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?