Emergency Medicine Orientationand Introduction Lecture OUWB School of Medicine Beaumont Health System

Emergency MedicineEmergency Medicine

OrientationOrientation

andand

Introduction LectureIntroduction Lecture

OUWB School of MedicineOUWB School of Medicine

Beaumont Health SystemBeaumont Health System

Lecture PurposeLecture Purpose

Introduce how emergency medicine may Introduce how emergency medicine may differ from previous rotationsdiffer from previous rotations

How do we think differently?How do we think differently? Explain where to begin with an ER patientExplain where to begin with an ER patient

Approach to the patient Approach to the patient What tests and imaging do you order?What tests and imaging do you order?

This is NOT meant to be a comprehensive This is NOT meant to be a comprehensive review, but a guide on where to begin!review, but a guide on where to begin!

TriageTriage The process of determining the priority The process of determining the priority

of patients' treatments based on the of patients' treatments based on the severity of their conditionseverity of their condition Priority 1 – Priority 1 – trauma, cardiac arrest, acute MI, CVA, psychtrauma, cardiac arrest, acute MI, CVA, psych Priority 2 - Priority 2 - afib, chf or copd, chest pain, “sick” peopleafib, chf or copd, chest pain, “sick” people Priority 3Priority 3 – – “routine” chest pain, abdominal pain, “routine” chest pain, abdominal pain,

cellulitiscellulitis Priority 4Priority 4 – – minor care, sprains, broken bones, coldsminor care, sprains, broken bones, colds Priority 5 – should be at home in bed or on the Priority 5 – should be at home in bed or on the

couchcouch

Who can you safely see in the department?Who can you safely see in the department?

Where to begin?Where to begin?

Look at the nursing sheet from triage Look at the nursing sheet from triage and the basic info in the computerand the basic info in the computer

LOOK AT THE VITALS LOOK AT THE VITALS (make sure (make sure complete)complete)

Check the physical chart for papers – Check the physical chart for papers – there may be EMS run sheet, NH there may be EMS run sheet, NH transfer papers, or who knowstransfer papers, or who knows

If lots of visits or complicated, may If lots of visits or complicated, may want to look them up in EPICwant to look them up in EPIC

Where to begin in room?Where to begin in room?

LOOK AT THE PATIENT!LOOK AT THE PATIENT! That’s right, just look at them!That’s right, just look at them!

Do they look sick?Do they look sick? Color, diaphoretic, RR, HR, position, mental statusColor, diaphoretic, RR, HR, position, mental status

Most Important Thing = Recognize Sick Most Important Thing = Recognize Sick Patient!Patient!

Other things to consider…Other things to consider…

Patterns – if chronic condition – does this Patterns – if chronic condition – does this fit the pattern or not fit the pattern or not (migraine, sz, abd pain)(migraine, sz, abd pain)

If lots of complaints – what is the one thing that If lots of complaints – what is the one thing that brought you here tonight or hurts the most or brought you here tonight or hurts the most or worries you the most? (Kur’s magic wand)worries you the most? (Kur’s magic wand)

If been going on for 6 months – what made you If been going on for 6 months – what made you come to the ER tonight?!come to the ER tonight?!

Resuscitation BasicsResuscitation Basics

IV, o2, monitor - IV, o2, monitor - usually a safe place to usually a safe place to startstart

What does the monitor include?What does the monitor include?

Start with ABCsStart with ABCs AirwayAirway BreathingBreathing CirculationCirculation

Resus BasicsResus Basics

LINE ACCESSLINE ACCESS PIV vs CentralPIV vs Central

What are some indications for central line?What are some indications for central line?

Fluids – how much and when?Fluids – how much and when? Kids – 10 or 20 cc/kg bolusKids – 10 or 20 cc/kg bolus Adults – generally 500 to 1000 cc bolusAdults – generally 500 to 1000 cc bolus

When would you bolus more?When would you bolus more? What are contraindications to fluid bolus?What are contraindications to fluid bolus?


IntubationIntubation What are some reasons to secure the What are some reasons to secure the

airway with intubation?airway with intubation?

What meds are typically used to intubate?What meds are typically used to intubate?

How about meds for continued sedation?How about meds for continued sedation?


Patient presents to EC via EMS as CPR in Patient presents to EC via EMS as CPR in progress…progress…

Call states pt is 55 year old male from Call states pt is 55 year old male from home who was working around the home who was working around the house when his wife heard a “thud”, house when his wife heard a “thud”, she found him laying at the basement she found him laying at the basement stepssteps what do you want to know and where to begin?what do you want to know and where to begin?

Resus BasicsResus BasicsCPR in progressCPR in progress

History – History – Events at time of arrest and right beforeEvents at time of arrest and right before Time of arrest or of EMS callTime of arrest or of EMS call Any question of ingestion, overdose, Any question of ingestion, overdose,

trauma, or known medical historytrauma, or known medical history Initial vitals, ecg rhythm and any Initial vitals, ecg rhythm and any

interventions done by EMSinterventions done by EMS


In the EC – everyone has a job In the EC – everyone has a job assigned prior to patient arrivingassigned prior to patient arriving MonitorMonitor Pulse oxPulse ox BP cuffBP cuff End tital CO2End tital CO2 CompressionsCompressions IV access x 2IV access x 2


ECP – start your ABCsECP – start your ABCs Airway – check if placed by EMS or secure Airway – check if placed by EMS or secure

yourself, remember if trauma suspected to place yourself, remember if trauma suspected to place C CollarC Collar

Breathing – breaths sounds, look at chest and Breathing – breaths sounds, look at chest and trachea, pulse ox and CO2trachea, pulse ox and CO2

Circulation – check pulse, listen for heart sounds, Circulation – check pulse, listen for heart sounds, look at the skin, look at the rhythm on the look at the skin, look at the rhythm on the monitor, IV access or central line, ultrasoundmonitor, IV access or central line, ultrasound

What if there is no pulse?What if there is no pulse? Where should pulse be checked?Where should pulse be checked?


Look at the monitor…Look at the monitor… The rhythm present helps to guide therapyThe rhythm present helps to guide therapy Must be re-evaluated oftenMust be re-evaluated often

Quick review of rhythms and Quick review of rhythms and managementmanagement


V fib or pulseless VTV fib or pulseless VT• #1 Defibrillation#1 Defibrillation• If not available, CPR until availableIf not available, CPR until available• Secure airway and IV accessSecure airway and IV access• Epinephrine q3-5minEpinephrine q3-5min• AmiodaroneAmiodarone• Repeat defibrillation 2 minutes after drugsRepeat defibrillation 2 minutes after drugs

• When do you consider magnesium or NaBicarb?When do you consider magnesium or NaBicarb?


PEA and AsystolePEA and Asystole CPRCPR Secure airway and IV accessSecure airway and IV access EpinephrineEpinephrine Atropine (for brady rhythm without pulse)Atropine (for brady rhythm without pulse) Treat reversible causesTreat reversible causes

5H = hypoxia, hypovolemia, acidosis, 5H = hypoxia, hypovolemia, acidosis, hypo/hyperkalemia, hypothermiahypo/hyperkalemia, hypothermia

5T = toxins, tamponade, tension pneumo, 5T = toxins, tamponade, tension pneumo, thrombosis/pe, thrombosis/cadthrombosis/pe, thrombosis/cad

Resuscitation: SIRS/SepsisResuscitation: SIRS/Sepsis

SIRS - 2 or more of the followingSIRS - 2 or more of the following Temp > 38 or < 36 CTemp > 38 or < 36 C HR > 90HR > 90 RR > 20 or PaCO2 < 32RR > 20 or PaCO2 < 32 WBC > 12 or <4WBC > 12 or <4

Resuscitation: SIRS/SepsisResuscitation: SIRS/Sepsis SepsisSepsis

Suspected infection and SIRSSuspected infection and SIRS Severe SepsisSevere Sepsis

Sepsis associated with organ dysfunction or Sepsis associated with organ dysfunction or hypotensionhypotension

Lactic acidosis, oliguria, MS changeLactic acidosis, oliguria, MS change

Septic ShockSeptic Shock SIRS with hypotension despite adequate fluid SIRS with hypotension despite adequate fluid

resuscitation, initiate pressor supportresuscitation, initiate pressor support

Resuscitation: SIRS/SepsisResuscitation: SIRS/Sepsis

Recognize this condition earlyRecognize this condition early

Initial TreatmentInitial Treatment Oxygen with Early intubationOxygen with Early intubation Adequate access with fluid resuscitationAdequate access with fluid resuscitation Appropriate antibioticsAppropriate antibiotics Central line with vasopressorsCentral line with vasopressors

Any Questions?Any Questions?

TraumaTrauma

Resus starts the same way…Resus starts the same way… IV x 2, o2, monitor, full set of vitalsIV x 2, o2, monitor, full set of vitals AMPLE historyAMPLE history

Mechanism of injury importantMechanism of injury important MVC vs Fall vs GSW vs hangingMVC vs Fall vs GSW vs hanging

TraumaTrauma Team approach between the Emergency Team approach between the Emergency

Department and Surgical TeamDepartment and Surgical Team

Level 1Level 1 – – Hemodynamic or respiratory compromise, MS change, Hemodynamic or respiratory compromise, MS change, Anticoagulant fall with GCS < 8, Penetrating injury to head/neck/chest/abd or Anticoagulant fall with GCS < 8, Penetrating injury to head/neck/chest/abd or proximal extremity, flail chest, pelvic fx, aputation proximal to wrist or ankle, proximal extremity, flail chest, pelvic fx, aputation proximal to wrist or ankle, skull fractures, any burn with airway compromise, trauma transfer with skull fractures, any burn with airway compromise, trauma transfer with hemodynamic or neuro compromise or receiving transfusionhemodynamic or neuro compromise or receiving transfusion

Level 2Level 2 – – GCS 8-13, anticoagulant fall with GCS 8-13, penetrating GCS 8-13, anticoagulant fall with GCS 8-13, penetrating injury distal to elbow or knee unless unstable, burns > 20% BSA, paralysis, injury distal to elbow or knee unless unstable, burns > 20% BSA, paralysis, victim thrown from any vehicle > 10feet, roll over or significant impact > victim thrown from any vehicle > 10feet, roll over or significant impact > 20mph, 2+ long bone fx, amputation or crush distal to wrist or ankle, stable 20mph, 2+ long bone fx, amputation or crush distal to wrist or ankle, stable trauma transfers, MVC with fatality or >50mph or ejection or extrication > trauma transfers, MVC with fatality or >50mph or ejection or extrication > 20min or major intrusion into compartment, fall > 15 feet, auto vs pedestrian 20min or major intrusion into compartment, fall > 15 feet, auto vs pedestrian or bikeor bike

Trauma Consults-Trauma Consults- anticoagulant falls with GCS 14-15, low anticoagulant falls with GCS 14-15, low speed mvc, any trauma admitted to non surgical servicespeed mvc, any trauma admitted to non surgical service

Trauma ATLSTrauma ATLSABCDE, secondary surveyABCDE, secondary survey A – airway and c spine immobilizationA – airway and c spine immobilization B – breathing and ventilationB – breathing and ventilation

(what is the difference between A and B?)(what is the difference between A and B?)

C – circulation and hemorrhage controlC – circulation and hemorrhage control D – disability and brief neuro examD – disability and brief neuro exam E – exposure and environment controlE – exposure and environment control Secondary Survey – Secondary Survey – head to toe eval, more head to toe eval, more

detailed H/Pdetailed H/P

FAST exam – FAST exam – can be done in the primary or can be done in the primary or secondary surveysecondary survey

Trauma CasesTrauma Cases

MVCMVC 45 year old male unrestrained driver hits 45 year old male unrestrained driver hits

the cement median is ejected from the the cement median is ejected from the car, smells strongly of alcohol, moaning, car, smells strongly of alcohol, moaning, obvious facial trauma with blood in the obvious facial trauma with blood in the mouthmouth

HR 120 BP 90/50 pulse ox 88% on NRB RR 22HR 120 BP 90/50 pulse ox 88% on NRB RR 22

Where do you begin?Where do you begin?


MVCMVC 45 year old male driving 45 mph drives into the 45 year old male driving 45 mph drives into the

side of a cement building trying to commit side of a cement building trying to commit suicide, although he was restrained with airbag suicide, although he was restrained with airbag deployment. He complains of difficulty deployment. He complains of difficulty breathing and lower abd pain. He thinks he hit breathing and lower abd pain. He thinks he hit his head on the steering wheel and may have his head on the steering wheel and may have briefly passed out.briefly passed out.

HR 120 BP 90/50 pulse ox 99 on NRB RR 35HR 120 BP 90/50 pulse ox 99 on NRB RR 35 Quick look reveals contusion to forehead and Quick look reveals contusion to forehead and seatbelt seatbelt

sign sign to chest and abdomento chest and abdomen

Now where do you begin?Now where do you begin?


Penetrating injuryPenetrating injury Patient presents with a hole in his left upper Patient presents with a hole in his left upper

chest wall, midclavicular line somewhere chest wall, midclavicular line somewhere around the 4around the 4thth rib rib

HR 120 BP 80/40 RR 40 pulse ox 99 on NRBHR 120 BP 80/40 RR 40 pulse ox 99 on NRB Where is the best place to begin?Where is the best place to begin?

What are potential differences if this is gsw vs knife?What are potential differences if this is gsw vs knife? What happens if you put in a chest tube and 1500cc of What happens if you put in a chest tube and 1500cc of

blood returns?blood returns? What if you put in a chest tube and no blood or air What if you put in a chest tube and no blood or air

returns and the patient is still in extremis?returns and the patient is still in extremis?


FallFall 23 year old male jumps out of the 23 year old male jumps out of the

second story window of a burning second story window of a burning building landing on his feet. He building landing on his feet. He complains of foot and back pain.complains of foot and back pain.

Vitals HR 100 BP 150/90 RR 20 pulse ox 99 Vitals HR 100 BP 150/90 RR 20 pulse ox 99 RARA

What is the classic injury pattern?What is the classic injury pattern?


StrangulationStrangulation 18 year old male hangs himself with a rope from 18 year old male hangs himself with a rope from

the garage rafters. EMS is bagging the patient on the garage rafters. EMS is bagging the patient on arrival and he had vitals on scene.arrival and he had vitals on scene.

HR 120 BP 100/50 RR agonal pulse ox 60s and the HR 120 BP 100/50 RR agonal pulse ox 60s and the patient was bluepatient was blue

Where do you begin? Do you anticipate any Where do you begin? Do you anticipate any issues?issues?

What are injuries to worry about?What are injuries to worry about?

Trauma Questions?Trauma Questions?

Chest PainChest Pain

Chest pain can be a lot of things…Chest pain can be a lot of things…

What are the 6 things we typically What are the 6 things we typically worry about as being life worry about as being life threatening?threatening?


Acute coronary syndromeAcute coronary syndrome Aortic DissectionAortic Dissection Pulmonary EmbolusPulmonary Embolus PneumothoraxPneumothorax Pericarditis with tamponadePericarditis with tamponade Esophageal RuptureEsophageal Rupture

ACSACS

Acute MI or STEMIAcute MI or STEMI NSTEMINSTEMI Unstable Angina (USA)Unstable Angina (USA) AnginaAngina Chest PainChest Pain

So what’s the difference?!So what’s the difference?!

Acute MI or STEMIAcute MI or STEMI

ecg with ST elevation = big dealecg with ST elevation = big deal Activate cath lab or interventional Activate cath lab or interventional

cardiologycardiology ASA, ntg, heparin ASA, ntg, heparin morphine, beta blocker, and possibly morphine, beta blocker, and possibly

plavix or integrillinplavix or integrillin

When do you hesitate to give ntg?When do you hesitate to give ntg?

NSTEMI or USANSTEMI or USA

Essentially the same without the cath labEssentially the same without the cath lab Asa, heparin, ntg, beta blocker, morphine, Asa, heparin, ntg, beta blocker, morphine,

plavix, integrilin, etcplavix, integrilin, etc

When do you talk to the cardiologist?When do you talk to the cardiologist? Positive enzymesPositive enzymes Still having painStill having pain Starting integrilin or other newer Starting integrilin or other newer

anticoagulantsanticoagulants


Management depends on the risk Management depends on the risk factors, clinical history, ecg and how factors, clinical history, ecg and how the patient looksthe patient looks

Big question is do you start all the Big question is do you start all the meds or do you give an asa and meds or do you give an asa and await the labsawait the labs

Chest Pain OrdersChest Pain Orders

EcgEcg Chest xrayChest xray Potential labsPotential labs

CbcCbc BmpBmp Hepatic panel and lipaseHepatic panel and lipase Troponin q3 x 3Troponin q3 x 3 Pt, ptt, type screenPt, ptt, type screen HcgHcg D dimerD dimer

Chest pain dispoChest pain dispo

Who goes where?Who goes where? ICUICU Progressive or step downProgressive or step down RMF with telemetryRMF with telemetry OBSOBS

ECG ReviewECG Review







Aortic DissectionAortic Dissection

Severe CP radiating to back or abdomenSevere CP radiating to back or abdomen Neuro complaints possible as dissect into Neuro complaints possible as dissect into

carotids or more peripheral arteriescarotids or more peripheral arteries Ischemia of limbsIschemia of limbs Asymmetric pulsesAsymmetric pulses Remember increased risk for Marfan’s or Remember increased risk for Marfan’s or

congenital bicuspid aortic valvescongenital bicuspid aortic valves

Aortic Dissection: TestsAortic Dissection: Tests

Ecg – Ecg – LVH, nonspecific changes, ischemic changes LVH, nonspecific changes, ischemic changes if dissect back to coronary arteriesif dissect back to coronary arteries

Chest XrayChest Xray – mediastinum widening, – mediastinum widening, WHAT ELSEWHAT ELSE??

Imaging – CT Dissection ProtocolImaging – CT Dissection Protocol What other imaging is availableWhat other imaging is available??

Potential LabsPotential Labs CBC, CMP, Lipase, troponin, pt/ptt, type screen, ua, d dimerCBC, CMP, Lipase, troponin, pt/ptt, type screen, ua, d dimer

Aortic Dissection: TreatmentAortic Dissection: Treatment

Suspected DissectionSuspected Dissection Pain controlPain control BP control – what meds?BP control – what meds? No anticoagulantsNo anticoagulants

Confirmed Dissection – what’s the Confirmed Dissection – what’s the difference?difference? Type AType A Type BType B

Pulmonary Embolism: PEPulmonary Embolism: PE

Sudden onset sharp pain or dyspneaSudden onset sharp pain or dyspnea 50% cough, <20% hemoptysis50% cough, <20% hemoptysis Angina like ssx 5%Angina like ssx 5% Risk FactorsRisk Factors

Post opPost op PregnantPregnant Oral contraceptives = Oral contraceptives = birth control or post menopausal birth control or post menopausal

replacementreplacement Heart DiseaseHeart Disease CancerCancer Immobility or prolonged sitting/layingImmobility or prolonged sitting/laying TraumaTrauma Previous dvt or PEPrevious dvt or PE

PEPE

What may be some abnormal vitals in What may be some abnormal vitals in a patient with PE?a patient with PE?

What may a patient with PE look like?What may a patient with PE look like?

PEPE

AnxiousAnxious Dyspnea at rest or with conversationDyspnea at rest or with conversation RR > 16RR > 16 Tachycardia = Tachycardia = #1 most common ecg #1 most common ecg

changechange Low grade feverLow grade fever HypoxiaHypoxia

PEPE

When do I really worry about PE?When do I really worry about PE? Good storyGood story But really when the patient is dyspneic, But really when the patient is dyspneic,

hypoxic, or tachycardic and the lungs hypoxic, or tachycardic and the lungs are clear and the chest xray is normalare clear and the chest xray is normal= patient looks short of breath and the vitals = patient looks short of breath and the vitals

are abnormal but the labs and chest xray are abnormal but the labs and chest xray are normalare normal

PE: diagnosisPE: diagnosis

Ecg – Ecg – tachycardia most common, right heart strain, new tachycardia most common, right heart strain, new RBBB, nonspecific changesRBBB, nonspecific changes

Chest xray – Chest xray – commonly normal, atelectasis, commonly normal, atelectasis, focal opacity from infarctfocal opacity from infarct

Potential Labs = Potential Labs = cbc, bmp, troponin, d cbc, bmp, troponin, d dimer, pt/ptt, type screendimer, pt/ptt, type screen When is d dimer most helpfulWhen is d dimer most helpful?? Why order a troponinWhy order a troponin??

PE: ImagingPE: Imaging

#1 Chest CT IV contrast PE protocol#1 Chest CT IV contrast PE protocol What are contraindications?What are contraindications?

V/Q scanV/Q scan 2d echo2d echo BLE venous dopplerBLE venous doppler

What do you do with pregnant What do you do with pregnant patients?!patients?!

PE TreatmentPE Treatment

Positive Chest CT with PEPositive Chest CT with PE Hemodynamically stable = heparinHemodynamically stable = heparin Unstable = consider thrombolyticsUnstable = consider thrombolytics

What if they have a positive D Dimer What if they have a positive D Dimer and you cannot obtain a chest ct…and you cannot obtain a chest ct… Because they are pregnant?Because they are pregnant? Because they have a contrast allergy?Because they have a contrast allergy?

PneumothoraxPneumothorax

Usually sudden onset of chest or back pain Usually sudden onset of chest or back pain with shortness of breathwith shortness of breath

Pleuritic = hurts to breath deeplyPleuritic = hurts to breath deeply Tension PTX – hypotension, tachy, Tension PTX – hypotension, tachy,

distended neck veinsdistended neck veins PE – decreased breath sounds, resonance PE – decreased breath sounds, resonance

on percussion, crepituson percussion, crepitus

What are some risk factors for PTX?What are some risk factors for PTX?

PneumothoraxPneumothorax

DiagnosisDiagnosis Tension = clinically by history and PETension = clinically by history and PE Chest xray – may need inspiratory and Chest xray – may need inspiratory and

expiratory viewsexpiratory views

Treatment – Chest TubeTreatment – Chest Tube

How do you determine size of chest How do you determine size of chest tube?tube?

Any Questions on Chest Any Questions on Chest Pain?Pain?

Atrial Fibrillation = Afib with Atrial Fibrillation = Afib with RVRRVR

Tachycardia, irregularly irregularTachycardia, irregularly irregular Narrow complex unless history of BBBNarrow complex unless history of BBB Max rate 150s-170sMax rate 150s-170s

If faster suspect an accessory conduction pathwayIf faster suspect an accessory conduction pathway Occurs in normal heart, underlying Occurs in normal heart, underlying

disease or “holiday” heartdisease or “holiday” heart CAD, valvular disease, pericarditis, CAD, valvular disease, pericarditis,

hyperthyroidism, SSS, contusion, HTN< hyperthyroidism, SSS, contusion, HTN< PE, CHFPE, CHF

Afib: TreatmentAfib: Treatment Rate ControlRate Control

calcium channel blocker = cardizemcalcium channel blocker = cardizem Beta blocker = lopressorBeta blocker = lopressor DigoxinDigoxin

Rate ConvesionRate Convesion Pharmacologic – Pharmacologic – amiodarone, procainimide, ibutilideamiodarone, procainimide, ibutilide

CardioversionCardioversion Anti CoagulationAnti Coagulation

Usually heparinUsually heparin Make sure to check med list, may already be on Make sure to check med list, may already be on

coumadin or xareltocoumadin or xarelto

AfibAfib

AfibAfib

Congestive Heart Failure: CHFCongestive Heart Failure: CHFPresentationPresentation

DyspneaDyspnea WheezingWheezing CoughCough SwellingSwelling Weight gainWeight gain Chest tightnessChest tightness PalpitationsPalpitations

CHF: things to considerCHF: things to consider

History of CAD/CHFHistory of CAD/CHF ACSACS HTNHTN DysrhythmiaDysrhythmia InfectionInfection AnemiaAnemia Myocaridits/Myocaridits/

PericarditisPericarditis ComplianceCompliance

PregnancyPregnancy ThyroidThyroid Valve DysfunctionValve Dysfunction PEPE PharmacologyPharmacology

Recent med changeRecent med change SteroidsSteroids NsaidsNsaids vasodilatorsvasodilators

CHF: DiagnosisCHF: Diagnosis

Ecg – Ecg – normal/unchanged, nonspecific or MInormal/unchanged, nonspecific or MI Chest Xray – cephalization, congestion, Chest Xray – cephalization, congestion,

effusioneffusion Labs to ConsiderLabs to Consider

CBC, CMP, trop, BNP, PT/PTT, MagCBC, CMP, trop, BNP, PT/PTT, Mag

Anything you think may have tipped them Anything you think may have tipped them over the edge…over the edge… Urine for possible utiUrine for possible uti TSHTSH

CHF: TreatmentCHF: Treatment

OxygenOxygen ASAASA ACS – treat as appropriateACS – treat as appropriate HTN – ntgHTN – ntg Diuresis – lasixDiuresis – lasix Pain – morphinePain – morphine Bronchospasm – breathing treatmentBronchospasm – breathing treatment BiPapBiPap Intubation – last resortIntubation – last resort

Respiratory: BronchospasmRespiratory: BronchospasmCOPD and AsthmaCOPD and Asthma

PresentationPresentation DyspneaDyspnea TachypneaTachypnea WheezingWheezing Tight, decreased, no wheeze (worse!)Tight, decreased, no wheeze (worse!) TachycardiaTachycardia ““tripoding” positiontripoding” position


HistoryHistory New onset or known diagnosisNew onset or known diagnosis Current therapy if anyCurrent therapy if any Exacerbating factorsExacerbating factors

Tobacco use or other inhalantTobacco use or other inhalant IllnessIllness ExposureExposure SeasonalSeasonal


Potential OrdersPotential Orders EcgEcg Chest xrayChest xray Labs – cbc, bmp, trop, bnp, pt/ptt, mag Labs – cbc, bmp, trop, bnp, pt/ptt, mag

levellevel


TreatmentTreatment Breathing TreatmentBreathing Treatment

Albuterol/atrovent, vapo, xopenexAlbuterol/atrovent, vapo, xopenex SteroidsSteroids Benadryl (or Epi) if allergic componentBenadryl (or Epi) if allergic component MagnesiumMagnesium Antibiotics?Antibiotics? BipapBipap Do everything you can not to intubate!Do everything you can not to intubate!

Abdominal PainAbdominal Pain

Any questions before we move Any questions before we move on?on?


10% of all ED visits10% of all ED visits Can be difficult to pinpoint a causeCan be difficult to pinpoint a cause

Anything in the chest, abdomen, pelvis, Anything in the chest, abdomen, pelvis, or back can be a cause of “belly pain”or back can be a cause of “belly pain”

High risk patientsHigh risk patients Old People – more likely to have a life Old People – more likely to have a life

threatening cause (AAA)threatening cause (AAA) Reproductive Age Women - ectopicsReproductive Age Women - ectopics


Why does female vs male matter?Why does female vs male matter?

What things are usually sudden in What things are usually sudden in onset?onset?

What does acute abdomen mean or What does acute abdomen mean or imply?imply?

Diffuse Abdomal Pain DDxDiffuse Abdomal Pain DDx PeritonitisPeritonitis Acute PancreatitisAcute Pancreatitis Sickle Cell CrisisSickle Cell Crisis Early AppendicitisEarly Appendicitis Mesenteric ThrombosisMesenteric Thrombosis GatroenteritisGatroenteritis Dissecting or Rupture AneurysmDissecting or Rupture Aneurysm Intestinal ObstructionIntestinal Obstruction Diabetes MellitusDiabetes Mellitus

35 yo male presents with epigastric pain after drinking a fifth 35 yo male presents with epigastric pain after drinking a fifth of vodka…of vodka…

85 yo female presents for aching epigastric and right flank 85 yo female presents for aching epigastric and right flank pain…pain…

RUQ Abdominal PainRUQ Abdominal Pain Cholecystitis or Biliary ColicCholecystitis or Biliary Colic HepatitisHepatitis Hepatic AbscessHepatic Abscess Hepatomegaly from CHFHepatomegaly from CHF Perforated Duodenal UlcerPerforated Duodenal Ulcer PancreatitisPancreatitis Retrocecal AppendicitisRetrocecal Appendicitis Herpes ZosterHerpes Zoster Myocardial IschemiaMyocardial Ischemia RLL PneumoniaRLL Pneumonia

40 year old female presents one hour after eating fried chicken with aching 40 year old female presents one hour after eating fried chicken with aching ruq pain and vomiting…ruq pain and vomiting…

RLQ Abdominal PainRLQ Abdominal Pain AppendicitisAppendicitis Mesenteric AdenitisMesenteric Adenitis Regional EnteritisRegional Enteritis Meckel’s DiverticulitisMeckel’s Diverticulitis Cecal DiverticulitisCecal Diverticulitis Leaking AAALeaking AAA Adominal Wall Adominal Wall

HematomaHematoma Psoas AbscessPsoas Abscess

Ruptured EctopicRuptured Ectopic Ovarian Cyst/TorsionOvarian Cyst/Torsion PIDPID MittelschmerzMittelschmerz EndometriosisEndometriosis Ureteral CalculiUreteral Calculi Seminal VesiculitisSeminal Vesiculitis HerniaHernia

22 year old male presents for one day of aching belly pain, nausea and decreased oral intake. Now he has tenderness in the rlq…

22 year old female presents for sudden onset of sharp rlq pain that is now worse when she ambulates…

LUQ Abdominal PainLUQ Abdominal Pain GastritisGastritis PancreatitisPancreatitis Splenic Enlargement, rupture, infarction or Splenic Enlargement, rupture, infarction or

aneurysmaneurysm Myocardial IschemiaMyocardial Ischemia LLL pneumoniaLLL pneumonia

24 year old male presents for burning luq pain and 24 year old male presents for burning luq pain and vomiting pain after eating nachos with jalapenos vomiting pain after eating nachos with jalapenos and drinking beer at the football game…and drinking beer at the football game…

LLQ Abdominal PainLLQ Abdominal Pain

Sigmoid Sigmoid DiverticulitisDiverticulitis

Leaking AAALeaking AAA Ruptured EctopicRuptured Ectopic Ovarian Ovarian

Cyst/TorsionCyst/Torsion MittelscherzMittelscherz PIDPID EndometriosisEndometriosis

Ureteral CalculiUreteral Calculi Seminal VesiculitisSeminal Vesiculitis Psoas AbscessPsoas Abscess HerniaHernia Regional EnteritisRegional Enteritis

55 year old female presents for one day of increased cramping llq abd pain with blood streaked loose stool and decreased oral intake…

Abdominal Pain DiagnosisAbdominal Pain Diagnosis

ECGECG LABS- cbc, cmp, lipase, lactic acid, trop, LABS- cbc, cmp, lipase, lactic acid, trop,

ua, hcgua, hcg Chest XrayChest Xray KUB or AASKUB or AAS Pelvis UltrasoundPelvis Ultrasound Abdominal UltrasoundAbdominal Ultrasound Abdominal/Pelvis CTAbdominal/Pelvis CT

With or Without Contrast?With or Without Contrast?

When is CT or Ultrasound better?When is CT or Ultrasound better?

Abdominal Pain: DispoAbdominal Pain: Dispo

Depends on the diagnosis…Depends on the diagnosis… Appendicitis, cholecystitis = ?Appendicitis, cholecystitis = ? Biliary colicBiliary colic PancreatitisPancreatitis DiverticulitisDiverticulitis Ovarian cyst vs torsionOvarian cyst vs torsion PIDPID Renal Colic – size does matter, what if UTI Renal Colic – size does matter, what if UTI

present?present?

ANY QUESTIONS?!ANY QUESTIONS?!

Documents

Emergency Medicine Orientationand Introduction Lecture OUWB School of Medicine Beaumont Health System