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Naval Medical Center Portsmouth IDC Symposium. “Welcome” . Emergency Medicine Pearls. David Johnson CDR , MC, USN Department of Emergency Medicine Naval Medical Center Portsmouth. Emergency Medicine on Ship. Platform dependent Various expertise levels Medication dependent Ask for help

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Naval Medical Center Portsmouth

IDC Symposium

“Welcome”


Emergency medicine pearls

Emergency Medicine Pearls

David Johnson

CDR, MC, USN

Department of Emergency Medicine

Naval Medical Center Portsmouth


Emergency medicine on ship
Emergency Medicine on Ship

  • Platform dependent

    • Various expertise levels

    • Medication dependent

  • Ask for help

    • Shipboard

    • Off ship

  • You’re the expert – find where to look

    • www.emedicine.com

    • www.mdconsult.com



Approach prepare
Approach - Prepare

  • Teamwork

  • Know your equipment and its location

  • ABC’s first

  • Train your crew and department


Arrival on scene
Arrival on scene

  • Take charge

  • Get the help you need

  • Defuse the situation

  • Get the pt where they need to go


Mass casualty
Mass casualty

  • If you don’t know what to do before it happens, it’s too late.

  • Know your plan

  • Write your plan

  • You are the expert


Trauma
Trauma

  • ABC’s, IV, O2 monitor

  • C-spine – NEXUS

    • No distracting injury

    • No neuro deficits

    • No altered mental status

    • No midline tenderness

    • No alcohol

  • Complete remainder of exam and intervene as needed


Minor trauma ottawa
Minor trauma - Ottawa

  • Ankle

    • Unable to bear weight (3 steps)

    • Lateral, medial malleolar pain

  • Foot

    • Unable to bear weight

    • Navicular bone pain

    • 5th metatarsal pain

  • Knee

    • Unable to bear weight

    • Patellar pain

    • Fibular head pain

    • >55 yrs

    • Unable to flex >90


Acute myocardial infarction
Acute Myocardial Infarction

  • Diagnosis

    • Suspicious Chest Pain History

    • EKG With Characteristic Changes

    • Elevated Serum Markers




Acute myocardial infarction2
Acute Myocardial Infarction

  • Treatment

    • IV, O2, Monitors

    • Antiplatelet (Aspirin 325mg)

    • +/- Nitroglycerine (0.4mg SL q5 x3)

    • Anticoagulation (heparin, lovenox 1mg/kg))


Hypertension

Emergency

End-Organ Damage

Urgency

DBP >115 mmHg

Not really used anymore

Hypertension


Hypertension1
Hypertension

  • Emergency

    • 30% in 1°

    • Meds: Nitroprusside, Nitroglycerine, Labetalol (20mg IV, double dose q10 until goal (max 300mg))

  • Urgency

    • 24-48°

    • Meds: Nifedipine, Labetalol, Clonidine, ACE I’s

  • Special Cases

    • Pregnancy

    • Cocaine




Closed head injury1
Closed Head Injury

CT Scan Indications - History

  • Any LOC

  • Amnesia

  • Coagulopathy

  • Post Trauma Seizure

  • Post Trauma Emesis

    CT Scan Indications - Physical

  • Focal Neurologic Findings

  • Asymmetric Pupils

  • Distracting Injury

  • Intoxication

  • Large Extracranial Hematoma

  • Signs of Skull Fracture


Increased icp
Increased ICP

  • Elevate HOB 30 degrees

  • Intubate!

  • Avoid Hypotension

  • Mannitol 1gm/kg

    • HTS?

  • ? Seizure prophylaxis (phenytoin)

  • Medevac/CT


Seizure
Seizure

  • ABC’s, IV, O2

  • Goal stop in 30 min

  • Stop the seizure

    • Ativan – 2-4mg IV, repeat up to 10mg

    • Phenytoin 20mg/kg IV at 50mg/min

  • Consider alcohol withdrawal

    • Thiamine 100mg IV, Dextrose

  • Make sure not pregnant!


Migraine headache
Migraine Headache

  • “Kitchen Sink:” IV, Oxygen, Benadryl 25mg IV, Toradol 30 mg IV, Compazine/Reglan 10 mg IV

  • Narcotics

  • Sumitriptans

  • Depakote: 500mg IV (1 dose and then d/c)

  • DHE: Q8° for 48-72 °’s

  • Lidocaine 4% Intranasal 1cc


Asthma
Asthma

  • History and physical

  • Acute Treatment

    • Beta Agonists (albuterol 2,5-5mg)

    • Anticholinergics (atrovent)

    • Steroids (solumedrol 125mg IV, decadron 10mg IV)

    • Subcutaneous epinephrine (1:1000) 0.1-0.5mg SQ

    • Magnesium 50mg/kg IV over 20 min

    • Peak Flows


Allergic reaction
Allergic reaction

  • Pruritis, urticaria, vomiting, SOB

  • Benadryl 50 mg IV

  • Zantac 50 mg IV

  • Epinephrine

    • 0.3mg IM of 1:1000

    • Dilute 1 ml of 1:10000 in 9 cc NS (100mcg/10ml) at 5-10 mcg/min

    • Mix 1 ml of 1:1000 in 250cc D5W (4mcg/ml) at 4-10mcg/min

  • Albuterol, Solumedrol, glucagon


Pneumonia
Pneumonia

  • Mycoplasmapneumoniae

  • Antibioitics

    • macrolide

    • fluoroquinolone

    • doxycycline


Pharyngitis
Pharyngitis

  • GABHS – Centor

    • Exudates

    • Anterior lymph nodes

    • Fever

    • Absence of cough

  • Suppurative Complications

  • Antibiotic Selection

  • Steroids


Acute gastroenteritis
Acute Gastroenteritis

  • Volume Assessment

  • IV vs Oral Rehydration

  • Antiemetics

    • Phenergan 12.5/25

    • Zofran


Acute gastroenteritis1
Acute Gastroenteritis

  • Oral Rehydration Formula

    • 1 qt water

    • 1 cup OJ

    • 4 tbsp sugar

    • 1 tsp baking soda

    • 3/4 tsp table salt


Acute gastroenteritis2
Acute Gastroenteritis

  • Antibiotics: Diarrhea + Blood, Fecal WBCs, Fever, Pain, >6 BMs/24°, Diarrhea >48°, Immunosuppression, or Travel History

    • Fluoroquinolones (cipro 500mg bid x3)

    • Macrolides

    • TMP-SMX

  • Antimotility Agents (pepto, Imodium)


Urolithiasis
Urolithiasis

  • Diagnosis

    • UA, CT

  • Treatment

    • NSAIDs (Ketorolac 30mg IV, Naprosyn 500mg po BID)

    • Opiates (Morphine 4mg IV, Vicodin 1-2 po q6h PRN)

    • Antiemetics (Phenergan /Zofran)


UTI

  • Simple

    • TMP-SMX

    • Nitrofurantoin

    • Fluoroquinolones

    • Pyridium

  • Pyelonephritis

    • Initial Long-Acting IV Antibiotic (Ceftriaxone), IVF & Analgesia

    • Fluoroquinolones

    • TMP-SMX

    • Pyridium


STDs

  • Quinolone Resistance

  • Antibiotics

    • Ceftriaxone250mg IM

    • PLUS

    • Azithromycin 1gm po x 1 OR

    • Doxycycline 100mg po BID f7


Lacerations
Lacerations

  • Antibiotics

  • Tetanus

  • Anesthesia Selection


Lacerations1
Lacerations

Tetanus Prophylaxis

dT: Diptheria & Tetnus Toxoids

TIG: Tetnus Immune Globulin

*Refer these patients to complete their series, dT in 6 weeks and 6 months


Laceration
Laceration

  • Suture Removal Timeline

    • 1. Face: 3 to 5 days (always replace with Steri Strips)

    • 2. Scalp and Trunk: 7 to 10 days

    • 3. Arms and legs: 10 to 14 days

    • 4. Joints: 14 days


Procedural sedation
Procedural Sedation

  • Amnesia

    • Benzodiazepines

    • Ketamine

  • Analgesia

    • Opiates


Altered mental status
Altered Mental Status

  • ABC’s, IV, O2, accucheck, C-spine

  • History and physical

  • Intervene as needed

    • D50, narcan, thiamine

  • Labs as available


Toxicology
Toxicology

  • Sympathomimetics, Anticholinergic, Cholinergic

  • Benzo’s are your friend

    • Alcohol withdrawal

  • Atropine / 2 PAM

  • Glucagon (B-blockers)

  • Naloxone, flumazenil



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