POTD: Eye Stuff (Trauma Tuesday!)

POTD: Eye Stuff (Trauma Tuesday!)

A.

Seidel's sign: Fluorescein stained vitreous flowing from the site of globe perforation. Should protect the globe from any external pressure with eye shield, elevate head of bed 30 degrees, analgesia, control hypertension, and prevent vomiting. Emergent Optho consult.

B.

Teardrop pupil: Usually indicated globe rupture/ FB. See management for Seidel's sign above.

C.

Corneal foreign body with rust ring: remove foreign body, urgent follow up for rust ring removal which should be done after 24 hours from initial injury- this is because reepithelialization makes removal easier.

D.

Exophthalmos: if in setting of trauma with increased intraocular pressure suspect retrobulbar hematoma. Obtain STAT CT scan, perform STAT lateral canthotomy and emergent optho consult.

E.

Hyphema: Blood in the anterior chamber of the eye. Elevate head of bed, control intraocular pressure. Patients on anticoagulation or antiplatelet agents should be admitted for reversal and observation. Consult ophthalmology depending on size of hyphema and rebleed risk.

Stay well,

TR Adam

A.

B.

C.

D.

E.

EMS Protocol of the Week - Asthma

EMS Protocol of the Week - Asthma 

From the perspective of an ED physician, Protocol 507 – Asthma (attached below) is one of the most frustrating ones to encounter. Not because it’s particularly complicated, but rather because it often doesn’t leave you with anything to do. The Standing Orders for 507 include almost everything you would do yourself for a patient coming through walk-in triage with an acute asthma exacerbation: albuterol/ipratropium nebs x3 followed by continuous albuterol, IV access, steroids, magnesium, and even IM epinephrine for severe exacerbations. Checking an EKG is also included for appropriate patients. The only MCO for these cases is for the patient that may benefit from a repeat dose of IM epi. Otherwise, everything else is done by the paramedics on their own. It’s not unusual to receive a patient who was in extremis on EMS arrival, got IM epi, multiple nebs, steroids, and magnesium, and who now feels entirely better on ED arrival and wants to go home. And maybe sometimes the patient can go home, but be extraordinarily careful in these instances that you’ve fully reviewed the patient’s prehospital course. Note that in this case, the patient in front of you is wildly different from the one EMS encountered, and consider that fact at length when determining the patient’s disposition. In any event, whether it’s admission, discharge, or observation, the only thing left for you to do at that point is order the chest x-ray and maybe labs.

See? Boring for us, fun for the medics. And good for the patient, which I GUESS is what really matters.

Questions, comments, concerns? Send an email! Otherwise keep checking www.nycremsco.organd the protocol binder for more fun stuff.

 PS, while it doesn’t say so explicitly, this protocol is written for adults. What do we do with the kids? Stay tuned!

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

POTD: Myxedema Coma

POTD: Myxedema Coma

Clinical Features (Remember LOW and SLOW: low HR, BP, Temp, sugar, RR, Na, Mentation, reflexes):

• Decreased mental status

• Hypothermia (<95.9F)

• Hypotension  

• Hyponatremia

• Hypoglycemia  

• Bradycardia

• Bradypnea

Work-Up:

• CMP- looking for hyponatremia, elevated CPK, elevated creatinine, transaminasas

• CBC- looking for anemia, leukopenia

• TSH, FT4, FT3- In primary hypothyroidism, TSH will be elevated and T4 and T3 will be low. In secondary hypothyroidism (Pituitary dysfunction) the TSH can be low or normal and T4 and T3 will be low

• Blood cultures- looking for a secondary sepsis source

• Cortisol level

• Lipid panel-  Hyperlipidemia

• VBG-  looking for hypoglycemia, respiratory acidosis

• CXR- looking for pleural effusions

• ECG- looking for bradycardia and rhythm

• Cardiac POCUS- looking for pericardial effusion

Treatment:

• Levothyroxine(T4)  100 to 500 mcg IV (Potentially safer in patients with CAD) or

• Liothyronine (T3) 20mcg IV (Start with 10mcg if elderly or has CAD)

• Hydrocortisone 100mg IV q8hr

• Passive rewarming (Do not actively rewarm as rapid peripheral vasodilation may induce worsening hypotension)

• Mechanical ventilation early may prevent respiratory collapse and severe respiratory acidosis

• IVFs- dextrose containing fluids for hypoglycemia. If patient is hyponatremic, be cautious of too rapid fluid correction

• Broad spectrum Antibiotics

Prognosis:

• Mortality reaches as high as 60%  

Dispo:

• ICU admission 

Stay well,

TR Adam