Emergency Medicine Section 1 Objectives PDF

Emergency Medicine Section 1 Objectives Into to EM ● ● ● ● History of the specialty and the role of the PA in the specialty ○ EMS reports vital to care – presentation, interventions, progress, decline; “the scene” ○ ED started in the 60s-70s; trauma centers, cardiac/stroke centers, etc. ○ Fast T...

Emergency Medicine Section 1 Objectives Into to EM ● ● ● ● History of the specialty and the role of the PA in the specialty ○ EMS reports vital to care – presentation, interventions, progress, decline; “the scene” ○ ED started in the 60s-70s; trauma centers, cardiac/stroke centers, etc. ○ Fast Track → someone who can be seen “fast” (minor wounds, splinting, etc.) ○ Main ED → IVs/medications, need a bed and monitoring, advanced care Identification/recognition of “sick vs not sick” patients ○ Sick – look at posture, VS (changes), breathing pattern, diaphoresis, anxiety or lethargy, not “acting right”, worsening/progressing, objectively bad evidence ■ Special groups! → very young, the very old ● Pregnant, Psychotic, Intoxicated, Immunocompromised, Non-English speaking, The difficult, offensive patient, The “inherited” patient ○ Not Sick – (more common) ■ Tips: Read triage, EMS record thoroughly – must account for each complaint or discrepancy. Review old records, past visits ■ Present the patient to supervising MD early, reassess pt frequently, document ■ Chart pertinent ROS positives AND negatives. You must account for your DDx! ABCDE of initial assessment – Airway, Breathing, Circulation, Disability, Environment/Exposure ○ Airway – Upright position, position preference, “universal choking sign”, Tachypnea, Anxiety, exhaustion, Diaphoresis, Gurgling, hoarseness, or stridor ○ Breathing – Tachypnea, pulse ox, Can’t talk, few words (1 or 2 words), Mental status changes, Diaphoresis, Use of accessory muscles, Unequal chest expansion or breath sounds, Exhaustion, Cyanosis ○ Circulation – Hypotension, Arrhythmia (Brady or Tachy), Acute blood loss, Decreased cerebral perfusion (anxiety, dizziness, lethargy, ALOC, syncope, coma), Decreased cardiac perfusion/output (chest pain, pulmonary edema, arrhythmias, AMI) ○ Disability – ALOC, Impairment, intoxication, Acute paralysis/neglect, Focal weakness, Head injury, Active seizure, Significant mechanism trauma ○ Environment/Exposure – Hazmat Environmental Exposure, Hyper/Hypothermia, “Found down”, Toxicology/Ingestion, Burns/smoke inhalation, Water – drowning, near-drowning Consent, Decision-making Capacity ○ Emergency care ■ Direct (Express Consent) – Registration form ● Limited contract for screening evaluation and treatment ■ Implied Consent (the Emergency Exception) ● Injury that threatens life/limb, need immediate care ● Pt can’t comprehend → LOC, mental status change, acute psychosis, dementia, severe intoxication, language barrier ● Both must be true/present to treat ○ Decision-Making Capacity (DMC) ■ The right to accept, reject, withdraw consent for tx ● All assumed to have it, must be determined by the MD, not PA alone ● Must have mental capacity/maturity to understand information provided ● Must be able to evaluate & deliberate info, realize the condition present & suggested tx, & present a choice and reasons for it ● Consider LOC, orientation, VS, language, personal values, etc. ● NOT the same as “competence” ○ No DMC? Cannot refuse tx — Proceed w/o consent, despite protests & contact pt family, +/- hospital administrators ○ Informed Consent ■ Consent for procedure, treatment; after discussion ● Consent: agree and of legal age to consent ● Assent: agree but not of legal age to consent ■ ● ● ● ● Components: condition requiring tx/procedure, name & purpose of treatment, potential complications, benefits, risks, alternatives ○ Consent in Minors <18 yrs old in CA (varies state to state) ■ Unless emergent (life/limb threat), parental/guardian/adult consent is required ● Reasonable tx until consent, cannot refuse tx if parent/adult consents, medical information may be shared w/ parent (w/ exceptions) ■ Pt w/o parent present – document efforts to obtain consent (time, number called) ■ “Sensitive Services” – Anyone/any age requesting treatment for reproductive health, sexual assault services OR >12yo: Prevention/Dx/Tx of STI, outpatient mental health or substance abuse counseling services Leaving AMA, EMTALA, HIPAA, Mandatory Reporting ○ AMA – anyone w/ DMC can, inform MD immediately, discuss pt concerns/reasons/how we can help, risks/alternatives “you can die”, involve friends/fam/social services, AMA form signed by MD, witnessed, specific return precautions, f/u plan, document, Tx when possible ○ EMTALA (Emergency Treatment and Active Labor Act) – anyone at ED must have “medical screening exam” to determine if emergency exists, regardless of ability to pay ■ Emergency? → must stabilize pt regardless of $ before transferring ○ HIPAA – in ED: need signed consent to get records, discussions about pt in public spaces, calls, police, family members, taking info home, VIPs in the ED, NO photos/social media ○ Mandatory reporting – PAs must report: suspected child, elder, DV, felonious/sexual assaults, serious dog bites, certain contagious diseases, diseases causing impairment of driving (local police, public health dept, DMV) 5150 Involuntary detainment – Allows cops & MDs to hold pt up to 72hrs, must get psych eval ○ Immediate risk for endangering self/others (suicidal or homicidal) or cannot care for self ○ Cannot sign out AMA< does NOT permit medical tx if refused, may sedate for safety Patient Safety, medical errors, how to manage errors in the workplace ○ RF for errors: ICLAP ■ Inexperienced (“just following orders”), Cognitive (we are tired, stressed, hurried, etc), Language (incomplete understanding), Age extremes (medication dosing, end-organ damage), Psych or intoxicated pt’s (poor hx, bias, poor f/u) ○ How we make the errors: ACBD ■ Anchoring (decide dx early/stick to it), Confirmation Bias (follow hunch, despite weak hypothesis), Diagnostic Momentum (dx w/o evidence, dx gains momentum) ○ Manage errors: Stop, Re-assess situation, Inform supervising MD immediately, Disclose error to pt after discussion w/ MD, Apologize, Describe how/why it occurred, Implications of the error, How we will prevent it in future, Apologize for the error again Documentation ○ Hx, negative and positive ROS (to r/o worst case scenarios in MDM!), RF, PE (what is there and what ISN’T), MDM reflects it ALL ^^^, INCLUDE EVERYTHING Airway and Breathing ● Recognition of airway compromise & “Red flags” of an airway is at risk or needs protection ○ Airway at risk or in trouble → highest clinical priority ○ Relax/collapse of tongue/submandibular m. blocks airway → MCC of airway obstruction ○ Our job: Recognize an airway in trouble → ­Anticipate potential airway problems → ­Protect an airway that is/may be at risk → Act: temporize/manage an airway that is/may be at risk ○ ● ● ● ● ● Pt pres: Universal choking sign, Unconscious, deeply sedated, Respiratory distress, position preference (tripod), Getting sleepy while working to breathe, Changes in level of consciousness → come in talking, now difficult to arouse, Sedated + vomiting (aspirate), head/facial trauma, smoke inhalation, face/neck edema ○ Sounds: Stridor → high pitched inspiratory/expiratory sounds (airway narrowing) ■ Inspiratory = problem at the glottis // Expiratory = problem below the glottis ■ Gurgling or voice changes, drooling Actions to relieve/prevent airway obstruction ○ Choking → heimlich // Open the airway → head-tilt, chin-lift, jaw-thrust (if c-spine inj) Intubation Indications ○ Airway Indications: pt can’t protect/maintain own airway (ALOC) or airway patency threatened (edema, secretions/blood, infx, trauma) ○ Breathing Indications: failure to ventilate or oxygenate (pulm, cardiac, systemic prob, trauma), or preemptive (threat to airway patency, LOC, poor O2, ventilation, aspiration) Adjuncts to protect the airway prior to intubation and their indications ○ Pre-intubation ■ Suction: rapidly clears secretions/blood, helps us see, prevents aspiration ■ Nasopharyngeal airway: semi-conscious pt w/ gag reflex, can still vomit so watch ■ Oropharyngeal airway: only in unconscious, unarousable pts, pre-intubation to keep airway open or post-intubation to keep pt from biting on tube ○ Prepare: SOAPME list (Suction, Oxygen, Airway Eqpt, Pharmacy, Monitoring Eqpt) ○ Rapid Sequence Intubation (RSI) ■ Beware of paralyzing pt → no respiratory effort, you must be able to ventilate them with a bag-valve-mask!! Must anticipate a successful intubation!! Plan ABC! ■ 7Ps: Possibility of success, Prepare, Pre-oxygenation, Pre-treatment, induction/Paralysis, Positioning/Protection, Pass it, prove it, post procedure tasks ■ Endotracheal intubation: direct vs video laryngoscopy, secures airway ● Beware of “tubing the goose!” aka esophageal intubation (no color change, O2 change, breath sounds) ○ Adjuncts/Alternatives: bougie (narrow space-smoke inhalation/edema), LMA (goal is esophagus-minor surgery, good plan B) ■ Surgical airway-Cricothyrotomy (intubation fails/not possible-plan B or C), Tracheotomy (placed in OR-pt needs prolonged airway support) Recognition of respiratory distress and the “red flags” ○ FOCUSED Hx: “Have you had this before?”, meds?, home O2? ever intubated? ○ Initial: Stridor → INTUBATE RIGHT NOW, Can’t talk or <4 word sentences?, Fighting for each breath – agitation? Tachypneic? >30/min? Posture – tripod? Won’t lie down? Moving air? Quiet lungs? Accessory muscles? Handling secretions? Diaphoretic? Cyanotic? Altered? Sleepy? Gag reflex? Stridor? ○ VS: BP (Hypotension-ominous), RR, pulse (brady-ominous), temp, O2 sat (improve w/ O2?) ○ PE: cap refill (>2sec–shock!), pulm exam first-bare the torso (same as above), skin (rash, diaphoresis, mottling), cardiac (RR, m/r/g), extremities (edema, clubbing), eyes (pallor), mouth (hydration, thrush), neck (JVD, masses, swelling), abd (distension, pain, ascites), neuro (AMS, muscle weakness) ○ Tx: VOMIT – give O2 now (+/- beta-agonist), prep for definitive airway control, VS/O2, IV access, cardiac monitor, undress, rapid assessment, prehospital hx, PE, focused hx ○ Dx: VOMIT, bedside US, CXR, EKG, basic labs (CBC, CMP, Upreg, tox, lactic acid-shock!) ○ Goals: airway control, reverse hypoxemia, avoid/tx hypercapnia, find/tx cause Differential Diagnosis of respiratory distress ○ Airway compromise or Lung problem or other: aka can be MANY things ■ ● ● Asthma or COPD exacerbation, Pneumonia, infectious, Covid-19 pneumonia, Pleural effusion, Pneumothorax, PE, Malignancy, Trauma, Rhematologic, connective tissue Dz, Sickle Cell, Pulmonary manifestations, Aspiration, foreign body, Cardiac problem → CHF/pulmonary edema, Metabolic problem → acidosis, Blood problem → anemia, Neuromuscular problem → diaphragm/chest wall problem, Shock (anaphylaxis), Other – GI, anxiety, psych, etc Oxygen therapy and pulse oximetry → Supplemental O2 is good! ○ O2 Therapy Options: ■ Nasal cannula – SOB, no/low distress (2-4L/min) ■ Face mask – mild distress, O2 deficit (4-10L/min) ■ Non-re-breather mask – moderate/serious distress, O2 in bag, exhale through one-way valve, significant O2 requirement (8-15 L/min) ■ High flow nasal cannula – heated/humidified, critical pt, up to 60 L/min ○ Pulse Ox: useful only if arterial O2 over 60%, hypoT/skin pigmentation/temp-false readings, tells us little about ventilation adequacy, tells us nothing about CO2/hypercarbia Non-invasive Positive Pressure Ventilation – indications, contraindications ○ Think: hypercapnic, hypoxemic respiratory failure ○ Indications (trying to avoid intubation) – KNOW THIS LIST CCOPPS ■ COPD exacerbations, severe asthma ■ Covid-19 pneumonia ■ Obstructive sleep apnea ■ Pulmonary edema/CHF ■ Post-extubation, chest trauma ■ Shock with respiratory failure ○ BiPAP or CPAP – constant or variable inspiratory and expiratory pressures ○ Reduces work of breathing, maintains alveolar inflation, assists ventilation, reduces preload & afterload ○ Contraindications: Must be relatively alert, not agitated, obtunded or unconscious, Intact face/skin, Must tolerate mask, dryness, Not vomiting/GI bleed, Pt decline → then intubate ACS/Cardiac Chest Pain in the adult ● ● ● ● ED approach to the patient with chest pain ○ Open-ended, OPQRST questions to quickly r/o red flags, History, history, history! Red Flag Symptoms ○ Typical Symptoms ■ Onset - abrupt // Location - midsternal, left chest // Duration - minutes to hours (30+ min) // Character - pressure, tightness, squeezing, elephant on chest // Associated symptoms - n/v, SOB, diaphoresis // Radiation - L arm/shoulder, neck, jaw, back // Timing - constant // Severity - severe Atypical presentations of cardiac chest pain ○ Who: Elderly, Diabetics, Women ○ Atypical Symptoms ■ Onset - gradual // Location - epigastric, right chest, flank pain // Duration seconds to days // Character - burning, pleuritic, reproducible, tearing // Associated symptoms - fever, cough, anxiety // Radiation - none // Timing intermittent // Severity - mild Differential diagnosis of both cardiac and non-cardiac chest pain ○ ○ ○ ● ● Trifecta of Chest Pain in ED ■ Myocardial Infarction**, Pulmonary Embolism, Aortic Dissection ○ Life threatening causes: ACS, PE, Aortic dissection, myocarditis, tension pneumo, acute chest syndrome (sickle cell), pericarditis, Boerhaave’s syndrome (perforated esophagus) “Big 6” causes: ○ PETMAC: Pulmonary embolism, Esophageal rupture (Boerhaave’s syndrome), Tension pneumothorax, Myocardial infarction (and ACS), Aortic dissection, Cardiac tamponade ACS – Unstable angina, STEMI, NSTEMI ○ Pt pres: normally pt with CAD ■ RF: ↑TG, ↑LDL, ↓HDL, sedentary, smoking, age 35+, male, HTN, DM, obese ■ New RF: stress, depression, insomnia, amphetamine/cocaine use, ESRD, connective tissue dz, vasculitis, HIV/HAART meds, trauma, high O2 demand ○ Initial ED management: VS, O2, monitor-cardiac, IV, 2+ sets of EKG/biomarkers ○ Unstable angina: 1+ of 3 of the following ■ Occurs at rest (10+ min), severe and new onset (4-6wk), crescendo pattern ○ HEART score ○ ● Identify EKG tracings of each of the following: ○ ○ Septal MI: V1, V2 – LAD // Right side MI: V3R, V4R, V5R, V6R – RCA ○ ○ ○ ● ● Concerning EKG findings: STEMI, changes from prior, dynamic changes NSTEMI: no STEMI on EKG + acute damage/ischemia + positive cardiac biomarkers ■ Partial occlusion of a coronary artery – ST depression or T wave inversion Cardiac biomarkers: ○ Troponins I & T (gold standard for dx of acute MI) ■ Proteins of cardiac myocytes, spill into bloodstream when heart is damaged ○ Increases: STEMI, NSTEMI, sepsis, PE ○ Treatments: Cardiac catheterization, thrombolytic indications ○ STEMI? → cath lab ASAP! ■ Balloon angioplasty or stent (+/- bypass if severe/multi-vessel) ■ Thrombolytics ONLY IF delay in transferring to STEMI center ○ NSTEMI? → Aspirin (325 non-enteric coated, chewable) + additional antiplatelet agents + Heparin/Lovenox + Nitro (except hypoT/R side MI/recent phosphodiesterase) + pain control ○ Unstable Angina? –? High dose statin, BB (after 24hrs), ACEi (when stable) Dysrhythmias ● Identify a stable/unstable patient with an arrhythmia and red flags for a symptomatic dysrhythmia. ○ EKG: No P waves, peaked T waves, ST elevation, dropped QRS, brady, LBBB, WPW ○ Stable: pulse reg/irreg, fast (<150) or slow (<60), BP, RR, O2 close to normal, nml PE ■ Tx → medication → refer to cardiology ○ ● Unstable: AMS, lethargy, hypoT, pulse >200 or <50 (causing instability), ↑RR, dyspnea, rales, diaphoresis, cool, clammy skin, ↓cap refill ■ Tx → electricity (cardiovert!) → refer to cardiology ■ 50J: Aflutter (initial) ■ 100J: SVT, Afib w/ RVR, vtach w/ pulse Identify an EKG tracing of each of the following: all get cardio consults! ○ Bradyarrhythmias: Sinus brady, 1st, 2nd (Type I&II), 3rd degree AV blocks ■ Three Most Important Causes: (DIE → Drugs, Ischemia, Electrolytes) ■ Tx: All Puppy Dogs Eat = Atropine, Pacing, Dopamine, Epi ○ Tachyarrhythmias: Sinus tach, SVT, Afib, Aflutter ■ SVT: symptomatic pt (palpitations, presyncope, CP, dyspnea) ● Stable: vagal maneuver → adenosine 6mg → 12mg ● Unstable: synchronized cardioversion (100J) ■ Afib: control the rate, rhythm, and anticoagulate ● New: convert the rhythm w/ Ibutilide (+/- cardioversion) ● Chronic: CCB, BB, (+/- Amiodarone, Digoxin) ● Unstable: Synchronized Cardioversion (150-200 J) ● Afib with BBB – Challenging EKG to interpret ○ Tx: Stable–cardiology ICD, CRT // Unstable–sync cardioversion ■ Aflutter: variable (irregular-looks like afib) or fixed block (2 wave to 1 flutter) ● Stable: AV nodal blockers (CCB – Diltiazem; BB – Metoprolol) ● Unstable: cardioversion begin at 50J → 100J ■ V Tach ● Stable: Amiodarone 1st; Lidocaine, Procainamide, Magnesium ● Unstable w/ pulse: Synchronized Cardioversion 100 joules ● Unstable pulseless: CPR, defib (Monophasic 360 J, Biphasic 120- 200) ■ Torsades: Polymorphic VT w/ prolonged QT ● Tx: Magnesium → Potassium → pacing or cardiovert ■ V Fib ● Tx: CPR → Defib immediately → ACLS ○ WPW – ECG Triad: short PR, initial Delta Wave of QRS, asymmetrically wide QRS ■ Sx (if present): palpitations, tachycardia, CP, dyspnea ■ Tx: Procainamide (50-100mg) q2 mins or Ibutilide for conversion ○ Brugada – syndrome: ECG + symptoms // sign: ECG only ■ Type I: leads V1-V2/V3 concave-down or “coved”, ST elevation, ≥ 2mm at J point, followed by inverted T wave, Incomplete RBBB or RBBB ■ Type II: leads V1-V2 “saddle-back” ST elevation, ≥ 2mm J point & upright T wave ■ Type III: morphology of either 1 or 2 but has <2mm ST segment elevation ■ Dx criteria: syncope, VT/VF, FHx of SCD, nocturnal agonal respiration, family members with similar ECG pattern ■ RF: fever, cocaine, alcohol, medications (CCB, BB, Na + channel blockers), hyperkalemia, hypothermia, ischemia, post Cardioversion ■ Tx: Cardiology Consult & Implantable cardiac defibrillator ○ Wellen’s – critical stenosis of LAD ■ ECG: deep T wave inversions anteroseptal leads at rest (V2-V3) ■ Pt pres: recent exertional CP, normal ECG during CP, ECG changes now at rest ■ Labs: normal or mildly elevated cardiac enzymes ■ Tx: Cardiology consult + Cath lab! ○ Prolonged QT – >440ms in men or >460ms in women ■ QTc > 500 ms is associated with risk of Torsade de Pointes ■ Causes: congenital, meds, electrolytes( ↓K, ↓Mg, ↓Ca), MI, CNS prob, hypothermia ■ Tx: Cardiology Consult, Beta Blockers, Pacemaker, ICD, Lifestyle, med changes Endocarditis/Pericarditis ● ● Endocarditis – Duke Classification (quantifies diagnostic certainty-blood culture + echo) ○ Vegetation on the valve ○ RF: IVDU, recent hospitalization, prosthetic valve, pacemaker ○ S/Sx: fever, chills, anorexia, weight loss ○ PE: cardiac murmur, splinter hemorrhages, Roth spots (fundoscopic), Janeway lesions (painless), Osler nodes (painful) ○ CF: fever, murmur (tricuspid regurg), bacteremia (blood cx), echo findings ○ MC Pathogens & empiric tx ■ Community: Staph aureus, Strep spp, enterococcus → Vanco + Ceftriaxone ■ Nosocomial: MRSA, coag neg Staph, enterococcus → Vanco ■ IVDU: MRSA → Vanco ■ Pacemaker/Prosthetic valve: Staph aureus → Vanco + Gentamicin ○ Dx findings: see Duke classification → Pericarditis – dangerous because can become → tamponade (diastolic collapse) ○ Causes: viral/idiopathic, rheumatologic/CA/post-cardiac injury, uremic, infection, covid ■ Infection pathogens: S aureus, pneumococcus, TB, fungal ○ S/Sx: retrosternal sharp, pleuritic CP-worse supine, better sitting, hours to days, +/- hx of recent URI, fever, sob ○ PE: pericardial friction rub near PMI ○ CF: typical pain, pericardial friction rub, EKG findings ○ Dx findings: ■ Labs – cardiac enzymes sometimes elevated ■ EKG – diffuse ST elevation, PR depression, inverted T waves ■ Echo – gold standard dx → check for pericardial effusion ○ Tamponade – normally complication related to CA, anticoagulants, effusion > 2cm ■ CF: tachy, hypoT, ↑JVP, muffled heart sounds, pulsus paradoxus, electrical alternans (alternate large/small R waves-specific pericardial effusion more than tamponade!!), echo findings (pericardial effusion) ○ Tx: TREAT THE CAUSE ■ Idiopathic: NSAID + colchicine ■ Febrile/toxic: admit/consult, blood cx, pericardiocentesis (echo guided) ■ Renal failure: emergent hemodialysis ■ Tamponade: volume loading, emergent pericardiocentesis Pain Management ● ● Be able to select an effective/safe pain control for a specific pt with a clinical scenario Modalities of Pain Assessment in the ED and documentation ○ Consider best agent/dose/route for this pt → tx source, intensity, locally when possible ○ Acknowledge, Assess, Reassess, Document ○ ● ● Oligoanesthesia pops: peds, elderly, cognitive delay, psych pt, AMS, alcoholics/drug addicts ○ Relate it to the pt: Visual analog scale, Word descriptor scale, Graphic scale (faces), Verbal scale (0-10), FLACC scale (non/pre-verbal) ○ Documentation/Discharge: pain does not have to be gone-just tolerable, VS normal, are they driving? Ask and document, when will meds wear off, take meds at beginning of pain onset, expectations for complete pain relief, local care-splint, ice/heat, elevation, CAM Routes of administration ○ Oral: easy, long duration – delayed onset, not if vomiting or NPO or significant pain ○ Paranteral (IM): easy, onset 10-20min, lasts longer – not titratable, unpredictable ○ Paranteral (IV): fast onset, titrate, NPO – stick, shorter duration, more SEs (best overall) ○ Topical/Mucosal: fast onset, short duration ○ Local infiltration/blocks: fast onset, lasts 1-4hrs, good duration for procedures (lacs, abscess, FB, digital block, ring block, dental block, cock block) ○ US guided regional nerve block: multi-site, excellent relief – operator dependent Agents – indications, contraindications, adverse effects, duration of action, routes and dosing: ○ Opiates: ■ Pregnancy: Category C & passes through breastmilk (pump & dump) ■ ADE: Respiratory depression-all, Hypotension-esp w/ morphine, AMS-dizzy, N/V/C, Flushing, rash, itching, Tolerance/dependence/addiction in long term ■ Commonly given w/ IV fluids (hypoT), antiemetic (n/v), +/- antihistamine (rash/itchy) ■ Doses: know 3 parenteral, 3 oral (equivalences) ● ○ ○ Morphine: hypoT, AMS, resp depression (esp children/elderly) ○ Dose: 0.1mg/kg // 4-8mg IM/IV // 15mg XR PO ● Hydromorphone (Dilaudid): high abuse potential, used less, very effective ○ Dose: 015mg/kg, 0.5-1mg IV // 1-2mg PO ● Fentanyl: NO hypoT, short duration, 80-100x more potent than Morphine ○ Dose: 25-50mcg IM/IV (to start) ● Meperidine (Demerol): removed, CI in MAOI-Serotonin Syndrome ● Methadone: opiate addiction/use disorder, effective for cancer pain ● Vicodin/Norco/Lortab (Hydrocodone + APAP): common for mod pain in ED ○ Vicodin 5/500 // Norco 5/325 – avoid higher doses ■ d/c from ED w/ 8-10 pills/3d MAX (& Colace/Senna) ● Tylenol w/ Codeine: moderate pain, mostly as outpt, avoid higher dose ○ Tylenol #3 (30/300): less potent than Vicodin/Norco ○ Elixir 12/120mg per 5ml: useful in kids/can't swallow pills ● Oxycodone, Percocet: huge abuse potential, avoid in ED & Rx Benzodiazepines: offer no analgesia and will lower BP, caution in combo w/ opiates ■ Anxiety: Lorazepam 0.5-1 mg PO/IM/IV, Diazepam 5mg PO/IV ■ Sedation: Midazolam 2-4 mg IM/IV – short duration, very sedating ■ Muscle relaxants: Diazepam 5mg PO, Baclofen 10mg PO, Flexeril 10mg PO ■ Lidocaine IV: 1.5mg/kg IV – emerging for renal colic tx (NOT FIRST LINE-ACLS) ● Lidocaine patch 4% preferred – local ■ Nitrous Oxide inhaled: analgesia and anxiolysis w/o deep sedation NSAIDs: great antipyretic, analgesia for mild/mod pain, Tylenol/NSAIDs for acute pain ■ ● ● Oral: Ibuprofen 600mg // Naprosyn 500mg // Gabapentin 300-600mg (neuropathic) ■ IM/IV Ketorolac 15mg ■ CI: 65+, renal/GI issues, on ASA/coumadin, bleeding issues, pregnant, BFing ■ Diclofenac topical gel for local joint tx ○ Acetaminophen (Paracetamol): great antipyretic, good analgesia, safe, combines easily ■ IV: 1g excellent // Oral: 1gm // Rectal in kids ■ CI: liver failure, big etoh use ○ Ketamine: “trance-like” state, analgesia, amnestic, great for opiate tolerate pts & kids ■ Dose: IM 0.3mg/kg // IV 0.1-0.3mg/kg // IN 0.5mg/kg (usual 10-15mg IM/IV) ■ SLOW IV push (10-15 min) to ↓SEs (anxious, hallucinations, emergence phenomenon – warn pt!) ○ Antiemetics ■ Zofran 4-8 mg IV/IM/SL // Metoclopramide 5-10 mg IV/IM // Phenergan 12.5-25 mg IV/IM/PR // Compazine 5-10 mg IV/IM/PR ○ Topicals ■ LET or EMLA cream – good for kids, apply prior to local anesthesia & surrounding skin, +/- in open wound, slow onset: 15-60 min ■ Ethyl chloride spray – “freezes” skin to numb, prior to needle stick or small incision ■ Proparacaine – topical anesthesia drops for eyes, burns x 10s, lasts 30 min, no Rx ■ Benzocaine – topical for oral mucosa ■ Viscous lidocaine – topical-open tissue wounds/mucosa, road rash, hemorrhoids ■ Topical cocaine – helps stop nosebleed, everybody happy. Do not use in kids ■ Auralgan – topical ear canal, otitis externa ■ Phenazopyridine 100-200 mg TID x2d – bladder spasm UTI Local, Digital and Regional nerve blocks: agents, indications ○ Local/Regional: ■ Lidocaine 1% or 2% – good general use, fast onset, lasts 1-3hr ● Max adults: 4mg/kg plain lidocaine 28cc of 1% for 70kg ■ Bupivacaine 0.25% or 0.5% – slower onset, lasts 2-5hrs ● Max peds: 7mg/kg lidocaine w/epi, 2mg/kg bupivacaine ● w/ epi: good for high vascular areas, bleeding (stings going in) ○ w/o epi: Fingers, nose, penis, toes (vasoconstricts!!) ● w/ bicarb: reduce pain, 4ml lido + 1ml bicarb ○ Digital blocks: lidocaine with EMLA before if needed ■ 7-8cc in finger, 8-10cc in toes (kids use half), check neuro status before! ○ Special nerve blocks: ■ Intra-articular: pre-reduction, arthritis, US guided – Bupivacaine +/- steroids ■ Hematoma: inject distal fx sites, pre-reduction – Bupivacaine ■ US guided: standard in ED when possible, operator dependent, comfort level/skill ● Forearm, femoral, interscalene brachial plexus, axillary, RAPTIR ○ Regional nerve block: Bupivacaine best // best for procedures ■ Facial, ear, dental – supratrochlear, supra/infra-orbital, mental, alveolar, auricle Procedural Sedation ○ Levels of sedation/Agents commonly used for sedation ■ Minimal – PO opiates & benzos ■ Moderate – IV benzos, IM/IV low-dose ketamine ■ Deep – IV sedation dose ketamine, propofol, brevitol ○ Indications: brief procedure/short-term sedation/amnesia ■ Uses: fx reductions, abscess, tricky procedures, kids, dev. delay, agitated, psych ○ Advantages: pt does not recall procedure, controlled setting ○ Disadvantages: labor/time intensive, staff + attending MD (min 4ppl), NPO status (ASK last oral intake), recovery period, airway/circulation risk, drug risk