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… http://www.mdcalc.com/heart-score-for-major-cardiac-events/ 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!

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