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![]() * Our lizard brain -- addiction affects the most primitive structures using the mesolimbic dopaminergic system * Try to hate the drugs, not the patient -- animal studies have repetitively shown that drug seeking behaviors are easily reproduced * May be self medication -- chemical coping for psychiatric disorder or pseudoaddiction * Yeah, I've heard that story -- behaviors more predictive of abuse are not that surprising. The more one has, the more likely it is opiate use disorder * "Nah, I don't want that" -- diversion patients will be uninterested in alternative therapies. People in actual pain will try anything just to feel relief (ketamine, nerve blocks, acupuncture) * We've all heard "avoid opioids for acute pain", but the chronic pain patient presents the greatest challenge * I want to relieve your pain, but... -- Have a script / set expectations with the patient -- there is little use in arguing if someone is in pain or not. * Hyperalgesia -- chronic pain can worsen not despite opioids but because of opioids creating new pain pathways * The emergency department is just a step in the process of recovery. We're not here to win the game for the patient to change but to at least get it started * Evidence is limited, but some suggest that PO Morphine less euphoric than oxycodone or hydrocodone with similar analgesic efficacy * Communicate! -- judging drug seeking behavior from a history is relatively unreliable, use the drug database, use past records, call pharmacies and send messages in Cerner ![]() 1. Intimate Partner Violence/Domestic Violence is the leading cause of injury in women aged 15-44. 2. 1 in 4 women will be victims of intimate partner violence. 3. Intimate Partner Violence is about control, not violence. 4. Women who leave a battering relationship are 75% more at risk of being murdered than those that stay. 5. US Preventative Services Task Force and JCAHO support universal screening of women for IPV in primary care settings and emergency departments. 6. Teen Dating Violence is an important risk factor for teen depression, suicidal ideation, drug and alcohol use, and pregnancy. 7. IPV can present without physical injuries, and can be related to multiple ED visits, anxiety and depression, chronic pain syndromes, and substance abuse. 8. As in child abuse, certain physical findings are important to recognize as non accidental and highly correlative to IPV injuries. These include bruises in multiple stages of healing, injuries not compatible with history, strangulation, bite marks, injuries to breast, abdomen, and perineal area. 9. Children in homes with IPV are at risk for neglect, emotional and physical abuse, and may become future perpetrators of IPV themselves. 10. It is important as ED physicians to develop supportive and non judgmental ways of screening all patients for IPV, and to maintain a high degree of suspicion with trauma victims, psychiatric patients, and patients with multiple ED visits. 11. Referrals to our Domestic Violence Healthcare Project WILL help victims gain access to services, provide counseling, and help with safety and discharge planning. Healthcare providers do NOT need patient consent to make a referral for DVHP services. 12. Physician documentation of physical abuse is the SINGLE MOST important correlate to successful prosecution of IPV cases in court. Remember to document patient history and injuries well. ![]()
![]() • Myxedema coma can closely mimic cardiogenic shock • TSH is an inexpensive screening tool to rule out myxedema coma • Management of myxedema coma includes airway management, IV levothyroxine, IV hydrocortisone, and supportive care • Greater than one half of patients presenting with sepsis syndrome will have negative blood cultures • Do not be falsely reassured by the presence of fever and leukocytosis • Always consider RUSH exam and reconsider differential diagnosis in complex hypotensive patients! ![]() Key history & PE components for diagnosing viral exanthems: - Hx: Where did it start, & where has it spread? Pruritic? Associated symptoms? - PE: Appearance? Confluence? Palms & soles? Oral lesions? Lymphadenopathy? Key clinical features: - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots - Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia - Roseola - Centripetal spread, fever defervesces before rash - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic - Mumps - Parotitis, orchitis - Coxsackie - Rash not just on hands, feet, & mouth - Mono - Rash not just after ampicillin - Nonspecific - MC viral exanthem ![]() - Measles - 3C's, cephalocaudal spread, confluencing rash, koplik spots - Rubella - Cephalocaudal spread, lymphadenopathy, forscheimer spots - Erythema infectiosum - parvo B19, slapped cheek rash, lacy rash, aplastic anemia, fetal hydrops - Roseola - Centripetal spread, fever defervesces before rash - Chickenpox - Lesions of different stages, dewdrops on a rose petal, pruritic - Mumps - Parotitis, orchitis - Scarlet Fever - During strep throat, sandpaper rash, strawberry tongue, pastia's lines - Coxsackie - Not just on hands, feet, & mouth - Mono - Rash after ampicillin - Nonspecific - Most common viral exanthem we will see ![]()
![]() -- Despite your location in the ER, treat all 'in extremis' patients with the same approach: ABCs, reversible causes (glucose, narcan, epi), resuscitate patient and then move to higher care area -- Contrast reactions cause an anaphylactoid reaction, which is treated with same supportive measures as an allergic reaction (epi, steroids, antihistamines) -- There are almost no contraindications to receiving contrast (the shaky area is with CKD or patients with AKI) - be sure to hydrate patients before and after scans if they can tolerate it -- Only need to order irradiated or CMV negative blood products for patients with leukemia/lymphoma or transplant patients -- Order Type and Screen (rather than T&C) on patients unless they need to be transfused in the ED/imminently. -- You can order MTP on patient as soon as they are registered; however, keep cooler closed until you definitively know you will need to transfuse - Always think inside AND outside the abdomen when evaluating children for abdominal pain
- Obstruction in children does not always produce distension or peritoneal signs - To accurately evaluate for obstruction you need supine and upright (or decubitus) Xrays - Lethargy can be the sole presentation of intussusception in infants and toddlers (See PedEMMorsel) - Bilious emesis in neonates is a surgical emergency even if they look well - Pyloric stenosis rarely occurs after 8-10 weeks of age |
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