Naval Medical Center Portsmouth IDC Symposium

1. Naval Medical Center Portsmouth IDC Symposium “Welcome”

2. Emergency Medicine Pearls David Johnson CDR, MC, USN Department of Emergency Medicine Naval Medical Center Portsmouth

4. 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

5. Book Recommendations

6. Approach - Prepare • Teamwork • Know your equipment and its location • ABC’s first • Train your crew and department

7. Arrival on scene • Take charge • Get the help you need • Defuse the situation • Get the pt where they need to go

8. 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

9. 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

10. 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

11. Acute Myocardial Infarction • Diagnosis • Suspicious Chest Pain History • EKG With Characteristic Changes • Elevated Serum Markers

12. Acute Myocardial Infarction

13. Early Repolarization

14. Acute Myocardial Infarction • Treatment • IV, O2, Monitors • Antiplatelet (Aspirin 325mg) • +/- Nitroglycerine (0.4mg SL q5 x3) • Anticoagulation (heparin, lovenox 1mg/kg))

15. Emergency End-Organ Damage Urgency DBP >115 mmHg Not really used anymore Hypertension

16. 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

17. Syncope

18. Closed Head Injury

19. 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

20. Increased ICP • Elevate HOB 30 degrees • Intubate! • Avoid Hypotension • Mannitol 1gm/kg • HTS? • ? Seizure prophylaxis (phenytoin) • Medevac/CT

21. 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!

22. 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

23. 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

24. 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

25. Pneumonia • Mycoplasmapneumoniae • Antibioitics • macrolide • fluoroquinolone • doxycycline

26. Pharyngitis • GABHS – Centor • Exudates • Anterior lymph nodes • Fever • Absence of cough • Suppurative Complications • Antibiotic Selection • Steroids

27. Acute Gastroenteritis • Volume Assessment • IV vs Oral Rehydration • Antiemetics • Phenergan 12.5/25 • Zofran

28. Acute Gastroenteritis • Oral Rehydration Formula • 1 qt water • 1 cup OJ • 4 tbsp sugar • 1 tsp baking soda • 3/4 tsp table salt

29. 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)

30. 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)

31. UTI • Simple • TMP-SMX • Nitrofurantoin • Fluoroquinolones • Pyridium • Pyelonephritis • Initial Long-Acting IV Antibiotic (Ceftriaxone), IVF & Analgesia • Fluoroquinolones • TMP-SMX • Pyridium

32. STDs • Quinolone Resistance • Antibiotics • Ceftriaxone250mg IM • PLUS • Azithromycin 1gm po x 1 OR • Doxycycline 100mg po BID f7

33. Lacerations • Antibiotics • Tetanus • Anesthesia Selection

34. 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

35. 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

36. Procedural Sedation • Amnesia • Benzodiazepines • Ketamine • Analgesia • Opiates

37. Altered Mental Status • ABC’s, IV, O2, accucheck, C-spine • History and physical • Intervene as needed • D50, narcan, thiamine • Labs as available

38. Toxicology • Sympathomimetics, Anticholinergic, Cholinergic • Benzo’s are your friend • Alcohol withdrawal • Atropine / 2 PAM • Glucagon (B-blockers) • Naloxone, flumazenil

39. Questions?