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Naval Medical Center Portsmouth IDC Symposium PowerPoint PPT Presentation


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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

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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

    • Shipboard

    • Off ship

  • You’re the expert – find where to look

    • www.emedicine.com

    • www.mdconsult.com


Book Recommendations


Approach - Prepare

  • Teamwork

  • Know your equipment and its location

  • ABC’s first

  • Train your crew and department


Arrival on scene

  • Take charge

  • Get the help you need

  • Defuse the situation

  • Get the pt where they need to go


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

  • 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

  • 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

  • Diagnosis

    • Suspicious Chest Pain History

    • EKG With Characteristic Changes

    • Elevated Serum Markers


Acute Myocardial Infarction


Early Repolarization


Acute Myocardial Infarction

  • Treatment

    • IV, O2, Monitors

    • Antiplatelet (Aspirin 325mg)

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

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


Emergency

End-Organ Damage

Urgency

DBP >115 mmHg

Not really used anymore

Hypertension


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


Syncope


Closed Head Injury


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

  • Elevate HOB 30 degrees

  • Intubate!

  • Avoid Hypotension

  • Mannitol 1gm/kg

    • HTS?

  • ? Seizure prophylaxis (phenytoin)

  • Medevac/CT


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

  • “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

  • 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

  • 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

  • Mycoplasmapneumoniae

  • Antibioitics

    • macrolide

    • fluoroquinolone

    • doxycycline


Pharyngitis

  • GABHS – Centor

    • Exudates

    • Anterior lymph nodes

    • Fever

    • Absence of cough

  • Suppurative Complications

  • Antibiotic Selection

  • Steroids


Acute Gastroenteritis

  • Volume Assessment

  • IV vs Oral Rehydration

  • Antiemetics

    • Phenergan 12.5/25

    • Zofran


Acute Gastroenteritis

  • Oral Rehydration Formula

    • 1 qt water

    • 1 cup OJ

    • 4 tbsp sugar

    • 1 tsp baking soda

    • 3/4 tsp table salt


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

  • 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

  • Antibiotics

  • Tetanus

  • Anesthesia Selection


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

  • 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

  • Amnesia

    • Benzodiazepines

    • Ketamine

  • Analgesia

    • Opiates


Altered Mental Status

  • ABC’s, IV, O2, accucheck, C-spine

  • History and physical

  • Intervene as needed

    • D50, narcan, thiamine

  • Labs as available


Toxicology

  • Sympathomimetics, Anticholinergic, Cholinergic

  • Benzo’s are your friend

    • Alcohol withdrawal

  • Atropine / 2 PAM

  • Glucagon (B-blockers)

  • Naloxone, flumazenil


Questions?


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