What causes CAP in US adults?? (per Gary Johnson, NEJM)


or…. why bother culturing blood or sputum??

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults
N Engl J Med 2015; 373:415-427
July 30, 2015
DOI: 10.1056/NEJMoa1500245


Wednesday Lectures, 7/29/2015

TTHM a2.2 Grand Rounds (7/29)

10a ~ Approach to Clinical Questions & Critical Review of Therapy Articles (Wojcik)
*BMA TXA article http://www.bmj.com/content/345/bmj.e5839 (from CRASH2 data)
Randomized studies: “intention to treat” versus “per protocol” ~ switching groups?
Odds Ratios show bigger effects in more common phenomena, more comparable to Relative Risk in rarer phenomena such as deaths in trauma.
*Odds Ratio https://en.m.wikipedia.org/wiki/Odds_ratio
*Relative Risk https://en.m.wikipedia.org/wiki/Risk_ratio
*Absolute Risk Reduction https://en.m.wikipedia.org/wiki/Absolute_risk_reduction
*Number Needed to Treat https://en.m.wikipedia.org/wiki/Number_needed_to_treat
*Heterogeneity https://en.m.wikipedia.org/wiki/Homogeneity_and_heterogeneity
*Validity https://en.m.wikipedia.org/wiki/Validity_(statistics)
Later will evaluate Diagnosis Articles…

11a ~ Airway Emergencies (Johnson)
Have your team with at least 4 roles (intubator, Resp Ther/bag, Cspine, cric&meds…)
Choice of Meds for:
*Blunt Trauma VSS
*Blunt Trauma Shock
*% that Fail?! 3-3-2 neck eval & Mallampati 1-4… OPAs & NPAs?
Try to get the view right away & don’t lose it!
Cric if needed! Atropine to prevent vagal response if 1:1:1 > 1:1 > PRBC… Colloids & Crystalloids… (frozen, fridge, & freeze dried products ~ FDP)… LR less acidosis so Military gives LR > NS (even with PRBCs).
How much blood before you give some Calcium? (every 4th unit in military)…
US in helicopter can look at RV & optic nerve… Special Operations Ultrasound Training
Portable ETcapno & O2 Sats, with pulse checks…
*Things for next shift… or not…
Safety Pins for the tongue to clear airway… “100 uses for a safety pin”… makes great suture replacement! Ketamine finally coming back. In Africa, they have antimalarials & ketamine. Raising ICP? …or might improve CPP? Ketamine can be USED to TREAT Ketamine or other emergence phenomena…
No ketamine to kids under 3? or known schizophrenia? military burn pts? Does not cause PTSD… “Retrieval medicine pts” get ketamine in Australia… don’t always get intubation!
*Pts on ketamine with trauma can still be hemodynamically unstable, hypotense…
*Great for opiate induced hyperalgesia/dependence. Can use IV, IM, or IN… Neb?
1200mcg Fentanyl lollipops… minimal PCA risk…
Special Ops use IOs… Tibia in hospitals… but field ops use “FAST1″ (green needle) at sternum.
Yellow (long) needle humerus vs Blue (medium) needle tibia. Only special smaller needle for sternum. Pink (short) needles for Peds & puppies.
Which tourniquet is the best tourniquet? ~ The one you have.
+”Plus One” loose proximal extra tourniquet. Venous Tourniquets dangerous too.
+ Pain Control & hemostatic agents
+ Time Mark: 6hrs ~ irreversible damage. Don’t remove from pt in shock!

230p ~ Emergency Ethics (Brenner)
ELSIM, Clinical BioEthics, Center for BioEthics & Humanities, Ethics Consult Service, ACEP Ethics Committee
Rapid Decision Making Model:
*Already a rule that applies?
*Is there an option to buy time?
*Impartiality test ~ what would you want? (Golden Rule)
*Universality test ~ would everyone approve?
*Interpersonal Justifiability test ~ could you justify actions to peers c good reason?
EMTALA: #1 Law governing the U.S. practice of EM.
Zink, “Anyone, Anything, Anytime”…
1968 ~ ACEP (vs AMA)
1989 ~ ABEM recognized by ABMS.
Good Samaritan Laws do afford some protections but vary across jurisdictions.
NY Safe Act 9.46 Mental Hygeine Law
Impaired Drivers ~ No law NYS; Mandatory: CA, DE, NV, NJ, OR, PA…
ID Reporting ~ NYS DOH requirements…
NYS Surrogate Decision Makers, differs by Jurisdiction: https://www.health.ny.gov/publications/1503.pdf

Wednesday Lectures, 7/22/2015

TTHM a1.4 PDR (7/22)


10a ~ PDR (Paolo)

General advice: *don’t forget about cric as option; *hypotension in the field = bad.  *Beware “stable for CT scan” in Trauma… *get BOTH Thorax & Lumbar spine MRI for Cauda Equina (spinal Sx do NOT well/localize!)… *Neuro & Rheumatology subjective Sx difficult to test or quantify… *Recheck Vital Signs (esp prior to DC) & *Nursing Notes most frequently missed data…

Notice of intent ~ makes you very angry.  1st step in a lawsuit, must respond within given time period…  (dukesw@upstate.edu EMS intubation project).  NYS NOI within 90 days of “event upon which the claim is based”.  NYS Lawsuit must be initiated within 1 year & 90 days of “event upon which the claim is based”. http://www.nycourts.gov/courts/6jd/forms/srforms/ntc_howto.pdf


11a ~ TQM (Shaw)

*Rare disease happens rarely, which means that it does happen.

*Epistaxis & HTN usually NOT HTN Emergency.


1230 ~ ED Admin (Joslin)

*Community Perspective (including EMS).  Appear Capable? Accessible? Compared to other Hospitals/EDs? What influences pt’s decision to come here? EMS? (No “take me to Crouse” resident joke shirts i.e.)… Greetings? Capabilities? Professional? Radio/Resource contacts/consults.  How do we handle EMS refusals? (There is a refusal policy/algorithm.)

*Hospital Perspective ~ Pt is “hospitalized to…” rather than ADM or OBS, if uncertain…

*Patient Perspective ~ worst day of their life. acknowledge.  learn about costs to help pt.  Decrease their length of stay, communicate.  Avoid unnecessary costs… i.e: “pt may take own home meds”.  Joslin hates CK-MB. (CK & CKMB ~ $102)

*Group Perspective ~ Team Health at St. Joes… different group models.  CROUSE is Hospital-based.  UHEM Physicians Group @ UH… Coding Charts… Charts are Level II, III, IV, V, Critical Care (30 to 60 minutes, high risk)…  LWOBS bad for business.  “Calling a consult is not a benign procedure”.  Avoid extraneous labs.  Don’t fish for nonemergent diagnoses.  “Pt condition improved after fluid administration” shows reevaluation, intervention, complexity…


130p ~ Bath Salts (Kloss)

Lecturing on Lecturing… doing conferences can be fun!  Syracuse as bath salts capital of the nation… new kids on the block ~ phenylethylamines ~ “25B” is one of the new ones ~ “AB Fubinaca” ~ “2ci, 2ce” = “Smiles”…

Substituted cathinones ~ “bath salts”… Leukocytosis c stress response.

*Can precipitate serotonin syndrome if pt on antidepressants… “wet dog shakes” autonomic instability leading to seizures…  MDMA identification charts “for law enforcement use only”.  Where do ppl purchase them? Alibaba… Darkwebs… Ebay… Bulk purchase as “Research Chemicals” “not for human consumption”… some ppl purchase precursor compounds… i.e: GBL to GHB… i.e: “Aqua Dots”  LegalBuds.com

*Spice/K2 ~ early synthetic marijuana

*Bath Salts/Plantfood ~ Cocaine/Ecstasy or LSD alternative

*Salvia ~ Diviner’s Sage ~ Mexican Mint ~ mild hallucinogenic

*Khat, Kratom ~ Asian Hallucinogen & Opiates…

John W Huffman ~ JWH-018

Syracuse Smoke Shop Industry ~ Twisted Heads on N. Salina, S. Salina, Tebb’s Headshop… in jail for Tax evasion. “Cloud 9”, “420 Emporium”

“Legal Buds” & “Herbal Smoke” since early 2000s…

Concentrations can vary 0.2 to 3% per serving of same chemical!!! Extremely variable chemicals & effects!  There have been reports of STEMIs & AKI!  Paranoia, agitation vs catatonia… VA “Primary Care Plus” often full workup, may include send-out urine cannabinoid tests in psychosis…

Dopamine ~ Pleasure

Serotonin ~ Hallucinations

“Krypton Kratom” in Sweden had Tramadol and Kratom (~opiate)

Crack free base & weak acid such as vinegar or lemon juice make better

Fun websites ~ EROWID.com ~ StreetRx ~ Opiophile


230p ~ Shock (Johnson) ~ “inadequate tissue perfusion”

*Hypovolemic ~ Blood Loss (chest, abd, pelvis, floor), Dehydration (I/O balance) ~ US exam

Massive Transfusion Protocol

*Cardiogenic ~ MI, arrhythmia, CHF ~ US exam

*Distributive ~ Neurogenic, Vasodilation, Anaphylactic, Septic ~ “warm”, hyperdynamic

*Obstructive ~ PE, tamponade, PTX, venous return ~ JVD

Needle, relieve obstruction…

…& remember adrenal insufficiency

Maximum IVF rate through wide short lines, rapid infusion ~500cc/minute max!

*MTP 1:1:1 ratio of PRBC:Plts:FFP typical, although other ratios possibly more ideal?

*TXA IS used if Trauma within 3 hours of massive trauma.  Consider calcium, cryoprecipitate, Factor VII, FEIBA, PCC… TXA validated by CRASH-2 trial (Lancet 2010).  End points of resuscitation somewhat unclear.  Repeat ABCs.  Recheck tubes & interventions.  Trace procedures & lines.

Troubleshooting: ABCDE… consider steroids!

Unable to intubate? = Cric.

Traumatic tamponade ~ thoracotomy > pericardiocentesis.

Stabilize fractures in Trauma Bay!

Don’t mess around with colloid!


Wednesday Lectures: 7/15/2015 – Cardiology/Chest Pain Day

TTHM a1.3 Cardiology/ Chest Pain Day  (7/15/15)  Tint. 52, 53, 55, 59, 60, 62, 122


10a ~ NSTEMI & STEMI (Johnson)
“We give back to you on Wednesdays” “for all the sh*t we give you to do the rest of the time”.  Know your STEMI/CVA/TraumaCode Policies!!!  Know your AHA & ACEP guidelines!

In presence of bundle branch block, Sgarbossa’s Criteria… 1mm concordant elevation or 5mm discordant elevation or depression (ST to T wave correlation).

Angina in the ED is ACS! ~ Leading cause of death, 1/5 of all malpractice $.

Chest Pain can be Abdominal Pain via diaphragm.

Visceral pain is nonspecific. Ischemic areas have penumbras.

Typical STEMI is ruptured atheroma causing acute vascular obstruction, ischemia, infarction.

3*HB often SA node problem supplied by RCA.

“If any symptoms sound like angina, it’s angina.”

Exertional? Ask if associated c fever or cough for DDx.

FamHx important for Chest Pain & Headaches.

Compare with old EKG whenever available!

National Standards state EKG must be obtained & interpreted within 10 min! ~ NYT Article…

Most MIs are NSTEMI > STEMI.  R sided EKG rarely done but may distinguish more dangerous kinds of MI…

ST segment elevation without MI? early repol, LVH, Pacer, Pericarditis/Myocarditis, Hypothermia, LV aneurysms…

23% of STEMI are “non actionable” but most should be acted on anyways.

1 to 4% of MI have completely normal EKG!!!

Twave inversions without ischemia… common in Peds, Intracranial Injury, Cor Pulmonale

BNP not very useful unless the hospitalist “needs” it for CHF admission baseline…

EchoCG, Stress Testing, other tools more specific once high risk is established…

Be wary of new “very high sensitivity Trops”.

Don’t send home new Pulm Edema… high cardiac risk, significant M&M!


11a ~ SG (Paolo & LaVoie)

STEMI transport tPa vs Dissection Case…

Intraventricular Conduction delays: RBBB, LBBB, Paced rhythms…

Sgarbossa (single lead changes in block):



12 ~ Rapid Procedure Lab (Vatti)

Review of Pericardiocentesis http://emedicine.medscape.com/article/80602-overview


1230 ~ Jr/Sr sessions (Paolo/LaVoie)

Wellan’s, Brugada, Sgarbossa criteria… aVR in lateral or LM, aVL in inferior…




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615989/ (aVR)


130 ~ PE (Schenker/Patel)



NOT to be confused with the DVT Wells: http://www.mdcalc.com/wells-criteria-for-dvt/



Lovenox, Heparin, DVT~US…


2p ~ Pericarditis (LaVoie)




230p ~ Ao Dissection (Prasad)


Stanford Type A (DeBakey 1&2) ~ “Arch” ~ Surgery, generally.

Stanford Type B (Debakey 3) ~ “Below” ~ Medical Mgmt, generally.

https://en.m.wikipedia.org/wiki/Michael_E._DeBakey, https://en.m.wikipedia.org/wiki/John_Ritter

https://en.m.wikipedia.org/wiki/Lucille_Ball, https://en.m.wikipedia.org/wiki/Jonathan_Larson

Beta Blockers or CCB rather than Nitrates alone to reduce BP, prevent reflex tachycardia!

~Esmolol (500mcg/kg loading, & 50 to 200mcg/kg/min),

~Labetalol (20mg, then 0.5 to 2mg/min),

~Propranolol (1 to 10 mg load, then 3mg/hr)

~Nicardipine/Nifedipine or Nitrates used secondarily…


3p ~ Peds Chest Pain (Thabet)

Case: Dizzy & Near syncope, worse c exertion, 2 cousins died of HOCM, 1 unknown early death… EKG 3*HB.  Cath & Pacer.  Good outcome.  Think TSH & Lyme!  Fvr/recent illness?

Good Hx & Physical very important!!! Details!!! Associated Sxs…

Dizziness? Syncope? SoB? Palpitations? HR? hormonal? Feeding intolerance/Apnea?

Collagen Vascular disease? Marfanoid? Familial hypercholesterol? Early cardiac deaths?

Don’t miss: MI, HOCM, AoDissection, CardioMyopathy, Pericarditis, Myocarditis, PE, Arrhythmias…   Long QT? Medication side effects…



Troponin cutoff same regardless of age, however, can be artificially elevated

ALCAPA (anomalous L coronary Aa) most common actual cause of ischemia in infancy.



Just get an EKG in kids.  Usually negative, but sometimes you’ll catch a zebra.  Trop less useful…  Peds Cardiology call & fax for EKG questions.