Wednesday Lectures, 8/26/2015 – ENT

TTHM a3.1 HEENT Day (8/26)

10a ~ Dental (Biondich) ~ 32 teeth, good to know terminology for consultants
Temperature sensitivity often precedes pain in dental caries
Pulpitis ~ infection to pulp chamber can precipitate rapid septicemia
Periapical abscess can be drained to relieve, associated c tooth injury or decay
Different kinds of abscesses… Gingival, Periodontal, Pericoronal (wisdom tooth), Combined…
Dental Blocks helpful for drainage ~ see Roberts & Hedges (or Google/YouTube)
Have suction going… they smell/taste bad & bleed some, don’t torture them.
Rinse well & home with mouthwash, consider Abx, depending on severity & tooth involvement…
Deep space infections ~ periapical infections can spread along maxilla or mandible, especially in immunocompromised hosts.
Ludwigs Angina ~ sublingual infection c tongue elevation ~ dangerous infection! can involve epiglottis, can be associated c trismus.
Vincent’s Disease/”Trench Mouth” ~ Pain to gums/Ulcerated dental papillae/Bleeding of gums, can become septic, not well understood, but opportunistic infxn common in WW1? Mainly anaerobic bacteria
Traumatic Dental injuries ~ 70% are maxillary central incisors: Ellis 1,2,3 & Alveolar Frxs
Ellis Class III should consider oral Abx, especially if capped with dental cement.
Dental box has dental cement, or even consider *dermabond & N95 mask wire splint!
Avulsion ~ tooth is out. Can potentially be reimplanted & splinted to next teeth?
!!! missing teeth can be subluxed into gums or aspirated or swallowed…
Baby teeth mixed from 6-12 yo, don’t reimplant dt risk to permanent teeth.

1030 ~ Acute Vision Loss (Prince)
Good eye exam: Funduscopic exam, Tetracaine & Fluorescein/Woods, Acuity Chart,
Visual Fields!, Slit Lamp, IOP Tonopen, perilimbic sparing?
*Acute Closed Angle Glaucoma ~ Fixed midposition pupil c conjunctival injection, treat c timolol, acetazolamide, pilocarpine… & Ophtho consult! CRAO v CRVO are emergencies ~ Stroke Code. Flashers & floaters c vision loss can be vitreous or retinal detachment (avg age 55)
Vitreous Hemorrhage, GCA/Temporal Arteritis, Venous Sinus Thrombosis, blurry vision occipital tract CVA…

11a ~ Small Groups (Lavoie)
Epistaxis & rhino rockets, LET…

1130 ~ Small Groups 2 (Rodney)
Epiglottitis Cric Case ~ tends to be fulminant
Lateral XR concerns, thumbprint sign, HFlu & SPneumo cover c Abx!
Airway Anticipation!!! Consider Atropine for secretions if using Ketamine…
While watching the airway, also consider the sats & pulse.

1230 ~ ICARE (Vince Calleo)
Review & Remind, keep expectations low & performance high (overshoot not undershoot)

1p ~ Jr/Sr Session (Lavoie)
Ear Hematomas get drained, elliptical, then packed & ENT follow-up
Ear Block is approximate diamond field block. Center is innervated separately by vagus.
Which NOT to fix? lid edge or medial canthus possibly involving canaliculi/ducts. leave the lid?
Risky wounds need Ophtho follow-up & repair… Home c erythromycin.
Parotitis ~ stensons gland, vs submandibular whartons duct… often a stone.
Lemon drops ~ sialogogue. Abx if fever or purulent, for oral flora… Augmentin/Clinda…
PCN great for strep, but not great anaerobic coverage… warm compresses & followup.
Dental Blocks ~ Infraorbital (Maxillary anterior) & Superior Alveolar branches (local, Maxillary posterior), Inferior Alveolar (Mandible) & Mental (Anterior Mandible)
If it goes to the neck, strongly consider imaging!

130 ~ Nose (Lavoie) ~ Epistaxis
Sphenopalatine Artery is potential more brisk posterior source
Posterior bleed avg age ~67 yo.
>90% anterior, Silver nitrate cautery can help but never do both sides at once!
LET & rhino rockets handy.
Surgicel handy for those pts who may be anticoagulated (hemostatic pad).
Take out within 3 days, & consider Abx for extended course dt TSS risk!?!
Foley for posterior packing needs ADM dt risks for complications.

2p ~ Ears (Pipas)
Anatomy: Tragus & Helix
Cerumen Removal ~ Cerumenolytics at home, Irrigation in ED c VasCath, or direct manual removal. potentially c eardrops for after…
Staph > Pseudomonas for Otitis Externa… CiproDex
Malignant Otitis Externa 98% Pseudomonas, mostly in immunocompromised.

230 ~ Eyes (Rodriguez)
DDx Red Eye… many things.
Anatomy & Terms: Blepharitis, Episcleritis, Keratitis, Uveitis, Endophthalmitis…
Vital Sign of the Eye: Visual Acuity
Limbic involvement is concerning for uveal involvement!
EOM important for limitation of movement or pain!
Hypopion = Bad. ~Uveitis
Dacrocystitis ~ Duct obstruction. ~ Abx & warm compresses.
Blepharitis ~ leads to hordoleum, chalazion… inflammation of sebaceous gland of eyelid
Chalazion ~ Chronic, Hordoleum/Stye ~ Acute.
Lid involved in Hordeolum, vs chalazion usually noninfectious, less painful, can become infected.
Viral Conjunctivitis ~ Incubation ~9 days, Infection for 2 weeks…
Bacterial Conjunctivitis ~ best treated c PolyTrim (vs Gent has more side effects). Polymixin actually does have some Pseudomonal coverage.
Cells & Flare ~ as sunlight angled through a window slat courses through dust.
~Dr. Cherrington, class poet
Periorbital Cellulitis usually appear nontoxic, still get Abx for cellulitis.
CT if in doubt for Orbital Cellulitis, which would need IV Abx & ADM.
HSV ~ Vesicles around the eye ~ keratitis c fluorescein ~ dendrites c terminal bulbs
VZV ~ Ramsey Hunt & Hutchinsons ~ pseudodendrites by fluorescein
Topical & Oral Antivirals, cycloplegics, ophtho consult & pain ctrl! …No steroids.
Both can have post herpetic neuralgia!

3p ~ Sinusitis (Rossettie) ~ see my presentation ūüėČ


Wednesday Lectures – 8/19/2015 (Alternate Week)

10a ~ PDR (Paolo)
*CTAs for PE ~ false positives? ~25%! but outcomes not improving with enhanced diagnostics.
*Low risk chest pain ~ Newman @ NY ACEP, “low risk to patient, high risk to provider”… HEART score, TIMI… Medicolegal concerns lead to admissions in 30% of CP admits.
*CAP in VA patients get Abx but rarely bacterial etiology. What is PNA gold standard? CXR? uncertain… Staph PNA tends to follow influenza PNA. Rhino, Influenza, metapneumovirus most common causes > bacteria. …but CXR not useful in immunocompromised, AIDS, etc.
*Abx for URIs ~ why? because it’s easy.
Nasopharyngitis, pharyngitis, sinusitis, acute bronchitis, URI, laryngitis, tonsillitis… …NONBACTERIAL & DON’T NEED ABX.
*Contrast Allergy reduced by 13,7,1 hour steroid course!?

11a ~ PSQ (Haswell/Shaw)
Fishbone Diagrams…
Syncope, ‘98% benign, 2% fatal’
NYS is highly litigious & M&M type discussion poorly protected, although limited QI protections.
We do have SANE order set at UH, but may be more limited resources in community hospitals.
PEP has potential kidney & liver side effects (~2%) & pts get 5 day supply to follow-up CARE clinic.

1pm ~ Jeopardy of Ultrasound (Nicholas)

2pm ~ Low Risk CP, Journal Club (Walker)
*CP dispo largely dependent on follow-up availability (i.e: better at St. Joes)
*Blunt trauma US/exam vs CT? reevaluation can be as good, roughly? Sensitivity much less with CUST Clinical/US tracking compared to CT (77% v 97% Sn?!)

3pm ~ TLLT Clinical Controversy (Finch)
“Backboards are useful to stabilize vertebral fractures”? 1966 Geisler et al. 2 pts set protocol, dt 2 bad paralysis outcomes! Bad outcomes c backboards? Yes ~ pain, can be caused by backboard, leading to additional tests?! Unnecessary CTs?! 97% of cspine XR are negative… can cause airway compromise & ETT difficulties! Supine restrained positioning causes reduced tidal volume, increases aspiration risks… Pressure sores more likely… ICP concerns with collar, flat supine, maybe backboard association? On scene delays? c bleeds needing SG.
*”NO ROLE” for Cspine immobilization in penetrating trauma…
Backboards no longer for “spinal immobilization”. They are extrication devices, not transport devices!? Backboards NOT to be used for transfers!
New NYS Protocol Update!!! Oct 31…
Ccollars still in place, but backboards minimized now.

330p ~ TLLT Topic Marathon Medicine (Finch)
2014 there were >1200 US marathons c >550,000 finishers.
Knee injuries greater in road races, Ankle injuries more common in track
Cramps & pain ~ single muscle ~ assisted walking…
Repeat cramping ~ electrolyte problem ~ hypokalemia, dyshydration ~ IVF, benzos, Mag???
Chafing & blistering not uncommon.
GI complaints in >50% of runners… often artificially guiac positive dt demand ischemia?
Case reports of cecal volvulus in marathon runners, 25-35yo?
Troponins will likely be artificially elevated dt physiologic muscle breakdown.
Sudden drop, check pulse as per BLS, ACLS…
Get glucose & core temp! Then EKG & electrolytes!

Program Director’s Rounds: Articles for 8/19/2015

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults
Seema Jain, M.D.,et al
N Engl J Med 2015; 373:415-427
July 30, 2015
DOI: 10.1056/NEJMoa1500245
Full text at NEJM

Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission.

Weinstock MB et al
JAMA Intern Med.
2015 Jul 1;175(7):1207-12.
doi: 10.1001/jamainternmed.2015.1674.
Full text at JAMA

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates.

Brooker JA et al
Acad Emerg Med.
2015 Jul;22(7):883-6.
doi: 10.1111/acem.12708.
Epub 2015 Jun 26.
Full text through Upstate library

Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography.
Hutchinson BD et al
AJR Am J Roentgenol.
2015 Aug;205(2):271-7.
doi: 10.2214/AJR.14.13938.
Full text through library at AJR Online

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study.
Jones BE et al
Ann Intern Med.
2015 Jul 21;163(2):73-80.
doi: 10.7326/M14-1933.
Full text through library at Annals of Internal Medicine

Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT.

Mervak BM et al
AJR Am J Roentgenol.
2015 Jul;205(1):77-84.
doi: 10.2214/AJR.14.13810.
Full text through library at AJR Online

Wednesday Lectures, 8/12/2015: Shock Day

TTHM a2.3 Shock Day   Tintinalli 25, 26, 28, 29, 30, 31, 32, 33, 34, 54, 146.


12p ~ Board Review (Cantor)

Congenital heart lesions, Clonidine Toxicity, bilious kid <3mo ~ malro/volvulus, constipation with empty rectal vault consider Hirschsprung, clostridium botulinum, laryngomalacia in kids, HF tox treat c Ca gluconate, HUS c ecoli bad beef, sickle cell splenic crisis, organophosphate poisoning with pralidoxime & atropine, ketamine preserves respiratory drive, packers v stuffers, ketamine at NMDA/glutamate antagonist like PCP,


130p ~ Acute Airway Management (Sarsfield)

Look externally, Evaluate 3-3-2, Mallampati, Obstruction/Obesity, Neck Mobility

Can we Ventilate? Can we Tube?  Always have BVM & Suction as backup!

Facial deformity may necessitate cric…


215p ~ RSI (Joslin)

Plan/Prepare/Protect Cspine (LEMON, Ccollar?, glidescope, bougie, shiley…)

Position, Preoxygenate, (SOAPME ~ Suction, O2, Airways, Pos, Mon/Meds, EtCO2/equipmt)

Pretreat meds to Induce (Etom, Ket, Propofol, Versed, consider Fentanyl, Atropine, Lidocaine),

Paralysis (Sux v Vec/Roc),

Placement & Proof (Direct Visualization, EtCO2, CXR)

PostIntubation Mgmt (Secure tube, Vent settings, Gtube, CXR, Resp Therapy, MICU)


245p ~ Hypovolemic Shock (Thurber) v Distributive, Cardiogenic, Obstructive…

Hemorrhagic & Nonhemorrhagic

Hemorrhagic includes Traumatic & NonTraumatic (GI, Coag, OB…)

NonHemorrhagic includes 3rd spacing & extracorporeal volume loss (dehydration)


3p ~ Early Shock in Peds (Cantor)

Babies shunt well so cap refill is important assessment measure.

Vasoactive & inflammatory factors, lactate… Tachycardia does happen in kids.

Recognize SIRS/Sepsis early & get IVF/Abx early!!! Get BldCxs, but don’t wait for LP!!!

Consider pressors & intubation early.

Holes & Blocks (LVO, AoSten, hypoplLV, Coarct, …>2wks) (ASD, VSD, canal, PDA, <10days)

5 Ts: TGA, TricAtr, TetFallot, TtPVR, Truncus (HippoEM)


Journal Club Articles for 8/19/2015

Journal Club articles (full texts are available in blackboard for residents and faculty):

Wednesday Lectures, 8/5/2015

TTHM a2.3 Abdominal Pain Day (Tint: 74, 82, 84, 85, 100, 124)

10a ~ Diverticulitis (Kloss)
preceded by diverticulosis, low residue diets? Seeds & grains NOT implicated. Microperforations in colon create inflamed area, possibly associated c abscess, obstruction, fistula… Abx first but may require surgical correction. Beware of “constipation” vs “fullness” sensation. Can go home with Abx in many cases, either Augmentin (after Zosyn dose in ED) or Cipro/Flagyl combo, after CT to r/o abscess or perf… Sepsis or poor follow-up or new onset may be good reasons to ADM…

1030 ~ Appy (Kloss)
Visceral Pain may be nonspecific, especially at first… Anorexia is most common associated Sx. Fever is a Late finding! Typically a disease of younger ppl, but does happen in elderly, who wait longer to present & get perforation, sepsis, higher M&M…

11a ~ Small Groups (Paolo/Prasad)
Cases: SBO, Mesenteric Ischemia, AAA, Sepsis,
Rigler Sign ~ Pneumatosis Intestinalis, needs Gen SG for removal of ischemic gut. Lower rectal temp = bad. Normally rectal ~1*F higher than oral. Mesenteric Ischemia mortality 60 to 80% acutely! Nonocclusive mesenteric ischemia well correlated with digoxin use. Intestinal Angina can occur with pain after eating.
SIM: 80M emesis abd pain, hx clots & afib, SIGMOID VOLVULUS! with ischemia & Sepsis, esp in RN home pts… AXR not sensitive but may be specific/helpful in very old & very young.

1230 ~ Jr/Sr (Cantor/Prasad)
Palpable BG ~ Pancreatic CA… Courvoisiers Sign…
Grey Turner Sign, Cullen Sign.

2p ~ Female Abd Pain (Sarsfield)
Pregnancy, TOA, Ovarian Torsion, Ectopic…

230p ~ Neonatal Abdominal Emergencies (Greenfield)
Volvulus 1/6000, Malrotation 1/600, Gastroschisis, Omphalocele, Pyloric Stenosis…
Volvulus: Upper GI series > Double Bubble AXR.
Intussusception… Can be absorption/electrolyte issues.

3p ~ Abd Pain in Children (Thabet)
DDx based on age… Cases: 8yo M colicky abd pain ~ Functional Constipation Criteria…
Miralax/PEG works well.