Wednesday Lectures, 11/05/2014

10a PDR (Kloss) Geriatric Abdominal Pain

Geriatrics are 65plus, 12% of population, to 30% by 2030!
Abdominal Pain in this age group requires SG 30% of the time & relatively higher M&M!
Decreased barriers to infxn, decreased physiologic reserve… think “2nd childhood”…
Decreased pain perception & dementia can be complicating factors, delay care…
Fear of losing independence, higher comorbidities…
NSAIDs & Polypharmacy issues…
“Atypical is Typical” ~ dt poor localization, less likely tachy dt Bblockers…
Infection > obstruction > PUD > UTI…
10% of Appy happens >60yo, more likely to rupture; Mortality up to 5% from baseline <1%.
1/2 do not have fever or Leukocytosis & exam findings may be nonfocal; Guiac may be wnl.
(*1/3 of all lawsuits involve signedout pts…)
Syncope increases risk…
Diverticulitis (simple) can be treated OutPt c Abx: Cipro, Flagyl…
Perforated diverticulitis? May be more serious…
Biliary Dsx more commonly stone related in elderly vs EtOH related in younger pts…
Cases… Cases… Cases…

11a PSQ (Shaw) Geriatric Abdominal Pain, mild anemia…

Transition of care c labs pending or refused? Needs documentation!
Policy exists CM M03 such that Pt may take own home medication.
http://www.upstate.edu/policies/documents/intra/CM_M-03.pdf
Looking into EPIC addenda…

1200p TLLT (Rosenfield)

Apnea & Nasal Oxygen in ED Intubations ~ Clinical Controversy
2012 Weingard? Physiology… “Apneic Oxygenation” ~ passive NC (?) helpful?
http://www.ncbi.nlm.nih.gov/pubmed/22050948
http://www.ncbi.nlm.nih.gov/pubmed/23836064
Preoxygenation > Apneic oxygenation! …might as well preoxygenate with NC, as long as it doesn’t delay care… & 20* Reverse Trendelenburg also good.
“RSI” is a NO BAG technique by definition, btw!

1230p TLLT2 (Rosenfield)

Review of the Ear
Impaction… Cerumenolytics, Irrigation, Manual Removal… ALL the same?
Color, Position, Lighting, Entire TM, Translucent v opaque
Pars flaccida bulges early in AOM, followed by purulent collection, protrusion can lead to rupture!
NNT 20 Pain relief
NNT 33 Perforation prevention
NNT 11 AOM unilateral to bilateral spread prevention
NNH 14 (Harm is rash or diarrhea or emesis, already Viral Sx???)
http://summaries.cochrane.org/CD000219/ARI_antibiotics-for-middle-ear-infection-acute-otitis-media-in-children

130p Journal Club (Cherrington)

Tox UEM Awareness Rothman
**Press Ganey scores between Narcotic & NonNarcotic Pain Rxs? <http://www.sciencedirect.com/science/article/pii/S0196064414001206?via=ihub&gt;
No specific correlation identified, so don’t just give analgesics for Press Ganey.
**EGDT for Septic Shock… “ARISE” study
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380
In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days. (Funded by the National Health and Medical Research Council of Australia and the Alfred Foundation; ARISE ClinicalTrials.gov number, NCT00975793.)

230p Radiologic Emergencies (Cooney)

http://emergency.cdc.gov/radiation/countermeasures.asp
Alpha Beta Gamma Neutron
http://www.frankswebspace.org.uk/ScienceAndMaths/physics/physicsGCE/images/penetration.jpg&gt;

EXPOSED is NOT the same as CONTAMINATED!
*Exposure depends on Time, Concentration of energy, Shielding (Distance dissipates)

http://emergency.cdc.gov/radiation/countermeasures.asp
http://emergency.cdc.gov/radiation/countermeasures.asp

http://en.m.wikipedia.org/wiki/3_Mile_Island
http://en.m.wikipedia.org/wiki/Radiation_effects_from_the_Fukushima_Daiichi_nuclear_disaster
http://en.m.wikipedia.org/wiki/Neutron_bomb
http://en.m.wikipedia.org/wiki/Dirty_bomb “Expose Many, Kill Few”
http://en.m.wikipedia.org/wiki/Geiger_counter
http://en.m.wikipedia.org/wiki/Mass_decontamination
http://www.ncsu.edu/ehs/radiation/forms/alara.pdf
http://www.remm.nlm.gov/ext_contamination.htm
Psychological impact of radioactive material exposure not to be underestimated…

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