Showing posts with label Emergency Medicine / Critical Care. Show all posts
Showing posts with label Emergency Medicine / Critical Care. Show all posts

14 December 2012

Hypovolemia ppts and 73 free full text published articles



Hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.
Hemorrhagic Shock
http://www2.latech.edu/

Shock
http://www.medschool.lsuhsc.edu

Fluid Therapy
Dan Belz
http://www.unmc.edu

Shock in the Newborn
GARRETT S. LEVIN, M.D.
http://www.ttuhsc.edu

Shock
Ruth M. Kolk, RN,MS,CEN, Joy Borrero, RN, MSN
http://www2.sunysuffolk.edu

Nursing Management: Shock
http://www.austincc.edu

Shock!
John Nation, RN, MSN
http://www.austincc.edu

The Evaluation and Management of Shock
Alberto Nunez, MD
http://webcampus.med.drexel.edu

Shock
 Scott G. Sagraves, MD, FACS
http://www.ecu.edu

ABCs of Shock
http://www.pediatrics.emory.edu

Shock
http://www.bcm.edu

Fluid, Electrolyte and Acid-Base Balance
Linda A. Martin, MSN APRN, BC, CNE
http://www.mccc.edu

Alterations In Homeostasis
http://www.mccc.edu

Care of the Patient in Shock
Becca Maddox
http://www.highlands.edu

Shock
http://peds.stanford.edu

Shock
http://www.cs.dartmouth.edu

Hypovolemic Shock
http://tulane.edu

Critical Concepts: Shock
http://www.medschool.lsuhsc.edu

Emergency and disaster nursing - Shock
http://elearning.najah.edu


73 free full text published articles on Hypovolemia

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26 September 2012

Hypovolemic shock



Hypovolemic Shock
Juan Duchesne MD, FACS, FCCP, FCCM
http://tulane.edu/

What Does Shock Look Like
http://legacy.owensboro.kctcs.edu

Shock and Resuscitation
Hugh M. Foy, MD
http://depts.washington.edu

Progressive Shock
http://www2.latech.edu

Types of Shock
http://medicine.creighton.edu

Overview of Shock
Ruth M. Kolk, RN,MS,CEN, Joy Borrero, RN, MSN
http://www2.sunysuffolk.edu

Care of the Patient in Shock
Becca Maddox
http://www.highlands.edu

Cardiopulmonary Resuscitation (CPR)
http://www.reproline.jhu.edu

Shock
UNC Emergency Medicine - Medical Student Lecture Series
http://www.med.unc.edu

Shock
Ghassan Fraij
http://www.med.unc.edu

Pediatric Shock Recognition, Classification and Initial Management
http://www.medschool.lsuhsc.edu

Evaluation and Management of Shock
Alberto Nunez, MD
http://webcampus.med.drexel.edu

Shock
http://peds.stanford.edu

Bleeding and Shock
http://facweb.northseattle.edu

Shock
http://www.austincc.edu

ABCs of Shock
http://www.pediatrics.emory.edu

Shock
Scott G. Sagraves, MD, FACS
http://www.ecu.edu

Hypovolemic Shock
http://www.mccc.edu/

Shock in Children
http://www.pediatrics.uthscsa.edu

400 Published articles on Hypovolemic shock

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28 May 2012

Emergency medicine lecture notes




Child Abuse
Jeff Erdner D.O
childabuse.ppt

Altered Mental Status and Coma
Brian Nelson
amscoma.ppt
Emergency medicine lecture notes from Texas Tech University Health Science Centre
Chest Pain
Chest Pain.ppt

Dysrhythmias and Blocks
Dysrhythmias and Blocks.ppt

Problem Wounds, Flaps and Grafts
problemwounds.ppt

Basic techniques
suturebasics.ppt

No touch technique
notouchtechniques.ppt

Hand injuries
handinjuries.ppt

Lacerations near the Eye
Lacerations.ppt

Ear lacerations
Earlacerations.ppt

Facial lacerations
Faciallacerations.ppt

Extension Injuries
extensio.ppt

Extension with rotation
extrot.ppt

Occipital Atlantal Dislocation
Occipital Atlantal Dislocation.ppt

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17 May 2012

Pediatric Emergency Medicine Ppts



Introduction To Epilepsy Semiology diagnosis Treatment
M. Scott Perry, M.D.
Introduction To Epilepsy Semiology diagnosis Treatment .ppt

Snakes, Spiders, and Creatures from the Sea
Adam Algren, MD
Snakes, Spiders, and Creatures from the Sea.ppt

Physical Examination of Patients with Suspected Sexual Abuse
P. Patrick Mularoni M.D.
Physical Examination of Patients with Suspected Sexual Abuse.ppt

Treating Life Threatening Asthma
Toni Petrillo-Albarano, MD
Treating Life Threatening Asthma.ppt

Concussion: return-to-play guideline
Thao M. Nguyen, MD
Concussion: return-to-play guideline.ppt

Highlights from the National Pediatric Infectious Disease Seminar (NPIDS)
Kalpesh Patel, MD
NPIDS.ppt

Evaluation of Altered Mental Status
Kalpesh Patel, MD
Evaluation of Altered Mental Status.ppt

Just an Itch? Beyond Benadryl
Michael Greenwald, MD
Just an Itch? Beyond Benadryl.ppt

Intraosseous Needle Insertion
Kalpesh Patel, MD
Intraosseous Needle Insertion.ppt

Ophthalmologic emergencies
Cecilia Guthrie, MD
Ophthalmologic emergencies.ppt

Emergency Issues in Pediatric Rheumatology
Elivette Zambrana-Flores
Emergency Issues in Pediatric Rheumatology.ppt

Approach to Common Cardiac Emergencies
Agustin E. Rubio, MD
Approach to Common Cardiac Emergencies.ppt

Sedation, Pain, and Analgesia
Ricardo R. Jiménez, MD
Sedation, Pain, and Analgesia.ppt

Code Green: PECC & EEC External Disaster Management
Charles A. Murphy, M.D.
External Disaster Management .ppt

Pediatric Ocular Trauma and Emergencies
Dafina M. Good, MD
Pediatric Ocular Trauma and Emergencies.ppt

Teaching physician rules - Based on Medicare guidelines
Jeffrey Linzer Sr., MD, MICP, FAAP, FACEP
Teaching physician rules.ppt

Nerve Blocks
Steven Lanski, MD
Nerve Blocks.ppt
129 free full text articles

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03 January 2011

Hemorrhage Powerpoint Presentations



Postpartum Hemorrhage

Obstetric Hemorrhage

Epidural Hemorrhage

Causes of Hemorrhage

Hemorrhage & Shock

Hypertensive Intracerebral Hemmorrhage

Suprachoroidal Hemorrhage

Intracranial hemorrhages

Viral Hemorrhagic Fever

Upper GI Bleed

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28 February 2010

Trauma: Stabilization and Transport



Trauma: Stabilization and Transport
Division of Critical Care Medicine
Children’s Healthcare of Atlanta
Atlanta, Georgia

Trauma:Stabilization and Transport
Objectives
* Discuss the epidemiology of pediatric trauma
* Review the primary survey
* Identify priorities in care
* Discuss differences between adult & pediatric trauma
* Discuss pediatric trauma management
* Review the development of and
guidelines for transport

Neurosurgeon
Resuscitation Team
Surgical Specialties
Medical Specialties
Nursing
ICU
OR
Anesthesia
Orthopedic Surgeon
Trauma Surgeon
ALWAYS OPEN TRAUMA CENTER

Trauma:Initial Stabilization
Trauma:Initial Stabilization
The Golden Hour
* R. Adams Cowley, MD
* Care within 60 min.
* mortality if care given > 60 min.
"You live or die depending on where you have your accident because they take you to the nearest hospital!"

R. Adams Cowley, MD
“In the Blink of an Eye”
A-M-P-L-E History

A - Allergies
M - Medications
P - Previous history
L - Last ate
E - Events of accident

Trauma:Initial Stabilization Management of Multiple Trauma
* Primary survey
* Initial stabilization
and resuscitation
* Secondary survey
* Definitive care

Trauma:Initial Stabilization The Primary Survey
* A rapid initial assessment
* An "ABC" approach
* Resuscitation done simultaneously

Trauma:Initial Stabilization The Secondary Survey
* After the "ABCs"
* Head to toe examination

Trauma Initial Stabilization Definitive Care Phase
* Overall management
* Fracture stabilization
* Stabilization/transport
* Emergent surgery

Trauma:Initial Stabilization Pediatric Considerations
* ABCs
* Differences:
1) Size
2) Injury pattern
3) Fluids
4) Surface area
5) Psychological
6) Long term effects

Trauma:Initial Stabilization
In pediatric trauma, you don’t just have and injured child, you have an injured family
M. Eichelberger, MD
“In the Blink of an Eye”
Trauma:Initial Stabilization The Primary Survey
A - Airway and C-Spine
B - Breathing
C - Circulation (with hemorrhage control)
D - Disability
E - Exposure

Trauma:Initial Stabilization The Primary Survey
* Airway:
o Establish patency
o Beware C- Spine
o Do not:
+ Flex
+ Hyperextend
* Oxygen
o treat potential hypoxemia
o all trauma patients get O2

Trauma:Initial Stabilization Pediatric Considerations
* Craniofacial disproportion
* "Sniffing" position
* Obligate nose breathers
* Anatomy
o tongue
o larynx
o trachea

Trauma:Initial Stabilization Suspected Airway Obstruction
* Stridor
* Cyanosis
* Absence of breath sounds
* Dysphagia, snoring, gurgling
* Altered mental status
* Trauma to head, face, neck

Trauma:Initial Stabilization Cervical Spine Differences
* Flexible interspinous ligaments
* Underdeveloped neck muscles
* Poorly developed articulations
* Anterior vertebral bodies
* Flat facet joints
* Large head to BSA

Trauma:Initial Stabilization Cervical Spine
* Predisposed to serious high cervical injuries
* Assume its presence in:
o Blunt injury above clavicle
o Multisystem trauma
o Significant injury - MVA, fall
o Altered sensorium

Trauma:Initial Stabilization Cervical Spine: Radiographs
* Pseudosubluxation
* distance dens and C-1
* Growth plate fracture
* SCIWORA

Trauma:Initial Stabilization Airway Management
* Clear airway
* Jaw thrust/stabilization maneuver
* Oral/nasal airway
* Oxygenate/ventilate
* Intubation
* Cricothyroidotomy

Trauma:Initial Stabilization C-Spine Immobilization
* Backboard
* Appropriate C-collar
* Snadbags or towel
* Tape
* Torso immobilization

Trauma:Initial Stabilization Primary Survey: Breathing
* Assess via
o Exposure
o Rate/depth of respiration
o Inspection/palpation
o Quality/symmetry of breath sounds

NB: An intact airway Does Not assure adequate ventilation!!

* Oxygen
* Assisted ventilation
* Alleviate life threatening injuries

Thoracic Injury Heart, Lung, Mediastinum
* Penetrating
o Sucking, Bubbling
o Hemopneumothorax
o Tamponade
* Blunt
o Flail Chest
o Contusion (lung, heart)
o Aortic Dissection
o Tracheal Rupture
o Diaphram Rupture

Trauma:Initial Stabilization Chest Trauma
* Tension pneumothorax
* Hemothorax
* Flail chest
* Cardiac tamponade

Trauma:Initial Stabilization Chest Trauma
* Blunt injury common
* More compliant chest wall
* Sensitive to flail segment
* Mobile mediastinum
* Major vascular injury uncommon

Trauma:Initial Stabilization Tension Pneumothorax
* Air in the pleural space without exit
* Collapse of ipsilateral lung
* Compressed contralateral lung
* Mediastinal shift

Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms
* Respiratory distress
* Unilaterally diminished breath sounds
* Hyperresonance on affected side
* Tracheal deviation
* Distended neck veins
* Cyanosis

Trauma:Initial Stabilization Tension Pneumothorax: Treatment
* Needle decompression
o 2nd intercostal space mid-clavicular line
* Chest tube
o 4-5th intercostal space mid-axillary line

Trauma:Initial Stabilization Hemothorax: Signs and Symptoms
* breath sounds on affected side
* Dullness to percussion
* Hypovolemia
* Flat vs distended neck veins

Trauma:Initial Stabilization Hemothorax: Treatment
* Fluids/blood
* Decompression
* Chest tube
* Autotransfusion

Trauma:Initial Stabilization Flail Chest
* Boney discontinuity of the chest wall
* Major problem = underlying injury
* Signs and symptoms
o respiratory distress
o paradoxical chest wall movement
o severe chest pain

Trauma:Initial Stabilization Flail Chest:Treatment
* Oxygen
* Stabilize segment
* Re-expand lung
* + intubation
* Give fluids cautiously

Trauma: Initial Stabilization abdominal trauma
* Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children
* significant morbidity and may have a mortality rate as high as 8.5%
* abdomen is the most common site of initially unrecognized fatal injury in traumatized children

Trauma: Initial Stabilization abdominal trauma
* Why more prone to abdominal injury
o child has thinner musculature
o ribs are more flexible in the child
o solid organs are comparatively larger in the child
o fat content and more elastic attachments leading to increased mobility
o bladder is more exposed to a direct impact to the lower abdomen

Intraperitoneal Hemorrhage Management
o Immediate surgical exploration
o Non-operative protocols
+ successful in more than 95% of blunt abdominal trauma in appropriately selected cases

Intraperitoneal Hemorrhage
Immediate Surgical Exploration
o Abdominal distention + “shock”
o Transfusion requirement > 40 cc/kg
o Peritonitis
o Pneumoperitoneum
o Bladder rupture

Intraperitoneal Hemorrhage
CT Scan
o Hemodynamically stable
o Unreliable exam
o Immediate non-abdominal surgery
o Specific Indicators
Hematuria (any)
SGOT 200, SGPT > 100
Hyperamylasemia

Intraperitoneal Hemorrhage
* FAST
o standard part of the initial evaluation of bluntly injured abdomens in adults
o rapid assessment of the peritoneal cavity and can detect free fluid

Intraperitoneal Hemorrhage
o Pediatrics role of FAST is still up for debate
+ Detailed information regarding the grade of organ injury is not provided by the FAST
+ operator-dependent and lacks specificity
+ FAST examination produces a significant number of false-negative results

Intraperitoneal Hemorrhage
Diagnostic Peritoneal Lavage
Trauma:Initial Stabilization Circulation
Trauma:Initial Stabilization Frequent Reassessment of Vital Signs
What Are Normal Pediatric Vital Signs?
Trauma:Initial Stabilization Pediatric Vital Signs
Trauma:Initial Stabilization Circulation: Vital Signs
Trauma:Initial Stabilization Circulation: Shock
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Blood Replacement
Trauma:Initial Stabilization Circulation:Pediatric Considerations
Trauma:Initial Stabilization Disability
Trauma:Initial Stabilization Disability: Children's Glasgow Coma Scale
Trauma:Initial Stabilization Pediatric Trauma Score
Airway Normal Oral or nasal Intubated, tracheostomy
Trauma:Initial Stabilization Expose: Pediatric Considerations
Trauma:Initial Stabilization Cathertization
Trauma:Initial Stabilization Definitive Care
Questions ??
References
Trauma: Stabilization and Transport .ppt

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Acute Mental Status Changes in the Intensive Care Unit



Acute Mental Status Changes in the Intensive Care Unit
By:Danagra Georgia Ikossi, MD
Stanford General Surgery Resident


* Brief review of Delirium, Seizures and Stroke
* “ICU Psychosis”
o How do you know if they’re confused? (J. Am. Ger. Soc. 2005)
o Why do they become delirious? (Critical Care 2001)
o Does delirium portend a poor outcome? (JAMA 2004)
o Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)


Disorders of Mentation
* Abnormalities of mental function
* Levels of Conciousness

Etiology of depressed level of consciousness
In non head injured patients
o SMASHED
o Substrate deficiencies (glucose, thiamine)
o Meningoencephalitis or Mental illness (malingering, psychogenic coma)
o Alcohol or Accident (CVA)
o Seizures
o Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
o Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
o Drugs

Eye Opening
Spontaneous
To Speech
To Pain
Verbal Oriented
Inappropriate
Incomprehensible
Abnormal Extension
Abnormal Flexion
Withdraws
Localizes
Obeys Commands
Motor
Glascow Coma Scale: GCS
“T” denotes intubation
Predictive value of GCS
* Septic Encephalopahthy
Delirium
DSM-IV Diagnosis of Delirium
A. Reduced ability to maintain and shift attention to external stimuli
B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech
C. At least two of the following:

1. Reduced level of consciousness
2. Perceptual disturbances: misinterpretations, illusions, or hallucinations
3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness
4. Increased or decreased psychomotor activity
5. Disorientation to time, place, or person
6. Memory impairment

D. Abrupt onset of symptoms (hours to days), with daily fluctuation

E. Either one of the following:
1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s)
2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified

Delirium
* Hypoactive delirium:
* Dementia and Delerium:
* Management
THIS IS MUCH MORE THAN WE USE
Important to differentiate Delirium from DTs
* Delirium Tremens
Cocaine Related Delirium
Who becomes delirious?

Delirium, Dementia or Both?
* Delirium is a risk factor for increased ICU and Hospital length of stay
* In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium
* Group at Brown did a prospective study of 118 patients in ICU
* Baseline dementia diagnosis given by family on Blessed Dementia Scale
* Delirium diagnosed by CAM and CAM-ICU scales
CAM ICU SCORE
Overall CAM ICU Score:
Delirium and mortality
Perspective on ICU Psychosis
AACM and SCCM Guidelines
Seizures
* Second most common neurologic complication in ICU
* Movements
* Generalized Seizures
* Partial Seizures
* Status Epilepticus
New Onset Seizures
* Drug intoxication
(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA)
* Drug withdrawal (EtOH, BZO, Barbiturates, Opiates)
* Infection (Meningoencephalitis, abscess)
* Ischemia (focal or diffuse)
* Space occupying lesion (tumors or bleeds)
* Metabolic derrangement
(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia)

* Evaluation:
o Examination looking for lateralizing signs
o Review of medications
o Imaging (CT)
o Procedural diagnostics (LP, labs, blood cultures)
* Management:
o BZO
o Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min
o Ativan 0.1mg/kg is as effective and lasts 12-24hrs
o Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level

Stroke
* Acute neurologic disorder
* Nontraumatic brain injury, vascular origin
* Focal findings (not global)
* Persists for more than 24 hours
* 80% ischemic, 20% of which are embolic
o Most thrombi are mural, LA, LV, DVT with PFO
* TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction)
* Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event
* Major Stroke = deficits persist for more than 3 weeks
* Evaluation: common things you’ll see at the bedside
o Full neuro exam, looking for focal deficits
o Seixures in 10% of cases, focal and within first 24 hours
o Fever in 50% of strokes (not with TIA) – look for other sources
o Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state
o Aphasia – Left MCA distribution
o Weakness in contralateral limbs (can also have other metabolic causes)

Diagnostic Studies
* Time is brain
* Coags, Chemistries: hypoglycemia, hyponatremia, ARF
* ECG: Afib?
* CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these
* Better if after 24 hours for infarct
* MRI: more sensitive esp for brainstem and cerebellar strokes
Diagnostics and Treatment
* ICP: monitoring not recommended routinely
o Elevate HOB 30 degrees
o Do not use measures that will decrease CBF
o minimize suctioning (HTN)
o Do not hyperventilate (reduces CBF)
o Steroids not recommended
o Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS)

Acute Mental Status Changes in the Intensive Care Unit.ppt

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10 September 2009

Venous Thromboembolic Disease



VENOUS THROMBOEMBOLIC DISEASE
by:R. Duncan Hite, MD
Section on Pulmonary and Critical Care Medicine

Venous Thromboembolic Disease

* Venous thrombosis - ~ 5 million pts yearly
+ Most caused by inadequate prophylaxis in hospitalized pts
* 10 % suffer pulmonary embolism ~ 500,000
* ~ 1% of all hospitalized pts have PE
* Contributes to 6 % of all hospital deaths
* ~ 125,000 deaths annually from PE
+ 3rd most common cardiovascular cause of death (MI, CVA)
+ Most deaths occur early – PREVENTION IS KEY!!
* Diagnosis of PE made in < 30% when contributes to death; < 10% if incidental

Case studies
Venous Thromboembolic Disease
Epidemiology

* 85 - 90% of PE pts have DVT risk factors
* 90-95% of PEs arise from lower ext. DVT
* Defined DVT Risk Factors: (Virchow’s Triad)
o Venous stasis - CHF, Immobility, Age > 70, Travel, Obesity, Recent surgery (4 weeks) or hospitalization (6 mos)
o Venous Injury - Prior DVT/PE, LE Trauma/Surgery
# LE trauma or surgery - Very high (50+%)
# Major surgery - (5 - 8%)
o Hypercoaguability - Cancer, Pregnancy, Nephrotic Syndrome, Hyperhomocysteinemia, Factor V Leyden mutation, Deficiency of Protein C/S or ATIII, Anti Phospholipid Ab, HITTS, Smoking

Pulmonary Hypertension Hemodynamic Effects
Deep Venous Thrombosis
Diagnosis
* Venography - remains the “gold standard”
+ Pitfalls: Difficult to perform, expensive, contrast load, DVT
* Compression Ultrasound (Sonography, Duplex and Color Doppler)
+ Criteria: echogenicity, noncompressibility, distension, free floating thrombus, absence of Doppler waveform, Abnormal color image
+ Accuracy:
# Symptomatic Patients: Sensitivity = 90-100%, Specificity = 95-100%
# High Risk Asymptomatic: Sensitivity = 50-80%, Specificity = 95-100%
* Impedance Plethysmography
* Radionuclide Venography (Indium-111)
* MRI - increasing popularity and utilization, includes deep pelvic veins

Deep Venous Thrombosis Prevention
* Orthopedic Surgery
o LMWH or Coumadin (INR 2.0 - 3.0) beginning preoperatively or immediately postoperatively. Adjusted dose SQ Heparin is an acceptable alternative but more complex.
o Adjuvant use of mechanical devices may add additional benefit. May be sufficient as primary prophylaxis for TKR if used optimally.
o Low dose SQ Hep, Aspirin, IPC alone are not recommended (less effective).
o Duration:
+ minimum of 7-10 days
+ Post Discharge Prophylaxis: 4-6 weeks for high risk patients
* General Surgery (including Urologic)
o Prophylaxis with SQHep, LMWH, ES or IPC
+ Moderate Risk - minor procedure with a risk factor or 40-60 yo, major procedures and <40
+ High Risk - minor procedure with risk factors or >60, major procedures with risk factors or age >40.
+ Increased Risk of Bleeding - use ES or IPC
o Combination therapy: very high risk - multiple risk factors
o Postdischarge Prophylaxis: selected very high risk pts
* Gynecologic Surgery
o Major surgery for benign disease
# SQ Hep BID, LMWH, IPC, continue for several days post op
o Major surgery for malignancy
# SQ Hep TID, Combination AC/Mech, high dose LMWH
* Neurosurgery
o Intracranial Surgery
# IPC or ES, Low dose SQHep or LMWH may be acceptable
# Combination IPC or ES with SQHep or LMWH in high risk

Deep Venous Thrombosis Prevention
* Trauma
o LMWH as soon as possible
o IPC or ES until LMWH started
* Acute Spinal Cord Injury
o LMWH recommended
o Low dose SQHep, ES or IPC are less effective
o Combination Mechanical/anticoagulant may be acceptable
o Continue throughout rehabilatation
* Medical (Cancer, CHF, Bedrest, MI, CVA…)
o Low dose SQ Hep or LMWH
o IPC if anticoagulation contraindicated

PE SIGNS AND SYMPTOMS
Symptoms
* Dyspnea - 80%
* Chest pain - 70%
* Cough - 50%
* Apprehension - 50%
* Hemoptysis - 30%

Signs
* Tachycardia - 60%
* Tachypnea - 70%
* Fever - 60%
* Clinical DVT - 30%

Pulmonary Embolism Diagnosis
* Chest x-ray - nonspecific abnormalities in most; normal early
+ Westermark's sign and Hampton's hump uncommon
* Arterial blood gas – hypoxemia is common
+ 15 - 20% will not manifest hypoxemia (i.e. normal A-a gradient)
* ECG – nonspecific changes typically
+ S1Q3T3 pattern in massive PE with RV strain
+ helpful in evaluating other causes of chest pain

PE – V/Q LUNG SCAN
* Radiolabeled Xenon inhaled for ventilation and radiolabeled Technetium for perfusion
* Safe
* Not very specific
* Not very useful if pre-existing lung disease

Pulmonary Embolism Diagnosis - V/Q Scan
Pulmonary Embolism
Diagnosis - Pulmonary Arteriogram
* Remains “gold standard” for Dx of PE
* Expensive
* Low morbidity and mortality
o Mortality < 0.1%
o Major morbidity < 0.5%
o Pulmonary Hypertension not a contraindication
Pulmonary Embolism
Diagnosis - Pulmonary Arteriogram
Lobar Defect
Segmental Defect
Pulmonary Embolism
Diagnosis - Chest CT
* Accurate for segmental or larger PE
+ Sensitivity 85 - 95% (Overall 50-60%)
+ Specificity 90 - 100%
* Accuracy depends on interpreter
+ Large Inter-interpreter variability
+ Reduced accuracy with less experience
* Significant contrast load ~ 65% of PA gram
* Similar expense to Pulmonary Arteriogram
* Can identify other pulmonary etiologies
Pulmonary Emboli Diagnosis - MRA
Venous Thromboembolism Treatment
Continuous IV Heparin:
Heparin-Induced Antibodies
Venous Thromboembolism Treatment
Low Molecular Weight Heparins:
Venous Thromboembolism Outpatient LMWH
Enoxaparin sodium
Unfractionated heparin
Venous Thromboembolism
Treatment
Synthetic Heparins:
Fondaparinux (Arixtra)
Oral anticoagulation (Coumadin)
Inferior Vena Cava Filter

VENOUS THROMBOEMBOLIC DISEASE.ppt

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07 June 2009

Multidisciplinary ICU Presentations



Multidisciplinary ICU Presentations
from Stanford School of Medicine

Shock
Trauma: Case Presentation
Upper Limb DVT… It’s not just for legs anymore
Prolonged Mechanical Ventilation Weaning Strategies in the ICU
Acute Renal Failure
Acid Base Disturbances
Perioperative myocardial infarction after noncardiac surgery
DVT Prophylaxis in the SICU
Endocrine Emergencies
Electrical Injuries
Blunt Abdominal Trauma:Evaluation
Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics
Acute Abdomen in the ICU Patient
Arterial Blood Gas Analysis
Benin Esophageal / Proximal Gastric Disease
Evaluation and Management of Hollow Viscous Injuries
Acute Mental Status Changes in the Intensive Care Unit
Tranfusion Medicine
Acute Respiratory Failure
holangitis & Management of Choledocholithiasis
AbdomnalCompartment Syndrome
Renal Replacement Therapy
GASTROINTESTINAL BLEEDING:Interventional Radiology Procedures
Nutrition
Crush Injuries and Rhabdomyolysis
Fluid and Electrolyte Physiology
Acute Respiratory Distress Syndrome
Principles of Mechanical Ventilation
Abdominal Trauma
Acute Abdomen in Pregnancy
GI Hemorrhage
ICU-acquired Weakness
High-frequency oscillatory ventilation in adults
Perioperative Management of Liver Transplant Patients
Sepsis Management in the ICU

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Emergency Medicine Presentations4



Multidisciplinary Medical Presentations from McGill University, Montreal, Canada

Acute Asthma Exacerbation: Management in the ED
Cocaine-induced chest pain Focus on Acute coronary syndromes
Fever in kids
Penetrating Trauma to the Extremities
Myth and Mechanisms of Firearm Injuries
Evaluation of Patients in Coma
Peds. Neurolgic Disorders
Pediatric Visual Diagnosis
Electrical Injuries
Petechiae and Hemorrhagic Rashes
Migraine Headaches
Two for One: Caring for the Pregnant Trauma Patient

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Emergency Medicine Presentations3



Multidisciplinary Medical Presentations from McGill University, Montreal, Canada

Advances In The Management Of Non Variceal Gastrointestinal Hemorrhage
Bioterrorism:The Public Health perspective
Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof
Atrial Fibrillation In The ER
Severe Acute respiratory Syndrome - SARS
Smallpox
Pediatric Resuscitation
Lithium poisoning To dialyse or not to dialyse…
Clinical Models in Venous Thromboembolism
Mechanical Ventilation

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Emergency Medicine Presentations2



Multidisciplinary Medical Presentations from McGill University, Montreal, Canada

Neuroradiology
Important Problems on Returning from the Tropics
Prehospital and ED Fluid Resuscitation in Trauma
Accidental Hypothermia
Intra - Arterial Thrombolysis for acute stroke
Genitourinary Trauma
Wound Care And Repair
Know about troponins
Carbon Monoxide - The Silent Killer
APAP and Salicylate Poisoning

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Emergency Medicine Presentations1



Multidisciplinary Medical Presentations from McGill University, Montreal, Canada

Selected Toxicological Antidotes
Food supplements in the athlete
Cases from Downunder
Update in reperfusion therapy for acute myocardial infarction
Altitude Medicine updates and controversies…
An ED Approach to Blunt Aortic Injury and Myocardial Confusion
Difference between dizziness and vertigo
Chemical Weapon Exposures Management in the ED
Heroic Procedures in Emergency Medicine
Non-ST-elevation Myocardial infraction and antithrombotics [2]

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30 May 2009

Emergency Medicine Video Lectures and Slides



Emergency Medicine Video Lectures
from Oklahoma State University

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Emergency Medicine Video Lectures



Emergency Medicine Video Lectures
from Oklahoma State University

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27 May 2009

Snake, Dog, Cat and other Bites



Bite Me
By:Howard J. McGowan, Maj, USAF, MC

Objectives
* Discuss general wound care principles
* Determine high risk vs low risk bites as related to antibiotic prophylaxis
* Determine need for tetanus prophylaxis
* Determine need for rabies prophylaxis
* Review common biting animals to include dogs, cats, humans, snakes, spiders, and ticks

General Wound Care
* Cleanse and debride wound
* Liberal application of ice or other cold packs
* Pressure to control bleeding
* Sterile dressing
* Hand and foot wounds require immobilization
* If wound high risk antibiotics should be started
* Consider need for tetanus/rabies

High Risk Wounds
o Location
+ Hand, wrist, foot
+ Scalp or face in infants (risk of cranial perforation)
+ Over a major joint (risk of perforation)
+ Through and through bite of cheek

o Biting species
+ Human (hand wound)
+ Cat (hand and lower extremity wounds)
+ Pig
o Type of wound
+ Puncture (impossible to irrigate)
+ Tissue crushing that cannot be debrided (typical of herbivore)
+ Carnivore bite over vital structure (artery, nerve, joint)
o Patient factors
+ Older than 50 years of age
+ Asplenia
+ Chronic alcoholic
+ Altered immune status (chemotherapy, AIDS, immune defects)
+ Diabetes
+ Peripheral vascular insufficiency
+ Chronic corticosteroid therapy
+ Prosthetic or diseased cardiac valve
+ Prosthetic or seriously diseased joint

Low Risk Wounds
* Face, scalp, ears, mouth
* Self-bite of buccal mucosa (not through and through)
* Large clean lacerations that can be thoroughly cleansed
* Partial thickness lacerations and abrasions

Antibiotics
To Close or Not
* Wound closure
o Puncture wounds, wounds that appear clinically infected, and wounds more than 24 hours old may have a better outcome with delayed primary closure
o May consider early primary closure if less than 8 hours old or located on face

Tetanus Prophylaxis
Rabies
Dog Bites
Cat Bites
Human Bites
Snake Bites
* Hemotoxic symptoms
* Intense pain
* Edema
* Weakness
* Swelling
* Numbness/Tingling
* Rapid pulse
* Ecchymoses
* Muscle fasciculation
* Unusual metallic taste
* Vomiting
* Confusion
* Bleeding disorders
* Neurotoxic symptoms
* Minimal pain
* Ptosis
* Weakness
* Paresthesia/Numbness at bite
* Diplopia
* Dysphagia
* Sweating
* Salivation
* Diaphoresis
* Hyporeflexia
* Respiratory depression
* Paralysis
* Evaluation/Treatment
Antivenoms
Spider Bites
Tick Bites
Summary
* Discussed general wound care principles
* Reviewed high risk vs low risk bites as related to antibiotic prophylaxis
* Reviewed need for tetanus prophylaxis
* Reviewed need for rabies prophylaxis
* Reviewed common biting animals to include dogs, cats, humans, snakes, spiders, and ticks

Bite Me.ppt

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07 May 2009

Ventilator Set Up video Part 2 of 2



Ventilator Set Up video Part 2 of 2

App. 7 minutes.

This video shows Respiratory Therapist students the correct and incorrect actions when placing a patient on a ventilator.


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Ventilator Set Up video Part 1 of 2



Ventilator Set Up video Part 1 of 2

App. 7 minutes.

Respiratory Therapists and students assess yourself. See how many correct and incorrect actions are demonstrated. Then watch Part 2 for most of the answers


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Ventilator Weaning Part3 of 3



Ventilator Weaning Part3 of 3


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Ventilator Weaning Part2 of 3



Ventilator Weaning Part2 of 3


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