TTHM 13.4 PDR
10a ~ PDR (Paolo)
*Vancomycin 1 dose does nothing & should be 15 to 20 mg/kg (IDSA recs) rather than 1000mg, often switched to Bactrim, Keflex, Clindamycin for Discharge?! In pyelonephritis, one dose IV (ceftriaxone?) loading may be helpful…
*Video Laryngoscopy useful for trainees? May allow for better supervision! 5% Esophageal Intubation vs 1% Esophageal Intubation (direct vs video intubation)… Likely to make a clinical difference. “Video is now the standard of care”? …but no institutions known to implement video first yet…
*IV, O2, Monitor ~ …but O2 may be harmful… hyperoxia may cause vasospasm!… reactive oxygen species may cause other harm. <94% placed on O2 with intention to treat analysis.
*Bouncebacks… common & multifactorial. 8.2% bounceback within 3 days. 29% ADM & 32% presented again to different hospital. “A chance to fix what I missed before”. Chronic Abdominal Pain…
*CT usage ~ is UP. (surprise!) ~30% of ED visits get CT. More harm, less benefit…
*ED Crowding ~ All metrics suffer with large # of patients. It’s not getting any better. ED Residencies NOT increasing.
11a ~ TQM
Push for Gyn formal consult & OBS when large cyst causes recurrent pain.
Always recheck your Radiology reads.
1230p ~ Academic & Quality Projects (Kai, Bbuye)
AMA Patients… need the form?
Bivalved casts too often without Ortho?
1pm ~ TLLT (Neal, Deepak, Umair)
*Anticoagulants: 1916 Heparin, 1954 Coumadin… Xarelto, Pradaxa…
None of our head injury rules apply to anticoagulated pts! ~ Trauma 24 hr OBS Policy…
*Eye Issues in the ED:
Chalazion ~ hard & not painful, warm compresses, baby shampoo
Hordeolum ~ painful, staph/strep
Blepharitis ~ eyelash follicles itchy, sandpaper, staph epi…
Dacryocystitis ~ epiphora tears excess, & inferomedially
Dacryoadenitis ~ supratemporal gland
Conjunctivitis ~ staph/strep, mucopurulent, should fluorescein (slit lamp?), Polytrim oint.
HSV Dendrite/Keratitis ~ acyclovir & ophtho consult
Corneal Ulcer > Abrasion ~ topical Abx, patch, consider cycloplegic?
Foreign Body ~ Consider Rust ring (delayed formation)
Globe Rupture ~ Cover eye & consult ophtho, tetanus, pain meds…
Cellulitis (Orbital > PreOrbital), get CT
CRAO ~ cherry red spot (CVA of the eye), painless vision loss > CRVO c hemorrhage…
Retrobulbar Hematoma ~ Lateral Canthotomy (for vision loss, proptosis, IOP>40) on HippoEM.
EYE US: Optic nerve 3mm deep no >5mm wide!
Also US good for Retinal or Vitreous Detachment.
2pm ~ Tox (Sullivan)
Mothballs & Related…
*Camphor (mothballs) Causes Seizures! Vicks VapoRub has <1% camphor…
Evaluate ALL Peds exposures! Odor is neither sensitive nor specific. Cinnamonum camphori tree or synthetic… Camphor floats in water.
*Naphthalene (mothballs) ~ hepatic metabolites cause hemolysis! (high indirect bilirubin). Infants have decreased NADH reductase activity; comes from coal tar & combustion.
*Paradichlorobenzene now most common mothballs dt decreased toxicity (minimal).
PDCBZ is radioopaque (& sinks in water).
230p ~ Prehospital Intubation (Veer Patel)
Evidence for harm, questionable benefit… BVM should be enough although combitube equivalent may be good for extended travel.
*Oncologic Emergencies ~ SVC Syndrome usually dt lungCA…
Tumor Lysis Syndrome ~ hyperkalemic crisis, hyperuricemia…arrhythmias, hypocalcemia, AKI…
Brain Mets… cerebral edema…
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