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Naval Medical Center Portsmouth IDC Symposium Naval Medical Center Portsmouth IDC Symposium “Welcome”

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Presentation on theme: "Naval Medical Center Portsmouth IDC Symposium Naval Medical Center Portsmouth IDC Symposium “Welcome”"— Presentation transcript:

1 Naval Medical Center Portsmouth IDC Symposium Naval Medical Center Portsmouth IDC Symposium “Welcome”

2 Emergency Medicine Pearls David Johnson CDR, MC, USN Department of Emergency Medicine Naval Medical Center Portsmouth

3

4 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

5 Book Recommendations

6 Approach - Prepare  Teamwork  Know your equipment and its location  ABC’s first  Train your crew and department

7 Arrival on scene  Take charge  Get the help you need  Defuse the situation  Get the pt where they need to go

8 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

9 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

10 Minor trauma- Ottawa  Ankle Unable to bear weight (3 steps) Lateral, medial malleolar pain  Foot Unable to bear weight Navicular bone pain 5 th metatarsal pain  Knee Unable to bear weight Patellar pain Fibular head pain >55 yrs Unable to flex >90

11 Acute Myocardial Infarction  Diagnosis Suspicious Chest Pain History EKG With Characteristic Changes Elevated Serum Markers

12 Acute Myocardial Infarction

13 Early Repolarization

14 Acute Myocardial Infarction  Treatment IV, O2, Monitors Antiplatelet (Aspirin 325mg) +/- Nitroglycerine (0.4mg SL q5 x3) Anticoagulation (heparin, lovenox 1mg/kg))

15 Hypertension  Emergency End-Organ Damage  Urgency DBP >115 mmHg Not really used anymore

16 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

17 Syncope

18 Closed Head Injury

19 CT Scan Indications - History Any LOC Amnesia Coagulopathy Post Trauma Seizure Post Trauma Emesis CT Scan Indications - Physical Focal Neurologic Findings Asymmetric Pupils Distracting Injury Intoxication Large Extracranial Hematoma Signs of Skull Fracture

20 Increased ICP  Elevate HOB 30 degrees  Intubate!  Avoid Hypotension  Mannitol 1gm/kg HTS?  ? Seizure prophylaxis (phenytoin)  Medevac/CT

21 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!

22 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 °’s  Lidocaine 4% Intranasal 1cc

23 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) mg SQ Magnesium 50mg/kg IV over 20 min Peak Flows

24 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

25 Pneumonia  Mycoplasma pneumoniae  Antibioitics macrolide fluoroquinolone doxycycline

26 Pharyngitis  GABHS – Centor Exudates Anterior lymph nodes Fever Absence of cough  Suppurative Complications  Antibiotic Selection  Steroids

27 Acute Gastroenteritis  Volume Assessment  IV vs Oral Rehydration  Antiemetics Phenergan 12.5/25 Zofran

28 Acute Gastroenteritis  Oral Rehydration Formula 1 qt water 1 cup OJ 4 tbsp sugar 1 tsp baking soda 3/4 tsp table salt

29 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)

30 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)

31 UTI  Simple TMP-SMX Nitrofurantoin Fluoroquinolones Pyridium  Pyelonephritis Initial Long-Acting IV Antibiotic (Ceftriaxone), IVF & Analgesia Fluoroquinolones TMP-SMX Pyridium

32 STDs  Quinolone Resistance  Antibiotics Ceftriaxone 250mg IM PLUS Azithromycin 1gm po x 1 OR Doxycycline 100mg po BID f7

33 Lacerations  Antibiotics  Tetanus  Anesthesia Selection

34 Lacerations Immunization History dT (0.5 ml)TIG (250 IU) Fully Immunized (<10 yrs since booster) No Fully Immunized (>10 yrs since booster) YesNo Incomplete Immunization (<3 injections) Yes*Yes dT: Diptheria & Tetnus Toxoids TIG: Tetnus Immune Globulin *Refer these patients to complete their series, dT in 6 weeks and 6 months Tetanus Prophylaxis

35 Laceration Suture Removal Timeline 1. Face: 3 to 5 days (always replace with Steri Strips) 2. Scalp and Trunk: 7 to 10 days 3. Arms and legs: 10 to 14 days 4. Joints: 14 days

36 Procedural Sedation  Amnesia Benzodiazepines Ketamine  Analgesia Opiates

37 Altered Mental Status  ABC’s, IV, O2, accucheck, C-spine  History and physical  Intervene as needed D50, narcan, thiamine  Labs as available

38 Toxicology  Sympathomimetics, Anticholinergic, Cholinergic  Benzo’s are your friend Alcohol withdrawal  Atropine / 2 PAM  Glucagon (B-blockers)  Naloxone, flumazenil

39 Questions?


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