![]() Change in Mental Status and Abnormal Laughter
![]() Abdominal Pain in Pt who has MS and Drinks Everyday
![]() Change in Mental Status
![]() Pupura on Ears of Pt
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![]() Actively Seizing Patient
Patient with hx of Sz who presents after Sz
New Onset Seizure Pt
![]() 1. Infectious disease still is a large contributor to morbidity and mortality in developing countries, but cancers and heart disease are on the rise. 2. In a resource challenged environment, efforts should focus on empiric treatment when confirmatory diagnostic testing is unavailable. 3. In addition to malaria, consider dengue fever in your differential for fever in the returned traveler. Management is supportive care. 4. Mortality remains high for pediatric congenital heart disease in a large portion of the world where surgical intervention is unavailable. 5. Always confirm the location of a newly-diagnosed pregnancy and be aware of the complications and risks involved in post-partum ABDOMINAL pregnancy. ![]() -NPH is a potentially reversible cause of dementia and early intervention can be life-changing for patients -The terms hydrocephalus and vetriculomegaly are not synonymous. All patients with NPH should have enlarged ventricles, not all elderly patients with enlarged ventricles have NPH. -Emergency department management should focus on maintaining a broad differential and managing post-shunt complications. ![]() 3 Major “can’t miss” causes of AFib · Acute myocardial infarction · Congestive heart failure · Pulmonary embolus Other common causes of AFib · Thyrotoxicosis · Hypertensive crisis · Valvular disease · Hypokalemia/Hypomagnesaemia · Drugs e.g. sympathomimetics · Pericardial disease · Cardiomyopathies · Pheochromocytoma · “Holiday heart” - too much ETOH Treatment of AF in the ED Unstable · Emergency Direct Current Cardioversion (DCC) o Biphasic 120J -200J o Pads in the AP position · Reasons DCC may not work o Underlying illness – CHF, thyrotoxicosis, valvular disease o Dilated left atrium o Longer duration of atrial fibrillation o Too low energy · Meds: o Suspicion for accessory pathway, consider one of the following: - Procainamide - Ibutilide - Amiodarone o No suspicion for accessory pathway, consider one of the following: - Ibutilide - Diltiazem - Magnesium - Amiodarone - Procainamide Stable Start with rate control then consider disposition · Rate control o Calcium Channel Blockers – 1st line treatment - Diltiazem - 0.25 mg/kg IV over two minutes then 0.35 mg/kg IV over two minutes, if there is no response at 15 minutes - Veramamil - 2.5-5.0 mg over 2-3 minutes, then 5-10 mg in 15-30 minutes if necessary ± drip 5 mg/h o β-blockers – good in increased adregnergic states - Metoprolol - 5 mg IV every 5 minutes up to 15 mg - Esmolol - 500 mcg/kg IV bolus over 1 minute followed by a 50-200 mcg/kg/min IV infusion. Repeat cycle and increase drip if no effect o Cardiac Glycosides – not used as monotherapy anymore - Digoxin - Load 0.5 mg IV repeat 0.25 mg every 4-6 hours for three doses o Class III Antiarrythmic – beware of unintended rhythm control - Amiodarone - 150 mg IV over 10 minutes followed by infusion of 1 g over six hours. May repeat bolus if needed o Magnesium Sulfate - beware of unintended rhythm control - MgSO4 - 2 g bolus over 10-15 minutes followed by 1 g/h infusion Disposition - “Elective” Cardioversion in the ED “Pro-ED Converters” o Safe if arrhythmia present for <48h and studies show that patients can reliably tell when their symptoms began (i.e within 48h or not) o Cardioversion – electrical, pharmacologic or spontaneous – of patients with recent onset atrial fibrillation carries a less than 1% embolism risk if performed within the first 48h of symptom onset o Early conversion ↓ need for anticoagulation o Many patients discharged means ↓ costs “Anti-ED Converters” o Risk of thromboembolism too great o Patients need heparin prior to cardioversion o New onset AFib patients need a complete diagnostic workup o Use of chemical agents requires prolonged observation in ED after successful cardioversion. o Shouldn’t risk conversion agents or electricity when 40-71% convert spontaneously in the first 24h Rhythm Control (a.k.a. Cardioversion) · Direct Current Cardioversion is the traditional Gold Standard o 90% to 100% acute success rate o IV/O2/Monitor/Sedation o Propofol/Fentanyl or Fentanyl/Versed o Airway Equipment o Defib pads in the AP position · Chemical Cardioversion o Class IA Antiarrythmic - Procainamide - 100 mg IV q 5-10 minutes to maximum of 1000 mg, or 20 mg/kg IV infusion to a maximum of 20 mg/kg o Class IC Antiarrythmic – “Pill in the Pocket Technique” - Flecanaide – 2 mg/kg IV over 10 minutes, or 300 mg PO x1 - Conversion rate 60-70% at 3 hours - 91% at eight hours - Propafenone - 2 mg/kg IV over 10 minutes, or 600 mg PO x1 - Conversion rate up to 76% at 8 hours o Class III Antiarrythmic - Ibutilide - 0.01 mg/kg IV over 10 minutes (max 1 mg), may Repeat times 1 if no response after 10 minutes. - Cardioversion 33-45% in first 70 min - Risk of torsades as high as 8% Ottawa Aggressive Protocol for emergency department patients with recent-onset atrial fibrillation 1. Assessment · Stable without ischemia, hypotension or acute CHF? · Onset clear and less than 48 hours? · Severity of symptoms? · Previous episodes and treatments? · Anticoagulated with warfarin and INR therapeutic? 2. Rate control · If highly symptomatic or not planning to convert · Diltiazem IV (0.25 mg/kg over 10 min; repeat at 0.35 mg/kg) · Metoprolol IV (5 mg doses every 15 min) 3. Pharmacologic cardioversion · Procainamide IV (1 g IV over 60 min; hold if blood pressure < 10 mm Hg) 4. Electrical cardioversion · Consider keeping patient NPO × 6 h · Procedural sedation and analgesia given by emergency physician (propofol IV and fentanyl IV) · Start at 150–200 J biphasic synchronized* · Use anterior–posterior pads, especially if not responding 5. Anticoagulation · Usually no heparin or warfarin for most patients if onset clearly < 48 h or if therapeutic INR for > 3 wk 6. Disposition · Home within 1 h after cardioversion · Usually no antiarrhythmic prophylaxis or anticoagulation given · Arrange outpatient echocardiography if first episode · Cardiology follow-up if first episode or frequent episodes 7. Patients not treated with cardioversion · Achieve rate control with diltiazem IV (target heart rate < 100 beats/min) · Discharge home on diltiazem (or metoprolol) · Discharge home on warfarin and arrange INR monitoring · Arrange outpatient echocardiography · Follow-up with cardiology at 4 wk for elective cardioversion 8. Recommended additions to protocol · Consider transesophageal echocardiography if onset unclear · Alternate rhythm-control drugs: propafenone, vernakalant, amiodarone · If TEE-guided cardioversion > 48 h, start warfarin ![]() Thyrotoxicosis and Cardiomyopathy
![]() Hypercalcemia - Hypercalcemia relatively uncommon in the ED, but highly correlated with cancer and poor prognosis - 25% of cancer patients - 50% die within a month of hypercalcemia dx - Severe levels can be life threatening - Renal failure - Dysrhythmias - Coma - Death - Occurs due to increased bone resorption and release of calcium - Bony mets release cytokines that break down bone - Tumors secrete PTHrP and an active form of Vitamin D, causing bone breakdown - Who to suspect: - Elderly - Acute confusion/MS change - Unexplained weakness - History of cancer -- especially breast, lung, lymphoma, or multiple myeloma - What to look for: - Neuropsych, GI and MSK à vague symptoms - Evaluate with serum calcium (must account for serum albumin and correct) or ionized calcium - Consider the clinical context and order additional labs/tests as necessary, including EKG and CXR Treatment Mild
Moderate
Severe
- Pamidronate – 60-90 mg over 2-24 hrs
- >18mg/dL - Renal failure - CHF ![]() Anatomy - Internal carotid, sympathetic chain, IJ, cranial nerves - all pretty close in this small area Risks for PTA - smoking, bad teeth, chronic tonsillitis Complications - airway blockage, necrosis into carotid sheath, deep space infection, Lemierre's Syndrome Imaging Indications CT Scans should not be done routinely for PTA. PTA is primarily a clinical diagnosis. Consider Contrasted CT in: - toxic folks - immuncompromised - concern for deep space spread - Bilateral PTA (high extension rate) - uncertain diagnosis Ultrasound all PTA - Helps to improve diagnostic accuracy. - Helps to guide needle during aspiration. When to Consult - airway compromise - gas producing organism or air fluid levels - deep space infection - failure to respond in 48-72 hrs of IV anbx; - if meet indications for quinsy tonsillectomy (removal of tonsils while PTA is present) - Uncooperative patient - Pediatric patient - Recurrent tonsillitis or PTA - Severe trismus How to Drain 1. Apply anesthetic - 2 seconds of spray - hurricaine or cetacaine; atomize 4% lidocaine 2. Identify tonsil - use blood flow to help distinguish tonsil from abscess; Identify carotid 3. Supplies - need good lighting - bottom 1/2 of speculum or DL blade; - needle - 18 gauge only need 1 cm unsheathed; consider spinal needle 4. Aspiration - Parallel to floor of the mouth; start at superior pole of tonsil - if you don' t get pus - then move to middle, then third pole - this is the only way needle aspiration is comparable to I&D; - aspiration = less painful than I&D - speed of relief may be higher with I&D; ED literature rec's aspiration Medical Management 1. Antibiotics - group A strep and anaerobe coverage - Unasyn, Clindamycin, or Vancomycin (if life threatening or fail to respond) (everyone should get a dose of IV anbx) - Oral 10-14 day course Pen VK QID plus flagyl 500 QID; clindamycin 300-450mg q 6 hrs; augmentin 45 mg/kg q12 - in young folks test for mono 2. Steroids - jury is still out; initially decreases pain but in 48-72 hrs no difference; use IV solumedrol Disposition 1. 4-6 hrs observation, then DC if can tolerate PO; f/up in 24-48 hrs; gargle with H2O2 at least after each meal; soft diet and good oral hydration; antibiotics 2. Admit (23 hr obs on IV anbx) - peds; toxic; immuncompromised; can't tolerate PO ![]() Immune System is the Bouncer - We know that there are bad microbes and good microbes. - It is now believed that the healthy Immune System acts much like a Bouncer at a Bar... allowing the good microbes in and keeping the bad microbes out. Illnesses associated with alterations in indigenous microbes - When "Bouncers go bad," illness like Obesity, IBD, Cdiff, asthma, or MRSA occur - Obesity - Giving antibx to animals make them gain weight - Obese people have less bacteroides - Markedly different gut flora in obese and skinny people - Inflammatory Bowel Disease - Increased correlation with antibiotic use - unclear causation - MRSA - Changes in microbiota related to MRSA status - Fecal transplants for recurrent C. difficile - Stool administered via NG tubes have a high success rate *Theoretically antibiotics in the last 70 yrs have altered normal human microbes* |
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