Naval Medical Center Portsmouth

IDC Symposium

Naval Medical Center Portsmouth

IDC Symposium

“Welcome” “Welcome”

Emergency Medicine Pearls

David JohnsonCDR, MC, USN

Department of Emergency MedicineNaval 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))

Hypertension

Emergency End-Organ Damage

Urgency DBP >115 mmHg Not really used anymore

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 LOCAmnesiaCoagulopathyPost Trauma SeizurePost Trauma Emesis

CT Scan Indications - Physical

Focal Neurologic FindingsAsymmetric PupilsDistracting InjuryIntoxicationLarge Extracranial HematomaSigns 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

Mycoplasma pneumoniae 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

Ceftriaxone 250mg IM PLUS Azithromycin 1gm po x 1 OR Doxycycline 100mg po BID f7

Lacerations

Antibiotics Tetanus Anesthesia

Selection

Lacerations

Immunization History dT (0.5 ml) TIG (250 IU)

Fully Immunized(<10 yrs since

booster)No No

Fully Immunized(>10 yrs since

booster)Yes No

Incomplete Immunization(<3 injections)

Yes* Yes

dT: Diptheria & Tetnus ToxoidsTIG: Tetnus Immune Globulin

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

Tetanus Prophylaxis

Laceration

Suture Removal Timeline1. Face: 3 to 5 days (always replace with Steri Strips)2. Scalp and Trunk: 7 to 10 days3. Arms and legs: 10 to 14 days4. 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?