Wednesday Lectures, 6/24/2015


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…