EM REMS: Prisoner gets rubber bullet to eye. CT scan pictures available.

Annals of EM: Man with rash and uncontrolled DM and triglycerides. Small pink-yellowish, shiny papules on trunk and extensor surfaces. Diagnosed with eruptive xanthoma.

The Trauma Professional’s Blog: Recommends 3 indications: physiological compromise (hypoxia, tachycardia, anxiety), enlarging pneumothorax over course of serial X-rays to prevent physiological compromise, and (softer indication) likely long time period for absorption in elderly with co-morbidities.

The Trauma Professional’s Blog: 1982 case report of 16 patients with symptoms consistent with lead poisoning with previous GSW either recently or in the past. All GSW involved a joint or bursa either in or passing through at time of wound. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures. Original PDF

St Emlyns: Emergency Medicine Journal: Retrospective data from 2006. Reviewed paramedic vitals vs initial vitals taken in the ED. Looked at the delta (change) in shock index (HR/BP), HR, BP, and RR. Then compared this to 48 hour mortality. No real significance found realistically. Did find increase mortality with significant differences in RR or shock index.

Radiopedia.org: Clinical case of 50yo with pelvic pain and palpable mass. MRI images available. Had IUD removed recently. Organism Actinomycosis prevalent with IUD associated infections.

St. Emlyns: Annals of EM: Single institute study did retrospective review of peripheral IV insertion in the ED and there utilization. Paper found 50% were not actually used at all, though did not take into account the patients admitted and if those IVs were used at all.

2 of 4: T>38 or <36, HR>90, RR>20 (pCO2<32), WBC >12 or <4 or 10% bands

Sepsis: SIRS with infectious syndrome

Severe sepsis: sepsis with organ dysfunction due to hypo perfusion (decreased urine output, AMS, hypotensive, elevated lactate >4)

Septic shock: severe sepsis with low BP not responding to fluid bolus

MODS (Multi-organ dysfunction syndrome): ARDS – acute respiratory distress syndrome, ATN, shock liver, GI:ileus, blood – decreased platelets, decreased hemoglobin, hyper coagulable. Go in ED is to stop MODS from happening in the ICU.

Early Goal Directed Therapy

Consider intubation to decrease work that had occurred from breathing.

Early broad spectrum antibiotics in the first hour.

NNT=6 for EGDT.

Want ‘tank is full.’ Need CVP > 8. Want BP up of MAP > 65 or SBP >90. Start with Levophed and then consider vasopressin. NE superior to dopamine. Next, make sure there oxygen capacity is high with SvOz > 70%. Can consider giving blood if Hgb < 10 or start dobutamine.

Shock –> crystaloid –> fluid resistant shock –> give pressors –> if resistant, consider steroids (hydrocortisone 50mg q6hrs)

Want low tidal volumes (6mL/kg IBW), glucose < 200, head of bed at 30 degrees to prevent aspiration, urine output > 0.5 cc/kg/hr.

Academic Life in EM: Patwari Videos: Early Goal Directed Therapy

PHARM: 2 min video where paramedic intubated with 4 MAC and bougie with King airway still intact on ventilator. Deflates the cuff and then intubates with bougie first, then slides ET tube over, then removes King airway.

Annals of EM: Massive PE with echo showing RV dilation, septal bowing. CT showed contrast reflux which is 98% specific for right sided heart strain. EKG showed t-wave inversions in inferior/anterior leads. Two videos of bedside echo.