UTSW EM R3s compiled slides of there favorite pearls from ACEP 2014.

1. Brady

2. Trauma: Lessons from the War
• Tourniquets – ARR 10% in mortality if placed
pre-hospital
– Placed pre-shock - mortality dec 96% to 4%!
– Use them! Know how to put one on, you will save
a life
• Morphine as pain control - inc mortality in
setting of shock
– Consider Ketamine for pain – low dose 0.3mg/kg,
longer lasting then fentanyl, no complications

3. Trauma: Lessons from the War
• Use TEG/Rotem
– give patients what they need
– Leaks from PROPPER trial; good data for 1:1:1
• Crash 2/TXA
– use in massive transfusion pts
– use early in the first 3 hours if your going to use it
– Military – MATTERs trial 7% reduction in mortality
• Burns
– We overestimate burns in ED
– Use rule of 10s
• Estimate TBSA to nearest 10%
• Multiple by 10 and run at maintenance IVF for adults 40 to 80kg
• For every 10kg above 80kg, add 100ml/hr

4. Cooper

5. Mattu Ischemia
• Beware straightening of the initial portion of the
T-wave
• Reciprocal changes often precede STE
– New TWI in aVL in setting of inf STEMI
• Pericarditis vs STEMI
– Reciprocal changes = STEMI
– STE in III>II = STEMI
– Concave downward morphology = STEMI
– Then, look at PR segments for PRD
– R-T Checkmark sign = STEMI
– Spodick sign – down-sloping TP segment

9. Mattu Syncope
• HOCM
– LVH in young person
– Deep, narrow Qs in lateral leads
• Prolonged QT
– Hypocalcemia and hypothermia prolong ST
• WPW afib
– Irregularly irregular with different wide complexes
– Rate > 200 at times
– No amiodarone or AVB

12. Durant

13. Mistakes you don’t want to make
in pediatric patients
Original lecture by:
Richard M. Cantor MD FAAP/FACEP
Professor of Pediatrics and Emergency Medicine
Director, Pediatric Emergency Services
Director, Pediatric Emergency Medicine Fellowship
Golisano Children’s Hospital
Syracuse, NY
Durant

14. Don’t forget to ask about
immunization history!
• 5 yr old Amish male with
intractable “seizures”
– Not responsive to benzos,
Dilantin, Phenobarb
– Subsequently intubated
– Foot wound found on
secondary survey
– TETANUS!!!
• Parents did not immunize
their children
• Tx: airway mgmt, clean
wounds, Flagyl, HTIG,
paralysis, supportive care
Durant

15. Pediatric Lethargy Mnemonic…
A Alcohol
E Epilepsy
I Insulin, Intussusception
O Overdose
U Uremia
T Trauma
I Infections
P Psychiatric
S Shock
Durant

16. Finger stick glucose
• Always get bedside glucose in any ill infant or
child
– Any serious illness
– Any gastroenteritis (esp. rotavirus)
– Any odd neurological presentation
– Any child with syncope
Durant

17. Miscellaneous…
• Always make sure every kid you discharge can
walk out
– Don’t forget about non-orthopedic causes of limps
• Psoas abscess
• Appendicitis
• Hernia
• Gluteal tears
• Kids more sensitive to anticholinergic OD
– As little as 3X the daily dose of Benadryl is toxic in
pediatric pts
• Don’t forget about crazy parents
– Non-accidental trauma
– Munchausen syndrome by proxy
Durant

18. Golwala

19. Protect that Airway! The Perils of
Intubating and Sedating a Critically
Ill Patient
Neel Golwala

20. Sedatives in RSI for septic pts
• Etomidate: In septic pt who is already cortisol-depleted:
SAFE to use
• Etomidate vs ketamine vs midazolam: no sig difference in
intubation conditions, 28-day morbidity/mortality, duration of
pressor-weaning, % pts needing pressors, duration of vent-weaning,
ICU length-of-stay

21. Sedation in combative, agitated pts
• Benzos: midazolam faster onset and quicker to
peak action vs lorazepam, but lorazepam
longer lasting
• Atypical antipsychotics
– Olanzapine faster in reducing agitation vs
haloperidol (though industry-funded study, RCT)
• Sig increase in dystonia and EPS rates w/ haloperidol

22. Sedation in combative, agitated pts
• Atypical antipsychotics
– Ziprasidone vs haloperidol (industry-funded, RCT)
– Ziprasidone faster in reducing agitation (but dosages were not
equivalent  20 mg IM ziprasidone vs 2.5-5.0 mg IM Haldol)
–No sig difference in adverse effects

23. Analgesia in hypotensive pts
• Morphine + ketamine vs morphine + placebo
• Morphine 0.1 mg/kg + ketamine 0.2 mg/kg, then
morphine 3 mg q5m prn
• Morphine/placebo group required twice as much
morphine as morphine/ketamine group

24. Kharbanda

25. Imaging Preggers
Bryan Kharbanda

26. Abdominal Imaging of Preggers
• There are random ‘stochastic’ effects of radiation
– 1 cancer/500 fetuses exposed to 3 rads
– 1-2 rads increased leukemia risk 1.5x over natural
incidence
– 1/2000 fetuses exposed to ionizing radiation develop
leukemia as children (twice normal risk)
• Then there are ‘deterministic’ effects
– 5-10 rads = clinically insignificant for CNS and
organogenesis development
– >10 rads = possible spontaneous abortion during
implantation phase. Increase risk MR or lower IQ.

27. Imaging is rad
• CXR = 0.00007 rads
• Pelvis XR = 0.04 rads
• L spine XR = 0.4 rads
• Abdo CT = 2.5-3.5 rads
• “If you have a sick patient, you really need to
get it”

28. Fetus + Contrast
• Iodinated Contrast Agents with Preggo
– Theoretical risk neonatal hypothyroidism
– HOWEVER, never once seen in studies or literature in
people or animals = FDA class B
• Gadolinium Contrast Agents with Preggo
– Brain malformations in animals
– No published reports on complications with humans
– FDA class C

29. Pt is knocked up & you’re concerned for…
• Appendicitis
– First choice = MRI without contrast
– Second choice = US RLQ
• Hepatobiliary/Pancreatic Disease
– 1st choice = US
– 2nd choice = non-con MRI
• Obstruction
– Non-con MRI
• Urinary Tract disease
– US (repeat studies if possible).
– Non-con CT (0.7 rads) if complicated stone
• Trauma
– EFAST and/or CT With IV contrast

30. Lawrence

31. Hypertensive Emergencies
Hypertensive Encephalopathy
Intracranial Hemorrhage
Aortic Dissection

32. • These three were the ones that were focused
on
• Also includes: MI, AKI, Stroke, LV dysfunction
causing pulmonary edema.

33. • This elevated pressure causes a natriuresis, so
these patients are volume down and fluids
should be administered
• Arterial monitoring if available would be ideal
for close monitoring of BP reduction

34. • Of these three, marked BP reduction should
only be attempted in dissection. No more
than 20% MAP reduction in the first hour for
most others for risk of causing stroke

35. Medications to avoid
• If you have diagnosed hypertensive emergency, do
not use anything other than parenteral medications
initially.
• In hypertensive encephalopathy and ICH, avoid
hydralazine, clonidine, diuretics (because of volume
depletion), and nitroprusside (because of decrease in
cerebral blood flow)
• Nitroprusside can be used in dissection

36. Medications to consider
• Short acting, easily titratable IV medications.
• Labetalol, Nicardipine are two that are
compared and heavily recommended. Also
Clevidipine when it comes off patent.
Fenaldopam can also be used if kidney injury,
but is more expensive

37. Lewis

38. The ICU Is Not Ready For Your
Critical Patient, Are You?
Lecture from ACEP Scientific Assembly 2014
Michael Winters, MD, FACEP

39. ICU Boarder
 Delayed admissions to ICU  increase ICU mortality 1.5% each hr
1. Analgesia and Sedation
• Protocols: pain and agitation
• 1st PAIN opiods (Fentanyl)
• 2nd SEDATION lighter levels of sedation
– Avoid benzos, use Propofol or Dexmedetomidine
2. Monitoring (cardiac, pulse ox, BP, UOP)
• Capnography
– Normal range 35-40 mmHg
– No waveform: extubation, ETT obstruction, ventilator malfunction, CA
• Ventilator pressures
– Low TV 6 mL/kg
– Plateau pressure < 30 mmHg

40. ICU Boarder Pearls
• Consider Abdominal Compartment Syndrome
– Compression IVC, decrease VR, increase SVR decreased CO
– Risk factors: trauma, aggressive IVF, sepsis and mechanical
ventilation
– Check bladder pressure, IAP >20 mmHg with new organ failure
– Tx: Decompressive laparotomy
3. Supportive Care
• Ventilator associated PNA
– Leaking of oral flora around ETT
– Risk factors: ED intubation and LOS, supine position
– Prevention: elevate HOB, LPV, NGT/OGT, cuff pressure 20-30
mmHg, oral care

41. Maynard

42. Pacemakers and ICDs
• First Steps
– Type?
• I.e. Medtronic, St Jude, Boston Sci
• Pt’s card can tell you, then you know…
– If pacer, ICD or both.
– Which rep to call for interrogation.
– Initial Orders for All pts
• EKG
– Not for ischemia (ST seg is useless if paced)
– Failure to pace, capture or sense
• CXR
– ICD or pacer? fractured or migrated leads?
• Labs (cbc, bmp, mag, phos, trop, drug levels)
• Get Pads on Pt and Magnet to bedside

43. CXR
Pacer ICD
RA
RV
Coil
Coil

44. Pacer Fails
• Failure to Pace (No spikes),
causes:
– Over sensing (push ups)
– Dead battery
– Dislodged lead
• Failure to Capture (Spike
No wave), causes:
– Fibrosis (exit block)
– MI
– Electrolytes, drugs
• Failure to Sense (Spikes
during QRS), causes:
– All above
– Tx? Place MAGNET

45. ICD Fails
• Misfire
– Shocking when not indicated
• Single shock
– Can prob DC and f/u cards
• Multiple shocks
– Needs interrogation, labs, magnet?, and admit

46. What does the Magnet Do?
In both Pacers and ICDs, it turns off Sensing
• Pacers
– Use Magnet in Pacers if
• Bradycardia and Asystole
• Magnet will turn off
Sensing func  Reverts to
Asynch pacing
(Automatically paces)
– Magnets cause pacers to
pace
• ICDs
– Use Magnet in ICDs if
• Misfires
• Magnet turns off Sensing
func  Will not shock
– Magnets cause ICDs to
NOT Shock (takes away
ability to “sense” VF/VT)

47. McClure

48. Rapidly Fatal Infections
ACEP 2014
Scott McClure PGY3

49. • Necrotizing soft tissue infections
• Difficult to differentiate from run of the mill soft
tissue infections
• May see gas on XR, pain out of proportion to exam
• Surgical consultation, vanc/zosyn AND clindamycin
• Severe C. Diff infections
• For mild-moderate infection Flagyl 10-14 days
• Severe infection PO vanc 10-14 days, may consider
adding IV flagyl
• Yes stool transplantation is real treatment

50. • Emphysematous Pyelo
• Aggressive resuscitation, broad spectrum antibiotics,
emergent surgical consultation(Urology)
• Usually caused by E. Coli
• Emphysematous Cholecystitis
• Pathogens include E. Coli, C. Perfringens, B. Fragilis
• Higher rate of necrosis and perforation
• Broad spectrum abx, emergent surgical consultation
• Mucormycosis
• Look for black eschars in nares and palate
• CT/MRI, Surgical consultation, Amphoterecin B

51. • Meningitis
• Vanc/Rocephin +/- Ampicillin
• Dexamethasone before or with antibiotics
• Not every case needs CT before LP, do not wait for LP to
start antibiotics
• Neutropenic fever
• ANC less than 500 cells/mm3Cultures(2 peripheral, line
cultures)
• Broad spectrum Abx
• Rabies post exposure ppx
• Vaccine and IgG
• IgG dose 20 IU/kg, infiltrate into wound as much as
possible, rest IM at different site than vaccine
• Vaccine days 0, 3, 7, 14

52. Mo

53. New Technology: There’s An App
For That
Jason C. Wagner, MD, FACEP
ACEP Scientific Assembly 2014

54. Introduction
• Apple vs. Android
– Most apps are on both platforms
– It’s hard to switch because of the re-investment if
you switch ecosystems
• SIZE MATTERS.
– Certain apps are optimized for
phones/tablets/computers
• 3 categories of apps are discussed…

55. Business (Medical Related)
• EMRA (Free - $16)
– PressorDex, Antibiotic Guide
• PediSafe ($2)
– Electronic Broselow Tape
• Clinical Calculators
– Medical Calculator, NIHSS, ABG, airway 911
• EZ-IO: for your humeral IO brush up
• Ultrasound: nothing really that useful while
working…better for studying
• Ophthalmology: EyeChart

56. Between
• Evernote
– Collects and keeps ideas/projects all in one place that
is searchable
• OmniFocus
– Task management – keeps you on top of things so you
get them done faster
• PDFPen
– Scan+
• Allows for you to sign PDF documents without having to
print it out first. Also lets you scan documents into PDF form.

57. Lifestyle
• Uber/Lyft – Don’t drive drunk.
• 1Password
• Sleep Cycle
• Podcasts
• Google translate

58. The End

59. Neal

60. Delayed Sequence Intubation
Catherine Neal, MD
PGY3

61. PEARLS:
• Critical oxygenation level: at saturation < 70%
patients are at risk for dysrhythmias and
asystole
• Preoxygension: 15 L NC and 15 L NRB more
effective than either independently
• CPAP preoxygenation:
– If failing standard preoxygenation (above) can place CPAP 5-15 cm H20
with 15 L NC
– This increase mean airway pressure which holds open alveoli
– Don’t exceed 15 cm H20 because the pressure of the lower esophageal
sphincter is 22 ccm H20

62. PEARLS
• Apneic oxygenation
– Concept: oxygen in alveoli exchanges across the membrane even
without positive pressure
– When the oxygen exchanges it creates a “mini-vacuum” pulling in
oxygen from the tracheobronchial tree
– How the do it: NC 15L/min with BVM with a PEEP valve (or CPAP)
produces enough pressure to keep the airway open and allow oxygen
to passively exchange

63. PEARLS
• Delayed Sequence Intubation—Inducing with Ketamine
– Goal is to maintain airway reflexes but sedate to
oxygenate prior to intubation
– Ketamine Review:
• Start with 1mg/kg then add aliquots of 0.5 mg/kg until desired sedation
reaches
• Once desired sedation reached, more ketamine will not result in deeper
sedation
• BUT, complications are dose related
• Rapid push of IV ketamine may result in 10-15 s of apnea
– Goal pre intubation sat 95%
– Ketamine is really the only medication currently
approved for DSI
– Precedex is a possibility but it is expensive and

64. Nelson

65. Practice Changing Cardiology:
Summary
Original presentation by Corey Slovis

66. Hypothermia
• Comatose STEMI patients + arrests from VF or VT
• 35-36° goal equivalent to 32-33°, should be
preventing hyperthermia
• No cooling in the field for short transport times
• PCI for non-STEMI arrest has survival and
neurologic outcome benefit
• VF/VT awake = PCI
• VF/VT + coma = PCI and cooling

67. Cardiac arrest
• No benefit of epi on survival, ROSC or
neurologic outcome
• Calcium? Also no evidence…unless signs of
hyperkalemia
• Optimal pre-shock pause is <10 seconds
• Does not recommend hands on defibrillation
• ST segment resolution of STEMI still equals a
STEMI

68. Misc.
• 140/90 Bp goal for <60 y/o
• 150/90 for >60 y/o
• D-dimer cutoff?
– if above age 50, then = age x10
• Intermediate risk PE = stable hemodynamics
with RV dysfunction or troponin elevation

69. Oubre

70. Critical Care
• In septic pt’s, do NOT tolerate hypotension. If
pt remains hypotensive after initial fluid bolus,
immediately move to pressors while
simultaneously giving more fluids.
• Retrospective study of 216 pt’s showed every 1 hour delay
in starting pressors increased mortality by 5.3%
• It cannot be repeated enough, Ketamine is a
great RSI drug - especially in shock states.
– consider a new pretreatment – 4 mg Zofran to
prevent the dreaded emesis

71. Critical Care
• In pt’s with ICH, aggressively lower their SBP <
140
– 2010 AHA guidelines had recommended BP <
160/90 or MAP < 100
– NEJM prospective RCT showed improved
functional outcomes in the SBP < 140 group
compared to the SBP < 180 group

72. Critical Care
• In pt’s on Coumadin with ANY INR and major
bleeding, give 10 mg Vitamin K IV (we already
knew that) and PCC!
– 25x more clotting factors than FFP
– Reverses INR in 3-15 minutes (compared to 13
hours – 48 hours with FFP)
– No ABO compatibility required (compared to
required ABO compatibility and 20 minutes of
thaw time with FFP)

73. Siciliano

74. Awake Intubation
Genine Siciliano, PGY 3
Summary of ACEP Lecture by Drs. Diane M. Birnbaumer, MD,
FACEP and
Peter M. DeBlieux, MD, FACEP

75. Who, When, Why?
• Airway compromise
• Obese
• Anaphylaxis
• Angioedema
• Trauma
• Consider in all Potentially difficult
airways
– Maintains airway patency,
breathing/oxygenation, muscle tone
• Urgent/emergent, but you have a few
minutes

77. How?
• Control Secretions/blood/vomit
– Glycopyrrolate  0.5 to 0.8mg IV
– Zofran  6mg IV
• LOTS of Lidocaine (oral, nasal, tracheal, lower airway)
– Nebulized w/o epi (4 mL 4% (40mg/ml))- 10min
– Atomized (2-3 mL 4% preferred) – best for oral/nasal
mucosa
– Viscous (4% preferred; 2% alternative)- gargle, sniff,
swab
– Don’t forget about toxic dose (4-5 mg/kg)
– Nasal prep
• Phenylephrine 0.5% or oxymetazoline 0.05%
• Extra syringe of 4% (or 2%) lidocaine for during
procedure if needed

78. How? – Sedation & Paralytics
• Ketamine
– 1 mg/kg IV dosed in 20 mg amounts until
desired effect is achieved
• If you see tears = almost there
– May use other agents but ketamine preferred
• Succinylcholine
– Paralytic of choice as fast acting

79. Pearls for the Intubation Moment
• Keep nasal cannula on during intubation –
apneic oxygenation
• Respect the BOUGIE!!!!!!!!!!
• Once in airway, THEN quickly follow
with more sedation and paralytic

80. Bonus! - Velez

81. • 2013 ACC/AHA guidelines – new o presumed
new LBBB no longer an indication for cath lab
or immediate repercussion. No longer a STEMI
equivalent unless hemodynamic instability or
Sgarbossa positive

82. • ECG in PE:
– S1Q3T3 or S1Q3 (R axis)
– New RBBB or iRBBB
– SVTs
– Vts
– ST segment deviations
– But….also new T inversions in anteroseptal and/or
inferior leads (Witting 2012: when seen together
is 95% specific for PE)

83. • Posterior MI, now is called inferolateral
– 3rd Universal Definition of MI 2012:
• ST depression in anteroseptal leads (V1-3)
– What to do: put two posterior leads on either side
of the L scapula
– Just need 0.5 mm elevation!!!
• Mimics: hypoK and anteroseptal ischemia –
that is why posterior leads are useful

84. • Mattu rule for SVT with aberrancy vs VT
– If clearly SVT (you see p waves), treat as such
– If not, treat as VT
– Why? Much to lose
• Verecki algorithm 93% sensitive but many steps
• R wave to peak time (RWPT): easy but 76% sensitivity