn)
• NAPNAP (American Academy of Pediatrics)
• Breathalyzers (BACtrack)
• ACEP (American Academy of Emergency
• Wireless Blood pressure (QardioArm’s)
Physicians)
• Advanced Stethoscopes (Eko)
• Medspoke Credentialing (Credentialing
organizer) 39 40

18
 $$$

Questions about any gadget? Apple Watch

Features
• Links aps from phone
to your wrist
• Quick glance text
alerts
• Your personal “Vitals”,
steps, calories, HR,
EKG
• Timers, reminders,
other alerts
• Facebook, Twitter and
Email updates
• Hands free talking
• Stop watch
• Weather
Just ask an ICU Nurse how to work it.
Apple Watch Series 3 or 4 Cost: $329 $399 (with GPS)

41 42

$$$$$$$$$$$$$$$$$$$$$$

Apple Watch Butterfly IQ App and US Probe

• The App on your iPad or iPhone is used with the US
probe to obtain immediate real time US imaging of
patients using the attached probe hooked up to your
phone
• 19 presents (abdomen, cardiac,
ocular, soft tissue etc.)
• Stores and saves images
wirelessly
• Multiple features and sharing
abilities with patient, provider
or institution.
43
• HIPPA compliant 44

19
 Podcasts/Blogs
• EMRAP (Herbert, Bukata,
Shoenberger, Swadron, Mattu,
Milne, Mason… MDs)
• The SGEM (Milne, MD)
• FEMinEM (Birnbaumer MD)
• Total EM (Chip Lange, PA)
• ERCast (Orman, MD)
• ALiEM (Lin, MD)
• Bouncebacks (Weinstock MD)
• Annals of Emergency Medicine
60 minute summary (Various
artists)
• Medscape (Various artists)
Thank You!
Keep in Mind
• The 2 View: EM Podcast for
PAs and NPs (Sharma • Peer reviewed information?
PA/Roberts NP)
• Trusted? Reliable? Accurate?
• Risk Management Monthly
(Bukata/Henry MDs) • Up to Date?
• EMCrit (Weingart, MD)
• HIPPO (Weinstock/Spangler • Evidence based?
MDs)
• The Proceduralist Blog • Easy to use, works for YOU?
(Roberts MD, Roberts NP)
• Interactive and easy to use?
• FOAMCast (Faust, Westafer
MDs)
• Doctor Radio ‐ Emergency
(Sirius XM)
45
#EMBootcamp
20
 Two Key Axioms

Approach to the ED Patient You never get a second chance to

make a first impression.
(Head & Shoulders Shampoo)

You’ll never make a diagnosis

you’ve never heard of before.
Know the Medicine –
Unknown
2

Patient Expectations General

• • Most patients don’t take
going to the ED casually
• Fear and anxiety are
routine emotions
experienced by ED
patients
• The department’s goal –
create a positive
experience

3 4

21
 Meeting Patients’ Expectations
• Meeting patients’
expectations requires
two key elements:
• The department must
have processes
focusing on meeting
expectations
• The providers must
individually strive to
meet patient
expectations and
department goals
5 6

Patient Expectations Wait Times Door to Provider Time

• EDs are often perceived as requiring long waits
• Probably the single most
• All kinds of strategies have been important time in the ED
concocted to address the waits:
• Most shoot for 30 minutes
– Billboards or less
– Individual ED website waiting • Some EDs do much better
time updates and some very much worse
– Website listings of regional ED • Now reported to CMS
waiting times (requires hospitals
to pay to subscribe) • Some game the system
– Paying for ED appointments • “Provider” = PA, NP or
physician / not the triage nurse
7 8

22
Minimizing Door to Provider Time Door to Provider Time Pointers
• There are multiple • Providers (clinicians)
strategies to minimize need to develop a sense
the door to provider of urgency in greeting
time new patients in as short
• “Provider in triage” has a time as possible
worked well for some • A simple greeting and
groups the starting of some
• “Fast tracks” are basic processes is all
another way to provide that’s needed
rapid service • Document the time of
initial contact
9 10

Documentation of Key Times ED Patients are Different

• CMS has mandated the • Patients coming to the
collection and reporting of ED are a self selected
selected key times as of 2013 (different from those
– Median time from ED arrival going to a physician’s
to departure for discharged office)
patients (what about admitted pts?) • Always consider possible
– Door to diagnostic evaluation by a life threats but work up
“qualified” provider only those for whom it is
appropriate (easier said
• The importance of consistently documenting than done)
these times and striving for short times is • Pay close attention to the vital signs
clear
• Know high risk complaints and take particular
11 care in evaluating those patients 12

23
 Approach to Patient Satisfaction Patient Satisfaction Surveys
• Patients may not be
good judges of the • Patient satisfaction
quality of medical care surveys are “open
book” tests
• BUT, they are very good
judges of the quality of • You must know the
the “caring” variables on which
you’re being rated
• Showing you care is not
optional; it is an • Get a copy of the
essential part of the job survey and mold
(like it or not) your behavior to it

13 14

Techniques to Meet Expectations, 1 Look the Part

• Look the part appropriate attire
helps generate patient confidence
• Smile, introduce yourself and give
your title (and introduce any who
are with you). Patients need to give permission
for students, etc. to participate in their care
• Encourage questions and offer explanations
• Be aware of your non verbal communication
(facial expression, eye contact, smile, nodding
in affirmation, body posture, tone of voice)
• Take care about offering personal information
– In general, don’t do it – it’s not about you 15 16

24

17
Techniques to Meet Expectations, 3
• Obtain a history and do an exam
that clearly demonstrates you are
being careful and thorough
• Have the nurse offer a chaperone
for more intimate exams (best if
a professional hospital employee
[not a housekeeper])
• Always ask if the patient is in any pain and
rapidly and appropriately address it (despite the
recent villainization of opioids)
• Explain what the plan of care is
19
25
Techniques to Meet Expectations, 2
• Appropriate touching
goes a long way in
establishing empathy
• Use a “qualified”
translator if there is
any doubt about communication – and
document the name (a JC 2012 requirement)
• Apologize for any waits, no matter how short
• Allow the patient to talk and try not to interrupt
• Avoid using computers or references in front of
the patient to look up medical information
18
Techniques to Meet Expectations, 4
• Visit and reassess the patient as indicated
– Depends on acuity – but even minor cases
can be visited ever half hour or less
• Deal tactfully with patient requests regarding
tests and prescriptions
• Studies show you can’t tell which patients
want prescriptions, particularly for antibiotics
• Most patients primarily want an explanation
of what’s wrong
– Some also want an explanation of why, or
why not, certain treatment is appropriate
20
Techniques to Meet Expectations, 5 Shared Decision Making
• Make an active effort to maintain patient • Most patients want a say in their care
privacy and dignity • Share decision making requires:
and be aware of the – Capacity does the patient have the capacity
HIPAA requirements to decide?
regarding confidentiality
– Equipoise are the choices to be
made more or less equal?
• “If you were a member • Requires you know the data
of my family …” works
very well to put your • Requires that you can present it
advice in perspective understandably
• Studies suggest it may decrease patient
21
complaints 22

Signing Out Care / Patient Discharge The HCAHPS Survey Overview

• When passing on a patient to another provider, • The Hospital Consumer Assessment of
do it at the patient’s bedside with the oncoming Healthcare Providers
provider and Systems (HCAHPS)
– Introduce the new provider is a survey mandated
by CMS for hospitalized
– Discuss what is pending patients (about half
(e.g., tests, consultations) come from the ED)
– Discuss the general plan • Results of the survey are publicly available on
for the ongoing care the internet (www.hospitalcompare.hhs.gov)
– Make it clear to the patient that the ongoing • Given that many patients are admitted from
provider will do a good job the ED (about 20%), providers should be
• Consider providing the aftercare instructions to attuned to what is being asked of these
the patient personally 23 patients upon discharge 24

26
 The HCAHPS Survey and the ED, 1 The HCAHPS Survey and the ED, 2
• The four choices for each of the 18 elements
of the survey are – Never, Sometimes, Usually • Additional elements of the survey are
and Always
– Were you given any new medicine you had not
• Elements of the HCAHPS taken before?
survey that are applicable
to ED providers are: – Before getting any new medicine, how often did the
hospital staff tell you what the medicine was for?
– How often (??) did
the doctors treat you – How often did the hospital staff
with respect and courtesy? describe possible side effects
– Did the doctors listen from new medicines?
carefully to you?
– How often (??) did the doctors explain things in a
way you could understand? 25 26

The HCAHPS Survey and the ED, 3

• Additional elements of the survey are:
– Did you need medicine for pain?
– If so, how often was your pain well controlled?
– How often did the hospital staff do everything
they could to help you with your pain?
– Rate the hospital from 0 (worst
possible) to 10 (best possible)
– Would you recommend this
hospital to friends or family?

27

27
28
 Vital Signs are Vital
• Vital signs = “vita” (life) signs
Vital Signs:
• They are extraordinarily important objective
Keys to Risk Avoidance measures of the function of key organ systems
• Consists of temperature, blood pressure, heart
rate, respiratory rate
• Pulse oximetry often referred to as the “fifth
vital sign”

Vital Signs and Risk Management Temperature Measurement

• Fever = Defined as a rectal temperature of 100.4F (38C)
• Failure to note and address abnormal vital signs is or greater (oral, 99.5F [37.5C]) / some use other cutoffs
common in malpractice claims
• Taking the temperature
• Check the nursing notes for any changes in vital signs – Oral method commonly used, but mouth breathing
during patient’s ED visit or consuming cool liquids can falsely lower the
• Be aware of the vital signs at temperature and miss a fever
discharge (do they indicate the – Axillary and tympanic temperatures can easily miss a
need for further assessment?) fever
• Avoid “VS stable” (a dead – Rectal temperatures more accurate
patient has “stable” VS; writing – Most accurate measurements are with
“VS normal” is better) with esophageal and bladder
thermometers; only used in critical patients
3 4

29
 Temperature Interpretation
• Most elevated temperatures are caused by an
infection
– Goal is to find the source
– In children fever is often caused by
viruses, but may need to check the
urine and lungs
• Other causes of elevated temperature (“TIME”)
–T Toxic (e.g., anticholinergics, NMS, etc)
–I Infectious
–M Metabolic (e.g., thyroid storm)
–E Environmental (e.g., heat stroke)
Blood Pressure Overview
• Blood pressure guidelines updated regularly
– See hypertension / syncope lecture for details
• If BP is elevated, repeat after a period of
observation
– “White coat hypertension”
• If a patient is to be discharged with
BP elevated make sure to note
“elevated blood pressure”
(not “hypertension”) on aftercare
and advise prompt recheck by PMD
J Am Coll Cardiol Nov 13, 2017
Fever Treatment
• Acetaminophen
– 15mg/kg orally for children
• Suppositories less effective; slower acting, dosing
often lower than needed to bring down
temperature
– 650 1000mg orally for adults
• Ibuprofen
– 10mg/kg orally for children
– 400mg orally for adults
• Both drugs are equally effective in bringing
down a fever
5 • (Check for latest dosing recommendations) 6
Blood Pressure Sources of Error, 1
• Sources of error in blood
pressure measurement
– Arm should be supported at
the level of the heart (not
held out by the patient
without support = isometric
exercise that may elevate
BP)
– Having the arm hang down
by the side can raise the BP
by about 10 points on
average
7 8
30
 Blood Pressure Sources of Error, 2 Blood Pressure Pitfalls
• Using wrong sized blood pressure cuff is a
frequent source of error • Do not attribute high blood
– Too small can result in a significant pressure measurements to
falsely elevated BP (10 30mm) anxiety, pain or stress
– Too large can result in a falsely • Do not attribute headaches
decreased BP (10 30mm)
or other symptoms to high
– Adult sizing is based on upper arm circumference blood pressure unless
• Adult small arms measuring 22 26cm
• Adult arms measuring 27 34cm markedly elevated
• Adult large arms measuring 35 44cm • Do not treat an elevated blood pressure unless
• Adult thigh arms measuring 45 52cm
there is an urgent medical need to do so
– Be sure right sized cuff is used
9 10

Shock Definition Shock Overview

• An imbalance between oxygen delivery and • BP may remain normal
demand that leads to tissue hypoxia – regardless despite a 30% acute blood loss
of the presence or absence of hypotension • Most patients in shock will have
• Measurement of anaerobic metabolism via a tachycardia (but about one third will not)
blood lactate may detect shock when vital signs
are not diagnostic of shock • Medications may impact ability to general
tachycardic response
• Shock index
– Shock index = heart rate / systolic blood pressure • Paradoxical bradycardia is the failure of a
– Should be less than 0.9 (normal range is 0.5 0.7) patient to become tachycardic in the presence
– May predict uncompensated shock of shock
11 12

31
 Heart Rate
• Take the patient’s pulse yourself… there is a lot
of information there
• Need to note rate (if counting, count for 30
seconds), regularity (feel for it; heart rate
monitor may not be reliable for irregularity) and
strength
• Normal range for adults = 60 to 100 (90?)
• If any irregularities on assessing
pulse are outside the range of
normal, consider putting
the patient on a monitor
13
Orthostatic Vital Signs Overview
• Commonly “used” to:
– Assess for occult hypovolemia
– Detect orthostatic hypotension due to defective
vascular responses to changes of position (often
seen in the elderly with autonomic dysfunction)
• Orthostatic vital signs can be very misleading
– A blood loss of 500ml or less may not result in a
“positive” set of orthostatic vitals, while normal
individuals, particularly adolescents, can have a
false “positive” test
• Bottom line – view the results very cautiously
15
32
Respiratory Assessment
• “Normal” respiratory rate is “20”
– But 12 16 is more “normal” for adults
• Must determine rate accurately
• Must also consider:
– Tidal volume (shallow, deep)
– Respiratory effort (easy breathing vs.
labored breathing [intercostal
retraction, pursed lip breathing,
nasal flaring in children])
• A patient can have a normal respiratory rate
and still be in respiratory distress
14
Orthostatic Vital Signs Technique, 1
• The literature is very inconsistent
– Most agree obtain pulse and
blood pressure in the supine
position after resting three minutes
– Repeat these measurements on standing (some
say to wait one minute)
– Other measurements controversial
• Repeat when sitting and the legs dangling?
– Some advise waiting one minute, some not
– Others specifically say not to measure in the sitting
position
16
 Orthostatic Vital Signs Technique, 2 Pulse Oximetry
• Pulse / blood pressure changes for a “positive” • Often referred to as the “fifth vital sign”
test are not consist in the literature • Normal at sea level is over 98%
• Common definition • Pulse oximetry of 90% highly worrisome
– Pulse increase of 20 beats per minute, and/or (translates to PaO2 of 60 mm Hg)
– Decrease in systolic blood pressure • While patient’s underlying medical condition
of 20 mmHg (e.g., COPD, obesity hypoventilation syndrome)
– Some use a diastolic drop may lead to baseline low
of 10 20 mmHg
pulse oximetry, assume any
• The patient becoming dizzy or low pulse oximetry is real
lightheaded on standing are – Put patient on monitor
also considered as positive
17 18

Pediatric Vitals, Dosing, Equipment Pediatric Norms by Age

• Consider using a Broselow Luten tape (length based) Age Heart Rate * Respiratory
Rate *
Blood
Pressure **
Weight (kg)

to determine weight, drug dosing, equipment sizes 0 1 month 180 60 60/40 34

(on flip side of tape), etc. 2 12 months 160 50 70/45 5 10
12 24 months 140 40 75/50 10 12
2 6 years 120 30 80/55 13 25
6 12 years 110 20 90/60 25 40
> 12 years 100 20 90/50 40 60

• * = Upper limits of normal for an awake, resting child

• ** = Lower limits of normal for an awake, resting child

• Most EDs record pediatric weights in kilograms

• 1 kg = 2.2 lbs
19 20

33
34
 Head Injuries – Be Careful

Head Trauma: Keys to

Judicious Assessment

35
36
3
 Head Trauma Overview The Glasgow Coma Score
• Accounts for half of all trauma deaths
• Males, ages 15 30 most common
• Major head trauma is easy, “minor” head trauma
is where you can get into trouble
• Scalp lacerations may bleed profusely
– May cause shock, especially in children
– Need to work fast / can staple to oppose edges
– Direct pressure (multiple hands may be needed)
– Lidocaine with epi into the bleeding sites Normal = 15
• Closed head trauma & hypotension – look Consider intubation if ≤ 8
elsewhere 4
Dead = 3 5

Skull Fracture Overview Skull Fractures

• Rule out abuse in stellate, complex fractures • Temporal bone
• Linear non depressed fracture does not require fractures (can be
treatment subtle on some CT
views – top right, but is
• Temporal skull fracture (middle meningeal artery obvious on the lower
region) associated with epidural hematoma image)
• Open or depressed skull fracture
(one bone table width = • They are often
antibiotics + neurosurgery) associated with
epidural hematomas
• Occipital skull fracture rule out SAH, contrecoup (in this case, bilateral)
injury, posterior fossa hematoma, cranial nerve
injury 6 7

37
 Basilar Skull Fracture Overview Basilar Skull Fractures, 1
• Clinical diagnosis – can cause CSF otorrhea or
rhinorrhea, bleeding from the ear canal, • Raccoon eyes • Battle’s sign
ecchymosis of the mastoid area or orbital area, (bilateral periorbital (post auricular
cranial nerve deficits (V, VI, VII and VIII [hearing ecchymosis) ecchymosis)
loss, nystagmus, ataxia]) / 20% of skull fractures
• CT findings air fluid level in sphenoid sinus, air
in the posterior fossa / CT is often negative
• Most CSF leaks resolve in a week
• Prophylactic antibiotics don’t
decrease the risk of meningitis
with CSF leaks
• Ring test for CSF halo of clear fluid beyond
blood tinged fluid / CSF fluid is glucose positive
8 9

Basilar Skull Fractures, 2 Major Head Trauma Overview

• Blunt or penetrating head injury with GCS 8
• Hemotympanum • Bloody otorrhea
(blood behind the ear
• Often need airway management to protect airway,
(bloody fluid from control ventilation
drum) ear canal) – Rapid sequence (using induction agent and paralytics)
– Normoventilation for most; only hyperventilate those
actively herniating – should be controlled
– Do not allow hypercarbia (vasodilates) or hypoxia
• Head CT, consult neurosurgery as soon as possible
• Medical management of ICP (hypertonic saline,
mannitol)
• Consider antiseizure meds (first 7 days post trauma)
• Consider reversing anticoagulation
10 11

38
 Epidural Hematoma Overview Subdural Hematoma Overview
• Usually arterial bleed (tear of middle meningeal • Tear of bridging veins between dura and
artery) between skull and dura arachnoid
• Early underlying brain injury may be mild • Elderly and alcoholics at increased risk
• “Classic” presentation • Six times more common than epidural / higher
mortality
– Immediate loss of consciousness, then lucid interval
• Types
• Usual presentation – Acute – rapid accumulation of blood and
– An immediate and sustained LOC neurologic decline (onset < 24 hours / white lesion
• Skull fracture (almost always) on CT)
– Subacute – 24 hrs 2 weeks / isodense on CT (hard
• Dilated ipsilateral (same side) to see)
pupil in 85% (impending herniation) – Chronic > 2 weeks (dark on CT)
• CT biconcave (lens shaped) bleed 12 • CT crescent shaped bleed 13

Subdural Hematoma Subdural Hematoma

Epidural Subdural
Hematoma Hematoma Subdural blood is free to spread over the convexity of the brain
while extension of epidurals is restricted by attachments of the
Lens-shaped Crescent-shaped 14 dura to the skull 15

39
Intracerebral Hematoma Supra and Infratentorial Herniation
Supratentorial herniation
1. Uncal (transtentorial)
2. Central
3. Cingulate
4. Transcalvarial
Infratentorial herniation
5. Upward
6. Tonsillar
Depending on location of
herniation, can cause coma,
hemiplegia, III nerve compress
16 (fixed dilated pupil) 17

Concussion Concussion Overview

• Concussion (mild TBI) = transient alteration in
mental status after head trauma (e.g., LOC,
amnesia) with a lack of focal neurologic findings
– Patients with a concussion (adults or children) with a
normal CT may have subtle abnormalities on MRI
• Post concussive syndrome = long term
neuropsychologic sequelae (insomnia, irritability,
inability to concentrate, headaches, dizziness, etc.)
/ Careful clearance needed for contact sports
• “Second impact syndrome” = irreversible brain
injury triggered by a fairly routine second head
18
impact after a prior concussion 19

40
 Canadian CT Head Rule Exclusions
• Exclusion criteria (patients not studied)
– Less than 16 years old
– Minimal injury (no LOC, amnesia,
disorientation)
– Penetrating skull injury /
depressed skull fracture
– Focal neurologic deficits; GCS < 13
– Unstable vital signs associated with trauma
– Seizure
– Bleeding disorder / anticoagulant therapy
– Pregnancy
– Return for reassessment of the same head injury
Canadian CT High Risk Criteria
• High risk criteria for brain injury with need for
neurologic intervention
– Glasgow coma score less than 15 at 2 hours after
injury (15 = spontaneous eye opening, oriented,
obeys commands)
– Suspected open or depressed skull fracture
– Any sign of basilar skull fracture (hemotympanum,
“raccoon” eyes, CSF oto/rhinorrhea, Battle’s sign)
– Vomiting two or more times
– Age 65 or over
• 100% sensitive for patients needing brain
surgery
20 21

Canadian CT Medium Risk Criteria

• Medium risk criteria for brain injury on CT
– Amnesia (over 30 minutes before impact)
– Dangerous mechanism
• Pedestrian struck by motor vehicle
• Occupant ejected from motor vehicle
• Fall from a height greater than three feet
• Fall from five or more stairs
• Combining the high and medium risk factors
picked up 98.4% of clinically important brain
injuries
• The criteria do not exclude brain injuries
considered to be nonimportant – so CT can
still be positive
22 www.mdcalc.com/canadian-ct-head-injury-trauma-rule 23

41
 New Orleans Criteria Anticoagulants in Head Trauma
• Inclusion
– Age > 18, GCS 15, blunt head trauma (BHT) in
previous 24 hours with LOC, amnesia or
disorientation
• End point: abnormal CT
• Factors
– NO head CT if NONE of…
• Headache, vomiting,
age > 60 years, seizure,
drug or alcohol intoxication,
persistent retrograde amnesia,
visible trauma above the clavicles, seizure
• Results
– Sensitivity 99%, specificity 33% 24 25

Head Injuries and Anticoagulants Head Injuries and Anticoagulants

• Warfarin – inhibits II, VII,
IX and X (reversed with
Vitamin K, FFP or
prothrombin complex
concentrates [PCC]) / affects extrinsic
pathway, elevates prothrombin time (PT) & INR
• New Xa inhibitors and thrombin inhibitors inhibit
the final common pathway of the intrinsic and
extrinsic limbs – may affect PT and PTT / reversal
agents available for all but edoxaban
26
• Patients on anticoagulants and platelet inhibitors
(e.g., clopidogrel [Plavix]) are considered at
increased risk for brain bleeds with trauma
• Concerns are for both immediate and delayed
bleeding
• Recommendations vary regarding initial CTs,
observation, clinical follow up, repeat CTs
• Ordering a PT for patients on warfarin and a PT
and PTT are reasonable for patients on Xa or
thrombin inhibitors (but hard to interpret)
27

42
 Baugh, C. et al.

doi: 10.1016/j.annemergmed.2019.09.001
43
28
 Head Injuries In Children Overview Brain CTs in Children Overview
• Can be a difficult challenge • Multiple prediction guidelines have been
when “minor” injury present developed
• Children have more • Not as good as adult
nonsurgical brain lesions guidelines
than adults (more cerebral • Because faster scanners
edema, contusions, axonal shear) obviate the need for sedation,
• Skull is thinner and more easily fractured children are the fastest growing
• Scalp hematomas (particularly nonfrontal) are segment of the population getting CTs
variably viewed as risks for fracture (especially – It is estimated – 1 in 1,000 to 1 in 5,000 children will
in those under 2) develop a fatal cancer from brain CTs
– The younger the child, the greater the risk
29 30

PECARN Brain CT Guidelines, 1 PECARN Brain CT Guidelines, 2

• Pediatric Emergency Care Applied Research • Children less than 2 years old – CT indicated if
Network (25 North American EDs)
– Altered mental status (GCS < 15, agitation,
• Goal – to find children with clinically important somnolence, repetitive questions, slow verbal
traumatic brain injury communication)
• Exclusion criteria (those not included by criteria) – Palpable skull fracture
– Over 18 years of age – Loss of consciousness for
5 or more seconds
– Trivial mechanism (ground level falls, walking or – Acting abnormally per parents
running into stationary objects with no signs of head
trauma other than scalp abrasions or lacerations) – Nonfrontal scalp hematoma
– Known brain tumor or preexisting – Severe injury mechanism
neurologic disorder • MVA crash with patient ejection, death of passenger,
– Penetrating trauma rollover, pedestrian or bicyclist without a helmet struck
by a motor vehicle, falls from more than 3 feet, struck by
– Prior head CT 31 a high impact object 32

44
 PECARN Brain CT Guidelines, 3 PECARN Brain CT Guidelines, 4
• Guidelines for those under age two
• Children aged 2 years or older – CT indicated if
– 100% negative predictive value for “clinically important
– Altered mental status (GCS < 15, agitation, slow verbal traumatic brain injury” (CITBI) (if all findings negative,
communication, somnolence, repetitive questions) none had a CITBI)
– Clinical signs of basilar skull fracture – Sensitivity, 100% (picked up all children with a CITBI)
• Same as Canadian CT guidelines • Guidelines for those two and older
– Any loss of consciousness – Negative predictive value of 99.5% (if all findings
negative, 1 in 200 had a CITBI)
– A history of vomiting
– Sensitivity of 96.8% (picked up this percentage of
– Severe headache children with a CITBI / missed 3.2%)
– Severe injury mechanism • If only one predictor is present the
• MVA crash with patient ejection, death of passenger, risk of a CITBI is 1%
rollover, pedestrian or bicyclist without a helmet struck by a
motor vehicle, falls from more than 5 feet, struck by a high
• Clinician judgment is still paramount
impact object
33 • In minor cases, consider observation 34

www.mdcalc.com/pecarn‐pediatric‐head‐injury‐trauma‐algorithm
35

45
46
 Charting is a Pain in the Butt
• Charting is extraordinarily costly when cast in the
light of provider compensation, but much more
Essential Charting importantly, lost opportunities to see more
patients (or spend more time with the ones you
Concepts have)
• It has been extraordinarily
difficult to demonstrate that
EMRs result in better patient
care or faster patient care
• One study (Am J EM, 11/13)
– 44% of clinician time was
charting
– Approximated 4,000 clicks per 10 hr shift 2

The Three Reasons to Chart Do’s of Charting

• Acknowledge that you are aware of the vital signs
• We chart to:
1. Tell others about the • Acknowledge that you have reviewed the nurses
care we provided notes
2. To get paid • Professionally counter any nursing observations
3. Quality assurance with which you do not concur
• The core charting elements are: • Do dictate the essential parts of the chart
– history
– physical • Do push to have scribes assist you (still true?)
– interval progress reports • Do finish the chart before you leave your shift,
– Interpretation of tests (by CPT codes) and preferably, as you go through your shift
– communications with other providers and relatives
– medical decision making • Do enter times when events occur – not just
– diagnosis when they were documented
– aftercare instructions 3 4

47
 Don’t’s of Charting CMS Key Measures, 1
• Don’t do data entry with your back to the patient • CMS mandates the
• Don’t look up information collection and reporting
in front of the patient of key times
• Don’t cut and paste from – Median time from ED
other charts and have it arrival to departure for:
appear as your own work
• Discharged and admitted patients
• Don’t use macros that
exaggerate the extent – Door to evaluation by a “qualified” provider
of the history or physical obtained • Physician, NP or PA (not triage nurse)
• Don’t allow surrogates for your door to provider – The importance of consistently documenting
times these times and striving for short times is clear
5 6

HCAHPS Admitted Patient Survey
• Hospital Consumer Assessment of Healthcare
Providers and Systems Survey
– 1. Communication with nurses
– 2. Communication with doctors
– 3. Responsiveness of hospital staff
– 4. Communication about medicines
– 5. Discharge information
– 6. Care transition
– 7. Willingness to recommend hospital
– 8. Cleanliness of hospital environment
– 9. Quietness of hospital environment
7 8
Hospital Care Compare Survey (1) (7/22)
• Timely and Effective Care
– 1. Percent of healthcare workers vaccinated
against Influenza
– 2. Percentage of patients who left the
emergency department before being seen
– 3. Percentage of patients who came to the
emergency department with stroke symptoms
who received brain scan results within 45
minutes of arrival
– 4. Percentage of patients who received
appropriate care for severe sepsis and septic
shock

48
Hospital Care Compare Survey (2) (7/22)
• Timely and Effective Care
– 8. Average number of minutes before
outpatients with chest pain or possible heart
attack who needed specialized care were
transferred to another hospital
– 9. Average time patients spent in the
emergency department before being sent
home
– 10. Outpatients with low back pain who had
an MRI without trying recommended
treatments first, such as physical therapy
– 11. Outpatient CT scans of the abdomen that
were “combination” (double) scans
2023 CMS Charting Guidelines, 2
• Levels of Service will be determined by the
Medical Decision Making (MDM) components
– Key factors in MDM:
• Problem(s): the number and complexity of
presenting problems
• Data: the amount and/or complexity of data
to be reviewed and analyzed
• Risk: the risk of complications and/or
morbidity or mortality of patient
management
11
2023 AMA/CMS Charting Guidelines, 1
• A DRASTIC CHANGE compared to 1995 guidelines
• History / Physical
– All levels of ED service will include a medically
appropriate history and examination as
determined by the treating physician/QHP
• Medical Necessity
– As medical necessity will be an overarching
criterion for selecting the level of ED E/M
service,
– The physician/QHP will have to consider whether
the nature of the presenting problem supports
the medical necessity of services rendered.
9 10
21st Century Cures Act, 1
• One provision allows patients access to their EHR
• They can read and potentially challenge what’s
written (incorrect? / disparaging? / test necessity?
• Physicians can block access to the chart, but only
for a very defensible reason (e.g., spousal abuse)
• Big fines are allowed (up to $1m per chart!!!)
12
49
 21st Century Cures Act, 2
• Additional elements that should be charted to
• When it comes to charting be very factual and
professional / it’s OK to use quotation marks
• Make sure your macros closely reflect what you
actual do
• Back up negative information with facts (drug
seeking, suspected malingerer)
• Charting examples
– Patient complains of = Patient presents with
– 24 Y/O sickler = 24 Y/O with sickle cell disease
– 35 Y/O morbidly obese = 35 Y/O with estimated BMI of
– 45 Y/O drug abuser = 45 Y/O with substance use
disorder / alcohol use disorder
13
15
50
Additional Importing Charting Elements
support the level of MDM should include:
– Prescriptions given
– Imaging studies reviewed with the radiologist
– Imaging studies reviewed by the treating provider
– Physician consultations (including the content)
– Review of old records (noting pertinent
findings)(not old ED records), EMS notes, nursing
home notes
– Family conferences (with specifics noted)
– Supplemental historian (parent, partner)
– Social determinants of health (poverty, homeless,
education, no family, etc)
14
Section I – Overview of 2023
Changes
16
 A Brief History of CPT Codes The Big Change
• 1992: CPT created the current E/M codes. • 2021: New E/M guidelines enacted by CMS and
• 1995: Documentation Guidelines (DG) created the AMA for Office/Other Outpatient E/M
by the American Medical Association (AMA) codes.
and the Health Care Financing Administration • 2023: New E/M guidelines analogous to
(HCFA) which is now called the Centers for Office/Other Outpatient 2021 E/M code
Medicare and Medicaid Services (CMS). changes will become effective for all other E/M
• 1997: Revised DG released by the AMA and codes.
HCFA. • Most consequential
• 1998: Providers are instructed to use either the change in the AMA
1995 or the 1997 DGs. CPT codes in 30 years.
• 1999 2015: Multiple failed attempts to revise
DGs were never approved.
17 18

2022 – History and Exam 2023 Change – History and Exam

• 2022, History and Physical Exam are key • 2023, elimination of History and Physical Exam
components in choosing the E/M code for as key component or elements in determining
emergency and hospital services based on the E/M code.
1995/1997 DG. • Elimination of individual History area
• Each individual requirements for E/M code selection.
area of the History • A medically appropriate History and/or Physical
(History of Present Exam is still required.
Illness, Review of
Systems, and Past • The nature and extent of the medically
Medical/Family/ appropriate History and/or Physical Exam is
Social Histories) determined by the treating provider.
have defined
element requirements for each E/M code.
19 20

51
 2022 – MDM 2023 Change – MDM
• 2022, MDM is another key component in • 2023, MDM alone is now the key component in
selecting the E/M code for emergency, and selecting the E/M code.
hospital services.
• The Marshfield Clinic scoring tool and DG will
• The Marshfield Clinic scoring tool is most often no longer be utilized to determine MDM
utilized in conjunction with DG to determine complexity.
MDM complexity.
• There is variability • New MDM grid created by the AMA will
across organizations’ determine MDM complexity and reduces vague
descriptions and eliminates contradictions.
methods of MDM
scoring due to vague • Three areas of scoring of the MDM: problem,
descriptions and contradictions in guidelines. data, risk remain in some form, but are
• There are three areas of scoring of the MDM: populated with new and/or revised
problem, data, risk. requirements.
21 22

52
 2023 – MDM Grid
Code Level of MDM Number and Complexity of Amount and/or Complexity of Data to be Reviewed and Risk of Complications and/or Morbidity OR
(2 of 3 Elements Problems Addressed Analyzed Mortality of Patient Management
of MDM)
H&P: 99221 Straightforward Minimal Minimal or none Minimal risk
Subsq: 99231 • 1 self‐limited or minor
H&P + DC: 99234 problem
ED: 99282
Low Low Limited (Must meet the requirements of at least 1 out of the 2 Low risk
• 2 or more self‐limited or categories)
minor problems; Category 1: Test and documents
• 1 stable, chronic illness; •Any combination of 2 from the following:
ED: 99283 • 1 acute, uncomplicated oReview of prior external note(s) from unique
illness or injury; source*;
• 1 stable, acute illness; oReview of the result(s) of each unique test*;
• 1 acute, uncomplicated oOrdering of each unique test*
illness or injury requiring Category 2: Assessment requiring an independent historian(s)
hospital inpatient or
observation level of care
Moderate Moderate Moderate (Must meet the requirements of at least 1 out of the 3 Moderate risk
• 1 or more chronic illnesses categories) •Prescription drug management
with exacerbation, Category 1: Test, documents, or independent historian(s) •Decision regarding minor surgery with
progression, or side effects of •Any combination of 3 from the following: identified patient or procedure risk factors
H&P: 99222
treatment; oReview of prior external note(s) from unique •Decision regarding elective major surgery
Subsq: 99232
• 2 or more stable, chronic source*; without identified patient or procedure
H&P + DC: 99235
illnesses; oReview of the result(s) of each unique test*; risk factors
ED: 99284
• 1 undiagnosed new oOrdering of each unique test* •Diagnosis or treatment significantly
problem with uncertain oAssessment requiring an independent limited by social determinants of health
prognosis; historian(s)
• 1 acute illness with systemic Category 2: Independent interpretation of tests
symptoms Category 3: Discussion of management or test interpretation
• 1 acute, complicated injury
High High Extensive (Must meet the requirements of at least 2 out of the 3 High risk
• 1 or more chronic illnesses categories) •Drug therapy requiring intensive
with severe exacerbation, Category 1: Test, documents or independent historian(s) monitoring for toxicity
progression, or side effects of •Any combination of 3 from the following: •Decision regarding elective major surgery
H&P: 99223
treatment; oReview of prior external note(s) from unique with identified patient or procedure risk
Subsq: 99233
• 1 acute or chronic illness or source*; factors
H&P + DC: 99236
injury that poses a threat to oReview of the result(s) of each unique test*; •Decision regarding emergency major
ED: 99285
life or bodily function oOrdering of each unique test* surgery
oAssessment requiring an independent •Decision regarding hospitalization or
historian(s) escalation of hospital level care
Category 2: Independent interpretation of tests
Category 3: Discussion of management or test interpretation
53
•Decision not to resuscitate or to
23
deescalate care because of poor prognosis
•Parenteral controlled substances
 2022 – E/M Descriptions 2023 Change – E/M Descriptions
• 2022, defined the Nature of the Problem or the • 2023, eliminates notation on the Nature of the
Presenting Problem (NOPP) for each E/M code Problem or the Presenting Problem as an
as an additional component for selecting the additional requirement for E/M code.
E/M code. • Removes discussion of counseling and/or
• Example: “Usually, the presenting problem(s) coordination of care as part of the E/M
are of high severity…” code.
• Defined counseling • E/M code descriptors are now brief and
and/or coordination concise.
of care as part of
the E/M code.

24 25

2022 vs 2023 E/M Descriptions 2022 vs 2023 E/M Descriptions

99285 (2022 E/M Description): “Emergency
department visit for the evaluation and management of
a patient, which requires these 3 key components within
the constraints imposed by the urgency of the patient’s 99285 (2023 E/M Description): “Emergency
clinical condition and/or mental status: A department visit for the evaluation and management of
comprehensive history; A comprehensive examination; a patient, which requires a medically appropriate history
and Medical decision making of high complexity. and/or examination and a high level of medical decision
Counseling and/or coordination of care with other making.”
physicians, other qualified healthcare professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of high severity
and pose an immediate significant threat to life or
physiologic function.”
26 27

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 2022 – Emergency E/M Codes 2023 Change – Emergency E/M Codes
• 2022, 5 codes of Emergency Medicine E/M • 2023, 5 codes of Emergency Medicine E/M
codes: codes remain.
– 99281 = MDM of straightforward complexity – 99281 significantly changed and may not
– 99282 = low complexity require the presence of a provider or MDM.
Questionable utilization, and an unlikely
– 99283 and 99284 = moderate complexity circumstance.
differentiated by the Nature of the
Presenting Problem. – 99282 = MDM of straightforward complexity
– 99285 = high complexity – 99283 = low complexity
– 99284 = moderate complexity
– 99285 = high complexity

28 29

2023 Change – Summary CMS Charting Rules, 13

1. Specific History and Exam requirements • Critical care (CC) services involve:
eliminated. – Decision making of high complexity to assess,
manipulate and support vital organ system failure
2. The new MDM Grid for determining and/or prevent further life threatening
complexity. deterioration of the patient’s condition
3. Concise E/M code descriptors without NOPP. • The time taken to perform any of these
functions is included in CC time:
4. 99281 now without provider presence. – Pulse oximetry Transcutaneous pacing
– Chest x ray interpret. Ventilator management
5. Observation E/M codes deleted and combined – Blood gas interpret. Vascular access
with Inpatient E/M codes. – Gastric intubation
6. Observation Discharge E/M is now time based. • The first 30 minutes of critical care time is not
counted
30 31

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 Aftercare (Follow up) Instructions, 1
• CMS has no rules relating to aftercare
instructions
• They are extraordinarily important in limiting
risk management issues
• Aftercare instructions are for the benefit of
the patient and follow up physician
• Ideally give patients:
– Copies of everything their lab tests, EKGs and a
listing of what imaging studies were done and
whether interpretations are preliminary or final
– Stamp or write “patient copy” (if lost, no HIPAA
violation risk)
32
Aftercare (Follow up) Instructions, 2
• Include the diagnosis on the aftercare
instruction in plain English (middle ear
infection vs. otitis media) and any incidental
findings (elevated blood pressure)
• Consider advising the patient to return to the
ED immediately if there are ANY new or
worsening symptoms or if the symptoms are
lasting longer than expected (provide a
reasonable estimation)
• Are there test results pending? Advise the
patient.
• Who will see the patient in follow up? Are
you sure? 33

Aftercare (Follow up) Instructions, 3

• Make sure patients / parents have the money
to pay for any prescriptions.
• Is there a pharmacy that is open?
• Learn the cost of commonly prescribed
medications for those without prescription
benefits (costs from Goodrx.com):
– Vicodin, 60 tablets, generic, $15 $48
– Bactrim DS, 20 tablets, generic, $8 $16
– Keflex 500mg, 40 capsules, generic, $10 $26
– Augmentin 875 125, 20 tablets, generic, $13 $60
34

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 Diaper Dermatitis
• Initially a chemical dermatitis
from urine, dampness, feces
Pediatric Rashes • Oral antibiotics may predispose
• Can become secondarily infected, most
commonly by candida; MRSA now also a cause
• Candida infections often have papules separate
from the main rash, called satellite lesions
• First treatment: DRY, CLEAN & BREEZE!
• Topical miconazole or clotrimazole is effective
• Sometimes mild topical steroids (OTC) are
helpful 2

Diaper Dermatitis Scabies Overview

• Severe pruritus (due to hypersensitivity reaction
to scabies mite burrowing into skin, excreta)
• Web spaces, elbow, axilla, groin, anterior wrist
(favors thin skin)
• Red papules, vesicles, crusts, linear burrows
• Crusted scabies (Norwegian scabies)
– (severe disease) seen in
immunocompromised, nursing homes, homeless
• Treatment permethrin cream, oral ivermectin
(an antihelminthic) (Mectizan, Stromectol) for
more severe cases
• Itching can last two weeks after treatment
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 Scabies Mitete Scabies Skin Lesions

5 6
Logical Images Inc. Logical Images Inc.

Pediculosis (Lice) Head Pediculosis (Lice) / Nits

• Head lice
– Scalp and neck (erythema, scaling)
– Nits (eggs) attached to the hair shaft
• Body lice
– Linear excoriations, nits in seams of clothing
• Pubic lice (crabs)
– Sexually transmitted
– Intense pruritus, papular urticaria on thighs/abdomen
• Treatment –
– Extensive cleaning of clothing and bedding (put in dryer),
– Pediculicide creams and shampoos
• Pyrethrin [RID], Permethrin [NIX]

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 Classic Childhood Exanthems Rubeola (Measles)
• Fever, cough, conjunctivitis, coryza (3 “C”s)
Number Common Name Other Name Etiology
First disease Measles Rubeola Measles virus • Koplik spots (appear ~48 hours before rash)
Second disease Scarlet fever Scarlitina Strep pyogenes – buccal mucosa, non tender, tiny white/gray
Third disease Rubella German measles Rubella virus spots on erythematous base near molars
Fourth disease Dukes’ disease N/A N/A – (“grains of salt or red background”)
Fifth disease Erythema infectiousum Slapped cheek Parvovirus B19
• Maculopapular, erythematous, rash
Sixth disease Roseola infantum Exanthem subitum HHV-6, HHV-7
– Starts at head and spreads caudally
– Initially blanching, but later not
• Symptomatic treatment
• Complications encephalitis, pneumonia,
otitis media, conjunctivitis
– <5 yrs > 20 yrs
9 10

Rubeola (Measles) Rubeola (Measles)

11 12
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 Rubeola (Measles), Koplik Spots Rubeola (Measles) Outbreaks in U.S.
• Prevent measles with MMR vaccine
– In 2000, measles declared “eliminated” from the U.S.
• Remains a common illness in other countries
• Measles cases/outbreaks related to unvaccinated
international travelers are ongoing in several
jurisdictions in the U.S. in 2019
– Even in healthy children, measles can cause serious
illness requiring hospitalization
– 1/1000 cases develop encephalitis = brain damage
– 2/1000 children will die from resp/neuro complications
– Subacute sclerosing panencephalitis (SSPE) is rare, but
can develop 7 10 years after the infection
13 14
Med-Challenger • EM

From January 1 to October 3, 2019, 1,250 individual Rubeola (Measles) Outbreaks in U.S.
cases of measles have been confirmed in 31 states.
• Review the CDC guidelines online.
This is the greatest number of cases reported in the
– “Healthcare providers should consider measles in
U.S. since 1992 and since measles was declared
patients presenting with febrile rash illness and
eliminated in 2000. clinically compatible measles symptoms, especially if
the person recently traveled internationally or was
New York has highest
exposed to a person with febrile rash illness.
# of outbreaks – Healthcare providers should report suspected
Rockland County measles cases to their local health department
Outbreaks
within 24 hours.” – CDC
• Lab testing = measles specific IGM antibody
(blood specimen) and measles RT PCR
(respiratory specimen). Urine also used to test.
15 16

60
 Rubeola (Measles) Exposures
• Exposed parent/family member or healthcare
worker who cannot prove or show immunity
offer post exposure prophylaxis (PEP)
– MMR vaccine <72 hours post exposure
or (DO NOT GIVE BOTH!)
– IG within 6 days
• Infants <12 months of age, measles vaccination
of infants as young as 6 months may be used as
an outbreak control measure.
• No specific antiviral therapy for measles. Care is
supportive, address complications. Quarantine
21 days. 17
Rubella (German Measles)
• Acute viral illness (fever, sore throat, headache)
– Different virus than Rubeola measles.
– MMR does vaccinate against Rubella.
• Rash starts on face then spreads caudally
– Pink, pinpoint maculopapular, “3 day measles”
• Low grade fever and Lymphadenopathy
– posterior cervical, auricular, and suboccipital
• Complications
– Arthritis (immune complex)
– Encephalitis
– 1st trimester pregnancy (congenital defects)
• Treatment symptomatic 18

Rubella (German Measles) Rubella (German Measles)

19 20
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 Scarlet Fever Overview Scarlet Fever, Strawberry Tongue / Sandpaper Rash
• A specific, toxin producing group A beta‐
hemolytic strep
• Sore throat, fever, headache, vomiting
• Sandpaper rash starts 12‐72 hours after fever
• Flexor creases (Pastia’s lines) then moves to
trunk and extremities
• “Strawberry” tongue (fine papules on tongue)
• Skin peeling (palms and soles)
• Diagnosis throat swab, increasing ASO titer
• Treatment – oral penicillin – 10 days
21 22
Med-Challenger • EM

Scarlet Fever / Pastia’s Lines Scarlet Fever / Desquamation, 1

23 24

62
 Scarlet Fever / Desquamation, 2 Erythema Infectiosum (Fifth Disease)
• Human Parvovirus B19 / Spring
• Fever (not always), myalgias, diarrhea, URI
symptoms / preschool age
• Rash abrupt onset, bright red cheeks (“slapped
cheeks”) then spreads to arms/legs second day
• Rash is “lace‐like” on limbs, trunk / may come and
go 1 2 weeks
• Usually a self limiting disease / symptomatic
treatment
• Pregnant women are at risk for fetal infection
25 26
Logical Images Inc.

Erythema Infectiosum (Fifth Disease) Roseola Infantum Overview

• Also called exanthem subitum
• Human herpes viruses (HHV) 6 and 7
• Most occur sporadically without known exposure
although horizontal transmission reported
• Common at ages 6 18 months
• High fever (3 5 days), then rash with
defervescence
• Febrile seizures (4%)
• Pink macules and papules on trunk
• May spread to neck, face, extremities
• Treatment symptomatic
27 28

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 Roseola Infantum Image Roseola Infantum Image

29 30
Med-Challenger • EM Med-Challenger • EM

Hand Foot Mouth Disease Hand Foot Mouth Disease

• Coxsackie virus (enterovirus)
• Occurs in outbreak / usually children under 7
• Fecal oral transmission
• Fever, sore throat, malaise, URI
• Oral lesions painful vesicles on buccal
mucosa, tongue, soft palate, gingiva
• Skin lesions red papules (change to gray
vesicles) on palms, soles, buttocks
• Symptomatic treatment
• Avoid viscous lidocaine in young children
because of risk of seizures
31 32

64
 Hand Foot Mouth Disease Hand Foot Mouth Disease

33 34
Logical Images Inc.

Herpangina Herpangina
• Painful ulcers on reddened base involving the
posterior soft palate, uvula, tonsillar areas
• Does not involve tongue, buccal mucosa or lips
• Cause – coxsackievirus / Summer
• Sudden onset fever (usually high temps), sore
throat, headache, loss of appetite (pain on
eating), maybe neck pain
• Supportive treatment / disease runs its course in
about a week

35 36

65
 Varicella (Chicken Pox) Varicella (Chicken Pox)
• Varicella zoster virus
– Highly contagious, >90% in susceptible individuals
• Fever, malaise, URI
– Increased severity: age >12, immunocompromised, pregnant
• Macules, papules, vesicles, crusts
– Lesions of various ages, dewdrops on a rose petal
• Complications (mostly adults)
– pneumonia, encephalitis, otitis media
• Treatment – acyclovir/valacyclovir
– Avoid salicylates (Reye’s syndrome)
• Prevention immune globulin if pregnant or
immunocompromised, vaccine in kids and non immune adults
37 38

Kawasaki's Disease Overview Kawasaki's Disease Diagnosis

• Previously mucocutaneous lymph node syndrome • Major criteria fever >5 days PLUS 4 of the following:
• About 20 cases/100,000 children/yr in the U.S. – Conjunctival injection
• B/L, nonexudative, >90%, limbus sparing
• 80 90% occur in children <5 yo – Oral mucous membrane changes
• Incidence highest in males, East Asian populations • Strawberry tongue, Injected pharynx, fissured/cracked lips
– Peripheral extremity changes
• Acute, febrile, exanthematous disease of children • Palm/sole erythema, hand/foot swelling (acute), desquamation
• Self limited vasculitis with predilection for – Polymorphous rash
coronary arteries • Erythematous rash (may start in perineal with desquamation)
– Cervical lymphadenopathy
• Cause unknown possibly an immunologic • Typically 15mm or greater
response to variety of triggers • WBC, ESR, platelets
• Important to make this diagnosis • Coronary artery aneurysms
• Treatment aspirin, IV immunoglobulin
39 40

66
 Kawasaki's Disease Monkeypox
• Characteristic rash
• Fever, swollen lymph
nodes before rash
• Unlike chickenpox, all
lesions with be at same
stage of development

• Flat macules papules

 vesicles  pustules
– Lesions carry most of
the virus
– Direct contact with
lesion = infection
41 Follow CDC and AAP 42
Med-Challenger • EM

Pediatric Infectious Rashes

• Measles (rubeola)
– Rash begins at the head and goes down
– Cough, coryza, conjunctivitis (three “Cs”)
• Rubella (German measles)
– Rash begins at the head and goes down
– Prominent lymphadenopathy
• Scarlet fever
– Strep throat with sandpaper rash
• Erythema infectiosum (fifth disease)
– Slapped cheeks
• Roseola infantum (sixth disease)
– Fever then truncal rash when fever is gone
• Chicken pox (varicella)
– Macules to papules to vesicles to crusted lesions of
various ages
43

67
Pediatric Infectious Rashes

68
44
 • Note:
– This is a huge topic
– This lecture focuses on information necessary
TIAs and Strokes: to diagnose and treat stroke and TIA, including
the stroke syndromes
State of the Art
– The Advanced Bootcamp Course includes a
lecture on stroke and TIA updates, focusing on
changes in this dynamic area of medicine

TIAs and Strokes Overview

• Two major causes

– Ischemia – most common
• Thrombotic or embolic
– Hemorrhage – less common
– Vessel dissection (carotid or vertebral – rare)
• Ischemic events usually present with a
constellation of symptoms based on the
vascular distribution of the event
– Anterior circulation more common
– Posterior circulation less common
3

69
Vascular Anatomy of the Brain

Middle cerebral artery

and anterior cerebral
arteries come off the
carotid artery (anterior
circulation)

Vertebral arteries join

to become the basilar
artery which splits into
the posterior cerebral
arteries (posterior
circulation)

70
4
 Middle Cerebral Artery TIAs and Strokes
TIAs and Strokes Vascular Distribution
• Middle cerebral artery (MCA) most common
• Symptoms occur based on area of vascular – Contralateral (= side opposite the involved vessel)
distribution hemiparesis (motor weakness), arms/face > legs
• Middle cerebral artery • Facial droop SPARING the forehead (facial nerve
palsy [Bell’s palsy] does NOT spare the forehead)
• Anterior cerebral artery
– Contralateral hemianesthesia (decreased sensation)
• Posterior cerebral artery
– Contralateral hemianopsia
• Vertebrobasilar arteries
• Eyes look TOWARD the side of the blocked artery
• Lenticulostriate arteries
– Aphasia (when dominant hemisphere affected)
– Unawareness of symptoms (when nondominant
hemisphere affected)
5 6

71
Middle Cerebral Stroke Contralateral Findings

Middle
Cerebral
Stroke

72
7
CT of Large Area of Infarction

73
8
 Anterior Cerebral Artery (ACA)
TIAs and Strokes
• Anterior cerebral artery (3%)
– Contralateral weakness, legs >> arms and face
– Sensory deficit
in same
distribution
as motor
findings
(contralateral)

74
9
Anterior Cerebral Stroke Contralateral Findings

Anterior
Cerebral
Stroke

75
10
 Posterior Cerebral Artery TIAs and Strokes
• Posterior cerebral artery (visual cortex)
– Contralateral homonymous hemianopsia
– Visual agnosia (can’t recognize objects)
– Minimal motor involvement

Posterior
Cerebral
Stroke

76
11
 Vertebrobasilar TIAs and Strokes
• Vertebrobasilar arteries
– Vertigo
– Nausea and vomiting
– Ataxia
– Headache
– Nystagmus
– Cranial nerve findings
– Variable motor
and sensory findings

77
12
 Lacunar TIAs and Strokes
• Lenticulostriate arteries
– A group of small diameter arteries that arise at the
commencement of the middle cerebral artery
– Pure motor hemiparesis
• Lacunar syndrome

78
13
 Transient Ischemic Attack (TIA)
• “A transient episode of neurologic dysfunction
caused by focal brain, spinal cord, or retinal
ischemia, without acute infarction”
• Not based on time, but rather on tissue findings
– Neuro or eye findings
– Negative imaging
• Means that imaging
is necessary to make
the diagnosis of TIA

79
14
 Transient Ischemic Attack (TIA) Symptoms Not Suggestive of a TIA, 1
• Symptoms usually < 30 min
• Symptoms NOT suggestive of a TIA
– Often less than 10 minutes
– Loss of consciousness (LOC)
– Means symptoms may be gone by the time the
– Dizziness (not vertigo)
patient arrives in the ED
– Generalized weakness
– Consideration of TIA will often be based on history
alone – patient or family or bystanders – Mental confusion
– Exam often normal or resolving – Loss of vision WITH decreased LOC
– Incontinence (feces or urine)

15 16

Symptoms Not Suggestive of a TIA, 2 TIA Differential Diagnosis

• Symptoms NOT suggestive of a TIA if in isolation • Hypoglycemia
– Vertigo (a feeling of motion when one is stationary) • Structural brain lesion
– Diplopia (double vision) • Infection
– Dysphagia (difficulty swallowing) • Post seizure transient
– Loss of balance localized paralysis
– Tinnitus (ringing in the ears) • Complicated migraine
– Localized sensory symptoms
• Multiple sclerosis flare
– Scintillating scotomas (flickering lights in the visual
axis) • Syncope
– Amnesia • Labyrinthine (inner ear balance disorders)
– Drop attacks (sudden spontaneous falls) • Hyperventilation syndrome / panic attack
– Isolated dysarthria (+/ ) (a motor speech disorder) 17 • Subarachnoid hemorrhage 18

80
 ED Evaluation of TIA, 1 ED Evaluation of TIA, 2
• ED evaluation testing
• ED Evaluation
– Rapid glucose
– Thorough history and physical exam
– ECG
• Document vital signs and whether
– Head CT without contrast
heart rate regular or irregular (emboli caused
• Consider including CTA of head
by atrial fibrillation are a common cause of
and neck
stroke)
– Diffusion weighted MRI (a TIA
• Document full and with a positive MRI is now
detailed neurologic exam considered a stroke)
• Document presence or • May be preferred over CT
absence of carotid bruits
– Appropriate laboratory testing
(patient dependent)
19 20

Treatment of TIA in ED Disposition of TIA

• Disposition
• Treatment
– Concern is risk of progression to stroke
– Do not lower blood pressure acutely in most cases
• 1 in 20 within 48 hours
– Assure adequate hydration • 1 in 12 within a week
– Antiplatelet therapy once head CT shows no bleed – Strongly consider admission for workup for all
• Aspirin (50 325 mg) TIA patients (discuss with consultant) / AHA - OR-
• Do not add clopidogrel if patient already on recommends admission
aspirin • ABCD2 scoring system commonly
used to risk stratify…
– If suspected cardiogenic source, consider
• BUT – ABCD2 IS NOT RELIABLE
anticoagulation
Too many low risk people have bad events
• Discuss with consultant
21 22

81
 “ABCD2” Score “ABCD2” Score

Criteria Points Criteria Points

A Age 60 years 1 A Age 60 years 1
B SBP > 140 and/or DBP > 90 (presentation) 1 B SBP > 140 and/or DBP > 90 (presentation) 1

C Clinical features 12 C Clinical features 12

Unilateral weakness = 2 points Unilateral weakness = 2 points
Speech impairment only = 1 point Speech impairment only = 1 point
D Duration 12 D Duration 12
60 minutes = 2 points 60 minutes = 2 points
10 59 minutes = 1 point 10 59 minutes = 1 point
D History of diabetes 1 D History of diabetes 1

Some authors recommend admission for ABCD2 scores 2 Some authors recommend admission for ABCD2 scores 2
23 24

Canadian TIA Score TIA Hospital Workup

• Workup in the hospital will
include
– Echocardiogram (looking at
cardiac function and for clots in
the heart as a source of emboli
to the brain)
– Carotid studies looking for
partial occlusion (CTA, doppler
ultrasound)
• Consider ordering CTA when
ordering noncontrast CT
– May have an MRI / MRA
25 26

82
 Clinical Presentation of Stroke Initial Stroke ED Treatment, 1
• Range of presentation: Subtle findings, profound • If comatose / altered
symptoms in a vascular distribution, or in a coma – Vascular access
• If possible ischemic stroke, time is of the essence – Cardiac monitoring
if patient to be considered for thrombolytic – Manage airway as necessary
therapy • Use etomidate for induction if rapid sequence
– Rapid workup intubation necessary / decreases intracranial
• Rapid glucose level pressure
• CT scan – Monitor blood pressure
• NIH stroke scale • Specific management varies depending on type
of stroke – more later
• Avoid hypotension
27 28

Initial Stroke ED Treatment, 2 Stroke Blood Pressure Management, 1

• Once signs or symptoms of possible stroke
identified • A controversial topic
– Check glucose; treat if indicated – In ischemic stroke, usually not treated – damaged
brain needs the cerebral perfusion pressure
– Perform NIH Stroke Scale or Canadian Neurologic
– Decision to treat depends on the type of stroke
Scale
– Medications should be IV and easily titrated to BP
– Review patient history to determine time of
– If treating, monitor patients closely for worsening
symptom onset or last known normal
neuro status; stop meds if occurs
– Order emergent CT scan (or MRI) – Usual meds:
– Provide oxygen if hypoxemic • Labetolol, nicardipine, clevidipine, esmolol
– IV access; send labs (CBC, CMP, PT, PTT, INR)
– Obtain 12 lead ECG
29 30

83
 Stroke Blood Pressure Management, 2
• If ischemic stroke
– Do not intervene unless blood pressure persists
over 220/120 (or patient has other indications to
treat hypertensive emergencies)
– Exception if patient is a candidate for
thrombolytics
• Desired BP < 185/110
• If higher, consider intravenous agent to lower
blood pressure (e.g. labetolol, nicardipine)
31
Stroke Imaging
• Review CT scan or MRI
– If hemorrhage – consult neurologist
or neurosurgeon (consider transfer
if none available)
– If no hemorrhage, consider thrombolytic therapy
• Best to work with your neuro consultants
• Check for fibrinolytic exclusions
• Repeat neuro exam to determine if deficits are
rapidly improving or now normal
• If patient not a candidate for fibrinolytic
therapy administer aspirin
33
84
Stroke Blood Pressure Management, 3
• If hemorrhagic stroke (not SAH)
– Target SBP < 180 mmHg
• Avoid precipitous drops in SBP: limit the
reduction to 25% of the initial SBP
– Use nicardipine, labetalol or clevidipine
Much less common than ischemic stroke but
higher mortality (35% at 1 week, 75% at 1
year)
32
Thrombolytics in Acute Ischemic Stroke
• AHA guidelines
– Inclusion criteria
• Clinical ischemic stroke with measurable neurologic
deficit
• Onset of symptoms < 4.5 hours before beginning
treatment (from last time patient known normal or
neurologic baseline)
• Age 18 years
– Additional exclusion criteria if between 3 and
4.5 hours
• Age >80 years
• Severe stroke (NIHSS >25)
• Taking an oral anticoagulant regardless of INR
• History of both diabetes and prior ischemic stroke 34
 Thrombolytics in Acute Ischemic Stroke Thrombolytic Treatment of Stroke
• AHA guidelines • If patient remains candidate
– Exclusion criteria for thrombolytic therapy
– List is very long and detailed – best to look it up – Discuss risks / benefits with
every time rather than trying to memorize it patient, family
• 6% get worse
• 12% get better
– If acceptable – give rtPA
– No anticoagulants or
antiplatelet treatment for 24
hours
35 36

Example: TPA Informed Consent / Refusal Dosing of rtPA in Stroke

“There is a treatment for your stroke called alteplase • Alteplase (rtPA) dosing
that must be given within 4.5 hours after the stroke
is started. It is a ‘clot buster’ drug. The likelihood of – 0.9mg/kg (maximum of
benefit decreases with time, but treatment is more 90mg)
likely to help than harm up to 4.5 hours after the – 10% of the total dose
stroke begins. However, this treatment has a major administered as an
risk, since it can cause severe bleeding in the brain in initial bolus over one
about 1 of every 15 patients. If bleeding occurs, it
can be fatal. When used to treat large numbers of minute
stroke patients we believe on average the potential – Remainder infused over
benefits outweigh the risks; however, this is a very 60 minutes
personal decision made by each individual patient
and their family.” (Up to Date)
37 38

85
 Endovascular Therapy for Stroke
• Big push recently for the modality
• Requires specialized centers / trained personnel
• Time window unclear, but likely longer than tPA
window
• Stroke must have specific characteristics for
patient to be a candidate
– Brain perfusion studies necessary to determine if
patient candidate
• Best managed by stroke teams and stroke
systems
39
TIAs and Strokes
• Crucial Points
– Know the different stroke syndromes
– TIA symptoms may be completely resolved on
patient presentation
– Some TIA patients are at high risk for stroke;
consider admission or observation for workup
– The clock is ticking in patients with ischemic
strokes with regard to administration of
thrombolytics or endovascular therapy
– Have ready access to the guidelines for use of tPA
in strokes
40

86
Thriving, Not Just Surviving:
Wellness and Self Care

I’m burned
out on talks
about
burnout

44

87
• Feelings of energy
depletion
or exhaustion

• Increased mental
distance from one's job

• Feelings of negativism
or cynicism related to
one's job

• Emotional exhaustion
and depersonalization
are components

66

88
99 1010

11 1212

89
 Gratitude Gratitude
Intellectual Intellectual
Compassion Stimulation Compassion Stimulation

Love Love
Mental Rest Mental Rest
Joy Joy
Beauty Beauty

Sleep Exercise Sleep Exercise

Good Good
(and rest) (and rest)
Nutrition Nutrition
13 14

15 16

90
 Gratitude
Intellectual
Compassion Stimulation

Love
Mental Rest
Joy
Beauty

Sleep Exercise Sleep Exercise

Good Good
(and rest) (and rest)
Nutrition Nutrition
17 18

Pay attention ON PURPOSE No judgment “No amount of regretting can change the past, and no amount of
worrying can change the future.”
Stay in the moment Respond, don’t react

“Worry does not empty tomorrow of its sorrow, it empties today of it’s joy.”

1919 20

91
 Types of Meditation

21 22

23 24

92
 Everything you put in your
body and in your mind
matters

in
Make thoughtful choices

25 26

Where Do YOU Focus? Where Do YOU Focus?

• The past • The future • The past • The future
• Things you can’t change • Things you can change • Things you can’t change • Things you can change
• Things you don’t have • Things you do have • Things you don’t have • Things you do have

27 28

93
29 30

31 32

94
33 34

• Smile!
• Go outside
• Laugh
• Move – dance, jump up and down, walk
• Reframe the situation
• S‐T‐O‐P
• Stop; take a few deep breaths; observe the situation;
proceed
• Use your senses (aromas, music, beauty)
• Get outside yourself
• Make someone smile / offer a compliment / say thank
you
• Breathe
35 36

95
Learn how to take a body inventory
Get enough sleep
Exercise… even a little bit… three times a week
Learn quick relaxation techniques
Limit news
Limit screen time (doomscrolling)
Practice empathy
Be grateful
Practice loving kindness

SCHEDULE some of these – make it a habit

37 38

39 40

96
41

Free your heart

from hatred

Be grateful

Don’t waste time

worrying

Live simply

Give more

Expect less
43 44

97
45 46

98
 External Ear Anatomy

Ear Disorders:
Newest Approaches

99
Internal Ear Anatomy

100
3
 How To Examine A Child’s Ear
• Smaller child?
– Either supine on the stretcher,
arms up and along the sides of the
head, adult holding child’s legs and
torso, or held by parent with head
resting on adult’s shoulder
• Larger child?
– Sit in adult’s lap, legs held
between adult’s legs, torso held
against front of parent with one
arm, head turned to the side with
the other
4 5
Foreign Bodies
• Bugs – If the TM is believed intact
and no ear tubes, drown with
mineral oil (alternatives?
lidocaine, saline need a
randomized trial) and flush out
thereafter
• Paper can usually be removed
with a forceps or similar (if a
child, hold the child VERY firmly)
• Beads and other round
embedded objects can be very
tough (see ”tricks”)
6 7
101
Cerumen Impaction
• Usually caused by “cleaning” of ears with cotton
tipped swabs
• Sudden decreased hearing
• Options
– Wax softening agents
• Docusate (Colace) (put the contents of the capsule into the
ear)
• Saline may be as effective as commercial products
– Irrigation (be careful – not too aggressive)
• Complications pain, vertigo, TM perforation, audio
vestibular damage
• Can be used in combination with wax softening agents; use
warm water
– Cerumen spoon or loop (can work well for hard wax)
Foreign Bodies
• Consider consultation if ANY difficulty removing
a foreign body with the usual instruments
• Tricks
– Need VERY good light, effectively restrain children,
consider procedural sedation, pull the pinna
backwards to get maximum visualization
– A right angle hook may be
able to get behind the FB
– Consider suction applied to a
small catheter held to the object
– Consider using alligator forceps
 Foreign Bodies Auricular Hematoma
• Another trick • Blood between the skin of the outer ear and
– Apply a small amount of tissue glue the cartilage
or “Crazy Glue” to the wooden end • If blood is not drained, can destroy cartilage
of a cotton swab (J Ped Child Health,
2/94)
over time causing a “cauliflower ear”
– Touch the swab to the FB
– When dry, withdraw swab and FB
– Works best with hard, bead like FBs
– FB must be easily visible / canal walls
must not be touched with glue
• Don’t hesitate to refer extractions that are
problematic to ENT / don’t push FBs further in
8 9

102
 Auricular Hematoma
• Treatment is large needle
aspiration (I&D if continues
to reaccumulate) &
compression dressing so
blood does not
reaccumulate

103 10
 Perichondritis Causes of TM Perforations
• An infection of the skin and tissue
surrounding the external ear • Multiple causes
• Ear piercing through cartilage is a major
– Barotrauma (ascent or descent causes
cause
unequal pressure on the TMs if the
• Clue to the diagnosis – no erythema Eustachian tubes are blocked)
of the earlobe (no cartilage there)
– Trauma
• Abscesses require drainage
• Noise / lightening
• Remove the foreign body • Penetrating (cotton tipped swabs)
• Oral fluoroquinolones (see 2016 Black • Blunt (slap, landing on ear while water skiing)
Box) have been considered drugs of choice due to – Otitis media – most common
antipseudomonal and antistaph activity
– Symptoms – decreased hearing, pain, bleeding
• Oral Alternatives: fosfomycin ?
11 12

Treatment of TM Perforations Otitis Externa

• Most heal spontaneously within a week in kids (70%, • Often due to retained water in ears
94% in a month) (swimmer’s ear) / local trauma
• Early ENT referral – penetrating trauma / • Pain on ear movement, canal
posterior perforation (that’s where the cellulitis, drainage
ossicles attach) • Pseudomonas, staph, strep
• Late referral – blunt trauma or noise related • Culture only in advanced cases
• Avoid water in the ear (cotton coated with petroleum • Topical antibiotics with steroids
jelly to seal the ear canal) – Ofloxacin drops ($20 v. $80)
• Topical or systemic antibiotics generally not required – Ciprodex & Cipro HC drops ($280 &
$390 / GoodRx.com)
(use if caused by infection or forceful entrance of dirty
water, e.g. water skiing) – Neomycin polymyxin hydrocortisone
solution
13 • Generic ($35) v. Cortisporin otic ($110) 14

104
 Otitis Externa Otitis Media Overview
• Ear drop nuances • Frequently occurs in young children with a URI
– Use “suspension” with a TM • Usually caused by viruses
perforation or tympanostomy
tubes (the “solution” has a lower • Ear tugging / fingering are
pH and may cause discomfort) not always reliable signs of AOM
– Warming the bottle in a pocket • Can cause ear pain (not always)
may be more comfortable than
cold drops and not cause caloric stimulation
• May cause a low grade fever (at most)
– Stay with head on the side for several minutes / – High fevers (> 40 C) in children with AOM are usually
pulling the tragus several times helps move the drops caused by concomitant viral infections
further in / cotton or ear tampon in the canal helps – Don’t ascribe high fever to just a AOM / find the cause
keep the drops against the skin of the ear canal / ear • Bacterial causes are mostly strep, H. influenzae
wick for severe cases and to a much lesser degree, M. catarrhalis
15 16

Otitis Media Diagnosis Otitis Media Treatment

• Diagnosis • Over 90% of AOM will resolve without treatment
– Ear pain (if old enough to talk) – NNT = 15 16 (less pain at 2 7 days) / NNH = 9 (diarrhea)
– Abnormal tympanic membrane • There is substantial concern about the overdiagnosis
• Red, grey, yellow
and overtreatment of AOM
• Bulging and effusion – key to dx
• The 2013 AAP/AAFP guidelines
• Decreased mobility on insufflation
– Amoxicillin is the drug of choice, if an antibiotic is
prescribed – the dose is 80 90mg/kg (twice prior usual
– May be caused by serous otitis (not really an “itis” – residual
fluid behind the TM from a prior OM – TM is not red, ear is not
dosage – risk of diarrhea)
painful) – Amoxicillin/clavulanate (Augmentin)
– Young children with OME need follow up to assure that fluid • If amoxicillin in past 30 days, or recurrent AOM
behind the TM has resolved (may cause decreased hearing with • Treatment failure at 48 72 hours of antibiotic therapy
potential for delayed speech)
• Concurrent purulent conjunctivitis
– Tympanostomy tubes are placed to drain chronic middle ear fluid
that does not resorb with other treatments (or time alone) 17 – Alternatives: cephalosporins and/or clindamycin
18

105
 Otitis Media Treatment
• Additional aspects of the AAP/AAFP guidelines
– Who to treat
• 6 months with “severe disease” – fever 39 C
(does OM cause fever??) or moderate or severe
otalgia or otalgia > 48 hrs
• 6 23 months with bilateral AOM
– Recommended treatment duration varies
• 10 days for children < 2 years and for those with
“severe disease”
• For those 2 5 years with mild to moderate disease a
7 day course is “appropriate”
Otitis Media Treatment
• Strong points in the AAP/AAFP guidelines
– The option for “observation” and no initial antibiotics
• Those with “non severe” symptoms/disease
– Unilateral 6 23 months
– Bilateral 2 years
• The “observation” option requires that follow up
can be assured and available in 48 72 hours
– There is emphasis on the use of both systemic and
topical analgesics (if available) in the management of
pain (both at home and in the ED). Topicals can be
prescribed if the TM is intact.
• Antipyrine/benzocaine – no longer available

• For those 6 years with mild to moderate disease a • Most OME will resolve without antibiotics
5 7 day course is “appropriate” – Cochran review – NNT 5, NNH 5
19 20

Bullous Myringitis External Ear Anesthesia

• Ear anesthesia
• Bullae noted on tympanic – For small lacerations, any local
membrane usually with AOM anesthetic without epi can be used
• More painful than AOM (bupivacaine [Marcaine] lasts the
• Associated with URI longest)
• Caused by the usual organisms that cause – Inject through the wound margins
otitis media – usually viral, occasionally – For larger lacerations, a regional
bacterial block with an epi containing local
• Antibiotic drops may decrease risk of anesthetic is acceptable (two injections
secondary infection in four directions as noted)

21 22

106
 Ear Laceration Repair Peripheral Vertigo Overview
• Suturing the ear • Vertigo = a type of dizziness in
– Cleanse wound per routine which there is a sensation of
– Inspect the skin, perichondrium and movement when one is stationary
cartilage for areas of necrosis – • The most common causes are due
sharply debride if present
to an inner ear dysfunction (“peripheral”) / less
– Suture the perichondrium with 5 0 or 6 0 absorbable common is brain based (“central”)
sutures – avoid putting sutures through the cartilage
– Suture the skin closed with non absorbable fine sutures
• Making the distinction is critical / there are many
causes / get help / know the chart!! (next slide)
– Evert the skin edges to limit the risk of a depressed scar
developing • Peripheral vertigo is usually a benign, self limiting
– Some use absorbable sutures on the skin behind the problem / central vertigo is ominous
ear (nonabsorbable ones can be difficult to remove) 23 24

Characteristics of Vertigo Common Causes of Peripheral Vertigo

Peripheral Central • Vestibular neuronitis (vestibular neuritis)
Onset Sudden Slow – Most likely cause of acute onset (usually awaken with
Severity Intense spinning Less intense, ill it in the morning), severe, persistent vertigo in the ED
defined – Cause is unclear (viral?) / subtle difference from
Pattern Intermittent Constant labyrinthitis (less common, more likely infectious)
Worse on movement Yes No – No decreased hearing / vomiting very common
Nausea / sweating Frequent Infrequent • hearing = Labyrinthitis; Add Tinnitus = Meniere’s Dz
Nystagmus Horizontal or rotatory, Vertical, – Worse with changes of head position / positional
unidirectional multidirectional nystagmus (disturbed vision looking to one side
Fatigue Yes No indicates the opposite ear is the cause)
Hearing loss / tinnitus May occur No – Treatment is sedation (ENTs often use benzos) /
Abnormal TM May occur No antinausea drugs / steroids (consult ENT) / some
require admission for symptom control
CNS Symptoms Absent Usually present 25 26

107
 Differentiation of Neuronitis vs CVA
• HINTs exam can help differentiate central from persistent
peripheral vertigo (dangerous HINTS if one element +)
• Sensitivity 97%, specificity 84% (Acad EM, 10/13) / Better
than MRI, if done correctly – not easy
• Head impulse test – tests vestibulo ocular reflex (VOR)
• Takes practice

27

108
 HINTS Exam
III. Exam (Mnemonic: HiNTs)
1.Head Impulse
1. See Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
2. Head is rapidly rotated 20-40 degrees to one side or the other
3. Observe for one eye that lags in response to maintain forward gaze (other eye will lack corrective saccades)
1. Makes quick saccade movement to catch-up or correct (HiNTs-Peripheral)
4. "Normal" test or HiNTs-Central (no saccade/correction on head provocation) strongly suggests posterior CVA
1. Test Specificity approaches 100%, but Test Sensitivity is only 85%
2. Although saccade/correction on testing suggests peripheral cause, it does not exclude posterior CVA
3. False positive (absent saccades) may also be present if Vertigo has resolved
2.Direction Changing Nystagmus (or Nystagmus that is vertical or torsional)
1. See Nystagmus
2. Patient follows examiner's finger as they move it slowly in all directions
1. Patient should look up, down, left or right, as well as to eccentric positions (off-center)
3. Nystagmus should be present in all cases of acute vestibular system whether of peripheral or central cause
4. Findings suggestive of peripheral Vertigo
1. Horizontal Nystagmus suggests a peripheral cause (although it does not exclude a central cause)
5. Findings suggestive of central Vertigo (e.g. posterior CVA)
1. Vertical Nystagmus
2. Torsional Nystagmus
3. Nystagmus that changes direction
1. Rightward Nystagmus with rightward gaze
2. Leftward Nystagmus with leftward gaze
3.Test of Skew
1. See Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
2. Perform as with Alternate Eye Cover Test (also used to evaluate for horizontal Strabismus in children)
3. Alternately cover one eye and then the other
4. Observe for quick vertical gaze corrections (abnormal)
1. Uncovered eye shifts to center from its abnormal, vertically displaced position
5. Abnormal skew test with quick vertical gaze corrections suggests a central cause (e.g. Brainstem CVA)
6. Examiner may also see a Head Tilt at rest that often accompanies Skew Deviation

109
28
 Common Causes of Peripheral Vertigo Diagnostic Test for BPPV
• Benign paroxysmal positional vertigo (BPPV) • Dix Hallpike is the diagnostic test for BPPV
– Most common cause of recurrent peripheral vertigo
– Duration of vertigo and nystagmus = 5 40 seconds
(therefore not particularly likely to present to the ED)
– Precipitated by head turning / mid 50s / females 2:1 male
– Cause – “canalolithiasis” – delayed unilateral activation of
the posterior semicircular canal because of impaired
endolymph flow caused by
clumped otoliths (otoconia)
– Vertigo / nystagmus and fatigue
with repeated head movement
– No associated hearing problems
or tinnitus
– Treatment – ossicle repositioning maneuvers (e.g. Epley
maneuver) / sedatives
29 30

110
Treatment if BPPV (Epley Maneuver)

111
31
 Causes of Central Vertigo Workup of Vertigo
• The differential is large – some examples: • Peripheral vertigo?
– Multiple sclerosis (auto immune / causes – Good exam (document findings consistent with
demyelination – brain and spinal cord) peripheral cause)
• Onset age 20 40 / female predominance – No imaging studies necessary
• Episodes of migratory neuro deficits may last hours – Treat as appropriate – antiemetics, sedatives
to weeks / ataxia, optic neuritis (eye pain and (benzodiazepines, antihistamines)
decreased vision) • Central vertigo?
– Vertebrobasilar insufficiency / stroke – Good exam (document findings consistent with
– Basilar migraine – vertigo, decreased hearing, central cause)
visual disturbances, dysarthria (motor speech – Preferred imaging is MRI
disorder) – Consult neurology or neurosurgery, as indicated
– Cerebellar hemorrhage
32 33

112
 Algorithm
for Vertigo

113
34
114
Neuropsychiatric
Disorders

115
Brain Anatomy

116
2
 Muscle Stretch Reflexes
Biceps C5 C6
Supinator (brachioradialis) C6
Triceps C7
Knee L4
Ankle S1

Cutaneous Reflexes
Abdominal – upper umbilicus T8 T10
Abdominal – below umbilicus T10 T12
Cremasteric L1 L2
Anal S2 S5
3 4

Dermatomes (Nerve Roots) Glasgow Coma Scale

• C4: clavicle “C” is for “clavicle” • Eye Opening (1 4) • Verbal (1 5)
• C6: thumb & index Left hand “OK” sign – 4: Spontaneous – 5: Full sentences / oriented
makes a “6” with – 3: Verbal – 4: Full sentences / confused
thumb and index – 2: To Pain
– 3: Understandable words
– 1: None
• C7: middle finger – 2: Garbled, moans
• Motor Response (1 6) –
• C8: little finger – 6: Follows commands
1: No vocalization

• T4: nipple line “T” is for “thorax” – 5: Localizes pain • N.B. A dead
– person has a
• T10: umbilicus BellybutTEN 4: Withdraws to pain
GCS of 3
– 3: Decorticate (Flexes)
• L1: inguinal ligament IL‐L1 – 2: Decerebrate (Extends)
• L4: knee “Down on all fours” – – 1: Flaccid
Down on L4 5 6

117
 Mental Status Exam
• Mental status exam = OMIHAT
Orientation
Memory
Intellect
Hallucinations
Affect
Thought
• More specifically appearance, attitude,
behavior, mood, speech, thought processes,
thought content, perception, cognition, insight,
judgment
7

118
The
Cranial
Nerves

119
8
 Cerebellar Exam Altered Mental Status General
• Broad differential diagnosis: AEIOU TIPPS
• Is the gait normal?
• Romberg test (stand unaided A- Alcohol T - Trauma, temperature
with eyes closed) E- Epilepsy I - Infection
• Coordination (heel to shin, I- Insulin P - Poisonings
finger to nose with eyes closed) O- Opioids P - Psychiatric
• Rapid finger pincer movements U- Uremia S - Stroke, shock
(tip of thumb to tip of index
finger bilateral and simultaneously) • Careful history and physical essential / check
• Finger nose finger exam vitals for abnormalities suggestive of diagnosis

9 10

Altered Mental Status Approach Bacterial Meningitis, 1

• Testing
– CMP (including Ca / Mg), CBC, LFTs, tox screen
(acetaminophen and aspirin levels), blood alcohol
level, UA; consider ammonia level, carbon monoxide
– Head CT if suspect mass, bleed, trauma or need to do
LP
– LP if infection suspected
• Treatment
– ABCs; give oxygen if hypoxic
– Check rapid glucose; administer D50 if low
– Consider naloxone (low RR, pinpoint pupils)
– Suspect alcoholism, malnutrition? Give thiamine.
– Suspect infection? Antibiotics early.
– Give other treatments based on diagnosis
• Incidence way down – U.S. annually 3 5,000 cases
• Early diagnosis and treatment is critical (20 25%
mortality rate)
• Risk factors to consider
– Lack of routine pediatric immunizations
– Age less than 5 and older than 60
– Those without a spleen (surgery or sickle cell patients)
– Chemotherapy and transplant patients
– HIV
– Diabetes, alcoholism, shunts for hydrocephalus
– Those living in close quarters (an indication for
11
meningococcal vaccine) 12

120
 Bacterial Meningitis, 3
• Classic signs in adults
– Headache (at least 90%)
– Complaint of stiff neck (at least 85%)
– Fever and chills (at least 90%)
– Vomiting (about 35%)
– Photophobia
– Altered mental status, focal abnormal neuro exam
– Petechial rash and ecchymoses
• Small children irritability, drowsiness, poor feeding,
bulging fontanelle, neonatal fever (100.4 or greater)
Don’t delay treatment waiting for CT or due to
difficult LP 13

121
Etiologies of Meningitis

122
14
 Meningitis Treatment
• 0 4 weeks ampicillin plus cefotaxime or an
aminoglycoside
• 1 3 months ampicillin plus cefotaxime*
• 3 months to 50 years ceftriaxone (high dose)
or cefotaxime*
• Over 50 years ampicillin plus ceftriaxone or
cefotaxime*
– * Add vancomycin if penicillin resistant S.
pneumoniae suspected or local high incidence
• Role of steroids is controversial, consider
consult with admitting physician
15
ED Evaluation of Seizures
• New onset
– Search for underlying cause
– Full workup: glucose, lytes, CT, +/ LP, toxicology screen
– Pediatric hyponatremia (most common in afebrile
children <2 – usually caused by caretaker induced
water intoxication), gastroenteritis (rotavirus, shigella)
• Febrile seizures covered in pediatric chapter
• Chronic
– Full workup if focal seizure, neuro deficit, atypical
• Breakthrough seizures in epileptic patients check
anticonvulsant levels (if low, supplement), glucose,
other labs very low yield
17
123
Etiologies of Seizures
• Etiology
– Epilepsy (idiopathic recurrent seizures)
– Metabolic ( glucose, or Na+, ++
2, Mg )
– Structural (CVA, mass)
– Traumatic
– Toxins, drugs (alcohol withdrawal, cocaine, INH OD)
– Febrile
– CNS infections
– Eclampsia, hypertensive emergencies
• True seizure abrupt onset, non purposeful
movement, LOC, incontinence?, postictal state,
increased CK / lactate from muscle spasms
16
Seizure Treatment
• Treatment
– Benzodiazepenes first. Diazepam 0.2 0.5mg/kg or
lorazepam 0.05 0.1mg/kg (longer acting; drug of
choice per some, esp. if alcohol withdrawal seizures)
– Levetiracetam (Keppra) 18 mg/kg IV
– Phenytoin 18mg/kg IV or PO (or fosphenytoin)
– Phenobarbital 8 20mg/kg (sedates)
Functional seizures (Pseudoseizures)
• Not intentionally produced (although some control)
• Consciousness is preserved
• Incontinence and/or oral biting very rare
18
 Mental Disorders Functional Disorder vs. Organic
• Functional • Organic
– Age 15 40 years – Onset <12 or >50
– Gradual onset – Acute onset, fluctuating
– Clear sensorium course
– Auditory – Disoriented
hallucinations – Visual and tactile
– Oriented hallucinations
– Flat affect – Abnormal vital signs
– Normal physical exam – Pupil size, nystagmus
– History of substance
abuse
19 20

Antisocial Personality Anxiety Disorders

• Most common personality disorder seen in ED
• Common complications substance abuse,
multiple divorces, trauma, poor medical
compliance
• Disrespect for rights of others, law
• History of conduct disorder as child
a teen
• Impulsive behavior, no remorse
• Inability to meet daily obligations and
responsibilities
• Severity decreases after age 30
21
• Anxiety with occupational / social dysfunction
• Common, age <45
• Motor tension
• Autonomic hyperactivity
• Increased vigilance
• Rule out organic causes (OTC medications, drugs,
caffeine)
Post-traumatic stress disorder: Continued anxiety
following a traumatic event, substance abuse
Panic attack: Recurring episodes of fear (impending doom) without
identified stimulus
Obsessive - compulsive disorder: Repetitive acts or
ritualistic behavior to relieve anxiety
Phobias: Unfounded fears that arouse a state of panic
22

124
 Bipolar Disorder Bipolar Disorder
• Onset in 2nd and 3rd
decade
• Estimated 2 million in U.S.
• Genetic predisposition
• Rule out toxic, metabolic
and CNS disorders
• Antipsychotics for
acute treatment of mania
• Watch for lithium toxicity
– GI symptoms, tremulous,
dystonia, ataxia, altered
mental status 23 24

Schizophrenia Depression
• Age of onset 15 to 35 years • Poor appetite
• Common in homeless • Insomnia
population • Loss of interest
• Delusions, auditory • Loss of energy
hallucinations, flat affect • Feelings of worthlessness
• Disorganized thought • Psychomotor retardation
processes, bizarre or eccentric behavior
• Loss of attention span
• Poor social interactions, poor appearance
• Suicidal ideation
• Lifetime suicide risk is 15%
25 26

125
 Suicide Somatoform Disorders
• Females attempt more often • Somatic symptom disorder
• Males succeed more often – Repetitive concerns (physical/medical/sexual)
– Widowed men greatest risk – Numerous physical symptoms with no findings
• Depression is a major risk factor • Illness anxiety disorder (“hypochondriasis”)
• Familial / increased risk in some groups (e.g. – Physical symptoms disproportionate
– Worrying excessively that you are or
teens) may become seriously ill
• Other risk factors psychosis, alcohol / drug – Preoccupation with body, care seeking
dependence, previous attempts, living alone • Functional neurologic disorder/Conversion disorder
• Detain patient until suicide risk assessment is – No organic basis / symptoms must include
complete neurologic complaints
– Diagnosis of exclusion!
27 28

126
 Delirium
• Clouding of consciousness
• Severity fluctuates
• Confusion
• Acute, deteriorating
course
• Visual hallucinations
• Abnormal vital signs
• Rule out
– Electrolyte imbalance / hypoxia / hepatic failure /
drug use / CNS lesions / infection
127
29
 Dementia Malingering
• Decreased cognitive functioning • Voluntary simulation of disease
• Decreased memory, judgment, personality • Exaggerated physical symptoms
• Gradual onset • Motivated by external incentives
• No clouding of consciousness • Frequently associated with litigation
• Alzheimer’s disease – usually • Marked disparity of symptoms with objective
over 65, no focal findings, no findings
trauma or stroke, CT or MRI
• Lack of cooperation with evaluation
shows cerebral atrophy
• Often antisocial behavior or substance abuse
• Acute worsening of dementia
• Risky to make this diagnosis in ED
– Rule out superimposed medical illness
30 31

Munchausen Syndrome
• Now called “factitious disorder imposed on self”
• Common features
– Repeated fabrication of disease symptoms for
the purpose of gaining medical attention
– Hospitalization is primary objective
– Healthcare workers at higher risk
– Demand invasive tests and procedures, angry
at discharge
– Distinguished from malingering by willingness
to undergo painful procedures
– By proxy (aka “Factitious Disorder Imposed on
Another”) parent, usually mother,
exaggerates, fabricates or induces medical
complaints for their pre school child
32

128

What You Must Know to
Avoid Being Sued
Avoiding Being Sued Insurance
• Insurance issues:
– It is reasonable to request a
copy of the insurance policy
– Unlikely to cover you for
practice outside the hospital
– Will not cover you for criminal
behavior, and failing to file mandatory
reports to the state can get you into
trouble (e.g., disorders characterized by
lapses of consciousness in California)
– Never take anything that can be construed
as compensation for Good Samaritan acts
The Keys to Not Being Sued
• Know the Medicine
• Know the Traps
• Act Like You Care
Avoiding Being Sued – The Medicine
• Up to 70% of EM claims relate to missed diagnoses
– Acute myocardial infarction (know the new
[2021] AHA chest pain guidelines)
– Pulmonary embolism (know the PERC rules)
– Aortic dissection (CXR, d dimer, pulses equal)
– Missed fractures
– Infections
• Necrotizing fasciitis
• Spinal epidural abscess
• Sepsis
• Appendicitis
3 • Airway management issues 4
129
 Avoiding Being Sued Pharmacology
• Pharmacology related issues
– Be aware of “black box” warnings
on ED drugs (e.g., quinolones)
(see BlackBoxRx.com)
– No prescribing of controlled
substances for self or family
– Advise patients regarding
drowsiness when prescribing such drugs and
put it on the prescription and chart (e.g.,
“muscle relaxers,” sedatives, opiates)
– Know the doses for the medications you use
– Check for drug interactions (especially
psychotropics)
Avoiding Being Sued Telephone Issues
• Telephone related issues
– Don’t give telephone advice
that may delay ED care
• Apply some ice to the
ankle, take an Aleve and
come into the ED now =
good advice
• Take some antacids and see how you feel
= bad advice
–Don’t leave HIPAA related information
on answering machines (have them
call back)
– If unable to contact patients with critical
values, ask the police to go to the house
Avoiding Being Sued Testing Issues
• Testing related issues
– Know the correct tests to
order in the specific situation
(avoid “knee jerk” testing)
– Know how to interpret key
tests – d dimer, troponin
– Know the limitation of tests
– Have a foolproof way to
convey delayed results
to the patient / personal
physician (and document)
5 6
Avoiding Being Sued EMTALA
• EMTALA related issues
– Medical screening by medical /
hospital authorized provider is
mandated
– No payment related
information should be
sought prior to completion of
the medical screening exam
– Patients are not to be discouraged from
receiving a medical screening exam
– If on call physicians won’t come in to see a
patient, advise the physician this can be a big
7 EMTALA issue / call another doctor 8
130
 Avoiding Being Sued Transfers Avoiding Being Sued HIPAA
• EMTALA issues: Transfers • HIPAA related issues
– Can be requested by patient – No accessing patient records
– Stable / admitted patients without a specific need
OK to transfer – No picture taking or recording
– Unstable patients can be in the ED by patients or
transferred if going to a higher level of care families (have a large sign very
(cannot be refused by the receiving prominently located and emphasize patient
hospital unless services not available) / it is privacy)
not required that all transfers be by – Do not give any patient related information
ambulance without the patient’s permission
– Follow the hospital protocol regarding – Do not even think about posting any pictures
transfers TO THE LETTER or patient related information on the internet
9 10

Avoiding Being Sued Orders Avoiding Being Sued Charting

• Ordering issues
– Be very careful regarding
writing of admission orders
for other providers
– It’s best to let nurses take
off phone orders of
consultants or admitting physicians / use
hospital order sets
– If transcribing orders requested by a
physician, indicate them to be at the request
of the physician
– Make it clear who should be contacted if
there are any problems after admission
• What not to put on the ED chart, 1
– Any derogatory, discriminatory,
disrespectful or unprofessional
comments about the patient
– Arguments, conflicts with
physicians, nursing or
administration – give just the facts
– Negative statements regarding prior care
– Use quotation marks
• Regarding any negative statements by the
patient about prior care
• Regarding key historical or other responses
11 12

131
 Avoiding Being Sued – Charting, 2 Avoiding Being Sued AMA Issues
• What not to put on the ED chart, 2 • Leaving AMA requires:
– Incident reports should not be – Does the patient have th e
placed in the patient’s chart and capacity to decide about care?
no reference to them should be
made in a patient’s chart – Advising the patient of the
– Addendums (are always self serving) possible consequences of
leaving AMA
• EMR – each has its own protocol for
addendums / beware of meta data – Offering medication that may physiologically help
the patient (but which will not mask symptoms)
• Written? Single line through, time, date, initial
– Do not alter the record after the fact, obliterate – Offer the option to return to the ED at any time
errors or remove pages from the record – Having a nurse and a family member witness the
• Some states say this should be interpreted as AMA conversation / provider and nurse should
supporting the plaintiff’s case 13
document 14

Avoiding Being Sued Elopement Avoiding Being Sued Consent

• Elopement • Consent related issues
– Ascertain the medical risks of – Requires ascertainment
the elopement of capacity to consent
– Call patient’s home and invite – If capacity to consent is
back, and document the call present, you need to
document 9 items:
– If potentially serious medical problem and • What you want to do, and the risks and
there is a mental capacity question, consider benefits of the suggested procedure
sending law enforcement to home
• What an alternative option is and the risks
– If patient considered to be potentially and benefits
dangerous to self or others, notify hospital • What the likely outcome is without doing
security and local police to find patient anything, and the risks and benefits
15 16

132
 Avoiding Being Sued Capacity
• Ascertaining capacity to
consent or to leave AMA
– Ability to communicate a
choice
– Ability to understand the
information
– Ability to appreciate the medical
consequences of the situation
– Ability to reason about treatment choices
• Big predictor of lack of capacity = inability
to appreciate risks
– Capacity may change during patient’s stay
– Next of kin may be required for consent
Avoiding Being Sued General Advice
• General advice
– Be very careful regarding
doing inadequate work ups
on “frequent flyers”
– Indicate to patients imaging
results are preliminary (if
not the final reading of a radiologist)
– If appropriate, consider a policy in which the
emergency physician reviews all imaging and
ECGs real time
19
Avoiding Being Sued – Error / Apology
• Many hospitals have adopted
“full disclosure” policies
when errors occur (even
if the patient is not harmed)
• Most states have some sort
of apology laws on the books
– They vary significantly – e.g., in CA, apology is
OK but admitting fault is admissible at trial
• This is dangerous territory – get guidance when
there are any significant care issues in the
setting of error
17 18
So You’ve Been Named
• Immediately tell the physician director of the
group if an independent contracting group, or
your supervisor if a hospital employee
• Deliver all letters of complaint,
etc., to the above person
• Say nothing specific
(circumstances, allegation, etc.)
about the suit to any others
(spouses are OK)
• You will be subsequently advised
by the attorney assigned to your
case
20
133
134
 Hypertension and
Syncope

American College of Cardiology

Guidelines
• Evidence based guideline for management
• Contains blood pressure definitions
• Adds categories of both “white
coat hypertension” and “masked
hypertension”
• Recommended treatment varies
– Lifestyle changes in all
– Specifics based on age, race,
presence of diabetes or chronic kidney disease
– Starting meds from ED somewhat controversial
3 44

135
 Hypertension in the ED Hypertensive Urgency / Emergency
• Make sure appropriately sized cuff is being used • New guideline defines “hypertensive crisis” as
– A cuff that is too small will cause a falsely elevated
SBP 180 or DBP 120
blood pressure – Controversial – may not really urgent at all
• Studies show patients’ symptoms (e.g. – If no signs or symptoms of organ damage, acute
headache) do not correlate with blood pressure intervention may be harmful
– Do a good history and exam – Behavior modification; initiation of therapy if
– Look for evidence of end organ uncertain access to care
compromise (eyes, heart, kidneys, – Close follow up in 1 2 days
brain)
• Hypertensive emergency
– Do not treat the number; treat
the patient – End organ and/or CNS signs
5 – Immediate BP reduction required in ED 6

Hypertensive Emergencies (1) Hypertensive Emergencies (2)

• Types
• Severe elevation of BP with associated end – Encephalopathy
organ damage – Stroke syndromes (lowering BP is controversial)
– Acute pulmonary edema
No specific BP level definition – Acute coronary syndromes
– Aortic dissection
• End organs include – Renal failure
– Heart (angina, MI, CHF, dissection) – Preeclampsia, eclampsia
– Brain (encephalopathy, hemorrhage) • Pediatric hypertensive emergencies
– Eyes (hemorrhages, exudates) – Blood pressure > 95th percentile
– Kidneys (failure, preeclampsia) – Common causes renovascular, nephritis,
pheochromocytoma
7 8

136
 Hypertensive Emergencies (3)
• Malignant hypertension (this is rare)
– Hypertension with end organ damage and/or
papilledema
– Not defined by absolute blood pressure reading
– Goal is to reduce mean arterial pressure by 30% in
30 minutes
MAP = [(2 x DBP) + SBP] / 3
Treatment: Nitroprusside, labetalol or
nicardipine
Hypertensive Emergencies (5)
• Cardiac angina, CHF
– IV nitroglycerin usually first
– Nitroprusside
• Aortic dissection
– Need to decrease rate
of rise of BP (dV/dT) to
decrease shear forces on aorta
– Beta blockers (esmolol, labetalol, propranolol),
then nitroprusside
• CAUTION May cause stroke symptoms by
dissection of the carotid arteries or MI symptoms
due to occlusion of coronary ostia at root of the
aorta / tPA contraindicated
Hypertensive Emergencies (4)
• CNS – encephalopathy (PRES), hemorrhagic CVA
– Nicardipine / nitroprusside / labetalol
• Ischemic stroke
– Hypertension usually resolves within hours
• Transient and cerebroprotective
– Treat only markedly elevated bp (see stroke lecture)
• Pregnancy induced hypertension, eclampsia
– Hydralazine
– Labetalol
– Magnesium sulfate or BZD for seizures
9 10
Hypertensive Emergency
Medications (1)
• Sodium nitroprusside
– Mode of action: arterial and venous dilatation
– Onset of action: 1 2 minutes
– Half life: 3 4 minutes
– Metabolized to thiocyanate (cyanide)
– Ideal medication for hypertensive emergencies
(rapid onset, potent, short half life)
– Can cause reflex tachycardia therefore, use with a
beta blocker (give beta blocker FIRST)
11 12
137
 Hypertensive Emergency Hypertensive Emergency
Medications (2) Medications (3)
• Labetalol • Nicardipine
– Alpha and beta blocker (primarily beta) – Mode of action: Calcium channel blocker
– Onset of action: 5 10 minutes – Onset of action: 10 15 minutes
– Half life: 5.5 hours – Half life: 1 4 hours
– No reflex tachycardia – Used primarily for managing blood pressure
– Low doses may lead to paradoxical hypertension elevations in patients with intracranial emergencies
due to predominant unopposed alpha
(vasoconstrictor) effects

Contraindicated in bronchospasm, CHF, AV-

blocks
13 14

Hypertensive Emergency Hypertension in the ED Summary

Medications (3) • Treat the patient, not the blood pressure
• NEW AGENTS??? • Most elevated blood pressure in the ED does
– Mode of action: Calcium channel blocker not need acute intervention or any tests
– Onset of action: 10 15 minutes
• Know the hypertensive emergencies and how
– Half life: 1 4 hours and when to lower the blood pressure
– Used primarily for managing blood pressure
elevations in patients with intracranial emergencies
• Note “elevated blood pressure” on the chart
and refer the patient for follow up of the blood
pressure (important medicolegally)
• Usually, outpatient medications should not be
routinely prescribed nor should existing
15 prescriptions be changed 16

138
 Syncope Overview Syncope Causes (1)
• Sudden, brief LOC with loss of muscle tone with • “P‐A‐S‐S O‐U‐T”
spontaneous recovery / due to a decrease in cerebral
blood flow – Pressure
• Some causes are benign and easily diagnosed • Vasovagal – most common cause
• Some causes are more occult • Orthostatic hypotension
and potentially deadly (particularly a risk in the elderly)
• Requires a careful, systematic –Medications
evaluation • Particularly blood pressure medications or
• The elderly are at particular risk anything that might interact with them
• A variety of clinical decision aids –Volume loss
have been developed for the risk • Bleeding (occult, GI, AAA), dehydration
stratification of syncope patients
but none are highly accurate –Situational
• Micturition and cough syncope, carotid
17 sinus sensitivity 18

Syncope Causes (2) Syncope Causes (3)

• “P‐A‐S‐S O‐U‐T” • “P‐A‐S‐S O‐U‐T”
– Arrhythmia – Output
• Be particularly careful looking for more occult, • Cardiac – AMI, aortic dissection, output
but lethal arrhythmias (Brugada) obstruction (exertional syncope = aortic stenosis
– Seizures (vs. syncope) or hypertrophic cardiomyopathy)
• Pulmonary – PE is at the top of the list (syncope
• Look for incontinence, post‐ictal state
with a PE reflects a very large clot), CO poisoning
• Oral bite wounds
– Unusual
• Elevated myoglobin / CK, low serum bicarbonate
from seizures • Anxiety, panic, hyperventilation, somatization
(multiple physical symptoms without a cause)
– Sugar (low)
– Transient
• Watch out for long lasting oral hypoglycemics –
often requires admission due to recurrent / • TIAs, basilar artery migraine, brain hemorrhage
prolonged hypoglycemia 19 20

139
 Syncope Work Up (1)
• Most important components
are history, exam and ECG
• History
– Ask about chest pain,
shortness of breath,
medications, recent illnesses,
prodrome, family history of
sudden death, etc.
• Exam
– Document heart rate, rhythm,
presence of murmurs, carotid
bruits, neurologic exam
21
Syncope Work Up (2)
• ECG indicated in most – look for (and document
that you looked for)
– Ischemia (including STEMI equivalents)
– Dysrhythmias
– Intervals (long QT, short PR  WPW)
– Hypertrophic cardiomyopathy (LVH, “dagger”
lateral Qs, deeply inverted T’s)
– Brugada syndrome
• Head CT NOT routinely indicated unless strong
suspicion of neurologic cause (neurologic
complaints, abnormal neurologic exam)
• Other tests as indicated (see algorithm slide) 22

Syncope Work Up (3)

• Most “scores” not
better than good
clinical judgment
• Of the scores,
Canadian Syncope
Risk Score
probably best one
out there

23

140
Syncope Work Up (4)

141
24
Syncope Causes (2)

142
25
Syncope Causes (2)

143
26
 Syncope Disposition
• Most patients can go home after thorough
H&P, ECG
• Decision rules may miss some serious cases
• Consider admission:
– Elderly patients
– Patients with CHF or CAD
– Patients with new anemia (bleed?)
– Patients with a pacemaker (or interrogate pacer)
– Patients with a concerning ECG
– Patients with an abnormal exam (aortic stenosis
murmur, carotid bruit, dehydration, significantly
abnormal vital signs) 27

144
 Sinusitis

Sinus, Nose
and Tooth Ailments

Sinusitis Overview Sinusitis Symptoms & Causes

• Normally the sinuses
are sterile
• A URI causes an acute viral
infection of the sinuses
– Sinus involvement is
essentially universal with “colds”
• Typically a “cold” lasts 7 10 days
• Sinus symptoms lasting more than 10 days, with
the resolution of the other URI symptoms,
suggests a transition from a viral to bacterial
infection
• About 0.5 2% of viral sinusitis becomes bacterial
3 4
• Symptoms
– Pain over the involved sinuses /
increased pain on bending forward /
headache (often atypical migraines) /
purulent nasal discharge / discomfort
in the upper molars (for maxillary sinusitis)
• Bacterial causes of sinusitis
– S. pneumoniae / H. influenzae / M. catarrhalis (the
same bacteria that cause otitis media)
– Less commonly: staph, anaerobes, Gram negatives

145
Sinusitis Treatment & Complications Sinusitis Treatment
• Choosing Wisely campaign says sinusitis is grossly
• Treatment
overtreated with antibiotics per:
– Imaging is not routinely needed
– ACEP, AAFP, American Academy of Asthma, Allergy and
– Short term use of nasal decongestants, nasal Immunology and Amer. Acad, of Otolaryngology
steroids, & sinus washes may be helpful – $5.8 billion per year / 16 million office visit
– Watchful waiting is probably okay with most – Cochrane (10 trial analysis, 2012), antibiotics, NNT= 20,
patients; do they have follow up? faster cure but clinical cure rates at 16 60 days are
– IDSA guidelines advise amoxicillin clavulanate as the comparable
initial treatment of choice; doxycycline is an – Ann Emerg Med, 3/16, NNT = 18, NNH =9
alternative – Shared decision making
– Treatment duration of 5 7 days seems as effective – AAP has an extensive 2013 review at:
as 10 14 days (children are advised 10 14 days) http://pediatrics.aappublications.org/content/132/1/e262
5 6

Sinusitis Complications Nasal Foreign Body Overview

• Typically occurs in a child up to age 4
• Also can occur in psychosis or
Orbital Cellulitis Osteomyelitis with Brain Abscess intellectual disability
Prefrontal Facial Edema Frontal Sinusitis
• Acute foreign body (FB) –
caretaker provides history
• Chronic FB – unilateral foul
smelling discharge
• Button batteries can erode the
septum within 6 hours and
require prompt removal (don’t
send patients to an ENT
specialist the following day for
removal of an unknown FB)
7 8

146
 Nasal Foreign Body Removal Nasal Foreign Body Removal
• Consider topical anesthesia and a • Depending on FB, consider
vasoconstrictor (e.g., lidocaine gel and alligator forceps, Kelly clamps,
phenylephrine [Neo Synephrine]) suction, irrigation, ear curette,
• May need procedural sedation depending on right angle hooks, balloon
difficulty and cooperation / limit head catheter device advanced over
movement the FB (Fogarty or Katz device)
• Consider having caretaker blow a brisk puff of
air into the mouth while
occluding the good nostril
or use bag valve mask

9 10

Nosebleed Overview Nosebleed Treatment

• Myth high blood pressure causes
nose bleeds
– Usually the reverse is true; the nose
bleed causes the surge in BP due to
stress and anxiety
– Treat the nosebleed, the BP will usually come down
• Always look for other evidence of bleeding
– Ecchymoses and petechiae (document + or – )
– NSAIDs, “G” herbals (ginko, ginseng, ginger), SJ Wort,
coag altering meds, liver disease
– Get an INR if on warfarin / testing for the effects of
newer anticoagulants is a problem (e.g. direct
thrombin inhibitors and factor Xa inhibitors “xabans”)
– Only measure a CBC and coag studies if there are
indications – not routinely needed
11
• Most nosebleeds are from the anterior
nasal septum
– Ice bags to the face do not work
– Local pressure (press against septum for
10 minutes) usually effective
– Topical vasoconstrictor / consider topical
thrombogenics /silver nitrate
– Tranexamic acid pledgets (2 positive
studies (Acad Emerg Med, 11/17, Am J
Emerg Med, 9/13)
– Use tamponade device, if needed
• Most posterior nosebleeds are in
elderly patients and are due to
atherosclerosis
– Requires nasal balloon devices in most cases
12

147
 Nosebleed Treatment
• Complications of packing or balloons
– Infection (toxic shock), septal necrosis
– Cardiac ischemia, arrhythmias, syncope
– Dislodgement of packing into the airway
– Sinusitis, otitis media
– Generally advised to admit all patients with
posterior packing as they are at risk for reflex
bradydysrhythmias due to stimulation of
posterior pharynx
– Usually are older patients
13
Nasal Fracture / Septal Hematoma
15
148
Nasal Fracture
• Some controversy regarding need for x ray
• Check for a concomitant neck or facial injury
• Look for septal hematoma (and document + or )
– Requires drainage & packing since blood on cartilage
can destroy it / long term complication = saddle nose
• Look for CSF drainage from a cribiform plate
fracture (if suspected, get a CT)
• CSF rhinorrhea
– Increased by jugular compression,
leaning forward
– Ring sign (filter paper / bed sheet)
– Dipstick CSF glucose > 30 mg/dL
14
(Both tests of inconsistent reliability)
Saddle Nose Deformity
Saddle nose deformity most commonly
results from septal trauma
Bonus!!! – cauliflower ear – both entities
result from the destruction of cartilage
by blood-induced lysis
16
 Dental Abscesses Dental Abscesses Images
• Periapical abscess
– Most common cause of severe tooth pain / tooth Periodontal Abscess Periapical Abscess Periapical Abscess
painful when tapped (a “toothache”)
– Inflammation, infection and necrosis of the apical
(base) portion of the tooth
– Abscess can erode through cortical bone and drain
externally on gums = parulis
• Periodontal abscess
– Gum disease is the most common cause of tooth loss
– Gum inflammation, calculus, infection, abscess Arrows denote areas of abscess formation with
decreased bone density and possible gas formation
• Treatment
– I & D, penicillin + either clindamycin or metronidazole
17 18

Avulsed Teeth / Tooth Fracture Fixation of Avulsed Teeth

• Replant quickly (1% loss of survival per minute)
• Can use sutures if no formal materials available
• Rinse first (do not scrub; injures periodontal
ligament) • Consider acquiring The Dental Box – has all
materials needed to glue supportive wire or
• Keep moist / saliva, milk, water grid to neighboring teeth. Has instructional
(least desirable) / no dry storage videos (also on YouTube and has cards). $600
• Only permanent teeth need
reimplantation (> 1 hr = poor outcome) • https://www.thedentalbox.smartpractice.com/
(no reimplantation of “baby” teeth)
• Tooth fractures exposing pulp (reddish blush or
frank blood) require early dental referral to
prevent infection
• Other dental fractures see dentist for cosmesis Med Challenger EM

and functional issues 19 20

149
Counting Teeth Dental Block
• Supraperiosteal infiltration block
– Local, one tooth; good for temporary pain control
– Mucobuccal fold, bevel towards bone
– 1 2 mL of anesthetic anterior / can also infiltrate
posterior to the tooth

21 22

150
 Sexually Transmitted Infections

STIs: Nonulcerating Ulcerating

Gonorrhea Herpes genitalis
Diagnosis and Treatment Chlamydia Syphilis
Nongonococcal urethritis Chancroid
Pelvic inflammatory disease Lymphogranuloma
venereum
Late syphilis Granuloma inguinale

Gonorrhea Overview Gonorrhea Testing & Treatment

• Caused by Neisseria gonorrheae
– Chlamydia coinfection in 30 50%
• Very infectious; adolescents, young adults
• Urethritis in men; purulent, often copious
discharge, dysuria
• Cervicitis in women; minimal to no symptoms,
cervix friable and may have purulence
• Proctitis, pharyngitis rarer
• Conjunctivitis very serious
• Can cause pelvic inflammatory
disease and can disseminate
• Testing
– Gram stain if eye involvement
suspected
– Urine nucleic acid testing for
urethritis, cervicitis
– Culture eye, pharynx, rectum if infection suspected
Treatment for uncomplicated urogenital, rectal or pharyngeal
gonorrhea: Single dose 500mg ceftriaxone IM (if > 150 kg,
give 1g)
If chlamydia has not been excluded, add 100mg doxycycline
BID X 7 days. (CDC 2021 recommendations)
3 4

151
 Disseminated Gonorrhea
• Disseminates in 0.5 3%
• Findings
– Fever / arthralgias / migratory
polyarthritis / septic arthritis /
tendonitis / tenosynovitis
– Skin lesions (hemorrhagic pustule or erythematous
base – mostly lower leg)
• Gram stain/culture of genital sites, lesions
• Blood/joint fluid cultures often negative
• Treatment is ceftriaxone 1g IV/IM QD X 7 days
Chlamydia
• Most common STI in U.S.
• Caused by Chlamydia trachomatis
• Urethritis, cervicitis; much less symptomatic
than gonorrhea; may be asymptomatic; high
complication rate in women (causes PID that
scars tubes)
• Diagnosed by nucleic acid testing
of urine in men and women
Treat with 100mg doxycycline orally BID
X 7 days. (CDC 2021 recommendations)

5 Azithromycin 1g orally single dose is an alternative 6

Pelvic Inflammatory Disease Pelvic Inflammatory Disease Diagnosis

• Infection of the endometrium, fallopian tubes • Spectrum of symptoms – mild to toxic
or peritoneum, alone or in combination • Goal treat mild disease and assure correct
• May cause tubo ovarian abscess diagnosis in serious illness
• Concern is scarring of tubes and risk for • Diagnostic criteria cervical motion
infertility and ectopic pregnancy tenderness OR uterine tenderness
This is a
• Caused by multiple organisms OR adnexal tenderness
CLINICAL
(gonorrhea, chlamydia, • If any of above, should test
diagnosis
mycoplasma, lactobacillus) (gonorrhea, chlamydia; consider
HIV/syphilis), then treat for PID
7
• Sick patients may need imaging (ultrasound, CT) 8

152
 Pelvic Inflammatory Disease Treatment Herpes Genitalis
• Admit sick patients, those unable to
take meds or possibly noncompliant and • Most common ulcerating STD in U.S.; 1 in 5
any outpatient failures sexually active adults infected
• Treatment guidelines found on • HSV 2 (more common). Can be HSV 1.
CDC website • Initial infection causes systemic symptoms
– Multiple IV treatment regimens
– Outpatient and inpatient variations • Fever, malaise, headache,
• Common to use ceftriaxone 1g IM/IV once plus myalgias, adenopathy
doxycycline 100mg orally BID plus
metronidazole 500mg orally BID X 14 days – Common in first episode

If d/c home, need re-check in 48-72 hrs

9 10

Herpes Genitalis Herpes Genitalis Diagnosis

• Primary lesion at 2 7 days after
contact (shallow, painful vesicles • Diagnosis
clustered on erythematous – Usually made clinically
base, then ulcerations, may – NAAT assays available
coalesce) • Most patients have symptomatic
• Local symptoms peak 8 10 days. recurrences in the first year (60% to 90%)
2 to 4 weeks to heal. • Recurrences often have prodrome burning,
itching, numbness, paresthesias
• Can shed virus during
recurrence as well as
asymptomatic periods
11 12

153
 Herpes Genitalis Treatment Primary Syphilis
• First episode? Should treat with antivirals. • Caused by the spirochete Treponema pallidum
– Acyclovir 400mg TID X 7 10 days (spirochete)
– Famciclovir 250mg TID X 7 10 days Counseling is crucial!

– Valacyclovir 1g BID X 7 10 days

• Primary – genital ulcers (chancre)
– Painless, indurated, sharply
• Suppressive/episodic therapy
demarcated, red smooth base
– Acyclovir/famciclovir (BID), valacyclovir (QD)
– Heals spontaneously 4 8 wks
– Dosing different than first episode
– Episodic therapy most effective if initiated within 1 – Incubation period – 9 90 days (2–4 weeks average)
day of lesion onset or during prodrome – Dark field microscopy 80% sensitive
(operator dependent)
Admission for those with severe disease with IV
antivirals: disseminated infection, pneumonitis, – Diagnosed using VDRL and RPR tests
meningitis or hepatitis (detect nonspecific treponemal antibodies)
13 14

Syphilis Syphilis Treatment

• Secondary
– Onset 2 10 wks after the
chancre / rash (maculopapular rash
that often includes palms and soles),
fever, arthralgias, condyloma lata,
painless lymphadenopathy
• Latent (no symptoms – can last years)
• Tertiary 3 25 years after infection
– Neurosyphilis (meningitis, dementia,
neuropathy) / cardiovascular syphilis
(thoracic aortic aneurysm, aortic
insufficiency) / skin lesions (gummas) /
bone and joint disease (Charcot’s joint
= neuropathic destruction of a weight
bearing joint – diabetes is usual cause)
• Treatment is Benzathine PCN G
2.4 million units IM single dose
(primary or secondary syphilis)
– Alternatives are doxycycline, ceftriaxone
• May develop Jarisch Herxheimer reaction a
release of endotoxin from spirochete death
(fever, arthralgias, headache, myalgias, several
hours after antibiotics) – warn patients
– 50% in primary / 90% in secondary
15 16

154
 Chancroid and LGV ULCERATIVE STDs
Herpes Syphilis Chancroid LGV
• Very rare in U.S.; occur in sporadic outbreaks Systemic Yes No No No
• Multiple painful genital ulcers PLUS unilateral illness (primary)
fluctuant inguinal node = chancroid Adenopathy Bilateral, Diffuse Unilateral, Groove sign
bubo
– Diagnosis often made clinically shotty (secondary) unilateral, spherical, painful
inguinal lymphadenopathy
Inguinal lymphadenopathy
split into two equal separate
parts caused by an inguinal

– Tx: multiple options – look up

ligament (groove that is
produced is almost
pathognomonic)

• Lymphogranuloma venereum Initial lesion Vesicle Papule Ulcers Single ulcer

– Caused by chlamydia; painless shallow ulcers that Lesions Multiple, Solitary, Multiple, Resolved by
rapidly heal; bubo formation weeks shallow, painless painful, the time
later painful (primary) shallow, adenopathy
purulent develops
– Tx: Doxycycline 100mg BID X 21d
17 base 18

Vulvovaginitis Vulvovaginal Candidiasis

• Inflammation of vulva and • Common
vaginal tissues • Most caused by Candida albicans (part of
• Vaginal discharge, itching, normal flora)
irritation • Risk factors diabetes, HIV, oral
• Usually due to infection, contraceptives, antibiotics,
but also may be due to pregnancy
irritant, allergy, vaginal FB,
atrophic vaginitis
• Very common
gynecological complaint
19 20

155
 Candida Vulvovaginitis Presentation
• Symptoms vulvar pruritis (most
common and may be intense),
vaginal discharge, dyspareunia and
dysuria (“external dysuria” – burning
when urine touches irritated vulvar
skin)
• Exam vulvar erythema, edema,
fissures or excoriation; may see thick,
curdy non odorous discharge (not
always present)
21
Candida Vulvovaginitis Treatment
• Wet mount pseudohyphae,
budding yeast
• Do not treat if asymptomatic
• Treatment is fluconazole (Diflucan)
150mg orally as a single dose or
topical azoles (clotrimazole, miconazole)
• In pregnancy use topical imidazoles only
– 80 95% effective / 2 3 days for relief
Consider checking glucose level (may find
undiagnosed diabetics)
22

Trichomoniasis Overview Trichomoniasis Diagnosis

• Caused by Trichomonas vaginalis, a flagellated • “Strawberry” cervix on
protozoan exam (punctate
submucosal hemorrhages)
• Presentation ranges from asymptomatic to 2% to 10%
complaints of yellow green, frothy, malodorous
(“fishy”) discharge, local pruritus and irritation • Wet mount shows
many WBC and
motile trichomonads
• NAAT testing more
common, better than wet
mount
23 24

156
 Trichomoniasis Treatment Bacterial Vaginosis Diagnosis
• Replacement of normal vaginal
• Treatment differs for women and men flora with Gardnerella/anaerobes
• Women: metronidazole 500mg BID X 7 days • NOT an STI / vaginal exam often
• Men: metronidazole 2g single dose normal / may have fishy or ammonia like odor
• Metronidazole gel is not • To diagnose 3 of 4 criteria per CDC:
effective – Thin, white homogenous discharge (milklike) that
smoothly coats vaginal walls
• Transmitted sexually / treat – Clue cells (vaginal epithelial cells with adherent
partner(s) bacteria) on microscopy
– pH > 4.5 (normal pH 3.8 4.2)
Most common non-viral STI – A fishy odor with potassium hydroxide (KOH) whiff
worldwide test
NAAT tests now available for BV too!
25 26

Bacterial Vaginosis Treatment Bartholin Cyst / Abscess

• Blockage of the Bartholin glands in
• Treat all symptomatic women and all pregnant the vaginal introitus
women
• May just be a cyst or become
– BV increases risk of preterm delivery, premature
rupture of the membranes, PID, STDs infected
• Can treat or not treat asymptomatic women • Abscesses are painful / anaerobic +
• Treatment aerobic bacteria, also gonorrhea,
– Metronidazole 500mg orally chlamydia
BID X 7 days or metronidazole gel X 5d • Treatment is I&D
– Clindamycin cream an alternative • Recurrent – refer for surgery
Consider testing for HIV
and other STIs
27 28

157
 Condyloma Acuminata
• Also called anogenital warts/ direct contact
with human papillomavirus (HPV)
• Found on perineum, penis and perirectal areas
• Usually painless and asymptomatic / may cause
discomfort / patient may notice cauliflower like
“bumps”
• Treated topically (imiquimod, podofilox)
• Cryotherapy, surgical removal
• Prevented by vaccination against HPV;
CDC recommends vaccine for all
children 11 12 years
Sexual Assault Screening
• Guidelines on CDC website
• NAATs (nucleic acid amplification tests – detects
genetic material of the infecting organism) / use
for chlamydia, GC / use regardless of the site of
penetration
• Wet mount for Trich, BV, candidiasis, especially if
vaginal discharge, malodor or itching
• Serology ASAP for HIV infection,
hepatitis B and syphilis (case by
case basis)
29 30

Sexual Assault Treatment

• CDC guidelines (updated 2021)
– Ceftriaxone 500mg IM in a single dose
PLUS
– Doxycycline 100mg po BID X 7 days
PLUS
– Metronidazole 500mg po BID X 7 days (not needed in
males)
• Valacyclovir 1gm orally QID for 5 days
(not a CDC recommendation)
• Emergency contraception
31

158
 Post Assault HIV Prophylaxis
• CDC guidelines:

Call the
national PEP
hotline for
help with
these
decisions:
1-888-448-
4911

159
32
160
 Knee Anatomy, 1
• Poor bony
stability
Knee Disorders • Menisci cushion
and add joint depth
• Ligaments stabilize
but are injury prone
• Large angle of ROM
• Soft tissue
problems are very
common
2

Knee Anatomy, 2 Plain Films of the Knee

• Muscles allow range of motion and stability • Often films reveal very little
• Iliotibial band runs along lateral thigh – can • AP, lateral, and supplemental
become inflamed and cause pain views such as sunrise and oblique
views
• Can consider using
Ottawa Knee Rules
Sunrise View
• Often needed to
rule out fracture first
• Exam is better!

3 4

161
 Ottawa Knee Rules Knee Examination
• An x ray is indicated for any of the following • McMurray’s test (menisci)
(acute knee injuries): • Lachman’s test (ACL)
– Inability to bear weight (4 steps) immediately after • Anterior drawer (ACL)
the injury and in the emergency department (unable
to bear weight twice on each limb regardless of • Posterior drawer (PCL)
limping) • Patellar apprehension (grind)
– Tenderness at the head of the fibula • Pivot shift test (ACL)
– Isolated patellar tenderness • Apley grind test (menisci)
– Inability to flex knee 90o
• Thessaly maneuver (menisci)
– Age 55 years
• See video of full exam at
5 http://www.youtube.com/watch?v=eRPvoNe9Aho&noredirect=1 6

Cruciate Ligament Injuries Segond Fracture

• ACL (anterior cruciate ligament) > PCL • Subtle x ray finding
• “Pop” at the moment of injury • Avulsion of lateral tibia by
• Often able to bear weight the lateral collateral ligament
• Large hemarthrosis develops • Correlates with ACL injury
• Acute knee exam difficult • Usually a large effusion too
• Lachman and anterior drawer (+) • Lateral meniscus injury?
• Negative plain films, EXCEPT: • Knee immobilizer
– Segond fracture or tibial spine fracture • Crutches non weight bearing
• Crutches, pain control, knee immobilizer, refer • Orthopedic referral
7 8

162
 Tibial Spine Fracture O’Donohue’s Terrible Triad
• Lateral knee blow,
• Another subtle x ray finding with a planted foot
• Avulsion by the ACL
• X ray negative
• Also has large effusion
• Three injuries
• Knee immobilizer
– ACL + MCL + meniscus
• Crutches non weight bearing
• Orthopedic referral • Hemarthrosis/effusion
• (This x ray also shows a • Football, soccer, rugby
Segond fracture) • Virtually always needs surgical repair;
9
immobilize and refer 10

Mechanism of Injury Meniscal Injury

• (medial meniscus & • Medial meniscus clearly associated with MCL tear
• ACL + MCL) • Lateral meniscus sneakier (even MRI negative)
• “Bucket handle” tears, flaps, and horn injury
• (Segond) • Degenerative
in elderly
• Delayed pain
• “Catching”
• “Gives way”
• Arthroscopy
11 12

163
 Collateral Knee Ligaments Knee Joint (not Patellar) Dislocations
• Usually spontaneously relocate, so exam may be
• MCL > LCL
relatively normal; history is key!
• In children, partial tears
• Serious problem
• LCL is sneaky – Popliteal artery injury significant concern
• Knee immobilizer + brace • CT angiogram often needed to assess artery
• Rehabilitation is key
• Increase muscle support
• Rarely need emergent MRI
• Ortho referral
• MCL often needs surgery
13 14

Bicruciate Ligamentous Instability Patellar Dislocation

• If on exam, both cruciate ligaments show laxity = • Laxity of the MPFL (younger), or a tear (older)
a bicruciate ligament injury • MPFL = medial patello femoral ligament tears
• IS A KNEE DISLOCATION that has relocated • Obvious on exam
• High risk for popliteal artery injury – if you miss it • Cannot straighten leg
amputation is a possible outcome! • Gently push medially
• Badly injured knees with large effusions should while extending the leg
be discussed with ortho even if x rays are ( ) to reduce
• Pulse assessment is critical, but pulses can be • No risk to vascular structures
present with a popliteal injury – if concerned get (vs. knee joint dislocation
CT angiogram which is high risk)
15 16

164
 Distal Femur Fracture Classification Tibial Plateau Fractures
• Major injury mechanism • Obvious to subtle
• Seek other injuries • Cannot bear weight
• Salter Harris II shown • Oblique views help
• Start an IV • Most need CT
• Admit: ORIF • Proximal fibula may be
• Long splint injured
• CT often needed • Admit or transfer most
• Can lose blood • ORIF required
into leg; consider
type and cross 17 18

Osgood Schlatter’s Disease Child Abuse and the Knee

• Apophysitis seen in the teen years • Child abuse injuries
• Patellar tendon insertion on the tibia • Can be subtle
• Avulsion fracture may occur • Metaphyseal corner
• Diagnosis is clinical fracture (big arrow)
• Not always a “bump” • Bucket handle fracture
• Trauma can provoke it (small arrows)
• R I C E (rest, ice, • Pathognomonic!
compression, elevation) • Full abuse work up
• Consider involving
19 child protective services 20

165
 Knee Osteoarthritis Acute Gout
• Very common
• Obesity
• Aging
• Low activity
• Post traumatic
• Repetitive stress
• Initially X ray ( )
• Acetaminophen
• Eventually total knee replacement
21 22

Knee Gout Pseudogout of the Knee

• Warm tender knee • Calcium pyrophosphate disease (CPPD)
• Alcohol abuse? • Crystals can be seen (in some) on x ray
• Prior history? • Positive birefringent rhomboid shaped crystals
• Knee tap possibly on arthrocentesis
indicated if new Dx
• Chondrocalcinosis
• Needle crystals (calcification of joint
• Uric acid can be cartilage)
normal (but not usually) • Older (60s +)
• No allopurinol in acute
flare (can worsen attack by mobilizing uric acid) • Different joint with each
attack (vs. same joint in gout)
• Usually NSAIDs / steroids; colchicine use more
controversial • NSAIDs + steroids
23 24

166
 Septic Arthritis Open Knee ?
• Staph (age < 2); gonorrhea in the sexually active • Wound exploration may not answer the question
years • Arthrogram may be necessary
• Post surgical (shown) is usually staph and strep • Obtain x rays
– Consult ortho ASAP – Air in the joint?
• Articular cartilage damage can rapidly ensue – Look for FB too
• True emergency, may • If open, consultation
need OR washout is appropriate
• Tap the knee • Ask if uncertain
• IV and lab tests
• WBC, ESR, CRP 25 26

Saline and Methylene Blue Arthrograms Patello Femoral Syndrome

• Runner’s knee
• Both saline and methylene blue (better) are used
for a knee arthrogram (preferences vary) • Chondromalacia
• Dilute the methylene blue dye prior to injection • Patellar apprehension (+)
• Method identical to tapping a knee (sterile)
• Avoid infected skin insertion points
A
• Need to inject a large volume (100cc in adult) D
V
• “Milk” the joint to assess effluent A
N
C
E
D
27 28

167
 Bursitis of the Knee Prepatellar Bursitis (Traumatic) Image
• Prepatellar is common
– Carpet layer’s knee
– Washer woman’s knee
• Traumatic vs. infectious
• Do NOT I&D, aspirate
• Antibiotics if purulent
• Suprapatellar may be
intra articular (unique)
Multiple Sites

29 30

Patellar and Quadriceps Tendon Rupture Popliteal (Baker’s) Cyst

• Adults (35 50 years) > children (4 7 years)
• Extensor mechanism “out”
• Rupture causes pain & swelling (DVT mimic)
• Jump or fall injury
• Ultrasound yields the diagnosis AND rules out DVT
• Patella displaces depending
on which tendon is injured
– Rides up if patellar
– Slips lower if quadriceps
• Bilateral in some
• Increased risk with
fluoroquinolones and steroids?
31 32

168
 Achilles Tendon Injury Plantaris Tendon Tear (Tennis Leg)
• “Push off” mechanism • Plantaris tendon at the
• Complain of a medial head of the
“snap” in the calf gastrocnemius muscle
• Consult ortho – often • “Push off” mechanism
needs surgical repair • Complain of a
• Splint in plantarflexion “snap” in the calf
• Pain higher than Achilles
• Usually partial tear
• Treatment: RICE, rehab
33 34

MRI or CT of the Knee When?

• Often these are not emergent studies, especially if
tendon and ligamentous injuries are the reason
• Patients request them frequently
• If neurovascular injury potential specialist
involvement is warranted
• Consultation timing is institution specific
• Discuss prior to emergent consultation
• MRI or CT may be a result of consultation

35

169
170
36
 Chances of Being Sued (1)
• A review of 9,477,150 ED visits:
Cutting Edge Medicolegal Issues: – 87 EDs in 15 states
Pearls from – Treated by 1,029 EPs in a single, self insured group
(USACS) (2010 2014)
Risk Management Monthly – 98 claims involved 90 physicians (1 in 11 EPs)
– Average patients per hour 2.6 / 20% admissions
• Body Systems
– Neurologic 28
– Gastrointestinal 15
– Cardiovascular 9
– Obstetrics and gynecology 9
– Orthopedics 8
– Respiratory 8
– Other‡ 21 (skin 7, GU 4, ENT 2, Endo 2, Psych 2 2

Chances of Being Sued (2) Behavior of Sued Physicians

• Resolution Survey of the behavior of 65 sued doctors after
– Dismissed 70 being named compared to 140 matched controls*
– Settled 21
– Trial • No significant changes in
• Defense verdict 4
measures of care intensity
(i.e., test ordering) or speed
• Plaintiff verdict 2
– Still in litigation 1 • Press Ganey satisfaction
scores improved immediately,
• Total numbers of years in practice and visit especially in the 46 that had
volume were the only predictors of being sued a failure to diagnose claim
• Being sued was not related to board certification,
sex, admission rate or test ordering volume

• Carlson, J, Ann Emerg Med, February 2020

Carlson, J., Ann Emerg Med, 2/18 3 4

171
Shared Decision Making & Complaints Shared Decision Making & Complaints
Does shared decision making with patients Does shared decision making effect the way
decrease the risk of complaints and intention to patient’s perceive a theoretic physicians?*
contact a lawyer?* • Participants exposed
• 804 adults took an online survey where they to either level of
were presented with a clinical scenario with a shared decision
bad outcome making reported
higher trust, rated
• The intention to complain or contact a lawyer as their physicians
a result of the bad outcome was studied more highly, and
• Participants exposed to shared decision making were less likely to
(some or thorough) were 80% less likely to fault their physicians for the adverse outcome.
report a plan to contact a lawyer or file a
complaint than those exposed to no shared
decision making (12% vs 11% vs 41%). 5
*Schoenfield, Ann Emerg Med, July 2019
6

Source of Lawsuits (1) Source of Lawsuits (2)

• Coverys 1,362 closed ED claims study • Coverys 1,362 closed ED claims study
• Ranking of sites of malpractice suits: • Severity
– Surgery (26%) – Death (36%)
– Physician’s office (25% – Grave injury (2%)
– Inpatient unit (17%) – Major permanent injury (8%)
– ED (13%) – Significant permanent injury (15%)
– Medication related (9%) – Minor permanent injury (9%)
– Procedure related (4%) – Varying severity but temporary (30%)
• Body systems • Top risk management issues
– Cardiovascular (23%) – Clinical judgment (44%)
– Infection (18%) – Clinical systems (10%)
– Neurologic (8%) – Documentation / EHR (10%)
– Medication related (7%) – Communication (8%)
– Fracture dislocation (7%) – Medication related (7%)
– GI related (6%)
– Psychiatric 7 8

172
 Source of Lawsuits (3) Sources of Lawsuits (4)
• Coverys 1,362 closed ED claims study* • The Doctors Company – 332 closed ED claims,
• Issues predisposing to mistakes 2007 2013
– ED environment = rushed, high pressure • The conditions that were most often
– A prematurely narrow diagnostic focus (anchoring) misdiagnosed (or were delayed in being
– Not using tools (guidelines, decision aides) to assist diagnosed)
in the diagnostic process – CVA
– Communication breakdown among providers – AMI
– Spinal epidural abscess
• E.g., the risky practice of conveying important – PE
notifications from the lab and imaging department by – Meningitis
electronic communication vs using something old – Torsion of the testis
fashioned the telephone.
– Subarachnoid hemorrhage
– Lack of caution regarding the top three categories of – Septicemia
drugs involved in ED litigation antibiotics, opioids – Lung cancer
and anticoagulants – Fractures
*Emergency Department Risk: Through the Lens of Liability Claims by Tara Gibson, et al. 9 10
– Appendicitis

Sleep Deprivation and

Sources of Lawsuits (5) Accident Causation (1)
• Patient assessment issues (52%)
– Failure to establish a differential diagnosis • 6,845 drivers involved in MVAs self reported
– Failure to order diagnostic tests
– Premature discharge sleep in the prior 24 hours* (Tefft, Sleep, 10/18)
•
– Failure to address abnormal findings or use available clinical information
Patient factors (21%)
• When compared with drivers reporting 7 to 9
– Physical characteristics (e.g., morbid obesity) hours of sleep, the odds of being found culpable
– Non adherence with follow up calls or appointments’
– Non adherence with treatment plan
among those drivers reporting:
• Communication among providers (17%) – 6 hrs of sleep = 1.3 times
– Failure to communicate
– Failure to review the medical record – 5 hrs of sleep = 1.9 times
– Poor professional relationships/rapport
• Communication between patient/family and clinicians – 4 hrs of sleep = 2.9 times
– Poor rapport with the patient
– Inadequate patient education regarding follow up instructions – Less than 4 hours of sleep = 15.1
– Language barrier
• Insufficient or lack of documentation (13%)
– Failure to record information
– Failure to review the medical record
• Workflow and workload (12%)
– Evening, weekend or holiday staffing inadequate for patient needs
– Long wait time for patients with chest pain or abnormal vital signs 11 12

173
 Sleep Deprivation and
Accident Causation (2) Proof Reading Dictated Notes
• National Sleep Foundation – “Drivers who have • In a review of 51,800 closed claims, automated
slept for two hours or less in the preceding 24 speech recognition was felt to be a factor in only
hours are not fit to operate a motor vehicle." 9 cases*
• In a driving simulation study, 21 hours of • It was not a direct cause of patient harm in any
continuous wakefulness was equivalent to a case
blood alcohol of 0.08g/dL • Despite the evidence
to the contrary
• Driving sleep deprived can the authors advised
be very costly for high net that records be
worth individuals proof read
• Maggie’s Law – NJ – driving • The data would
without sleep for > 24 hours suggest just the
is a criminal offense opposite – proof reading
appears to be a waste of time
13 14

How to Make $500,000 Fast Obtaining Evidence from Prisoners

• Your obligations are to the patient
• You are not an agent of the state
• You cannot be commanded to
do anything relative to the
collection of evidence if a
patient refuses
• A warrant authorizes the police to take certain
actions – warrants do not apply to citizens
• Do not put down any NG tubes or go up
anyone’s butt looking for evidence if the
patient refuses
• Advise the patients of the risk if drug packets
15
break loose. 16

174
 Interesting Situations
• Asymptomatic hypertension
• Retaining intoxicated patient in the ED (Kowalski)
• Residual effects of ED meds ($850,000 crutches)
• Consent for TPA for stroke
• Prescribing unfamiliar doses of psychiatric meds
($1M)
• Co signing chart of patients never seen (billing??)
• Patients assumed care was by an MD/DO
($500,000)
• Audio/video recording of clinicians – HIPPA
• Acknowledging the policy manual of the
department
17
National Practitioner Databank
• Medical malpractice payments (not if you pay personally)
• Federal and state licensure and certification actions
(always, always get an attorney for Medical Board issues)
• Adverse clinical privileges actions (lasting at least 30 days)
• Adverse professional society membership actions (ACEP)
• Negative actions or findings by private accreditation
organizations and peer review organizations
• Health care related criminal convictions and civil
judgments
• Exclusions from participation in a Federal or state health
care program (including Medicare and Medicaid
exclusions) 18

19

175
176
 Headaches: Don’t Miss the
Serious Ones

Approach to Headache, 1 Approach to Headache, examples, 2

Characteristic Concern Need CT? Need LP?
Rapid onset, severe Subarachnoid hemorrhage Yes If CT negative
• Our goal in the ED: pain (maybe)

– To relieve the patient’s pain and discomfort Fever +/ AMS Meningitis, encephalitis Sometimes Yes
Progressively worse, Mass lesion Sometimes Not usually
– Not to miss the emergent, life threatening causes of worse in AM or
head down position
headache
New onset head, Dissection of Yes (angio) No
neck, facial pain cervical/carotid/vertebral
Examples of Types of “Primary” Headaches artery
o Migraine
Vision loss, Idiopathic intracranial HTN Yes Yes (with OP)
o Tension
Response to analgesia does not papilledema,
o Cluster
help distinguish between these increased BMI, F
types of headaches! Acute onset eye Acute angle closure glaucoma No No
Examples of Types of “Secondary”
pain, redness,
Headaches (the serious ones are here!)
decreased acuity
o Trauma
o Vascular Age >50, jaw Giant cell arteritis No No
o Infectious claudication, visual
loss
3 4

177
 Large Subarachnoid Hemorrhages Warning Leak Subarachnoid Hemorrhage
• Acute large bleed
• Sudden headache, possibly abnormal mental status, • Warning leak headache
vomiting, hypertension, stiff neck, severe distress • “Thunderclap” headache
• Most are due to ruptured aneurysms (they run in • Sudden onset, maximum intensity at
families) (1 2% of population) 10 minutes (can be up to one hour),
• CT shows bleed +/ vomiting
• Airway if • May completely resolve with pain
unconscious / medication; still worry about SAH
BP control • May resolve by the time patient
controversial presents for care; still worry
• 50% mortality / • Thunderclap headache – many
50% of survivors causes may be associated with sex,
have neuro deficits exertion, carotid or vertebral
dissection, others

5 6

CT of Subarachnoid Hemorrhage SAH Warning Leak Evaluation, 1

• Some “warning leak” patients will have a normal • Acute, sudden headache and you are
brain CT (esp. if > 6 hours after onset) suspicious for SAH, get a CT head
• The CTs below are abnormal – as noted without contrast
– If < 6 hours after onset, negative
per neuroradiologist read,
effectively rules out SAH
(supported by 2019 ACEP
guidelines)
• Diagnosis of a warning leak must be
made because it may be a harbinger
of a subsequent large, catastrophic
bleed
• Further bleed can be prevented by
either coiling or clipping an aneurysm
to prevent a future bleed after a
7 8
warning leak is detected

178
 SAH Warning Leak Evaluation, 2 CSF Xanthochromia / Bloody CSF
• If CT is negative, more tests needed
– Some recommend LP, but some problems with this
test
• A traumatic tap can sometimes be difficult to
distinguish from a SAH
• Decreasing red cells in successive tubes is
consistent with a traumatic tap, but SAHs have
been reported with these findings as well
• The CSF may appear yellowish if the warning leak
hemorrhage occurred 6 12 hours prior (breakdown Xanthochromia Water
of hemoglobin to bilirubin)
– Others suggest imaging to find source – e.g. CTA
• If negative, workup effectively negative
• If positive, still need LP to determine if lesion
(aneurysm or AVM) actually bled 9 10

SAH Warning Leak Evaluation, 3 Idiopathic Intracranial Hypertension

• Evidence based/Risk stratification approach
– A negative 3rd generation CT within 6 hours of onset read by
• Young, obese, female, irregular
neuroradiology excludes the diagnosis
menstruation
• Perry JJ et al. Stroke 2020 Feb;51(2):424 30
• Nausea, vomiting, visual complaints
• Perry JJ et al. BMJ 2011 Jul 18;343:d4277
• Due to impaired CSF absorption
– Ottawa SAH Rule – no workup needed if none of the • Elevated CSF pressure without mass or
following are present (100% sensitivity (95% CI 94.6% 100%) / obstruction
specificity 13.6%): • Serious outcome – blindness
• Symptoms of neck pain or stiffness (starts peripherally) due to intraocular
ACEP Clinical Policy on hypertension / papilledema
• Age > 40 years old
• Witnessed LOC
Headache (2019)
supports use of this rule
• CT – “slit like” ventricles or normal
• Onset during exertion • LP – high opening pressure
• Thunderclap headache (peak pain instantly) • Treatment – neuro referral, repeat LPs,
acetazolamide, shunt surgery
• Limited neck flexion upon exam 11 12

179
 Post Concussive Headache Post Lumbar Puncture Headache
• Follows trauma (hours to days)
• Technique is a major factor in decreasing the
• Can have dizziness, nausea, incidence of post lumbar puncture headache
decreased concentration, • Use a small needle (#25)
insomnia, anxiety, etc.
• Have bevel of needle parallel
• Physical exam and CT normal with spinal column (hole in
• No resumption of contact dura seals more easily)
sports until cleared at follow up / • Ideally, use a pencil point
serial concussions can be needle – drastically decreases
progressively worse spinal headache incidence (from about 30% to 5 10%)
and it takes a little practice to learn how to use them
• Psychobehavioral symptoms may continue • Limit the amount of fluid withdrawn
for months
• Fluids and flat bed rest not shown to be helpful
• In rare cases, a repeat concussion can result • Analgesics; blood patch is definitive treatment
in brain edema, permanent brain damage
13 14
and even death

Ventricular Shunt Headache

• V P shunts divert CSF to peritoneal cavity when CSF
drainage is blocked
• System has a ventricular catheter, pumping chamber with
one way valve and catheter into peritoneal cavity
• Blockage of the drainage system (kinking, fibrin clot,
disconnection) causes an increase in CSF pressure
• Headache, vomiting, lethargy, irritability
• If unable to compress pumping chamber (usually palpated
on the skull), it is consistent with obstruction / shunt
imaging an option
• Chamber may need to have needle inserted to drain CSF
and lower pressure – may be life saving

15

180
Ventricular – Peritoneal Shunt Image

181
16
 Space Occupying Lesion Headaches Common Headache Types
• Brain tumor headaches
(usually due to increased
CSF pressure)
• New headache
• Increasing in frequency
or duration
• Pain on awakening
• Worse with Valsalva
• Worse when lying down
• Nausea, vomiting
• Look for abnormalities on neuro exam
• Brain abscess (often from frontal sinusitis)
• Toxoplasmosis – most common CNS mass lesion in
HIV patients 17 18

Acute Migraine Treatment

Migraine Characteristics
• First line: NSAID/acetaminophen/triptans
– But patients have usually tried something at home….
• Mostly unilateral
• Second line: Dopamine antagonist anti emetics –
• Nausea, vomiting, photophobia prochlorperazine (drug of choice to relieve most
• Severe, throbbing/pulsatile symptoms), metoclopramide, droperidol
• Migraine without aura (common migraine) • Second line: Triptans – large variety now
• Migraine with aura (classic migraine) has scotomata available contraindicated in heart disease, HTN,
(area of decreased visual acuity), focal neuro signs – Second line also: IV/IM NSAID (ketorolac)
• Have a higher risk of subarachnoid bleeds • ? role of newer drugs in the ED: CGRP, gepants
and ditans
– $$$, some are for prevention only
19 20

182
 Endocrine and
Acid Base Disorders

183
184
2
Diabetic Ketoacidosis Signs and Symptoms

185
3
Diabetic Ketoacidosis Signs and Symptoms Causes of DKA
• Classic manifestations “The I’s Have It”
– Usually due to type 1 diabetes, may be initial
• The “I’s”
manifestation of diabetes
– Infection (PNA, UTI,
– Dehydration – due to osmotic diuresis induced by pancreatitis) *
high glucose (polyuria), vomiting, increased thirst – Infarction (AMI)
– Rapid and/or deep breathing – due to burning of – Infraction (noncompliance –
fats for energy (vs. glucose) / byproduct is ketones diet or meds) *
and ketoacids / acidosis induces a compensatory – Infant (pregnancy)
respiratory alkalosis – Ischemia (CVA)
– Progressive lethargy – can lead to coma – Illegal (illicit drugs)
– Often have abdominal pain with vomiting – Iatrogenic (steroids)
– Idiopathic (new onset)
– Look for precipitants (infection, MI, stressors) 4 5

Diabetic Ketoacidosis Testing, 1 Diabetic Ketoacidosis Testing, 2

• DKA – lab test abnormalities
– Blood
• Elevated blood sugar (can check fingerstick)
• Metabolic acidosis (low pH, low bicarbonate)
• Elevated anion gap
• BUN may be elevated (dehydration)
• Check potassium: May be low,
normal or high
– Urine
• High glucose
• Ketones (a rapid screen in patients
with high fingerstick glucose)
• Tests
– Complete metabolic panel
• Especially anion gap, potassium, HCO3, glucose
– Consider liver function tests
• Mild amylase or lipase elevations nonspecific
• Very high suggests pancreatitis (lipase is much preferred
over amylase to make this diagnosis)
– CBC – Elevated WBC  infection or stress response
– UA Look for infection, ketones, glucose
– CXR look for infection or CHF
– ECG / troponin – if cardiac ischemia suspected
6
– Consider serum ketones, lactate 7

186
 The “Corrected” Serum Sodium Diabetic Ketoacidosis Initial Treatment
• In cases of marked hyperglycemia intracellular • Fluid replacement is crucial
fluid moves from inside cells into the – Balanced crystalloid probably
preferred over normal saline *;
extracellular fluid may change to half normal or
• This dilutes sodium and D5 half normal after rehydrated
serum sodium levels fall – Aggressiveness depends
1.6mEq/l* for every on clinical status
100mg/dl increase in – A depressed level of consciousness may warrant an
immediate rapid infusion of a liter of saline (10ml/kg
plasma glucose in children)
• Corrected sodium = measured sodium + • Subsequent fluids as clinically indicated
([serum glucose – 100)/100] x 1.6*) – Fluid replacement in children with DKA can be tricky
• Consider consulting pediatric intensivist or endocrinologist
• Note: * Some suggest using factor of 2.4 instead 8 • Concern is cerebral edema – rare 9

Diabetic Ketoacidosis Initial Treatment

• Insulin (regular)
– Do not start until potassium level is
known
• Insulin drives potassium into cells
• Timing and dose are linked to initial
K results (if low, hold off)
– Infusion is typically 0.1 units/kg/hour
• No bolus necessary – no longer recommended
– Continue infusion until glucose drops to 250mg/dl,
then change to fluid with dextrose (D5NS or D5 half
NS)
– BMP every 1 2 hours for first few hours, until
electrolytes improve
– K+ supplementation often needed; timing varies 10

187
Diabetic Ketoacidosis Treatment Schema

188
11
 Hyperosmolar Hyperglycemic State
• Typically associated with Type 2
diabetes
• Manifestations
– Nonspecific complaints such as
abdominal pain, nausea, vomiting,
malaise; confusion or coma may be
seen (follow mental status)
– Very high blood glucose / dehydration
due to osmotic diuresis / if abnormal
neurologic function, due to
hyperviscosity
– Ketosis usually not present (or, if so,
mild)
12
189
Hyperosmolar Hyperglycemic State
• Treatment
– Rehydration (deficit can be 8 10
liters) / can give balanced crystalloid
or 0.9% NS at a liter an hour initially
– May change to 0.45NS if corrected
serum sodium high or normal (see
next slide)
– Watch K+ – if low, 10mEq/hr is
reasonable after urine flow
established
– Insulin (hold off if K+ low below 3.3)
/ 0.1 units/kg/hr
13
Hyperosmolar Hyperglycemic Schema

190
14
 Symptoms of Hypoglycemia Diabetic Hypoglycemia
• Symptoms largely epinephrine mediated • In Type 1 diabetes
– Epinephrine increases to release stored glucose – Too much insulin
(glycogen) from the liver – Too little food
• Many CNS symptoms since glucose is brain fuel – Burning too many calories
(exercise, infection)

• Treatment
– Oral sugar, then a serious
meal
– D50W IV if unable to take oral
sugar (D25W in children)
– Can use glucagon
15 16

Diabetic Hypoglycemia Thyroid Related Emergencies Overview

• In Type 2 diabetes • They are uncommon
– Usually due to excess insulin from sulfonylureas
• Measuring a thyroid stimulating hormone level is
– Almost always requires admission or observation due to
prolonged effects usually the fastest way to get a sense of thyroid
• Treatment activity
– Oral sugar / D50W IV if unable to take oral sugar (D25W in – Elevated TSH is consistent
children) with hypothyroidism
– May need IV dextrose infusion if hypoglycemia recurs – Low TSH is consistent
– If sulfonylurea and hypoglycemia continues to recur, consider with hyperthyroidism
IV octreotide • Or pituitary failure –
• Prevents insulin release different clinical picture
• 100 mcg subQ – If TSH is abnormal, more
– Can repeat 50 100 mcg subQ every 6 hours comprehensive thyroid
– Usually 1 3 doses are enough testing can be done
– Alternative: 50 125 mcg/hr IV continuous infusion
17 18

191
Thyroid Related Emergencies Overview

192
19
 Hyperthyroidism and Thyroid Storm Thyroid Storm Treatment
• Hyperthyroidism – end organ • Treatment considerations
effects include tachycardia, – General supportive care
tremor, weight loss, anxiety • IV fluids (with dextrose – watch glucose),
• True thyroid storm is rare acetaminophen for fever, consider cooling measures
– Altered behavior, tachycardia, – Beta blockers
hypertension, hyperthermia, • Blunt the adrenergic excess symptoms
diaphoresis • Propranolol (80 120mg PO) / esmolol 50
– Often precipitated by stressors 100mcg/kg/min if IV beta blocker needed
• Consider doing a TSH in new – Definitive treatment
onset atrial fibrillation • Anti thyroid drugs – PTU is black boxed (liver injury)
/ methimazole is first line except in first trimester of
pregnancy
• Iodine (>1 hour after anti thyroid drugs)
20 – Consider hydrocortisone 100 mg IV q8h 21

Hypothyroidism and Myxedema Crisis Myxedema Crisis Treatment

• Hypothyroidism • Treatment considerations
– Fatigue, cold intolerance, constipation, dry skin, coarse – Pan culture to rule out sepsis / empiric antibiotics
hair, weight gain, progressive lethargy – Passive rewarming if patient is hypothermic
• Myxedema crisis – Hydrocortisone FIRST (100 mg or 5 10mg/hr) after
– A rare clinical diagnosis drawing a cortisol level (absolute or relative adrenal
– Usually occurs in known hypothyroid patients insufficiency often present)
– Confusion, hypotension, hypothermia, slow pulse and – Immediately after hydrocortisone, IV thyroid
respiration hormone (500 800mcg
– Often precipitated by stressors (cold weather, levothyroxine)
infection, many drugs, other stressors) – Correct low glucose and
– Lab – T4/T3 very low, TSH high / creatinine often low sodium
elevated, hypoglycemia / elevated muscle CPK / check
a cortisol level
22 23

193
Before After Hypothyroidism Treatment Acid Base Disorders Quick and Dirty

24 25

Acid Base Disorders Basic Principles Acid Base Disorders Basic Principles
• Respiratory compensation takes minutes to
Acidosis Alkalosis
hours
Respiratory pCO2 > 42 pCO2 < 38 – Example: Respiratory alkalosis attempts to
Metabolic [HCO3] < 24 [HCO3] > 28 compensate for the metabolic acidosis (e.g., DKA)
• Metabolic compensation takes hours to days
• The pH always determines the primary process – Example: Increased serum HCO3 in response to
– Acidemia < 7.38, alkalemia > 7.42 elevated paCO2 in COPD

• “ osis” vs. “ emia” • Compensation never completely corrects

– “ osis” is the process causing the abnormality
– “ emia” is the blood pH measurement • IMPORTANT NOTE: Acid base disorders can
occur even when the pH is in the normal range
26 27

194
 The Blood Gas The Blood Gas
• pH • Base excess
– Determined by both metabolic and respiratory – Amount of excess or insufficient
processes bicarbonate in the system or
– Normal is 7.38 7.42 amount of H+ ions required to
– Venous is fine for pH return the pH to 7.35 if the pCO2
were adjusted to normal
• pCO2 and pO2 reflect – Negative? Base deficit or acid excess in blood
ventilation and
– Normal is 2 to +2 mEq
oxygenation • Base excess > +3 mEq = metabolic alkalosis
– pO2 – check pulse ox • Base excess < 3 mEq = metabolic acidosis
– pCO2 capnography
28 29

Acid Base Concepts Acid Base Concepts

• Four lab values are needed to interpret a
patient’s acid base status • Anion gap = Na + K – (Cl + HCO3)
– From the ABG/VBG – Normal anion gap = 7 12
• pH – Caused because unmeasured anions (e.g., calcium,
• pCO2 magnesium, gamma globulins) exceed unmeasured
– From the chemistry panel cations (albumin, organic acids, etc)
• HCO3
• Anion gap

• If metabolic acidosis, need

to calculate the anion gap (need Na, Cl, K, HCO3)

30 31

195
 Acid Base Concepts Acid Base Concepts
pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Additional
pCO2 should be Disorders? Calc. predicted pCO2 pCO2 should be Disorders? Calc. predicted pCO2
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2 > 40 but < 55 (1.5 x HCO3) + 8 +/- 2

Actual pCO2 too high? Actual pCO2 too high?

Additional respiratory acidosis Additional respiratory acidosis

Actual PCO2 too low? Actual PCO2 too low?

Additional respiratory alkalosis Additional respiratory alkalosis

32 33

Acid Base Concepts Acid Base Concepts

pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Additional
pCO2 should be Disorders? Calc. predicted pCO2 pCO2 should be Disorders? Calc. predicted pCO2
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2 > 40 but < 55 (1.5 x HCO3) + 8 +/- 2

Actual pCO2 too high? Actual pCO2 too high?

Additional respiratory acidosis Additional respiratory acidosis

Actual PCO2 too low? Actual PCO2 too low?

Additional respiratory alkalosis Additional respiratory alkalosis

34 35

196
 Acid Base Concepts Acid Base Concepts
pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Additional
pCO2 should be Disorders? Calc. predicted pCO2 pCO2 should be Disorders? Calc. predicted pCO2
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2 > 40 but < 55 (1.5 x HCO3) + 8 +/- 2

Actual pCO2 too high? Actual pCO2 too high?

Additional respiratory acidosis Additional respiratory acidosis

Actual PCO2 too low? Actual PCO2 too low?

Additional respiratory alkalosis Additional respiratory alkalosis

36 37

Acid Base Concepts Acid Base Concepts

pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Additional
pCO2 should be Disorders? Calc. predicted pCO2 pCO2 should be Disorders? Calc. predicted pCO2
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2 > 40 but < 55 (1.5 x HCO3) + 8 +/- 2

Actual pCO2 too high? Actual pCO2 too high?

Additional respiratory acidosis Additional respiratory acidosis

Actual PCO2 too low? Actual PCO2 too low?

Additional respiratory alkalosis Additional respiratory alkalosis

38 39

197
 Acid Base Concepts Acid Base Concepts
pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Additional
pCO2 should be Disorders? Calc. predicted pCO2 pCO2 should be Disorders? Calc. predicted pCO2
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2 > 40 but < 55 (1.5 x HCO3) + 8 +/- 2

Actual pCO2 too high? Actual pCO2 too high?

Additional respiratory acidosis Additional respiratory acidosis

Actual PCO2 too low? Actual PCO2 too low?

Additional respiratory alkalosis Additional respiratory alkalosis

Calculate Anion Gap

40 (Na + K) – (Cl + HCO3) 41

Acid Base Concepts Acid Base Concepts

pH? pH?
>7.4? <7.4? >7.4? <7.4?
Alkalosis Acidosis Alkalosis Acidosis

pCO2? pCO2?
>40? <40? >40? <40? >40? <40? >40? <40?
Metabolic Respiratory Respiratory Metabolic Metabolic Respiratory Respiratory Metabolic

Additional Calculate
pCO2 should be Disorders? Calc. predicted pCO2 Corrected
> 40 but < 55 (1.5 x HCO3) + 8 +/- 2
Bicarbonate
(Patient’s Anion Gap – 12) + Patient’s Serum Bicarbonate
Actual pCO2 too high?
Additional respiratory acidosis

Actual PCO2 too low? >30? <23?

Additional respiratory alkalosis Underlying Metabolic Underlying non-AG
Alkalosis Metabolic
Acidosis
Calculate Anion Gap
(Na + K) – (Cl + HCO3) 42 43

198
 Metabolic Acidosis Common Causes of Metabolic Acidosis
• Elevated anion gap • Normal anion gap Bicarbonate Loss Increased acid load Impaired acid secretion

• “CMUDPILES” • “Dr FiSHPUCS”

Gastrointestinal losses
Diarrhea
Organic acidosis
Lactic acidosis
Renal failure

– Pancreatic drainage Diabetic ketoacidosis

C = CN or CO toxicity
– M = methanol/metformin
– U= uremia
– D = DKA
– P = paraldehyde
– I = iron, INH, ibuprofen
– D = Diarrhea * Biliary drainage Ethylene glycol intoxication
– R = RTA * Methanol intoxication
Salicylate intoxication
– Fi – Pancreatic fistulae
Renal losses Mineral acidosis Type 1 RTA
– H = Hyperparathyroidism Carbonic anhydrase HCL administration
inhibitors NH4Cl administration
– S = Saline administration Type 2 RTA Cationic amino acid
– P = Parenteral nutrition administration

– L = lactic acidosis – U = Ureteroenteric conduits Dilutional acidosis Adrenal insufficiency

– E = ethanol, ethylene – C = CA inhibitors

glycol – S = Spironolactone
– S = salicylates, starvation * = most common 44 45

Metabolic Alkalosis – “High pH”

• H = Hyperaldosteronism
• I = Iatrogenic (diuretics)*
• G = Gastric losses (vomiting, NG suction)*
• H – Hypercortisolism, Hypercarbia (chronic)
• P = Potassium depletion (severe)
• H = High calcium (interferes with ability to
concentrate urine)
• * most common
• “Chloride responsive”

46

199
Compensation in Acidosis

200
47
Compensation in Alkalosis

201
48
 Acid Base Bottom Line
• Don’t freak out!
• Metabolic acidosis?
– Elevated anion gap?
• Possible life threats –
use the mnemonic
– No elevated anion gap?
• Usually, diarrhea or RTA
• Respiratory acidosis?
– We can fix this
(increase ventilation)
49

202
 Hip and Pelvis Disorders:
Don’t Miss the Subtle Ones

Pediatric Hip Disorders Pediatric Hip Anatomy

• Ossification centers
• Slipped capital
femoral epiphysis • Acetabulum shallow
• Legg Calve Perthes • Non weight bearing
• Septic hip for the first year
• Toxic synovitis • Less muscle mass in
• Hip dysplasia the legs and trunk
• Dislocations • Vascular continuity
• The “limping” child from femur to joint
• Referred knee pain through growth plate
• Difficult diagnosis 3 4

203
 Neonatal Congenital Hip Dysplasia Ortolani Test For Hip Dysplasia
• Screening at birth • The Ortolani Test
• 0.4% of deliveries – Flex hip and knee to
• First born girls: L > R 90 degrees
• Breech birth – Abduct the thigh
• Oligohydramnios – The lateral aspect of
both thighs should
• Barlow and Ortolani touch the table
tests (should only be – The dislocated side
performed in infants will be restricted and
3 months or less – may a click will be
result in inability to relocate hip in older infants – perceived as the hip
no click will be felt and hip will remain slips out of the
acetabulum
dislocated) 5 6

Barlow Test For Hip Dysplasia “Limp” Differential Divided By Age

• The Barlow Test
– Hip is flexed and
thigh adducted
– Push posteriorly in
line of the shaft of
the femur
– Will cause femoral
head to displace
posteriorly from
acetabulum
– Dislocation is
palpably appreciated
• Is usually done in
conjunction with the
Ortolani test 7 8

204
 Legg Calve Perthes Legg Calve Perthes
• Avascular hip necrosis
• 10 15% bilateral
• Age 4 10 (M>F)
• Causes
– Genetic
– Sickle cell
– Steroids
– Trauma history in
the minority of cases
• Intermittent limp
• Referred pain to knees; always examine one joint
above and one below painful joint
9 10

Slipped Capital Femoral Epiphysis, 1 Slipped Capital Femoral Epiphysis

• Occurs during phase of maximum growth (11 13
for females, 13 15 for males) / overweight
• Often bilateral / variable history of trauma
• Consider diagnosis if complaints of knee pain
referred pain to the knee
• Typical position of hip = external rotation
• Melted ice cream cone on radiograph (below)

11 12

205
 Slipped Capital Femoral Epiphysis, 2 SCFE Klein’s Lines

• Klein’s line – drawn along superior border of the

femoral neck
• In SCFE Klein’s line “misses” the femoral head 13 14

Septic Hip Overview Septic Hip Etiology

• Clinical predictors • In pediatrics, most is due to
– Fever > 38.5, WBC > 12 hematogenous spread
– Non weight bearing • In adults, due to IVDU and
– CRP > 20 and ESR > 40
post surgical causes
– Prior hip surgery in adults • Most cases are staph,
but not ALL (often Gram
• Blood cultures often negatives in IVDU / also
negative most likely to involve
• Ultrasound allows diagnosis of a joint effusion non extremity joints)
and can guide aspiration for diagnosis • Rapidly destructive
• MRI allows diagnosis of extra articular pathology • TRUE EMERGENCY
15 16

206
 Infections Mimicking Septic Hip Toxic Synovitis (Irritable Hip)
• Toxic synovitis is a misnomer, because child is not
toxic, no bacterial infection, just inflammation
• Also called “irritable hip” – hip pain, limp – don’t
mistake for a bacterial process
• Joint effusion develops
• Ages 2 5 / M>F
• CBC and sed rate usually normal (usually elevated
in septic hip)
• Can be post viral or post strep
17 • Resolves with NSAIDs 18

Avulsion Fractures Overview Pelvic Avulsion Fractures Locations

• Occurs in pubertal athletes, when muscle
strength exceeds new bone strength
• 2:1 male to female ratio (M>F)
• Apophyseal injuries can have negative x rays if
the apophysis is not calcified or is non displaced
• Ischial tuberosity (track), anterior inferior iliac
spine (soccer) and anterior superior iliac spine
(ballet) are the most common injury sites
• Can present as hip pain, with an audible “pop”
• Bruising often absent
19 20

207
 Adult Hip Anatomy Hip Dislocations Overview
• Posterior = 95%
• Traumatic (as shown)
• Knee into dashboard;
also slip and fall
• Internally rotated + short +
adducted
• Time to relocation determines incidence of AVN
• Early aggressive pain management a priority
• Procedural sedation and analgesia will be
necessary to achieve relocation
21 22

Posterior Hip Dislocation Images Posterior Hip Dislocation Images

Posterior
Dislocation

Internal Rotation

23 24

208
Posterior Hip Dislocation Reduction Anterior Hip Dislocation
• Rare < 5%
• External rotation +
abduction
• Can occur when
Allis knee strikes
Method
dashboard with
thigh abducted /
blow from back
“Whistler Internal Rotation when patient in
Method” a squatted position Inferior Anterior Dislocation
• Two Subtypes:
inferior to acetabulum and superior to it
• Neurovascular compression of the femoral nerve
and artery can occur as can associated fractures
25 (esp. femoral head) 26

Anterior Hip Dislocation Dislocated Prosthetic Hip

• Special situation
• 3 4% of first time
replacements and
about 15% of revisions
• Can be recurrent
• Relocation can displace
the socket (a major
problem)
Inferior Anterior Dislocation • Consult ortho
27 28

209
 Hip Fracture Overview, 1
• Intertrochanteric and subtrochanteric fractures
require high force look for other injuries
• Pain management will usually require an IV and
labs (pre op) will usually be sent
• Consider regional nerve block (femoral)
• CXR, ECG, and Foley per institution protocols
(but, in general, Foley catheters are significantly
overused in the ED setting)
• Elderly patients generally have comorbidities
• Rapid surgery (same day) substantially decreases
post op morbidity
29
Types of Hip Fractures
31
210
Elderly Hip Fracture Overview, 2
• Minimal trauma (osteoporosis)
• Pathologic fracture incidence goes up
• Films can be hard to interpret due to DJD,
osteoporosis, overlying calcifications, etc.
• Surgery is easier when non displaced than when
displaced, therefore delayed diagnosis with
associated displacement is bad
• Comorbidities often require an internist or
hospitalist to provide medical care and often the
orthopedist will be a consultant not the primary
• Need rapid surgery – do what you can to make it
happen (decreases post op morbidity)
30
Occult Hip Fracture Overview
• Occult fractures in about 4%
• Patient usually cannot / will not walk, but may be
able to walk with pain
• No trauma or falls required (can break
spontaneously due to osteoporosis)
• Plain x rays can miss the diagnosis
• Low threshold for CT / MRI (MRI may be better)
• A “missed fracture” can become displaced
(harder to fix, potentially worse outcome)
• Don’t assume hip pain is due to “arthritis”
32
 Occult Hip Fracture Algorithm Occult Hip Fracture Images

33 34

Greater Trochanteric Bursitis

• Inflammation of the
trochanteric bursa
• The buttock muscles
(gluteus medius and
minimus) attach to the
greater trochanter
• Can be post traumatic
• Pain and tenderness
over lateral proximal hip
• Most common in middle aged women
• Treatment – avoiding movements that cause the
pain (usually hip abduction), NSAIDs, steroid
injections (usually by an orthopedist), PT 35

211
212
 Bony Anatomy Overview

Elbow and Forearm

Complaints Olecranon

Distal Forearm Soft Tissue Anatomy

• Flexors of the
fingers and
wrist are in the
anterior
compartment
(ulnar nerve)
• Extensors are
in the posterior
compartment
(12 muscles,
3
radial nerve) 4

213
 Key Concepts Who Needs an Elbow X Ray?
• Always examine the joint above and below the • The ability to lock the
area of any extremity injury / document
elbow in full extension
• Any exam of a traumatized extremity should has been shown to be
include a neurovascular exam / document
about 95% accurate in
• After splints or casts are applied ALWAYS excluding a fracture
examine for, and document, a neurocirculatory
exam to assure that there is no compromise prior • Point tenderness should
to discharge also help indicate who
• If neurovascular compromise, consider involving needs an x ray
specialist urgently • Amount of x rays saved
– May need to reduce fracture – can restore circulation varies by study (15 50%)
5 6

Elbow Fat Pad Overview Fat Pad X Ray Images

• Most abnormal fat pads are caused by
intraarticular fractures with blood in the joint • Normal anterior • Abnormal fat pads
• A small anterior fat pad can be normal fat pad (anterior and posterior)
• A larger anterior fat pad is abnormal
• Most abnormal anterior fat pads are associated
with subtle fractures even when plain x rays are
negative
• A posterior fat pad is virtually always abnormal
• Usually sling or splint and refer – although one
study indicated that many were pain free with a
week
Subtle Radial Head Fracture
7 8

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 Radial Head Fracture Overview Radial Head Fracture X Rays
• By far the most common
adult fracture of the elbow
• Fall on outstretch hand
(FOOSH) the usual
mechanism
• Often very, very subtle
• Most pathologic
anterior fat pads
are caused by radial
head fractures
• Opinions differ
regarding the extent • A very subtle vertical fracture thru the radial
of immobilization
9 head with both anterior and posterior fat pads 10

Supracondylar Humerus Fractures Important Lines of the Elbow

• Most common elbow fracture in children
• In subtle cases do the anterior humeral line test
– In most children (not all), the anterior humeral line
goes thru the middle third of the capitellum
– If the line goes thru the anterior third it suggests that
the capitellum has been displaced posteriorly
consistent with a supracondylar fracture
• Significantly displaced supracondylar fractures can
frequently compromise neurovascular function –
consider immediate ortho consultation, often
need surgery
11 12

215
 Anterior Humeral Line
• A normal anterior humeral line – goes through
middle third of capitellum
Occult Elbow Fractures
PEDIATRIC
• Consider ability to lock in
extension / point tenderness
• Supracondylar humerus
fractures are most common
• Anterior humeral line analysis
is key
• Fat pad analysis; posterior fat
pad never normal
• Can be very subtle
• If any doubt, consider ortho
consultation
Anterior Humeral Line
• An abnormal humeral line with obvious
pathologic anterior and posterior fat pads
consistent with a supracondylar fracture
13 14
Epicondylar Fractures
ADULT
• Usually a pediatric injury
• Consider ability to lock in
extension / point tenderness • Ages 9 14
• Radial head fractures are the • Avulsion fracture; most
most common
commonly medial (shown)
• Obliques or radial head
capitellum views help with • Extra capsular
diagnosis
• No fat pad signs
• Fat pad analysis; posterior fat
pad never normal • Comparison views?
• Radial head palpation on exam
• Can be Salter Harris IV
+/ crepitance
15
• ORIF commonly done for displaced fractures 16
216
 Growth Plates at the Elbow Elbow Dislocations
• Posterior most common
• Growth plates • Fall on outstretched hand
FOOSH the usual mechanism
may be confused 9
5 • May require procedural
with fractures sedation
11
• C R I T O E; in • Traction at wrist, countertraction
order by age 1 7
above the olecranon
– 1 3 5 7 9 11 3 • Post reduction check
• Comparison views? of neurovascular status
is essential
• Clinical exam is • Recent studies show
important C = Capitulum T = Trochlea
improved outcomes with
R = Radius O = Olecranon
I = Internal epicondyle E = Ext. Epicondyle 17 sling vs. splint (when no fractures) 18

Olecranon Bursitis Overview Olecranon Bursitis Treatment

• If infection is suspected, can do CBC, Gram stain,
• Often caused by local irritation (persistent resting culture
on olecranon area of elbow) • If mechanism of injury is suspicious for infection
• Can be infected (erythema, warm, tender) – if so, (abrasion, puncture) consider antibiotics (usually
generally staph antistaph drugs)
• Gout can be a cause as well • If aspirate is turbid, consider infection even if
Gram stain negative
as rheumatoid arthritis
• Aspirate WBC – noninflammatory if less than
• X rays generally not needed 2000 cells per microliter
– A calcium deposit may • If no infection (clear fluid, no clinical signs of
be noted off the olecranon infection, etc.) intrabursal steroids and
process – it is not a fracture anesthetic agent (50:50 triamcinolone /
lidocaine) and a compressive dressing work
19 better than NSAIDs 20

217
 Olecranon Bursitis Images Radial Head Subluxation Overview
• Also called “nursemaid’s elbow”
• Olecranon bursitis with and without
inflammation (exclude infection) and calcium • Caused by pulling on extended upper extremity
deposit off olecranon • Radial head pulls slightly away from its normal
position and surrounding ligaments slip into the
Not Inflamed joint
Inflamed
• Sudden decrease in elbow movement by child
with little complaint of pain
• Extremity held adducted, slight flexion, pronated
• Age 2 3 most commonly / about a third recur
21 • Explain to parents how to prevent and how to fix
22

Radial Head Subluxation Mechanism Radial Head Subluxation Reduction

• No films necessary if diagnosis is certain and
responds to treatment – click felt, moves normally
• Supination and flexion with pressure on the radial
head (standard approach for years)
• Hyperpronation technique a better option, less
painful Hyperpronation Technique
Classic Technique: Supinate and Flex

23 24

218
 Specific Forearm Fractures Colles Fracture

25 26

Distal Forearm Fracture Types Distal Forearm Fracture Treatment

• If minimally displaced, splint and refer
• If greater displacement and angulation, closed
reduction will be required
• Intra articular fractures should be noted
• Wide variation in management provider to
provider
• Can be Salter Harris (usually type II) in children
• Careful median nerve examination a must!
• Some will require ORIF; consult ortho
27 28

219
 Salter Harris Fracture Classification Salter Harris Images
• Slip/Straight – Above – Lower – Through – Ram Salter Harris II Salter Harris V Salter Harris III
• Spells out SALTR and helps to keep these straight (most common) (severe) (intra articular)

Slip Above

Lower Through Ram Above Lower

Ram (Below
(Epiphysis)
Epiphysis)

29 30

Overuse Syndromes Finklestein’s Test

• Epicondylitis
– Lateral (tennis elbow) – wrist extensors
– Medial (golfer’s or Little League elbow) – wrist flexors
– Rest, NSAIDs, counter force
bracing and physical therapy
– Injected steroids have some risks
and long term outcomes are not as good as short term
• Wrist into thumb (DeQuervain’s tenosynovitis)
– Positive Finklestein test (pain on ulnar deviation)
– Often with palpable crepitus on ulnar deviation Location of pain
– Thumb spica splint and NSAIDs
• Steroids injection if no improvement
31 32

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 Essential Pediatrics

Consent for Treating Minors Treating Children, General Principles

• EMTALA – medical screening needs no consent • Keep family in room unless child
• Life / limb threatening emergency becomes more agitated in their
• State protected right to treatment presence
– Child abuse
– Pregnancy • Appropriately sized equipment
– STDs vitally important
– Substance abuse – When weight unknown, best to
– Outpatient mental determine equipment sizes and drug
health (some states) doses using length based systems
• Failure to report child abuse with a bad outcome = such as the Broselow tape
criminal and civil suit
• State defined “emancipated minor” status • Dosing errors can be avoided with
– Married the eBroselow bar code system
– Member of armed forces
– Self supporting and living on own 3 4

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 Inconsolable Crying
• Intestinal colic – most common cause of excessive
crying in infants – 3 or more hours/day for 3 or more
days per week over a 3 week period / self limited / 13%
of neonates
• Trauma
– Soft tissue or bony trauma
(falls or battered child)
– Strangulation of digit / penis (Nair)
– Corneal abrasion
• Infections
– Meningitis, otitis, UTI, gastroenteritis
• Surgical conditions (look under the diaper)
– Incarcerated hernia, testicular torsion, anal fissure
Neonatal Jaundice, 2
• Breast feeding related jaundice (5 10% of cases)
– Glucuronyl transferase inhibitors in breast milk
– Can reach a peak of 10 27mg/dl by days 10 21
– Cessation of breast feeding leads to a rapid decline over 2 3
days but is not generally advised / is unlikely to cause
kernicterus (neurotoxicity)
• AAP / UV light treatment in those otherwise well
– If 24 48 hrs old and at least 15mg/dl, 49 72 hrs old and at
least 18mg/dl, over 72 hrs and at least 20mg/dl
• Screening tests
– Bilirubin – if “direct” (conjugated) bilirubin is elevated
(already processed by the liver) suggests possible biliary
obstruction with regurgitation into blood steam admission
– CBC, Coombs test for hemolytic antibodies (they lyse RBCs)
Neonatal Jaundice, 1
• Most common cause of readmission
• ED presenting jaundice:
– Physiologic (>50% of cases)
• Due to hemolysis of fetal RBCs
• Characterized by bilirubin rising
at <5mg/dl per 24 hrs
• Peak of 5 6mg/dl during the 2nd to 4th days of life
• Decrease to <2mg/dl by 5 7 days
– Sepsis related jaundice
• Higher levels and associated signs of sepsis are likely
5 6
Vomiting in Infants
• Vomiting (forceful compared to regurgitation =
“spitting up”)
– Infections (UTIs, sepsis, gastroenteritis)
– Hepatobiliary disease (usually have jaundice)
– Malrotation of the gut (bilious vomiting = surgical
emergency) / half diagnosed in the first month of life
– Pyloric stenosis
– Incarcerated hernia
– Increased ICP (shaken baby) (abusive head trauma)
– Intussusception
• Ondansetron – dosing recommendations vary
– 0.15mg/kg or 8 15kg=2mg, 15 30kg=4mg, >30kg=8mg
– Or 6 12 mo [1.6mg], 1 3 yr [3.2mg], 4 and over 4mg
7 8
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 Diarrhea in Infants Pyloric Stenosis
• Infections (infectious enteritis) • Most common cause of GI obstruction in infancy
– Viruses = rotavirus (adenoviruses are 2nd most • Can run in families (esp., northern European)
common) / 3 15 months of age / Winter • 4:1 males / 30% are first borns
• Oral rotavirus vaccines are available (given at 2, 4, 6
months [RotaTeq] or 2 and 4 months [Rotarix) / • Usual age = 3 weeks (95%, 3 12 weeks)
about 90% effective in preventing severe disease, • Nonbilious vomiting (projectile
66% for mild
– Bacteria = most common Summer cause
in up to 70%) after eating /
• Staph causes diarrhea rapidly due to preformed persistent hunger
exotoxin • Palpable pyloric “olive” in up to
• Bloody diarrhea = salmonella & shigella / shigella = 60 80% (ultrasound)
high fevers, febrile seizures then bloody diarrhea
• Leading causes of blood in the stool in infants: • Classically have hypochloremic, hypokalemic
– Unknown, cow’s milk intolerance, anal fissure, some metabolic alkalosis (check routine labs)
say swallowed maternal blood (?? cracked nipples) • Surgical consult
9 10

Intussusception Brief Resolved Unexplained Event (BRUE)(1)

• Most common cause of bowel • AAP clinical guideline, Pediatrics, May 2016
obstruction between 3 mo – 6 yr • Duration < 1 min, age < 1 with at least one of the
(most at 2 12 mo) following:
• Predisposers = Meckel’s / polyp – Cyanosis or pallor
– Absent, decreased or
• Ileocolic most common irregular breathing
• “Currant jelly” stools is a late finding / 50% only – Marked change in muscle
• Sudden pain with sudden relief tone (hyper or hypotonia)
of pain – Altered level of consciousness
• Some become very still, listless • Patient must be otherwise well appearing and
and pale between episodes of pain back to baseline health at the time of
• Sausage shaped tumor mass in right abdomen presentation, and, on evaluation, have no
or epigastrium in two thirds / do ultrasound condition that could explain the event (e.g., URI)
11 12

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 Brief Resolved Unexplained Event (BRUE)(2) Characteristics of Simple Febrile Seizures
• Criteria for designating low risk:
– First BRUE / Age > 60 days
• Fever (usually over 102F [39C])
• Gestational age equal to or greater than 32 weeks • Age 6 months to 6 years
and postconceptual age of 45 weeks or greater • Brief, generalized seizures, no or minimal post
– No CPR required by trained medical provider ictal period
– No worrisome Hx (e.g., abuse, FH sudden death, toxic • Resolves without treatment
exposure, GER) or PE (brusing, murmur, nasal congestion)
• Management recommendations for low risk: • Duration 5 minutes or less
– Shared decision making re. evaluation, disposition, F/U • Previously normal neuro exam
– May get pertussis testing? ECG?, brief period of • Tend to occur in families
continuous pulse ox monitoring with serial observation • No other cause found
– Don’t order testing or monitoring for cardiopulmonary,
child abuse, neurologic, ID, GI, IEM, or anemia, • Can have no or minimal work up
including home cardiorespiratory monitoring and depending on exam and age
admission solely for cardiorespiratory monitoring • 2% risk of subsequent epilepsy
– Long list of “need not” items 13 14

Characteristics of Complex Febrile Seizures Nonfebrile New Onset Seizures

• Age, fever, normal baseline same as for simple
febrile seizures • Consider
• Seizure is atypical – Hypoglycemia D10W
focal
prolonged (> 15 min)
– Hyponatremia – NS or 3% NaCl
multiple seizures in a row – Hypocalcemia calcium gluconate
residual paralysis (called Todd’s paralysis)
– Hypomagnesemia magnesium sulfate
• Often need workup including lab tests,
imaging, LP, cultures – INH ingestion – pyridoxine (B6)
• Treatment – usually requires none (cooling) – Hypertension – hydralazine
• Can give rectal or IV benzo (lorazepam,
midazolam or diazepam) See Amer. Epil. Soc. – CNS infection
guidelines https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850470/#B8 – Head trauma
15 16
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224
 Causes of Pediatric Dehydration Pediatric Dehydration Assessment
• Common causes Symptom/Sign
Mild
Dehydration
Moderate
Dehydration
Severe Dehydration

– Gastroenteritis
Level of Alert Lethargic Obtunded
• “Gastro” = vomiting consciousness
Capillary refill* 2s 2-4 s >4 s, cool limbs
• “Enteritis” = diarrhea
Mucous membranes Normal Dry Parched, cracked
• Need both to technically Tears Normal Decreased Absent
call it gastroenteritis Heart rate Slightly increased Increased Very increased

• Usually viral / self limiting Respiratory

rate/pattern*
Normal Increased Increased and
hyperpnea
– Stomatitis Blood pressure Normal Normal, but orthostasis Decreased

– Diabetic ketoacidosis Pulse Normal Thready Faint or impalpable

Skin turgor* Normal Slow Tenting

– Febrile illness Fontanel Normal Depressed Sunken
– Pharyngitis Eyes Normal Sunken Very sunken

• Uncommon causes (extensive list) 17

Urine output Decreased Oliguria Oliguria/anuria
18
* Best indicators of hydration status[6]

Pediatric Fluid Rehydration Pediatric Fluid Maintenance

• AAP says oral rehydration therapy (ORT) for mild to
moderate dehydration (“sippy diet” – 5ml q 2 5 minutes)
Pedialyte or similar (failure rate – about 5%), consider
ondansetron / check a finger stick glucose
• Estimation of dehydration – use clinical judgment
assessing the overall constellation of symptoms
• How much fluid (AAFP guidelines, 2009 – excellent read)
– Mild dehydration = 50ml/kg fluid deficit (30ml/kg if >10kg)
– Moderate dehydration = 100ml/kg deficit (60ml/kg if >10kg)
– Severe dehydration = after serial boluses of 20ml/kg over 10
15 minutes (often 60ml/kg over an hour) (D5NS or D5RL) then
ORT at 100ml/kg over 4hr) / do chemistries in this subset
• How fast? – generally rehydrate over 4 hours 19
• Maintenance fluids for 24 hours (Holliday Segar
Method)
– 100 mL/kg for each of the first 10kg of weight
– 50 mL/kg for each of the second 10kg of weight
– 20 mL/kg for each remaining kg of weight
• Fluid deficit for 24 hours
– 10 mL/kg for each % of dehydration
• Additional fluid for ongoing losses
– 10mL/kg for persistent fever
– 10mL/kg for each loose stool
20

225
 Apgar Score Neonatal Resuscitation Priorities
Component of
Score - 0 Score - 1 Score - 2
Acronym • Dry, warm, positioning, suction, tactile
blue all
blue at stimulation
Skin color extremities normal Appearance
over
body pink • Oxygen
Heart rate absent <100 >100 Pulse • Bag valve mask ventilation
Reflex
no
grimace/
feeble cry
sneeze/cough/pulls • Chest compression
response away Grimace
irritability when
to stimuli
stimulated
when stimulated • Intubation
Muscle tone none some flexion active movement Activity • Access via umbilical venous line
Respiration absent
weak or
irregular
strong Respiration • Drugs – watch glucose, epinephrine,
fluids, bicarb, naloxone, dopamine
Mnemonic -- How Ready Is The Child?
H = heart rate, R = resp. effort, I = irritability, T = tone, C = color 21 22

Pediatric ACLS Procedures, 1 Pediatric ACLS Procedures, 2

• Defibrillation = 2 J/kg (double dose if unsuccessful) • Most pediatric arrests are due to a respiratory
cause
• Cardioversion = 0.5 J/kg (synchronized)
• Asystole is the most common arrest rhythm
• ET intubation: Cuffed or uncuffed tube okay
• Bradycardia is 2nd most common arrest rhythm
• ET size: Cuffed size = 3.5 + (age/4), uncuffed tube
size = 4 + (age/4) • Epinephrine is the drug of choice in asystole
and the inotrope of choice in children
• Air leaks are normal with an uncuffed tube at peak
inspiratory pressures • Always intubate, ventilate and oxygenate before
giving drugs
• Surgical cricothyrotomy is not recommended for
children younger than 8 yrs • Correctable causes of PEA hypovolemia,
tension pneumothorax, tamponade
• Fluid resuscitation: 20 mL/kg NS boluses; consider
intraosseous access • Vfib and Vtach are rare think hyperkalemia,
tricyclics, hypothermia
23 24

226
 Hand and Wrist (Carpus) Injuries
• Extremely common injuries
Hand and Wrist • Complex anatomy
Problems • Unfamiliar injuries are not recognized
• Alcohol intoxication can affect both delayed and
missed diagnoses (some providers wait for
patient to sober up just to get a thorough exam)
• Some injuries are ONLY found by thorough
wound exploration
• A solid, working knowledge of hand and wrist
anatomy and function is essential
2

Bony Anatomy Hand and Wrist Sensory Innervation of the Hand

• Name fingers
– Index, long, ring
and small
• Use “radial” and
“ulnar” to describe
sides of fingers (vs.
medial or lateral)
• DIP, PIP, MCP joints
• Dorsal (palmar) and
volar
3 4

227
 Motor Innervation of the Hand
• Median nerve = “tea drinking”
– Have patient make circle with
thumb and index finger
• Ulnar nerve = intrinsic muscles
– Have patient cross their index
and long fingers
– If injured, “Pope’s sign” (ring
and small fingers flexed, others
extended)
• Radial nerve = extensor muscles
– Have patient “stop traffic” by
extending the wrist
– If injured, wrist drop
5

228
Finger Flexor Tendon Anatomy

Flexes PIP Flexes DIP

Joint Joint
229
6
 Finger Flexor Tendon Anatomy
• Flexor digitorum
profundus (= deep)
(flexes DIP joint)
• Flexor digitorum
superficialis
(= superficial)
(flexes PIP joint)

230
7
 Finger Flexor Tendon Testing Basic Nerve Functions and Exams
• Flexor digitorum profundus
– Hold proximal interphalangeal
joint and the metacarpal
phalangeal joint in extension
and try to flex the distal
interphalangeal joint

• Flexor digitorum superficialis

– Hold the unaffected fingers in
extension and attempt to flex the
injured finger

8 9

Tuft Fractures Mallet Finger

• Closed in a door • Injury to distal extensor
• Dropped heavy object tendon insertion
• Subungual hematomas • Swann neck deformity
• Avulsion fracture may
• If open, treat with be involved
anti staph antibiotics • Simple hyperextension
– Some do not agree splinting is usual
• If intra articular, refer treatment
• Splint for protection • If fractured & involves
larger intra articular
• Pain medications surface, pins may be
10
needed 11

231
 Subungual Hematomas Nailbed Repair
• Trephination with 18g • If complex lacerations are involving the nail
needle, red hot paper clip plate; consider removal and repair
or electrical cautery • Fine absorbable suture
• Do not need to remove • Restore anatomy
nail • Reinsert nail?
• If a fracture is below, use – Controversial
of antibiotics debated
• Splint
• Antibiotics
• Nail regrowth is
12 very slow… warn the patient it will take time 13

Trigger Finger Felon and Paronychia

• DIP or PIP joints stays flexed
and can’t be easily straightened Felon Paronychia
actively / a palpable click is felt • Pulp space infection • Nail bed only
on active or passive extension
• Digital block • Digital block
• Cause is development of a fibrocartilaginous lump
in the extensor tendon sheath locks the distal • Antibiotics + drainage • Drainage only
phalanx in flexion • More serious • Stab v. Elevate
• Treatment activity moderation, NSAIDS, splints, • Easier to treat
hand therapy, steroid injections, and finally
surgery (in an escalating fashion)
• Consider injection but risky (infections, tendon
weakening and rupture)
• Radiographs are usually negative (unnecessary?) 14 15

232
 Herpetic Whitlow Flexor Tenosynovitis
• Note the vesicular pattern • Bite, splinter, puncture;
• Do NOT I&D these herpetic may be hematogenous (GC)
myositis may result! • Violated tendon sheath
• Distinguish from paronychia • Kanaval’s signs:
or felon – Fusiform swelling
• HSV 1 (simplex) or 2 – Pain with passive extension
• Acyclovir treatment – Pain with palpation of
proximal tendon sheath
• If superinfected may
– Flexed posture at rest (maximizes space for infection)
consider antibiotics
• Surgical emergency
16 17

Boxer’s Fracture Metacarpal Fractures

• Common injury
• Open MC joint?
• Extensor tendon injury?
• Rotational deformity is
not acceptable
• < 40 degrees flexion OK
• Ulnar gutter splint
– Buddy taping an option?
• Ortho referral • Multiple varieties, some need surgery, some do
well casted
• Assess for rotational aspect & joint involvement
19
18

233
 Boutonniere’s Deformity Proximal Thumb Fractures
Rolando’s Fracture Bennett’s Fracture
• Central slip of extensor
• More severe of the two • Tends to become displaced
tendon is disrupted • Intra articular with collapse • ORIF/pins often needed
• Avulsion fracture +/ of the thumb base
• Comminuted & shortened
• Classic position shown
• Surgically repaired; consult
• Lateral bands pull PIP into
a flexed position (in blue)
• Operative repair needed
• Ortho or hand surgeon

20 21

Skier’s Thumb (Gamekeeper’s) Carpal Tunnel Syndrome

• Ulnar collateral ligament • Work related (?) cumulative
trauma or repetitive stress
• Exam as shown • Hand numbness and ache
• May have avulsion fracture • Median nerve compression
• Compare to normal side • Carpal tunnel is crowded
• Laxity and focal pain • Atrophy of thenar muscles
• Some need operative care • Phalen’s test – median nerve
distribution pain and/or
• Injury on the opposite side (radial collateral paresthesias within 60 sec
ligament is less common (bull rider’s thumb) on gently flexing the wrist
• Thumb spica splint or cast for both initially as far as possible
22 • Wrist splint, NSAIDS, refer 23

234
 Common Subtle Wrist Injuries Scaphoid Fracture Overview
• Be very cautious making the diagnosis of a wrist
“sprain” • A “can’t miss” fracture due to potential for
avascular necrosis and nonunion due to unique
• The most common retrograde blood supply
mechanism for wrist
injuries is the fall on • Clinical characteristics
the outstretched hand – The most frequently
( a “FOOSH”) fractured carpal bone
– Usually a FOOSH
• Can generate a substantial axial load mechanism
• Common serious injuries are scaphoid fractures, – “Snuff box” tenderness
scapho lunate dissociations, lunate and perilunate – Pain on thumb axial loading
dislocations – Tenderness of the scaphoid tubercle
• Often difficult to diagnose but they can have – X rays are often nondiagnostic
substantial long term consequences if missed
24 25

Scaphoid Fracture Tests Scaphoid Imaging Options

• Multiple options / all assume clinical suspicion is
• Snuff box • Scaphoid tubercle relatively high
tenderness tenderness – Plain x ray with scaphoid views (lateral [external]
rotation of the hand)
• If negative, long arm thumb spica (safest method of
immobilization – some use short arm thumb spicas) and
repeat x ray and exam in 7 10 days
– CT scan (better than plain films)
– MRI (costly but most accurate and preferred to CT) /
avoids unnecessary immobilization
• Look for other associated fractures (distal radius,
26 ulnar styloid, radial head at the elbow) 27

235
 Scaphoid Plain X Rays Scapholunate Dissociation Overview
• Normal scaphoid • Fractured scaphoid
• 25% delayed diagnosis
• If missed, chronic arthritis,
pain and dysfunction
(scapholunate advanced
collapses = SLAC)
• Most common serious
ligamentous injury of
the wrist

28 29

Scapholunate Dissociation Diagnosis Lunate and Perilunate Dislocations

• Gap between scaphoid
and lunate of >3 mm • Mechanism
(likened to wide gap • Perilunate usually FOOSH
between front teeth – Dislocation
David Letterman / • Malalignment of
Terry Thomas) lunate and
• Tenderness dorsal capitate
proximal wrist and at
Lister’s tubercle / look for concomitant injuries Perilunate Lunate • Both are surgical
Dislocation Dislocation emergencies
• Thumb spica cast or splint for 6 8 wks / surgery?
30 31

236
 Scapholunate Dissociation Splinting of the Hand and Wrist
• Lister’s tubercle – bony ridge between the ulna
and radius on the posterior and distal aspect of • The “position of function” will generally allow
these two bones the least joint stiffness to develop

32 33

Digital Nerve Blocks Transthecal Nerve Block Technique

• Palpate distal palmar crease
• Sensory nerves run on • Just proximal to MCP joint
either side of the fingers palpate flexor tendon
(and toes) • Penetrate skin at a 45 degree
angle
• Various techniques • Aim tip of the needle toward
– Web space block the tip of the finger
– Transthecal block • Advance needle to the flexor
sheath
– Direct digital • Inject 2ml of lidocaine local
• Can use plain lidocaine (1 2% lasts 30 60 anesthetic
minutes) or bupivacaine (0.25 0.5% lasts 4 6 • Should flow freely
hours) / epinephrine is fine • Can also go more distally
(lower picture)
34 35

237
 Additional Digital Nerve Blocks Digital Nerve Block Complications
• Infection – don’t go through infected skin, do
• Web space injection • Direct digital injection good local cleansing
• Avoid hematoma – avoid multiple needle
insertions and use a fine needle – 27 30 gauge
(will also significantly decrease pain)
• Avoid vascular injury – do intermittent aspiration
• Generally avoid use of epinephrine (multiple
studies refute this being a dangerous practice),
limit the injection volume to 2ml per side
(consider use of web blocks)
• Nerve injury – withdraw if the patient complains
of significant pain and don’t inject with high
pressure
36 37

238
 Congestive Heart Failure,
Myocarditis and Pericarditis
Congestive Heart Failure (CHF) Overview
• Medicare’s most costly
diagnosis / freq. admit
• About 6 10% of those
over 65 have it
• About 6 million patients
with CHF in the U.S.
• Readmission is common
• Average LOS = 4 5 days
• Mortality is about 10%
per year (higher than
some cancers)
Systolic / Diastolic Heart Failure, 1
• Systolic dysfunction
– Can be left or right sided
– Impaired contractility
• Low ejection fraction (easily determined by doppler
ultrasonography) / <45% (normal is 55% 70%)
• Low cardiac output
– Causes – MI, ischemia, hypertension, valvular
heart disease, dilated cardiomyopathy
• Diastolic dysfunction
– Impaired relaxation of heart in diastole leads to
decreased left ventricular filling and pulmonary
congestion
– May eventually lead to systolic dysfunction
3 – Causes ischemia, hypertrophy 4
239
Systolic / Diastolic Heart Failure, 2

240
5
 Left Sided Heart Failure Right Sided Heart Failure
• Left sided failure • Right sided heart failure
– Can be due to systolic (LVEF 40% or less)(HFrEF) or – The most common cause of
diastolic dysfunction (LVEF 50% of more)(HFpEF) right heart failure is left
– Left ventricle does not adequately pump blood heart failure
– Blood backs up into the lungs – Back up of blood causes
jugular venous distention,
– Excess blood in the lungs causes capillary leakage liver engorgement (enlarged,
(rales on exam) pulsatile liver),
– Lungs become heavier, work of breathing peripheral
increases edema
– Work of the heart is increased while oxygenation
of tissues is decreased, resulting in a vicious cycle
6 7

Causes of Heart Failure Decompensation

• Decompensation of chronic heart failure is most
commonly due to
– Intercurrent illness (e.g., pneumonia)
– Myocardial infarction or ischemia (NSAIDs)
– Arrhythmias
– Uncontrolled hypertension (NSAIDs)
– Excess fluids, increased salt intake
– Anemia
– Hyperthyroidism
– Valvular disorders, carditis, dissection, PE
– Medications:
• NSAIDs (a class effect)
• Calcium channel blockers (amlodipine [Norvasc])
• Dipeptidyl peptidase 4 inhibitors (sitagliptin [Januvia])
8

241
Symptoms of Acute Heart Failure

242
9
 Testing in Decompensated CHF, 1 Testing in Decompensated CHF, 2
• In most cases the diagnosis is straightforward • ECG
• The diagnosis of intercurrent pneumonia and/or – Looking for ischemia, infarction, tachydysrhythmia
COPD can muddy the waters significantly (the compromised heart is particularly unable to
• The role of BNP perform in the presence of new onset atrial fib)
– B type natriuretic peptide is secreted by the ventricles
in response to wall stress (as occurs in CHF)(or large PE)
– In grey zone cases, this test may help determine
whether a patient who is dyspneic has heart failure as a
component of the dyspnea
• Levels below 100pg/ml indicate no heart failure
• Levels of 100 300pg/ml suggest heart failure is present
• Levels above 300pg/ml indicate mild failure
• Levels above 600pg/ml indicate moderate failure
• Levels above 900pg/ml indicate severe failure
• Troponin
10 – If initially normal, serial testing may indicate AMI 11

Chest X ray in Decompensated HF Ultrasound in Decompensated HF

• Acute exacerbation of left heart failure with • More sensitive and specific than CXR / “B lines”
improvement over time • Prospective study of 99 ED patients with SOB
– 32 had CHF and 40 had COPD
• Cardiomegaly, vascular congestion, pulmonary
edema (CXR can be normal in about 15%) • Compared to the final
discharge diagnosis, POCUS
had a 96% sensitivity for
pulmonary edema
(specificity 90%) vs 65%
for CXR (specificity 96%)
• Can measure LVEF
• POCUS was performed by
– MD with > 5 years US
experience & 2nd year IM resident
• Radiologist read the CXR
12 • Wooten, W., et al, J Ultrasound Med, 4/19 13

243
 Testing in Decompensated CHF, 3
• Comp. metabolic panel (CMP)
– Looking for renal or liver dysfunction
– Looking for electrolyte abnormalities
• Chronic diuretics? Look for low
potassium
• Potassium low? Consider measuring
magnesium
– Thiazides and loop diuretics (e.g.,
furosemide) deplete both potassium
and “the forgotten electrolyte,” magnesium
– Replacement of potassium is facilitated by the
simultaneous replacement of magnesium
• CBC
– Anemia is a stressor for the decompensated heart
– Elevated WBC may suggest concomitant infection
Treatment Priorities in Acute CHF, 2
• Reduction of preload
– In the decompensated state the right heart is unable
to handle the volume of blood being returned to it
– Venodilatation is indicated
– IV diuretics help reduce volume overload
– Furosemide can cause initial
vasoconstriction – giving vasodilators
first may avert this little known phenomenon
– Not all patients with acute CHF are volume
overloaded – only in this subset are diuretics
advantageous (check for peripheral edema)
– “Flash pulmonary edema” can occur in the setting of
an acute MI without fluid overload / also ICH / high
dose IV nitrates (starting at 100 400mcg/min)
Treatment Priorities in Acute CHF, 1
• Monitor, oximetry, IV line
• Oxygen if low / hyperoxia = +/ pulm. vasoconst. /
assisted ventilation if needed – BiPAP, CPAP, HFNC
• Reduction of afterload
– Most patients with acute CHF have
elevated blood pressure which makes
unloading of the left ventricle more
difficult than usual
– Goal of immediate therapy is to lower
the blood pressure with vasodilators
– IV nitrates are the fastest, most effective way to relieve
symptoms in acute CHF (reduce both afterload and
preload) – may need high doses (200 400mcg/min)
14 15
Treatment Priorities in Acute CHF, 3
• Angiotensin converting enzyme inhibitors (ACEIs)
can be very effective at reducing both afterload
and preload
• Other benefits
– Improved renal hemodynamics
– Prevent sodium retention
– Attenuate sympathetic stimulation
– Maintain or enhance left ventricular
function
• Sublingual captopril (Capoten), 12.5 25mg
• IV enalaprilat (Vasotec), 1.25mg IV over 5 minutes
16 17
244
 Myocarditis, 1 Myocarditis, 2
• Inflammation of the heart • Addition etiologies
– Often associated with pericarditis
– Sarcoid myocarditis: Lymphadenopathy, also with
• Etiology arrhythmias, sarcoid in other organs (up to 70%)
– Idiopathic – Acute rheumatic fever: Usually affects heart in 50 90%;
– Infectious (usually viral) / other signs, such as erythema marginatum,
Chagas disease is most polyarthralgia, chorea, subcut. nodules (Jones criteria)
common worldwide – Hypersensitive/eosinophilic myocarditis: Pruritic
(Trypanosoma cruzi) maculopapular rash and history of using offending drug
(unicellular protozoa)
– Drugs (chemotherapy, – Giant cell myocarditis: Sustained ventricular
tachycardia in rapidly progressive heart failure [1]
antipsychotics [clozapine])
– Toxins (particularly alcohol), – Peripartum cardiomyopathy: Heart failure developing
carbon monoxide in the last month of pregnancy or within 5 months
following delivery
– Immunologic
18 19

Myocarditis, 3 Myocarditis, 4
• Clinical manifestations • Diagnosis
– ECG (often associated
– “Flu like” illness (myalgia, fatigue, joint pains,
recent viral illness) with pericarditis as well)
– Troponin elevation
– Fever
– Elevated markers of
– Out of proportion sinus inflammation (CRP,
tachycardia sed rate)
– Congestive heart failure – Cardiac MRI visualizing
– Dysrhythmia markers of myocardial
– Sudden death inflammation
• Estimated to be the cause of sudden death in
up to 20% of young adults
20 21

245
 Myocarditis, 5 Myocarditis ECG
• Treatment
– If CHF present, treat in usual manner except, avoid
sympathomimetic (increase necrosis and mortality),
avoid beta blockers in acute illness
– In those with fulminant myocarditis and sinus
tachycardia, avoid the use of rate control agents (in
particular, those with negative inotropic properties:
metoprolol, diltiazem, verapamil, etc). [
– Also, avoid the use of nonsteroidal anti inflammatory
agents (NSAIDs) to avoid increasing sodium retention,
myocardial harm, and exacerbation of renal
hypoperfusion.
22 23

Pericarditis, 1
• Etiology
– Infectious
• Viral (most common)
• Bacterial
• TB
• Fungal
– Acute MI
• Pericardial
inflammation 2 3
weeks post AMI =
Dressler's syndrome
– Connective tissue
disease
– Neoplasm
– Uremia
– Radiation
24

246
Pericarditis, 1

247
25
 Pericarditis, 2 Pericarditis, 2
• Clinical manifestations
– Chest pain (may radiate to trapezius)
– Pleuritic chest pain can increase with movements:
• Deep Inspiration / yawning
• Swallowing
• Rotating trunk
– Dysphagia
– Relief on sitting up,
bending forward
– Fever, malaise

26 27

Pericarditis, 3 Pericarditis ECG

• Physical exam
– Friction rub (increased by sitting up and leaning
forward) (present in about 85% of cases)
– Tachycardia, pulsus paradoxus (an exaggerated BP
response to breathing – BP goes down on inspiration
and up on expiration)
• ECG four phases
1. Diffuse ST elevation (not
corresponding to coronary
artery distribution) and PR
segment depression (first few days to 2 weeks)
2. ST segments return to baseline (days to weeks)
3. T wave inversion (may persist) (after 2 3 weeks)
4. Normalization of ECG
28 29

248
 Pericarditis, 4 Pericardial Tamponade
• Chest x ray usually normal
• Causes
• Echocardiogram – may show
pericardial effusion – Trauma, uremia, anticoagulation,
neoplasm
• Complications
– Dysrhythmias (atrial) • Clinical signs
– Tamponade – Hypotension, JVD, muffled heart
– Residual pericardial sounds, pulsus paradoxus
constriction (abnormally large decrease
– Heart failure in systolic pressure during
• Treatment inspiration – normal drop is
less than 10mm Hg)
– Treat underlying cause
if possible • Chest x ray
– NSAIDs, steroids – Enlarged (water bottle) heart
30 31

Pericardial Tamponade
• ECG
– Electrical alternans (beat to beat alteration in the
amplitude of the QRS complex), low voltage

• ECHO findings
– Effusion
– RV diastolic collapse
(specific for tamponade)
32

249
250
 Altitude Illness General
• Due to relative hypoxia / increased sympathetic
activity / capillary leak (brain and lungs)
Environmental
• Can occur in anyone; being fit is not protective
Disorders

Acute Mountain Sickness HACE / HAPE

• Usually > 8,000 feet • HACE = high altitude cerebral edema
• Starts early often day 1 – Severe, life threatening; increased ICP
at altitude – Ataxia, vomiting, confusion, seizures, coma
• HA, nausea, fatigue, insomnia – Descent ASAP (+/ steroids, hyperbarics)
• Worsened with sedatives, alcohol • HAPE = high altitude pulmonary edema
• May be prevented by prophylactic acetazolamide – Most lethal of the altitude illnesses
– Causes a metabolic acidosis which generates a – Usually second night at altitude
respiratory alkalosis – increased ventilation increases – Shortness of breath, fever, rales, pink
oxygenation sputum, hypoxia; normal heart size on CXR
• Usually self limited (1 2 days); can treat with – Descent ASAP
Usually have symptoms of Acute Mountain
NSAIDs, steroids, oxygen, descent Sickness before HACE/HAPE
3 4

251
 Hypothermia Hypothermia
• Core temperature < 35oC (95F)
• Can occur even in non freezing temperatures
• Only use accurate thermometers; rectal, bladder,
esophageal
• Risks include extremes of age, altered sensorium,
burns, trauma; may also see in
sepsis, hypoglycemia
• Findings altered mental
•Bradycardia with an idioventricular or junctional escape rhythm
status, bradycardia •Prominent J waves in the anterior leads = Osbourne waves
(named after the fact that they occur on the “J” point of the EKG)
5 6

Hypothermia Frostbite
• Rewarming should start ASAP • Think of it as burns caused by cold (local
tissue freezing)
• External rewarming
– First degree – superficial
– Passive – remove wet clothes, give warm blanket
– Second degree – full thickness, clear blisters
– Active – radiant heaters, hot water bottles, warming
– Third degree – hemorrhagic blisters (blood = deeper)
blankets
– Fourth degree – to bone
– Watch for core temperature afterdrop with passive
rewarming (cold blood from the periphery goes into • Rapid rewarming with warm
the central circulation) circulating water
• Active core rewarming • Do not allow refreezing
– Warm humidified oxygen, warmed IV fluids, warm • Do not debride bloody blisters
lavage (NG tube, foley)
7 8

252
 Heat Illness General Types of Heat Illness
• Two groups at risk • Heat edema – swelling of feet/hands, transient,
– Very young, very old, certain medications do not treat with diuretics
(particularly psychotropics, diuretics, • Heat cramps – after exertion in hot climates /
antiparkinsonism medications, amphetamines, beta
usually after cooling / resolves without
blockers, many “street drugs”), intoxicated, obese
treatment
– Lack of air conditioning is associated with summer
heat illnesses in the elderly • Heat syncope – pooling of blood in extremities /
– Athletes, military recruits treat by lying patient down in cool place
• Usually during heat waves, • Heat exhaustion – “summer flu” / nausea,
but can occur in ambient vomiting, due to salt and water depletion / treat
climates (exertion, enclosed auto) by moving to cooler environment, PO hydration
9 with fluids with electrolytes/sugar 10

Heat Stroke Heat Stroke

• A true emergency – must cool ASAP • Classic • Exertional
– Epidemic (with heat – Isolated
• Multiorgan failure / brain, liver and
wave) – Exertional
endothelium at highest risk, but all – Non‐exertional
systems affected – Healthy, active
– Elderly with chronic
• Core temperature usually 40oC (104F) disease, very young, – Profuse sweating
chronic illnesses – May have diarrhea
• Altered mental status, tachycardia, tachypnea,
– Dry skin – DIC, ATN,
may be hypotensive
– Rare to see rhabdomyolysis
• May see acidosis, rhabdomyolysis, ARDS, renal acute common
failure, hyperkalemia tubular
necrosis
• Two types, classic and exertional (ATN), rhabdomyolysis
11 12

253
 Heat Stroke Treatment Burns Definitions
• Cooling is crucial – change “ABCs” to “C ABCs”
• Resuscitate as usual, but cool simultaneously
• Methods of cooling
– External strip patient / body bag filled with ice/
tepid mist plus fans / wet sheets plus fans / ice packs
to groin, axillae, neck
– Internal iced water gastric lavage / bladder lavage
• Goal is to decrease temperature by 0.1 0.2oC per
minute to 38.5oC (101.3F), then stop; watch for
overshoot (hypothermia)
13 14

Burns Definitions Burns Definitions

• Definition • Definition
– First degree (superficial) – Deep partial thickness: To
epidermis only, painful, red dermis, painful, red and white
and dry, hypersensitive. (mottled), thick walled blisters,
Heals in 3 7 days. slight decrease in sensation.
– Superficial partial thickness Heals in weeks months with
to dermis, painful, red and scarring and pigment changes.
wet, thin walled blisters, – Full thickness: To deeper tissues,
hypersensitive. Heals in 7 14 painless, white and brown and
days without scarring (called dry. No sensation. Needs
“second degree”) grafting.

15 16

254
 Burns Body Surface Area Lund/Browder Chart
Infant <10 kg Child
• Body surface area Anatomic structure Surface area Anatomic structure Surface area
(BSA) Head and neck 20% Anterior head 9%
Anterior torso 16% Posterior head 9%
– Patient’s palm =
Posterior torso 16% Anterior torso 18%
1% of patient’s BSA Leg, each 16% Posterior torso 18%
– Adults – rule of 9’s Arm, each 8% Anterior leg, each 6.5%
Genitalia/perineum 1% Posterior leg, each 6.5%
– Children –
Anterior arm, each 4.5%
Lund/Browder chart Posterior arm, each 4.5%
Genitalia/perineum 1%

17 18

Minor Burns Treatment Major Burns Treatment

• Minor burns • Major burns
– Cool ASAP – Cool > watch for hypothermia
– Treat pain with NSAIDs, opiates – Assess airway > look for singed nasal hairs, oral
burns; intubate early for respiratory distress, concern
– Leave blisters intact if unruptured for airway edema
and not tense
– Enclosed space? Think carbon monoxide,
– Debride if blisters broken, tense, cyanide toxicity.
across joints
– Fluid resuscitation crucial – Parkland formula
– Update tetanus
• 4 mL x kg x %BSA per day of Ringers lactate
– Can manage ”open” (topical
antimicrobials) or “closed” (occlusive • Half of volume given over first 8 hours
dressings) • Watch urine output – goal is > 1ml/kg/hr
19 20

255
 Burns Disposition Electrical Injuries
• Most minor burns (< 10% BSA burn in non • Tissue damage caused by electrical current
strategic locations) can be treated as outpatients • Injuries common (falls)
with close follow up • AC 3X worse than DC at same voltage
• Major burns need transfer to burn center • Degree of injury determined by
• Specific criteria vary, but general principles – Type of current
– Circumferential burns to extremities – Duration of contact
– Facial, ear, eye, hand, foot, genital, perineal burns – Tissue in path of current
– Inhalation injuries
– Electrical burns
– Percent BSA/degree of burn – check with burn center
21 22

Electrical Injuries Electrical Injuries

• Biggest risk of death is either trauma or cardiac • Examine carefully look for entrance and exit
arrhythmia – treat them as a trauma patient sites
• Mouth burns in children usually from biting • Resuscitation and ABCs
electric cord; risk of arterial bleeding at 7 10 days • Household current exposure generally
after burn requires no specific treatment,
testing or monitoring
• If more than minor electric shock, consider labs
CMP, CBC, CK (risk of rhabdomyolysis), coag
studies if seriously injured
• Monitor urine output / admit to monitored bed
23 24

256
 Mammalian Bites Rabies
• Human bite is the worst “mammal” bite • Rare in US; most cases imported in
– “Fight bite” – wound over MCP joint developing countries (often dog bites)
– High risk; may need to go to OR • Bites at risk fox, skunk, raccoon, bats (most
• Dog bites common risk animal) / rodents, rabbits and
squirrels do not pose risk
– Lowest infection rate but
high crush injury rate • A bat in an occupied room – assume bite
• Cat bites • Early post exposure prophylaxis is key
– Passive human rabies immune globulin (HRIG); give
– Puncture wounds increase risk of as much as possible around and into wound,
infection remainder give IM
• All mammal bites can be treated – Active human diploid cell vaccine (HDCV) – 4 doses
with amoxicillin/clavulanate (days 0 3 7 14)
25 26

Bites and Stings Spider Bites

• Bees, wasps and ants • Black widow spider bite
– Black with red hourglass, aggressive
• Usually only cause local
symptoms – burning, pain, – Immediate pain
swelling – N/V, cramps, rigid abdomen (appy mimic)
– Treat with ice, opioids/benzos, antivenom (?)
• Treatment usually ice to
area, OTC pain meds • Brown recluse spider bite
(NSAIDs, acetaminophen) – Brown with “violin,” reclusive
– Delayed pain, “volcano” lesion
About 10-15% of those stung will have unusually – Systemic symptoms including hemolysis, necrosis
large areas of swelling lasting up to a week with a
sting – Treat with analgesics, debridement if needed
27 28

257
 Rattlesnake Bites
• Envenomation – amount of venom in bite / up to
one quarter are “dry bites”
• Local effects – swelling, ecchymosis, pain
• Systemic effect – DIC, capillary leak
• Males, teens twenties, intoxicated – highest risk
• Ooze at site of bite suggests envenomation
• Do not I&D, tourniquet or try to extract venom
• If ecchymosis, blisters, systemic
effects – treat with antivenom –
look up doses, side effects
29

258
 Hypernatremia Overview

Electrolyte Disorders

The “Natremias” Treat the patient, not the number

Fast versus slow matters

3 4

259
 Elderly / very Start with oral fluids if the patient can take them
young Measure serum (and urine?) electrolytes every 1‐2 hours

Altered mental Is it REALLY acute? Is the patient sick?

If not, GO SLOW
status
(Sudden change? Still likely Is the patient sick?
Goal: Lower Na by 10 mEq/L in 24
chronic) hours*
Treat with D5W 3 6 mL/kg/hr
(no more than 8‐10 mEq in 24 hrs)
Goal: Correct Na at rate of 2 3
mEq/L/h x 2 3 hr*, then max 12 CALCULATE the amount of D5W
mEq/L over first 24 hours needed: Rate ~1 1.5 ml/kg/hr
* Recheck neuro exams: slow IVF when improvement is noted

260
 HYPERNATREMIA
Admit or observe
All patients with hypernatremia
(unless corrects easily in ED)

• Almost always chronic

• Rarely need to
aggressively reverse
• Oral first if possible
• Calculate the free water
deficit
• Fluid: D5W

Hypernatremia Overview Hypernatremia Treatment

• Hypernatremia (>145mEq/L)
– Usually due to a lack of water (vs. too much salt)
– Look for sources of fluid loss (often GI) or fluid • Treatment
deprivation – Oral water preferred if
– Normal homeostasis induces thirst patient able
• Those without access to water are at risk (infants, – IV saline if unstable vitals
psychiatric patients, those with dementia) • Normal saline has 154mEq/L sodium; often lower than the
patient’s sodium
• Severe symptoms seen @ 160mEq/L – In general, don’t correct at a rate greater than 0.5
– Lethargy, weakness, anorexia, 1mEq/L per hour
irritability, vomiting, twitching, • Especially if chronic, slow onset (which it usually is)
hyperreflexia, ataxia, tremor
– Can calculate total body water deficit to guide
• Severity of symptoms therapy (use an app or online calculator, e.g.,
depends on rapidity of onset
(almost always chronic!) MDCalc)
11 12

261
 Low Sodium?
Hyponatremia

Check for
pseudohyponatremia

13 14

Corrected Na = Measured Na
+ Symptoms?
1.6* x (glucose – 100)
100 Check the glucose
(*2.4 may be more accurate)

Seizing/coma?

Other causes?
Also remember… Yes
No

Sodium Elevated lipids?

Elevated bilirubin? Treat other
Still Treat 100 mL over 10
h/o plasma cell
cause 3% NaCl minutes x 3 as needed
Low?? dyscrasias?
(513 mEq/L NaCl) ‐ BUT ‐
15 16

262
 Symptoms?

Seizing/coma? Onset?

Other causes? < 24 48 hrs? > 48 hrs?

Correct quickly 100 mL to start
Yes
No Rate of correction should not exceed 0.5 1 mEq/L/h
Correct carefully
Max total first 24 hrs Increase of 8 12 mEq/L
Treat other Treat
cause Goal: Improved symptoms
3% NaCl
(513 mEq/L NaCl)
or
Na > 120 mEq/L
17 18

Symptoms?

Anything else

Patient’s Volume Status?

Fluid Restriction Isotonic saline Fluid Restriction

Possible loop Potassium if
diuretics needed
19 20

263

Admit*
Sick on presentation
Sodium < 120 mEq/L
Other indications to admit
Observe
Sodium < 125 mEq/L and not sick
Consider discharging everyone else
Hyponatremia Overview
*Order extra labs • Hyponatremia (<135mEq/L)
Serum osms – Remember to consider pseudohyponatremia (elevated
Urine osms glucose, elevated lipids “dilute” sodium; can correct –
Urine Na see endocrine lecture)
– Patients are either hypovolemic, euvolemic or
hypervolemic
• Often seen in patients with CHF, liver or renal
failure, pneumonia, on diuretics
– Severe symptoms
• Headache, malaise, nausea, lethargy, altered LOC, seizures
(<115mEq/L) / due to progressive brain edema
• Seen at sodium of 125mEq/L
• Severity also depends on rapidity of onset
21 22

Hyponatremia Treatment Hyperkalemia Overview

• Treatment • Hyperkalemia (>5.5mEq/L)
– Can be complex – May have a paucity of symptoms
– Crucial to know volume status, (fatigue, weakness) yet sudden
duration (hyperacute, acute, subacute, chronic), arrhythmia (arrest rhythm often
severity of clinical symptoms
asystole) / immediate EKG needed
– Most cases are chronic
to see if signs of cardiac effects or
• Can often treat with
fluid restriction electrolyte imbalance are noted
• Unless severe, correction – May see only bradycardia
should not exceed – Main causes – renal failure (most
0.5 1mEq/L/hr
– Faster may cause permanent, severe neurologic sequelae common cause) / leakage from cells
(central pontine myelinolysis) (e.g., DKA induced leak) / ACE
– If emergent and clinically indicated, hypertonic saline to
increase sodium by 4 6 meq/L may be administered inhibitors and potassium sparing
• Symptoms should resolve when Na > 125 mEq/L 23 diuretics 24

264
 Progressive Hyperkalemia EKG Changes
May see only bradycardia without other EKG changes
Hyperkalemia Treatment, 2
• Potassium “Shifters”
– Glucose + insulin
• D50 / 10U regular insulin IV
• Drop to 5U in elderly, low BMI
• Watch for hypoglycemia
– Bicarbonate
• Raises blood and urine pH / likely
only effective if patient is acidotic
(pH <7.3; if < 7.2, use 2 amps)
• Onset of action within minutes /
lasts 15 30 minutes
– Inhaled adrenergics (albuterol)
• Drives K intracellularly / lowers
0.5 1.5mEq/L / particularly helpful
in renal failure / continuous
Hyperkalemia Treatment, 1
• Level of aggressiveness relates to
K+ level, symptoms and EKG
• If K+ elevated, treat…
– Widened QRS/sine wave
– Bradycardia (+/ heart blocks)
– Loss of P wave (K+ usu. 6.5)
• Calcium is treatment of choice
– 5 10ml of CaCl (3x more Ca than the gluconate) over
2 5 minutes / titrate with EKG monitoring / works in
< 5 min – lasts 30 60 minutes
– Repeat if no improvement in EKG / usually not
indicated if only peaked T waves
– Problem – CaCl if it extravasates can cause tissue
necrosis / also risk of hypercalcemia and
dysrhythmias – can give 15 30ml of the 10% calcium
25 gluconate instead 26
Hyperkalemia Treatment, 2
• Potassium “Eliminators”
– Consider IV fluids (with care)
– Binding resins
• Sodium polystyrene sulfonate
[Kayexalate])
– No longer recommended
» Slow onset (2 12 hours), modest effect, risk of colonic
necrosis (especially with sorbitol)
• Sodium zirconium cyclosilicate [Lokelma]
– “LIMITATION OF USE: LOKELMA should not be used as an
emergency treatment for life threatening hyperkalemia
because of its delayed onset of action”
• Patiromer (Veltassa)
– Binding agent / not absorbed / takes time for effect / meant
for chronic management / $$$
– Dialysis is most effective way to remove K+
27 28
265
 Hypokalemia Overview Hypokalemia Treatment
• Hypokalemia (<3.5mEq/L) • Treatment
– Causes – Treat the cause if possible
• GI and renal losses, inadequate diet, transcellular – Total body deficits always very high
shifts, diuretics, alkalosis (causes intracellular – Mild cases can be treated with oral replacement
shift) only; remember foods (potatoes, citrus, bananas)
– Symptoms – If level < 2.5 mEq/L give both IV (max of 20mEq per
• Weakness, constipation, palpitations, nausea, hour [unless urgent]) and oral
polyuria • Total body deficit often
• When severe (<2.5mEq/L) – PACs, PVCs, more than 200 300mEq
hypotension, ileus, brady or tachycardia (arrests • May need admission/obs
often are V. fib), decreased DTRs – Treatment of low K also
– Low magnesium is routine when potassium is low; requires Mg replenishment
must replace both to get potassium to increase • Be sure to give both
29 30

Hypokalemia / Hyperkalemia EKGs Hypercalcemia Overview, 1

• Hypercalcemia (greater than 10.5 mg/dL)
– Major causes are hyperparathyroidism and cancer
(predominantly lung, breast, prostate, myeloma – most
due to secretion of a parathyroid hormone mimic)
– Acute signs usually indicate a level over 14mg/dl
– 40% is protein bound / 50% is ionized (active)
– Serum calcium measures both protein bound and
unbound Ca
– If low protein, total calcium is decreased but ionized
may be normal
– Lethargy, vomiting, constipation, altered LOC,
headache, polyuria (dehydration [increased BUN]),
polydipsia, decreased reflexes, hypertension,
31 bradycardia 32

266
 Hypercalcemia Overview, 2 Hypercalcemia EKG
• Shortened Q T interval (more accurately, short ST
segment) / rarely Osborn waves (J waves arrows)

33
33 34

Hypercalcemia Treatment, 1 Hypercalcemia Treatment, 2

• Treatment of severe hypercalcemia • Treatment of severe hypercalcemia
– Most patients are very dehydrated – Salmon calcitonin is the most
– Rehydrate with saline FIRST (be careful rapid onset of the anticalcemic
if there is underlying CHF) agents (inhibits osteoclasts /
• Often all that is needed in ED promotes excretion)
• Causes dilution of high Ca and • Onset within a few hours – but peaks at 12 24 hours) / 4 8
promotes renal excretion units/kg SC or IM every 12 hours
• If renal failure, dialysis is required – Bisphosphonates inhibit
(dilution is not an option) osteoclastic activity – all
– After hydration well under way, have a prolonged onset of
loop diuretics (e.g., furosemide) action (some say
promote excretion (avoid pamidronate has highest
thiazides – they do the opposite) efficacy)
35 36

267
 Hypocalcemia Overview
• Hypocalcemia (usually less than 9.0 mg/dL)
– Renal failure, parathyroid hormone deficiency, vitamin
D deficiency or high or low magnesium levels
– Calcium is bound to proteins; ionized calcium level is
what is most important but not available in ED
– “CATS GO NUMB” – convulsions, arrhythmias, tetany,
numbness/paresthesias of hands, feet, lips
• Also carpal spasms, hyperreflexia, hypotension, decreased
myocardial contractility (CHF)
– Latent tetany (carpal spasms precipitated by inflating a
BP cuff [Trousseau sign] / Chvostek’s sign – masseter
spasm on tapping by zygoma)
– Need an albumin level to get calculate a corrected
calcium level 37
Hypomagnesemia Overview
• Hypomagnesemia (<1.7mg/dl [1.4mEq/L])
– Causes – starvation, alcoholism, GI and renal losses
(diuretics and other causes), multiple other causes
– Serum measurements don’t reliably assess magnesium
(99% is intracellular or in bone) / extracellular Mg is
30% protein bound (so low albumin can give a low Mg
level)
– Mg and K are very similar with regard to function
– When Mg is low, 40 60% of patients will have a low K
– Low Mg, like low K, is associated with arrhythmias,
muscle weakness and cramps / can both emulate and
cause low Ca
– EKG manifestations similar to low K
39
268
Hypocalcemia Treatment
• Treatment
– Most cases of hypocalcemia are mild and not
emergent (do not need repletion in the ED)
– Must know if the hypocalcemia is acute or chronic
• If chronic, IV calcium may predispose to life threatening
cardiac electrical instability caused by over correction
– Can give IV calcium gluconate ONLY if acute and
symptomatic
• 90mg of elemental calcium, 1 2 amps [10ml] over 10
minutes
– Calcium chloride contains too much elemental calcium
– best not to infuse in a peripheral vein – can cause
sclerosis and, if extravasates, necrosis
– Can follow with a drip (start at 0.5mg/kg/hr)
38
Hypomagnesemia Treatment
• Treatment
– Oral therapy in asymptomatic patients (sustained
release products to decrease risk of diarrhea) – Slow
Mag / Mag Ox / Mag Tabs – 2 4 tabs daily for mild low
Mg / 6 8 tabs for more severe low Mg
– For combined low Mg and low K in symptomatic
patients can give 50mEq Mg slow IV over 8 24 hours
(1gm of MgS04 contains 8mEq of magnesium) and K
supplementation
– In an arrest situation or obvious cardiotoxicity due to
hypomagnesemia, can give 1 2gm MgSO4 IV push,
depending on urgency
– If low Ca as well, must give Ca supplementation
40
 Hypermagnesemia Overview EKGs of Electrolyte Abnormalities
• Hypermagnesemia (>3.5mEq/L)
– Kidney is primary regulator of Mg homeostasis
– Hypermagnesemia is rare without kidney failure
– Vomiting, skin flushing (Mg is a vaso and
bronchodilator), weakness, lightheadedness / very
high levels can cause heart block, asystole, flaccid
paralysis
– Increased K and Ca are common with high Mg levels
• Treatment
– Saline dilution if working kidneys plus loop diuretics
– IV calcium antagonizes the effects of Mg – is reserved
for patients with severe or symptomatic increased Mg
41 42

269
270
 Shoulder Disorders:
A Systematic Approach

271
Shoulder Anatomy, 1

272
2
Shoulder Anatomy, 2

273
3
 Shoulder Key Concepts The Shoulder Exam
• The shoulder is an incredibly complex and • Inspection
mobile joint with a huge range of motion • Palpation
• Bursa are very important in this joint • Range of motion
• Low bony stability (prone to dislocations) – Forward flexion
• May have combination injury patterns – Extend behind back
fracture plus dislocation plus ligament injury – Abduction and adduction
• Function is highly dependent on soft tissues: – External rotation
– Rotator cuff (SITS muscles = supraspinatus,
– Internal rotation
infraspinatus, teres minor, subscapularis)
– Joint capsule • Strength testing
– AC joint, acromial process, coracoid process and the • Sensory testing
associated ligaments 4 • Good video: http://www.youtube.com/watch?v=VSrLbzZzJU8 5

Acromioclavicular Separation Acromioclavicular Separation

• Mechanism of injury is
often a direct blow
• Grades I, II, and III
• Local pain, deformity?
• Radiographs may be
negative and may not
always be needed
• Simple management
(sling) usually adequate

6 6a

274
 Shoulder Impingement Syndrome
• Soft tissue swelling results
in friction and blockage of
free gliding movement
• Passive range of motion
decreased – “painful arc
syndrome”
• Pain on abduction of arm
• Treated with oral anti
inflammatory medications
(beware contraindications),
stretching exercises, rest 7

275
 Shoulder
Impingement
Syndrome

276
7a
 Calcific (Calcifying) Tendonitis Biceps Tendon Rupture
• Shown calcific supraspinatus • Popeye’s arm….proximal long head rupture
tendonitis with radio opaque
• Occurs during strenuous exertion
deposition
• Patient may complain of snapping sensation or
• Also results in “painful arc
feeling of something rupturing
syndrome”
• Possible risks include fluoroquinolone use,
• Treatment
steroid use / rheumatoid arthritis, history of
– Rest and ice
bicipital tendonitis
– NSAIDs / opiates if severe
• If not clinically obvious,
– Steroids orally or by local
injection (e.g., 20mg triamcinolone [1ml] + 5 7ml of consider ultrasound
1% lidocaine [or bupivacaine, 0.25% lasts longer]) 8 9

Thoracic Outlet Syndrome EAST Test and Adson’s Test

Adson’s Test
• Thoracic outlet bordered by scalene muscles, •Patient rotates head to tested arm
first rib and clavicle •Lets head tilt backwards
• Compression of •Examiner feels radial pulse
neurovascular structures •Positive test = pulse disappears
in thoracic outlet EAST Test
• Can compress vessels, • Arms up as shown
nerves or both • Opens and closes hands
slowly for 3 minutes
• Adson’s test – only • Positive = pain, heaviness,
tests arterial involvement numbness, hand tingling
• Elevated arm stress test (EAST) 10 11

277
 Clavicle Fractures Overview Clavicle Fracture Treatment
• Falls onto a shoulder • Pain medication
• May fracture at several places along the clavicle • Ice
• Commonly an isolated injury, but NOT always • Immobilization
• Usually just a sling and meds, but if distal third – Sling preferred over
with AC injury, consider ortho consult figure of 8 brace
• Severely tented skin, – More comfortable
consider ortho consult – Less skin breakdown
– No vascular issues
– Better tolerated

12 13

Rotator Cuff Syndrome Rotator Cuff Mechanism

• S‐I‐T‐S muscles Supraspinatus, Infraspinatus, • Pins humeral head into the glenoid fossa
Teres minor, Subscapularis • When arm is down, deltoid forms a cover
• Pain and difficulty with abduction over 90 • Supraspinatus, infraspinatus and teres minor
degrees, external insert on greater tuberosity and pull medially
and internal
rotation
• Various causes
– Tendonitis
– Tears
– Prior injury 14 15

278
 Shoulder Dislocation Types
• Anterior most common (over 95%)
– Squared off shoulder
• Posterior dislocation rare
– May be due to seizures, electric shock
– May be missed
• Luxation erecta (inferior dislocation) very rare,
extremity held over the head with elbow flexed 16
Shoulder Dislocation Imaging
• Prereduction films may not be necessary
– Mechanism of injury consistent with anterior
dislocation and low grade force injury
– Previous dislocation with appropriate
mechanism
• Who needs prereduction films?
– Older, possible pathologic fracture,
inconsistent mechanism of injury, any doubt
about diagnosis clinically (or the physician
you are working with always wants them)
18
279
Shoulder Dislocation Evaluation
• Check distal neurovascular status
– Including axillary nerve (sensation over
deltoid)
• Relocation often requires
pain control (intraarticular,
parenteral) and may require
procedural sedation
17
Anterior Shoulder Reduction Overview
• Stimson prone with weights (5 10lbs)
• Scapular rotation rotate scapular tip medially
• FARES – Milch + “waggle” (anterior / posterior
small oscillating movement with traction)
• Spaso vertical traction + external rotation
• Hennepin external rotation + elbow adduction
• Milch external rotation + elevation
• Snowbird downward traction by foot in a loop
of stockinette on the flexed forearm
• Traction countertraction sheet into axilla 19
Stimson and Scapular Rotation Techniques FARES and Spaso Techniques
FARES Technique
Spaso Technique
Fast / Reliable / Safe

20
21

Hennepin and Milch Techniques Other Anterior Shoulder Reductions

• Some consider the following method to
Hennepin Technique Milch Technique require more force than the prior methods
and thus may have an increased risk of
fracture or axillary nerve injury (should avoid;
use a different method – lots to choose from)
– Hippocratic foot in axilla with traction
– Eskimo dangle + foot on chest wall
– Kocher – external rotation, then anterior position,
then internal
• See shoulderdislocation.net/videos
22 23

280
 Posterior Shoulder Dislocation Luxatio Erecta
• Rare form of anterior dislocation
• Easy to miss on x ray • Classic “forearm to forehead” position
• Greater tuberosity and • Locked and cannot lower the arm…..
lesser tuberosity
• In line traction
contours lost due to
internal rotation of arm • Scapular rotation
• Very round appearance • These all have major
of the humeral head rotator cuff injuries
variously called
– Gun barrel sign / light bulb sign / drumstick sign
24 25

Adhesive Capsulitis / Frozen Shoulder Codman’s Exercises

• Shoulder injury without
• Slight bend forward
subsequent rehab
• Support with uninvolved arm
• Immobilization leads to
decreased mobility long • Swing arm in side to side
term pendulum motion
• Older women more • Move arm in concentric circles
prone • Movement only to point of
• Codman’s exercises pain; do not overwork
recommended (see next
slide)
26 27

281
 Proximal Humerus Fractures Proximal Humeral Fracture / Dislocation
• Often requires
• Usually due to fall
consultation
• Common in patients
• If stable, can be
with osteoporosis
immobilized (sling)
• May be both fractured and referred
and dislocated
• Pain control
• Sometimes described
• Consider other
by the five part Neer
injuries
classification

28 29

Midshaft Humeral Fracture

• Can injure radial nerve
• Radial nerve runs in a spiral
groove of humerus
• Causes wrist drop consult if
any neuro deficit
• Treat with sling and pain meds
• Coaptation splint sometimes
required
• Ortho referral
30

282
Lower Abdominal
Disorders

283
 Lower Abdominal Pain
• Huge differential diagnosis
for abdominal pain in
general
• It’s easy to make mistakes
• “Gastroenteritis” is likely
the most common
diagnosis to be associated
with mistakes
• Be very careful especially
in the elderly. Test liberally.
Consult liberally. 2
284
 Constipation Constipation
• One of the more difficult and dangerous ED • Always inquire about narcotic use
diagnoses in adults a diagnosis of exclusion • Check for fecal impaction
• Many patients with – Disimpaction can be a major undertaking in the ED
serious pathology have – Consider taking patient to a standard private room in
a chief complaint of the hospital with a toilet
“constipation” – Severe impactions can be
• There is no definitive test life threatening
• Plain films and CT are neither • Consider liberal use of labs
sensitive nor specific and CT to rule out other
diagnoses
May be a symptom of something else
• Enemas, laxatives, suppositories all can be used
rather than a diagnosis depending on severity of constipation
3 4

Infectious Diarrhea Overview Infectious Diarrhea Overview

• Viruses are most common • Toxigenic
– No WBCs or blood in stool – “Traveler’s diarrhea”
– Adults unlikely to present • E. coli – most common
to ED (brief, self limiting) cause
• Invasive • 85% bacterial
(multiple varieties),
– Abdominal cramps, fever common 10% parasites
– WBCs and bleeding (occult to obvious) – Staph – onset in about 6 hours due to preformed
• Campylobacter – most common bacterial diarrhea toxins / contaminated food / often multiple victims /
– Contaminated water, food (esp. poultry) antibiotics generally not needed
• Shigella – high fevers, febrile seizures in young children
(often before diarrhea onset) • Large number of other, less common, infectious
• Salmonella – contaminated food, turtles, poultry causes
5 6

285
 Infectious Diarrhea Treatment
• Initial diagnosis based on history
• Cultures, stool WBCs and occult blood depends on
suspected cause and condition of patient
• If toxic, fever or bloody diarrhea – strongly consider
physician eval / routine labs, stool tests, rehydrate
• Diarrhea in children
– If no blood in stool, not toxic, no fever, main focus is
on rehydration / antimotility drugs usually avoided
• Diarrhea in adults
– Often 3 days of antibiotics and loperamide (OTC) for
routine traveler’s diarrhea (ciprofloxacin [or
levofloxacin] / TMP SMZ)
– Controversy exists about use of antibiotics / antimotility agents
in diarrhea caused by other suspected bacterial sources –
consult
C. Difficile Treatment
• Treatment
– Metronidazole no longer first line as of 2018
– For both severe and non severe C diff infection (CDI)
• Current recommendation is oral vancomycin 125
mg four times a day – OR – fidaxomicin 200 mg
twice daily for 10 days (can be very expensive)
– CDI with shock / hypotension / ileus / megacolon
• Vancomycin 500 mg four times a day PLUS
parenteral metronidazole
– Recurrent disease
• Check CDC website for recommended treatment
C. difficile: A Particular Problem
• Significant problem with surge of cases
• Some cases are associated with antibiotic use,
but may not be
• Consider diagnosis if significant diarrhea,
especially if bloody diarrhea and risks for
infection
• Most centers have a PCR C. Diff test.
– The test cannot distinguish between colonization and
infection. We want to know if they have C. Diff colitis.
– To avoid false positives, patients should have either
documented fever, abdominal pain or tenderness or
an elevated WBC count and not be taking any
laxatives in the last 48 hours.
7 8
C. Difficile Hygiene matters
• Hygiene important
– Hand washing crucial (spores not killed by
gels or foams)
– Chlorine containing cleaning agents for
environmental contamination
CONTACT
PRECAUTIONS!
9 10
286
 Appendicitis Appendicitis History
• Classic history diffuse mild abdominal pain
• In most cases, a fecalith obstructs the lumen
and nausea and/or anorexia, followed by
• Infection and inflammation migration to right lower quadrant with
occurs distal to the tenderness at McBurney’s point
obstruction
• May not present classically – elderly, kids
• Time to perforation related
• Constipation can occur, mild fever, pain with
to how proximal the
ambulation
obstruction is
• Time to perforation varies
• 20% no physical obstruction /
just functional / spontaneous resolution possible • Pain may diminish with
perforation
11 12

Appendicitis Physical Exam Appendicitis In Children

• The only constant ( > 95%) physical finding is
abdominal tenderness
• Everything else, including labs, is very variable
• Some eat, have diarrhea, no fever, no elevated WBC
• In non communicative patients (young children, very
elderly) diagnosis can be very tough / liberal imaging
• The most common non traumatic surgical
disorder in children > 2 years
• Perforation rate <15% in adolescents, nearly
100% in those under 3 years
• Diarrhea (9 16%) / constipation (5 28%) /
dysuria (3 20%)
• Initial misdiagnoses – gastroenteritis (42%), URI
(18%), pneumonia (4%), sepsis (4%), UTI (4%)

Perform/document an abdominal exam

13 in kids with a diagnosis of URI 14

287
 Appendicitis Imaging Appendicitis Management
• Imaging may not be necessary in classic cases
• Ultrasound as the first imaging choice becoming • Old paradigm of immediate surgery for all may
more common. CT or MRI if US indeterminate or be changing
appendix not visualized – Options include delayed
– CT radiation of the abdomen = 500 chest x rays / 1:2,000 surgery, IR drainage, and even
fatal cancers estimated antibiotics only
• CT • Choice decided by surgeon, often based on CT
– Oral contrast not necessary and increases time in ED findings
– Radiologist may request IV or oral contrast • Pre op antibiotics (within 1 hr of operation)
• MRI use in pregnancy/kids is a reasonable option sometimes given in ED cefoxitin and
15 ciprofloxacin/metronidazole common 16

Diverticulitis Overview Diverticulitis Treatment

• Very common in elderly
• Some surgeons treat the mildest cases (no fever
• Small pouches in colon which can get inflamed
and microperforate (rarely free air) or elevated WBC) as outpatients with antibiotics
with close follow up
• The pain is almost always left sided
• The ones that bleed are usually right sided • Gram negative and anaerobic coverage
(and don’t hurt) – Ciprofloxacin / metronidazole common
• Most are now diagnosed – Many other antibiotic options – surgeons have
favorites, consult
with CT (either with or without
contrast depending on • CT scan looks for complications (abscess,
institution) perforation, free air) and helps confirm diagnosis
17 18

288
 Sigmoid Volvulus Overview Sigmoid
Sigmoid Volvulus Imaging
Volvulus
• Unlike the cecal variety, this is a condition of
older patients, often institutionalized, with little
mobility and, often, constipation
• Chronic straining leads to lax sigmoid
• Classic plain film inverted “U” with loops
aiming toward RUQ now most often
diagnosed on CT
• Treatment consult surgery
for sigmoidoscopy and
decompression
19 20

Cecal Volvulus Overview Cecal Volvulus Imaging

• Significantly different from sigmoid volvulus in
every way
• Youngish (20 40); acute onset
• Congenital mobility of cecum
• KUB kidney shaped bowel
loops in LUQ
• Usual diagnosis by CT
• Most common cause of obstruction in pregnancy!
• Only treatment is surgical

21 22

289
 Regional Enteritis (Crohn’s Disease)
• An inflammatory disease of unknown cause that
can affect entire GI tract, especially small bowel
• Not an ED diagnosis
• Diarrhea, bleeding, pain common
• Surgery for complications only fistula, abscess,
perforation
• Usually admitted for antibiotics, hydration,
immunosuppressives
• Increased risk of cancer
• CT shows wall thickening and complications
• Also kidney (oxalate) stones, rashes, arthritis,
fissures
23
Ulcerative Colitis (UC)
• Another inflammatory GI disease, also in youngish
patients; also high risk of cancer (30x)
• Only in colon and rectum (colectomy cures it)
• Can bleed, hurt, obstruct
• Usually supportive and immunosuppressive
therapy
• Also has extra GI manifestations
• Surgery for complications
Beware of other abdominal diagnoses in
patients with UC or Crohn’s
24

Small Bowel Obstruction Small Bowel Obstruction Imaging

• 2 common causes: • Many (most) do not require surgery
– Post operative adhesions • IV fluids, analgesia +/ NG tube
– Incarcerated hernias • Vomitus or GI aspirate is not feculent
• Lots of rare causes including • Consider electrolyte imbalance
malignancy
• Clinical diagnosis (nausea, vomiting, abdominal
pain, distension, high pitched bowel sounds)
• Confirmed by imaging classic plain film
findings (distended bowel loops and air/fluid
levels)
• CT is replacing plain films very sensitive
(maybe too sensitive) and defines location of
obstruction 25 26

290
 Large Bowel Obstruction Large Bowel Obstruction Imaging
• Malignancy is a major cause
• Also consider intussusception, diverticular
disease/abscess, volvulus
• Plain film (distended bowel with haustral
markings – go partially across lumen); being
replaced by CT
• Clinical diagnosis distension, pain,
constipation, fecal smelling emesis
• Most require IVs, NG tube, analgesics and
surgery 27 28

Mesenteric Ischemia Mesenteric Ischemia Diagnosis

• An often fatal condition – high index of
suspicion required
• Decreased blood flow to the mesenteric vessels
which supply the gut leads to ischemic gut
• May be embolic (sudden onset, often atrial
fibrillation), thrombotic or just low flow / onset
sudden or gradual depending on etiology
• Risk factors – elderly, atrial fib, digoxin,
vasculopathy, diabetes, hypotension, sepsis
Pain out of proportion is key clinical finding
29
• Think of it prompt surgical consult
• History or signs of vascular disease
• Atrial fibrillation especially bad
• Very high WBC and lactate
• Metabolic acidosis, shock
• Diagnosis is by CT with IV contrast
• Treatment surgery and/or intravascular
intervention (interventional radiology)
• Diagnosis is often made late
30

291
 Hernias
• Incarcerated means it can’t be reduced
• Strangulated means the blood flow is impaired
and you can’t (and shouldn’t) reduce it
• Two types of inguinal hernias
– Direct bulges through a
weakness in the abdominal wall
– Indirect goes thru inguinal
canal and into scrotum
• Femoral more likely to incarcerate
31
292
Perforated Bowel
• Not always with free air and not always a dramatic
presentation (elderly, immunosuppressed)
• Proximal GI perforations usually have free air and are
very painful
• More distal perforations (appy, diverticulitis) rarely
have free air
• CT much more sensitive for free air than upright
chest
• Prompt surgical consult – antibiotics against
anaerobes (metronidazole or clindamycin) plus
Gram negatives
32
Free Air on Chest X Ray

293
33
 Free Air on CT Scanning
• Note tiny amounts of non luminal (free) air noted by
colored arrows, could never be seen on plain films

294
34

Adult Chest Disorders:
Part 1
Reading a Chest X Ray
• ALWAYS be systematic and review the WHOLE x ray
• Quality?
– Good penetration – can just see the spine through
the heart
– Rotation – clavicular heads should be equidistant
from spinous processes
– Adequate breath – lungs should go down to at
least the 10th rib
• Bones: Trauma, lesions, abnormalities
• Soft tissue: Subcutaneous air, swelling
• Diaphragm: Height, free air, hernias
• Lungs: Free air, infiltrates, nodules, masses, fluid
• Mediastinum: Aorta, hilar masses, trachea
• Heart: Size, chamber prominence
Doctor, Is It My Lungs?
Reading a Chest X Ray
• From Life in the Fast Lane…
• “DRSABCDE”
– D = Details (pt. identifiers, type of film, date/time
of study)
– R = RIPE (image quality) – rotation, inspiration,
picture, exposure
– S = Soft tissues and bones
– A – Airway and mediastinum
– B = Breathing (lung fields, pleura)
– C = Circulation (heart size/shape/borders, aortic
stripe)
– D = Diaphragms (including under the diaphragms)
– E = Extras (lines, tubes, AICD, etc.)
3 4
295
296
5
 Pulmonary Basics, 1 Pulmonary Basics, 2
• Hemoglobin carries 95% of the • Cyanosis appears when more than 5 grams of
oxygen to the tissues hemoglobin (Hb) is not carrying oxygen
– 5% is dissolved in the plasma • Normal patients (Hb of 13 15 grams)
• After hemoglobin gives up its – Appear cyanotic when 5 grams are deoxygenated
oxygen to the tissues it is • Polycythemic patients (Hg 17 20 grams)
deoxygenated – E.g. COPD, pulmonary HTN, patients living at altitude
• Normally most hemoglobin is – Can appear cyanotic when they have 15 gm of Hb
oxygenated carrying oxygen and 5 gm deoxygenated (25%
deoxygenated) – e.g., “blue bloater”
• Cyanosis is noted when a
critical degree of hemoglobin • Severely anemic patients (Hb < 10 grams)
deoxygenation occurs – May never become cyanotic
– Would require half of their Hb to be deoxygenated to
show cyanosis
6 7

Pulmonary Basics, 3 Blood Gases Overview

• Must consider respiratory rate, tidal volume
(volume of air per breath), respiratory effort
when assessing ventilation
• Increasing levels of carbon dioxide are the main
driving forces of ventilation
• Patients can have relatively normal levels of
oxygen yet elevated levels of carbon dioxide
when…
– Ventilation is impaired
– Diffusion of gases at the alveolar level is inhibited
– Perfusion of the lungs with blood is compromised
• Excess carbon dioxide level causes decreased
level of consciousness and respiratory effort
(hypercarbic respiratory failure)
8 9
• Blood gases often not necessary (but are ordered)
• Oxygenation and ventilation are measured
differently
• Need to know oxygenation?
– Pulse oximetry is usually adequate
• Need to assess ventilation?
– Capnography usually adequate
• Blood gases are sometimes used to determine the
pH in assessing for the presence of metabolic
acidosis (can use a venous blood gas for this)

297
 Respiratory Failure Treatment of Respiratory Failure
• Hypoxic respiratory failure • Non invasive ventilation
– Inability to maintain oxygenation despite – Continuous positive airway pressure
supplemental oxygen (CPAP) or bi level airway positive
– Usually requires non invasive ventilation, high flow airway pressure (BiPAP)
oxygen therapy or intubation – For hypercarbia OR hypoxia OR both
– Can aid ventilation and potentially
• Hypercarbic respiratory failure avoid intubation
– Excess CO2 production sepsis, heat illness – Use early in COPD, CHF, obesity
– Retention of CO2 hypoventilation syndrome
• Muscle failure (paralysis, weakness), • High flow oxygen therapy
• Over oxygenation with subsequent – For hypoxic respiratory failure
decreased respiratory drive (COPD, • Intubation
obesity hypoventilation syndrome) – The definitive treatment for
• Manage with non invasive ventilation ventilatory failure but is associated
or intubation with substantial risks
10 11

Noninvasive Ventilation Basics Who needs a CXR?

• Considering noninvasive ventilation? • Some guidelines
• Any patient with at least one of the
– Clinical judgment usually adequate following
– Only use blood gases if significant uncertainty in clinical • Temperature over 100F (37.8C)
assessment • Heart rate greater than 100
– NIV basics • Respiratory rate greater than
• Continuous (CPAP) and bilevel (BLPAP) usually equivalent 20
– COPD an exception – BLPAP better
• Any patient with at least two of the
following
• Initial settings usually 8/3 or 10/5 • Decreased breath sounds
– Higher in acute decompensated CHF Pneumonia • Rales (crackles)
• Still hypoxic? • Absence of asthma
– Increase IPAP and EPAP • What to look for
• Still hypercapnic? • Lobar infiltrate, cavitation, effusion
– Increase IPAP = +/ bacterial or TB
– High flow nasal cannula an option in hypoxic patients • Diffuse patchy involvement = +/
Legionella or viral
12 1313

298
 Bilateral Interstitial Infiltrates, Image Pneumonia, Images
• Interstitial infiltrates consistent with viral, chlamydial Upper lobe infiltrate Lobar consolidation
and mycoplasmal pneumonias with cavitation consistent with
concerning for TB pneumococcal
(respiratory isolation!) pneumonia

14 15

Pneumonia Pneumonia
• Presentation
– Cough (not always), sputum, fever, chills, tachycardia, Treatment
tachypnea / older patients more atypical findings
(high level of suspicion)
• Diagnosis • Initial treatment is usually
– Pneumonia diagnosis probably requires positive empiric
imaging (CXR, CT or ultrasound) • Vital pieces of information
• Some patients may have false negative CXRs – Recent hospitalization?
– Other lab testing as indicated (consider blood – Recent antibiotics?
cultures if admitting)
– Travel?
– Admitting? Testing depends on severity
– Your hospital’s antibiogram
• Routine labs are reasonable (CBC, CMP) (antibiotics may vary by region)
• Blood and sputum cultures rarely change treatment in
non ICU patient but are often performed (performance – Need to know guidelines
measure) 16 17

299
 Pneumonia Treatment 2
Pneumonia Severity Index
• First decision – inpatient or outpatient care
– Hospitals may use different predictive instruments
(Pneumonia Severity Index / CURB 65 / SMART COP
/ IDSA/ATS) to supplement provider judgment
– None easily memorized / make readily available
– Unnecessary hospitalization risks hospital acquired
complications (thromboembolism, superinfections,
catheter associated infection)
• Once disposition decided, then choose
antibiotics
– Factor in local recommendations at your home
institution
– Choices can be very complicated
18 19

Pneumonia Etiologies
• Treating as outpatient?
– Mycoplasma (16%), viruses (15%), S. pneumo
(14%), chlamydia (12%), legionella (2%),
hemophilus (1%), unknown (44%)
• Admitting, non ICU?
– S. pneumo (25%), viruses (10%), mycoplasma
(6%), H. influenzae (5%), chlamydia (3%),
legionella (3%), unknown (37%)
• Admitting, ICU?
– S. pneumo (17%), legionella (10%), Gram
negatives (5%), viruses (4%), H. influenzae (3%),
unknown (41%)
20

300
2019 IDSA Pneumonia Guidelines

301
21
 Atypical Pneumonias Bacterial Pneumonias
ORGANISM CLINICAL FEATURES SPECIAL FEATURES ORGANISM TYPICAL PATTERN TYPICAL HOST

Mycoplasma “Walking pneumonia” Extrapulmonary findings Everyone

Guillain-Barré, encephalitis,
Streptococcus Lobar Community-acquired
pneumoniae Young adults
hemolysis, cold agglutinins, pneumoniae (Rusty sputum,Single Rigor) Most common overall
CXR: Patchy interstitial bullous myringitis, erythema
multiforme Haemophilus Lobar or patchy COPD
Non-toxic appearing Staccato cough influenzae Smokers
Chlamydia
pneumoniae
Infants at 3-20 weeks Conjunctivitis Staphylococcus Pleural Effusion Post-viral
Outbreaks in young adults
(in infant group) aureus (including MRSA) Necrotizing (Abscesses, IVDA
CXR: Patchy interstitial Cavitation, Empyema)

Legionella Associated with water GI symptoms (N,V,D) Klebsiella Lobar (esp. RUL) Alcoholics
sources, air conditioning
pneumophilia units
Low serum sodium pneumoniae Bulging minor fissure
(Currant jelly sputum) COPD, Diabetics
Older, sickly men Abnormal LFTs
Pseudomonas Patchy, multilobar, Hospital acquired
Toxic, altered with relative No person-to-person necrotizing, fulminant Immunocompromised
bradycardia transmission and Enterobacter (sickly sweet odor) Cystic fibrosis
CXR: Unilateral lobar No organisms on
infiltrates standard smear Anaerobes Patchy(esp. lower lobes) Alcoholics
22 (foul smelling sputum) Poor dentition 23

Spontaneous Pneumothorax Overview Spontaneous Pneumothorax Treatment

• Large ones are clinically obvious, but subtle ones • Treatment
are the challenge – Some can just be watched; no intervention needed
• Seen in tall, thin people, COPD, asthma, – If chest tube needed,
recreational drug use (inhaled) use small tube (size 24 28)
• Present with sudden onset of pleuritic chest – Pigtail catheter as effective
pain, shortness of breath, unilateral decreased • Watch for tension pneumothorax
breath sounds – Compresses the heart and
• CXR – look for lung opposite lung
markings all the way – Causes progressive shortness of
to periphery breath, tachycardia and shock
(decreased venous return)
• Lung ultrasound – Treatment – Needle thoracostomy
more sensitive in the 4th or 5th intercostal space in
24 the anterior or mid axillary line 25

302
 Hemoptysis Overview Massive Hemoptysis Treatment
• Causes •
A
Supplemental O2
– Most common is acute bronchitis • Rapid sequence intubation
– Other infections • Large bore ETT (>7.5)
• Pneumonia, bronchiectasis
– Neoplastic • Keep the bleeding side down
– TB B •
•
Aggressive pulmonary toilet
Selective mainstem intubation
– Vasculitis
– Mycetoma (fungus balls) Keep the bleeding side down
– Foreign bodies (esp. in children)
– Cardiovascular
C •
•
Correct coagulopathy
Fluid and/or blood resuscitation

• Minor versus massive

– Massive = >600mL in 24 hrs or Bronchial artery embolization
Sputum is bright, red, frothy 50mL in single cough will often be required
and alkaline compared
with hematemesis
– Death is by asphyxiation, not
hemorrhage Open surgery may also be
necessary
26 Selective mainstem intubation 27

303
304
Ankle & Foot Disorders

305
 Ankle Anatomy

• Lots of ligaments to injure (especially laterally)

• Muscles extending down can yield avulsions
306
2
 Ankle Plain Film Interpretation

• Need 3 views:
• AP, lateral, and mortise
307
3
 “Os Misdiagnose ‘em” Ossification Centers – Not Fractures
• Os trigonum is a
normal radiographic
variant
• It is NOT a fracture of
the posterior talus
• Found in 2.5 14%
of people

4 5

Ankle Sprain Overview

• Inversion >> eversion
• Lateral ligaments
– All sprains involve the
anterior talofibular
– More severe also involve
the calcaneofibular
– Severest sprains also involve
the posterior talofibular
• Ottawa Ankle Rules
• When sprained – PRICER
– Protect (crutches and splint
in more severe cases), rest, ice, compression,
elevation, rehabilitation early mobilization (in the
pain free range is important)
6

308
Ottawa Ankle Rules

309
7
 Deltoid Ligament Injury Non Pediatric Ankle Fractures
• The medial ankle • Common injuries
ligament (deltoid) is
particularly thick and • Can range from isolated
sturdy distal fibular fractures to
• These sprains are trimalleolar fracture
eversion injuries • Always examine the knee
• Much less common (Maisonneuve injuries)
than lateral ankle sprains
• Distal fibula fractures may
• Rarely tears completely be placed in walking boot
• Look for fracture of the • Unstable fractures often
medial malleolus
need surgery
• PRICER treatment 8 9

Maisonneuve Fractures Salter Harris Ankle Injuries

• Routinely examine the joint above and • Common in kids
the joint below an injury / document • Growth problems
• A Maisonneuve fracture involves the increase with the S H
proximal fibula in association with a number
ligamentous tear of the lateral • SH V is the worst
malleolus from the tibia (ankle • SH III is shown
mortise is opened) • I & V are sneaky
• If proximal leg tender, x ray the leg • “S A L T R” to
• Require ORIF and often are admitted remember
Slipped Above Lower Two Rammed
10 11

310
 Fifth Metatarsal Avulsion Fracture Fifth Metatarsal Diaphysis Fracture
• Very commonly accompanies severe ankle • Jones Fracture easily
sprains (Dancer’s fracture) confused with a 5th
• All ankle exams should metatarsal avulsion fracture
include the foot, with • Can be associated with
special attention to the nonunion (up to 25%)
fifth metatarsal • Requires much more
• A 5th metatarsal avulsion conservative care
fracture heals well on its • Nonweight bearing and
own – consider a bulky ortho follow up
dressing or cast shoe to • Some require surgery
limit discomfort 12 13

Fifth Metatarsal Apophysis Metatarsal Stress Fracture

• Can be confused • A fatigue / stress fracture of
with a fracture a metatarsal / running,
• Seen in marching (March fracture),
adolescents prolonged weight bearing
• Some adults • Most commonly the 2nd and 3rd
never fuse this • Subtle onset of pain and local
apophysis tenderness
• Key to the exam • Routine x rays seldom helpful
no tenderness in
• Callus can show healing fracture
the area
• CT or MRI can help (not in ED)
• A radiologist can be helpful in distinguishing
subtle findings differentiating an avulsion • Limit activity / cast shoe?
fracture from an apophysis 14 15

311
 Lisfranc (Midfoot) Injuries, 1
• The Lisfranc joint complex is the ligamentous
junction of the proximal metatarsals with the
cuneiform and cuboid bones
• The Lisfranc joint maintains the arch of the foot
• Injuries can vary from sprains to severe fracture /
dislocations
• Mechanisms of injury can be severe twisting
injuries to major force trauma
• Sprains and small fractures can be easily missed
16
Lisfranc (Midfoot) Injuries, 2
• Fractures with or without dislocations result in
severe foot pain, swelling and inability to bear
weight
• The concern – missing more subtle injuries
• Weight bearing x rays are more likely to be
abnormal / the anatomy is complex – get a
radiologist to review
• More severe injuries can be associated with
midfoot compartment syndromes
• These are potentially serious injuries / consult
17

Lisfranc Ligamentous Disruption Image Calcaneal Fractures Overview

• Plain x rays can be
• Widening of the misleading
space between the • MRI and CT gives much
first and second better visualization
cuneiforms is • Know how to measure
indicative of a Bohler’s angle
rupture of the • Angle is decreased with
specific ligament collapse of the calcaneus
referred to as the • A “Harris” view of the calcaneus can be helpful
Lisfranc ligament • Look for spine injuries (esp. lumbar) in the
setting of calcaneus fractures (falls from heights)
18 19

312
 Harris View of Calcaneus Toe Fractures
• Common painful
injuries
• Stubbed toe or crush
injuries
• If minimally
displaced, buddy tape
+/ rigid shoe
• If open, angulated,
rotated, or intra
articular, best to
discuss with
20 consultant 21

Plantar Fasciitis Achilles Tendon Rupture

• An inflammation of the fascia • Pain and an audible “pop”
on the sole of the foot • Palpable defect of heel cord when complete;
(connects the heel to the toes
and creates the arch of the foot) Thompson test for complete tears
• Not generally an ED problem • Partial tears are sneaky (ultrasound diagnostic)
• Classically, severe plantar pain • Steroids and quinolone (“black box” warning )
on taking the first steps out of association
bed with resolution of pain
with taking additional steps • Avulsion fracture?
• Lots of suggested treatments but most are not • Splint in plantar
particularly effective (shoe inserts, NSAIDs, etc.) flexion
• Often spontaneously resolves with time 22 • Refer to ortho 23

313
 Gastrocnemius Tear, 1
• Can be confused with
Achilles tendon rupture
• Clinically is significantly
proximal to the Achilles
tendon
• No palpable defect as
with Achilles tendon
rupture
• Typically involves the
medial head of the muscle
Gastrocnemius Tear, 2
• Typically occurs with a “pushing off” motion of
the lower extremity (e.g., climbing up hill, start
of a sprint race)
• Treatment = RICE, early ambulation (use caution
with NSAIDs may predispose to bleeding and
hematoma formation)
• May need splinting in
plantar flexion to relieve
tension on the muscle
• Crutches as needed

24 25

Tibia Fibula Fractures Leg Compartment Syndrome, 1

• Beware other injuries
• Examine skin carefully
• Open fractures common
• Minor wound can be
an open fracture!
• Tibia is just below skin
• Infection is a problem
• If open, IV antibiotics
• Tib fib fractures at high risk
• Auto pedestrian is most
common mechanism of injury
• Measure intracompartment
pressures if considering dx
• Clinical signs: The 5 “P’s”
– Pain, Paresthesia, Paralysis,
Pallor, Pulseless

• Most will need “admit” • Pain (first finding) that is hard to control should
make you consider the diagnosis
26 27

314
Leg Compartment Syndrome, 2 Compartment Syndrome, 3

• Timely (or on time) fasciotomy is limb saving!

29
28

315
316
 Eye Anatomy

Eyes: Essential
Diagnosis and Treatment

Components of the Eye Exam Components of the Eye Exam

• Anterior segment
• Visual acuity – vital signs of the eye
– Conjunctiva, cornea,
– Many patients, particularly the anterior chamber, iris & lens
elderly, are unaware they have – Perform a slit lamp exam (gold standard)
chronic decreased visual acuity • An 8 minute video: https://www.youtube.com/watch?v=g0qqwJIKQlY

(refer for routine eye exam) • Retina and optic nerve

– Panoptic (5x > field width)
• External exam (periocular)
• Measure intraocular
– Symmetry, lids, lashes, orbits pressure
• Eye motility – extra ocular movements – normally 8 21 mm Hg
– avoid if concern for open globe
• Pupil exam • Fluorescein staining
– Note pupil size, shape, and reactivity – Wood’s lamp to assess for abrasions
3 • Visual fields by confrontation 4

317
 Eye Basics Chemical Exposure
• Skip triage if a chemical exposure or serious injury • Gross contamination is worth a rapid
• If not a chemical exposure or serious injury, rinse at an eye wash faucet
always document a visual acuity in both eyes first • Use a topical eye
• If they don’t have their glasses, consider doing a anesthetic and consider
pinhole visual acuity doing some local irrigation
– Limits vision to the center of the personally and evert the
visual axis and eliminates lids to see if any particulate matter
refractive errors needs to be removed with a
• If the patient wears glasses, do cotton applicator
the visual acuity with glasses on • Learn how to evert lids
5 6

Washing Out the Eye Eye Foreign Bodies

• For more prolonged irrigation –
the Morgan Lens • Topical anesthetic
– Requires topical anesthesia • Fluorescein strip
– Generally normal saline is used • Evert the lids and sweep
(but pH is about 5.5 vs. 6.5 for RL) with Q tip moistened
– Typically 500 1,000 ml with local anesthetic
– Can use nasal cannula to irrigate both • Vertical abrasions?
eyes simultaneously
– A FB is, or was, under
• Check eye pH periodically to the upper lid
determine when acids and alkalis – Scratched during
have been neutralized (pH 7.0 7.4) blinking
7 8

318
 Eye Foreign Bodies Corneal Abrasions
• Rust rings • Usually from being poked in the eye
– Need to be removed by someone or foreign body
who knows how to do it (can stain – very painful
cornea) • Do slit lamp exam for other injury
• Injuries associated with drilling, – blood in the anterior chamber = hyphema
grinding, hammering • Topical antibiotics are often prescribed
– Consider an intraocular foreign
• Use of cycloplegics to reduce pain largely disproven
body – x ray or CT, check Seidel sign • Patches for abrasions not routinely recommended
(https://www.youtube.com/watch? • Topical local anesthetic – shared decision making
v=GlFcAv0DR4c) – Literature states reasonable for discharge
• Early follow up (next day?) – Still controversial
9 10

Corneal Abrasions Blunt Eye Trauma

• Beware of abrasions associated with contact lenses
• Hyphema is the term for blood in
– In actuality may be early infections – usually caused
the anterior chamber
by pseudomonas
• As seen in the picture, it is an
• Watch for corneal lacerations
obvious sign of intraocular injury
– Seidel test – fluorescein dye is washed away from
corneal leaking site • Microhyphemas can be noted on
slit lamp exam as red cells floating
• Eye patches are specifically not advised in contact
in the anterior chamber (behind
lens associated abrasions and those associated with
organic matter the cornea and in front of the iris)
– May act like an incubator for infection • Can be associated with multiple
less obvious eye injuries
• Tetanus immunization?
• Consult ophthalmologist
• Follow up if in 48 hours if symptoms persist
11 12

319
 Viral Conjunctivitis
• Pink eye most common
• Gritty feeling to the eye
• No photophobia / normal vision
• Redness is more likely peripheral
• Preauricular lymph node often
• Often bilateral / watery discharge
• Lids may be puffy
• Often with a concomitant URI
• Lasts 4 7 days (a URI of the eye)
• Schools often ban attendance
• Routine slit lamp exam advised
• No specific treatment
– Hand washing, separate towels, avoid close contact
Iritis/Uveitis
• Uveitis
– An inflammation of the middle
portions of the eye
• Iritis anterior uveitis (4x more common)
• Multiple causes
– Keys to the diagnosis of iritis
• Pain in the eye, worse with light
– Unrelieved by topical anesthetic
• Reddened eye especially at the limbus
(the area right around the cornea)
– Distinction from conjunctivitis which is more
peripheral
• Abnormal slit lamp exam (cell and flare)
– Consult ophthalmologist, can cause blindness
Bacterial Conjunctivitis
• Mucopurulent or purulent discharge
• Often have matted lids in the morning
• Caused by Staph, Strep, H. flu, Moraxella
• May be an STD like GC (serious)
• Look for corneal involvement on slit lamp
• Low threshold for involving the physician
• Topical antibiotics
– Children may do better with ointments
• Erythromycin, bacitracin polymyxin (e.g.,Polysporin),
TMP polymyxin B (e.g., Polytrim)
– Sulfacetamide is only bacteriostatic and not “cidal”
• Conjunctivitis otitis syndrome = oral antibiotics
13
• https://2view.fireside.fm/18 14
Other Causes of the Red Eye
• Important questions to ask
– Vision affected, foreign body sensation,
photophobia, trauma, contact lens wearer?
• There is a large differential for the red eye
– Unless certain of the diagnosis and not serious,
strongly consider discussing with specialist
– Examples of benign causes
• UV keratitis
– Sun, snowblindness, welding
– Pain, corneal stippling
• Allergic conjunctivitis
– Itching, cobblestone appearance under lid
15 16
320
 Hordeolum / Chalazion Pingueculum / Pterygium
• Thickened conjunctival tissue
• Hordeolum (stye) – a purulent
– Wedge shaped, medial or lateral
inflammation of the eyelid
– Associated with chronic sun exposure
– Eyelash follicle or tear gland
– Treatment – warm compresses • Pingueculum
• Little evidence antibiotic ointment helpful – Localized to conjunctiva
• If persistent, may need I&D • Pterygium
• Chalazion – cyst in lid, painless – Extending onto the cornea
– Treatment – warm compresses • Treatment lubrication
• Antibiotics not indicated • Refer to ophthalmologist
• Refer for I&D, glucocorticoid injections

17 18

Dacryocystitis / Dacryoadenitis Orbital vs. Periorbital Cellulitis

• Preseptal cellulitis – infection
• Inflammation / infection of the of the eyelid and skin anterior
tear ducts and lacrimal sac to the orbital septum
• Painful, red, swollen along – Does not involve the orbit or
lower inner lid and along nose ocular structures

– Differentiate from periorbital cellulitis • Orbital cellulitis – infection of

the contents of the orbit
• May express pus out of punctum – Fat and ocular muscles
• Treatment – oral antibiotics • Distinction may be difficult
– amoxicillin clavulanic acid, – Both can cause ocular pain, lid
clindamycin or dicloxacillin swelling erythema

19 20

321
 Periorbital (Preseptal) Cellulitis
• Anterior to the orbital septum, more common
• Etiology – surrounding tissues of the face/lids
– local trauma, insect/animal bites, foreign bodies
– sinusitis may be cause
– Staph, Strep, anaerobes, CA MRSA increasing
• Clinical presentation
– Ocular pain, eyelid swelling, erythema
• Treatment – clindamycin
– TMP SMX plus cephalexin/cefpodoxime/cefdinir
21
Orbital Cellulitis
• Etiology – paranasal sinuses, Staph/Strep
• Clinical presentation (ocular pain, lid swelling
and erythema)
– Pain with eye movement, proptosis, fever
– Chemosis, ophthalmoplegia, diplopia
• Complications – loss of vision, death
– Subperiosteal/orbital/brain abscess,
cavernous sinus thrombosis
• Diagnosis – CT w/contrast or MRI
– Consult ophthalmology
• Treatment – IV vancomycin plus
– Ceftriaxone, ampicillin sulbactam, piperacillin tazobactam 22

Subconjunctival Hemorrhage Acute Angle Closure Glaucoma

• Nontraumatic version • Ocular emergency
– Rapid increase in IOP
– Most commonly occurs • Shallow anterior chamber
spontaneously, does not affect • Pain onset often in dark room (pupil dilated and blocks exit of
vision, painless aqueous humor)
– Resolves in 2 3 weeks, – Normal IOP 8 21mm Hg
reassurance • Typically pressure can be >30, causes ischemia of optic nerve
• Traumatic version
– Relatively uncommon, history
of trauma, may involve vision
– Worrisome if all conjunctiva
involved (laceration, rupture)
23 24

322
 Acute Angle Closure Glaucoma Red Eye Algorithm Blepharitis
Chalazion / Hordeolum
• Clinical presentation 26 Proptosis or External Swelling?
Dacrocystitis and dacroadenitis
Periorbital/Orbital Cellulitis ***
– Decreased vision, halos, headaches, eye pain, vomiting
– Mid dilated poorly reactive pupil Keratitis (includes abrasion and ulcer ***
Scleritis / Episcleritis ***
Severe pain, FB sensation, or limbal Anterior uveitis and hypopyon ***
– Conjunctival erythema, corneal clouding injection? Acute angle closure glaucoma ***
Hyphema ***
• Needs immediate intervention Endophthalmitis ***
Focal Redness or Bulbar
• Treatment goal – drop IOP / inflammation Conjunctiva Inflamed pingueculum / Pterygium
Subconjunctival hemorrhage
– Acetazolamide 500mg IV (decreases aqueous humor production) Foreign body / perforated globe ***
Purulent Discharge
– Timolol (beta blocker) (reduces aqueous humor production) Bacterial Conjunctivitis *** (if severe)

– Apraclonidine (alpha adrenergic) (reduces aqueous humor) Itching sensation w/wo other
26
Allergic conjunctivitis
– Pilocarpine (cholinergic) (causes pupillary constriction) symptoms

• Initial IOP should be below 50 mm Hq to relieve iris ischemia yes

Airborne Allergen, topical med, or Contact dermatoconjunctivitis
• Emergent ophthalmology consultation cosmetics? Toxic Conjunctivitis
no
Chlamydial conjunctivitis *** Should involve a physician in these cases
25 Viral conjunctivitis
26

Eye Problems to Consider Referring

• All patients who have only one functional eye
and who have a problem in that eye
• All patients presenting with a laceration of the
lids going through the lid margins
• All patients with any new onset visual problems
(blurred, double, visual loss) not due to a
medical or neurological cause

27

323
324
 Approach to Reading an EKG, 1

• Mnemonic: A RARE PQRST

Cardiac Dysrhythmias • Age: Pathology will differ depending on
patient’s age
• Rate: Fast or slow?
• Axis: Left or right?
• Rhythm: Regular or irregular? P before every
QRS? QRS after every P?
• Evaluate the EKG elements (next slide)
2

Approach to Reading an EKG, 2 EKG Complexes and Intervals

• 1 vertical box = 0.1mV
• P wave: Present or absent? Peaked? PR interval • 1 horizontal box = 0.04 sec
– short or prolonged?
• Q wave: Present? Deep? Short or long QT
interval?
• R wave: Tall? Duration of QRS complex? LBBB
or RBBB?
• ST segment: Elevated or depressed?
• T wave: Peaked or inverted? U wave present?

3 4

325
 First Degree AV Block
• PR greater than 0.20 sec [200msec] (5 small boxes)
• Not associated with increased risk of mortality /
progression to higher degree blocks is rare
• Can be seen with increased vagal tone (athletes),
inferior MI, low K or Mg, most antiarrhythmic
drugs
• Is associated with a two fold increased risk of
future atrial
fibrillation
5 6
Second Degree AV Block, Type 2
• This means a QRS will suddenly be dropped
• No progressive lengthening of PR before drop
• This is worse cardiology consult indicated
– Implies more serious damage to conducting
system / often with anterior MI
• Pacer may be indicated as it may progress to
third degree
7 8
326
Second Degree AV Block, Type 1
• Comes in 2 varieties – Mobitz Type 1 and Type 2
• Type 1 (otherwise know as Wenckebach)
– Gradually lengthening PR until a QRS is missing
– Causes drugs (beta blockers, calcium channel
blockers) and ischemia (not infarction) of the
AV node as with inferior MI
– Associated with increased vagal tone / usually
abolished with atropine and exercise / worsens with
carotid massage / benign, resolves without treatment
Second Degree Block Comments
• In Type 1, the RR interval decreases as PR increases
– Treatment of Type 1 – usually nothing
• In Type 2, the RR (like the PR) does not increase
before there is a dropped beat
– In the acute setting, Type 2 is “always” dangerous
• Chronic Type 2 is not common
 Third Degree AV Block
• Also called complete heart block
• Hallmark atrial and ventricular rates are
different / atrium does not capture ventricle
• In acute setting, assume new and bad
– Rarely, can be chronic and stable
• Ventricular rate likely to be too slow
• Seen mostly with acute ischemia (anterior and
inferior MI is very high risk) / also drugs (beta
and calcium channel blockers, antiarrhythmic
[amiodarone], digoxin) / treatment = pacer
9 Type 2
Premature Atrial Contractions (PACs)
• A beat originating above the AV node that
comes early; shape of aberrant P wave may
vary
• Usually very benign, no treatment
• Subsequent QRS usually looks normal or may
be widened due to aberrant conduction
• The QRS is followed by a pause before the next
beat
11
327
Heart Block Summary
This could be
Mobitz 1 with 2:1 block
or Mobitz 2
• Note that 2:1 second degree block can be hard
to differentiate between Type 1 or Type 2
• Wide QRS complex and patient sicker favors
10
Supraventricular Tachycardia (SVT), 1
• Terminology any fast rhythm from above the
ventricles is an “SVT” by definition
• Atrial fibrillation and flutter, multifocal atrial
tachycardia, junctional tachycardia, sinus
tachycardia (HR over 100) all qualify but…
• The term SVT here (and usually) refers to a re
entry arrhythmia involving the atria and/or AV
node which is rapid, regular,
sudden onset, and
always has 1:1 conduction
(no AV block)
12
Supraventricular Tachycardia (SVT), 2 Supraventricular Tachycardia (SVT), 3
• These are often healthy, youngish people • Although usually narrow complex, SVT can be
• Easy and fun to diagnose and treat wide…
• A narrow complex, very rapid (>170 180) – … if patient has WPW, or a bundle branch block,
regular rhythm can only be SVT either old or due to rate

• These can be very hard to distinguish from

• With adenosine or vagal maneuvers, it either ventricular tachycardia (VT) and consultation
terminates abruptly or there is no effect at all or immediate cardioversion (if unstable) is
(it never slows even a little) indicated / be safe assume the worst
13 14

Paroxysmal SVT Treatment Paroxysmal SVT Treatment

• Hemodynamically unstable, pulmonary edema, ischemic • Otherwise… transiently blocking the AV node generally
chest pain? breaks the reentrant circuit and the dysrhythmia
– Synchronized cardioversion – 50 100J – IV adenosine: 6 mg; 12 mg if unsuccessful
• Otherwise… transiently blocking the AV node generally • Half life of 10 20 seconds
breaks the reentrant circuit and the dysrhythmia • Can cause temporary flushing, chest pain, dizziness
– Consider vagal maneuvers – Calcium channel blockers (e.g., verapamil, diltiazem)
• Valsalva maneuver (bearing down) are also very effective and last longer and, as such,
• +/ carotid massage (on nondominant cerebral hemisphere may prevent short term recurrence
side) / generally reserved only for young patients ? risk of
stroke in older patients)
• *REVERT – modified Valsalva
– Semi recumbent
– Have patient blow into syringe for 10 15 seconds
– Simultaneously lower head/raise legs
• “Reverse Valsalva”
15 16

328
 Wide Complex SVT vs. VT Atrial Fibrillation / Atrial Flutter Etiology
• Etiologies
• Looks like VT? – it was SVT
– AMI, hypertension, rheumatic heart disease
– Thyrotoxicosis
– Renal failure, dialysis
– Digoxin toxicity (rare); antiarrhythmics
– Chronic obstructive pulmonary disease
– Pericarditis, CHF, valvular disease
– PE, hypoxia, catecholamines, cocaine,
– Electrolyte abnormalities (low K, Ca, Mg)
17 18

Atrial Flutter Diagnosis Atrial Flutter Treatment

• Atrial flutter
– Causes – binge drinking, CHF, hypertension,
hyperthyroidism, mitral valve disease, CAD (post MI)
– Saw tooth baseline (flutter waves not always
evident)
– Narrow QRS complexes with atrial rate 300
– Ventricular rate usually blocked (2:1, 3:1, 4:1), so QRS
rate is therefore 150, 100, or 75 (300 2, 3 or 4)
– When irregularly irregular usually NOT flutter, but
rather is A fib
19
• Usually requires no treatment; reverts to NSR or
degrades to atrial fibrillation spontaneously
• If unstable, cardiovert
• If stable, a wide variety of drugs can slow the rate
– Remember, can often just wait – not a rhythm people
tend to stay in
– Calcium channel blockers are popular for slowing the
rate – verapamil, diltiazem / beta blockers are
considered second line drugs by some
– Class I and III antiarrhythmics can be used in an
attempt to convert the rhythm after rate control has
been obtained / IV amiodarone probably best 20

329
 Atrial Fibrillation Diagnosis
• By far the most common cause of an irregular
rhythm, especially when “irregularly irregular”
• Most common problem is when rhythm is new
and (therefore) too fast
• Causes similar to atrial flutter
• When acute, often has nothing to do with
intrinsic heart disease
A Fib with RVR Treatment
• Atrial fibrillation treatment considerations
– May be appropriate physiologic response to
infection or hypovolemia, especially in patients with
chronic atrial fibrillation
• Treat those conditions first if present, may slow rate
– If rate needs to be treated
• Treatment basically the same as atrial flutter slow the
rate; consider conversion (chemical or electrical)
• Many are doing cardioversion as the initial treatment
– Indications for emergent electrical cardioversion for
atrial fibrillation with rapid ventricular response
• Unstable blood pressure, significant shortness of breath or
ischemic symptoms
Atrial Fibrillation Issues
• Treatment affected by other issues
– Assess for associated conditions (such as sepsis,
volume depletion, pulmonary and other emboli,
stroke, CHF, hyperthyroidism)
– Hypotension (if fast or slow), decreased cardiac
output (lack of atrial kick), atrial and ventricular
enlargement, acute cardiac ischemia
• Generally, persistence of atrial fibrillation beyond 48
hours requires prophylactic anticoagulation before
cardioversion
– Can consider TEE if need to cardiovert semiurgently
21 22
Vagal and Carotid Sinus Maneuvers
• The Valsalva maneuver and carotid
sinus massage both act to block
conduction through the AV node
• For true SVT (re entry) they either
break the rhythm (to sinus) or do nothing
• For atrial fibrillation and sinus tach they might
slow it down briefly but will never convert it to
something else
• For atrial flutter they can increase the ratio of
the block (like 2:1 to 3:1 or 4:1) but do not
break it
23 24
330
 Multifocal Atrial Tachycardia (MAT) MAT vs. A Fib vs. Wandering Pacemaker
– Irregularly irregular narrow complexes, rate
>100
• If rate < 100 consider due to a wandering atrial
pacemaker MAT
– Typically has at least 3 different P wave
morphologies
– Variable PR intervals – can look like many PACs
– Associated with hypoxia, COPD (classically A Fib
theophylline toxicity)
– Treat the underlying condition

25 Wandering Atrial Pacemaker 26

Wolff Parkinson White (WPW) WPW Tachycardias, 1

• Regular and narrow complex
• A congenital condition in which
there are bypass fibers from atria – Treated as usual SVT
to ventricles (not through the • Regular and wide complex
AV node) (0.1 3% prevalence) – Could be SVT with aberrant conduction, SVT
with WPW or ventricular tachycardia
• On the EKG, this leads to…
– Treat as VT
– A short PR interval (< .12 sec)
• The BIG danger… atrial fibrillation with WPW
– A delta wave (slurred early QRS)
– A long QRS (> .12)

27 28

331
 WPW Tachycardias, 2 WPW Tachycardias, 3
• Atrial fibrillation with WPW • Irregularly irregular, complexes vary in size and
– Irregularly irregular, complexes vary in size and width, bursts of rapid rates (250 300) = atrial
width, bursts of rapid rates (250 300) fibrillation with WPW
• Suggests the diagnosis
• DO NOT USE ANY AV BLOCKERS IN THESE
PATIENTS
– May facilitate exclusive use of bypass tract
pathway and result in grossly excessive rate or V
fib. (no dig, verapamil, diltiazem, adenosine and
beta blockers, amiodarone)
– Treatment is cardioversion or procainamide

29 30

332
 SVT Algorithm – Narrow Complex

Excellent article: Link MS: Evaluation and Treatment of SVT. NEJM 2012;367;1438.
333
31
 SVT Algorithm – Wide Complex

Excellent article: Link MS: Evaluation and334Treatment of SVT. NEJM 2012;367;1438. 32

Premature Ventricular Contractions (PVCs) Multifocal PVCs
• Premature beats from below the AV node • PVCs may be from one or more foci – reflects
• Always wide (>.12 sec) increased cardiac irritability
• Ventricular ectopy, especially in setting of ACS, • More is worse; multifocal is worse
is potentially a problem / may be a harbinger of
ventricular tachycardia or fibrillation
– However, do not treat isolated PVCs
• In the non ACS setting, especially without CAD,
they are less concerning

33 34

Ventricular Tachycardia (V Tach) Torsades des Pointes

• More than 3 PVCs in a row • Best thought of as a special type of V tach
• Especially dangerous when seen with ACS and / • Especially common with cyclic antidepressant
or cardiomyopathy overdose and some (many) drugs that prolong
QT and / or QRS
• May lead to hypotension / ventricular
fibrillation • Usually refractory to countershock
• Always wide complex – V tach is more likely • Main treatment bicarbonate if acidotic
than SVT with aberrancy in the old and the sick and/or antidepressant related
• Magnesium (2 4gm) IV is very reasonable
• If stable, consult and
lidocaine or amiodarone
• If unstable, cardiovert
• If pulseless treat as V fib
35 36

335
 Brugada Syndrome Overview Brugada Syndrome EKG Findings
• Syncope or sudden death resulting from • Every ED provider needs to learn to recognize
ventricular fibrillation in young patients with a the characteristic EKG findings (look at the
structurally normal heart precordial leads)
• Most common cause of sudden death in young • Type 1 is most common
males without heart disease
• Familial autosomal dominant (ask family history)
• Particularly common in SE Asian males
• Precipitants – can occur spontaneously, alcohol,
stress, vagal stimuli, beta blockers
• Implantable defibrillator is treatment
37 38

Nobody Learns It Without Studying

39

336
 “Minor” C Spine Injuries in the ED
Cervical Spine Disorders:
Most Benign, Some Not

“Minor” C Spine Injuries Cervical Spine Immobilization

• Multisystem major trauma is generally managed • The immobilization of
by multiple physicians in a resuscitation bay the cervical spine by
• The focus of this lecture will be on cervical injuries prehospital staff has
become virtually routine
that might slip by because they seem minor, or
largely independent of
that present to triage and get sent to “fast track” the risk of a neck injury
– This presentation will not cover obvious spinal injuries
with neurologic deficits • Patients often wait long
periods to be “cleared”
• Patients with “minor” c spine injuries still require
a careful general exam (esp. neuromuscular exam) • EDs have varying
thresholds for the
• Advanced imaging (CT or MRI) may be indicated “clinical clearance” of such patients
3 4

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 Clinical C Spine Clearance NEXUS Cervical X ray Criteria
• Does ED policy allow clearance by non physicians?
• If so, what guidelines will
be followed?
• The Canadian C‐Spine Rules
and the NEXUS guidelines
are the most commonly
studied and validated
• To limit medicolegal risk, both should be readily
available and consistently applied

5 6

338
Nexus, The Fine Print

339
7
 8
340
 NEXUS vs. the Canadian Spine
Rules
• Percentage of time that U.S. physicians use each of
the NEXUS or Canadian C spine rules

341
9
342
10
Canadian Pediatric Spine Evaluation Pathway

343
11
 CT vs. Plain Cervical X Ray CT vs. Plain Cervical X Ray, Image
• Still debated in some places
• Although plain films will pick up most injuries,
there is no question that CT is overall superior
• Problems with CTs – loads of radiation and very
high charges (true costs are actually modest)
• If a CT of the head is clinically indicated and neck
imaging is required, it is reasonable to CT both

12 13

C Spine Plain Films

• Plain films are not yet
dead and gone
• Consider them in…
– Minor cases not
clearable by NEXUS
– Patients with chronic
neck pain
• 3 views: AP, lateral, and odontoid
• If more significant, and head CT will be
obtained, it is reasonable to CT the
neck while you are there
14

344
 C Spine Soft Tissue Anatomy
• Trauma related swelling of
tissues of the prevertebral
space can be a tip off to
occult injuries
• Here are the numbers
– 6 mm at C2,
– 22 mm at C6
– Atlanto dens interval (the
red) 5mm in peds
and 3mm in adults
• One of the major errors with
c spine x rays = failure to see
the entire cervical spine to T 1
345
15
 Odontoid Assessment
Neuro Exam of the Cervical Spine
• Important view
• Old and young tend to
get fractures in C1 C2
• Seek radiology reads
• The stakes are high
• Dashes = required symmetry of the lateral
masses of C2
• Dash Dot = required symmetry of the dens
• Lines = required symmetry C1 on C2
16 17

Cervical Plexus Motor Components C spine Sensory Innervation

• C 3 4 5 keeps the diaphragm
alive
• S 2 3 4 keeps the feces off the
floor (just for fun)
• C 5 6 7 reflexes as shown
• No C8 reflex
Biceps = C5
Brachioradialis = C6 • Sensory as shown in the
Triceps = C7
next slide
• Symptoms may suggest cord
or peripheral nerves….
18 19

346
Cervical Strain or Sprain (“Whiplash”) Seatbelt Sign of the Neck
• If plain films or CT ( ), and neuro exam intact
• Anterior bruises
• Ligamentous injury and paraspinous muscle strain
– Carotid injury?
• Treatment: soft collar (for 3 4 days only) + NSAID – Larynx fracture?
+/ narcotics +/ steroids (usually by NS consult) – Paresthesias?
– Positive neuro exam?
• Do not dismiss
– Should prompt further
evaluation

20 21

Cervical Rib Syndrome

• Congenital
• Narrows thoracic outlet
• Nerve or artery pressure
• Chronic arm symptoms
• Heavy, tingling, swollen
• Color change
• Adson’s test may be (+)
Loss of radial pulse when head is rotated to
the same side with extended neck and deep inspiration

• Can mimic carpal tunnel

22

347
348
23

AKA “EAST”
Cervical Stenosis
• Degenerative changes (age > 50)
with narrowing of the canal
• Symptoms progressive – neck
pain, stiffness, numbness in
neck, back, extremities,
weakness
• Good neuro exam is key
• MRI often indicated
– Not usually done in the ED
• Treat symptoms first: NSAID,
narcotics, steroids
Cervical Disc Disease
• Chronic symptoms
• Good neuro exam key
– Motor loss?
– Muscle wasting?
– Fasciculations?
– Reflexes down?
• Eventually surgery
• MRI may be indicated
– Not usually done in the ED
24 25
Cervical Facet Syndrome
• Facet (zygapophyseal) joint
pain
• Post whiplash
• Postural issues
• Occupational stress
• Cervical nerves affected
• NSAIDs, narcotics, steroids
• C2 3 mimics occipital
neuralgia
26 27
349
 The “Stinger” or “Burner”
• High impact sports
• Symptoms from traction
or compression of upper brachial
plexus or cervical roots 5 or 6
• Symptoms often sensory only
(numbness, dysesthesia)
• BEWARE if bilateral, think MRI –
this is likely a cord injury
• Sport protection (collars etc.)
• R I C E and NSAIDs +/ sling for support
28

350
 PA / NP Collaboration in the ED Setting
• Collaboration in the ED environment is unique in
Clinician Collaboration in the that:
1. Physicians are always
Emergency Department in the department or
immediately available
2. PAs / NPs may work with
different physicians every
day (getting to mutually
know practice styles may be a challenge)
3. Departments may have varying policies regarding
whether PAs / NPs see selected categories of
patients, all patients, and which patients need to be
also seen by a physician 2

Number of PAs in EM1,2,3 Number of NPs in EM1,2

● Over 125,280 certified PAs in the US (4/22) • Over 325,000 currently licensed NPs in the U.S.
● 287 PA programs in the U.S. ● 400+ NP Programs in the U.S.
● Approximately 10,000 new PAs graduate ● Over 36,000 new NPs graduated in 2019
each year.3 2020
● 12.4% of PAs work in EM= 13,219 ● Estimated 7,500 9,000 NPs work in EM
● ENP certification available (as of 2017)
● 8% increase since 2016
● Average age is 49 years
● Median age of EM PAs is 38
● Almost 90% of NPs are women
● 58% of EM PAs are female
● Certificate of Added Qualification
(CAQ) in EM offered by NCCPA
1 Based on data AANP National Nurse Practitioner Database, 2020.
1 Based on data from the 2020 Specialty Report @ NCCPA 2021 2 Based on AAENP data (2021) (http://aaenp-natl.org/)
2 Data from ARC-PA Website http://www.arc-pa.org/?s=number+of+programs
3 Data from May 2020 PAEA Program Report
3 4

351
PA / NP Collaboration – Teamwork Staffing & “Supervision”
• A successful team requires
trust, communication,
evidence based practice
guidelines, feedback and
experience
• Although state laws vary
regarding the extent of
practice and level of supervision for PAs and
NPs, hospitals and physician groups may
independently set their own standards for
supervision above that of the statutes.

5 JAAPA Volume 31, Number 5, May 2018 6

Procedures PAs/NPs by ED Setting

JAAPA Volume 31,

Number 5, May 2018 JAAPA Volume 31, Number 5, May 2018
7 8

352
Effective Team Practice Characteristics PA/NP Collaboration Types
• Writing and reviewing the assessment and
treatment guidelines. Establishing when
Shared Goals Prospective and under what circumstances physician
supervision
intervention is required.

Clearly Defined • Reviewing patients on a real time basis

Mutual Respect
An Optimistic
Roles

Concurrent
based on departmental guidelines or
Can-Do Attitude
supervision ad hoc.

Effective & Timely

Communication
Shared • An after-the-fact review of charts.
Knowledge & Skills Retrospective
supervision

Source: https://www.aafp.org/fpm/2012/0500/p26.html 9 10

Dealing With Conflict Five Generations

• The interests of the patients are utmost
• Physicians need to understand that
they are responsible for the care of
ALL the patients in the department
• Departmental policy should mandate that a
physician see any patient requested by a PA or NP
• Policies regarding when it is required for a
physician to write a note on a patient should be
clear-cut
• Avoid getting into a “he said, she said” situation --
the lawyers love it
11 12

353
Regulations PAs & NPs MUST KNOW!
• Familiarize yourself with the state statutes and
regulations that govern your scope of practice
– This is especially important if there are specific
supervision or collaboration rules.
• Be prepared to present applicable statutes, rules,
and regulations to the physicians if needed
• Know whether any reimbursement restrictions exist.
• Be sure to review IRS guidelines for employee
status versus independent contractor status.
https://www.irs.gov/businesses/small-businesses-self-
employed/independent-contractor-self-employed-or-employee
13
Coding and Billing (1)
• The core expectations of a clinicians in the ED:
1. Know the medicine
• Subscribe to EMRAP or other authoritative
podcasts, read, take courses
2. Know the Medicare charting rules
• Chart by the numbers. Medical decision
making the most important part of the chart
3. Know how to chart defensively
• Know what to say in the chart – and what
not.
4. Treat patients as you would want you family
treated – be nice
15
354
LIABILITY INSURANCE
• Find out which type of liability insurance is offered
(occurrence-based or claims-made), as well as the limits
of liability.
– Occurrence-based insurance is usually recommended.
– If the policy is claims-made, it’s important to know if the tail
coverage (insurance that covers you for claims after you are no
longer worker with the group or hospital) that will be paid by the
employer, or if there is a rider on the physician’s policy.
• Determine if your contract will allow for the cost of the tail
to be deducted from final amounts that may be owed to
you upon termination.
• Be prepared to acquire the tail, if needed, to ensure
coverage.
* Inadequate collaboration is one of most common complaints in
medical malpractice cases involving PAs and NPs
14
Coding and Billing (2)
• Advanced practice clinicians (APCs) had been
reimbursed at 85% of Medicare rate (but 100%
during the COVID emergency)
• 100% reimbursement when physician also sees
– Called a “Shared Visit” by Medicare
– Requirements
• Applies only to E & M codes / seen on same day
• The physician must perform some part of the
service in a face to face encounter with the patient
• The physician is required to write a clear note
detailing their service (avoid “agree as above” or
“see and agree”
• There needs to be a clear distinction between the
physicians and PAs work 16
 Liability Claims = Diagnostic Errors
Source:
The Elephant in the Room
• Board certified emergency physicians
– ACEP 2021 Workforce study
– By 2030 there will be about 9,000 too many
ABEM certified emergency physicians
– Average emergency physician salary $301,500
(range $257,000 $353,100 (Salary.com)
• PAs/NPs working emergency medicine
– PA/NP numbers are increasing substantially
faster than emergency physicians
– The average EM PA salary $132,931 (range
123,515 $145,527) (Salary.com)
– The average EM NP salary is $118,983 (range
17 $110,585 $132,398) (Salary.com) 18

PA / NP Resources
• Resources:
– AAPA
• (www.AAPA.org)

– SEMPA
• (www.SEMPA.org)

– AANP
• (www.AANP.org)
– AAENP
• (http://aaenp natl.org/index.php)

19

355
356
 Pulmonary Embolus Risk Factors
• Virchow’s triad
Adult Chest Disorders: – Stasis
• Immobilization
Part 2 • CHF, COPD
– Endothelial damage
• Trauma, postoperative, IV lines
• Smoking
– Hypercoagulable states
• Cancer
• Hormonal (pregnancy, OCP, estrogen
therapy)
• SLE (lupus anticoagulant)
• HIV, nephrotic syndrome
(antithrombin III deficiency)
2

357
PE Clinical Presentation
• Symptoms (can be very subtle)
– Dyspnea
– Pleuritic chest pain
– Syncope
• Signs (can be very subtle)
– Tachypnea
– Tachycardia
– DVT
– Wheezing or rales
– Fever (pulmonary infarction)
– Shock
358
3
 Pulmonary Embolus The CXR Large PE Chest X ray Image, 1
• Normal chest x rays are common
– A normal CXR in someone hypoxic or short of
breath is very concerning
– About 12% 24% in older studies
– Probably higher now that threshold for evaluation
has become low
• Findings variably seen with PE
• Atelectasis
• Parenchymal density widest at pleura and wedge
shaped = Hampton’s hump
• Pleural effusion Hampton’s Hump Westermark Sign
• Elevated hemidiaphragm Wedge-shaped pulmonary Marked decreased vascularity
infarction broadest at the pleural distal to a large PE
• Blunting of costophrenic angle edge
• Westermark’s sign (oligemia distal to infarct) 4 5

Large PE Chest X ray Image, 2 Pulmonary Embolism EKGs

Westermark sign
• Statistically speaking, most PE patients have a
(oligemia distal to PE) normal EKG
• When PEs are large enough, they can alter the
EKG
– Sinus tachycardia
– Signs of right heart strain (right ventricular
outflow blocked by large embolus)
– Echocardiography can sometimes demonstrate
Hampton’s hump
(pleural based wedge infarction) right heart dilatation in these serious cases

6 7

359
 Right Heart Strain on PE EKG
RBBB
P pulmonale Pattern

S1Q3T3

(Rightward
axis)

Tachycardia Inverted T waves V1-V4

360
8
 Pulmonary Embolus – ABG D Dimer Testing: Issues
ABG/VBG
• D dimer is a product of blood clot breakdown
– ABG is not recommended as part of the workup in patients
with possible PE – Not just pulmonary emboli / DVTs
• Can be normal (10% are normal) – D dimer testing for PE is associated with false
positives
• Only order after you have risk stratified the
patient
• Do not order if there is no likelihood the
patient has a PE!!
NO! NO !
– If sent and falsely positive it will likely trigger a PE
work up (to include a pulmonary CT angiogram –
costly, lots of radiation)
9 10

Pulmonary Embolism D Dimer Testing Pulmonary Embolism Core Concepts

• Over testing is rampant, expensive, exposes
• D dimer levels vary by age and patients to radiation and overtreatment
trimester of pregnancy
• MUST RISK STRATIFY the patient BEFORE testing
• Consider using age specific
– A careful assessment of the likelihood that a patient
cutoffs when interpreting d has a PE based on history/physical/pulse oximetry
dimer results
– Divide into no likelihood, low or moderate likelihood
– < 50 year old – 500 mcg/L and high likelihood
– > 50 years old – (age x 10) mcg/L as
• May use “PE unlikely” or “PE likely” **
lower limit of normal
– The hardest decision is between no and low
• Pregnancy cutoffs still being likelihood
debated to determine whether
– If NO likelihood, DON’T begin
using them is reliable – data
looks promising – If low likelihood or higher, begin
11 the evaluation 12

361
 Validated Decision Aids Wells Risk Prediction Score for PE
• Multiple decision aids have been created to • Clinical feature Points
assist providers in risk stratification for PE – Clinical symptoms of DVT 3
– Other diagnosis less likely than PE 3
– Wells rules (probably the most widely studied), – Heart rate greater than 100 1.5
Geneva, Revised Geneva, PERC, Charlotte – Immobilization or surgery within past 4 weeks 1.5
– Important concept collectively, as a group, – Previous DVT or PE 1.5
physician judgment (physicians were studied) – Hemoptysis 1
results in similar decision outcomes as the validated – Malignancy 1
risk predictor scales – but not necessarily when a • Risk score interpretation (probability of PE)
single provider is making this judgment – >6 points: high risk (78.4%)
– 2 to 6 points: moderate risk (27.8%)
• It is prudent to use a validated risk stratifier to – <2 points: low risk (3.4%)
start • Simplified Probability Score
– Can “override” with clinical judgment – > 4: PE likely
13 – 4 or less: PE unlikely 14

The PERC Rule

• Pulmonary Embolism Rule Out Criteria
– Somewhat controversial Low Likelihood

– Clinician must first classify the patient as low risk

(15% or less risk of having a PE) PERC

– Then, if all of the other criteria are met, patient has

a less than 2% chance of having a PE PERC PERC
Neg Pos
• Age < 50 years
• Pulse < 100 bpm
**
• SaO2 > 94%
• No unilateral leg swelling
• No hemoptysis
• No recent trauma or surgery
• No prior PE or DVT
• No hormone use
15 ** Use age-adjusted d-dimer 16

362
 CTPA vs. VQ Scanning General
• When CXR normal, gives comparable
results to CTPA per large recent studies
• CTPA = 500 CXR radiation dose / risk
is particularly high to female breasts /
radiation substantially less with V or
VQ scans
• Ventilation scans may not be needed,
and only a perfusion scan performed
with a normal CXR
• Real life: CT scans are much faster
and are available 24/7 in most
hospitals
17
The Approach to PE in Pregnancy
• Position of the American Thoracic Society /
• Issues in diagnosing PE in
pregnancy
– Wells has limited value (high
prevalence resting tachycardia in
pregnancy, etc.)
• Revised Geneva score may be better*
– Clinical gestalt less reliable in
pregnancy
• Clinical features overlap with
changes common in pregnancy
– Need higher clinical index of
suspicion
19
363
PE CTPA / VQ Scan Images
CTPA
Large opacity left lung / offers
specific alternative diagnoses /
substantially more radiation than
VQ scanning
VQ Scanning
Large perfusion defect in the
setting of normal ventilation,
right lung
18
The Approach to PE in Pregnancy
American College of OB/GYN (2018)
– Don’t use D dimer to exclude PE in pregnancy
• This may be changing – recent studies support its use
– If signs or symptoms of DVT do bilateral venous
compression ultrasound of the legs
• Positive? Treat
• Negative? More testing indicated
– If no signs or symptoms of DVT, do a pulmonary study
• Chest x ray first study indicated
– If normal, lung scan is advised over CTPA (“strong
recommendation”)
– If the chest x ray is abnormal, CTPA advised
20
An Approach to PE in Pregnancy

MRPA may be alternative –

somewhat controversial

364
21
Geneva and Pregnancy Adapted
Geneva Scores

365
22
The Approach to PE in Pregnancy
The YEARS Algorithm (N Engl J Med Mar 2019)
• PE dx in 4%

• CTPA
avoided in
39%

• Only one
miss (DVT)
in 3-month
follow-up

• Best in first
trimester;
still useful in
third

366
23
 Pulmonary Embolus Treatment Pulmonary Embolus Disposition
• Heparin • Most patients are still admitted, but some may be
– 80u/kg bolus, followed by 18u/hour infusion safe for outpatient treatment
• Studies show ED initiation of treatment (vs. when • Scoring systems / patient resources / additional
admitted) decreases mortality testing may be integral to determine if safe to
– May use LMWH (enoxaparin) 1mg/kg SC q12 hours treat patient as outpatient
• Treatment of choice in pregnant women – Simplified Pulmonary
• Novel anticoagulants an alternative OP treatment Embolism Severity Index (PESI)
• Fibrinolytics (tPA) • Score 0 – mortality risk 1.1%
– Now indicated only for cardiac arrest, PE causing shock – Hestia Criteria
• More complicated than PESI
– Echocardiogram showing RV enlargement may help
• Low risk patients may be safe to
identify candidates (can use POCUS)
discharge
24 25

Deep Venous Thrombosis Overview Deep Venous Thrombosis Images

• PE and DVT are collectively known as VTE
(venous thromboembolism)
• VTE is the third most common cardiovascular
disease in the U.S. (heart attack and stroke
are the top two)
• PE and DVT are intimately related
• A patient with signs and symptoms of PE who
is proven to have a DVT (probably) needs no
further work up to confirm the PE

26 27

367
 DVT Diagnostic Concepts DVT – Wells Criteria
Diagnostic approach similar to PE
1. Clinical risk assessment (Wells DVT criteria)
2. D dimer testing
3. Ultrasonography based on results of 1 and 2
• Ultrasound is very sensitive and specific in
symptomatic legs
– Per one meta analysis, 94% sensitive for proximal DVT,
64% for distal DVT, 94% specificity
– CCT scanning, 95% sensitivity for proximal and distal DVT,
97% specificity
• Less sensitive in asymptomatic legs
4. If positive, anticoagulation therapy
5. Many patients can be treated as outpatients
28 29

DVT Diagnostic Algorithm DVT Ultrasonography Image

• Top image
– Left picture shows normal
left popliteal vein
– Right picture shows that
vein, with external pressure,
can be occluded = normal

• Bottom image
– Left picture shows normal
popliteal vein before
attempted occlusion with
external pressure
– Right image shows vein
cannot be compressed
closed = clot
30 31

368
 VTE Treatment
• Novel anticoagulants have been approved for
treatment of DVT and PE
– Offer some benefits over warfarin plus bridging
• Effective immediately
• No need to follow labs
• Minimal food/drug interactions
• Can be started in ED before discharge – assure
ability to obtain as outpatient
• Know the pitfalls of prescribing from the ED
(e.g., renal disease, etc.)
• If US unavailable in ED, single dose can be
given to patient, then US next day
32

369
370
 Acute Coronary Syndromes
• Goals in evaluating patients with possible ACS
Acute Coronary Syndrome • ECG within 10 minutes
• Identification of patients who would benefit from
Essential Concepts emergent reperfusion
• Initiate medical therapy for patients with ischemia
Jessie Werner, MD • Utilize risk assessment tools and chest pain protocols
Assistant Professor of Emergency Medicine
UCSF Fresno

Acute Coronary Syndromes

• Objectives
• Identification of STEMI and STEMI equivalent ECGs
• Medical management of ACS
• Risk assessment of low to moderate risk chest pain

371
The Heart

372
4
 Acute Coronary Syndromes Clinical Presentation
2021 JACC Update

• Chest Pain: More Than Pain in the Chest – Chest “discomfort”

• STEMI
– All of the following should be considered anginal equivalents:
• ST elevation, troponin elevation
• Pain, pressure, tightness
• Suggests full wall thickness involvement
• Discomfort in the chest, shoulders, arms (not just left),
• NSTEMI neck, back, upper abdomen or jaw
• Symptoms suggestive of ischemia • SOB, fatigue
• Troponin elevation, may have ECG changes • Accompanying Symptoms
• Suggests partial wall thickness involvement – Chest pain is the dominant and most frequent symptom for both
• Unstable Angina men and women diagnosed with ACS
• No troponin elevation (or rise in serial levels) • Women may be more likely to present with accompanying
symptoms (nausea, SOB)
• Angina at rest, with minimal exertion, or worsening from
• Symptoms may be gone prior to ED arrival
a previously stable pattern
• Terminology: “cardiac”, “possible cardiac,” “noncardiac” not
5 “atypical” 6

STEMI ACS Initial Assessment

• IV, cardiac monitor, labs, chest x ray
• STEMI ECG criteria
• Review chest x ray for
• A new ST elevation, measured at the J point relative to
the PQ junction, in two contiguous leads with the • CHF and signs of dissection
following cutoffs: • Alternative explanation for chest pain (eg. Pneumothorax)
• V2 V3: 2 mm in men 40 y old; 2.5 mm in men <40 y • Give aspirin if consistent with ACS
old, or 1.5 mm in women regardless of age • 162mg to 325mg chewed
• Other leads: 1 mm • STEMI —> emergent reperfusion
• Activate the Cath lab or give thrombolytics

7 8

373
 ACS Medical Management ACS Medical Management
• STEMI: • STEMI:
• Aspirin 162 325 mg chewed • “Dual antiplatelet therapy” generally means
• Unfractionated heparin aspirin plus at P2Y12 inhibitor
• P2Y12 inhibitor (usually clopidogrel or ticagrelor) • But it could also mean aspirin + a glycoprotein
per cardiology discretion or institutional protocol IIb IIIa inhibitor (tirofiban, eptifbatide,
• +/ Other treatments such as nitroglycerin absciximab)
• Sometimes all 3 are given

9 10

ACS Management Morphine in ACS

• Morphine
? Morphine • Much of the medical • Currently recommended to give morphine or fentanyl if
management that was the patient has persistent chest pain despite anti
Oxygen classically taught has fallen
ischemic medications
out of favor
Nitroglycerin • Several of these • Retrospective review showed an association between
Aspirin interventions have been morphine and overall mortality (CRUSADE registry)
shown to be harmful • Other registries find no association
? Beta blocker • Concern that opioids delay GI uptake of antiplatelets or
may inhibit antiplatelets
• Harm may be due to masking ongoing ischemic
symptoms (expert opinion)

11 12

374
 Oxygen in ACS Nitrates in ACS
• Oxygen supplementation only if hypoxic (<90%) • Nitroglycerin
• Hyperoxia may be harmful vasoconstrictor effect
• AHA Guidelines 2014 • Consider for pulmonary edema, hypertension, or
• “Administer supplemental oxygen only with oxygen saturation <90%, respiratory refractory chest pain
distress, or other high risk features for hypoxemia”
• IOTA (Improving Oxygen Therapy in Acute‐Illness), Lancet 2018 • Administer IV or sublingual, not transdermal
• Systematic Review & Meta analysis
• 25 RCTs comparing liberal vs. conservative O2 in critically ill patients • Avoid nitroglycerin in patients receiving alteplase
• Increased overall mortality
• O2 Therapy in Patients with AMI, AM J Med 2018 • Nitroglycerin increases the metabolism of
• Systematic Review & Meta analysis
• Confirms lack of benefit for routine O2
alteplase which decreases alteplase levels and
• DETO2X‐AMI, NEJM 2017 decreases its efficacy
• Large, randomized clinical trial
• Patients with suspected MI, SPO2>90% randomized to receive O2 or RA • Avoid nitroglycerin in patients taking sildenafil
• No difference in mortality or rehospitalization with MI at 1 year
• AVOID Trial, Circulation 2015 (refractory hypotension)
• Multicenter, Prospective RCT of STEMIs
• Increase in infarct size, arrhythmia and recurrent MI
13 14

Aspirin in ACS Beta Blockers in ACS

• Aspirin • Beta blockers
• Consider in patients with ongoing ischemia and significant
• Non enteric coated 162 325 mg loading dose hypertension contributing to supply/demand mismatch
• ISIS 2 trial showed a number needed to treat of 42 • Metoprolol: improved survival in anterior STEMI with SBP>120,
no tachycardia, no AV block
for mortality
• Multiple contraindications
• CHF or low cardiac output (SBP <120, HR <60 or >100)
• High risk for cariogenic shock
• Over age 70
• Signs of AV node dysfunction
• It is reasonable to defer this decision to cardiology since it is
much harder to treat cardiogenic shock than dysrhythmias

15 16

375
 Additional Therapies in ACS Troponins
• Heparin (or enoxaparin, or bivalirudin) • Troponins (I and T) are exclusive to myocardial cells but
• Should be given as bolus and infusion for any can leak out for a large variety of reasons – not just
critically ill ACS patient with primary PCI ischemia
• Traditional troponin (I and T) elevations in the setting of
• Procedural benefit for PCI (prevent thrombosis)
ischemia
• Heparin may act as a bridge to definitive therapy – Rises within 3 6 hours of ischemic insult
• Transient protection in patients with unstable – Peaks at 12 24 hours
plaques – Normalizes at about 7 days
• Ultra high sensitivity troponins are 1,000 to 10,000
• Statins can be started within 24 hours
times more sensitive
• High Sensitivity Troponins Preferred (2021 AHA/ACC
guidelines)

17 18

Non MI Causes of Troponin Elevations Treatment For STEMI

• Tachycardia (24%)
• Myocarditis (16%)
• Congestive failure
• Pulmonary embolism
• Electrical injury
• Chest contusion
• Stroke
• Sepsis
• Collagen vascular disease
• Gastrointestinal bleeds
• Diabetic ketoacidosis
• COPD Exacerbations
• Renal failure
• Cardiomyopathy
• Post coronary bypass
• Cardiac arrest resus.
• CO poisoning
• Pancreatitis
• Hypoxia / hypercarbia
19
• The clock is ticking
• Percutaneous cardiac intervention
(PCI) within 90 minutes of arrival
(door to balloon time) per AHA
(120 for non PCI facilities)
• Thrombolytic treatment within 30
minutes of arrival (door to needle
time) per AHA
20

376
Percutaneous Coronary Intervention
• Who should get PCI (the Cath lab)? • Recommended if:
• STEMI with ischemic symptoms <12 h, or 12 24 h
if ongoing ischemia
• NSTEMI with electrical or hemodynamic
instability (acute pulmonary edema, shock,
ventricular dysrhythmia)
• NSTEMI with refractory ischemia (symptoms of
angina or ECG findings of ischemia) despite
maximum medical management
21
Thrombolytics for STEMI
• >90 120 min from time of first medical contact to
PCI, or
• >90 min from STEMI diagnosis to PCI, AND
• Symptoms <12 h, or 12 24 h if a large area of
myocardium is at risk or hemodynamic instability
is present, or
• ECG shows high “acuteness” (large upright T
waves, persistent R waves, persistent ST
elevation)
22

Thrombolytics for STEMI

• Always review contraindications before giving
thrombolytics
• Options include tenecteplase or alteplase
• Tenecteplase dosing is much simpler since it is a
weight based single IV push over 5 seconds with
no prolonged infusion
• Post thrombolytic care
• Transfer to PCI capable facility
• May still need “rescue PCI” if there is no ECG
evidence of reperfusion
23

377
 Sequence of an Evolving MI

Illustration courtesy of CorePendium

Artist Graham Smith 378
24
 ECG Leads and Anatomic Distribution Coronary Artery Anatomy

Illustration courtesy of CorePendium

Artist Jaye Weiner 25 Illustration courtesy of CorePendium 26
Artist Jaye Weiner

ECG Leads and Anatomic Distribution A Normal ECG

Illustration courtesy of CorePendium

Artist Graham Smith 27 28

379
 Anterior Myocardial Infarction Anterior MI ECG
• ST elevation V3, V4 (V1,V2 = septal)
• ST depression II, III aVF (not always)
• ST elevation I, aVL, V5, V6 = Lateral involvement

Illustration courtesy of CorePendium 29 30

Artist Jaye Weiner

Lateral Myocardial Infarction Lateral MI ECG

• ST elevation in the lateral leads (I, aVL, V5 6)
• Reciprocal ST depression in the inferior leads (III, aVF)

Illustration courtesy of CorePendium 31 32

Artist Jaye Weiner

380
 Inferior Myocardial Infarction Inferior MI ECG
• ST elevation in II, III, aVF
• Q wave in III and aVF
• Reciprocal ST depression and T inversion aVL

Illustration courtesy of CorePendium 33 34

Artist Jaye Weiner

Posterior MI ECG Posterior MI ECG

• Tall R wave in V1 and V2 (R:S >1), upright TW
• Marked ST depression in V1 V4
• Looks like an anterior MI when flipped vertically • Looks like an anterior MI when flipped vertically

35 36

381
 Posterior MI ECG STEMI Equivalents
A wide variety of beliefs exist regarding this
• Tall R wave in V1 and V2 (R:S >1), upright TW
• Marked ST depression in V1 V4
• ST elevation V7 V9 • Posterior STEMI
Posterior Leads Added • Hyperacute (de Winter) T waves
• Tall, prominent, symmetrical T waves in the precordial leads
• Suggests an acute proximal LAD occlusion
• Modified Sgarbossa criteria
• Suggests STEMI in patients with LBBB
• ST elevation in aVR with diffuse ST depressions
• Suggests ischemia vs proximal LAD occlusion
• BUT, AHA only recognizes one situation as a “STEMI equivalent”:
• Left Bundle Branch Block + original Sgarbossa criteria

37 38

Chest Pain Risk Stratification 2021 AHA/ACC Updates

• Clinical decision pathways for chest pain • Testing Not Needed Routinely for Low Risk Patients
should be used (2021 AHA/ACC guidelines)
– For patients with acute or stable chest pain determined to be low risk
• Patients with chest pain and normal or (either by a clinical decision pathway such as the HEART pathway or
nonspecific ECGs EDACS, or by negative high sensitivity troponins), urgent (within 30
• HEART Score days of ED visit) diagnostic testing (CCTA or stress test) for suspected
• History coronary artery disease is not needed
• ECG
• Risk factors • Identify Patients Most Likely to Benefit From Further Testing
• Troponin – Patients with acute or stable chest pain who are at intermediate risk or
• 3 is low risk for major cardiac event in the intermediate to high pre test risk of obstructive coronary artery disease,
next six weeks respectively, will benefit the most from cardiac imaging and testing
• Combine HEART score with an accelerated
diagnostic pathway
• Other risk stratification tools and • Share the Decision Making
accelerated diagnostic pathways exist but – Clinically stable patients with chest pain should be included in decision
are less commonly used making

39 40

382
 Special Considerations
• Young patients can have ACS; there is bias in our care
(women, elderly, diverse patients)
• Relief with a “GI cocktail” does not exclude ACS
• Risk factors are red flags, but lack of risk factors does not, by
any means, preclude ACS
• Commonly acknowledged risk factors:

Hypertension Diabetes
Hyperlipidemia Family history of ACS or stroke
Older age Lack of physical activity
Cigarette smoking Cocaine or similar drugs

41

383
384

Upper Abdominal
Disorders
Esophageal Foreign Bodies 1
• Tend to get stuck in four places
– Cricopharynx (most common in
children – C6)
– Arch of aorta indentation (T4)
– Tracheal bifurcation (T6)
– Gastroesophageal junction
(most common in adults T11)
• Patient’s sensation
of level usually correct
3 4
385
ccmelive.org
Esophageal Foreign Bodies 2
• First step is visual inspection of throat – remove if
possible
• If radio opaque (dentures, coins, some medicines,
some bones)
– PA and lateral soft tissue of neck +/ CXR is first step
• If radiolucent (fish, chicken bones, plastic, food
bolus, toothpicks) AND foreign body sensation,
non contrast CT is reasonable
• Imaging not always required
 Esophageal Foreign Bodies 3 Esophageal Foreign Bodies 4
• Food impaction (drooling, can’t swallow saliva) • Plain films/plain CT usually non
– Usually elderly patients, dentures / food (meat) tops diagnostic, current
the list / consult regarding any contrast related recommendation is endoscopy
imaging – risk of aspiration (contrast imaging associated with
– Can be very distressing for patient aspiration)
– Allow to sit up in order • Most need GI follow up even if
to spit out saliva they pass the bolus in the ED
– Endoscopic retrieval is (looking for esophageal
usual outcome pathology, especially the elderly)
– Early GI consult advised

5 6

Esophageal Foreign Bodies 5 Esophageal Foreign Bodies 6

• Food impaction treatment
– Literature not very supportive
• Glucagon
– Relaxes lower esophageal smooth muscle (1 2 mg
IV); vomiting and flushing are common with its use
• Carbonation (70%)
– Gaseous pressure may push bolus into the
stomach – need to be very careful regarding risk of
aspiration
– EZ gas / effervescent granules (sodium
bicarbonate, citric acid, simethicone) followed by
240 ml of water
– Carbonated beverages
• On the horizon – nitro SL 0.4mg tab
dissolved in 10mL water?
• Button batteries
– If seen in esophagus, must be removed
immediately by GI specialist
– Look for “stacked sign” on film
– Rapidly burns with perforation in 6 hours
– Lithium batteries are the worst
– Batteries that do not need to be removed
• Into stomach, asymptomatic
• Through pylorus within 48 hours
– Asymptomatic batteries in the
stomach are followed by serial x rays
– Most will pass completely in 48 72
7 hours 8

386
 Esophagitis
• A diagnosis of exclusion /
consider cardiac pain
• Inflammation – usually due
to reflux of stomach acid
(gastroesophageal reflux disease = GERD / hiatal
hernia is also a source of reflux)
– Pill esophagitis may require urgent EGD
• Burning or substernal pain
• Some try a “GI cocktail” – viscous lidocaine,
liquid antacid and donnatal; antacid alone is fine
– Improvement of pain does not reliably exclude a
cardiac cause of chest pain
Vomiting
• Do NOT assume benign cause
– Always consider increased intracranial
pressure, obstruction, hepatic or renal
failure, electrolyte abnormality, glaucoma,
cannabinoid hyperemesis syndrome
• Drug treatment fairly effective
IV hydration often key
– Ondansetron (Zofran) usual 1st choice (4 8 mg IM/IV)
• Consider other meds in 1st tri pregnancy – mild > oral clefts
– Metoclopramide (Reglan) especially with
gastroparesis (seen with diabetes) (10 20mg IV)
– Prochlorperazine (Compazine) especially with
migraine or peripheral vertigo (5 10mg, IV)
– Avoid promethazine (IV unless diluted and infused)
• 25mg/ml is highest concentration to be given IV
Gastritis
• Inflammation of the stomach often due to
alcohol, NSAIDs, infection (acute = viral,
chronic = H. pylori)
• Findings can resemble peptic ulcer disease
• Midline upper abdominal pain with or without
vomiting
• Acute therapy same as for esophagitis
• Additional therapy may be
needed for vomiting
• Outpatient follow up advised
• Don’t mistake for cardiac pain
9 10
Gastrointestinal Bleeding by Site
• Hematemesis (vomiting blood)
– UGI bleeding – may be bright red or blackish due
to effect of gastric acid on blood
– Hemoccult type cards may not be as accurate as
Gastroccult cards in detecting occult stomach
bleeding
• Hematochezia (red rectal bleeding)
• Anus, rectum, sigmoid bright red
• Transverse and right colon maroon
• Rapid UGI bleed (uncommon)
• Usually colon or small bowel
• Melena (black, tarry stools) usually UGI bleed
11 12
387
 Upper GI Bleeding 1
• Sources
– Esophageal varices (can be massive) or esophageal
tears due to recurrent vomiting (Mallory Weiss v.
Boerhaave’s)
– Stomach gastritis, peptic ulcer disease
• Initial treatment
– At least one large bore IV saline or lactated Ringer’s
solution
– Labs – CBC, CMP, bleeding studies (PT, PTT, INR) if any
suggestion of coagulopathy or on warfarin or other
anticoagulants, type and screen (cross if unstable or
suspected large bleed)
– If very unstable – transfuse type O (Rh – for females
in the child bearing years, Rh + for all others)
13
Large Volume Transfusions
• Stored packed red cells have no platelets and are
deficient in clotting factors
• Repeated infusions of packed cells will be associated
with a dilutional coagulopathy & poss hypocalcemia
• Actively bleeding patients who need aggressive
transfusions should be considered for preemptive use
of fresh frozen plasma (has essential clotting factors –
usually at least 4 units) and plateletpheresis packs
• If on warfarin, reversal is best done with prothrombin
complex concentrate or fresh frozen plasma (15ml/kg)
• Novel anticoagulants:
– Dabigatran  use idarucizumab / Praxbind
– Xarelto / Eliquis  Andexxa (but not for other Xa inhibitors)
15
388
Upper GI Bleeding 2
• Upper GI bleeding treatment (continued)
– If somewhat stable but can’t wait for type and
crossmatch, can order type specific blood
• Usually blood type can be determined quickly – risk
is very small
• Consider IV H2 blockers (famotidine or others) or
proton pump inhibitors (omeprazole or others)
– Literature does not support routine use
• NG tube is occasionally placed to confirm a history
of UGI bleeding (but a rectal for occult blood is
easier and usually positive)
• Most need endoscopy, sometimes emergently
14
Pancreatitis Overview
• https://jamanetwork.com/journals/jama/article
abstract/2775452 // https://2view.fireside.fm/3
• An inflammatory process of the pancreas
• Upper abdo midline pain ( back, + vomiting)
• Severe cases (usually acute – leaking enzymes)
– Acute respiratory distress syndrome (ARDS)
– Shock (due to “third spacing” – leakage of vascular
fluids into the retroperitoneal space)
– Death (due to multi organ failure as a result of
systemic absorption of pancreatic enzymes)
• Chronic pancreatitis less severe – presents with
pain and vomiting, complications rare
16
 Pancreatitis Causes Pancreatitis Evaluation / Treatment
• M > F, can occur in children • Labs
– Lipase better than amylase to diagnose
• Common causes • 2 3 x normal lipase is considered diagnostic
– Alcohol (~25%) • Height of enzyme does not reflect severity
• Have vomiting / typically • May be low or normal in chronic cases
after binge drinking – Also check CMP, LFTs and CBC
– Gallstones (~25%) blocking the • Consider US in all cases; CT usually diagnostic
pancreatic or common bile
duct
in acute, but not needed early if dx clear
– High triglycerides (~5%) • Moderate IV hydration (LR over NS?) key in
– Drugs – estrogens, steroids, thiazide diuretics, others acute cases; also treat pain, vomiting
– > Ca2+ • Early PO decreases mortality!
– Many cases are idiopathic 17 • NG aspiration unnecessary 18

Markers of Severe Pancreatitis Cutaneous Signs of Pancreatitis

• Ranson criteria historically used • Necrosis/hemorrhage may cause subcutaneous
– > Age, > WBCs, > glucose, >AST/LDH blood leakage
– Cannot calculate completely in the ED – Cullen’s sign (periumbilical ecchymosis)
• B – Grey Turner’s sign (flank ecchymosis)
I
S
A
P
– BISAP <= 2, mortality risk <=2%
• SIRS may be enough to predict severe outcome • Both findings are uncommon but should be
• All scoring systems very sensitive, < specific 19 sought 20

389
 Hepatitis 1
• Acute inflammation of the liver
• Common causes
– Viral infections (usually A, B and C)
– Alcohol
– Many drugs (watch for acetaminophen – low
threshold for getting a blood level if ANY suspicion)
– Chlorinated hydrocarbons (carbon tetrachloride,
trichlorethylene)
• Despite cause, symptoms are similar
– Malaise, nausea, anorexia, upper abdominal
discomfort, dark urine, sometimes fever, weight loss,
light stools, maybe hepatomegaly and jaundice
21
Hepatitis 2
• Cause of hepatitis often deduced by good H&P
• Blood tests include liver panel, coagulation
studies, viral hepatitis tests (results not
immediately available)
• Admit
– Encephalopathy
• Ranges from agitation to coma
• Check serum ammonia level, but does not necessarily
correlate with degree of encephalopathy
– Elevated PT/INR (a very sensitive test of liver function)
– Dehydration, hypoglycemia, significantly elevated
bilirubin, severity of clinical symptoms
• Most patients with hepatitis can go home
22

Biliary Disease Overview

• Most (>90%) biliary disease is related to gallstones
(i.e. calculous biliary disease)
• Stone(s) form in gallbladder and intermittently
obstruct the cystic or common bile duct causing
biliary colic
• Fat in duodenum stimulates
gallbladder to contract
• Stone passage causes pain
and may cause pancreatitis
• Inflammation / infection in blocked gallbladder can
lead to cholecystitis fever, elevated WBC and
signs of inflammation on imaging 23

390
Biliary Tract Anatomy

Hepatic
duct
Cystic
duct

Common
duct

Pancreatic duct

Ampulla of Vater

Sphincter of Oddi
391 24
 Biliary Disease Imaging Acalculous Cholecystitis
• Acalculous cholecystitis
• Ultrasound can detect – No stones
gallstones and note – Usually a complication of another process
presence of GB wall (trauma, burn, postpartum, post op, narcotics)
thickening, distention – Patients often critically ill
of ducts – Can cause GB perforation
• If diagnosis less clear, – Increased risk with diabetics and elderly
CT is a better choice – Greater morbidity than calculous cholecystitis
as it is almost as good • Ascending cholangitis
for the gallbladder – Infection spreading through biliary tree
and fine for – Charcot’s triad jaundice, fever (shaking chills), RUQ
pain
everything else
– Classically very sick / IV antibiotics (surgeon’s choice)
25 26

Biliary Disease Management

• Biliary colic without signs of inflammation
– Afebrile, normal WBC, normal liver panel, no
persistent vomiting, pain controllable
– Can usually be handled with pain meds, antiemetics
and parenteral nonsteroidals (decrease biliary
pressure), fluids as needed and can be treated as
outpatient
• Biliary colic with signs of inflammation and/or
infection or obstruction
– Usually require surgical consultation, parenteral
antibiotics (examples: piperacillin/tazobactam or
ampicillin/sulbactam or ceftriaxone and
metronidazole) and admission 27

392

Asthma and Chronic
Obstructive Pulmonary Disease
Asthma
Pathophysiology
• Early (minutes)
bronchospasm; sympathetic
and cholinergic control
• Late (hours to days)
airway inflammation /
bronchial
hyperresponsiveness
/microvascular leakage /
airway edema / tenacious
secretions / mucus plugging
3 4
393
Asthma Definition
• Asthma is defined as a chronic inflammatory
disorder associated with variable airflow
obstruction and hyperresponsiveness.
• Asthma exacerbations refer to severe episodes
of worsening disease, characterized by
– cough,
– shortness of breath,
– wheeze, and
– chest tightness.
Source: Management of asthma exacerbations in the emergency department: Clinical Management Review.
Hasegawa, et. al. J Allergy Clin Immunol Pract. 2020 2
Intervention
• The best strategy for management of acute
exacerbations of asthma is early recognition
and intervention before attacks become
severe and potentially life threatening
–Goals of acute therapy
• Reversal of bronchospasm and reversal of
inflammation
–Goal of chronic therapy
• Modulate immune
response
 Asthma Patient History
• Patients may present with wheezing, SOB,
chest tightness and/or cough
– Cough common in kids (especially at night)
• To assess severity, ask about:
– Duration of episode; severity
– Use of steroids, beta agonists
– Associated symptoms (fever, chest pain)
– History of hospitalization, intubation and ED visits
– Age at onset of asthma
– Other potentially complicating illnesses (e.g., diabetes,
heart disease)
5

394
 Risk Factors for Death From Asthma

Source: Management of asthma exacerbations in the emergency department: Clinical Management Review.
Hasegawa, et. al. J Allergy Clin Immunol Pract. 2020
395
6
 Differential Diagnosis

Source: Management of asthma exacerbations in the emergency department: Clinical Management Review.
Hasegawa, et. al. J Allergy Clin Immunol Pract. 2020

396
7
 Asthma Examination Asthma Evaluation
• Examine for and document • Pulse oximetry in all patients
– Speech pattern (full sentences?) • Measurement of pulmonary function
(FEV1, PEF) recommended can use to follow
– Wheezes / air movement /inspiratory
response to therapy
to expiratory ratio
– ABG rarely indicated consider if severe or if PEF
• Silent chest = no air movement = severe episode 25% predicted after initial treatment (but may not
– Respiratory rate change therapy)
– Retractions / accessory muscle use – CXR is rarely useful; consider if rales, fever, unequal
breath sounds (pneumothorax risk)
– Diaphoresis if present, indicates severe disease
– Labs are rarely useful unless other medical
– Cyanosis rare, but a sign of severe disease problems or other specific indications (i.e. if on
– Mental status combative or somnolent very theophylline, measure the level)
concerning for impending respiratory failure
8 9

Classifying Asthma Severity General Asthma Treatment

Symptoms
and signs
Initial PEF Clinical Course
• Oxygen if hypoxic, moderate to severe distress
(or FEV1)
Mild SOB with PEF 70% Usually home care with • Mild to moderate exacerbations can
activity short acting beta agonist be treated with inhaled and oral
(SABA); maybe steroids medications
Moderate SOB limits PEF 40 69% Office/ED visit • Severely ill patients need IV access,
usual activity SABA; oral steroids monitoring, multiple concurrent
Severe SOB at rest; PEF 40% Likely hospitalize breathing treatments, close
cannot Partial relief from SABA; observation and admission (often ICU)
converse Oral steroids
Life‐ PEF < 25% ED/Hospitalized/ICU
• NHLBI recommends all patients receive serial
threatening Frequent SABA, IV measurements of lung function to assess
steroids, adjuncts treatment effect
10 11

397
 Albuterol Beta‐Agonist Treatment Albuterol Beta‐Agonist Treatment
• Short acting inhaled • Hand held nebulizer equivalent to metered dose
beta agonists inhaler plus spacers
(albuterol most commonly) – Dose 4 8 puffs every 20 minutes for three doses /
is first line therapy for all higher than used for chronic, stable disease / mild to
patients moderate exacerbations
• Nebulized albuterol 2.5 • More cost effective, more rapid onset and fewer side
5mg via nebulizer effects than nebulizers
– Continuous if patient
– Allows assessment of patient’s
moderately / severely ill inhaler technique (literature says
– Intermittent (every 20 many patients have poor
minutes to 1 4 hours) if technique)
patient mild
12 13

Anticholinergic Treatment of Asthma Other Beta‐Agonists

• Synergistic with beta agonists in acute asthma
in Asthma
Treatment
with no additive side effects
– Do not use as sole first line agent
– NHLBI recommends use in severe exacerbations • Levalbuterol
– 1.25 2.5mg every 20 minutes for 3
– Associated with lower admission rates and greater doses / more expensive than
improvement in PEF / FEV1 albuterol / no clear benefit except
perhaps in children (where it is used
• Ipratropium bromide 0.5mg every 20 minutes for most commonly)
• Epinephrine 1:1000 (1 mg/mL)
3 doses, then as needed (children 0.25 0.5mg for – 0.3 0.5 mg every 20 minutes
3 doses) subcut. for 3 doses (0.01 mg/kg
up to 0.3 mg every 20 minutes
– Can add to same nebulizer as albuterol for 3 doses in children)
– Can use 4 8 puffs via MDI and spacer instead in mild to – Terbutaline also an option
subcutaneously
moderate exacerbations
14 15

398
 Systemic Corticosteroids in Asthma
Inhaled Steroids in Asthma Treatment
Treatment
• Inhaled corticosteroids cause vasoconstriction
• Underutilized, use reduces rate of relapse, may and decrease inflammation
decrease need for admission
• Early use (e.g., within 1 hr of ED arrival) is a critical – Can and should be started in the ED in most
component of ED treatment asthmatics
• Oral as effective as parenteral (IV or IM) • Current evidence equivocal
– Specific steroid used unimportant regarding replacing systemic
steroids with ICS in ED
• Doses over 40mg/day (prednisone equivalent) at
discharge appear equally effective – Should be prescribed at
– Taper unnecessary in most patients; use 1 2 mg/kg discharge in all patients with
for 3 5 days (in children) and 5 7 days (in adults) 40 persistent asthma
mg daily for 3 10 days – no taper needed • Are very expensive (about $200), can patient
afford them?
16 17

399
 Low, Medium, and High doses of Inhaled Steroids

Source: An Update on Treatment Options for Children and Adults With Asthma. Alan G. Kaplan, MD,
CCFP(EM), FCFP; Mark L. Vandewalker, MD, FACAAI. Supplement to Clinician Reviews.
September/October 2018.

400
18
 Magnesium Treatment of Asthma
• Indicated in patients with impending
respiratory failure or who are still severe after
1 hour of treatment
– Dose is 2gm IV over 20 minutes in adults
– (25 75mg/kg up to 2 grams in children)
• Short half life (< 30 minutes)
– Use appears to decrease admission
rates in severe asthmatics
– Minimal adverse effects if normal
renal function (mild flushing)
Asthma Disposition
• Discharge if pulmonary function returned to
70% of baseline and able to walk without
significant shortness of breath
– Oral steroids and start ICS immediately
– VERY important to teach concept of “controller”
versus “rescue medication” to patients
• Pts with 50% 69% of predicted with mild to
moderate symptoms should be repeatedly
reassessed while reviewing the risk factors
for fatal asthma exacerbations.
– Consider observation units if improving but not
yet able to go home
Drugs Not Indicated in Asthma
• Methylxanthines (e.g., aminophylline), a weak
bronchodilator, narrow therapeutic range, high adverse
effect profile
• Antibiotics – Little evidence supports the use/ only if
evidence of bacterial infection
– (i.e.; pneumonia)
• No proven benefit
– Aggressive hydration
– Mucolytics
– Sedation
• Also has potential harmful effect (respiratory depression)
19 20
Asthma Discharge Medications
• Depending on severity – Steroids: use 1 2 mg/kg
for 3 5 days (in children) and 5 7 days (in adults)
40 mg daily for 3 10 days – no taper needed
– Can use dexamethasone as single dose – lasts 3 days
• Start inhaled corticosteroids (ICS) if not on them
– Fluticasone (Flovent) / Budesonide (Pulmicort)
– Mometasone (Asmanex) / Beclomethasone (Qvar)
• Various types (dry powder, aerosol) and doses / all are
expensive (about $200)
– Get familiar with one and its starting dose
• Rescue short acting beta adrenergics
21
– E.g., albuterol metered dose inhaler (about $50) 22
401
Chronic Obstructive Pulmonary Disease Mechanisms Underlying
Airflow Limitations in COPD

Chronic obstructive pulmonary disease (COPD) is the third leading cause of

death in the United States1 and is predicted to rise from the fifth to the third
leading cause of death worldwide by 2030.

GOLD Website
www.goldcopd.org
23 24

Medical History COPD Presentation

Patient’s exposure to risk factors
• Often symptomatic at baseline
Past medical history
with periodic exacerbations (AECOPD)
Family history of COPD or other chronic respiratory
disease. that bring patient to the ED
Pattern of symptom development • Patients present with
History of exacerbations or previous hospitalizations – dyspnea,
for respiratory disorder
– chronic cough and/or
Presence of comorbidities
– chronic sputum production
Impact of disease on patient’s life
Social and family support available to the patient. • May have
Possibilities for reducing risk factors, especially – fever (consider pneumonia),
smoking cessation. – chest pain (consider acute coronary syndrome)
© 2018 Global Initiative for Chronic Obstructive Lung Disease 25 26

402
 COPD Examination COPD Examination
• Check vital signs, especially respiratory rate • Patients with right sided heart
• Lung sounds may vary between rhonchi, failure due to COPD have
wheezing, or minimal air movement polycythemia (causes cyanosis)
and peripheral edema (“blue
– If diaphoretic, accessory muscle use, agitation,
bloater”) / large heart with no
somnolence – suspect severe exacerbation obvious hyperinflation
– May have signs of right heart failure (peripheral • Others without right sided heart
edema, distended neck veins) if longstanding
failure and polycythemia (“pink
COPD with pulmonary hypertension
puffer”) / small heart with
hyperinflation

27 28

COPD Assessment
• Chest x ray
– Exclude alternative diagnosis PNA, CHF, PTX
• ECG
• Pulse oximetry
– If available, compare to baseline
– If low in a symptomatic patient, consider as a
measure of illness and treat
• Maybe ABG / VBG
– May need to check for hypercarbia (use pH to
assess acuity – low pH with high PaCO2 suggests
acute CO2 retention)
29

403
404
30
Examples of Commonly Used Maintenance Medications in COPD

Source: Interpreting Recent Developments in COPD Treatments Sanjay Sethi, MD; Mark T. Dransfield, MD. Supplement to
Clinician Reviews. September/October 2018. 405
31
 Important Characteristics, Advantages, and limitations of Inhalers
Used in the Treatment of COPD

Source: Interpreting Recent Developments in COPD Treatments Sanjay Sethi, MD; Mark T. Dransfield, MD. Supplement
to Clinician Reviews. September/October 2018. 406
32
 Management of Exacerbations COPD Treatment
Oxygen as indicated (titrate to O2 sat 88-92%)
Use with care; watch mental status (if patient has • Noninvasive ventilation for moderate to severe
hypoxic drive, may retain CO2, become hypercarbic, symptoms
become altered)
Inhaled short-acting beta-agonists – At least one of the following
Inhaled anticholinergics • Respiratory acidosis (PaCO2 45mmHg and arterial pH
Systemic corticosteroids 7.35)
Can shorten recovery time and hospitalization • Severe dyspnea
duration.
• Persistent hypoxemia despite supplemental oxygen
Antibiotics
When indicated, can shorten recovery time, reduce the – Bilevel positive airway pressure preferred
risk of early relapse, treatment failure, and – 8/5 usually first settings
hospitalization duration.
Methylxanthines are not recommended (side effects,
minimal benefit)
© 2018 Global Initiative for Chronic Obstructive Lung Disease 33 34

COPD Treatment COPD Disposition

• Antibiotics somewhat controversial use in: • Consider hospitalization in patients with:
– All patients with mechanical ventilation – Marked increase in baseline symptoms,
– Patients with all three cardinal symptoms
• increased dyspnea,
– severe underlying COPD, onset of new physical
• increased sputum volume and signs
• increased sputum purulence
– Patients with increased sputum purulence and one other cardinal symptom – inadequate response to treatment,
• Use effective, inexpensive antibiotics – serious comorbidities, frequent exacerbations,
– Trimethoprim sulfamethoxazole DS 1 tab PO q12hx 10 14 days; clarithromycin older age or insufficient home support
500mg PO twice daily for 7 days; doxycycline 100mg PO twice daily for 10 days
– Consideration to the development of resistant organisms should be factored into • Can discharge if none of the above
decision making.
– More expensive: Quinolones such as Levaquin, Avelox used to be first line for – Discharge meds should include inhaled long acting
COPD?? These cover better for pseudomonas or anaerobes which smokers tend to beta agonists, oral / inhaled corticosteroids,
have due to the chronic bronchitis nature
– Be aware of May, 2016, black box regarding quinolones antibiotics if indicated
35 36

407
 Discharge Criteria
Recommendations for Follow‐Up
• Full review of clinical and laboratory data
• Check maintenance therapy and understanding
• Reassess inhaler technique
• Ensure understanding of withdrawal of acute
medications (steroids and/or antibiotics)
• Provide management plan for comorbidities and follow
up
• Ensure follow up arrangements; early follow ups
• All clinical or investigational abnormalities have been
identified
© 2018 Global Initiative for Chronic Obstructive Lung Disease
37

408
 FLU LIKE SYMPTOMS
Flu-Like Symptoms
Headache Wheezing

Colds and Influenza: Insomnia Fever

Not So Straightforward
Vomiting, diarrhea
Cough

Sneezing Body
aches
Rhinorrhea
Chills
2

Disclaimer: This lecture is not

But, did you consider...
about COVID
• The following illnesses should be considered
– although you should also consider the
diagnosis of COVID and complete your work
up and plan with a COVID test or proof of
vaccination.
– Did the patient follow the appropriate
vaccination schedule?
• If so, when and how long ago?
– Can you obtain a rapid COVID test?
• If so, will it change your management?
3 4

409
• URI?
• Acute
Bronchitis?
• Influenza?
• Something
SLIT
Subjective (what are they telling you?)
else?! Listen to Lungs!
• COVID?! Do they look ILL?!
Timing (how long has this been going on)?

5 6

Upper Respiratory Illness (URI) URI Treatment

Diagnosis
– Upper respiratory tract infections: Mostly effect
the neck up (throat, ears, sinuses)
• Do not usually have muscle aches, vomiting
and diarrhea
• Not usually a high fever, lasts 4‐7 days
• Don’t look particularly ill, symptoms minor
• Self limiting
– Patients should be advised to return for review
if their condition “worsens, new symptoms
develop or exceeds the expected time for
recovery”.
7 8
• Supportive
• Rest, nutrition and hydration
• Symptomatic treatment, OTC medications +/
– Analgesics, decongestants, antihistamines, honey
– Probiotics, sleep, antitussives, saline rinses
– Maybe Zinc, Vitamin C and Echinacea
• Treatment does NOT include:
– Antibiotics and antivirals: These can cause MORE
HARM than good
LOOK AT THE EVIDENCE

410
Acute Bronchitis Diagnosis Acute Bronchitis Diagnosis
• One of the top 10 diagnoses for which patients • Additional symptoms variably used to make the
seek medical care diagnosis of acute bronchitis
• On average, patients receive 2 prescriptions and – Low grade dyspnea
miss 2 3 days of work – Wheezing
• There are no standardized diagnostic criteria and – Chest pain
providers vary widely on how the diagnosis is – Low grade fever
made (uncommon)
• Cough is consistently present – Hoarseness
• Usual course: – Malaise
– Usually lasts 2‐3 weeks – Rhonchi and rales
– Don’t tell patients they’ll be better in a few days
9 10

Acute Bronchitis Diagnosis Acute Bronchitis Treatment

• No routinely performed tests diagnose bronchitis
• Be aware of the vital signs when considering a
diagnosis of bronchitis
– Fever, tachycardia and an increased respiratory rate?
• Suggests there may underlying pneumonia or influenza
• Check for hypoxia (pulse oximetry)
and consider getting a chest x ray
• Reserve chest x‐rays for
patients at increased risk
– Those suspected with pneumonia
(or with recent prior pneumonia), elderly or
debilitated patients, COPD patients, cancer, TB or
immunocompromised
• An analysis of the medical literature provides little
support for prescribing antibiotics
• Use of antibiotics may be associated with a minor
shortening of illness (less than a day)
– Is associated with the risk of side effects
• Development of personal resistance to antibiotics
• Unnecessary expense
• Despite the evidence, antibiotics are commonly
prescribed / patient expectations are often a
barrier to evidence based care
• An MDI of albuterol may lessen symptoms in the
subset of patients that have mild evidence of
airway restriction (slight exertional wheeze)
11 12

411
EVALI: Vaping Related Illness
• Nicotine salts allow higher concentrations to
be inhaled more easily/absorbed more quickly,
than regular nicotine.
–Addiction happens fast, and can lead to further
substance abuse.
–Some vaping products have 1000’s of chemicals.
•Vaping suspected to cause Acute Lung Injury
•THC is present in most of the samples tested by
FDA to date, most patients
report a history of using
THC‐containing products (86%)
EVALI: CDC
Recommendations
• As of Jan 2020, ~3,000 cases
(~100 deaths) of EVALI have
been reported to CDC.
• Symptoms usually include:
Fever, body aches, bilateral
Vaping is NOT an FDA
infiltrates, sudden onset. approved nicotine
replacement therapy.
• No obvious bacterial source.
• Tx: Steroids (high dose) have
been effective +/ antibiotics.
• +/ High flow nasal cannula.
EVALI: Vaping Related Illness
• Many of the cases are in young, otherwise
healthy men (70%) and women (30%)
• The median age of patients is 24 years and ages
range from 13 to 75 years. 79% of patients are
under 35 years old.
• Commonality among all ALI cases is that patients
report the use of e cigarette, or vaping, products.
• Vitamin E acetate may cause these illnesses.
– Vitamin E is inhaled = interferes with lung functioning.
• Many different substances and product sources
13 are still under investigation. 14
Recent Influenza Updates/In the News
• Influenza Vaccine: Fluzone High Dose
• “More powerful, more protective” (>65 years old)
• 24% more effective than standard vaccine
• Lower risk of hospital admissions
• CDC Flu vaccine: LAIV vs. IIV vaccine
• Live Attenuated Influenza Vaccine [LAIV], (age >6
months old AAP has no preference for a specific type
of flu vaccine; depending on the child’s age and
health, they may receive either the inactivated
influenza (IIV), given IM, LAIV nasal spray
• Do not give nasal to pregnant women, children <2,
15 adults >50, immunosuppressed, +/ dx asthma 16
412
AAP Flu Vaccine Recommendations
• Children with acute, moderate or severe
COVID 19 should not receive influenza
vaccine until they have recovered;
– children with mild illness may be vaccinated.
• Children with an egg allergy can receive
influenza vaccine (IIV or LAIV) without any
additional precautions.
• Pregnant women should receive an IIV at any
time during pregnancy
– Influenza vaccination during breastfeeding is safe
for mothers and their infants.
Flu Vaccines in the ED
• Often given in the ED and urgent care, and
offered to patients (COVID vax also offered)
• The AAP supports mandatory vaccination of
health care personnel as a crucial element in
preventing influenza and reducing health care
associated influenza infections.
• ACEP, AAEM, CDC, WHO and numerous other
governing bodies STILL RECOMMEND THE
FLU VACCINE and continue to work on vaccine
17 awareness. 18

CDC Reports on Influenza Influenza Symptoms / Presentation

– Weekly, monthly, seasonally published information • They look ill
– Includes what types of flu, incidence and prevalence, • Significant symptoms
deaths, hospitalizations all over the world • Fever (but not all)
• Weekly U.S. Influenza Surveillance Report: “Fluview” • Cough
• Sore throat, rhinorrhea
CDC.gov • Body aches, headache, chills
• Fatigue, nausea/vomiting/diarrhea
• One cannot distinguish flu from other viral
illnesses just based on symptoms, therefore,
testing can confirm

19 20

413
 Influenza Diagnosis CDC Guidelines for Treatment
•Molecular assay RT‐PCR test (nose/throat swab) • If test is positive for influenza
•ED analysis: rapid antigen testing • <48 hours of symptoms
– Results in 15 minutes 1 hour
– Much lower sensitivity than RT PCR, rapid • No other contraindications
molecular assays, and viral cultures – Negative rapid test (but remember, false
– Many false positives/negatives, may negatives are uncommon), but high suspicion
differentiate between A or B or H1N1
•Differentiating flu strains = Treat with antivirals
– The Lab in a Tube (Liat) flu A/B assays
– FilmArray/BIOFire respiratory panel/Variable results Applies especially to high risk patients
May detect: Adenovirus, Corona Nl63, 229E, O43, SARS-CoV2, Human metapneumovirus,
Rhinovirus, Enterovirus, Influenza A, A/H1/H/H1-2009, Influenza B, Parainfluenza virus 1, 2, 3, 4,
RSV, Bordetella parapertussis, Bordetella pertussis, Chlamydia pneumoniae, Mycoplasma
21
CDC GUIDELINE 22
pneumoniae, Pneumocystis jirovecii and many more! $$$$$$$$$ 300-1500/test

Three FDA‐approved antiviral drugs Baloxavir marboxil

recommended by the CDC – Note: since 2018, the FDA approved a new
– Must be given within first 48 hours of symptoms influenza antiviral drug, baloxavir marboxil (trade
• All effective against influenza A and B name Xofluza®) single oral pill ($30 150)
Medication Dose Considerations
• Given for uncomplicated influenza in patients
age 12+ years / symptomatic for <48 hours.
Oseltamivir 75 mg po bid 5‐7 Pill or liquid
(Tamiflu®) days Age 14 days and • Dosing: 40 80kg = 40mg dose / 80kg = 80mg
older
Pregnant women
dose
Zanamivir 10 mg inhaled 2 Powder only
Age 7+
(Relenza®) puffs bid for 5‐7 Caution in COPD or *Claims to be
days asthma patients more effective
Peramivir 600 mg IV once Age 2 and older than Tamiflu for
Hospitalized patients resistant strains
(Rapivab®) over 15‐30 mins 23 24

414
Be Skeptical of Antivirals
• They do have side effects – nausea, vomiting and
psychiatric issues.
• In children and adults treated with the
neuraminidase inhibitors oseltamivir or zanamivir
– Shortens the symptoms, but does not reduce number
of hospitalizations, deaths in healthy or high risk
individuals (such as children with asthma or the elderly)
• The prophylactic effect seems minimal.
– Don’t prescribe to asymptomatic family members
– Medicolegal issues
• Osetamivir costs about $50 (GoodRx) vs $120 for
Tamiflu (no generic liquid formulation)
25 26

FAKE NEWS?
• The flu shot or nasal spray cause the flu: FALSE
– The shot does not cause the flu.
• The flu shot causes body aches and low grade
temperature. POSSIBLY
– Symptoms are mild and short lived.
– Randomized, double blind studies showed no difference
in side effects from the flu vs. salt water injection.
• Flu shot causes Guillain Barre Syndrome: POSSIBLY
– Risk according to studies 1 or 2 cases per 1 million
vaccinated. Other studies show no association. No GBS
post nasal spray vaccine reported.
27 28

415
 Myth‐busting
FAKE NEWS?
• Milk consumption during colds
• Children who have never been vaccinated before
– Does not worsen symptoms or thicken secretions
only need ONE flu shot. FALSE
– The AAP recommends children receiving a flu shot for
• Color of the sputum = means nothing
the first time have two shots, 4 weeks apart. – Green, orange, black, brown, purple, sparkly
• The flu shot works RIGHT away. FALSE – The only color to investigate further is RED (blood).
– It takes two weeks to protect against the flu.
• Egg allergy? Cannot get the flu shot. FALSE You swallow about
1 liter / 1 quart of
– People with egg allergies can receive any licensed,
snot a day. TRUE
recommended age appropriate influenza vaccine
– Severe egg allergy, give shot in medical setting
– Rate of anaphylaxis after all vaccines = 1.31/million29 30

Over the Counter Medications for Cold and Flu‐

OTC Medications and More Like Symptoms: It’s a Mixed Bag Baby
• Nasal decongestants • NSAIDS
• Steroid sprays • Acetaminophen
• Decongestants • Home remedies
• Expectorants • Herbs and foods
• Cough suppressants • Vitamins, herbs
• Antihistamines • Onions in your socks

31 32

416
 Pseudoephedrine (SUDAFED)
•Decongestant, need ID to get it,
used to make amphetamines
•May be more useful in patients
with eustachian tube dysfunction /
otitis / perforation
•Studies are mixed on usefulness and effectiveness.
•Nasal form “SINEX” of pseudoephedrine better
than the oral for rhinitis.
•At least one meta‐analysis has concluded that it
is more effective than placebo as a decongestant
• 7 crossover studies: a single oral dose of
phenylephrine 10mg was considered “effective” as a
decongestant in adults with acute nasal congestion
associated with the common cold.
33
WARN ABOUT REBOUND RHINITIS!
• Good rule of thumb, do not use nasal
Phenylephrine or Oxymetazoline for more than
72 hours.
35
417
Nasal Decongestants: Phenylephrine
(Neosynephrine) and Oxymetazoline (AFRIN)
• Both are nasal decongestants that provide temporary
relief of nasal congestion caused by allergies or cold
• Phenylephrine may be more useful in sinus headache
pain, but may increase restlessness
• Caution in those with heart disease/HTN
• Oxymetazoline more effective than phenylephrine, and
longer acting, but has increased risk of rhinitis
medicamentosa (rebound rhinitis). Caution in children
• A 2006 review of the pathology of rhinitis
medicamentosa concluded the use of oxymetazoline for
>3 days may result in rhinitus medicamentosa and
recommended limiting use to 3 days.
34
What else can I put up my nose?
• Fluticasone propionate (Flonase)
• Glucocorticoid nasal spray
• Used for asthma, colds, rhinitis, nasal polyps, nasal
inflammation
• The treatment for rebound rhinitis
• May help with sinus headache pain
• May help decrease nasal inflammation
• Best reserved for CHRONIC sinusitis or rhinitis
instead of common cold or flu
• Caution patients:
causes dry nares and epistaxis
36
 Cromolyn sodium Something to help me sleep?
intranasal/inhalational • Alka Seltzer products
• Mast cell stabilizer – Many contain aspirin, May cause GI upset
– Just a box of mixed drugs for a high price
• Helps control rhinorrhea,
• Nyquil and other sleep aid products
throat pain and cough
– Zzquil and Nyquil promote sleep by adding
• Symptoms may resolve faster diphenhydramine (Benadryl)
• Good for children, especially – Polypharmacy ingredients including
acetaminophen, cough suppressants and more
hose with underlying allergies – NO proven efficacy for shortening illnesses
although may provide temporary symptom relief,
addicting
• Antihistamines: May assist with sleep and rhinorrhea,
37
best when combined with decongestants 38

Other ideas? Vitamin C: An inconsistent truth

Naturopaths
• Zinc: Current studies suggest possibly if zinc
lozenges are used in the first 24 hours of the
onset of a cold, it may shorten the duration of
overall illness, suggesting 100mg+/day
–FDA issued public health warning nasal sprays
can cause permanent anosmia!
• Echinacea:
–If taken at the first “onset” of symptoms 12 24
hours, may lessen or stop the onset of a cold.
–A review over 12 studies, published in 2014, found
the herbal remedy had a very slight benefit in
preventing colds, but not lessening symptoms.
39
• A 2013 review of 29 randomized trials with >11,000
participants: among extremely active people—(i.e.
marathon runners, skiers, and Army troops) doing heavy
exercise in subarctic conditions—taking at least 200mg of
vitamin C every day appeared to cut the risk of getting a
cold in half. But for the general population, taking daily
vitamin C did not reduce the risk of getting a cold.
• A 2000 Cochrane data base study of 30 trials: Long term
daily supplementation with vitamin C in large doses daily
does not appear to prevent colds.
– Modest benefit reducing duration of cold symptoms from
ingestion of relatively “high doses” of vitamin C
• Studies evaluating effectiveness during acute illness
show, at best, an 8% speedier recovery = you’ll feel better
13 hours sooner during a typical seven day illness. At
worst, the studies demonstrate no benefit at all. 40

418
 Vicks, Essential Oils and Rubs
• No proven efficacy to either relieve or
shorten symptoms, but you do smell good.
41
Antitussives
• Dextromethorphan: tablets, syrup, spray, lozenge
– Can be addicting / recreationally to get high
– Studies found the symptomatic effectiveness of
dextromethorphan similar to placebo
– Do not take with MAOIs
– Caution SSRIs (serotonin syndrome)
– Do not take with grapefruit juice  toxicity
• Benzonatate (Tessalon Perles)
– Caution toxicity, 100 mg capsules are enough TID
• Albuterol and other inhalers
– Expensive, tachycardia, shakiness, anxiety, insomnia
• Codeine
– 5 10mg per dose, might promote sleep
43
– Mixed studies on whether it truly stops cough
419
42
Children and Antitussives
• AAP: Suggests quieting a cough is not needed in
healthy children with a cold, especially under the
age of 6 and do not need cough or cold meds
– Many additives, risk for overdose, poorly
metabolized, acetaminophen and ASA toxicity
– Systemic effects of oral decongestants and
antihistamines in infants and young children
• Older children
– Dextromethorphan (Delsym) may help
• Caution age <4
• Codeine in children?
• Not recommended in children <12
• Respiratory depression and death
– Honey and pineapple recent studies show promise 44
Honey > OTC Antitussives
– Multiple studies have shown the benefits of
honey for cough suppression.
• This is particularly helpful in children >1 year of age
– 2007 Study in JAMA: honey vs.
dextromethorphan (DM) vs. no treatment,
parents rated honey most favorably for
symptomatic relief of their child's nocturnal
cough and sleep difficulty due to upper
respiratory tract infection.
– AAP: Honey may be a preferable treatment for
cough and sleep difficulty associated with
childhood URI.
– Cochrane database reviews also show honey is
preferred and more effective
Expectorants: Only two FDA Approved
• Guaifenesin (Musinex)
– Sometimes combined with
dextromethorphan, oral dose
– Action: aid in the flow of
respiratory tract secretions,
allowing ciliary movement
to carry the loosened secretions up toward pharynx
• Acetylcysteine (Mucomyst)
– Inhaled formulations for expectorant use
– Helpful for those with emphysema, bronchitis, cystic
45 fibrosis, pneumonia 46

OTC Concerns: i.e. multiple reasons to do nothing

• Caution: Hypertension
– Decongestants can cause high blood pressure
– Avoid pseudoephedrine, ephedrine,
phenylephrine, and oxymetazoline
• Caution: Prolonged QT syndrome
– Macrolides (e.g., azithromycin), diphenhydramine/
antihistamines, phenylephrine/amphetamines
• Caution: Acute Narrow Angle Glaucoma
– Antihistamines
• Caution: Poly‐pharmacy
• Caution: Antibiotic diarrhea and dehydration
– Consider probiotic if you are prescribing antibiotic
– Studies support their use and effectiveness 47 48

420
 Pediatric Infections:
A Consistent Approach
Fever, General Concepts, 1
• Fever is defined as a rectal
temperature of 100.4F (38C)
or higher
• A surprising number of people
don’t know how to take a
temperature in an infant
• Anxiety regarding measuring
a rectal temp has led to the use
of all sorts of thermometers that
may have multiple sources of error
3 4
421
Fever, General Concepts, 2
• In infants it is particularly important to know if
they are febrile (need a rectal / infrared temp)
• The concern with some
thermometers is that they
will miss a fever / axillary
temperatures are a good
example of an inexact method
• Parents who say their infants have a fever by
touch or thermometer should be given the
benefit of the doubt if the ED temp is normal
• Home use of antipyretics muddles the issue even
further
 Fever Phobia, 1
• Practices that reinforce “fever phobia”
– Advising use of alternating ibuprofen and
acetaminophen / many practitioners do this
• Alternating sends a message that aggressive
treatment of fever is necessary and beneficial
• The AAP specifically advises against this practice
and views it as a source of potential dosing errors
and they note that it reinforces “fever phobia”
– Febrile convulsions occur in predisposed children
(about 5 10% and in half they can recur) and are
thought to occur from a rapid change in
temperature, not the absolute temperature
– The primary purpose of fever reduction is to make
an uncomfortable child more comfortable 5 6
Fever Phobia, 3
• A common ED practice??
– Starting an IV when the child is only mildly to
moderately dehydrated (specifically advised against
by the AAP)
• Implies to the parents that the child is quite sick
• Is painful unless measures are taken to limit pain
• Can create fear towards clinicians in the future
• Unnecessarily drives costs up
– Give IV acetaminophen since an IV line is in place???
• IV acetaminophen costs $35 for 1gm (charge is likely a
multiple of the hospital cost)
• The effect on fever is minimally different compared
with oral APAP (of no clinical importance)
7 acetaminophen.”
422
Fever Phobia, 2
• What caretakers need to
know from providers
– The vast majority of
older children with fevers
(even high fevers) have
viral infections that will
resolve without specific
treatment
– Fluid intake should be increased when there is fever
– Fever does not cause brain injury and is an important
part of the body’s defense against infection (it also
improves WBC function)
– It is a child’s behavior that is more important;
abnormal behavior is more concerning than the fever
Fever Phobia, 4
• IV vs PO acetaminophen for fever in adults
– RCT, E.coli endotoxin produced fever in 105 healthy
adult males (33yo ave.) Peacock, Acad EM, April 2011
– Funded by the maker of IV APAP
– Core temperature measured over 2 hours
– Compared 1gm IV (max dose) vs 1gm PO (stingy dose)
– Maximum temperature difference with IV was 0.3C
– Graphs optically looks like there is a big difference (but
look what the increments of temperature are (0.1C)
– Conclusion
• “A single dose of IV acetaminophen is as safe and
effective in reducing endotoxin induced fever as PO
8
 Fever Phobia, 5 Fever Phobia, 6
• IV vs PO acetaminophen for fever in children
– Comparison of Antipyretic Efficacy of Intravenous (IV)
Acetaminophen versus Oral (PO) Acetaminophen in the
Management of Fever in Children, Indian J Ped, 1/18
– 400 children 15mg/kg IV or PO / 3.5% “allergic” vs 0%
• Conclusions: A single dose of intravenous acetaminophen is
safe and effective in reducing fever where patients are unable
to tolerate oral administration or when rapid reduction of
temperature is desirable.

9 10

Importance of Immunizations (1) Importance of Immunizations (2)

• Ever improving vaccines have radically changed • The incidence of invasive pneumococcal disease has
the approach to fever in most age groups: dramatically dropped, especially after the 2010
– Pneumococcus strains introduction of the 13 valent vaccine
– H. Influenza, type B, • See https://www.cdc.gov/pneumococcal/surveillance.html
– Meningococcal meningitis
(375 cases in 2015)
– Pertussis
– Influenza
– Rotavirus
• In children, the quest to
find pneumococcal sepsis is largely over
• Bacterial meningitis, 4,000 cases a year, average
age = 42 (mostly children and the elderly results
in an average age where nobody gets meningitis)
11 12

423
 Finding the Source of Fever
• The goal of the examination of
fever in children is to find
treatable sources
• Aside from viral sources
(the most common cause, by far),
specific sites of potential bacterial
infections need to be sought
• The age of the child is the primary driver of the
fever work up
– Children less than three months of age who are febrile
can have serious sources but a nonspecific exam
– Older children (3 36 months of age) are easier to
assess clinically
Urine Infection in Febrile Toddlers
• Finding UTIs in febrile toddlers is
the latest challenge
– Prior to pneumococcal and
H. influenzae vaccines, the
challenge was “occult bacteremia”
• The implication is that febrile
UTIs in toddlers are upper tract
(kidney) infections = pyelonephritis
• Some question many of the current
recommendations
13 14

AAP UTI Guidelines in Febrile Toddlers, 1 Getting a Clean Catch in an Infant

• Pediatrics, September 2011 (age 2 24 months) • Hold baby under the arms like a chicken
• Tap on suprapubic area 100 times in 30 seconds
• Reaffirmed, Pediatrics, December 2016 • Light circular massage of the lumbar area
• Key points • Catch urine (69 of 80 peed within 5 minutes)
– The overall prevalence of UTIs in source unknown fevers Archives of Diseases of Children, January 2013 / See also British Medical Journal (BMJ), April 12, 1986
in well appearing infants and toddlers is about 5%
– Febrile infants who appear to warrant antibiotics due to
an ill appearance should have a cath urine (or
suprapubic aspiration [SPA]) obtained for UA / C&S
before antibiotics
– Don’t even think of culturing a bag urine (false positive
rates up to 88%)

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AAP UTI Guidelines in Febrile Toddlers, 2
• Risk factors in girls
– White race, age < 12 mo, temperature 39C (102.2F)
or higher, absence of other source
– Probability of UTI is 1% or less if no more than 1 risk
factor (2% or less if no more than 2 risk factors)
• Risk factors in boys
– Nonblack race, temperature 39C (102.2F) or higher,
fever > 24 hrs, absence of other source
– Probability of UTI exceeds 1% if uncircumcised
independent of risk factors / in circumcised males
with no more than 2 risk factors 1% or less and 2% or
less with no more than 3 risk factors
A Newer Risk Calculator
• Development of UTICalc by investigators at the
University of Pittsburgh (JAMA Pediatrics, 6/18)
• Estimated risk for UTIs / age 2 24 months
• Derivation set = 1,686 patients / Validation = 384
• Compared with the AAP guidelines, UTICalc
decreased testing by 8% and decrease cases of
missed UTIs
AAP UTI Guidelines in Febrile Toddlers, 3
• Further assessment
– If children have a low risk of UTI (per prior slide),
clinical follow up without further testing is sufficient
– Two options if not low risk
• Do a cath urine or suprapubic aspiration for UA and culture
• Obtain urine via another method (bag, spontaneous void
into cup) and obtain a dip UA
– If positive (+ nitrites, + leukocyte esterase or positive
microscopic) do cath urine (or SPA) culture
– If a fresh voided urine (< 1 hour since void) is negative
for both nitrites and leukocyte esterase, then follow up
without antibiotics is reasonable (although a negative
UA does not rule out a UTI with certainty)
17 18
AAP UTI Guidelines in Febrile Toddlers, 4
• To establish a diagnosis of UTI requires both
– A positive UA suggesting infection (pyuria or
bacteriuria) PLUS 50,000 colony forming units (CFUs)
of a uropathogen on a cath or SPA culture
– E. coli is the usual cause
• Antibiotic choice should be based on local
susceptibility
• Initial treatment is equally
efficacious orally or
parenterally
19 20
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AAP UTI Guidelines in Febrile Toddlers, 5 Pediatric UTIs and Kidney Damage
• If a parenteral agent is used to initiate treatment, • What’s the risk of pediatric upper tract UTIs
although multiple agents are ranked, ceftriaxone, causing kidney damage?
75mg/kg offers once a day dosing • Salo, Pediatrics, November 2011
• Multiple oral empiric treatments are listed – A review of 10 studies,
– The advised duration of treatment is 7 14 days plus their own data,
– Cefixime suspension (8mg/kg) (Suprax) is the only suggests that a childhood
agent listed for once daily dosing (ultra expensive – UTI appears to be the
possible cause of chronic
100mg/5ml = $215/ $65 $85 with GoodRx coupon) kidney disease in only
– TMP SMX suspension (generic available) (6 12mg/kg 0.2 0.3% of children, at most
TMP 30 60mg/kg SMX per day in two doses) ($40
with coupon / $60 $100 without)
– All other suggested options are at least BID dosing and
more expensive than TMP/SMZ 21 22

Pediatric Pneumonia, 1 Pediatric Pneumonia, 2

• IDSA and Pediatric Infectious Disease Society
Guidelines, Clin Infect Dis, October 1, 2011 (new
guidelines are in development per the IDSA)
• Key points
– When to admit (strong recommendation)
• Respiratory distress, hypoxemia O2 sat <90%, toxic, sick
• Infants less than 3 6 months
• Caused by pathogen of increased virulence
• Poor supervision or other issues at home
– Testing
• Don’t do blood cultures routinely in nontoxic, fully
immunized children (strong recommendation)
• Sputum Gram stain & culture if hospitalized (weak rec)
• Urinary antigens for strep pneumoniae not rec (strong) 23
• Key points
– Testing (continued)
• Do sensitive / specific tests for flu and other viruses (strong)
– Antibiotics not generally advised unless evidence of
bacterial co infection (clinical, lab or radiographic
findings)
• Do testing for Mycoplasma if suspicious signs / symptoms
(weak rec)(Looking for IgG and IgA antibodies
• CBC – do in more serious cases (weak rec)
• Acute phase reactants (ESR, CRP, procalcitonin) cannot be
used as the sole determinant of viral vs bacterial (strong)
– May be useful in more serious cases or not fully
vaccinated
• CXR – not necessary for confirmation of suspected CAP in
those treated as OP!!!! / if sick, hypoxia, do two views 24

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25 26

Pediatric Pneumonia, 3
• Key points
– Treatment (Outpatient)
• Antibiotics not routinely required for preschool age with
CAP, because great majority are viral (strong)
• Drug of choice is amoxicillin (90mg/kg/day) in previously
healthy, vaccinated, preschoolers if bacterial origin is
suspected (Strep. pneumo is most common)
• Use macrolides in primarily school age children or
adolescents with finding consistent with atypical pneumonia
• Early antiviral therapy if findings consistent with flu (even if
rapid test is negative [false negative?] and even if >48 hours)
– Treatment (Inpatient)
• Lots of caveats (immunization status, local susceptibility,
findings suggestive of atypicals) (look up the guidelines)
• Nobody will criticize an initial dose of ceftriaxone and
27 azithromycin (WRB) 28

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29
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30
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31
Management of Fever In Children 3 36 Months of Age

Younger

431
32
432
 Thoracolumbar Back Pain
• Topics Covered • Specific Syndromes
Back Disorders: – Overview – Epidural abscess
– Cauda equina syndrome
Don’t Miss the Red Flags – General approach
– Back exam
– Discitis (vertebral osteomyelitis)
– Central cord compression
– Red flags – Vertebral fractures
– Imaging – Vertebral metastases
– Treatment – Aortic catastrophes
– Sciatica
– Piriformis syndrome
– Spinal stenosis
– Spondylolisthesis
– Spondylosis (DJD)
– Meralgia paresthetica

Lumbar Back Pain Causes Thoracolumbar Back Pain Overview

• Mechanical
• Multiple causes – degenerative disc disease, facet joint
deterioration, muscle spasms, ruptured discs
• Injuries
• Sprains (ligamentous injury), strains (muscle injury), fractures
(trauma or osteoporotic)
• Acquired disorders
• Arthritis, spinal stenosis, spondylolisthesis, osteoporotic
fractures, sciatica, meralgia paresthetica, piriformis syndrome
• Infections (0.1%) and tumors (0.7%)
• Osteomyelitis, spinal epidural abscesses, cancer, cauda
equina syndrome
• Overview
• Thoracolumbar back pain is second only to URIs as a cause
of symptom related visits to a physician (about 80 90% of
the population will have at least one episode)
• Most cases (up to 85%) cannot be given a specific diagnosis
• Typical onset age 30 45
• Most common cause of work related disability
• Most common cause of disability in those under 45
• Can occur with and without risk factors
• Most (90+%) resolve within 6 8 weeks independent of
treatment

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 General Approach to Back Pain Red Flags
• Goals • Do not miss diagnoses:
• Identify signs and • Spinal cord compression syndromes
symptoms of “do not miss • Spinal epidural abscess
diagnoses” • Cauda equina syndrome
• Treat pain • Central cord compression
• Judicious use of imaging • Vertebral fractures
• Counseling • Vertebral metastases
• Discitis (vertebral osteomyelitis)
• Aortic catastrophes (AAA rupture, dissection)

5 6

Red Flags History and Exam History

• Trauma
• Discitis or Spinal cord • Saddle anesthesia • Chronicity
compression syndrome • Vertebral fractures • Triggers (movement, timing, Valsalva)
(epidural abscess, cauda • Trauma with midline • Radiation of pain
equina, central cord tenderness • Age
compression) • Vertebral metastases • Elderly at risk with minor trauma, ground level
• Fever • History of cancer falls
• Immunosuppression • Night sweats • Pediatric patients (red flag)
(including steroid use, • Weight loss • RED FLAGS
DM) • Age >50 • Bowel/bladder dysfunction
• IVDU • Aortic catastrophes • Numbness or weakness
• LE neuro deficit • Syncope • Fevers
• Incontinence • Pain radiating to back • IV drug use
• Bilateral neurologic • Hx of HTN • Immunosuppression, steroids, diabetes
symptoms or findings • Night sweats, weight loss
• History of cancer
Abnormal gait 7 8

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 The Back Exam Nerve Roots in the Legs
• Be consistent with your exam ROOT REFLEX SENSORY MOTOR
• Visualization of the back DECREASED LOSS WEAKNESS
• Palpation spinal vs muscular tenderness L4 Knee jerk Knee, Knee
• Range of motion medial leg extension
• Trigger point tenderness
• Neurologic exam: L5 Dorsum foot, Foot
• Sensation L3, L4, L5 at the knee big toe dorsiflexion,
gr. toe exten
• Motor heel and toe walk (dorsiflexion is L5, plantar
flexion is S1) S1 Ankle jerk Lateral foot, Foot plantar
• Reflexes Babinski (Up is an Upper motor neuron sole flexion
lesion)
9 10

Sensory Dermatomes Red Flags Workup

• Labs
• CBC, ESR, CRP
• Calcium may be elevated in patients with bony
metastases
• Imaging
• CT or MRI

Illustration courtesy of CorePendium

Artist Jaye Weiner 11 12

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Imaging of Thoracolumbar Back Pain
• Reserve imaging for patients with red flags
• Most back pain improves within 4 weeks
“Red Flags” – Spinal Epidural Abscess
• A particularly insidious but very dangerous infection
• Often missed on the first visit and very high medicolegal
risk
• Findings consistent with those of other red flag
infections (note the patient’s temperature)
• Special considerations
• Pain is often located in the thoracic back area and, as such, is
somewhat atypical for back pain
• Tenderness over a spinous process may be present (again, this
is not a typical finding in MSK back pain)
• Sed rates are usually substantially elevated
• Imaging study of choice = MR; NOT a CT or plain film

13 14

“Red Flags” Infection “Red Flags” – Spinal Epidural Abscess

• Discitis, epidural abscess
• Persistent fever (100.4 or above)
• NOTE: It’s a good idea to ALWAYS note the temperature of
a back pain patient
• History of IV drug use
• Severe pain
• Spine surgery within the last year
• Recent bacterial infection – UTI, cellulitis,
pneumonia, wound, decubitus ulcer, IV drugs
L2 osteomyelitis with
• Immunosuppression – DM, steroids, organ epidural abscess
L5 osteomyelitis with epidural abscess
transplant, HIV, biologic medications

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 “Red Flags” – Cauda Equina Syndrome “Red Flags” – Cauda Equina Syndrome
• Caused by anything that compresses the spine
(midline disc protrusions, tumors, infections, • Cauda equina = “horse’s
pathologic or osteoporotic fractures) tail” indicating the lesion
• Urinary retention or overflow incontinence is below the end of the
• Saddle (perianal area) anesthesia spinal cord (usually L1/L2)
• Anal sphincter tone decreased, fecal incontinence
• Below L1/L2 individual
• Bilateral lower extremity weakness or numbness
spinal cord nerves run
• Progressive neurologic sensory or motor weakness
in the spinal canal
• A neurosurgical emergency
• MR is the imaging modality of choice; emergent
Illustration courtesy of CorePendium
Artist Jaye Weiner

17 18

Spinal Stenosis Spinal Stenosis

• More common in the elderly
• Caused by facet hypertrophy / ligamentum
flavum thickening
• Pain, numbness and leg tingling on walking
(pseudoclaudication)
• Can occur in one or both legs
• Often relieved by flexion and sitting
• Aggravated by extension
• Remains stable (70%) or worsens (15%) vs.
most back pain, which tends to get better
C2 C4 spinal stenosis on MRI
• CT / MR are diagnostic
• Leg exercises, NSAIDs, PT, epidural steroids

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 Vertebral Fractures Vertebral Compression Fracture
• Due to axial loading with flexion (falls, seat belt
related injuries)
• See one fracture? Look for noncontiguous others
• Often due to significant trauma in younger patients
but may be seen with minimal trauma in osteoporotic
and older patients
• Incidence by location? L1 > L2 > T12
• Usually stable
• May be unstable if burst (>50% loss of anterior body height)

21 22

“Red Flags” Cancer

• Cancer
• Prior history of cancer
• Unexplained weight loss (>10kg
within 6 months)
• Age over 50 or under 17
Chance fracture • No inciting event
• Failure to improve with back pain
treatment
• Pain persists for more than 4 6
weeks
• Night pain or pain at rest
• Lung, breast and prostate in
particular go to bone
Lytic lesion with cord compression
Burst fracture
Burst fracture 23 24

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 Aortic Catastrophes Definition of Sciatica
• Aortic Dissection
• Sudden, severe pain, maximal intensity at
onset • The sciatic nerve is
• Ripping, tearing, sharp composed of lumbar nerves
• Pain between the shoulder blades
L4 and L5 and sacral nerves
• Presentation highly variable
• CT angiogram S1, S2, and S3 (the large
• Abdominal or Thoracic Aortic yellow nerve on the right)
Aneurysm Rupture • Symptoms from compression
• Classic triad (often absent): abdominal of some of these nerves or
pain, hypotension, pulsatile mass
the entire nerve bundle is
• Can also present with back pain,
especially in a contained rupture into the called sciatica
retroperitoneal space
• Ultrasound (abdomen) or CT angiogram
• Aneurysm is >3.0 cm diameter
• Most ruptures have a diameter >5 cm
25 26

Sciatica Tests Sciatica Tests

• Sciatica = pain, weakness or numbness extending down
the leg, elicited by stretching the sciatic nerve • Testing the reflexes
• Aggravated by cough, sneeze, Valsalva and strength of
selected muscles,
• Straight leg raise test lift the patients leg 30 70° while along with checking
keeping the knee straight; positive if the symptoms are sensation, will
reproduced (80% sensitive, 40% specific) generally indicate
• Crossed straight leg test raising the unaffected leg which nerve(s) are
reproduces symptoms in the affected leg (90% specific) being compressed in a
patient with sciatica
• Sciatica on exam is 95% sensitive and 88% specific for a
herniated disc

27 28

439
 Piriformis Syndrome Spondylolisthesis
• The piriformis is a deep buttock muscle
• Anterior slippage of one vertebral body on
• It rotates the thigh outwards another / back pain, possibly sciatica (rare)
• In 15% of people the sciatic nerve goes • Pediatric version = usually due to a birth defect
thru the muscle or trauma / typically L5 on S1
• Spasm or swelling of the muscle • Some believe due to repetitive hyperextension
compresses the nerve simulating back
induced sciatica stress fractures as would occur with cheerleading
• Diagnosis = increased pain after sitting,
maneuvers, weight lifting and gymnastics
lying or standing / pain decreases with • Generally requires stopping hyperextension
walking / tenderness on buttock • Young patients with back pain should be imaged to
palpation and pain on external rotation exclude this diagnosis
of the hip / treatment = rest
• Adult version = degenerative disease (L4 on L5)
• Refer to primary care or orthopedist

Illustration courtesy of CorePendium

Artist Graham Smith 29 30

Spondylolysis vs Spondylolisthesis Spondylolisthesis

Age related degenerative Anterior slip of a vertebral

disc disease body

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 Meralgia Paresthetica
• Lateral femoral cutaneous nerve
compression where it passes between
the ilium and inguinal ligament (pain
on pressure just below the anterior,
superior iliac spine)
• Lateral thigh tingling, numbness and
burning
• Common predisposers
• Pregnant women / workmen with belts
• Tight clothing / obesity / local trauma
• Treatment – address the cause,
NSAIDS, bupivacaine 0.5% just below
ASIS
Imaging of Thoracolumbar Back Pain
• Outside of red flags, use of imaging should be judicious in
the emergency department
• Choosing Wisely campaign joint society guidelines
(American Academy of Family Physicians, American Assoc.
of Neuro Surgeons, Amer. College of Physicians, etc)
• Patients with uncomplicated low back pain are unlikely to
benefit from imaging
• Unlikely to alter management
• Unlikely to identify a cause
• Most patients improve within 4 weeks
• Consider imaging after failing to improve in 6 weeks

33 34

Imaging of Thoracolumbar Back Pain Treatment Options

• Treatment in the ED
• Options range from APAP, NSAIDs, opioids, ketamine, topicals
• Lumbar and thoracic spine x rays have poor • Severe flare of sciatica:
sensitivity • Consider benzodiazepines or single dose of IM opioids
• Muscular back pain
• If imaging is warranted, consider CT or MRI • Consider trigger point injections
depending on the suspected diagnosis • For patients who can go home
• Encourage ambulation
• One study estimated that patients who received • APAP or NSAIDs
MRI during the first month of back pain were 8x • “Muscle relaxants” aren’t – they’re sedatives
more likely to have surgery with no observed • Topical treatment
• Methol, methylsalicylate (IcyHot, Salonpas, Ben Gay)
benefit compared to those with conservative • Lidocaine patches
management • Stretches
• Close follow up
• Return precautions
35 36

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 Urology: Rapid
Assessment and Treatment
Lower Tract Infection Overview
• Virtually always in females
• Dysuria, frequency, urgency,
hematuria
• Often occurs after intercourse
(postcoital voiding not helpful)
• Potentially some discomfort over the bladder
• No systemic symptoms (fever, chills, nausea,
flank pain)
• An STI can easily be misdiagnosed as a lower
tract UTI in sexually active females
3
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22
Lower Tract Infection Diagnosis
• Diagnosis – positive clinical history plus
positive micro UA or positive dip UA
• Culture generally not needed unless
recurrent UTI, immunocompromised
• Consider STIs in sexually active females
with multiple partners (particularly under 25)
– Chlamydia is most common STI
• Some advise sending a “dirty” urine (small
amount of first voided urine) for a nucleic acid
amplification test – (NAAT) ($129@STDcheck) for
chlamydia and gonorrhea (especially if any
vaginal symptoms), then sending a “clean catch”
for a standard UA 4
 Lower Tract Infection Treatment, 1
• IDSA recommendations Mar 2011 (IDSociety.org)
• AUA/CUA/SUFU recs for rUTI 2019 (auanet.org) //
https://2view.fireside.fm/1
• First line antibiotics for cystitis
– Nitrofurantoin macrocrystals (100mg)
• One capsule BID x 5 days ($6 21)
• Avoid if early pyelonephritis suspected
• Pregnancy – 2nd & 3rd term until due or delivering
• No change in resistance patterns in decades
– Trimethoprim‐sulfamethoxazole (160/800mg)
• One DS tablet BID x 3 days / very inexpensive ($4 7)
• Check your antibiogram, avoid if local resistance is high
– Other options: fosfomycin [$25 45 – one dose] or
pivmecillinam [Selexid]
Fluoroquinolone Toxicity Syndrome, 1
Lower Tract Infection Treatment, 2
• If unable to use first line antibiotics can use
– Beta lactams
• Cephalexin, cefdinir, cefpodoxime
• Avoid ampicillin or amoxicillin alone due to lower
efficacy than other agents
– Fluoroquinolones? (black box warning)
• Resistance high in some areas
• Avoid in pregnancy
• Local hospital antibiogram to know
local resistance patterns
• Cranberry juice, wiping, pericoital
voiding don’t help prevent rUTIs,
but 1.5L/day of H2O might
5 6
Fluoroquinolone Toxicity Syndrome, 2
• Neurologic problems (”floxing,” “floxed”)
– FDA warned about worsening myasthena gravis, 2011
– First lawsuit against J & J, 2014 / est. incidence, 1 2%
– Black Box, May 16, 2016 – neuropsychiatric problems
• Psychiatric – mania, delirium, insomnia, anxiety,
hallucinations, psychosis
• Neurologic – seizures, myoclonus, confusion, headaches
– Onset, hours days / avg. 14 mo / lasts as long as 9 yrs
• “Health care professionals should not prescribe systemic fluoroquinolones
to patients who have other treatment options for acute bacterial sinusitis
(ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and
uncomplicated urinary tract infections (UTI) because the risks outweigh
the benefits in these patients.”
7 8
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 Overview
Overview, Upper Tract Infection, 2
Upper Tract Infection, 1
• All UTIs are treated as if an upper tract infection
• Upper tract infection means the infection is NOT if:
– Fever (>100.4), chills, flank pain, vomiting
limited to the bladder the kidneys (one or
– Pregnancy (consider admitting in 2nd and 3rd
both) are involved trimesters)
• Pyelonephritis often used to refer to any – Known disease of the kidney/ ureters
upper urinary tract infection (UTI) but also used – Males (true cystitis bladder infections are rare in
to refer to the clinical picture of fever, chills, men)
leukocytosis and flank pain with infected urine – Diabetes (this is controversial)
– Immunocompromise (steroids, HIV, transplants)
• May present either after lower UTI symptoms or
acutely without previous lower tract symptoms
9 10

Upper Tract Infection Diagnosis, 1 Upper Tract Infection Diagnosis, 2

• Clinical symptoms as noted (although may not • Urine culture positive
be obvious in the elderly, very sick or in children) – historically: 105 CFUs (colony forming units)
• WBC is usually elevated – however, 102 threshold may be more appropriate in
pts highly suspicious for UTI
• Microscopic UA – WBCs, RBCs, bacteria present • Blood cultures often done in admitted
• Dip UA patients but do not affect tx of UTI
– Leukocyte esterase (indicates WBCs) (sensitivity and
specificity both about 80%)
– Nitrites (requires bacteria to convert nitrates to
nitrites – requires a number of hours for this to occur
– sensitivity about 50% but specificity about 98%)
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 Upper Tract Infection Treatment, 1 Upper Tract Infection Treatment, 2
• Consider admission • Do not give nitrofurantoin for
– If toxic or unable to take fluids (although several upper tract infections – does not
hours of IV fluids and IV antibiotics may quickly adequately concentrate in kidneys
improve the picture)
• Do not give ciprofloxacin if
– Pregnancy / males / poorly controlled diabetes /
obstructive uropathy pregnant (has been known to
• Often first dose IV or IM in ED (ceftriaxone is a affect fetal cartilage)
good choice – lasts 24 hours – others don’t) (now new Black Box)
• If being discharged, can give oral antibiotics • 10 14d of oral therapy is
based on local sensitivities recommended for an upper tract infection

13 14

Urinary Tract Infections in Children Kidney Stones Presentation

See • Classic presentation – sudden onset
of severe flank pain with radiation to
Pediatric groin / possibly microscopic
Infections hematuria (not always) / maybe slight
Lecture abdominal discomfort / flank tenderness
• If older than 50 and is first
episode for male, consider
rupturing abdominal aneurysm
(can cause virtually identical
symptoms – sometimes with hematuria)
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446
 Kidney Stone Imaging
• First stone suspected = CT without contrast
(specify for r/o stone, don’t CT whole abdomen)
– A whole abdomen CT is the equivalent to 500 chest x
rays / some say 1 in 2,000 will get cancer from it (the
younger the patient the greater the risk) / some say
2% of all future cancers will be due to CT scans
• Recurrent stones – imaging not mandatory /
consider KUB (may show location of stone),
ultrasound (shows hydroureter)
– Some recurrent stone patients
have gotten 30 CTs!
Kidney Stone Treatment
• Rapid, aggressive pain management
is a top priority
– IV ketorolac (prostaglandin synthetase inhibitor –
decreases renal blood flow and collecting system
pressure) / IV works much quicker than IM
• IM works no faster than oral ibuprofen and is no more
effective
– Serial IV opiates (fentanyl, morphine, hydromorphone)
– Treat nausea (ondansetron, promethazine)
• Hydration doesn’t facilitate
passage and may increase pain
– The excess urine goes out the
unobstructed kidney
Kidney Stone Lab Work
• Comprehensive metabolic panel is often done
with first stone but is low yield
– Looking for renal function (creatinine, BUN),
calcium, phosphorus, uric acid
• A dip UA for blood is routine (but about 15%
don’t have it); more important to check for
infection (WBCs)
• Lab work on stones is usually unnecessary but
some believe stones should be collected and
analyzed and used to modify diet (calcium
stones [oxalate 70% / phosphate 10%], uric acid
(5 10%), struvite 10%)
17 18
Kidney Stone Disposition
• If pain and nausea largely resolved can discharge (w/
instructions to return if > pain or signs of infection)
• May discharge on oral NSAID (ibuprofen or naproxen)
with supplemental opiates if needed
• Alpha blockers had been thought to facilitate passage
or reduce pain – some studies positive, others not
12/1/16 BMJ meta analysis mostly positive, esp. for
stones >6mm / risk of hypotension / tamsulosin
[Flomax] 0.4mg / day
• STONE trial (8/18)– RCT, 512pts, no benefit if <9mm
• Urine strainer at discharge (save stone); follow up
with primary care or urologist
19 20
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 Testicular Torsion Presentation, 1 Testicular Torsion Presentation, 2
• Sudden, progressive or intermittent testicular
or groin pain / swelling of the testicle / • Testicle is tender, swollen
neonates, children and young adults • May be elevated and/or more
• May be associated with nausea / vomiting horizontally oriented compared
• Often precipitated by straining, with the other
exercise or trauma • Cremasteric reflex (stroking the medial
• Note: The clock is running proximal thigh on the affected
regarding viability – 6 hours – side) may be absent (testicle is
time is testicle / most common normally supposed to retract
incorrect diagnosis is superiorly)
epididymitis / law suits if delayed diagnosis
21 22

Testicular Torsion Presentation, 2 Testicular Torsion Testing

• Diagnosis is primarily clinical
• Doppler ultrasound can be used to ascertain
decreased blood flow – can be falsely negative
and may result in delays
• UA is usually normal
(pyuria in an adolescent
or older – consider
epididymitis)
• Picture shows lack
of blood flow to right testis
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 Testicular Torsion Treatment Torsion Appendix Testis
• Have a low threshold for early consultation • Appendix testis – a small appendage off of the
with a urologist – before ultrasound testicle / sometimes twists / local pain
• Some say surgical exploration is the most • Torsion of the appendix testis is the most
expeditious approach common cause of the acute scrotum
• Manual derotation – rarely attempted • Can mimic testicular torsion
– May be indicated if • Located at the superior pole
urologist delay is a concern • Clinical findings – usually acute onset of pain,
– “Open the book” rotate but may develop over time / mild to severe
testes outward intensity / pain is at the superior pole and may
• Surgical fixation is still be limited to site of the torsion / no systemic
symptoms / no urinary symptoms
required
2225 26

Torsion Appendix Testis Blue Dot Sign Epididymitis Diagnosis

• Usually an infection – epididymis is located
behind the testis / most common between ages
20 39 / local tenderness / UA may show pyuria
(do culture) / scrotal pain, tenderness and
swelling / test for STIs
• Ultrasound showing increased
blood flow may be helpful /
cremasteric reflex is normal
• Etiology is largely age related – under
39 usually a STI (50 60% chlamydia,
gonorrhea) / over 39 usually E. coli
27
• Do NAAT tests of urine for STI 28

449
 Epididymitis Treatment
• CDC guidelines, 2021
– If most likely caused by chlamydia
or gonorrhea
• Ceftriaxone 500mg* IM plus
• Doxycycline 100mg BID for 10 days
– If considering STI & enterics (anal sex)
• Ceftriaxone 500mg* IM plus
• Levofloxacin 500mg QD for 10 days
– If considering enterics only
• Levofloxacin 500mg QD for 10 days
• Analgesics, scrotal support (no boxers)

*Ceftriaxone 1g IM for pts => 150 kg 29

450
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30
 Prostatitis Overview Prostatitis Treatment
• Prostatitis presenting with acute pain is bacterial • Empiric therapy is against Gram negative
• Fever, chills, dysuria, malaise, perineal pain enterics
• Most infections are caused by urinary pathogens • Suggested drugs include fluoroquinolones
• Don’t do prostatic massage (rarely necessary) (levofloxacin 500mg PO BID), TMP SMX DS (1
and contraindicated if febrile tab PO BID), and ampicillin with gentamicin /
other quinolones are options
• Do UA / culture – urethral
swab if discharge • 30 day course!!
• PSA of no value • Admission for IV therapy
is warranted for clinically
ill patients
31 32

Urinary Retention Overview Urinary Retention Treatment, 1

• Common in older males
• Usually associated with prostatic hypertrophy
• Always consider medications as contributors –
antihistamines, anticholinergics/antispasmodics,
tricyclics, ask about herbals
• Some routinely do a UA /
always palpate prostate
(expect it to be large, but
not necessarily – any evidence of masses?)
• Rare in females and often due to a serious
(neurologic) cause
• Treatment – rapid Foley catheter / leg bag
– Always use urethral anesthetic jelly with Foley / a
larger catheter may go in easier than a smaller one
– Consider systemic analgesics if any delay
– No problems with rapid drainage (or clamping)
– May try trial of removal in ED after some observation
33 34

452
 Urinary Retention Treatment, 2 Phimosis
• Alpha blockers have been associated with some • Inability to retract the foreskin over the glans
increased success in being able to void without the
catheter (48 62%) vs. their non use (26 57%) • Is routine at birth and by age 3, 90% are
• No major differences seen between specific alpha retractable, 99% by age 17
blockers tested • Usually causes no problems
• A study of one 10mg alfuzosin XL (Uroxatral) tablet regarding penile function
daily for two days resulted in a 60% success without
catheter vs. 34% in controls • If infected (balanitis), can use topical antibiotics
• Warn about potential hypotension or antifungals / diabetics should control glucose
• Some urologists give • If urinary retention and/or unable
prophylactic to void – Foley cath and acute
antibiotics
consult for possible dorsal slit
• F/U urology / PCP
35 36

Paraphimosis
• Inability to return the retracted foreskin over
the head (glans) of the penis
• Often iatrogenic / swollen
foreskin can compromise
blood flow to corona a
true urologic emergency
• Compression of glans, lubrication, manual
reduction, analgesia usually works
• If severe, acute urology consult for
dorsal slit or circumcision
37

453
 Dorsal Slit

• Phimosis

• Paraphimosis 454
38
 Soft Tissue Infections and
Sepsis: Optimized Care

Jessie Werner, MD
Assistant Professor of Emergency Medicine
UCSF Fresno

Cellulitis vs. Abscess Treatment of Abscesses

• ED visits for these infections have increased markedly in the last 10 years
• Differentiating abscess vs cellulitis often difficult
• I & D remains the treatment of choice
• Ultrasound very useful
• Helps differentiate pus / no pus • Decision to I&D an abscess in the ED
• Quick, easily learned – Depends on the site and size of the abscess
• Can avoid nonproductive I&D – The condition of the patient (febrile, toxic)
• Often changes anticipated treatment
• Consultation is advised if any doubt
• Most abscesses can be managed with local anesthesia
– Some may require ultrasound guided nerve block
– Some may require procedural sedation
– Some may require admission
– See Soft Tissue Injuries lecture for details regarding anesthesia

3 4

455
 I & D Nuances

•Linear incision usually adequate

•Loop drainage is a reasonable alternative
•Incise parallel to skin lines if discernible
•Gently pinch large amount of skin together to see if creases form
in a certain direction. If so, cut parallel to the creases.
•May lessen scarring
•Drain purulence
•Break up loculations
•If abscess caused by a FB (e.g. splinter), find it and remove if possible
456
5
I & D Nuances

Loop drain technique

457
6
 I & D Nuances Antibiotics and Abscesses
• Wound culture – usually not necessary • Traditional antibiotic use depended on abscess characteristics and
evidence of systemic illness
• Consider if systemically ill or immunocompromised • IDSA recommends no antibiotics if simple abscess
• Labs, blood cultures only if toxic appearing • If used, should cover CA MRSA
• May decrease recurrences of MRSA infections
• Packing – most studies suggest it is not needed
• Cause of abscesses
• May want to place a small drain to keep wound from sealing • Most community acquired abscesses are caused by methicillin resistant
• Update tetanus!!! (good opportunity to give Tdap) Staph aureus
• Abscesses in IV drug users can be caused by a combination of aerobic and
• Follow up – typically 24 48 hours anaerobic microbes
• Two recent papers say routine antibiotics can provide better outcomes in
• See NEJM abscess drainage video https://www.youtube.com/watch?v=dGtj6kd9hq0 a minority of pts:
• See EMRAP HD video https://www.emrap.org/episode/abscessincision/abscessincision • Daum, NEJM 6/29/17 – NNT= 8 (TMP SMZ less side effects vs. clinda)
• Talan, NEJM 3/3/16 – NNT = 14 (used TMP SMZ)
• Monotherapy with MRSA coverage

7 8

2014 Infectious Disease Society of America Cellulitis

• When to culture
• Severe local infection • Usually caused by break in skin
• Signs of systemic illness • Typically Staph/Strep
• Immunocompromised • First line treatment should be anti strep agent
• Poor response to initial treatment • 5 7 day treatment
• A cluster of outbreaks • Cephalexin, dicloxacillin, azithromycin
• Antibiotics (see studies by Daum and Talan) • If complicated cellulitis or systemic signs, cover for both staph and
strep
• Immunocompromised / signs of systemic illness
• Single dose or once weekly antibiotics:
• Severe or multisite abscesses
• oritavancin (Orbactiv, $3,000 w/GoodRx coupon),
• Rapid progression with cellulitis • dalbavancin (Dalvance, $3,000 initially plus $1,500 for week two
• Extremes of age / comorbid conditions with coupon)
• Difficult to drain areas (face, hands, genitalia) • Watch for pain out of proportion to exam!!!
• Associated septic phlebitis • Consider necrotizing fasciitis
• Lack of response to I&D

9 10

458
 Erysipelas Impetigo
• A strep infection with sharply demarcated and raised borders • A strep or staph infection involving the superficial epidermis
• Infants, toddlers, elderly • No systemic signs, highly contagious
• Localized – often face, legs, ear • Painless, “honey crusted” lesions
• Bullous variety suggests staph
• Butterfly facial rash (warm and tender)
• Mupirocin ointment for mild cases
• Responds to the usual anti strep antibiotics
• requires a prescription
• If more extensive, beta lactams, erythromycin

11 12

Diaper Dermatitis Necrotizing Fasciitis

• Initially a chemical dermatitis from urine, dampness, feces • Easily misdiagnosed initially as a
• Oral antibiotics may predispose musculoskeletal strain or simple
• Secondary infections, most commonly by candida and MRSA cellulitis
• Candida frequently have papules separate from the main rash, • Findings may initially be minimal
satellite lesions • A true surgical emergency
• Topical miconazole or clotrimazole is effective / sometimes • Fatality rate up to 70%
mild topical steroids (OTC) are helpful • May present as a “flu like” illness
• With no respiratory symptoms
• Some have GI complaints
• Many don’t have fever
• Can be a complication of a
diabetic foot wound

13 14

459
 Necrotizing Fasciitis Necrotizing Fasciitis
• Restlessness or tachycardia without another cause
• Pain out of proportion to exam • Labs: hyponatremia/ leukocytosis/ bandemia
• An obvious source is not necessary • LRINEC score (not validated)
• IV drug users are at increased risk • Laboratory Risk Indicator for Necrotizing Fasciitis
• Group A strep vs. polymicrobial vs. • (CRP, WBC, Hgb, Na, Cr, Glucose)
MRSA • Empiric treatment
• May have gas in the tissues (crepitus) • Vancomycin or linezolid PLUS
• Hemorrhagic blisters highly • Piperacillin/tazobactam, imipenem/cilastatin
concerning
• Cefepime and metronidazole
• Do not wait for imaging to consult
surgery!! • Clindamycin and ciprofloxacin
• XR, CT, MRI, US • Consult a surgeon immediately
• High mortality rate

15 16

Sepsis and Septic Shock Sepsis and Septic Shock A History

• Sepsis is “life threatening organ dysfunction due to a • The Surviving Sepsis Campaign (SSC) launched in
dysregulated host response to infection.” 2002
• Goals
• Identify sepsis early – Funded primarily by the drug company Eli Lilly
• Start resuscitation with crystalloid and pressors – Evidence based guidelines to reduce deaths
early from severe sepsis and septic shock
• Start antibiotics early – Separate management “bundles” created to
implement the guidelines
• Can be updated
• Compliance is tracked by Center for Medicare
17 and Medicaid Services (CMS)

460
 Sepsis and Septic Shock
• Surviving Sepsis campaign 2016
• “3 hour bundle” if hypotensive or lactate 4 mm/L:
• Obtain blood cultures before antibiotics
• Start broad spectrum antibiotics
• Give a 30cc/kg crystalloid bolus
• “6 hour bundle”
• Recheck lactate
• Pressors if hypotensive with target MAP 65 mmHg
• Sepsis Reassessment
• Used SIRS criteria for risk stratification
• Used categories “sepsis,” “severe sepsis,” and “septic
shock”
19
Sepsis and Septic Shock – Controversy
• Inappropriate Industry influence
– Big pharma sponsored studies of products
incorporated into the recommendations
• Eli Lilly – Xigris (initially recommended,
now off the market)
• Protocolization of Care
• Over testing and over treating?
• Early recommendations were not well validated
461
Sepsis and Septic Shock
• Surviving Sepsis campaign 2018
• “1 Hour Bundle”
• Check lactate; repeat if >2mmol/L
• Blood cultures before antibiotics
• Start broad spectrum antibiotics
• Give 30 cc/kg crystalloid bolus if hypotensive or lactate 4
mmol/L
• Start pressors if patient remains hypotensive
• Uses qSOFA tool for risk stratification
• 3 point scale for predicting mortality among patients with
suspected infection (AMS, hypotension, RR 22)
• Removed category “severe sepsis” and has just:
• “Sepsis”
• “Septic shock”
20
Early Goal Directed Therapy vs “Usual Care”
• ProCESS Trial, NEJM Mar 18 2014
• Large, multicenter trial, 1:1:1 RCT of protocol based early goal directed therapy (EGDT) vs.
protocol based standard therapy vs. “usual practice”
• No significant difference between EGDT and usual practice in all cause mortality at 60 days or
secondary mortality/morbidity outcomes
• Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE),
NEJM Oct 16,2014
• EGDT vs usual care
• No significant difference in survival time, in hospital mortality, duration of organ support, or
length of hospital stay
• The Protocolized Management in Sepsis Trial (ProMISe), NEJM April 2, 2015
• Large multicenter, randomized control trial
• EGDT vs usual care
• 90 day mortality: no significant difference
• Mean SOFA score at 6 hours, the proportion of patients receiving advanced cardiovascular
support, and the median length of stay in the ICU were significantly greater in the EGDT group
than in the usual care group
22
 Sepsis and Septic Shock Issues
• Issues with the “1 Hour Bundle”
• Time cutoffs are arbitrary
• There is no high quality prospective evidence to support a 1 hour
bundle
• It doesn’t take into account the realities of emergency departments
• Many patients don’t get seen within one hour of arrival
• Every patient would need blood cultures and a lactate drawn when
they check in
• Broad spectrum antibiotics would have to be given indiscriminately
• Many potential barriers: patients take time to declare themselves,
time is needed for the evaluation, IV access may be difficult, etc.
• 30 cc/kg bolus is NOT appropriate for patients with CHF or renal
failure
• Fallacy in the assumption that protocolized care is better than
individualized assessment
23
Sepsis and Septic Shock – EM Response
ACEP task force on the early care of adults with suspected
sepsis (April 2021):
• Detection can be difficult as other diagnosis can mimic
sepsis and this often requires repeated testing and
observation
• 20 40% of patients with suspected sepsis in the ED
ultimately have a non infectious etiology (PE, cardiogenic
shock, overdose, etc)
• There is no validated evidence based tool for sepsis
screening
• Once sepsis is recognized, prompt treatment of infection
and hypoperfusion is important
24

Sepsis and Septic Shock – EM Response Sepsis and Septic Shock – EM Response
ACEP task force on the early care of adults with suspected ACEP task force on the early care of adults with suspected sepsis
sepsis (April 2021): (April 2021):
FLUIDS
• We support balanced crystalloid solutions
• qSOFA was developed to assess outcomes in patients • There is no data to support a specific fluid volume to
already diagnosed with infection optimize patient outcomes
• Only 1 in 3 patients who are qSOFA positive have
infection ANTIBIOTICS
• Only 1 in 6 have sepsis • Prompt administration of antibiotics is recommended
• Obtaining blood cultures should NOT delay
administration of antibiotics

LACTATE
• Only repeat lactate levels if elevated >4 or if there is
clinical deterioration
25 26

462
 October 2021 Guidelines
Surviving Sepsis Campaign
• Recommend against using qSOFA compared with SIRS, NEWS,
or MEWS as a single screening tool for sepsis or septic shock
• For sepsis induced hypoperfusion or septic shock: 30ml/kg of IV
crystalloid fluid within the first 3hr of resuscitation
• Guide resuscitation to decrease serum lactate in patients with
elevated lactate over not using serum lactate
• Use capillary refill time to guide resuscitation along with other
measures of perfusion
• For adults with possible septic shock or high likelihood for
sepsis, recommend administering antimicrobials immediately,
ideally within 1 hr of recognition; if sepsis is possible (but not
clear) and shock is absent assess causes (infectious vs non
infectious) and give abx within 3 hours if concern for infection
Sepsis and Septic Shock Takeaways
RESUSCITATION:
• 30 cc/kg may not be the best option for all patients
• Patients should be reevaluated for fluid
responsiveness
• Ringer’s lactate or Plasmalyte are recommended
over normal saline to avoid hyperchloremic
metabolic acidosis
• Consider transfusion if Hgb <7.0
ANTIBIOTICS
• Start early and start broad
29
463
October 2021 Guidelines Cont’d
Surviving Sepsis Campaign
• For adults with sepsis or septic shock, we suggest using
balanced crystalloids instead of normal saline for resuscitation
• For adults with septic shock, we suggest starting vasopressors
peripherally to restore mean arterial pressure rather than
delaying initiation until central venous access is secured
• After initial resuscitation, there is insufficient evidence to make
a recommendation on the use of restrictive versus liberal fluid
strategies in the first 24 hours of resuscitation
• For adults with sepsis induced severe ARDS, we suggest using
veno venous (VV) ECMO when conventional mechanical
ventilation fails
• For adults with septic shock and an ongoing requirement for
vasopressor therapy we suggest using IV corticosteroids
• We suggest against using IV vitamin C
Sepsis and Septic Shock Takeaways
VASOPRESSORS:
• Norepinephrine is first line
• Titrate to MAP of 65 mm Hg
• Starting pressors through a well secured, non distal
peripheral catheter is safe
• Requiring infusion of pressors via a central venous
catheter delays treatment
MONITORING
• Invasive monitoring (eg. Central venous and arterial
catheters) may aid but are not routinely needed in
early sepsis care
30
Sepsis and Septic Shock Takeaways
STEROIDS
• Routine steroids do not have benefit
• Consider if concerned for adrenal insufficiency or if
the patient is on high dose steroids for another
reason

OVERALL
• Care bundles have become the standard, but the
evaluation and treatment should be tailored to the
patient

31

464
Soft Tissue Injuries:
Optimized Care

465
Closed Soft Tissue Injuries Overview

466
2
West Point Sprain Grading System Treatment of Closed Soft Tissue Injuries
• “P‐R‐I C E R”
Tearing Swelling Joint Weight
Instability Bearing – Protect the injury
Grade I Microscopic Minimal None Fully/ • Often involves
partial immobilization, splints
or crutches
Grade II Partial Moderate/ Mild/ Unable for a short period of time
severe moderate
– Rest the involved area
Grade III Complete Severe Moderately Unable
rupture severe • But not too long
• Excessive immobilization of joints can result in
joint stiffness (particularly in the elderly)
Source: http://reference.medscape.com/features/slideshow/ankle-injuries
• Early mobilization in the pain free range is
encouraged
3 4

Treatment of Closed Soft Tissue Injuries Treatment of Closed Soft Tissue Injuries
• “P R‐I‐C‐E R” • “P R I C‐E‐R”
– Ice – Elevation
• Not directly on the skin (cover with a towel) • Reduces edema
• Frozen peas can conform to the injury and are a good idea • Try to elevate the injured part
for home cryotherapy (but not directly on the skin) above the level of the heart
• Apply ice no more than 30 minutes at a time • Some suggest avoiding simultaneous
compression and elevation
• Claims for the value of ice – decreased pain, decreased (but not all agree)
swelling (but ice can cause vasodilatation [especially if left
on for protracted periods] and capillary leak and actually • Maximal benefit is in the first 72 hours
increase swelling), decreased inflammation – Rehabilitation
• The evidence base for the value of ice is quite limited • Some soft tissue injuries, particularly around joints, may
– Compression require rehabilitation to limit the likelihood of permanent
joint stiffness
• Reduces edema, disperses excess tissue fluid, aids venous
return. Make sure pressure is greater distally than • This is particularly true of shoulder injuries in the elderly
proximally (otherwise may act as a tourniquet) 5 6

467
 Laceration Management
7 8
Cleaning Lacerations
• Wounds that are very dirty,
greasy can be cleansed at
the sink with soap and water
with copious irrigation using
tap water – after local
anesthesia
• Some believe pulsatile jet
irrigation is a particularly
effective way to cleanse
routine wounds
9 10
468
Cleaning Lacerations
• Lacerations really can NOT be
adequately cleansed without first
performing anesthesia
• Have a high priority regarding
anesthetizing wounds as soon as
patients arrive (to relieve pain,
will help stop bleeding)
– Be sure to do and document a
functional and neuro exam before
anesthesia
• Despite common practice, soaking
does little to clean a wound
• Povidone iodine solution 10%
should not be put directly into
wounds (tissue toxic)
– Diluting povidone iodine to a 1%
solution is OK in wounds
Wound Care Chatter
• “I’m going to do my best to make sure you
have as little discomfort as possible”
• “I’m cleaning the wound very thoroughly”
• “I’ve tried very hard to remove all the
foreign material I can find – but there’s
always a chance some can be hiding”
• “I don’t see any evidence of a tendon or
nerve injury”
• “Wounds always heal with scars but I’m
going to try to make yours as small as
possible”
 Local Anesthetics
Bupivacaine vs. Lidocaine
Dosing and Durations
• Some general observations on
local anesthesia Formulations Duration of Action Maximum Dosage

– Bupivacaine (Marcaine) vs. lidocaine

(Xylocaine) Lidocaine 1% (10 mg/ml) 30 60 min 4.5 mg/kg, max
• Relative equivalence – 0.25% 2% (20 mg/ml) 300 mg
(30ml of 1%; 15 ml
bupivacaine = 1% lidocaine of 2%)
• Onset of action – lidocaine may be Lidocaine with 1% (10 mg/ml) 120 360 min 7 mg/kg
slightly faster, but not likely to be epinephrine 2% (20mg/ml) (50 ml of 1%; 25 ml
of 2%)
of clinical significance
Bupivacaine 0.25% (2.5 mg/ml) 120 240 min 2.5 mg/kg, max
• Bupivacaine may decrease the 0.5% (5 mg/ml) 175 mg
need for post procedure (70 ml 0.25%; 35
analgesics compared with the ml 0.5%)
shorter acting lidocaine Bupivacaine with 0.25% (2.5 mg/ml) 180 420 min 225 mg
epinephrine 0.5% (5 mg/ml) (90 ml 0.25%; 45
ml 0.5%)
11 12

Local Anesthesia Tricks of the Trade Local Anesthesia Tricks of the Trade
• Warmed local anesthetic is less painful when • Use a small gauge needle – 27 or
30 / may require a special order
injected (consider carrying a bottle in your for your ED
pocket) • Inject slowly so as not to rapidly
• Alkalinized lidocaine (1ml bicarbonate [8.4%] to swell the tissues (larger syringes
10ml lidocaine) is less painful when injected generate less potential pressure
than smaller ones)
– pH is raised from about 6.6 to 7.7 (less burning)
• Avoid multiple needle sticks – pull
– Works faster at higher pH back and redirect rather than
– Get the pharmacy to make repuncturing the skin
it and to label it properly • Inject thru the open wound edge
– not through the intact skin
13 14

469
Regional Nerve Blocks of the Face
• Regional nerve blocks
of the face can
anesthetize large areas
with minimal amounts
of local anesthesia and
few injections

470
15
Parotid Duct / Facial Nerve Proximity

Important Relationship
A vertically oriented
laceration posterior to the
corner of the eye and
bisecting a line drawn from
the tragus of the ear to the
center of the upper lip can
involve both the facial nerve
and the parotid duct

471
16
 Tips Regarding Facial Lacerations
• Don’t shave eyebrows
– They might not grow back
• Consider getting a specialist for eye lid
lacerations that transect the margins /
alignment of the two sections needs to be perfect
• Thru and thru lip lacerations need closure of the
front, back and middle (not just the front and back)
• Lacerations thru the vermilion border
of the lip need perfect alignment and
eversion of the edges to minimize
visible scarring
Tips Regarding Wound Foreign Bodies
• Organic foreign bodies in wounds will cause
infections – they need to be found and removed
if at all possible
– Any type of glass except tiny (<2mm) fragments will
show up on x ray/ have a low threshold for imaging
• Glass is inert and may extrude over time
(typically shattered windshield causing multiple
fine forehead lacerations with retained glass)
• Small glass fragments in tight spaces (fingers)
should be sought and removed
• It is wise not to assure patients all foreign
bodies have been removed – you may be wrong

17 18

Tips Regarding Wound Foreign Bodies Tongue Laceration Closure Guidelines

• When a foreign body is suspected in a wound
and imaging is attempted, it is important to • Consider closing
order the correct study – Large lacerations >1cm
– Foreign bodies not seen on plain x rays may be – Large, gaping wounds, esp. with the tongue at rest
visible on ultrasonography – Wounds requiring suturing for hemostasis
– Ultrasonography can miss – Anterior split tongue
organic foreign bodies
but is better than plain films • Wounds not requiring closure
– Small lacerations <1 2 cm
– The ultrasound image
visualizes a toothpick in – Non gaping wounds
the sole of the foot (white
arrow = toothpick) hollow Source: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=39&seg_id=737
arrows = acoustic shadowing
19 20

472
 Puncture Wounds
• Most practice is anecdotal / literature is
scant
• Must consider and remove any foreign
bodies (may consider coring of
puncture wounds of the feet under
local anesthesia if a foreign body is
suspected – puncture through shoe,
sneaker or socks – irrigation may force
foreign body deeper into tissues)
• Early infections of foot puncture
wounds are usually staph / delayed
infections (weeks) tend to be
pseudomonas
• It is not the standard of care to give
prophylactic quinolones for sole of the
foot puncture wounds
21
General Wound Repair Tips
• Debride devitalized tissue (sparingly on
the face)
• Close the fat and dead space (otherwise
leaves room for hematomas to form) and
bury the knot
• An optimal scar requires minimal tension
on the skin edges – may require a
multilayer repair
• Buried absorbable sutures are foreign
bodies and decrease the critical bacterial
load needed to precipitate an infection –
use the minimum number to get the job
done well
• Monofilament absorbable sutures are
associated with less bacteria in a wound
than multifilament 22

The “Plastic Surgeon”

• Sutures with tiny loops
can be very difficult to remove
without ripping them out
• This is especially the case when crusts form and are
not removed by the patient as part of routine care
• Have the person who put them in take them out to
see how difficult it can be
• Sutures that are too tight
(right picture) can cause
“railroad track” marks
when removed
23 24

473
 Running Subcuticular Sutures Simple and Locking Running Sutures
• Running subcuticular sutures using • It is not lazy or a sin to
nonabsorbable material can be a sophisticated use running sutures
way of closing straight line lacerations with
minimal wound tension – Since when does each loop
suture require its own
• Tie knots at both ends personal knot??
• The skin margins may be • The cosmetic effect
reinforced with tape can be exceptional
• If a wound becomes infected the running suture
can be cut over the site of infection, unwound
several loops and the opposite edges taped
down
25 26

Mattress Sutures Pretibial Flap Lacerations

• Mattress sutures simultaneously close the • These lacerations are
deeper tissues plus the skin particularly difficult to
repair in the elderly with
thin skin
• Approximation as best as
possible with “steristrip”
type tapes with
granulation of the
unopposed skin edges
may give the best result
Horizontal Vertical Running – This technique works for
mattress mattress continuous vertical these types of lacerations
suture suture mattress suture
27 anywhere 28

474
 Corner Stitches Staples
• It is tempting to put a • Staples are fine for the
single suture thru the tip scalp
of a “V” shaped flap – • Can also be used on the
don t do it trunk and extremities
• It puts too much tension • Use in other places may
on the wound not yield optimal scars
• A corner stitch is much • Be careful to make sure
sturdier that wound edges are
everted and of equal
• In “X” shaped wounds heights
the corner stitch can also
be used • Are associated with fewer A really good stapling job
29 infections than sutures 30

Tissue Glue Prophylactic Wound Antibiotics

• Tissue glue – a gift from the gods
• Don’t use in high tension areas or
those that stay moist
• Avoid in those at higher risk for
poor healing
• Cosmetic results, dehiscence rates
and infection risk are comparable
to sutures
• Wound rechecks are generally not
required
• Don’t use antibiotic ointment or
petrolatum – will dissolve the glue
31
• Controversial / practice is very variable
• Little data support routine use
• Consider in
– Sutured animal bites
– Heavily contaminated wounds
– Devitalized tissue (remove as much as possible)
– Any open fractures (most commonly open tuft
fractures)
– Through and through mouth lacerations
– Hand and foot lacerations
– Immunocompromised
32

475
 Follow‐Up of Sutured Wounds Follow‐Up of Sutured Wounds
• The incidence of ED wound infections is about • After the wound check, to minimize scarring and
5% facilitate suture removal patients should
– Infection rates vary by – Remove crusts with a cotton tipped applicator
location moistened with peroxide at the daily dressing change
– Lowest on the scalp and face, – After removing any crusts, apply an ointment such as
highest on the extremities Polysporin (or petrolatum) to the wound surface
• Has been show to accelerate wound healing and
decreases crusting
• Studies show that patients are not good judges
of whether their wounds are infected – Once fully healed, use sunscreen
religiously
– A routine wound check in 2 3 days is a good idea – Avoid other creams (e.g.
vitamin E); no proven efficacy

33 34

Suture Removal Guidelines Tetanus Prophylaxis

Suture location Suture Suture • Today, tetanus is uncommon in the United
Removal Removal
(Adults) (Children)
States, with an average of 30 reported
Eyelid, nose, forehead, other parts of face 3 5 days 3 5 days
cases each year.
Ear, lip 4 5 days • Nearly all cases of tetanus are
Scalp 5 7 days 5 7 days
among people who have never received
a tetanus vaccine, or adults who don't stay up
Chest, abdomen, arm, hand, flexor joint surfaces * 8 10 days 6 8 days
to date on their 10 year booster shots.
Lower extremity 10 days 6 10 days

Feet, fingertip, extensor joint surfaces * 10 14 days 8 10 days https://www.cdc.gov/teta

nus/about/index.html
Back 12 14 days 10 12 days

* Consider splinting joints to reduce movement while

healing
35 36

476
 Wound management and tetanus prophylaxis

Clean and minor wound All other wounds***

Previous Tetanus Human Tetanus Human

doses of toxoid‐ tetanus toxoid‐ tetanus
tetanus containing immune containing immune
toxoid* vaccine globulin vaccine ** globulin
<3 doses or Yes No Yes Yes
unknown
Equal to or > Only if last No Only if last No
than 3 doses dose given does given >
equal to or > or greater
than 10 years
ago

* Tetanus toxoid may have been administered as diphtheria-tetanus toxoids adsorbed (DT), diphtheria-tetanus whole-cell
pertussis (DTP, DTwP; no longer available in the United States), diphtheria-tetanus-acellular pertussis (DTaP), tetanus-diphtheria
toxoids adsorbed (Td), booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap), or tetanus toxoid (TT; no longer
available in the United States).

** The preferred vaccine preparation depends upon the age and vaccination history of the patient: <7 years: DTaP Under
immunized children 7 and <11 years who have not received Tdap previously: Tdap. Children who receive Tdap
between age 7 and 11 years should receive another dose of Tdap at age 11 through 12 years. 11 years: A single dose
of Tdap is preferred to Td for all individuals in this age group who have not previously received Tdap. Pregnant women
should receive Tdap during each pregnancy.

*** Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; or wounds
resulting from missiles, crushing, burns, or frostbite.

Adapted from: Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2018; 67:1. 37

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478
 Oropharyngeal Disorders
• The Guinness World Record for the widest mouth
Oropharyngeal
and Neck Disorders

Facial Nerve Palsy Facial Nerve Palsy

Differentiation from central origin ‐‐ forehead
muscles don’t work in peripheral seventh nerve lesions
• Facial droop, can’t close eye Differentiation from
• Causes central origin ‐‐
– Bell’s palsy (= idiopathic) forehead
– Herpes zoster muscles don’t work
– Herpes simplex in peripheral
– Lyme disease seventh nerve
– Otitis media lesions
• Treatment
– If Bell’s, steroids + acyclovir (?)
– If not Bell’s, treat cause
– Protect with artificial tears and patch at night to
prevent keratitis 3 4

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 Candidiasis / Moniliasis Leukoplakia
• White, curd like plaques of C. albicans
• Predisposers • White plaque on
– Extremes of age mucosal surfaces
– Antibiotics that cannot be
– Dentures scraped off
– Diabetes (unlike candidiasis)
– Steroids
• Precancerous, males,
– HIV
– Chemotherapy smoking, HIV,
• Treatment trauma
– Clotrimazole lozenges $25 50 with GoodRx coupon • Refer for biopsy
($115 without)
– Nystatin suspension ($7 20 with / $60 without) 5 6

Aphthous Ulcers (Canker Sores) Herpes Simplex Gingivostomatitis

•Fever and adenopathy
• “Aphtha” is Greek for “ulcer” (may precede lesions by
• Red macules with ulcerations 3 days)
• Painful, often multiple •Initially, vesicles
• A cell mediated immune •Painful ulcers on gingiva
response to an unknown trigger? and mucosa
• Treatment •Secondary infection of
lip lesions is common
– Debacterol (recurrent lesions
acidic) needs Rx $60 •Dormant virus
activated by sun, stress,
– OTC Zilactin® and Zilactin® B, unknown factors
Orabase®, and Orabase® Soothe N
Seal™. •Antivirals (valacyclovir,
acyclovir) may lessen
– Kenalog in Orabase discontinued 7 severity and duration 8

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Herpangina
• A coxsackie virus infection
• Young children, summer, resolves
7 10 days
• High fever, sore throat, lesions
in the back of the mouth /
on the soft palate, tonsillar
pillars (no lesions on tongue,
cheeks, lips)
• Lesions progress from red macules
to ulcers
• Supportive treatment
Tongue Angioedema
Angioedema Overview
•Angioedema – similar to urticaria but involves the
deeper dermal and subcutaneous tissue / local
vascular dilatation and capillary leak
•Typically involves little pruritus / predilection for face,
extremities and male genitalia / also can involve GI
form tract (can resemble surgical abdomen)
only •Hereditary or acquired varieties / excess bradykinin,
some excess histamine
•ACE inhibitor angioedema – 0.1 0.2% / can develop
years after starting ACEI
•Responds poorly to usual treatment of allergy /
urticaria – epi, antihistamines (H1 /H2), steroids
•Icatibant (NEJM 1/29/15) superior to 500mg
9 prednisone in ACE induced angioedema ($6,800) 10
Sore Throat
• Majority of cases are viral
• Also consider strep throat,
infectious mononucleosis; more
serious causes including epiglottitis
and Lemierre’s disease
• Sore throat, pain on
swallowing and normal
oropharyngeal exam?
Worry about epiglottitis,
need to look at epiglottis (direct visualization
optimal); manipulate thyroid cartilage
11 12
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Streptococcal Pharyngitis Diagnosis (1) Streptococcal Pharyngitis Diagnosis (2)
Centor Criteria Points • Centor Criteria – Tests and Treatment
Fever 1 Points Incidence Tests? Treat?
No Cough 1
Ant. Cervical 1 <2 <10% None None
Lymphadenopathy 2 15% Rapid test or Wait for test
Tonsillar Exudates 1 culture results
3 14 yrs old Plus 1 McIsaac 3 30% Rapid test or Wait for test
Modification culture results
45+ yrs old Minus 1
>3 55% No? Yes?
More effective in ruling out than ruling in the infection
13 14

Streptococcal Pharyngitis Complications Scarlet Fever

• Tx is usually penicillin tabs vs amoxicillin susp (more • Complication of erythrogenic toxin producing
palatable for kids)
• Adjunct in more nasty cases: steroids (10mg IM/PO strains of Group A (and C) beta hemolytic
dexamethasone / 0.6mg/kg in kids) streptococci
• Rheumatic fever can be prevented with antibiotic • Sandpaper rash (1 2 days after onset of illness);
treatment within 9 days of symptoms (rare in U.S.) strawberry tongue, Pastia’s lines
– 10 days of treatment is considered appropriate • See details in Peds Rashes chapter
– Penicillin G benzathine (Bicillin L A) can be used (dose
is age dependent) – single dose lasts long enough
• <27kg = 600,000 units
• >27kg = 1.2 million units
• Post streptococcal glomerulonephritis cannot be
prevented by treatment
• Suppurative complications also not prevented by tx
• NNH for anaphylaxis from PCN = 1:500; worth it? 15 16

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 Peritonsillar Abscess Overview Peritonsillar Abscess Treatment
• Most common deep neck infection in adults • Treatment
• Rare in children under 12 – Anesthetize / keep patient still (carotid artery)
Using a
• Usually a complication of streptococcal laryngoscope
pharyngitis to visualize
is a neat trick!
• Symptoms and signs
– Aspiration or incision and drainage with #11 scalpel
– Unilateral sore throat, fever, – Remove, cut and replace “cover” on needle or
trismus (masseter muscle spasm), scalpel to act as a “guard”
peritonsillar mass displacing • Usually antibiotics given concomitantly
soft palate and uvula; often • Kaiser study – IV ceftriaxone, clindamycin and
have “hot potato voice” dexamethasone comparable to surgery plus medical
treatment (but less opioids, less work missed) (Battaglia, Otol
17 Head Neck Surg, 2/18) 18

Retropharyngeal Abscess Retropharyngeal Abscess

• Infants and young children (but adult cases are seen –
if so, look for mediastinal extension)
• Fever, neck pain, difficulty talking, swallowing and
breathing, torticollis
• “Cri du canard” (duck like voice)
• Intraoral exam shows anterior
displacement of posterior
pharyngeal wall
• X ray may show posterior pharyngeal wall anterior soft
tissue displacement (neck flexion may give a false
positive X ray)
• Diagnosis: CT / Hx (e.g. fall with stick/pencil in mouth)
• ENT consult
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 Diphtheria Infectious Mononucleosis
• Corynebacterium diphtheriae = club shaped Gram + bacillus • Diagnosis
– Epstein Barr virus (95% of U.S.)
• Respiratory droplet transmission or via skin lesions – Exudative pharyngitis
(cutaneous diphtheria less severe – urban outbreaks) – Posterior cervical adenopathy
• Upper respiratory variant (pharyngeal pseudomembrane considered pathognomonic
forms as the result of exotoxin induced necrosis) – May have splenomegaly
• The extent of the membrane parallels clinical severity and is – Mono spot test (can be falsely
associated with cervical adenopathy (“bull neck”) negative esp early)
• Exotoxin causes disruption of protein synthesis – CBC – looking for lymphocytic
• Multiorgan system damage (primarily heart, CNS, kidneys, predominance (advantage –
liver) not a black and white test
• Neuropathy is routine in severe illness as is myocarditis but shows a gradation of
• Death due to myocarditis / airway obstruction lymphocytic predominance)
• Treatment
• Treatment = equine serum diphtheria antitoxin plus – Symptomatic / warn regarding spleen trauma / no
antibiotics (erythyromycin / penicillin) / antibiotics to carriers antibiotics (ampicillin/amox may cause a rash)
21 22

Croup Epiglottitis
• Laryngotracheobronchitis • Acute inflammation of the supraglottic region (not just
• Most common cause of upper the epiglottis)
respiratory obstruction in • 3:1 male/female – age 45
childhood • Signs and symptoms
• 6 mo – 6 yr (2 yr peak) – Usually rapid onset, fever,
• Parainfluenza virus (50%) sore throat, dysphagia,
• Subglottic edema, respiratory muffled voice, stridor and
distress, barking seal cough tripod positioning if severe
• Treatment: – Beware – oropharyngeal exam can be normal (the
• Inhaled epinephrine (either racemic pathology is below where you can see)
or L epi [standard epi]) – Pain on moving the thyroid cartilage side to side is
• Steroids, no antibiotics an important tipoff
• Beta-adrenergics not advised – • Visualize epiglottis (videoscope, fiberoptic)
may cause vasodilation due to
vascular beta receptor activation
• Treatment – ceftriaxone (multiple bacterial causes)
and increase airway narrowing 23
and close observation/admission – watch airway 24

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 Epiglottitis Cervical Adenopathy
• Causes
– Primary infection (lymphatic bacteria get caught in
the gland) / usually staph or strep / treat empirically
– a cephalosporin is a good choice
– Response to a local
infection / look for
infections of the scalp,
throat or mouth
– Response to systemic
https://2view.fireside.fm/7 infections / mono, TB, toxoplasmosis
– Malignancy, sarcoidosis
25 26

Lemierre’s Syndrome Ludwig’s Angina

• Can be initiated by a head or neck infection
• Infection of the floor of the mouth
• Usually starts (85%) with a typical sore throat
• A neck abscess forms and is secondarily • Caused by mouth flora
infected by Fusobacterium necrophorum (Fusobacterium), usually due to
poor dentition
• Subsequent development of swollen, tender,
painful neck unilaterally due to abscess • Rapid onset, sore throat, difficulty
• Abscess causes septic swallowing, tongue pushed upward
thrombophlebitis of jugular veins in mouth, cellulitis
• Jugular vein septic emboli seed • Airway compromise a potential life
lungs threat / airway management
• High fever, cervical adenitis, lung priority / may need surgical airway
symptoms, can > to septic shock • A true surgical emergency
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 Esophageal Foreign Bodies
• Consider adding a lateral x ray (may show a
second FB behind the first)
• Button batteries have a characteristic step off
between front and back (require urgent removal)

29

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 Analgesia
• Pain is the most common reason patients come to
Analgesia and the emergency department
• EMTALA considers acute pain to be an emergency
Procedural Sedation medical condition
• Early, effective pain relief is the goal
• If parenteral medications are indicated, serial doses of
medication with frequent reassessment is the best
Jessie Werner, MD
Assistant Professor of Emergency Medicine approach
UCSF Fresno • Goal is to “get on top” of the pain and stop the pain cycle

Oligoanalgesia Analgesia General Principles

• Document the patient’s pain scale
• Oligoanalgesia
• Before and after treatment
• Inadequate treatment of pain • Can use scales developed for children
• A relatively common problem in emergency
• Consider asking about pain in every patient
medicine
encounter
• Especially in elderly, children, minorities, women
• Consider following your introduction to the
• Particularly seen in long bone fractures patient with specific question addressing
• Beware the trap of under treating pain patient’s pain
• Treatment of acute pain in ED important • Always offer pain relief; does NOT have to be
opioids
• There is no “test” for pain; assume it is real and
• If patient prefers not to receive pain medicine,
err on the side of treating document in chart (e.g. “pain medication offered;
patient declined”)

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 Local Pharmacologic Analgesia
Nonpharmacologic Analgesic Measures
• Distraction – headphones, toys, iPad or • Local / topical anesthetics
phone • Digital or regional blocks
• Acupuncture • Do after thorough exam and
Digital nerve block
• Visualization before imaging
• Vibration • Good choice for hand / foot injuries,
• For example, jiggle patient’s
skin near injection sites to minimize pain
hip fractures, painful joint effusions,
some dislocations
• Ice (wrap in towel to prevent cold
injury) • Intraarticular injections (e.g.
• Elevation shoulder for relocation)
Intraarticular shoulder
injection

5 6

WHO Analgesic Ladder Pharmacologic Analgesia Measures

• General considerations
• Route of administration (PO, IV, IM, other)
• Desired onset, duration
• Contraindications
• Side effects
1. Non opioids (acetaminophen, NSAIDs, topicals)
2. Add opioids (PO hydrocodone, oxycodone, etc)
3. Add parenteral medications (morphine, hydromorphone, ketamine)

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 Acetaminophen
• Good for mild pain, chronic pain (osteoarthritis)
• Less effective than NSAIDs for inflammatory conditions
(not anti inflammatory)
• Comes in liquid, pill, and rectal forms
•IV form – can be expensive
• Effective dose is 15mg/kg (analgesic ceiling in adults is
about 1,000mg)
• Maximum 24 hr daily adult dose is 4 g per FDA
•Concern for liver injury if higher doses used or if
underlying liver disease (e.g. cirrhosis)
• Lasts 4 6 hours in usual formulations
• Good option when NSAIDs are contraindicated
9 10
Aspirin, The Forgotten NSAID
• Effective – consider as outpatient treatment for mild
pain
• Routine adult doses for pain, fever = 325 650mg PO q
4h (maximum single dose is 1g and and maximum
daily dose 4g)
• Lasts 2 4 hours
• Gastrointestinal side effects (dyspepsia, GI bleed)
• Enteric coated lessens side effects
• Avoid in children and adolescents, esp. after viral
illness / chicken pox (risk of Reyes syndrome)
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NSAIDs General Information
• Analgesic (lower doses) and anti inflammatory (higher doses)
• May be a benefit to higher doses in chronic inflammatory
conditions, but not evidence for benefit in acute conditions
• Excellent choice for renal and biliary colic
•Anti prostaglandin effect – relaxes ureter / bile ducts
• Side effects
•GI bleeding (esp. elderly)
•Worsened CHF and hypertension (salt retention)
•Worsened renal function (affects renal blood flow)
•Consider other agents if history of GI bleed, age > 60 years,
bleeding disorder, taking ASA, steroids or anticoagulants
Ibuprofen / Naproxen
• Ibuprofen
• Children 10mg/kg every 8 h
• Adults 400 800mg PO every 8 h
• Lower doses effective for pain (analgesic
ceiling is 400mg)
• Higher doses provide more anti inflammatory
• Max daily dose for non inflammatory pain =
1200mg
• Naproxen
• 500mg PO followed by 250mg PO every 6 8 hr
• OR 500mg every 12 hr / max daily dose 1500
mg / avoid in renal impairment
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 Ketorolac Opioids
• Only parenteral NSAID in U.S.
• Studies show IM dosing neither more • The opioid epidemic is real
effective nor any faster onset than oral
ibuprofen • It’s complicated
• IV a good choice for renal or biliary colic due • The ED is not the whole problem – but we do have a role
to antiprostaglandin actions • Alternatives should be emphasized, but in the ED opioids
• Up to 25% of patients get no effect can be a vital part of treating patients’ pain
• Therapeutic ceiling at 10 mg IV • Oral preparations for moderate pain
• Intravenous opioids for severe pain; titrate dosing to efficacy

13 14

Opioids Parenteral Opioid Agents

• Best agents for acute pain control are fentanyl, morphine, and
hydromorphone
• Meperidine (Demerol) less frequently used (banned in some
hospitals – CNS irritant from a metabolite – causes seizures)
• Best oral agents for control of moderate to severe pain are
hydrocodone, oxycodone
• Codeine and tramadol of questionable efficacy in most patients
(adds little analgesic effect and increases side effects)
• Codeine unpredictable metabolism (toxic in some, minimal
effect in others)
• Tramadol unpredictable metabolism and can cause seizures.
• “Trama DON’T”
• Morphine sulfate (JC requires that it be spelled out – not MS)
• 0.1 0.2mg/kg IV
•May cause histamine release (hives, hypotension)
• Hydromorphone (Dilaudid)
• 0.015mg/kg IV
• Be careful with dosing – 5x more potent than morphine
• Start at 1 mg, titrate up in 0.5 1 mg doses
• Fentanyl
• 50 100 mcg IV (most say 100x more potent than morphine)
•Minimal histamine release; slow push over 60 seconds
•Rapid onset (1 minute) but short duration (10 15 min)

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 Opioid Adjuncts Oral Opioids Overview

• Can be used in the ED where rapid pain relief is not

• Practice of using concurrent antiemetics (promethazine,
hydroxyzine, ondansetron) as opioid “adjuncts” has been
challenged in the literature and basically debunked
• Does not increases analgesic efficacy
• Adds unnecessary costs
• If patient develops nausea and vomiting, can add antiemetic
agent as needed
required
• May be needed to control pain at discharge in some
conditions* (cancer pain, fracture pain, burns,
lacerations, other significantly painful conditions)
• Need to caution patient regarding no driving, drinking,
operating machinery… and document it
• Advise patients to take as little as is needed and to
start a bowel regimen as needed

* limited quantities

17 18

Specific Oral Opioid Agents Pain Medication: Miscellaneous

• Hydrocodone • Fentanyl
•5 10mg PO every 4 6 hrs for moderate to severe pain • Atomized intranasal delivery
•Multiple formulations with acetaminophen
•Most commonly used are 5mg/325mg, 7.5mg/325mg (keeps
effective
acetaminophen dosing low) • 100 mcg/2mL strength
•Also as elixir (5mg hydrocodone/500mg APAP per 15ml) • First dose 1.5 mcg/kg
• Oxycodone • Second dose at 10 minutes – half to
•5 15mg PO every 4 6 hrs for moderate to severe pain
full dose
•Multiple formulations with acetaminophen; most commonly used
are 5mg/325 mg, 7.5mg/325 mg • Ketamine
•Also as elixir (solution: 5 mg oxycodone in 5 ml) • Subdissociative doses may be useful
• 0.15 0.3 mg/kg IV

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 Pain Medication: Miscellaneous Discharge Pain Medications Approach
• Nitrous oxide (considered procedural sedation)
• Self administered, 50:50 (nitrous:oxygen) mixture • Mild pain?
• Consider for short, painful procedures • Acetaminophen
• NSAIDs
• LP, IV insertion, NG placement, nail removal, laceration repair,
• Nonpharmacologic measures (ice, elevation, etc.)
abscess incision and drainage, removal of foreign body, simple
fracture reduction • Inflammatory pain?
• Avoid in… • NSAIDs in higher doses if no contraindications

• Closed head injury, altered patients, suspected elevated ICP, • Moderate pain to severe pain?
penetrating globe injury/recent eye surgery, maxillofacial injuries, • Consider non opioid regimens
acute asthma, emphysema, pneumonia, chest • If opioids prescribed, write for small amounts,
trauma/pneumothorax, bowel obstruction or ileus, pregnancy, combine with non opioids, and counsel patients
recent SCUBA diving

21 22

Procedural Sedation Overview Procedural Sedation Overview

• Procedural Sedation • Know the baseline end tidal CO2 before starting the
• Ranges from mild sedation (oral anxiolytics) to deep sedation
sedation (e.g., propofol) • Closely monitor the patients end tidal and vital
• Strict requirements from the JC regarding its use signs
• Protocols highly advisable to assure adherence to • Jaw thrust is a common intervention
requirements and assure safety
• Patient consent / screening (ASA categorization) • Be prepared to assist ventilation
• Personnel
• Airway management skills / equipment
• Monitoring / pulse oximetry / oxygen / capnography

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Procedural Sedation Choice of Agents Midazolam
• Choice of agent dependent on
• Reason for sedation
• Midazolam best benzodiazepine for sedation
• May be combined with fentanyl for analgesia
• Depth of sedation required
• Combination significantly increases risk of
• Onset and duration of sedation desired
hypoventilation
• Patient factors (age, volume status, comorbid conditions,
• Multiple formulations / routes available
last PO intake, etc.)
• Onset: 3 5 minutes
• Know that each agent or combination of agents has pros
and cons; there is no perfect sedative agent
• Duration: 30 60 minutes
• Dose for sedation: 0.03 0.1mg/kg
• Know that sometimes it should just not be done (unsafe)
• Can cause respiratory depression

25 26

Ketamine Ketamine
• PCP like agent; causes dissociative anesthesia (an awake •Onset: 1 3 minutes
•Duration: 10 15 minutes
trance like state producing feelings of detachment
•Downsides:
[dissociation] from the environment) •Hypersalivation, laryngospasm,
• Analgesic in addition to sedative emergence reaction, movement, vomiting
• Maintains blood pressure, airway reflexes •Contraindications: < 3 mo of age, severe
• Slow push to avoid apnea
CAD, CVD or hypertension, elevated IOP,
psychosis
• Nausea is common afterwards •No longer contra indicated in head trauma
• Dosing (dissociation) •No co meds needed
•IV 1 2mg/kg •Can be a drug of abuse
•IM 4 5mg/kg

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 Etomidate Propofol
• “Milk of amnesia”
• Developed as an agent for induction (initiation) for
• Deep sedative – it’s the real deal
intubation
• Dose: 0.5 1mg/kg IV
• No analgesic effect • Onset: < 1 minute
• Sedation dose 0.1 0.2mg/kg IV • Duration: 3 5 minutes
• Onset: 1 minute • May need repeat doses
• Duration: 5 10 minutes • Painful on injection
• Can see myoclonus (brief, involuntary twitching), • No analgesia
nausea/vomiting • No longer considered contraindicated in
soy or egg allergy
• Can cause hypotension, respiratory
depression

29 30

Ketofol

• Mixture of ketamine and propofol (50:50) in single syringe

• Theoretically minimizes adverse effects of both drugs
(hypotension, nausea/vomiting, emergence)
• Usual dose: 0.5mg/kg first dose
• Onset: < 1 minute
• Duration: 10 12 minutes
• May need repeat dosing

31

494
 Outpatient Dermatology
• About this lecture:
Dermatology: – The emphasis is on skin conditions in which the
patient is likely to go home
Rashes to Anaphylaxis – All patients with petechiae, multiple
ecchymosis, exfoliating skin, toxic
appearance, or abnormal vital signs
are specifically excluded from this
presentation
– Those conditions may indicate a life threatening
disorder, so consider consultation and/or admission

Eczema (Atopic Dermatitis) Overview

• A chronic pruritic skin condition
– Erythema, crusts, fissures, pruritis, excoriations,
lichenification
• Infants crusts, exfoliation (face, scalp, extremities) /
first few months of age / resolves by age 2
• Adults dryness and thickening in antecubital and
popliteal fossae, neck
– Positive family history, worse in winter (dry weather)
• Treatment – corticosteroids (start with OTC versions
in infants), antipruritics (cetirizine now preferred over
diphenhydramine – latter may be better to use at
night to help with sleep)
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 Eczema (Atopic Dermatitis), Image 1 Eczema (Atopic Dermatitis), Image 2

Excoriations and
lichenification
in the antecubital
fossa

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Eczema (Atopic Dermatitis), Image 4 Eczema (Atopic Dermatitis), Image 5

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 Allergic Contact Dermatitis Allergic Contact Dermatitis, Image 1
• Delayed type hypersensitivity
– Poison ivy, poison oak, poison sumac (linear
lesions)
– Contact with metal jewelry (nickel)
– Hair dyes, detergents
• Erythema, pruritus, vesicles, bullae
• Blister fluid contains no antigen
• Oral corticosteroids for severe cases or
widespread; topical for mild and limited area
9 10

Allergic Contact Dermatitis, Image 2 Allergic Contact Dermatitis, Image 3

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Allergic Contact Dermatitis, Image 4

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 Poison Ivy (Three Shiny Leaves)

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Poison Ivy (Toxicodendron)Treatment
• Topical symptomatic therapy — Soothing
measures such as oatmeal baths and cool, wet
compresses are anecdotally helpful.
– Topical treatment with compounds containing
menthol and phenol (calamine lotion) may also
provide symptomatic relief.
– Topical astringents such as aluminum
acetate (Burow's solution) or aluminum
sulfate calcium acetate used under occlusion may
be useful to dry weeping lesions.
– A soap mixture of ethoxylate and sodium lauroyl
sarcosinate surfactants may also be of benefit.
17
500
16
Poison Ivy (Toxicodendron)Treatment
• Antihistamines
– Topical antihistamines, anesthetics
containing benzocaine, and antibiotics
containing neomycin or bacitracin should be
avoided because of their own allergenic potential.
– Although there is little to no evidence to support
the use of Antihistamines:
• their use, sedating and nonsedating oral antihistamines
are commonly used to try to reduce pruritus.
– However, the itching in poison ivy dermatitis is not
caused by histamine release
18
Poison Ivy (Toxicodendron)Treatment
• Corticosteroids
– Topical:
• High potency topical corticosteroids are most helpful
early in allergic contact dermatitis
• Little impact is vesicles have occurred, but may
relieve symptoms
– Systemic
• Consider if face, genitals, severe dermatitis
• Oral prednisone started at a dose of approximately 1
mg/kg/day (maximum initial dose 60 mg/day)
• Taper over two or three weeks (for instance, 60
mg/day the first week, 40 mg/day the second week,
20 mg/day the third week would be one possible
taper for a 21 day course)
19
Poison Ivy (Toxicodendron)Treatment
• Antibiotics
– If secondary bacterial infection is suspected,
appropriate systemic antibiotics (typically directed
at gram positive organisms) should be
administered.
– Most patients with secondary impetigo will be
infected with S. aureus or group A Streptococcus.
– Given increasing rates of community acquired
methicillin resistant S. aureus, performing a skin
culture is reasonable if pus is present.
20

Pityriasis Rosea Overview Pityriasis Rosea, Image 1

• Children, young adults, Spring and Fall
– Etiology unknown
• No epidemics, not contagious
• Rash evolves over weeks
– Herald patch single salmon colored lesion with
raised border on trunk, 1–5 cm
– 1 2 weeks after herald patch widespread eruption,
pink maculopapular oval patches that follow the ribs
(“Christmas tree” pattern)
• Rule out syphilis (if sexually active); drug reaction
• Resolution in 2 10 weeks

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Pityriasis Rosea, Image 2 Pityriasis Rosea, Image 3

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Pityriasis Rosea, Image 4 Urticaria / Anaphylaxis Overview

• Diffuse pruritus, wheals, hives (superficial
dermis)
– Etiology is often unknown / drugs, food (about a
third of cases), insect stings
• IgE mast cells histamine release
• Usually self limited
• Severe cases can have
wheezing, hypotension,
swelling of lips, mouth
and airway, flushing, pruritis
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 Urticaria, Image 1 Urticaria, Image 2

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Urticaria / Anaphylaxis Treatment Angioedema

• Urticaria can be mild and only require oral • Edema of face, extremities, bowel wall
antihistamines and perhaps steroids • Unlike urticaria, swelling originates deeper in
• Urticaria with anaphylaxis can be life the soft tissue / no pruritis
threatening • Can result in difficult to treat tongue and
– Establish a secure IV line airway swelling – may need airway
– Epinephrine (IM if severe; drug of choice) management
• 1:1,000 – adults, 0.2 0.5ml q 15 min x 2 if needed / • Most common drug cause is ACE inhibitors
children 0.01ml/kg to max of 0.2 0.5ml q 15 if needed – Patients can be on ACE inhibitors for years before
– Inhaled albuterol if wheezing an episode occurs
– IV steroids (methylprednisolone, dexamethasone, or others)
– Both types of antihistamines
• May start with usual
• H1 = diphenhydramine (Benadryl), 1 2mg/kg IV to max of
anaphylaxis treatment but
50mg (but if tolerate PO consider cetirizine [Zyrtec]) other therapy may be required
• H2 = cimetidine (Tagamet), 4mg/kg IV or famotidine (fresh frozen plasma if hereditary,
(Pepcid), 20mg IV or a bradykinin or kallikrein
29 antagonist) 30

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 Angioedema, Image 2 & 3 Tinea (Dermatophytosis)
• Tinea capitis (scalp) and tinea barbae (beard)
– Bald, broken hair / scaly patch / edematous nodules
• Tinea corporis (ringworm)
– Non hairy parts of the body, outward spreading,
annular lesion, clear center
• Tinea pedis (athlete’s foot)
• Tinea cruris (jock itch)
– Groin and inner thigh (sharp demarcation)
• Consider elevated blood glucose as facilitator
• Treatment – all are OTC / tolnaftate (Tinactin),
clotrimazole (Lotrimin), / miconazole (Micatin) /
treat for one week after resolution
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Tinea (Dermatophytosis), Image 1

Tinea Tinea (Dermatophytosis), Image 2
Tinea
Capitis Corporus Pedis

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 Tinea (Dermatophytosis), Image 2
Tinea Tinea Versicolor
Cruris (Jock Itch) • Hypopigmented or
hyperpigmented
circular, scaly patches
• Poor hygiene, moisture
• Fungus, Malassezia
furfur
• Treatment selenium
shampoo (e.g., Selsun
Blue), ketoconazole
shampoo or cream
35 36

Tinea Versicolor, Image 1 Lyme Disease

• Transmitted by tick bite / bite often not noticed
• Erythema migrans – initial phase = annular,
expanding erythematous lesion with central clearing
(spares palms, soles)
• Secondary phase
– Neuro CN VII palsy, meningitis, peripheral
neuropathy
– Cardiac myocarditis, pericarditis, heart block
– Musculoskeletal – waxing and waning arthritis
• Diagnosis ELISA (screening); Western blot
• Treatment doxycycline, erythromycin, amoxicillin,
ceftriaxone
• Probable risk test / Probable disease – treat
37 38

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 Lyme Disease Lyme Disease, Image 1

Ziegler, R; Didas, C; Smith, J. Diagnosing and managing Lyme disease. JAAPA. Vol 26. No. 11. November 2013.

39 40
Logical Images Inc.

Lyme Disease, Image 2 Lyme Disease, Image 3

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Logical Images Inc.

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 Lyme Disease, Image 4
43
Aphthous Ulcers (Canker Sores)
• Small painful lesions that form on the soft tissue
linings of the mouth or on the gums
• Starts as a vesicle then a grey based ulcer with an
erythematous rim
• Begins in childhood and recurrences are common
• Cause – largely speculative – immunologic (stimulus
unknown), nutritional factors, dietary allergies
• Treatment – topical steroids QID (triamcinolone
[Kenalog Orabase], others / amlexanox (Aphthasol)
45
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Lyme Disease
Ziegler, R; Didas, C; Smith, J. Diagnosing and managing Lyme disease. JAAPA. Vol 26. No. 11. November 2013.
44
Herpes Labialis
• HSV 1 and HSV 2 – either can cause oral (herpes
labialis, ”cold sores,” “fever blisters”) or anogenital
lesions (genital herpes)
– HSV 1 is typically oral / HSV 2 typically anogenital
• Herpes labialis initial infection involves fever, sore
throat or swollen neck glands / painful vesicles in
several days, crust over, possible secondary infection
• Recurrences are common / antivirals (acyclovir, et al)
46
 Herpes Labialis Image 1 Herpetic Whitlow
• A painful herpes simplex (60% HSV 1) viral infection
on the finger
– Very contagious
• Frequently seen in healthcare
workers, dental workers and
children
• DO NOT attempt to I & D these
lesions
– Can last weeks
• Treatment
– Acyclovir / valacyclovir / famciclovir / topical
acyclovir
47 48

Herpetic Whitlow, Image 1 Herpes Zoster (Shingles)

• Varicella zoster (chicken pox virus) reactivation
• Painful vesicles in dermatomal distribution
• Cranial nerve involvement
– HZ ophthalmicus ophthalmic branch of CN V,
lesion seen on tip of nose (Hutchinson’s sign)
suggests it is vision threatening
– HZ oticus (Ramsay Hunt syndrome) CN VII,
presenting with facial nerve palsy, ear pain
• Complications pneumonia, meningitis, post
herpetic neuralgia, 2nd infection, dissemination
• Treatment: acyclovir and analogs, prednisone
49 50

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 Herpes Ophthalmicus Image 2

Herpes
Zoster,
Image 1

Hutchinson’s Sign

51 52

Herpes Zoster (Shingles), Image 4

Herpes Oticus (Ramsay Hunt Syndrome)

Image 3

53 54
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 Odds and Ends in EM:
THE LAST LECTURE

Top 10 Reasons People go to the ER Top 10 Causes of Death in the U.S.

Most common to less common ~74% of all deaths in the United States occur
as a result of 10 causes. Over the past 5
1. Abdominal pain 6. Back pain years, the main causes of death in the U.S.
have remained fairly consistent.
2. Chest pain 7. “Pain” (other)
3. Fever 8. Dyspnea 1. Heart Disease 6. Alzheimer’s Disease
4. Cough 9. Accidental trauma 2. Cancer 7. Diabetes
5. Headache 10. Vomiting 3. Accidents 8. Influenza & Pneumonia
4. Chronic lower 9. Nephritis, nephrosis
WORK
NOTE respiratory disease 10. Suicide
5. Stroke
3 4

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5
 High Risk Populations
• Remember, who is high risk?
• Highest rate of readmission
in 30 days after discharge:
Circulatory system diseases,
Respiratory diseases, infections,
GI diseases, mental health, accidental injuries
• 30 Day readmission: Consistently highest among
patients with stays billed to Medicare, followed
by those with Medicaid, uninsured patients, and
those with private insurance
Before they go…
• Final reassessment?
– Vital signs, did they improve?
• What is normal? Abnormal?
• What may I have overlooked?
• What did I find?
– Copies of “incidental findings” printed off and
handed to the patient with highlighted concerns
• Does this patient have access to resources?
• Did I set up an appointment or make a needed
call to specialist?
• Do they have questions?
High Risk Populations
• “High risk” medications /Polypharmacy
– Antibiotics, glucocorticoids, anticoagulants,
narcotics, antiepilectics, antipsychotics,
antidepressants, hypoglycemic agents
• More than 6 diagnosed conditions
– Specifically, advanced chronic obstructive
pulmonary disease, diabetes, heart failure, stroke,
cancer, weight loss, depression, sepsis
• Prior hospitalization in the last 12 months
• Black race, low health literacy, people who live
6 alone, lower socioeconomic status, AMA 7
Discharge Approaches
• National Patient Safety Foundation“Ask Me 3”
– What was my main problem?
– What do I need to do? (Manage at home, what if I
run into problems)?
– Why is it important for me to do this?
• 40% of patients are unable to describe the
reason for their hospitalization, 54% could not
recall instructions at follow up appointments.
• “Teach Back” techniques
• “Check list” (Society of Hospital Medicine)
8 9
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 Discharge Paperwork
Requirements “My doctor
• Patient name
• Physician name
• Patient instruction(s)
• Medication
never
• Purpose of discharge ‐ side effects told me…”
instruction • Follow up
• Diagnosis • Specific time lines
‐ expected course • Documentation of
• Potential complications receipt
‐ patient signature

10 11

Abdominal Pain Chest Pain

• 5‐10% of all ED visits
– 25% of the time, work up is normal or inconclusive.
• Normal abdominal pain work up +/ testing:
– Review all completed labs and images
– Discuss with the patient
– Put your hands back on the belly!
• Documentation keys:
– “Abdomen soft, non tender”
– “Patient much improved”
– “Tolerating po fluids”
– “Non distressed, eager to leave”
• 5‐8% of all ED visits
– “chest pain unspecified”
• Consider age, presentation and risk factors if
discharging
• Review sat and repeat EKG, document findings
• Documentation keys:
– HEART score, wells/PERC, risk factors
– Other serious pathology was ruled out and why
– Other diagnoses considered, but not likely
– Vital signs, plan for follow up
12 13

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 Back Pain
• 3% of ED visits
• Discharge paperwork: exercises and
specific treatment plan, follow up plan,
prescriptions and over the counter
treatments
• Documentation keys:
– Red flags on exam? i.e. denies: fever,
saddle anesthesia, incontinence/retention,
neck pain/headache, chest pain, recent
surgery, DM, hx of CA, vaginal bleeding,
rectal bleeding, rash
Cough
• 3% of ED visits
• Tell the patient their cough may last a
week should improve in 3 7 days
– Smokers may take longer
• Strict return precautions i.e. fever, vomiting, sob
– Remind patients of side effects of OTC meds and
provide a structured discharge plan
• Documentation keys:
– Concerning features of URI, pneumonia and other
serious respiratory pathology has been ruled out.
– The patient has an intact airway and in no distress with
normal sat, no hemoptysis or fever.
– Vital signs are WNL, patient appears non toxic
Back Pain
• Documentation keys continued:
– Document sensation, motor, and movements
– “Patient up to the bathroom without assistance”
– “Patient voided/had normal BM in the
department”
– “Patient has improved pain and mobility,
evidenced by” (they said so, they walked etc.)
– “No obvious signs of cauda equina or SEA on
exam, as evidenced by exam (also documented)”
14 15
Asthma or COPD
• If possible, have respiratory therapist assist with
discharge and dispense new inhalers or spacer
as needed.
• Documentation keys:
– Sat and vital signs
– Improvement?
– Lung reassessment charted
• Document smoking cessation conversation
– Provide materials and resources
16 17
515
 Fever, Pediatric
• Complete and document a full exam
– Tell parents as you go what you are/not finding
– “Johnny’s belly is soft, heart sounds normal…”
• Review Motrin/Tylenol regiment with parents
– Generic hand out (they work with mL’s and tsp. not
lbs and kgs)
• Documentation keys:
– Does the child look well or does the child look sick?
– Vital signs, activity level, tolerating po fluids, breast
feeding / bottle?
Laceration
• “Today you had a laceration to your ____. We
have placed ____ sutures. They need to be
removed in ____ days. You may do this in your
doctor’s office or here if necessary.
• “We updated your tetanus shot today.”
• If you smoke, it will delay the healing of your
wound, and increase your risk for infection.
• Documentation keys:
– Bleeding controlled, neurovascularly intact, no
tendon involvement, full ROM

18 19

Fractures and Splints Inconclusive Diagnosis

“Today, we completed a work up for ______.
• Speak to a specialist about (most) fractures, Sometimes, we do not always find the cause for your
reductions or dislocations symptoms in one ER visit.
• Remind patients not to get the splint wet and The findings on your exam today and on your blood work
strict return precautions for pain or numbness and/or imaging is reassuring. At this time, it is not 100%
• Documentation keys: certain what is causing your symptoms, but we feel you
can be discharged form the emergency department.
– Neurovascularly intact before and post splint
It is possible this may worsen or you may get better.
(actually check it and document it)
Please, if your get worse or your symptoms change,
– Sling applied for comfort return to the emergency department.
– Follow up referral provided Otherwise, please follow up with your primary care
– Pain control given doctor in 1 2 days or any of the specialists we have
• Core measures provided or recommended.
20 21
Read the attached instructions.”

516
 Motrin and Tylenol “Smart Phrase”
• For your chart: Short comment on pain control
choice (especially if using additional narcotic)
• For your discharge paperwork:
“Please take Ibuprofen (Motrin) or Acetaminophen
(Tylenol) for pain. These are available over the counter.
You may take Ibuprofen 600 mg every 8 hours with food
for pain. You may also take Acetaminophen 650 mg every
4 6 hours for pain. Do not exceed 3000 mg of Tylenol a
day as this can cause liver damage. Do not drink alcohol
with either of these medications. Evidence based
research has shown taking these two drugs together
work the same (or better in some cases) for pain than
opioids or narcotic pain medication.
22
Chronic Pain “Smart Phrase”
• For your chart: “This patient has chronic pain.
We have spoken about multiple previous
evaluations and workups. I explained at length
that I would be ready to address the complaints
appropriately. I stressed importance of safe care
and did not disregard or dismiss the complaints,
but explained that I was quite concerned about
narcotic dependence, misuse and/or potential
abuse. I explained that I provided a stabilizing
exam and will pursue the least invasive course.”
24
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Narcotic Smart Phrase
• For your chart: Patient has a ride, instructed
them not to drive or drink alcohol.
• For your discharge paperwork:
– “If we have prescribed your narcotic pain
medication, please try the Ibuprofen or
Acetaminophen regimen first. Narcotic pain
medication is addicting, can cause nausea and
dizziness that can lead to falls or impair driving”
– “Narcotic pain control can cause severe
constipation. Please take an over the counter stool
softener such as Colace during the course of
treatment”
23
Chronic Pain “Smart Phrase”
• The patient was informed of our department's
analgesia policy and given discharge
instructions for this condition. The patient's
presentation to the ER today is of concern for
either narcotic dependence or inappropriate
use of narcotic medications for chronic /
recurrent painful conditions. The patient was
informed that if they have future ED visits for
chronic / recurrent pain that narcotic
medications may not be provided.”
25
 Important, Your Signature
Dear Mr. Bukata,
Your diagnosis today is _______________.
Generally, you should start to feel better in _____.
If you do not improve in ____ days, follow up with
the specialist provided. ___________.
IF YOU ARE WORSE, RETURN TO THE ER!
Please read the attached instructions, they highlight more specific
treatments and interventions for you at home.
Thank you for letting me participate in your care,
Martha A. Roberts, ACNP, PNP
mar79@georgetown.edu
Do not hesitate to contact me with questions, but if you experience a
life threatening emergency, return to the ER.
Additional Resources
• Other thoughts to consider…
– Copies of images on a disk
– Print outs of lab testing or radiology dictation
– Phone number and address of your facility
– Homeless shelters (CA laws, new guidelines)
– Addiction specialists (ETOH, drugs)
– Suicide/mental health referrals (Joint Commission)
– Chronic Pain management
– Primary care “who’s taking new patients” form
– Dental resource sheet 28
Additional Discharge Instructions
• If you smoke, please stop. There are many ways
to quit and we have resources to help you. If
you do not quit, you have a 90% chance of
dying from a smoking related illness, that may
have been preventable by NOT smoking.
• Please see the dentist at least twice a year. Do
an annual cleaning every 6 months. Please see
our attached dental referral list for assistance.
• Don’t have a PCP? Please contact this number
or this care specialist or this doctor who can
help you get an appointment.
26 27
Bonus Points
• If late/pharmacies closed: dispense
pain medication and/or antibiotics
first/second dose
• Consider dispensing eye or ear
drops that may be difficult to obtain
financially or physically for a
patient
• Giving a particular name of a
specialist, instead of just the group
name 29
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Caring Callbacks Closing Remarks
• Thank you for joining us at the bootcamp this
year! Please check out our website for more
courses www.CCME.org
• The SLIDO questions will be emailed to you
• The LIVE STREAM will be available for the next
few days and then will be removed
www.ccmelive.org
– You can purchase the self study course by going to
the website!
• You can get a copy of your CME certificate
30 after completing your survey on ccme.org 31

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