Dosing the Turkey Sandwich: De-Escalation in the ED

Categorizing Agitation
1) Agitated but cooperative
2) Disruptive without danger
3)Agitated delirium

-Multiple ways to classify the increasingly agitated patient, pick one that works for your practice.
-Consider having a step-wise treatment approach for each level of agitation

1) Calming environment: Safe space, someone to talk to, sandwich, ginger ale
2) Offer calming medications Willing to take a PO?
3) Medication immediately: IM/IV

Medications to consider:
-Benzodiazepines (Midazolam 2.5-5mg IV/IM, short acting, rapid onset)
-Antipsychotics (PO? Quetiapine , IM/IV? Haldol)
-Don’t forget about Ketamine! Dissociated >0.7 mg/kg (avoid a partially dissociated state)

EMRAP, Approach to Agitation:
EmDocs, Art of the ED Takedown:
Life in the Fast Lane Review:


Evaluation of Hypoxia Post-Intubation

DOPE Mnemonic
Displacement: ETT in correct place?
Obstruction: Mucous plug, kink in ETT?
Pneumothorax: Listen, US, CXR
Equipment failure: Disconnect from vent and bag manually

Vent Settings to Consider:
-VC & PC: Set a mandatory rate, control for max volume or pressure
-APRV (airway pressure release ventilation)

-Review “How to Dominate the Ventilator”:

Lung Protective settings (ARDS Net)
-Low TV 6-8cc/kg ideal body weight (less alveolar distension)
-Approximate baseline minute ventilation
-Minimum PEEP 5 (avoid cyclic atelectasis)

After Intubation
-Give these patients fentanyl, make sure pain is controlled
-Hypotensive? Consider low dose fentanyl drip

Recruitment Maneuvers:


Hyperglycemia Cases
Type 1 – insulin deficit, Type II insulin resistance
Ketone bodies – Beta-hydroybuterate (not measured), Acetone, Acetoacetic acid

DKA: pH <7.3, Bicab <18, glucose >250, ketones present
HHS: Effective serum osm >320, pH >7.3, bicarb >18, Glucose >600, ketones variable, +AMS

Transitioning to Subcutaneous long acting insulin (glargine, detemir)
Weight based approach: Typical example for DKA transition. Use 0.8U/kg /day for total daily insulin. Divide this 50% for basal, and 50% for nutritional. (100kg male = 80U total insulin/day = 40 units basal)
-Or calculate the 24-hr insulin requirement
UTILIZE pharmacy and endocrine as needed to adjust dosing based on patient specifics including renal function
-Allow 1-2 hours overlap between discontinuation of infusion

Mind the GAP!
1) Close the anion gap first
2)Avoid gaps in care, transition to subQ
3)Avoid gaps in communication, closed loop with nursing/pharmacy

Spine Imaging Basics

Cervical Spine
-3 lines: Anterior vertebral line, Posterior vertebral line, Spinous process line
-Pre-vertebral soft tissue thickening (>3mm adult CT), sensitive indicator of ligamentous injury

MRI Review
T1 – CSF/fluid dark, Fat white
T2 – CSF/fluid white, Fat dark
Should see a “happy spinal cord, swimming in fluid”

Thoracic/Lumbar Spine
-Plain films can evaluate compression fracture, alignment
-Spinal fractures more common (compared to cervical spine)

Traumatic Spine: 3 column theory
-Anterior: anterior vert body
-Middle: posterior vert body
-Posterior:: pedicles, lamina, facets, spinous processes

Atlanto-occipital dissociation (AOD)
-Evaluate the basio-dental ligament

Dens Fractures
Type 1 – tip, Type 2 – body of dens only, Type 3 – involve dens and body of C2

Blunt Cerebrovascular Injury (BCVI)
Grade I – intimal irregularity with <25% narrowing,
Grade II – vessel dissection with raised flap, intramural hematoma, >25% narrowing
Grade III – pseudo aneurysm
Grade IV – vessel occlusion/thrombosis
Grade V – vessel transection

Injuries other than fracture/ligamentous?
-Hemorrhage can cause pressure on spinal cord (epidural or ventral)

Lesions skipping between vertebral bodies?
Consider TB, Pott’s Disease

Chief Talk – Dr. Wallace
Depression and Wellness among medical students and physicians. Why do we care?

“Beyond prevalence to process: the role of self and identity in medial student well-being”
-High self-complexity may be protective from burnout
-Group status as “medical student” may offer support, but positive/negative feelings spread quickly

“Burnout Among US Medical Students, Residents, and Early Career Physicians”
-Peak burnout/depression during residency, decreases over time

Depersonalized doctors: a cross-sectional study of 564 doctors
-No correlation between doctors feeling burnout and patient feeling depersonalized encounters
-We are expert at hiding our feelings

Suicidal Ideation Among American Surgeons
-Only 25% of physicians who express SI seek help
-Concern about their medical license or professional lives being affected if they seek help

Stigma of Seeking Help
-Starts in medical school
-Culture that it is sign of weakness to seek help and will negatively affect their career (ability to get into residency etc)
-60% would hide the fact they were receiving mental health treatment
-Fear of lack of confidentiality. Peers most often the source of break in confidentiality

Why does it matter?
-Higher rate of medical errors in depressed and burned out residents
-Decreased empathy for patients
-6% suicidal ideation in medical professionals (3x higher than general population)

What works?
-Increase sense of control of the subject and social/peer unity

ERCast (Nov 12 2017) Beating stress and the hot offload
-Changing perspective to a positive outlook and thought process. Choose to see challenging times as an opportunity for positive change


Center for Injury Prevention – Opioid Crisis

Heroin, Overdose, Death
-Americans consume by far more opioids than any other country
-Every adult could use 5mg hydrocodone every 4 hours for a month (based on current prescription data)
-Vicodin is the most prescribed drug in America
-Why this epidemic? More reported pain, more humane (people adhering to the “5th vital sign”), more campaigns (led by drug companies)
-Fentanyl  increased in 2013-2015

The Lives of Heroin Users (Data from Fall River)
-What are opioid users concerned about? #1 drugs, #2 money, #3 relationships, #4 mental health, #5 cigarettes
-Each additional injection day increased the risk of infection 92% (absolute value)!!
-70% of injectors report a history of skin/soft tissue infection
-Increased acute hepatitis C cases
-Trauma/accident is the 4th leading cause of death in young injectors
-Opioid detox patients, 1 year: Fights: 28.6%, Fractures 10.4%, Driving accidents  9%
-Opioid users: >30% own a gun, >50% present when shots fired, >50% able to get a gun quickly, ~30% view guns as protective
-51% of opioid users have shared buprenorphine
-96% heroin users believe fentanyl increases risk for overdose/death
-Only 59% always tried to avoid fentanyl

Detox is a 3-5 day course, GOAL is to start treatment medications!
Evidence for mortality benefit: Methadone and Buprenorphine only!

Good News
-Attention to the treatment system, training students on addiction
-Lawsuits on drug industry for deception
-Medicaid pays for 25% of all substance use treatment

Bad News
-New users are mostly heroin users or starting after little use of pills
-No easy policy answers to stop the heroin surge


Resident Author: Jeffrey Rixe, MD