Conference Recap 8/23/2023

Pulmonary Emboli– Dr Matthew Spring

• If you have high clinical suspicion for PE, it may be more beneficial to go straight to CTPA
• YEARS Study– can we increase the DDimer threshold to scan fewer people safely?
  • Criteria- hemoptysis, clinical suspicion, signs of a DVT
  • Then risk stratified by DDimer cutoff
  • Originally validated in pregnant patients
• Risk stratification of patients with PE
  • High risk- shock, hypotension
    • Low threshold to start pressors and give TPA
  • Intermediate risk- hemodynamically stable with RV strain, elevated biomarkers
    • Further stratified into low and high intermediate
    • Will also use the SPESI score to further stratify
  • Low risk- no RV dysfunction, normal biomarkers
    • Start DOAC and potentially DC
• Acute RV failure
  • In patients with acute RV failure due to obstruction, the decreased RV contractility will decrease forward flow
  • The decrease in forward flow will decrease LV preload and thus coronary and systemic perfusion worsening RV preload
  • AVOID large fluid boluses, intubation, increasing RV strain
• BMC PERT team pager- 7378
  • Used ideally for high and high intermediate risk PE
• Resources
  • EMCrit RV failure article
    • https://emcrit.org/ibcc/rv/
  • Rebel EM YEARS
    • https://rebelem.com/the-years-study-simplified-diagnostic-approach-to-pe/
  • CHEST VTE guidelines
    • https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/02/15/45/antithrombotic-therapy-for-vte-disease#:~:text=For%20patient%20with%20subsegmental%20PE,is%20high%20(Grade%202C).

Safety Evaluation of Psych Patients in the ED– Jeffrey Cheah

• There are no specific BMC policies regarding cell phone use in patients with psychiatric disorders if there is low risk for harm and patient has capacity
• If there are people who were seen in the community by BEST, please CONSULT PSYCH in order to see if there has already been a disposition made
• Be thoughtful about which patients need to be searched and which patients ought to be able to keep their phones

Pediatric Sedation and Analgesia– Dr Shahid Dodson

• Intranasal sedation
  • Midazolam- onset about 20 minutes, approximately 30 minute duration
    • 0.2mg/kg with a max dose of 10mg
  • At other centers you may have access to nitrous oxide as another agent
• Skin anesthesia- use LET for every laceration, order EARLY
• Other adjuncts- ketamine IM 4mg/kg for pain and sedation, IN fentanyl 2mcg/kg for pain
• It is not uncommon to need procedural sedation
  • Make sure you have all your airway adjuncts and preoxygenate your patients
  • Can use ketamine, propofol, or a mix of both
    • Typically for both start with 1mg/kg bolus with multiple 0.5mg/kg additional doses
    • Can decrease adverse effects associated with both by using lower doses by combining
• For neonates can use sucrose as well
• Resources
  • Pediatric sedation pearls
    • http://www.emdocs.net/pediatric-procedural-sedation-what-are-your-options/
  • Pediatric pain management
    • https://www.acep.org/siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/pediatrics/jacep-open—2022—chumpitazi—managing-acute-pain-in-children-presenting-to-the-emergency-department-without-opioids.pdf

Hidradenitis in the ED– Dr Gregory Orlowski

• I&D- temporary pain relief but this is non-infectious and the recurrence is almost 100% and scarring can WORSEN the disease process
• Preferred management– 6mm punch incision/I&D
  • Improved recurrence with longest lasting response
  • After punch biopsy want to rinse the tunnel/abscess with saline
  • Debride the area with a hemostat and sterile gauze
• Urgent/rapid referral to derm for medical/surgical management
• Can administer intralesional triamcinolone for pain (3cc max dose)
• If you are worried about patients bouncing back have a low threshold to admit for derm consultation, pain control, and initiation of medical regimen
• DC regimen: antibiotic (doxy BID for 30 days, augmentin BID for 10 days), steroid (prednisone taper for 12 days starting at 40mg with decrease dose by 10mg every 3 days), pain regimen with NSAID
  • Topical prescriptions– hibiclens (everyday neck down), clindamycin 1% (daily to affected area after hibiclens)
  • HS treatment guide and support groups
    • EPIC phrases- GOHSRESOURCES, GOHSSUMMARY
  • Reach out to on call derm to establish follow up
• Resources
  • Additional resources for ED management
    • https://www.jem-journal.com/article/S0736-4679(22)00448-6/fulltext
  • Performing a punch biopsy
    • https://www.healthcert.com/blog/learn-how-to-perform-punch-biopsy