1. Emergency Medicine Orientationand Introduction Lecture OUWB School of Medicine Beaumont Health System

2. Lecture Purpose Introduce how emergency medicine may differ from previous rotations Introduce how emergency medicine may differ from previous rotations How do we think differently? How do we think differently? Explain where to begin with an ER patient Explain where to begin with an ER patient Approach to the patient Approach to the patient What tests and imaging do you order? What tests and imaging do you order? This is NOT meant to be a comprehensive review, but a guide on where to begin! This is NOT meant to be a comprehensive review, but a guide on where to begin!

3. Triage The process of determining the priority of patients' treatments based on the severity of their condition The process of determining the priority of patients' treatments based on the severity of their condition Priority 1 – trauma, cardiac arrest, acute MI, CVA, psych Priority 1 – trauma, cardiac arrest, acute MI, CVA, psych Priority 2 - afib, chf or copd, chest pain, “sick” people Priority 2 - afib, chf or copd, chest pain, “sick” people Priority 3 – “routine” chest pain, abdominal pain, cellulitis Priority 3 – “routine” chest pain, abdominal pain, cellulitis Priority 4 – minor care, sprains, broken bones, colds Priority 4 – minor care, sprains, broken bones, colds Priority 5 – should be at home in bed or on the couch Priority 5 – should be at home in bed or on the couch Who can you safely see in the department?

4. Where to begin? Look at the nursing sheet from triage and the basic info in the computer Look at the nursing sheet from triage and the basic info in the computer LOOK AT THE VITALS (make sure complete) LOOK AT THE VITALS (make sure complete) Check the physical chart for papers – there may be EMS run sheet, NH transfer papers, or who knows Check the physical chart for papers – there may be EMS run sheet, NH transfer papers, or who knows If lots of visits or complicated, may want to look them up in EPIC If lots of visits or complicated, may want to look them up in EPIC

5. Where to begin in room? LOOK AT THE PATIENT! LOOK AT THE PATIENT! That’s right, just look at them! That’s right, just look at them! Do they look sick? Do they look sick? Color, diaphoretic, RR, HR, position, mental status Color, diaphoretic, RR, HR, position, mental status Most Important Thing = Recognize Sick Patient! Most Important Thing = Recognize Sick Patient!

6. Other things to consider… Patterns – if chronic condition – does this fit the pattern or not (migraine, sz, abd pain) Patterns – if chronic condition – does this fit the pattern or not (migraine, sz, abd pain) If lots of complaints – what is the one thing that brought you here tonight or hurts the most or worries you the most? (Kur’s magic wand) If lots of complaints – what is the one thing that brought you here tonight or hurts the most or worries you the most? (Kur’s magic wand) If been going on for 6 months – what made you come to the ER tonight?! If been going on for 6 months – what made you come to the ER tonight?!

7. Resuscitation Basics IV, o2, monitor - usually a safe place to start IV, o2, monitor - usually a safe place to start What does the monitor include? What does the monitor include? Start with ABCs Start with ABCs Airway Airway Breathing Breathing Circulation Circulation

8. Resus Basics LINE ACCESS LINE ACCESS PIV vs Central PIV vs Central What are some indications for central line? What are some indications for central line? Fluids – how much and when? Fluids – how much and when? Kids – 10 or 20 cc/kg bolus Kids – 10 or 20 cc/kg bolus Adults – generally 500 to 1000 cc bolus Adults – generally 500 to 1000 cc bolus When would you bolus more? When would you bolus more? What are contraindications to fluid bolus? What are contraindications to fluid bolus?

9. Resus Basics Intubation Intubation What are some reasons to secure the airway with intubation? What are some reasons to secure the airway with intubation? What meds are typically used to intubate? What meds are typically used to intubate? How about meds for continued sedation? How about meds for continued sedation?

10. Resus Basics Patient presents to EC via EMS as CPR in progress… Call states pt is 55 year old male from home who was working around the house when his wife heard a “thud”, she found him laying at the basement steps Call states pt is 55 year old male from home who was working around the house when his wife heard a “thud”, she found him laying at the basement steps what do you want to know and where to begin? what do you want to know and where to begin?

11. Resus Basics CPR in progress History – History – Events at time of arrest and right before Events at time of arrest and right before Time of arrest or of EMS call Time of arrest or of EMS call Any question of ingestion, overdose, trauma, or known medical history Any question of ingestion, overdose, trauma, or known medical history Initial vitals, ecg rhythm and any interventions done by EMS Initial vitals, ecg rhythm and any interventions done by EMS

12. Resus Basics CPR in progress In the EC – everyone has a job assigned prior to patient arriving In the EC – everyone has a job assigned prior to patient arriving Monitor Monitor Pulse ox Pulse ox BP cuff BP cuff End tital CO2 End tital CO2 Compressions Compressions IV access x 2 IV access x 2

13. Resus Basics CPR in progress ECP – start your ABCs ECP – start your ABCs Airway – check if placed by EMS or secure yourself, remember if trauma suspected to place C Collar Airway – check if placed by EMS or secure yourself, remember if trauma suspected to place C Collar Breathing – breaths sounds, look at chest and trachea, pulse ox and CO2 Breathing – breaths sounds, look at chest and trachea, pulse ox and CO2 Circulation – check pulse, listen for heart sounds, look at the skin, look at the rhythm on the monitor, IV access or central line, ultrasound Circulation – check pulse, listen for heart sounds, look at the skin, look at the rhythm on the monitor, IV access or central line, ultrasound What if there is no pulse? What if there is no pulse? Where should pulse be checked? Where should pulse be checked?

14. Resus Basics CPR in progress Look at the monitor… Look at the monitor… The rhythm present helps to guide therapy The rhythm present helps to guide therapy Must be re-evaluated often Must be re-evaluated often Quick review of rhythms and management

15. Resus Basics CPR in progress V fib or pulseless VT V fib or pulseless VT #1 Defibrillation #1 Defibrillation If not available, CPR until available If not available, CPR until available Secure airway and IV access Secure airway and IV access Epinephrine q3-5min Epinephrine q3-5min Amiodarone Amiodarone Repeat defibrillation 2 minutes after drugs Repeat defibrillation 2 minutes after drugs When do you consider magnesium or NaBicarb? When do you consider magnesium or NaBicarb?

16. Resus Basics CPR in progress PEA and Asystole PEA and Asystole CPR CPR Secure airway and IV access Secure airway and IV access Epinephrine Epinephrine Atropine (for brady rhythm without pulse) Atropine (for brady rhythm without pulse) Treat reversible causes Treat reversible causes 5H = hypoxia, hypovolemia, acidosis, hypo/hyperkalemia, hypothermia 5H = hypoxia, hypovolemia, acidosis, hypo/hyperkalemia, hypothermia 5T = toxins, tamponade, tension pneumo, thrombosis/pe, thrombosis/cad 5T = toxins, tamponade, tension pneumo, thrombosis/pe, thrombosis/cad

17. Resuscitation: SIRS/Sepsis SIRS - 2 or more of the following SIRS - 2 or more of the following Temp > 38 or 38 or < 36 C HR > 90 HR > 90 RR > 20 or PaCO2 20 or PaCO2 < 32 WBC > 12 or 12 or <4

18. Resuscitation: SIRS/Sepsis Sepsis Sepsis Suspected infection and SIRS Suspected infection and SIRS Severe Sepsis Severe Sepsis Sepsis associated with organ dysfunction or hypotension Sepsis associated with organ dysfunction or hypotension Lactic acidosis, oliguria, MS change Lactic acidosis, oliguria, MS change Septic Shock Septic Shock SIRS with hypotension despite adequate fluid resuscitation, initiate pressor support SIRS with hypotension despite adequate fluid resuscitation, initiate pressor support

19. Resuscitation: SIRS/Sepsis Recognize this condition early Recognize this condition early Initial Treatment Initial Treatment Oxygen with Early intubation Oxygen with Early intubation Adequate access with fluid resuscitation Adequate access with fluid resuscitation Appropriate antibiotics Appropriate antibiotics Central line with vasopressors Central line with vasopressors

20. Any Questions?

21. Trauma Resus starts the same way… Resus starts the same way… IV x 2, o2, monitor, full set of vitals IV x 2, o2, monitor, full set of vitals AMPLE history AMPLE history Mechanism of injury important Mechanism of injury important MVC vs Fall vs GSW vs hanging MVC vs Fall vs GSW vs hanging

22. Trauma Team approach between the Emergency Department and Surgical Team Team approach between the Emergency Department and Surgical Team Level 1 – Hemodynamic or respiratory compromise, MS change, Anticoagulant fall with GCS < 8, Penetrating injury to head/neck/chest/abd or proximal extremity, flail chest, pelvic fx, aputation proximal to wrist or ankle, skull fractures, any burn with airway compromise, trauma transfer with hemodynamic or neuro compromise or receiving transfusion Level 1 – Hemodynamic or respiratory compromise, MS change, Anticoagulant fall with GCS < 8, Penetrating injury to head/neck/chest/abd or proximal extremity, flail chest, pelvic fx, aputation proximal to wrist or ankle, skull fractures, any burn with airway compromise, trauma transfer with hemodynamic or neuro compromise or receiving transfusion Level 2 – GCS 8-13, anticoagulant fall with GCS 8-13, penetrating injury distal to elbow or knee unless unstable, burns > 20% BSA, paralysis, victim thrown from any vehicle > 10feet, roll over or significant impact > 20mph, 2+ long bone fx, amputation or crush distal to wrist or ankle, stable trauma transfers, MVC with fatality or >50mph or ejection or extrication > 20min or major intrusion into compartment, fall > 15 feet, auto vs pedestrian or bike Level 2 – GCS 8-13, anticoagulant fall with GCS 8-13, penetrating injury distal to elbow or knee unless unstable, burns > 20% BSA, paralysis, victim thrown from any vehicle > 10feet, roll over or significant impact > 20mph, 2+ long bone fx, amputation or crush distal to wrist or ankle, stable trauma transfers, MVC with fatality or >50mph or ejection or extrication > 20min or major intrusion into compartment, fall > 15 feet, auto vs pedestrian or bike Trauma Consults- anticoagulant falls with GCS 14-15, low speed mvc, any trauma admitted to non surgical service Trauma Consults- anticoagulant falls with GCS 14-15, low speed mvc, any trauma admitted to non surgical service

23. Trauma ATLS ABCDE, secondary survey A – airway and c spine immobilization A – airway and c spine immobilization B – breathing and ventilation B – breathing and ventilation (what is the difference between A and B?) (what is the difference between A and B?) C – circulation and hemorrhage control C – circulation and hemorrhage control D – disability and brief neuro exam D – disability and brief neuro exam E – exposure and environment control E – exposure and environment control Secondary Survey – head to toe eval, more detailed H/P Secondary Survey – head to toe eval, more detailed H/P FAST exam – can be done in the primary or secondary survey FAST exam – can be done in the primary or secondary survey

24. Trauma Cases MVC MVC 45 year old male unrestrained driver hits the cement median is ejected from the car, smells strongly of alcohol, moaning, obvious facial trauma with blood in the mouth 45 year old male unrestrained driver hits the cement median is ejected from the car, smells strongly of alcohol, moaning, obvious facial trauma with blood in the mouth HR 120 BP 90/50 pulse ox 88% on NRB RR 22 HR 120 BP 90/50 pulse ox 88% on NRB RR 22 Where do you begin?

25. Trauma Cases MVC MVC 45 year old male driving 45 mph drives into the side of a cement building trying to commit suicide, although he was restrained with airbag deployment. He complains of difficulty breathing and lower abd pain. He thinks he hit his head on the steering wheel and may have briefly passed out. 45 year old male driving 45 mph drives into the side of a cement building trying to commit suicide, although he was restrained with airbag deployment. He complains of difficulty breathing and lower abd pain. He thinks he hit his head on the steering wheel and may have briefly passed out. HR 120 BP 90/50 pulse ox 99 on NRB RR 35 HR 120 BP 90/50 pulse ox 99 on NRB RR 35 Quick look reveals contusion to forehead and seatbelt sign to chest and abdomen Quick look reveals contusion to forehead and seatbelt sign to chest and abdomen Now where do you begin? Now where do you begin?

26. Trauma Cases Penetrating injury Penetrating injury Patient presents with a hole in his left upper chest wall, midclavicular line somewhere around the 4 th rib Patient presents with a hole in his left upper chest wall, midclavicular line somewhere around the 4 th rib HR 120 BP 80/40 RR 40 pulse ox 99 on NRB HR 120 BP 80/40 RR 40 pulse ox 99 on NRB Where is the best place to begin? Where is the best place to begin? What are potential differences if this is gsw vs knife? What are potential differences if this is gsw vs knife? What happens if you put in a chest tube and 1500cc of blood returns? What happens if you put in a chest tube and 1500cc of blood returns? What if you put in a chest tube and no blood or air returns and the patient is still in extremis? What if you put in a chest tube and no blood or air returns and the patient is still in extremis?

27. Trauma Cases Fall Fall 23 year old male jumps out of the second story window of a burning building landing on his feet. He complains of foot and back pain. 23 year old male jumps out of the second story window of a burning building landing on his feet. He complains of foot and back pain. Vitals HR 100 BP 150/90 RR 20 pulse ox 99 RA Vitals HR 100 BP 150/90 RR 20 pulse ox 99 RA What is the classic injury pattern? What is the classic injury pattern?

28. Trauma Cases Strangulation Strangulation 18 year old male hangs himself with a rope from the garage rafters. EMS is bagging the patient on arrival and he had vitals on scene. 18 year old male hangs himself with a rope from the garage rafters. EMS is bagging the patient on arrival and he had vitals on scene. HR 120 BP 100/50 RR agonal pulse ox 60s and the patient was blue HR 120 BP 100/50 RR agonal pulse ox 60s and the patient was blue Where do you begin? Do you anticipate any issues? Where do you begin? Do you anticipate any issues? What are injuries to worry about? What are injuries to worry about?

29. Trauma Questions?

30. Chest Pain Chest pain can be a lot of things… Chest pain can be a lot of things… What are the 6 things we typically worry about as being life threatening? What are the 6 things we typically worry about as being life threatening?

31. Chest Pain Acute coronary syndrome Acute coronary syndrome Aortic Dissection Aortic Dissection Pulmonary Embolus Pulmonary Embolus Pneumothorax Pneumothorax Pericarditis with tamponade Pericarditis with tamponade Esophageal Rupture Esophageal Rupture

32. ACS Acute MI or STEMI Acute MI or STEMI NSTEMI NSTEMI Unstable Angina (USA) Unstable Angina (USA) Angina Angina Chest Pain Chest Pain So what’s the difference?!

33. Acute MI or STEMI ecg with ST elevation = big deal ecg with ST elevation = big deal Activate cath lab or interventional cardiology Activate cath lab or interventional cardiology ASA, ntg, heparin ASA, ntg, heparin morphine, beta blocker, and possibly plavix or integrillin morphine, beta blocker, and possibly plavix or integrillin When do you hesitate to give ntg? When do you hesitate to give ntg?

34. NSTEMI or USA Essentially the same without the cath lab Essentially the same without the cath lab Asa, heparin, ntg, beta blocker, morphine, plavix, integrilin, etc Asa, heparin, ntg, beta blocker, morphine, plavix, integrilin, etc When do you talk to the cardiologist? When do you talk to the cardiologist? Positive enzymes Positive enzymes Still having pain Still having pain Starting integrilin or other newer anticoagulants Starting integrilin or other newer anticoagulants

35. Chest Pain Management depends on the risk factors, clinical history, ecg and how the patient looks Management depends on the risk factors, clinical history, ecg and how the patient looks Big question is do you start all the meds or do you give an asa and await the labs Big question is do you start all the meds or do you give an asa and await the labs

36. Chest Pain Orders Ecg Ecg Chest xray Chest xray Potential labs Potential labs Cbc Cbc Bmp Bmp Hepatic panel and lipase Hepatic panel and lipase Troponin q3 x 3 Troponin q3 x 3 Pt, ptt, type screen Pt, ptt, type screen Hcg Hcg D dimer D dimer

37. Chest pain dispo Who goes where? Who goes where? ICU ICU Progressive or step down Progressive or step down RMF with telemetry RMF with telemetry OBS OBS

38. ECG Review

45. Aortic Dissection Severe CP radiating to back or abdomen Severe CP radiating to back or abdomen Neuro complaints possible as dissect into carotids or more peripheral arteries Neuro complaints possible as dissect into carotids or more peripheral arteries Ischemia of limbs Ischemia of limbs Asymmetric pulses Asymmetric pulses Remember increased risk for Marfan’s or congenital bicuspid aortic valves Remember increased risk for Marfan’s or congenital bicuspid aortic valves

46. Aortic Dissection: Tests Ecg – LVH, nonspecific changes, ischemic changes if dissect back to coronary arteries Ecg – LVH, nonspecific changes, ischemic changes if dissect back to coronary arteries Chest Xray – mediastinum widening, WHAT ELSE? Chest Xray – mediastinum widening, WHAT ELSE? Imaging – CT Dissection Protocol Imaging – CT Dissection Protocol What other imaging is available? What other imaging is available? Potential Labs Potential Labs CBC, CMP, Lipase, troponin, pt/ptt, type screen, ua, d dimer CBC, CMP, Lipase, troponin, pt/ptt, type screen, ua, d dimer

47. Aortic Dissection: Treatment Suspected Dissection Suspected Dissection Pain control Pain control BP control – what meds? BP control – what meds? No anticoagulants No anticoagulants Confirmed Dissection – what’s the difference? Confirmed Dissection – what’s the difference? Type A Type A Type B Type B

48. Pulmonary Embolism: PE Sudden onset sharp pain or dyspnea Sudden onset sharp pain or dyspnea 50% cough, <20% hemoptysis 50% cough, <20% hemoptysis Angina like ssx 5% Angina like ssx 5% Risk Factors Risk Factors Post op Post op Pregnant Pregnant Oral contraceptives = birth control or post menopausal replacement Oral contraceptives = birth control or post menopausal replacement Heart Disease Heart Disease Cancer Cancer Immobility or prolonged sitting/laying Immobility or prolonged sitting/laying Trauma Trauma Previous dvt or PE Previous dvt or PE

49. PE What may be some abnormal vitals in a patient with PE? What may a patient with PE look like?

50. PE Anxious Anxious Dyspnea at rest or with conversation Dyspnea at rest or with conversation RR > 16 RR > 16 Tachycardia = #1 most common ecg change Tachycardia = #1 most common ecg change Low grade fever Low grade fever Hypoxia Hypoxia

51. PE When do I really worry about PE? When do I really worry about PE? Good story Good story But really when the patient is dyspneic, hypoxic, or tachycardic and the lungs are clear and the chest xray is normal But really when the patient is dyspneic, hypoxic, or tachycardic and the lungs are clear and the chest xray is normal = patient looks short of breath and the vitals are abnormal but the labs and chest xray are normal

52. PE: diagnosis Ecg – tachycardia most common, right heart strain, new RBBB, nonspecific changes Ecg – tachycardia most common, right heart strain, new RBBB, nonspecific changes Chest xray – commonly normal, atelectasis, focal opacity from infarct Chest xray – commonly normal, atelectasis, focal opacity from infarct Potential Labs = cbc, bmp, troponin, d dimer, pt/ptt, type screen Potential Labs = cbc, bmp, troponin, d dimer, pt/ptt, type screen When is d dimer most helpful? When is d dimer most helpful? Why order a troponin? Why order a troponin?

53. PE: Imaging #1 Chest CT IV contrast PE protocol #1 Chest CT IV contrast PE protocol What are contraindications? What are contraindications? V/Q scan V/Q scan 2d echo 2d echo BLE venous doppler BLE venous doppler What do you do with pregnant patients?! What do you do with pregnant patients?!

54. PE Treatment Positive Chest CT with PE Positive Chest CT with PE Hemodynamically stable = heparin Hemodynamically stable = heparin Unstable = consider thrombolytics Unstable = consider thrombolytics What if they have a positive D Dimer and you cannot obtain a chest ct… What if they have a positive D Dimer and you cannot obtain a chest ct… Because they are pregnant? Because they are pregnant? Because they have a contrast allergy? Because they have a contrast allergy?

55. Pneumothorax Usually sudden onset of chest or back pain with shortness of breath Usually sudden onset of chest or back pain with shortness of breath Pleuritic = hurts to breath deeply Pleuritic = hurts to breath deeply Tension PTX – hypotension, tachy, distended neck veins Tension PTX – hypotension, tachy, distended neck veins PE – decreased breath sounds, resonance on percussion, crepitus PE – decreased breath sounds, resonance on percussion, crepitus What are some risk factors for PTX?

56. Pneumothorax Diagnosis Diagnosis Tension = clinically by history and PE Tension = clinically by history and PE Chest xray – may need inspiratory and expiratory views Chest xray – may need inspiratory and expiratory views Treatment – Chest Tube Treatment – Chest Tube How do you determine size of chest tube?

57. Any Questions on Chest Pain?

58. Atrial Fibrillation = Afib with RVR Tachycardia, irregularly irregular Tachycardia, irregularly irregular Narrow complex unless history of BBB Narrow complex unless history of BBB Max rate 150s-170s Max rate 150s-170s If faster suspect an accessory conduction pathway If faster suspect an accessory conduction pathway Occurs in normal heart, underlying disease or “holiday” heart Occurs in normal heart, underlying disease or “holiday” heart CAD, valvular disease, pericarditis, hyperthyroidism, SSS, contusion, HTN< PE, CHF CAD, valvular disease, pericarditis, hyperthyroidism, SSS, contusion, HTN< PE, CHF

59. Afib: Treatment Rate Control Rate Control calcium channel blocker = cardizem calcium channel blocker = cardizem Beta blocker = lopressor Beta blocker = lopressor Digoxin Digoxin Rate Convesion Rate Convesion Pharmacologic – amiodarone, procainimide, ibutilide Pharmacologic – amiodarone, procainimide, ibutilide Cardioversion Cardioversion Anti Coagulation Anti Coagulation Usually heparin Usually heparin Make sure to check med list, may already be on coumadin or xarelto Make sure to check med list, may already be on coumadin or xarelto

60. Afib

61. Afib

62. Congestive Heart Failure: CHF Presentation Dyspnea Dyspnea Wheezing Wheezing Cough Cough Swelling Swelling Weight gain Weight gain Chest tightness Chest tightness Palpitations Palpitations

63. CHF: things to consider History of CAD/CHF History of CAD/CHF ACS ACS HTN HTN Dysrhythmia Dysrhythmia Infection Infection Anemia Anemia Myocaridits/Pericarditis Myocaridits/Pericarditis Compliance Compliance Pregnancy Pregnancy Thyroid Thyroid Valve Dysfunction Valve Dysfunction PE PE Pharmacology Pharmacology Recent med change Steroids Nsaids vasodilators

64. CHF: Diagnosis Ecg – normal/unchanged, nonspecific or MI Ecg – normal/unchanged, nonspecific or MI Chest Xray – cephalization, congestion, effusion Chest Xray – cephalization, congestion, effusion Labs to Consider Labs to Consider CBC, CMP, trop, BNP, PT/PTT, Mag CBC, CMP, trop, BNP, PT/PTT, Mag Anything you think may have tipped them over the edge… Anything you think may have tipped them over the edge… Urine for possible uti Urine for possible uti TSH TSH

65. CHF: Treatment Oxygen Oxygen ASA ASA ACS – treat as appropriate ACS – treat as appropriate HTN – ntg HTN – ntg Diuresis – lasix Diuresis – lasix Pain – morphine Pain – morphine Bronchospasm – breathing treatment Bronchospasm – breathing treatment BiPap BiPap Intubation – last resort Intubation – last resort

66. Respiratory: Bronchospasm COPD and Asthma Presentation Presentation Dyspnea Dyspnea Tachypnea Tachypnea Wheezing Wheezing Tight, decreased, no wheeze (worse!) Tight, decreased, no wheeze (worse!) Tachycardia Tachycardia “tripoding” position “tripoding” position

67. Respiratory: Bronchospasm COPD and Asthma History History New onset or known diagnosis New onset or known diagnosis Current therapy if any Current therapy if any Exacerbating factors Exacerbating factors Tobacco use or other inhalant Tobacco use or other inhalant Illness Illness Exposure Exposure Seasonal Seasonal

68. Respiratory: Bronchospasm COPD and Asthma Potential Orders Potential Orders Ecg Ecg Chest xray Chest xray Labs – cbc, bmp, trop, bnp, pt/ptt, mag level Labs – cbc, bmp, trop, bnp, pt/ptt, mag level

69. Respiratory: Bronchospasm COPD and Asthma Treatment Treatment Breathing Treatment Breathing Treatment Albuterol/atrovent, vapo, xopenex Albuterol/atrovent, vapo, xopenex Steroids Steroids Benadryl (or Epi) if allergic component Benadryl (or Epi) if allergic component Magnesium Magnesium Antibiotics? Antibiotics? Bipap Bipap Do everything you can not to intubate! Do everything you can not to intubate!

70. Abdominal Pain Any questions before we move on?

71. Abdominal Pain 10% of all ED visits 10% of all ED visits Can be difficult to pinpoint a cause Can be difficult to pinpoint a cause Anything in the chest, abdomen, pelvis, or back can be a cause of “belly pain” Anything in the chest, abdomen, pelvis, or back can be a cause of “belly pain” High risk patients High risk patients Old People – more likely to have a life threatening cause (AAA) Old People – more likely to have a life threatening cause (AAA) Reproductive Age Women - ectopics Reproductive Age Women - ectopics

72. Abdominal Pain Why does female vs male matter? Why does female vs male matter? What things are usually sudden in onset? What things are usually sudden in onset? What does acute abdomen mean or imply? What does acute abdomen mean or imply?

73. Diffuse Abdomal Pain DDx Peritonitis Peritonitis Acute Pancreatitis Acute Pancreatitis Sickle Cell Crisis Sickle Cell Crisis Early Appendicitis Early Appendicitis Mesenteric Thrombosis Mesenteric Thrombosis Gatroenteritis Gatroenteritis Dissecting or Rupture Aneurysm Dissecting or Rupture Aneurysm Intestinal Obstruction Intestinal Obstruction Diabetes Mellitus Diabetes Mellitus 35 yo male presents with epigastric pain after drinking a fifth of vodka… 85 yo female presents for aching epigastric and right flank pain…

74. RUQ Abdominal Pain Cholecystitis or Biliary Colic Cholecystitis or Biliary Colic Hepatitis Hepatitis Hepatic Abscess Hepatic Abscess Hepatomegaly from CHF Hepatomegaly from CHF Perforated Duodenal Ulcer Perforated Duodenal Ulcer Pancreatitis Pancreatitis Retrocecal Appendicitis Retrocecal Appendicitis Herpes Zoster Herpes Zoster Myocardial Ischemia Myocardial Ischemia RLL Pneumonia RLL Pneumonia 40 year old female presents one hour after eating fried chicken with aching ruq pain and vomiting…

75. RLQ Abdominal Pain Appendicitis Appendicitis Mesenteric Adenitis Mesenteric Adenitis Regional Enteritis Regional Enteritis Meckel’s Diverticulitis Meckel’s Diverticulitis Cecal Diverticulitis Cecal Diverticulitis Leaking AAA Leaking AAA Adominal Wall Hematoma Adominal Wall Hematoma Psoas Abscess Psoas Abscess Ruptured Ectopic Ruptured Ectopic Ovarian Cyst/Torsion Ovarian Cyst/Torsion PID PID Mittelschmerz Mittelschmerz Endometriosis Endometriosis Ureteral Calculi Ureteral Calculi Seminal Vesiculitis Seminal Vesiculitis Hernia Hernia 22 year old male presents for one day of aching belly pain, nausea and decreased oral intake. Now he has tenderness in the rlq… 22 year old female presents for sudden onset of sharp rlq pain that is now worse when she ambulates…

76. LUQ Abdominal Pain Gastritis Gastritis Pancreatitis Pancreatitis Splenic Enlargement, rupture, infarction or aneurysm Splenic Enlargement, rupture, infarction or aneurysm Myocardial Ischemia Myocardial Ischemia LLL pneumonia LLL pneumonia 24 year old male presents for burning luq pain and vomiting pain after eating nachos with jalapenos and drinking beer at the football game…

77. LLQ Abdominal Pain Sigmoid Diverticulitis Sigmoid Diverticulitis Leaking AAA Leaking AAA Ruptured Ectopic Ruptured Ectopic Ovarian Cyst/Torsion Ovarian Cyst/Torsion Mittelscherz Mittelscherz PID PID Endometriosis Endometriosis Ureteral Calculi Ureteral Calculi Seminal Vesiculitis Seminal Vesiculitis Psoas Abscess Psoas Abscess Hernia Hernia Regional Enteritis Regional Enteritis 55 year old female presents for one day of increased cramping llq abd pain with blood streaked loose stool and decreased oral intake…

78. Abdominal Pain Diagnosis ECG ECG LABS- cbc, cmp, lipase, lactic acid, trop, ua, hcg LABS- cbc, cmp, lipase, lactic acid, trop, ua, hcg Chest Xray Chest Xray KUB or AAS KUB or AAS Pelvis Ultrasound Pelvis Ultrasound Abdominal Ultrasound Abdominal Ultrasound Abdominal/Pelvis CT Abdominal/Pelvis CT With or Without Contrast? With or Without Contrast? When is CT or Ultrasound better?

79. Abdominal Pain: Dispo Depends on the diagnosis… Depends on the diagnosis… Appendicitis, cholecystitis = ? Appendicitis, cholecystitis = ? Biliary colic Biliary colic Pancreatitis Pancreatitis Diverticulitis Diverticulitis Ovarian cyst vs torsion Ovarian cyst vs torsion PID PID Renal Colic – size does matter, what if UTI present? Renal Colic – size does matter, what if UTI present?

80. ANY QUESTIONS?!