[PPT] - Emergency Medicine No nancial Topics disclosures David Duong, MD PowerPoint Presentation

SLIDE 1

Emergency Medicine Topics

David Duong, MD MS UCSF-SFGH Emergency Medicine Residency

UCSF Family Medicine Board Review Course

Tuesday, March 17, 15

No Þnancial disclosures

Tuesday, March 17, 15

Case #1

¥ 20-yo M with no PMHx presenting

with non-radiating, pleuritic right sided chest pain starting about 5 hours ago while playing video games. transient sensation of palpitations. no

dyspnea. no leg swelling, denies

trauma.

¥ occasional TOB, remainder of history

unremarkable

Tuesday, March 17, 15

Case #1

¥ Exam is unremarkable except that

the patient is tachycardic and with decreased breath sounds on right.

¥ Pt is speaking comfortably, chest

wall non-tender

¥ CXR is obtained

20-yo M with CP

Tuesday, March 17, 15

SLIDE 2

Tuesday, March 17, 15

Case 1, Q #1

¥ Which of the following conditions is most

likely to be a precipitating factor for pneumothorax? a) COPD b) cigarette smoking c) marfan syndrome d) exertion e) Pneumocystis pneumonia

Tuesday, March 17, 15

Case 1, Q #1

¥ Which of the following conditions is most

likely to be a precipitating factor for pneumothorax? a) COPD b) cigarette smoking c) marfan syndrome d) exertion e) Pneumocystis pneumonia

Tuesday, March 17, 15

Pneumothorax

¥ Primary Spontaneous - occurring in

patients without underlying lung dz

¥ account for 2/3 of all PTX ¥ more common in tall, thin men,

20-40 years of age and SMOKERS

¥ 20:1 increased risk in smokers

Tuesday, March 17, 15

SLIDE 3

Other choices

¥ Marfans is a risk factor in primary

spontaneous PTX, but is not as strong a risk factor

¥ Exertion is not a risk factor ¥ COPD and PCP pneumonia are

important risk factors for secondary PTX, but are not as common as primary PTX

Tuesday, March 17, 15

Pneumothorax

¥ Secondary Spontaneous - occurring in

patients with existing underlying lung disease (COPD, PCP)

¥ PCP is the most common cause of

pneumothorax in HIV patients

Tuesday, March 17, 15

Traumatic Pneumothorax

¥ More common in penetrating trauma

(stab wound, gun shot wound) than blunt trauma (rib fractures)

¥ Includes iatrogenic PTX ¥ Transthoracic needle procedures

(thoracentesis, needle biopsies)

¥ Subclavian central lines

Tuesday, March 17, 15

Case 1, Q #2

¥ The nurse reports that this patient has become very

dyspneic and his blood pressure is now 80/50. His neck veins are distended. What is the next best course of action? a) 100% oxygen via non-rebreather b) immediate placement of a chest tube c) intubation d) needle thoracostomy e) normal saline 1000 cc IV bolus

Tuesday, March 17, 15

SLIDE 4

Case 1, Q #2

¥ The nurse reports that this patient has become very

dyspneic and his blood pressure is now 80/50. His neck veins are distended. What is the next best course of action? a) 100% oxygen via non-rebreather b) immediate placement of a chest tube c) intubation d) needle thoracostomy e) normal saline 1000 cc IV bolus

Tuesday, March 17, 15

Tension Pneumothorax

¥ Positive pressure from PTX reduces

venous return to the right heart, thus decreasing cardiac output

¥ PE: distended neck veins, tracheal

deviation (away from side of PTX), hypotension

¥ Immediate decompression required: 14

gauge needle - 2nd intercostal space, mid-clavicular line us return to the right hear easing cardiac output distended neck veins, trach ation (away from side of PT

tension

ediate decompression requ e needle - 2nd intercostal s

Tuesday, March 17, 15

Pneumothorax and Treatment

¥ High-Flow oxygen:

¥ promotes resorption of nitrogen-rich air in PTX ¥ appropriate as sole therapy in small (<15%), stable,

and atraumatic PTX

¥ Observation:

¥ for small, primary spontaneous PTX ¥ repeat CXR in 6 hours - if no change on CXR and

clinically, follow-up is ensured, and reassuring social situation -> may be discharged with another repeat CXR recommended in 12-48 hours.

Tuesday, March 17, 15

Pneumothorax and Treatment

¥ Needle thoracostomy:

¥ indicated in tension pneumothorax ¥ insert 14 gauge IV in 2nd intercostal space,

mid-clavicular line

¥ Tube Thoracostomy:

¥ for larger (>15%) spontaneous PTX and all

traumatic PTX

¥ chest tube is placed at 4th or 5th intercostal

space, mid-or anterior-axillary line

Tuesday, March 17, 15

SLIDE 5

Case # 2

¥ A 23-yo man presents holding both hands over his

right eye. He was playing basketball when another player hit him in the eye. He is able to cooperate with the examination and reports decreased vision. The BEST treatment option is: A) Carbonic Anhydrase Inhibitor B) Gentle pressure to reduce the eye C) Lateral canthotomy D) Ophthalmology outpatient follow-up next day E) Decongestant nasal sprays, oral antibiotics, and pain medications s s ov en en en en

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Tuesday, March 17, 15

Case # 2

¥ A 23-yo man presents holding both hands over his

right eye. He was playing basketball when another player hit him in the eye. He is able to cooperate with the examination and reports decreased vision. The BEST treatment option is: A) Carbonic Anhydrase Inhibitor B) Gentle pressure to reduce the eye C) Lateral canthotomy D) Ophthalmology outpatient follow-up next day E) Decongestant nasal sprays, oral antibiotics, and pain medications

Tuesday, March 17, 15

Retrobulbar hemorrhage

¥ caused by blood accumulation within the orbit with

transmission of pressure to the optic nerve and globe. This in turn leads to central retinal artery occlusion and optic nerve ischemia

¥ signs - acute proptosis, vision loss, decrease in ocular

movement, increased IOP

¥ irreversible vision loss occurs within 60 minutes ¥ the best DEFINITIVE treatment option is a lateral

canthotomy y y y blood accumu mu mu mula la la lati ti ti tion within the or

r

Tuesday, March 17, 15

Lateral Canthotomy

Tuesday, March 17, 15

SLIDE 6

Other selections

¥ CA inhibitor, mannitol, and topical beta-blocker

may be used to decreased IOP, but is not deÞnitive treatment

¥ Gentle pressure to reduce the eye would cause

more damage. This may be treatment for a globe luxation without suspicion of globe rupture.

¥ Ophthalmology consultation is necessary but since

vision loss can quickly ensue, next day followup is inappropriate.

Tuesday, March 17, 15

Other selections

¥ The most common orbital fracture is the inferior

wall blow-out fracture. There is communication with the ethmoid and maxillary sinuses in this fracture.

¥ Emergent ophthalmology consultation is needed if

there is diplopia, enophthalmos, or large fractures (>1/3 of the orbital ßoor).

¥ Treatment is avoidance of nose blowing, nasal

decongestants, +/- oral antibiotics, pain management and ophthalmology referral.

Tuesday, March 17, 15

Case #3

¥ A 40-yo M presents with cough, low-grade

fever, and myalgias for the past 3 to 4 days. Today he has severe, sharp pleuritic chest pain radiating to the left shoulder, worse when he is

supine. He smokes 1 ppd. BP 160/95, HR 110,

RR 18, T 37.2. The ECG shows:

Tuesday, March 17, 15

question 4

¥ Appropriate next steps include:

A) Aspirin 325 mg, morphine 2 mg IV, and admit to CCU B) Aspirin 325 mg, nitroglycerin SL x3, heparin bolus, activate cardiac cath team C) Ketorolac 30 mg IV, followed by ibuprofen 800 mg PO TID for 1 week as outpatient care D) Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, and admit to a monitored bed E) Metoprolol 5 mg IV, nitroglycerin IV infusion titrated to pain, and cardiology consultation

Tuesday, March 17, 15

SLIDE 7

question 4

¥ Appropriate next steps include:

A) Aspirin 325 mg, morphine 2 mg IV, and admit to CCU B) Aspirin 325 mg, nitroglycerin SL x3, heparin bolus, activate cardiac cath team

C) Ketorolac 30 mg IV, followed by ibuprofen 800 mg PO TID for 1 week as outpatient care

D) Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, and admit to a monitored bed E) Metoprolol 5 mg IV, nitroglycerin IV infusion titrated to pain, and cardiology consultation

Tuesday, March 17, 15

acute pericarditis

¥ typical ECG Þndings (Stage 1 - hours to

days): diffuse ST-segment elevation with a Òconcave upÓ pattern (except aVR and V1), PR interval depression (except aVR and V1)

Tuesday, March 17, 15

acute pericarditis

¥ Stage 2: ST and PR segments

normalize, but T waves ßatten

¥ Stage 3: deep symmetric T wave

inversion

¥ Stage 4: normalization, though T wave

inversions may be permanent

¥ Stage 2: ST and PR segments

normalize, but T waves ßatten

¥ Stage 3: deep symmetric T wave

inversion

¥ Stage 4: normalization, though T wav

inversions may be permanent

Tuesday, March 17, 15

acute pericarditis

¥ treatment includes NSAIDs,

hydration, and reassurance

¥ Patients with idiopathic pericarditis

who achieve reasonable pain control in the ED may be sent home with instructions for outpatient follow-up care.

Tuesday, March 17, 15

SLIDE 8

acute pericarditis

¥ vs. acute MI and BER

Tuesday, March 17, 15

ther choices

¥ In acute MI, ST segments correspond to

ischemic portions of the heart and typically have ST-segment depression in reciprocal leads.

¥ Although aspirin can be an effective

treatment in pericarditis, there is no indication for nitrates, anticoagulation, beta-blockers, or admission to a monitored setting. The tachycardia and hypertension are most likely secondary to pain.

Tuesday, March 17, 15

Case #4

¥ A 55-yo M with an unknown PMHx brought

in by ambulance with altered mentation. Dextrose stick was 100 mg/dL. He had a thready femoral pulse in the Þeld. The RN is having a hard time getting a BP and is trying

again. You cannot Þnd a femoral pulse and

you see this on the monitor:

¥

Tuesday, March 17, 15

question 5

¥ What is the next appropriate step in

the management of this patient? a) intubation b) epinephrine 1 mg IV c) magnesium 1-2 g IV d) cardioversion at 100 J monophasic e) deÞbrillation at 360 J monophasic

Tuesday, March 17, 15

SLIDE 9

question 5

¥ What is the next appropriate step in

the management of this patient? a) intubation b) epinephrine 1 mg IV c) magnesium 1-2 g IV d) cardioversion at 100 J monophasic e) deÞbrillation at 360 J monophasic

Tuesday, March 17, 15

Question 5

¥ Wide complex tachycardia + no pulse =

unstable ventricular tachycardia

¥ DeÞbrillation is the most apropriate

next step, above managing the airway

r giving pressors.

¥ Synchronized cardioversion is not

appropriate for an unstable patient

¥ Magnesium for torsades de pointes

Tuesday, March 17, 15

question #6

¥ After the initial deÞbrillation, what is

the next MOST appropriate step? a) start CPR, 2 minutes b) check for a pulse c) check the monitor, and administer another shock if needed d) administer epinephrine 1 mg IV

Tuesday, March 17, 15

question #6

¥ After the initial deÞbrillation, what is

the next MOST appropriate step? a) start CPR, 2 minutes b) check for a pulse c) check the monitor, and administer another shock if needed d) administer epinephrine 1 mg IV

Tuesday, March 17, 15

SLIDE 10

question #6

¥ 2005 and 2010 AHA/ACLS guidelines

emphasize uninterrupted chest compressions after deÞbrillation

¥ Only after CPR should a pulse and

monitor check be performed

¥ Giving epinephrine should not delay

resumption of CPR

Tuesday, March 17, 15

Ventricular Fibrillation Pulseless V-Tach

CABÕs deÞbrillation, immediate CPR, then check rhythm intubation, establish IV epinephrine 1 mg IV/IO every 3-5 minutes may substitute 1st or 2nd dose of epi with vasopressin 40 U IV/IO after 3 shocks/CPR, consider amiodarone 300 mg IV consider other drugs: lidocaine, magnesium Think of HÕs & TÕs Remember the order: shock - CPR - check - shock - CPR - check - drugs deÞbrillation, immediate CPR, then check rhythm intubation, establish IV

Tuesday, March 17, 15

Asystole & PEA

CABÕs initiate CPR early intubation, establish IV epinephrine 1 mg IV/IO every 3-5 minutes may substitute 1st

r 2nd dose of epi

with vasopressin 40 U IV/IO atropine REMOVED from asystole/PEA algorithm! no shocks, no pacing Think of HÕs & TÕs no shocks, no pacing Think of HÕs & TÕs initiate CPR early intubation, establish IV

Tuesday, March 17, 15

HÕs and TÕs

Hypovolemia Hypoxia Hydrogen Ions (acidosis) Hyperkalemia/ hypokalemia Hypoglycemia Hypothermia Toxins/Tablets Tamponade - cardiac Tension Pneumothorax Thrombosis (coronary or pulmonary) Trauma

Tuesday, March 17, 15

SLIDE 11

Case #5

¥ A 19-yo F with depression and multiple

suicide attempts presents to hospital 1 hour following an ingestion of 30 tablets of extra strength tylenol in a suicide attempt. She denies any EtOH or illicit drug use.

¥ Physical exam is unremarkable

Tuesday, March 17, 15

Case #5

The physician decides to administer activated charcoal.

19-yo F s/p OD of acetaminophen. VS and exam unremarkable

Tuesday, March 17, 15

Question #8

¥ Which of the following oral overdoses

will NOT beneÞt from activated charcoal administration? a) acetaminophen b) iron c) lorazepam d) levothyroxine

Tuesday, March 17, 15

Question #8

¥ Which of the following oral overdoses

will NOT beneÞt from activated charcoal administration? a) acetaminophen b) iron c) lorazepam d) levothyroxine

Tuesday, March 17, 15

SLIDE 12

Activated Charcoal

¥ Highly adsorbant, inert material made

from distilled wood pulp with a very large surface area that non- speciÞcally binds to many substances

¥ Decreases absorption by 75% if given

within 1 hour

¥ Do not give if patient cannot protect

their airway

Tuesday, March 17, 15

Activated Charcoal

Tuesday, March 17, 15

Question #9

¥ Activated charcoal is absolutely

contraindicated in the treatment of toxic ingestions of: a) caustics (acids/alkalis) b) any substance if milk was co-ingested or administered c) lithium d) heavy metals e) digitalis

Tuesday, March 17, 15

Question #9

¥ Activated charcoal is absolutely

contraindicated in the treatment of toxic ingestions of: a) caustics (acids/alkalis) b) any substance if milk was co-ingested or administered c) lithium d) heavy metals e) digitalis

Tuesday, March 17, 15

SLIDE 13

Question #9

¥ The only absolute contraindication to the

use of AC is ingestion of acids/alkalis. AC does not absorb these well and ineffective in preventing tissue damage.

¥ AC interferes with subsequent endoscopy

and may cause vomiting as well as further caustic injury to the esophagus and upper airway.

¥ Although it doesnÕt work in Li and heavy

metals, it is not contraindicated.

Tuesday, March 17, 15

Question #10

If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal? a) You cannot force the patient to take charcoal b) You must wait to get parental permission prior to treating her c) A court injunction is needed to force her to drink the charcoal d) After repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment e) Refusal to take charcoal orally is an indication for IV charcoal

Tuesday, March 17, 15

Question #10

If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal? a) You cannot force the patient to take charcoal b) You must wait to get parental permission prior to treating her c) A court injunction is needed to force her to drink the charcoal d) After repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment e) Refusal to take charcoal orally is an indication for IV charcoal

Tuesday, March 17, 15

Question #10

¥ Suicidal patients do not have the right

to refuse potentially life-saving care. Physicians may do what they need to do in an effort to save the patient. In emergencies, parental permission for treatment is unnecessary.

¥ Charcoal is not used IV.

Tuesday, March 17, 15

SLIDE 14

Case #5

ECG was unremarkable urine pregnancy test negative chemistry and LFTÕs unremarkable

acetaminophen level 175 micrograms/mL

19-yo F s/p OD of acetaminophen. VS and exam unremarkable

Tuesday, March 17, 15

Question #11

¥ Which of the following statements about

acetaminophen ingestion is TRUE? a) serial LFTs are indicated in all acetaminophen ingestions b) renal sequelae are expected c) IV N-acetylcysteine (NAC) is safer than

ral NAC

d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy

Tuesday, March 17, 15

Question #11

¥ Which of the following statements about

acetaminophen ingestion is TRUE? a) serial LFTs are indicated in all acetaminophen ingestions b) renal sequelae are expected c) IV N-acetylcysteine (NAC) is safer than

ral NAC

d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy

Tuesday, March 17, 15

Acetaminophen toxicity

¥ An acetaminophen level drawn at

hours 4-20 can be plotted on the Rumack-Matthew nomogram to guide therapy based on hepatic (not renal) toxicity. he be ew n en level drawn at e plotted on the w nomogram to guide n hepatic (not renal)

Tuesday, March 17, 15

SLIDE 15

ther choices

¥ Liver function tests are not indicated

for trivial acetaminophen ingestions, but may be useful in severe ingestions.

¥ One potential side effect of IV NAC is

an anaphylactoid reaction.

Tuesday, March 17, 15

Case #6

A 32-yo man presents 30 minutes after getting a tooth knocked out in a Þght. On examination, a small clot in the socket is noted. The next step in management is: A) Call the patientÕs dentist B) Clean the tooth with a brush C) Gently irrigate the socket D) Immediately replace the tooth E) Tell the patient the tooth cannot be reimplanted

Tuesday, March 17, 15

Case #6

A 32-yo man presents 30 minutes after getting a tooth knocked out in a Þght. On examination, a small clot in the socket is noted. The next step in management is: A) Call the patientÕs dentist B) Clean the tooth with a brush C) Gently irrigate the socket D) Immediately replace the tooth E) Tell the patient the tooth cannot be reimplanted

Tuesday, March 17, 15

Question 12

The patient has an avulsion injury and the tooth should be reimplantated. Although little preparation is needed to ready the socket for reimplantation, clots should be removed with gentle irrigation with NS, though there should be as little manipulation of the socket as possible.

Tuesday, March 17, 15

SLIDE 16

ther selections

¥ Reimplantation is possible within 2 to 3 hours ¥ The avulsed tooth should be rinsed with sterile

NS or tap water to remove debris before implantation

¥ The avulsed tooth should not be scrubbed as this

may injure the periodontal ligament, which might still be attached to the tooth.

¥ early improper tooth reimplantation holds a

higher success rate for tooth salvage than delayed reimplantation resulting in waiting for an oral surgeon

Tuesday, March 17, 15

Tooth avulsion

Tuesday, March 17, 15

Tooth avulsions

1. Where is the tooth?
2. How old is the patient?
3. How long has the tooth been out?

(periodontal ligament cells die within 60 minutes outside the oral cavity)

4. Is there other signiÞcant

maxillofacial trauma?

Tuesday, March 17, 15

Case #7

A 24-yo woman presents with diffuse tongue swelling and hoarse voice that began shortly before arrival. Now she is drooling, dyspneic, and can barely talk. She has hypertension and is on lisinopril and

hydrochlorothiazide. She has not eaten new

foods, used any new toiletries, clothing, or medications.

Tuesday, March 17, 15

SLIDE 17

Question 13

¥ Which of the following medications would be

most efÞcacious to treat this condition?

A) Cetirizine B) Diphenhydramine C) Epinephrine D) Methylprednisolone E) Solumedrol

Tuesday, March 17, 15

Question 13

¥ Which of the following medications would be

most efÞcacious to treat this condition?

A) Cetirizine B) Diphenhydramine C) Epinephrine D) Methylprednisolone E) Solumedrol

Tuesday, March 17, 15

Angioedema

¥ Severe allergic reactions range from urticaria to

angioedema to anaphylaxis.

¥ In this patient with airway compromise from

angioedema, intramuscular epinephrine is indicated.

¥ Epinephrine-induced catecholamine release

causes vasoconstriction to reduce periglottic edema and improve patency.

¥ It also increases systemic vascular resistance

to maintain blood pressure in anaphylactic shock.

Tuesday, March 17, 15

Angioedema

¥ Angioedema is an allergic reaction involving the

dermis and presents as nonpruritic edema of the submucosa (tongue, lips, face)

¥ Have a high degree of suspicion for airway

compromise, consider laryngoscopic evaluation

¥ Treatment is same for urticaria, but consider IM

epinephrine (0.3-0.5 cc of 1:1000) for impending airway compromise and early airway protection with intubation with intraoral, pharyngeal, and lingual involvement gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gioe

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vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi vi v ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng ng t t t t t t t t rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rm rmis is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is is a a a a a a a a a a a a a a and nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p pre re re re re re re re re re re re re re re re re re re re re re re re re re re re re re re re rese se se se se se se se se se se se se se se se se se se se se se se se se se se se sent nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nts s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as as n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n non

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Tuesday, March 17, 15

SLIDE 18

Urticaria

¥ Urticaria is an allergic reaction involving the

epidermis and presents with pruritic, erythematous, raised wheals of the skin.

¥ Treatment is mainly supportive ¥ removing the offending agent, cold compresses ¥ H1 blockade/antihistamines ¥ H2 blockers added for severe or refractory sx ¥ corticosteroids for severe or refractory sx (use

short course)

Tuesday, March 17, 15

Anaphylaxis

¥ A severe systemic hypersensitivity reaction

characterized by multisystem involvement, manifested by hypotension or airway compromise

¥ Look for bronchospasm, voice changes and stridor

from laryngeal edema, drooling

¥ Treatment is same as urticaria/angioedema, but also

consider:

¥ intubation for unstable patients, pressors ¥ usual ACLS resuscitation

Tuesday, March 17, 15

¥ A 22-yo M presents with a Òspider bite,Ó after

he was cleaning his garage. He developed crampy muscle aches that spread up his arm

initially. Now he has abdominal cramping,

nausea, and dizziness. He has a rigid abdomen

n your exam. Which of the following is the

likely culprit? a) tarantula d) wolf spider b) hobo spider e) black widow spider c) brown recluse spider

Case #8

Tuesday, March 17, 15

¥ A 22-yo M presents with a Òspider bite,Ó after

he was cleaning his garage. He developed crampy muscle aches that spread up his arm

initially. Now he has abdominal cramping,

nausea, and dizziness. He has a rigid abdomen

n your exam. Which of the following is the

likely culprit? a) tarantula d) wolf spider b) hobo spider e) black widow spider c) brown recluse spider

Case #8

Tuesday, March 17, 15

SLIDE 19

Spider bites

¥ Black widow spiders ¥ Classically present with an initial

pinprick sensation followed by a mild local inßammatory response (<1 hr)

¥ Then crampy mylagias at the bite site

and spread up the extremity

¥ Myalgias eventually involve the entire

body; patient may present with a rigid abdomen which is difÞcult to differentiate clinically from peritonitis

Tuesday, March 17, 15

Black widow

¥ Treatment is

supportive

¥ Opioids and BZs for

pain and muscle spasms

¥ Ca-gluconate found

NOT to be effective

¥ Antivenom may be an

ption in severe cases

Tuesday, March 17, 15

Brown Recluse

¥ Classically causes

dermal necrosis and black eschars, which are self-limited

¥ Rarely causes DIC

and hemolysis

¥ Treatment is

supportive

Tuesday, March 17, 15

Case #9

¥ A 20-yo M with no PMHx comes to your

fÞce after being bitten on his left forearm

by his neighborÕs cat only 2 hours ago. There is no bleeding, no swelling, and the patient is neurovascularly intact.

Tuesday, March 17, 15

SLIDE 20

question #15

¥ Which of the following statements regarding

bite wounds is correct? a) Cat bites are most commonly polymicrobial b) Cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound c) Mammal bites are not tetanus-prone wounds d) Only 5-6% of dog bites ultimately become infected

Tuesday, March 17, 15

question #15

¥ Which of the following statements regarding

bite wounds is correct? a) Cat bites are most commonly polymicrobial b) Cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound c) Mammal bites are not tetanus-prone wounds d) Only 5-6% of dog bites ultimately become infected

Tuesday, March 17, 15

question 15

¥ Most dog bite infections are polymicrobial

and may involve Pasturella, but not usually multocida. Only 5-6% of dog bites become infected (about the same for nonbite lacerations).

¥ EXCEPT for wounds involving the hand

and high-risk patients

¥ Cat bites become infected 60-80% of the

time and thought to be related to virulent strains of P. multocida.

Tuesday, March 17, 15

Mammalian Bites Principles

¥ Assess for life-threatening bites (vascular,

bites on the neck)

¥ Examine for joint & tendon involvement ¥ Emphasis on wound cleaning ¥ XRs if foreign body is suspected ¥ DonÕt close hand/foot bites, puncture-type

bites, bites >6 hrs, & contaminated wounds

Tuesday, March 17, 15

SLIDE 21

Dog Bites

¥ Uncomplicated dog bites do not routinely

need prophylactic antibiotics

¥ EXCEPTION: patient is immuno-

compromised (EtOH liver dz, asplenia, chronic corticosteroid use)

¥ risk of sepsis from C. canimorsus (with

gangrene, purpura, petechiae)

Tuesday, March 17, 15

Dog Bites

¥ amoxicillin/clavulanate for 5-7 days ¥ alternatives: ßuroquinolone

(moxißoxacin), doxycycline

¥ tetanus toxoid

Tuesday, March 17, 15

Cat Bites

¥ All cat bites should receive prophylactic

antibiotics

¥ amox/clavulanate for 5-7 days ¥ PCN, amoxicillin, cefuroxime,

doxycycline will cover P. multocida

Tuesday, March 17, 15

Human Bites

¥ Treat all human bites as contaminated

puncture wounds

¥ Usually polymicrobial (Staph and

Strep species, Eikenella corrodens, anaerobes)

¥ treatment of choice is amox/

clavulanate

Tuesday, March 17, 15

SLIDE 22

Case #10

¥ What is the total body surface area (TBSA) of

a man who presents with blistered burns of the anterior halves of both his thighs and legs after spilling scalding water? a) 9% b) 18% c) 27% d) 36%

Tuesday, March 17, 15

Case #10

¥ What is the total body surface area (TBSA) of

a man who presents with blistered burns of the anterior halves of both his thighs and legs after spilling scalding water? a) 9% b) 18% c) 27% d) 36%

Tuesday, March 17, 15

Rule of Nines

¥ Head - 9% ¥ Chest - 18% ¥ Back - 18% ¥ Each Leg - 18% ¥ Each Arm - 9% ¥ Perineum, Palm - 1%

Tuesday, March 17, 15

burns classiÞcation

¥ SuperÞcial ¥ 1st degree ¥ only involves the

epidermis

¥ local pain and

erythma

¥ no blistering ¥ heals without

scarring

¥ Partial Thickness ¥ 2nd degree ¥ involves dermis

and epidermis

Tuesday, March 17, 15

SLIDE 23

Partial Thickness Burn

¥ SuperÞcial Partial ¥ blisters, blanches,

scarring risk low

¥ Deep Partial ¥ blisters, no

blanching, scarring risk high

Tuesday, March 17, 15

Third degree burn

¥ involves all layers of

skin (may involve muscle and bone)

¥ painless ¥ variable color, dry ¥ do not heal

Tuesday, March 17, 15

Indications for Burn Unit Admission

¥ Burns of face, hand, feet, genitalia,

perineum, major joints

¥ Electrical burns ¥ Chemical burns with potential for cosmetic/

functional impairment

¥ SigniÞcant inhalation injury ¥ Co-morbid disease ¥ Partial thickness burns >10% TBSA ¥ Full thickness burns in any age group

Tuesday, March 17, 15

Parkland Formula

Tuesday, March 17, 15

SLIDE 24

Pearls in Burn Cases

¥ Consider carbon monoxide poisoning ¥ Look for singed nasal hairs,

carbonaceous sputum, and facial burns as markers for potential airway edema and obstruction

¥ Look for circumferential burns ¥ Prophylactic Abx are not indicated in

burns

Tuesday, March 17, 15

Case 11

13-yo with no PMHx accompanied with Dad, presenting with left thigh pain for 1 week starting 1 day after football practice. He used Òicy-hotÓ with no relief. It hurts mainly to run. exam - obese. nl abdominal and GU exam. left groin is tender with decreased and painful internal ROM of the hip. + antalgic gait. thigh & knee exam WNL. an n ra rts nied with Dad, for 1 week

actice. He used

ts mainly to run.

Tuesday, March 17, 15

Case 11

Tuesday, March 17, 15

Case 11

Tuesday, March 17, 15

SLIDE 25

Case 11

¥ Which of the following is the most common

adolescent hip disorder? a) Osgood-Schlatter b) Hip fracture c) Septic arthritis d) Growing pains e) Slipped Capital Femoral Epiphysis

Tuesday, March 17, 15

Case 11

¥ Which of the following is the most common

adolescent hip disorder? a) Osgood-Schlatter b) Hip fracture c) Septic arthritis d) Growing pains e) Slipped Capital Femoral Epiphysis

Tuesday, March 17, 15

SCFE

¥ Most common adolescent hip disorder ¥ Risk factors: obesity, male, black/

hispanic

¥ Obtain AP and frog-leg OR cross-table

lateral XRs - look for KlineÕs lines.

¥ Non-weight bearing and surgical

intervention as soon as recognized to prevent avascular necrosis

Tuesday, March 17, 15 Tuesday, March 17, 15

SLIDE 26

KleinÕs lines

Tuesday, March 17, 15

¥ Pneumothorax ¥ Orbital Trauma ¥ Pericarditis ¥ Unstable VTach/VFib ¥ AC & Acetaminophen Toxicity

Summary

Tuesday, March 17, 15

¥ Tooth Avulsion ¥ Angioedema/Anaphylaxis ¥ Spider & Mammalian Bites ¥ Burns ¥ SCFE

Tuesday, March 17, 15

Thanks for your attention!

Good Luck on the Boards!

Tuesday, March 17, 15