8:00 am Case conference by Dr. Jackie Fane

Intern in a hot seat: Dr. Bronia Agress
Senior lifeline: Dr. Mike Torre

CC: SOB

Cardiac tamponade

Causes:
Malignancy
Uremia
Pericarditis
Trauma
TB
Iatrogenic
SLE
Aortic dissection
Radiation mediastinal
Post MI

Clinical features:
Beck’s triad: JVD, distant heart sounds, hypotension. Rarely have all 3 signs.
SOB, tachycardia, narrow pule pressure, pulsus paradoxus, distant heart sounds
JVD
Enlarged cardiac silouette
Low voltage QRS and STE with PR depression, electric alternans

Echo:
R atrial compression, RV diastolic collapse
Abnormal respiratory variations in tricuspid and MV velocities
Dilated IVC, no collapse

Treatment:
Volume expansion
Hemodynamic instability – ED pericardiocentesis
Pericardial window

Emergent pericardiocentesis
Treatment of hemodynamic compromise from tamponade, resuscitation from PEA arrest after other causes have been excluded
Use US whenever possible, blind pericardiocentesis has 20% mortality rate
Contraindications:
Traumatic tamponade (need thoracotomy)
AD
Myocardial rupture
Uncorrected coagulopathy
Low platelets

Complications:

• Left internal mammary artery puncture or aneurysm
• Dysrhythmias
• Coronary artery puncture
• Hemothorax
• Pneumothorax
• Pneumopericardium
• Hepatic injury
• False-negative aspiration – Clotted blood in the pericardium
• False-positive aspiration – Intracardiac aspiration
• Re-accumulation of pericardial fluid

Voltage criteria for low-voltage ECG:
The amplitudes of all the QRS complexes in the limb leads are < 5 mm
or
The amplitudes of all the QRS complexes in the precordial leads are < 10 mm.

How much fluid is too much on US?
- We always want to measure the effusion at the point in the cardiac cycle when the effusion is at its smallest
- Grading the size of an effusion:
Physiologic/trivial: < 5mm
Small: < 10mm
Moderate: 10-20mm
Large: > 20mm

9:00 am Case conference by Dr. Jackie Fane

Intern in a hot seat: Dr. John Skilton
Senior lifeline: Dr. Kevin Kammel

CC: Altered mental status

Necrotizing soft tissue infections

Risk factors:
Age, DM, HIV, alcoholism, PVD, heart disease, renal failure, Ca, NSAID use, decubitus ulcer, chronic skin infections, IVDA, immune system compromise

Most are polymicrobial
Group A Strep, MRSA, vibrio vulfinicus

Direct invasion of subQ tissue from external trauma, causes widespread gangrene

Clinical features:
POOP to exam
Crepitus, skin necrosis, bullae
Finger test – not formally studied
Early Surgery consult

Imaging:
X-ray – gas in soft tissue, not very sensitive
CT with IV contrast
MRI with contrast
US

Treatment:
Early Surgery consult for fasciotomy
Broad spectrum Abx
Symptomatic
Aggressive IVF resuscitation

10:00 am "The High BMI Patient" by Dr. Ernie Leber

Rates of obesity doubled over the past 30 years
10x increase in patients with BMI > 50
It’s worldwide

In obese patients:
Increase O2 demand, increased CO2 production, increased VO2, increased WOB
Decreased reserve, increased chest and abdominal pressure
Even with mild doses of opioid pain meds they may develop respiratory failure due to impaired respiratory mechanics. It’s called OHS
Obesity-Hypoventilation syndrome (OHS) criteria:
BMI > 30
Hypoventilation - retain CO2 > 45
No other reason for hypoventilation

OHS:
Has poor prognosis
Significant pulmonary hypertension
25% mortality at 18 months
50% mortality at 36 months

Pearls/pitfalls:
Avoid hyperoxia
Avoid overly aggressive diuresis
Wheezing is not COPD

Obesity Supine Death Syndrome (OSDS):
BMI > 50
Change in position
Acute respiratory failure, shock or cardiac arrest

They get air trapping/autoPEEP, acute hypoxia from collapse of dependents portions of lungs, right heart failure, myocardial ischemia

Avoid laying them flat
Give them a trial of laying flat
NIV if they need support
Consider higher level of care for these patients
Don’t miss it
Take positioning seriously

Pre-Ox:
Keep them sitting up
NRB – flush rate
BVM – use PEEP valve at least 2 person technique
Consider high-flow NC
BiPAP
Ear to sternal notch position

RSI meds:
Etomidate – total body weight
Ketamine – ideal body weight
Propofol – ideal body weight
Sux – total body weight
Roc – ideal body weight

Ventilation:
TV by ideal body weight
RR – need higher rates
PEEP – need higher 8-15
Positioning – in reverse Trendelenburg

11:00 am "Dental and Oral Emergencies" by Dr. Ed Ramoska

Toothache:

1. Dental caries – plaque erodes enamel. Sensitivity to cold and sweets, then pulpitis with constant pain
2. Periapical abscess – most common. Pulpitis to necrosis to abscess. Exquisite pain with percussion, gum boil (parulis). Rx Abx, analgesia, referral to dentist for extraction or root canal.
3. Wisdom teeth – vestigial molars, help grind plants, evolution made jaw smaller. B/w 17 and 25 yo, may get impacted. Pain control, referral.
4. Pericoronitits – inflammation of gingiva around 3rd molar. Saline rinses, Abx, pain control, referral

Treatment of toothaches:
NSAIDs, Tylenol, may be opioids
Topical agents (20% Benzocaine gel)
Nerve blocks (subperiosteal on maxillary teeth or inferior alveolar) with Bupivacaine
Abx (PCN VK, Clinda, Flagyl). Dental referral

Post-extraction pain

• Due to trauma of surgery
• May have trismus, self-limited usually
• Pain meds, ice packs, HOB elevation
• Recognize Dry Socket Syndrome (post extraction osteitis) – disintergration of clot from socket and exposes the bone, significant pain. Consider X-ray for retained root tips, pain management (opioid). Irrigate socket with warm saline, lightly pack with gauze soakes with Alvogel, Eugenol or 5% Lidocaine – relief will be immediate. Abx for severe or purulent. Back to dentist.

Post-extraction bleeding

• Dislidged clot
• Firm pressure for 20 min with gauze or tea bags
• Infiltrate with lido/epinephrine
• Gelfoam, Surgicel sutured into socket
• AgNO3 cautery
• TXA
• OMFS consult

Mouth pain:

Gingivostomatitis

• Usually Herpes, may be Coxsackie
• Viscous lido, warm saline rinses
• Acyclovir/Famcyclovir if immunocompromised
• Abx for secondary bacterial infection

Thrush (Oral Candidiasis)

• Benign in kids
• Immunocompromised adults – HIV, chemotx
• Nystatin rinses, Clotrimazole lozenges, Oral Fluconazole

Aphthous ulcers (Cancer sores)

• Common
• Etiology unknown
• Erythematous macules turn into ulcers, then eschar

Topical steroid mouth rinses

Gum bleeding:
Chronic gingivitis
Poor mouth hygiene, pregnancy, some meds, may be scurvy
Can cause demineralization and tooth loss
Proper oral hygiene

ANUG (Acute Necrotizing Ulcerative Gingivitis)

• Periodontal dz, bacteria invade non-necrotic tissue
• HIV, poor oral hygiene, poor diet
• Painful gums, swollen, fiery red, ulcerated, covered with grey membrane
• Fusobacteria and Spirochetes
• Treatment: Flagyl, H2Os rinses, dental referral

Facial Space Infections:

Masticator spaces (trismus), submandibular spaces (Ludwig’s angina)
Dx: CT with IV contrast
OMFS consult
Mixed flora
Broad spectrum Abx

TMJ dysfunction:
Trauma, DJD, RA, SLE, anatomic dysharmonies
Unilateral pain, worsens during day
Soft diet, massage, analgesics, muscle relaxants, referral to OMFS

TMJ Dislocations:
Can’t close their mouth
Yawing, laughing, vomiting, trauma
Reduction:
Classic technique: push down and back
Recumbent approach: push back and superior
Syringe technique
Extraoral technique

Dental trauma:

Dental fractures:
Central incisors are most common
Goal in ED: to maintain pulpal vitality until they see a dentist
Ellis 1: only enamel
Ellis 2: involves dentin, hot/cold sensitivity, cover exposed dentin
Ellis 3: Exposure of pulp, true dental emergency, need referral for root canal, cover exposed dentin

Dental luxations:
Concussion: tooth hurts, not mobile
Subluxation: injury to attachment apparatus, some mobility
Extrusive luxation: tooth is partly out, reposition and splint the tooth
Lateral luxation: lateral avulsion, reposition and splint
Intrusive luxation: tooth pushed in, referral to OMFS

Avulsions:
Total tooth dislodgement
Re-implant asap
Rinse tooth with saline or tap water, don’t wipe off
Re-implant and stabilize
Transport tooth; Hank’s solution, saline, milk, saliva
Primary teeth not re-implanted

Splinting teeth: Coe-Pack
If no Coe-Pack, use Dermabond and metal part from N95 mask

Mandibular fractures:
Tongue blade test – if you can twist it in the mouth with squeezed teeth, they probably don’t have mandibular fx.

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

 
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