Conference Notes 8-8-2018

Editor's note: A Big Thank you to Mitch Lorenz and Anita Shroff for writing the majority of the Conference Notes this week!

Drs. Marek, Muhammad, Schroeder, Mishra, Kemp, Akhter

Joint EM/PEDs   Expert Panel on Asthma

PASS score- use the cumulative score to guide appropriate management and disposition

 PASS Score   Can also be found in MD Calc App

PASS Score   Can also be found in MD Calc App

 A score of 3 or higher is severe asthma.

A score of 3 or higher is severe asthma.

Albuterol dosing- when should we use continuous vs unit nebs?

-continuous nebs have lower admit rates and no difference in adverse events when compared to intermittent nebs (Carmago CA, Cochrane Database 2003)

-Schroeder comment: from a practical standpoint in the ED, it is difficult to do q15-20min reassessments, so it is often beneficial for the patient to start an hour long neb

-Muhammad comment: try to reassess them 15-20 min after the END of the albuterol treatment for it to take full effect

Ipratropium

-giving 2-3 doses in the initial dosing of asthma reduces the amount of total albuterol needed and the total length of stay, and had lower hospitalization rates

Steroids- who should receive steroids?

-Schroeder comment: anyone who gets an hour long neb gets steroids

 

Which patients need a CXR?

-routine CXR is NOT recommended

-it is recommended if the patient has  persistence  of any of the following: severe symptoms, significant hypoxemia, marked asymmetry on lung exam

-cxr is is infrequently associated with change of management  (Ann Emerg Med 2018)

-Kemp (PICU) comment: if patient is admitted to the PICU, they will get a CXR to assess for pneumomediastinum or pneumothorax. This info is critical when using higher nasal cannula flow rates, higher bipap or ventilator peak flow rates, or higher peep.

Who should receive antibiotics?

-NHLBI guidelines recommend not routinely giving antibiotics

Carlson/Lorenz        Oral Boards

1. Rocky Mountain Spotted Fever - treat tick borne diseases with doxy, think about these in anyone who has been camping, most prevalent outside of the Rocky mountains

 The rash of  Rocky Mountain Spotted Fever starts on the ankles and wrists and moves toward the trunk.  Fever precedes the rash by a few days.

The rash of  Rocky Mountain Spotted Fever starts on the ankles and wrists and moves toward the trunk.  Fever precedes the rash by a few days.

 

Dr. Lovell comment - check labs before a LP especially when you're not sure whats going on to make sure platelets/coags are normal

Rickettsia rickettsia, the causative organism of Rocky Mountain spotted fever (RMSF), is transmitted by the bite of an infected tick. Fever, headache, rigors, abdominal pain, myalgias, and malaise occur 2 to 14 days after inoculation. Three to five days after the onset of symptoms, the rash begins with erythematous, blanching macules on the distal extremities (wrists and ankles). This is followed by centripetal spread to the trunk and to the palms and soles. The lesions evolve into papules and petechia. Without treatment, RMSF has a 25% mortality; delayed diagnosis and delayed antimicrobial treatment results in 3% to 4% mortality. (Atlas of EM reference)

2. Heat Stroke - 2 types, diagnositic criteria > 40C, AMS.

-elderly more commonly not diaphoretic

-young/athletes more likely  to be diaphoretic

-treat w/ ice water immersion or evaporative cooling and benzos to control shivering

-antipyretics are normally ineffective

 Tintinalli 8th edition

Tintinalli 8th edition

The cardinal features of heat stroke are hyperthermia (>40°C [>104°F]) and altered mental status. Although patients presenting with classic (nonexertional) heat stroke may exhibit anhidrosis, the absence of sweat is not considered a diagnostic criterion because sweat is present in over half of patients with heat stroke.15

The CNS is particularly vulnerable in heat stroke. The cerebellum is highly sensitive to heat, and ataxia can be an early neurologic finding. Virtually any neurologic abnormality may be present in heat stroke, including irritability, confusion, bizarre behavior, combativeness, hallucinations, plantar responses, decorticate and decerebrate posturing, hemiplegia, status epilepticus, and coma. Seizures are quite common, especially during cooling. Neurologic injury is a function of the maximum temperature reached and the duration of exposure.15

The distinction between exertional and classic (nonexertional) heat stroke is not clinically important, because immediate cooling and support of organ system function is the therapeutic goal for both. A delay in cooling increases the mortality rate.    (Tintinalli 8th ed)

 

3. intranasal foreign body - button battery

-do not attempt to irrigate out a button battery as it may cause it to leak its corrosive contents

-if it does not come right out, consult ENT

A button battery lodged in the ear can result in tympanic membrane perforation or destruction, necrosis of the epidermis of the external auditory canal, hearing impairment, destruction of ossicles, and facial nerve paralysis.25 Intranasal button batteries can produce chondritis, nasal septal perforation, and superficial burns of the nasal mucosa.35

A child with a button battery in his nose or external auditory canal should be immediately referred to an otolaryngologist for its removal. If its instillation was recent, for example, less than 1 to 2 hours, the emergency physician may consider an attempt of removal.   (Tintinalli 8th edition)

Carlson     Toxicology

Unfortunately I missed this outstanding lecture.

Kishi   Safety Lecture

Unfortunately I missed this outstanding lecture.

Hormese     New Medication Therapies for EM Applications

Angiotensin II is indicated for patients who are in shock despite high-dose norepinephrine.   Patients started on Angiotensin II need prophylactic heparin and SCD's because this medication increases patients' risk for DVT/PE

Patients with low risk DVT and PE can be discharged home on xarelto or eliquis.  Use modified Hestia criteria to decide who can go home.  Patients need PCP follow up and are reliable to follow up.  The first month of treatment with xarelto will be free of charge.  After the first month, the patient will need to pay for the medication through insurance or cash.

 Hestia Criteria. If you answer yes to any of these questions, the patient cannot be treated at home.  Tintinalli also notes that an extensive DVT should be treated in the hospital.

Hestia Criteria. If you answer yes to any of these questions, the patient cannot be treated at home.  Tintinalli also notes that an extensive DVT should be treated in the hospital.

 

Quick Pharmacy Factoids:

Ciprodex not covered by insurance.

Prednisolone ODT not covered by insurance

Zofran liquid not covered by insurance

Please list the ingredients and the volume of each ingredient of magic mouthwash on your script.  Pharmacies are calling our pharmacists with many questions about our magic mouthwash prescriptions.

Lovell                Town Hall Meeting