STATEN ISLAND UNIVERSITY HOSPITAL

EMERGENCY MEDICINE CLERKSHIP HANDBOOK

© SHOROK HASSAN, DO

DIRECTOR OF MEDICAL STUDENT EDUCATION

BILLY CAPUTO, MD

ASSISTANT RESIDENCY DIRECTOR

TRAUMA/RESUSCITATION SECTION:

Trauma resuscitation from an Emergency Medicine standpoint should be ran in a quiet and organized manner.

Appropriate preparation is paramount to running a successful trauma code.

We follow the ABC’s, though generally many things happen simultaneously:

Primary Survey:

Airway:

If a patient is awake and talking, their airway has been checked.  Always use C-spine precautions in a trauma patient with a concerning injury.

Indications for Emergency Intubation in Trauma patients:

When a patient requires Endotracheal intubation, the appropriate medications for Pretreatment, Induction, and Paralysis should be used (if necessary).  Additional information is available in the Respiratory section.

Agent

Pharmaco-kinetics

Indications

Dose

Warnings/

Special Use

Benzodiazepines

Lorazepam

(Ativan)

Onset:  5-20 min

Duration: 6-8 hrs

Half-Life: 5-15 hrs

Initial Sedation

Cont. Sedation

1-4 mg

0.01-0.1 mg/kg/hr

Long-acting

Beware of slow onset of drug (Risk for over sedation with multiple doses)

Effective Anxiolytic

Midazolam

(Versed)

Onset: 60-90 sec

Duration: 2-4 hrs

Half-Life: 1-4 hrs

RSI

Procedural Sedation

Int. Sedation

Cont. Sedation

0.1-0.3 mg/kg

(2nd Line)

0.05 mg/kg

1-5 mg Bolus

0.04-0.2 mg/kg/hr

IM or IV (Not PO)

Often used with Fentanyl

Shorter duration than Ativan

Can also be given Intranasally for Sedation.  This is common in Pediatrics

Sedative-Hypnotics

Propofol

(Diprivan)

Onset: < 1 min

Duration: 3-10 min

Half-Life: 5-10 min

RSI

Procedural Sedation

Cont. Sedation

2 mg/kg

1 mg/kg

5-80 mcg/kg/min

Can ↓ BP and HR

Antiepileptic

Prolonged or high doses increase risk for Propofol Infusion Syndrome

Etomidate

(Amidate)

Onset: < 1 min

Duration: 3-5 min

Half-Life: 3-12 min

RSI

Procedural Sedation

Cont. Sedation

0.3 mg/kg

0.1-0.2 mg/kg

N/A

Vasoactively Neutral (does not lower BP)

Most common induction agent used in the ED

May cause Myoclonus

Dexmedet-omidine

(Precedex)

Onset: 5-30 min

Duration: 1-2 hrs

Half-Life: 2 hrs

RSI

Procedural Sedation

Cont. Sedation

N/A

0.5-1 mcg/kg over 10 mins

0.2-1.5 mcg/kg/hr

Minimal Respiratory Depression (Approved for non intubated patients)

Anxiolytic  with some analgesic effect

α2- Agonist (↓ BP, HR)

Dissociatives

Ketamine

Onset: < 1 min

Duration: 30-45 min

Half-Life: 5-15 min

RSI                                    

Procedural Sedation

Cont. Sedation

1-2.5 mg/kg IV 4-10 mg/kg IM

0.5-1 mg/kg

0.5-1 mg/kg/hr

Maintains respiratory drive, Bronchodilator

Favorable Hemodynamic profile (↑ BP, HR)

Emergence Reaction

Opiates

Morphine

Onset: < 1 min

Duration: 2-4 hrs

Half-Life: 2-3 hrs

Analgesia

1 mg/kg starting dose

Can cause hypotension, itching from histamine release

Fentanyl

Onset: < 30 secs

Duration: 30-60 min

Half-Life: 2-4 hrs

Analgesia

Sedation

1-3 mcg/kg

bolus

25-250 mcg/hr

More HD Stable (Less hypotension)

Faster acting than MS

Remifentanil

Onset: < 1 min

Duration: 3-10 min

Half-Life: 3-10 min

Analgesia

Sedation

1-1.5 mcg/kg

0.25-0.5 mcg/kg/min

Ultra short acting

Safe in Renal and Hepatic Failure

NEXUS Criteria: Are used to determine whether or not your patient requires C-spine imaging.  All patients deemed to require C-spine imaging should have a cervical collar in place.  The Mnemonic for the NEXUS criteria is NSAID (the class of medications you would give to most of these patients who are not seriously injured:

N – Neurological deficits

S – Spinal tenderness (Midline tenderness to the C-spine)

A – Alertness/AMS (Make sure your patient is not altered)

I – Intoxication (Alcohol, drugs, etc)

D – Distracting Injury (This is generally defined as a long bone fracture.  If someone breaks their Femur, they may not feel the pain they have in their neck)

If any of these are positive, patient should be collared (or remain collared) and should have C-spine imaging.  C spine imaging can either be a CT scan or x-rays, with CT scan being a more sensitive/accurate test.

Breathing: Every trauma patient should have lung auscultation immediately to assess breathing, including intubated patients. Lung Ultrasound can also be done to assess for lung sliding.

M-mode ultrasound images of the lungs (right and left) show a normal "lung sliding" on the left side "Left" and absence of it on the right side "Right".

Facts:

Pneumothorax on US

Circulation:

IV Access:

Obtain Large bore IV access (16, 18 gauge IV’s)

For fluid or blood administration that needs to go as fast as possible, utilize the Level I Transfuser (depicted) or Pressure bags.

The Level I should be prepared and ready for all Trauma notifications. It also warms the blood or fluid as it goes through the chambers.

Hemorrhage Control: Patients should be evaluated for bleeding, both externally and internally.  Externally, this involved direct pressure to the wound.  There are times arterial extremity bleeding must be controlled with a tourniquet.  Sometimes this also involves stitching a scalp wound (using a “whip stitch” – rapidly closing the wound with a large, strong, running suture.)  Internal bleeding is looked at using a FAST or eFAST exam, assessing stability of the pelvis, and portable CXR.  The locations where a patient can exsanguinate from are the lung cavities, abdominopelvic cavity, and the thigh.


FAST EXAM

Focused assessment with sonography for trauma (FAST) is a rapid bedside ultrasound examination performed after trauma to evaluate for internal bleeding in the abdominopelvic cavity, around the heart, and in the lungs (seen better in the E-FAST).

The four classic areas that are examined for free fluid are the perihepatic space (also called Morison's pouch or the hepatorenal recess), perisplenic space, pericardium, and the pelvis. These areas are visualized because they are the locations most likely for free fluid (or blood) to collect. Free fluid on Ultrasound appears as anechoic or black.

The Curvilinear (Abdominal Probe) or the Echo Probe may be used for the FAST exam.

Views:

  1. Right Upper Quadrant (Morrison’s Pouch)

(Probe marker directed up towards the head)

  1. Left Upper Quadrant

(Probe marker directed up towards the head)

  1. Bladder (Transverse [Probe marker to patients right] and Sagittal [probe marker up])


bladder-long.jpg

  1. SubXiphoid View of Heart (Probe marker to patients right)

Free fluid on a fast exam appears black.  This is assumed to be blood in the setting of trauma and an indication to go to the Operating Room inside the abdomen.

Examples of Free fluid:

Ultrasound Pearls:

Ultrasound vs CT scan: Ultrasound is portable, faster, has no radiation, no contrast needed, and is highly specific in detecting free fluid (needs ~ 200 cc).

CT scan is a lot better at visualizing hollow structures (intestines), is more sensitive, evaluates retroperitoneal cavity, and visualizes musculoskeletal system.

Pelvic Fractures:

External fixation is indicated as the immediate treatment in a hemodynamically unstable patient with an unstable pelvic fracture. This can be done with a pelvic binder or with sheets.

Secondary Survey: Get an AMPLE history from patient, EMS, family (Allergies, Medications, PMH, Last Meal, Events)

Level of Consciousness: Determine patient’s GCS score:

GCS ≤ 8: Severe head injury, indication for intubation

GCS 9-12: Moderate head injury

GCS 13-15: Mild head injury

Assess Pupils: Size, Shape, Reactivity

Assess for lateralizing signs of spinal cord injury

In the secondary survey, every area and joint should be examined. (Dental, face, ears, neck, arms, legs, back, chest, abdomen, GU).  A rectal exam is generally done to check for good tone and the presence of blood.

Do not insert Foley Catheter if Urethral blood, scrotal hematoma or high riding Prostate due to concern for a Urethral injury.

Common Trauma Orders:

Antibiotics:  If there is significant skin damage or violation, it is common to give 1 g of Ancef (Cefazolin) to adults.

Tdap:  All patients not up-to-date with tetanus should receive a tetanus shot if there is violation of the skin.

Major Trauma/Bleeding: Consider giving the patient TXA (Tranexamic acid): 1 gram over 10 minutes and then 1 gram over 8 hours. TXA is an antifibrinolytic.

Pain control: An Opioid to the correct patient population (e.g. Morphine, Fentanyl, Dilaudid)

Trauma Labs: CBC, CMP, Coags, Lipase (if abdominal trauma), Type and Screen, ETOH, Pregnancy test (if needed)

Imaging: CXR and pelvis x-ray are good portable tests to aid in your work up, unless there is an isolated injury. Order CT scans (Head, C-spine, Chest, Abd/Pelvis) as needed.

Massive Transfusion Protocol: If needed for life threatening hemorrhage, this activates the blood bank to release blood, FFP, and Platelets in large quantities.


RESPIRATORY SECTION:

Airway Management

Rapid Sequence Intubation:

Rapid sequence intubation (RSI) has become the mainstay of emergency airway management.  This is a different technique than what is classically done by anesthesia in the operating room. Since we do not know the last time our patient ate, we ideally want to avoid bagging the patient unless necessary to decrease their aspiration risk. The general principal is to pre-oxygenate the patient and optimizing airway condition with medications, followed by intubation.

RSI is not indicated in a patient who is unconscious and apneic. This situation is considered a "crash" airway, and immediate BVM ventilation and endotracheal intubation without pretreatment, induction, or paralysis is indicated.

Creating optimal airway conditions includes choosing an induction agent and a paralytic.

The following are the most commonly used induction agents (Benzodiazepines and Barbiturates can also be used):

 

Paralytic Agents:

Succinylcholine (Depolarizing agent)

Dose: 1-2 mg/kg IV

Onset: within 45 seconds (Extremely Fast)

Very Short Duration: 4-6 minutes

Nondepolarizing: There are many agents, but Rocuronium and Vecuronium are the commonly used drugs of this class in the Emergency Department. These have a slower onset than Succinylcholine, but have longer duration of action and less contraindications.

Rocuronium

Dose: 0.8-1.0 mg/kg (Using 1 mg/kg makes dosing very easy)

Onset: Up to 2 minutes

Duration: 30-45 minutes

Vecuronium

Dose: 0.1 mg/kg (The common go to adult dose is 10 mg)

Onset: 1-4 minutes

Duration: 30-60 minutes

The basic approach to RSI consists of the "Seven P's":

1) Preparation – Make sure all equipment needed is working and available (Ambu-bag, suction, Handle, Blade, CO2 detector, Back up devices, etc)

2) Pre-oxygenation – This is extremely important to understand.  Most of the air is your lungs when breathing room air is Nitrogen. If you are able to replace Nitrogen with all oxygen (a concept called Nitrogen Wash out), you can form a reservoir of oxygen for your patient.  Correctly pre-oxygenating your patient can allow your patient to have 100% O2 Saturation for up to 8-10 minutes without a single breath! This time can be drastically reduced in very sick patients, patient with lung disease, pregnancy, obesity, etc (Sometimes as low as 3 minutes).  

→ Correctly pre-oxygenating you patient is how we have time to intubate them without bagging them at all. This involves 100% oxygen for 3 minutes or 8 respiratory cycles.

→ This is generally done by immediately placing your patient on 100% Oxygen as soon as possible.  Most commonly, this is done with a non-rebreather (NRB) mask.  BIPAP/CPAP also has a utility in this and can be the best way to pre-oxygenate the proper patient.

3) Pretreatment – There are times where drugs are given prior to the induction phase of RSI for the purpose of mitigating adverse effects associated with intubation.

Traditionally there are four options for pretreatment for RSI:

Take this with a grain of salt as there is little evidence that any of these are beneficial clinically

4) Paralysis with induction

5) Protection and positioning

6) Placement with proof – Once the intubation is performed, confirmation of proper endotracheal tube placement is crucial; unrecognized esophageal intubation leads to devastating complications.

Methods: Direct visualization, End-tidal CO2 determination, fogging of tube, b/l breath sounds, CXR, Lung US

7) Post-intubation management – The endotracheal tube must be secured, a post-intubation chest radiograph checked for evidence of complications, and appropriate ventilator management started. You must provide adequate longer-term sedation, analgesia, and sometimes paralysis.

→ Many times a sedation bolus and drip is given.  You want to ensure proper sedation and proper pain relief.  An example of drips that can be started post-intubation are a Fentanyl drip (for pain relief) and a Versed drip (Sedation)

Asthma:

In the Emergency Department, patients come in with asthma exacerbations ranging from the simplest wheezing to possible death from respiratory failure.  It is important to know the proper treatment and have the proper preparation for this disease process.

Nebulizer treatments:  Commonly given as Combi treatments (Albuterol/Atrovent) and most often given as 3 nebulizer treatments 15 minutes apart.

Steroids:  Has been proven to help improve asthma patients with exacerbations and decrease the risk of having another attack.  Generally given as Prednisone (60 mg PO or 2 mg/kg in pediatric patients), Dexamethasone (up to 16 mg) PO or IV.  Solu-medrol is the most common steroid given IV, dose is 50-125 mg (Most common is 125 mg).  Steroids take 3-4 hours to start working.

Simple Asthma Exacerabations:

In the Emergency Department these patients generally get an oral steroid (e.g. 60 mg Prednisone) and up to 3 combi-treatments.  Though Vital Signs are important, determining improvement in an Asthma patient can be better ascertained by their Peak Flow and whether or not they have dyspnea on exertion.  You must make sure patient has access to getting an inhaler and steroids.  

More Complex Asthma Exacerbations:

Once you have an asthma patient that is in respiratory distress or has a chance for rapid deterioration, being properly prepared is essential.  This includes having the patient in a monitored setting, having IV access, having appropriate airway equipment available, and knowing the additional medications the patient may benefit from.

  1. IV fluids: These patients are generally dehydrated and benefit from a bolus of IV fluids
  2. Nebs:  It is recommended to get a total of 3 Atrovent treatments (Ipratropium).  For sick asthma patients, you should be giving continuous nebulizer treatments.  After 3 Combi-treatments, you can give your patient Albuterol only.  
  3. Magnesium Sulfate:  Given as an adult dose of 2 g IVPB (slow).  Thought to help by causing smooth muscle relaxation.  Can cause rate related hypotension and should be avoided in renal patients.
  4. Positive Pressure Ventilation (BIPAP, CPAP):  Is showing promise in small ED studies that it is beneficial for asthma patients.  This supports the work of breathing in asthma patients.  

This is non-invasive Ventilation!  BIPAP is very important in Emergency Medicine because of its many uses.  It is standard of care for treating dyspnea in COPD and CHF.  It saves patients from intubation! It can also pre-oxygenate your patient in case your need to perform intubation in the immediate future.

BIPAP Settings: You need to know the initial settings to start a patient on. This includes your IPAP, EPAP, FiO2, and RR.

The general starting settings we use are IPAP: 10-12, EPAP: 5-6.  The FiO2 is variable but for very sick patients we start with 100%.

BIPAP is an intervention that can save your patient from intubation. That being said, it is not for everyone.  You generally will know fairly quickly who will tolerate BIPAP/CPAP and who won’t. The patients who show increasing agitation and are trying to remove the mask should have alternative treatment.

  1. Epi/Terbutaline:  Epinephrine should be given immediately to those in severe respiratory distress.  It should be used with caution in those with a history of CAD.  

Epi Dosing:

Terbutaline:

Terbutaline can be administered subcutaneously (0.25-0.5 mg) and is the preferred treatment in pregnant females. Subcutaneous administration of epinephrine or terbutaline should not be delayed since it is well tolerated even in older patients with no history of myocardialinfarction.

Status Asthmaticus: Is generally the admission diagnosis for asthma patients as it is severe asthma that does not respond to appropriate ED treatments (steroids, nebs)

Intubation:

This is the last resort for patients with severe asthma attack in Status Asthmaticus that is deteriorating despite aggressive therapy.  Since asthma is an obstructive process and patients have difficulty exhaling, there is a concern for air trapping.  There are several steps an ED clinician can take to help the underlying process:

Pneumonia:  

From an Emergency Department perspective, it is important to know how to risk stratify patients with pneumonia.  We want to know which patients can safely be discharged and which require admission and where.  Two scoring systems, CURB-65 and the PORT score have been developed and validated.  They should not be memorized, but you should know to refer to them when you have a patient with pneumonia.

CURB-65, also known as the CURB criteria, is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia and infection of any site. The score is an acronym for each of the risk factors measured. Each risk factor scores one point, for a maximum score of 5:

The risk of death at 30 days increases as the score increases:

PORT Score

The PORT score was developed because there was a lack of evidenced-based admission criteria for pneumonia.  The scoring system divides patients into 5 classes based on points and each has a different mortality.

Scoring

Risk Factors

Points

Demographic Factors

Age for men

Age

Age for women

Age -10

Nursing home resident

+10

Coexisting Illnesses

Neoplastic disease (active)

+30

Chronic liver disease

+20

Heart Failure

+10

Cerebrovascular disease

+10

Chronic renal disease

+10

Physical Exam

AMS

+20

RR > 30/min

+20

Sys BP < 90

+20

Temp <35 or >40

+15

Pulse > 125

+10

Lab and xray findings

Arterial pH < 7.35

+30

BUN > 30

+20

Na <130

+20

Glucose > 250

+10

Hematocrit <30%

+10

PaO2 < 60 or SpO2 < 90%

+10

Pleural effusion

+10

Classification

Class

Points

Mortality

I

<51

0.1%

II

51-70

0.6%

III

71-90

0.9%

IV

91-130

9.3%

V

>130

27%

Criteria for admission to ICU:

One of the following:

Septic shock requiring vasopressors

Acute respiratory failure

3 or more minor ICU criteria:

Respiratory rate > 30

PaO2/FiO2 < 250

Multilobar infiltrates

Confusion

BUN > 20 mg/dL

Leukopenia

Thrombocytopenia

Hypothermia

Hypotension requiring aggressive resuscitation

Health Care Associated Pneumonia (HCAP) risk factors:

* Hospitalization for 2 or more days of the past 90 days

* Resides in nursing home or long-term care facility

* Received chemotherapy, IV antibiotics, or wound care within the prior 30 days

* Attended a hospital or hemodialysis clinic in the last 30 days

Antibiotic coverage:

When the patient requires admission, think of coverage as what you are going to give for typical coverage and atypical coverage, then whether or not you need to cover for MRSA or Pseudomonas.  Typical vs Atypical is only their appearance on Gram stain, but this difference helps you ensure appropriate coverage.

Atypical Coverage: Macrolide (e.g. Azithromycin), Doxycycline, Levaquin (Levofloxacin), Avelox (Moxifloxacin)

All of these medications can be IV or PO

Typical Coverage (Oral): Amoxicillin, Amoxicillin-clavulanate (Augmentin), Cefpodoxime, Cefprozil, Cefdinir (Omnicef)

Typical Coverage (IV): Cefotaxime, Ceftriaxone, Ertapenem , Meropenem, Imipenem, Unasyn, Piperacillin-tazobactam (Zosyn), Cefepime, Gentamicin, Tobramycin, Amikacin

Pseudomonas Coverage: Piperacillin-tazobactam (Zosyn), Cefepime, Imipenem, Meropenem, Levaquin, Ciprofloxacin, Gentamicin, Aztreonam, Ceftazidime, Tobramycin, Amikacin

MRSA Coverage (IV): Vancomycin, Linezolid

1) Outpatient Healthy Adult Pneumonia Treatment:

*Keep it simple and cover atypical agents:

 Azithromycin, Doxycycline, Clarithromycin

2) Outpatient Treatment, Pt With Comorbidities or Recent Antibiotics 

* Use either Respiratory Fluoroquinolone or pick an oral antibiotic to cover typical and another to cover atypical agents:

Monotherapy: Moxifloxacin(Avelox) or Levofloxacin (Levaquin)

Dual Therapy:

 

Beta-lactam

Amoxicillin

Amoxicillin-clavulanate

Cefpodoxime

Cefprozil

Cefdinir

PLUS

Macrolide

Azithromycin

Clarithromycin

OR

Doxycycline 

Inpatient Treatment: You have to consider whether you are treating CAP (Community Acquired Pneumonia) or HCAP, then if your patient has MRSA or Pseudomonas risk factors and needs coverage.  The same thing pertains with typical coverage and atypical coverage.  All antibiotics should be given IV.

Typical Coverage (IV): Cefotaxime, Ceftriaxone, Ertapenem , Meropenem, Imipenem, Unasyn, Piperacillin-tazobactam (Zosyn), Cefepime, Gentamicin, Tobramycin, Amikacin

Atypical Coverage (IV): Azithromycin, Levaquin, Avelox, Doxycycline

MRSA Coverage (IV): Vancomycin, Linezolid

Pseudomonas Coverage: Make sure your typical or atypical choice has Pseudomonas coverage if your patient has one of the following:

 Prolonged hospital or long-term care facility stay (>5 days)

 Structural disease of lung (e.g., CF, bronchiectasis)

 Steroid Rx (>10 mg prednisone / day)

 Broad-spectrum antibiotics for >7 days in the past 1 month

 AIDS, especially CD4 < 50/mL

 Neutropenia (ANC < 500)

Note:  Our sepsis order sets have Cefepime and Vancomycin as the 2 appropriate antibiotics for sepsis of unknown origin.  From reviewing the above pneumonia treatment, for ICU patients we are generally giving 3 antibiotics.  If something on the CXR is concerning for an infiltrate, we generally add atypical coverage to the regimen (e.g. Azithromycin, Levaquin, Avelox, Doxycycline)

AIDS Patients:

Patients with human immunodeficiency virus (HIV) are at risk for a number of pulmonary infections. Pneumocystis jiroveci (PCP) remains the most common opportunistic infection in this group;

HIV is considered to be the greatest risk factor for TB.  Patients with HIV are more likely to develop active tuberculosis (TB) once infected, and they have a higher risk of death from TB.  If TB is suspected, patient should be on respiratory isolation.

The most common bacterial pathogen causing pneumonia in patients with HIV is Streptococcus pneumoniae.  Other infectious agents which are more likely to cause pneumonia in HIV are: Histoplasmosis, Coccidiomycosis, Cryptococcus, MAC

PCP work up:

1) LDH level: LDH levels are usually elevated (>220 U/L) in patients with P carinii pneumonia (PCP). (Sensitivty 78-100%)

2) ABG: Corticosteroids (Prednisone X 3 weeks) are used as adjunctive initial therapy only in patients with HIV infection who have severe P carinii pneumonia (PCP) as defined by a room air arterial oxygen pressure of less than 70 mm Hg or an arterial-alveolar O2 gradient that exceeds 35 mm Hg.  [A-a gradient at sea level = (150 – 5/4 (PCO2)) – PaO2]

Treatment: 1st line to 3rd line

1) Bactrim (Trimethoprim-Sulfamethoxazole)X 21 days

2) Bactrim and Dapsone OR Clindamycin and Primaquine

3) Atovaquone OR Pentamidine

PCP images:

Legionella Pneumonia:

Legionella pneumonia: Gram negative atypical pneumonia

Test question key words: water delivery systems (e.g. air conditioners).  More common in people with chronic disease (e.g. COPD)

Clinical presentation: Fever, cough, chest pain, neurologic symptoms (Headache, lethargy, AMS, Encephalopathy), GI symptoms (Diarrhea, Nausea, Vomiting, Abdominal pain)

* CXR shows pneumonia

Lab tests: Urinary antigen test for diagnosis, PCR

Possible lab abnormalities: Hyponatremia, elevated liver function tests, elevated ESR and CRP, Microscopic hematuria/proteinuria, hypophosphatemia, elevated ferritin

Treatment: Same pneumonia antibiotics (Macrolide, Fluoroquinolone, Doxycycline) only possibly a longer course


COPD Exacerbation:

Patients present to the Emergency Department with wheezing and shortness of breath from a COPD flare.  This is defined as a sustained worsening of dyspnea, cough or sputum production, leading to an increase in the maintenance medications and/or supplementation with additional medications'.

The mainstays of therapy for acute exacerbations of chronic obstructive pulmonary disease (COPD) are oxygen, non-invasive ventilation, bronchodilators, and definitive airway management.

Oxygen:  If a patient is very sick, they may require high oxygen deliverance for pre-oxygenation and potential intubation.  Otherwise, a reasonable O2 saturation is 92-95%.

Bronchodilator: Combi-treatments (Albuterol and Atrovent) can be given in the same doses as asthma patients. These should be given to all COPD flares.

Steroids: Should also be given in all COPD flares in the Emergency Department. Dosing is also the same as asthma.

Antibiotics: exacerbations of COPD associated with increased cough and sputum purulence, antibiotic therapy, regardless of choice, significantly decreases short-term mortality, treatment failure and sputum purulence. This effect was greatest in the most severe patients who are hospitalized. The most studied antibiotics for this are Macrolides, with Azithromycin being the most commonly used in the Emergency Department.  Other medications with respiratory coverage (e.g. Doxycycline, Levaquin, Avelox, Omnicef) should also be beneficial.

Non-invasive ventilation:

BIPAP/CPAP have robust evidence that they work in patients with COPD.  This should be a first line treatment for any COPD patient in severe respiratory distress.

Evidence from 14 studies with 758 patients shows that the use of NIV results in 50% less mortality, 60% fewer intubations, 52% fewer treatment failures and rapid improvement within the first hour in pH and respiratory rate (~3 breaths/min). In addition, complications associated with treatment were reduced by 62% and there was a reduction in the length of hospital stay (decreased by ~3 days). The NNT to avoid one treatment failure was five (95% CI: 4–6).

Source: Ram FSF, Picot J, Lightowler JV, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Syst. Rev. 3, CD004104 (2004).


Pulmonary Embolism:

Many patients arrive to the Emergency Department with chest pain or trouble breathing.  Determining whom to work up for a possible PE can be challenging task.  

The most widely accepted approach in the Emergency Department (For patients you are concerned about a PE) is to use the PERC Rule, followed by the Well’s Score for PE if necessary.

The PERC Rule:

You can use the PERC rule for patients who are LOW risk for PE:

* Kline et al. J Thromb Haem 2008; 6 (5):772-80

Again, the PERC rule can be used for only low risk patients, they have to be < 50 years old, and not have any mentioned risks factors, historical features, or exam features listed.  If the patient is PERC Negative, you can stop their work up for PE without any further testing.

When a patient does not fit into the PERC criteria, their Well’s Score can be calculated to determine their PE risk and the best next test.

Well’s Score:

Management:

ACEP recommends using a Two Tier Model using the Well’s score (There is also a Three Tier Model)

Two Tier Model

  1. If the dimer is negative consider stopping workup.
  2. If the dimer is positive consider CTA of Chest.

Patient risk is determined to be “PE Likely” (>4 points, 37.1% incidence of PE) - Consider CTA of Chest testing. D-dimer testing would be inappropriate in these patients.

Note: For patients that cannot have a CTA of the chest (Renal insufficiency, Allergy), a Ventilation-Perfusion (V/Q) scan can also be performed.


Chest Pain

Many patients present to the Emergency Department for chest pain.  Risk Stratifying patients can help you determine the appropriate work up for this patient population.

The most commonly used scoring system to risk stratify patients is by calculating their TIMI score.

TIMI Risk Score

In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making.

TIMI Score Calculation (1 point for each):

Mnemonic: 3 A’s, 3 C’s, 3 Risk Factors

  1. Hypertension -> 140/90 or on anti-hypertensives
  2. Current cigarette smoker
  3. Low HDL cholesterol (< 40 mg/dL)
  4. Diabetes mellitus
  5. Family history of premature CAD
  1. Male first-degree relative or father younger than 55
  2. Female first-degree relative or mother younger than 65

Score Interpretation:

% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.

'TIMI risk' estimates mortality following acute coronary syndromes.

The TIMI score is under a lot of scrutiny in the Emergency Department. It was not developed in patients presenting to the Emergency Department with chest pain.

A newer decision tool, called the HEART Score, is likely a better way to risk stratify emergency department patients with chest pain.

The HEART Score is a prospectively studied scoring system to help emergency departments risk-stratifiy chest pain patients: who will have a MACE (Major Adverse Cardiac Event) within in the next 6 weeks and who will not?

While HEART is sometimes compared to TIMI and GRACE (older ACS scores), these measure risk of death for patients with ACS, and do not do as well telling who has ACS in the first place.

Though the HEART score is likely a better scoring system, it is not as widely known as the TIMI score is (By some Emergency Medicine doctors and Internal Medicine/Cardiologists)


Burns

Emergency Management:

When the patient arrives in the ED, treatment is as follows:

ABC’s:

Airway:

Breathing:

Circulation:

The Parkland formula for calculating fluid needs for burn victims in the first 24 hours is as follows:

Fluid requirement (mL) = (4 mL of crystalloid) × (% TBSA burned) × body weight (kg)

Other important steps:

Indications for transfer to a burn center:

Wound Care Management (Partial Thickness Burns):


PROCEDURES

Lacerations and Wound Repair

Preparation

The wound must be thoroughly examined and explored prior to repair. The main objective of wound exploration is the removal of any substance, foreign body, or devitalized tissue that can facilitate infection or delay wound healing.

There have been several studies and literature reviews that indicate tap water is equivalent to sterile normal saline for wound irrigation in the emergency department. Volume appears to be the main variable for adequate irrigation, and tap water often provides the mechanism for highest irrigant volume. The volume of irrigation varies in practice. Available studies indicate amounts between 200-500 mL per wound, as well as wound surface area-based protocols where approximately 50 mL of fluid per cubic centimeter of wound is utilized are appropriate.

Based on this clinical variation, 500 mL of fluid for an average wound is likely adequate. Wounds that have high levels of debris contamination, high bioburden debris such as stool, or that occur in immunocompromised patients should be more aggressively irrigated.

Imaging:

Plain film radiographs should be obtained of any wounds that have a high likelihood of retained foreign body, i.e., broken glass, road rash, or penetrating injuries. Metal fragments are easily seen on plain films. Plain films are generally able to detect glass if the size is greater than 1 mm, and can detect glass fragments larger than 2 mm with a sensitivity above 95%. Ultrasound is also a valuable resource to detect foreign bodies in wounds, especially if the material is not likely to be seen on x-rays (e.g. wood). If there is still concern for foreign bodies not seen on X-ray or ultrasound, a CT scan can be obtained.

Further decreasing the bacterial burden of the wound and surrounding tissue is accomplished with antiseptic solutions. Cleansing the area surrounding the wound with iodophor (10% betadine) solution is recommended.

Local Anesthesia

Lidocaine: The maximum dose of lidocaine is 4-4.5 mg/kg in a single injection of plain lidocaine, or 7 mg/kg if epinephrine is used. Since 1% lidocaine for cutaneous anesthesia is 10 mg/mL (one 20 mL bottle has 200 mg), the entire bottle can safely be used on any patient > 50 kg. This needs to be more closely watched when 2% Lidocaine is used, there are multiple large lacerations, or you need more than one bottle of anesthetic.

Tips for local anesthesia:

Topical anesthetics are often used in the pediatric population, and are associated with less discomfort to the patient during application when compared to injectable anesthetics.

LET (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.5%) is available as both a solution and a gel and has been shown to be as effective in controlling pain as injected lidocaine.

EMLA (2.5% lidocaine and prilocaine) and LMX (4% lidocaine) are often applied to intact skin before venipuncture or abscess drainage; however, these mixtures take 45-120 minutes for maximal effectiveness and their benefit has been reported inconsistently in the literature

Common Topical Anesthetics and Locations of Use

Topical Anesthetics

Intact Skin

Wound

LET

 

X

EMLA

X

 

LMX

X

 

Skin refrigerant

X

 

Suture Materials, Selection, and Applications

The primary materials used for wound closure are sutures, staples, and skin adhesives.

Sutures are the most common method of wound closure. The initial decision when selecting a suture material is whether to use absorbable (see Table 4) or non-absorbable sutures (see Table 5). Several studies have examined the cosmetic outcomes, scar formation, and patient satisfaction with the use of absorbable and non-absorbable suture. A meta-analysis did not appear to reveal any statistical difference between any of these outcomes; however, there have been no large, randomized controlled studies across age groups evaluating these two options. Absorbable sutures should be used in areas that are likely to heal over and make removal difficult, such as mucosal surfaces in the mouth or vagina. Absorbable sutures should be used for all deep sutures and whenever the wound must be closed in multiple layers. Absorbable sutures are also appropriate for patients with poor follow-up who are unlikely to return for suture removal, and for patients for whom removal will be difficult secondary to young age or agitation. Non-absorbable sutures should be used in areas that are at risk for poor wound healing, wounds under significant tension, and wounds over flexor and extensor surfaces.

Types of Absorbable Sutures

Suture

Material

Duration of Tensile Strength

Absorption

Plain gut

Sheep intestine mucosa

5-10 days

Variable

Chromic gut

Chromium trioxide

10-21 days

Up to 90 days

Vicryl

Polyglactin

20-30 days

30-120 days

Types of Non-absorbable Sutures

Brand Name/Suture

Material

Tensile Strength

Dermalon

Nylon

Intermediate

Ethilon

Prolene

Polypropylene

Greatest

Surgilene

Silk

Silk

Least

Sutures come in either monofilament or braided forms. Monofilaments are less immune reactive, are associated with lower risk of infection, and result in less scarring when compared with braided suture materials. Most physicians choose monofilament material for these reasons.

Braided sutures generally have a higher tensile strength, and are at lower risk of spontaneous rupture.

Staples are quicker and easier to place than sutures. Skin staples are less biologically reactive and associated with less infection risk than sutures, and are especially good for lacerations in hair-covered areas, and long or straight lacerations involving the extremities or trunk. They have comparable cosmetic outcomes to sutures. Be aware that skin staples do not penetrate deeply and will not close subcutaneous skin well.

Topical skin adhesives (e.g. Dermabond) are liquid monomers that polymerize once exposed to moisture from the wound and the atmosphere. They form a hard, water-resistant, bonding substance over the wound. The adhesive remains on the skin and eventually sloughs off, usually in 7 to 10 days. Skin adhesives are best utilized for linear wounds that are under little tension, and are often the method and material of choice for facial wounds and wounds in children.

Suture Size:

In general, the sizes of the suture used in the Emergency Department range from 0 (largest) to 6.0 (smallest).  The actual needle size is depicted on the outside of the suture packet, as needle size is sometimes different with the same sized suture. A general guide to suture size is:

Location

Suture Size

Face

5.0 – 6.0

Scalp

4.0 – 5.0, Staples

Trunk

3.0 – 4.0

Extremities

3.0 – 4.0

Over Joints

2.0 – 4.0 (Consider splinting after repair)

Choice of suture size depends on how much tension is involved with the area, the strength of the area, the anticipated movement or strain on the stitches, and whether or not you have subcutaneous sutures placed.

Timing of Suture Removal

Location

When to Remove (Number of Days)

Face

3-5

Scalp

7

Trunk

7-10

Extremities

10-14

Fingertip

10-12

Palms/soles

14

Extensor joints

14

Joints

8-10

Indications for Prophylactic Antibiotics

Consensus Indications

  • Tendon, bone, joint involvement
  • Implanted hardware (heart valves, hip replacement)
  • Contamination with saliva, vaginal secretions, or feces
  • Old wounds or delayed closure

Relative indications (base on clinical judgment)

  • Bite or other puncture wounds to the hand
  • Any human bites
  • Through and through lip lacerations
  • Risk of infection greater than 10%

Tetanus: Ensure Tetanus status is up-to-date (every 8-10 years) and that patient received all 3 tetanus immunizations of their schedule. Be aware that an unvaccinated patient may also require tetanus immunoglobulin as well.

Chest Tube

Chest tube placement also called Tube Thoracostomy is the placement of a tube through the thoracic cavity into the pleural cavity. It is placed in order to evacuate, blood, air or any other fluid that has collected into the pleural space.

The indications for a chest tube following a blunt or penetrating thoracic trauma include: pneumothorax, hemothorax, hemopneumothorax, chylothorax, or hydrothorax. The indications for a chest tube in medical conditions include: pneumothorax, empyema, recurrent pleural effusion, malignant pleural effusion or pleurodesis.

The absolute contraindication to chest tube insertion is in a patient who requires a thoracotomy. There are several relative contraindications which include: coagulopathy, pulmonary adhesions, large pleural blebs, infection of insertion site. These contraindications should be considered in patients who don’t require emergency placement of chest tube.

Technique

  1. Place the patient in the supine position with the arm raised above their head
  2. Then apply chlorhexidine or iodine solution to the chest wall and allow to dry
  3. Place a sterile drape over the patient. Make sure you are dressed in a sterile cap, gloves and gown.
  4. Identify the 5th intercostals space at the mid-axillary line. This is where you will be inserting your chest tube.

Image not available.

  1. Numb the desired area with lidocaine with epinephrine. Make sure to place a good amount in the subcutaneous tissue through the chest wall into the pleural cavity
  2. Make a 3 -5 cm incision with a # 10 scalpel over the rib below the 5th intercostals space
  3. Bluntly dissect a tunnel from your incision site with Kelly clamps.  The tract should end at the upper border of the 5th rib
  4. Briskly push the closed tips of the clamp into the pleural cavity over the 5th rib. This will avoid injury to the intercostal vessels and nerves
  5. You should feel a quick rush of air or gush of blood to show that you are now in the pleural cavity

Image not available.

  1. Dilate the jaws of the clamp to dilate the hole that you have made into the pleural cavity
  2. Place a finger into the hole that you have made to ascertain that you are in the cavity. You should feel lung. Leave your finger or the clamp in the hole to make sure you don’t lose the access to the pleural cavity
  3. Clamp each end of the chest tube with a Kelly clamp. The fenestrated end to ease the insertion into the pleural cavity and the other to prevent leakage of bodily fluids onto the floor.
  4. Insert the chest tube through the tract and guide the tube anteriorly and posterior to the lung. Once the tube has entered the pleural cavity you can take off the clamp on the fenestrated end to ease insertion of the tube into the cavity.
  5. Rotate the tube in the chest to make sure that it rotates freely to ensure its not kinked inside the chest cavity
  6. Insert the tube as far as you are able without force. The goal is to make sure all the fenestrations are in the patient.
  7. Once the tube is in place secure it with a stitch. There are many different techniques for suturing the chest tube, the goal is to make sure it doesn’t come out.

Image not available.

  1. Once done place an occlusive dressing to the site and connect the tube to the pleuravac.

Pearls

       Man 28-32F, Women 28F, Child 12-28F, Infant 12-16F, Neonate 10-12F


ORTHOPEDICS

The Salter Harris Classification of fractures is something that frequently comes up in Emergency Medicine.  It is important to know why it is important and the different types. Salter-Harris fractures are epiphyseal plate fractures and are common and important as they can result in premature closure and therefore limb shortening and abnormal growth.  They represent ~ 35% of all skeletal injuries in children.

The Classification also goes from the best prognosis to the worst prognosis.

Classification

Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR.

Type I

  1. Slipped
  2. 5-7%
  3. fracture plane passes all the way through the growth plate, not involving bone
  4. Cannot occur if the growth plate is fused
  5. Good prognosis

Type II

  1. Above
  2. ~ 75% (By far the most common)
  3. Fracture passes across most of the growth plate and up through the metaphysis
  4. Good prognosis

Type III

  1. Lower
  2. 7-10%
  3. Fracture plane passes some distance along the growth plate and down through the epiphysis
  4. Poorer prognosis as the proliferative and reserve zones are interrupted

Type IV

  1. Through and Through
  2. Intra-articular
  3. 10%
  4. Fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis
  5. Poor prognosis as the proliferative and reserve zones are interrupted

Type V

  1. Ruined or Rammed
  2. Uncommon < 1%
  3. Crushing type injury does not displace the growth plate but damages it by direct compression

Worst prognosis

It is sometimes confusing because of how the bone is arranged to classify these fractures.  A good way to remember this is to know is that the Epiphysis is always at the End.

Upper Extremity Emergency Orthopedics

Colles Fracture:

* Colles fractures are the most common type of distal radial fracture and are seen in all adult age groups

* Dorsal angulation of the distal fracture

* Mechanism: Most Colles fractures are secondary to a fall on an outstretched hand (FOOSH) with a pronated forearm in dorsiflexion (the position one adopts when trying to break a forward fall)

Treatment: Closed reduction (if necessary) and Immobilization

Emergency Department Splint of Choice:  Sugar Tong Splint

Smith’s Fracture:

* Fractures of the distal radius with associated palmar angulation of the distal fracture fragment. Classically, these fractures are extra-articular transverse fractures and can be thought of as a reverse Colles fracture.

* Smith fractures usually occur in one of two ways:

1) fall onto a flexed wrist 2) direct blow to the back of the wrist

Treatment:

Treatment depends on the type of fracture, stability and ability to successfully reduce the fracture. In most cases these fractures can be treated with closed reduction and cast application. 

If the fracture can be reduced but remains unstable, or cannot be reduced then operative fixation is usually required

Emergency Department Splint of Choice: Sugar Tong Splint

Boxer’s Fracture:

* Minimally comminuted, transverse fractures of the 5th metacarpal and are the most common type of metacarpal fracture.

* An impaction injury (axial loading of the 5th metacarpal) almost always results as a consequence of a direct blow with clenched fist against a solid surface.

* The apex dorsal angulation for neck fractures should not exceed 30-40 degrees

* Closed reduction and splinting is performed in the Emergency Department, but these fractures are relatively unstable. K-wire fixation is often required for better results.

* An Ulnar nerve block is a good way of providing analgesia for possible closed reduction.  Conversely, a hematoma block can also be performed.

Emergency Department Splint of Choice: Ulnar Gutter Splint

Proper Orthopedics follow up for possible surgical fixation

Scaphoid Injury:

* The most common type of carpal bone fracture

* Scaphoid fractures usually cause pain and sensitivity to palpation in the anatomic snuffbox at the base of the thumb accompanied by swelling in the same area.

* Fractures of scaphoid can occur either with direct axial compression or with hyperextension of the wrist, such as a fall on the palm on an outstretched hand (FOOSH)

* Not all Scaphoid fractures are apparent on initial x-rays.  All patients with snuffbox tenderness should be splinted and be referred for repeat x-rays.

* Because of the blood supply to the Scaphoid, avascular necrosis (AVN) is a common complication of a scaphoid fracture.

Treatment:

Suspected Scaphoid injuries or distal non-displaced fractures may be immobilized in a splint and referred to Orthopedics.

Proximal or displaced fractures will likely require surgery

Emergency Department Splint of Choice: Thumb Spica

Elbow

Fat Pad Sign:

* It is important to look at lateral x-rays of the elbow to evaluate for a fat pad sign

*  It is caused by displacement of the fat pad around the elbow joint. Both anterior and posterior fat pad signs exist, and both can be found on the same X-ray.

* In children, a posterior fat pad sign suggests a supracondylar fracture of the humerus. In adults it suggests a radial head fracture.

Normal anterior fat pad in a non-fractured arm

This is what an abnormal x-ray looks like, with both an abnormal Anterior Fat Pad sign and an abnormal Posterior Fat Pad sign,

Sail Sign: Elevation of the Anterior fat pad to create a silhouette similar to a sail from a boat.

Emergency Department Splint of Choice: Posterior Splint

 For both Supracondylar and Radial head fractures (which can also be put in a sling)

More severe fractures require surgery.

Posterior Splint:

Humeral Shaft Fractures

*  3-5% of all fractures

* Radial nerve is the most common injured nerve

* Many of these fractures are non-operative

* Most frequently humeral shaft fractures occur as a result of a direct blow to the upper arm (transverse fractures)

Treatment:

Coaptation splint followed by functional brace

Proximal Humerus Fractures:

* Proximal humeral fractures usually result from a fall on an outstretched arm.

* Third most common fracture pattern seen in elderly

* Axillary nerve injury most common

Treatment:

* Sling immobilization followed by rehab

 85% of proximal humerus fractures are minimally displaced and can be treated nonoperatively

PEDIATRICS

An Easy Clinical Guide to the Workup of Pediatric Fever

**Please note that the following chart does not apply to the toxic patient as toxic patients should receive full sepsis workups consisting of CBC with BCX, CXR, UA with UCX and LP with antibiotics.  Disposition will be Admission

** This is for the NON TOXIC appearing febrile patient.

Rules: Correct age for prematurity and use Corrected age to categorize (an 8 week old baby born at 28 weeks is corrected to age of “just born”: thus 1st column not second)

If you LP, you must give Antibiotics (and most probably admit)- Avoid Ceftriaxone < 1 month of age secondary to biliary sludging

Neonate (< 8 Weeks)

8 Weeks to 3 Months

3 Months – 36 Months

SOURCE

>100.4 F

>100.4 F

>102.2 F

Temperature for work up

LP w/ A-biotics

LP w/ A-biotic ^^

+ Meningeal signs observed LP

CSF

UA w/ UCX

UA w/ UCX

UA w/ UCX (10 %)

UTI

CBC w/ BCX

CBC w/ BCX

CBC w/ BCX

Bacteremia

*CXR

*CXR

*CXR

PNA

**Stool Sample

**Stool Sample

**Stool Sample

Stool

Neonate (< 8 Weeks)

*CXR is only obtained as part of full septic workup IF there is clinical suspicion for pneumonia or if there are respiratory symptoms (cough, runny nose etc...)

**Stool samples only obtained as part of full septic workup IF there is Diarrhea

8 Weeks to 3 Months

LP w/ A-biotic ^^ In this particular group, we look at the CBC to determine risks for meningitis.              

        If the WBC is < 5 or > 15, or ANC < 1500, this is high risk LP with A-biotics and Admit

        If the WBC does not meet these parameters, low risk no LP, no A-biotics

3 Months – 36 Months : Note that “Febrile Temp” here is 39.0 C or 102.2 F

This is first time you can reliably use meningeal signs to decide on +/- LP

UTI is responsible for 10 % of fever in this age group, but must know who gets Catheterized:

Females up to 2 years old,  Circum. Males up to 6 months, Non Circ Males  up to 12 months

http://image.slidesharecdn.com/feverwithoutasourcepediatrics-151101130453-lva1-app6892/95/fever-without-a-source-pediatrics-32-638.jpg?cb=1446383214

http://image.slidesharecdn.com/fws-090821172951-phpapp01/95/fever-without-a-source-in-pediatrics-36-728.jpg?cb=1250875902

Treatment

Antivirals
 Acyclovir
 In patients 0-1 month
 20 mg/kg/dose three times daily
 Ill appearing
 Mucocutaneous vesicles
...

Antipyretics
Acetaminophen
15mg/kg/dose q4hours prn
temperature > 39oC (102.2 F)
Ibuprofen
10mg/kg/dose q6hours prn
te...