Family Practice Notebook Updates 2014

Aka: Family Practice Notebook Updates 2014, FPN Updates 2014

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II. Updates: December 2014

  1. Trauma in Pregnancy
    1. Extensive updates to Obstetrical Trauma, Cardiopulmonary Resuscitation in Pregnancy and Perimortem Cesarean Section
  2. Uveitis and Iritis
    1. Extensive updates
  3. Superficial Fungal Infection
    1. Updated Tinea Infections and the medications used to treat them
  4. Difficult Intravenous Access in Children
    1. Added pearls for Difficult Intravenous Access in Children (beyond the IO)
  5. Massive Hemorrhage
    1. Updated with newer measures (for XStat, REBOA)
  6. Appendicitis
    1. No lab marker has sufficient Test Sensitivity to exclude Appendicitis
    2. Antibiotics only regimen for Appendicitis
  7. Status Epilepticus
    1. Diazepam is as effective as Lorazepam in Status Epilepticus
    2. Diazepam IM dosing is as effective as IV dosing in Status Epilepticus
  8. Benign Prostatic Hyperplasia
    1. Updated based on review article
  9. Unconsolable Crying
    1. Updates on the approach to the unconsolable Crying Infant
  10. Nephrolithiasis
    1. Debunking the myths of alpha Antagonists and Intravenous Fluids to aid stone expulsion
  11. HSV Encephalitis
    1. General update
  12. Schizophrenia
    1. Updates include Psychosis, Psychosis Differential Diagnosis, Schizophrenia
  13. Incidentaloma
    1. Includes Pituitary Incidentaloma, Thyroid Nodule, Pulmonary Nodule, Hepatic Incidentaloma
    2. Also includes Pancreatic Cyst, Adrenal Incidentaloma, Renal Cyst, Ovarian Mass
  14. Emergency Department Patient Satisfaction
    1. Updates organized by patient expectations
  15. Ankle-Brachial Index
    1. Updated criteria and technique
  16. Mass Casualty Incident
    1. Includes JumpSTART Pediatric Multiple Casualty Incident Triage, SALT Mass Casualty Triage Algorithm, START Triage
    2. Also updated Decontamination in Children, Personal Protection Equipment and Respiratory Personal Protective Equipment
  17. Developmental Dysplasia of the Hip (Congenital Hip Dislocation)
    1. Extensive updates
  18. Gouty Arthritis
    1. Extensive updates
  19. Down Syndrome
    1. Extensive updates, focused on children with Down Syndrome
  20. Miscellaneous
    1. Chronic Pain Management (and Chronic Narcotic Guideline)
    2. Asthma Management
    3. Contraception and Intrauterine Device (IUD)
    4. Insulin Pens and Incretin Mimetics (GLP-1 Agonist)
    5. Systemic Corticosteroids and Psychiatric adverse effects
    6. Hepatitis C Antiviral Regimen
    7. Influenza management with Neuraminidase Inhibitor (Tamiflu, Relenza)
    8. Diabetic Foot Ulcer and other Wound Dressings
    9. Chemotherapy-Induced Vomiting
    10. ACE Inhibitor

III. Updates: November 2014

  1. Chest Trauma
    1. Added Chest Trauma and Sternal Fracture
  2. Conflict Resolution
    1. Updated Conflict Resolution and Emergency Department Patient Satisfaction
  3. Prothrombin Complex Concentrate
    1. Updated Prothrombin Complex Concentrate (is it worth the extra thousands of dollars per dose)
  4. Decision Making Capacity
    1. Updated Decision Making Capacity
  5. Laceration Repair
    1. Updated Laceration Repair, Eyelid Laceration, Nail Bed Laceration, Suture Material, Absorbable Suture, Catgut Suture
    2. Added Nail Injury
  6. Pediatric Sepsis
    1. Updated Pediatric Sepsis
  7. Acute Pancreatitis
    1. Extensive updates to Acute Pancreatitis evaluation and management
    2. Added Revised Atlanta Criteria for Acute Pancreatitis Severity
    3. Added Acute Physiology and Chronic Health Evaluation II (APACHE II Score)
    4. Added Modified Glasgow Severity Criteria for Pancreatitis (Imrie Scoring System for Pancreatitis, PANCREAS Score)
    5. Added BALI Score
    6. Added CT Severity Index in Pancreatitis (Balthazar Computed Tomography Severity Index)
  8. Altered Level of Consciousness
    1. Updated Altered Level of Consciousness Causes with pitfalls
    2. Updated Altered Level of Consciousness with an approach to Lumbar Puncture and empiric Antibiotics
  9. Adult Health Maintenance Screening
    1. Updated Prostate Cancer Screening (ACS and AUA softened their PSA recommendations)
    2. Updated Lung Cancer screening
      1. USPTF recommends annual low dose CT in ages 55 to 74 years (if >30 py Tobacco with last use in prior 15 years)
  10. Multiple Sclerosis
    1. Extensive updates to Multiple Sclerosis
  11. Coronary CT Angiography (CCTA)
    1. Reviewed approach to use in Low Risk Chest Pain
  12. Antibiotic Resistance
    1. Methicillin Resistant Staphylococcus Aureus (MRSA)
    2. Vancomycin Resistant Enterococcus (VRE)
    3. Carbapenem-Resistant Enterobacteriaceae (CRE, esp. Carbapenem-Resistant Klebsiella)
    4. Multi-Resistant Gonorrhea
  13. Obesity Medications
    1. Contrave added (do we need still another expensive combination agent with marginal efficacy)
  14. Anticoagulation in Thromboembolism
    1. Added Apixiban, Rivoroxaban and Dabigatran as options for Anticoagulation and their dosing protocols
  15. Pneumococcal Vaccine in older adults over age 65 years
    1. Updated the combined Pneumovax 23 with Prevnar 13 protocol
  16. Oral Mucositis
    1. Updated Stomatitis and Oral Mucositis including symptomatic management
  17. Polypharmacy
    1. Updated additional strategies to decrease or discontinue medications in the elderly
  18. SSRI and SNRI agents increase risk of bleeding events
    1. Occurs when combined with Anticoagulants and antiplatelet agents (especially Warfarin)
    2. Fluoxetine and Flovoxamine are highest risk with Warfarin
  19. COPD Management
    1. Inhaled Corticosteroids increase Pneumonia risk in COPD (NNH 50 in 18 months)
    2. Consider tapering off high dose fluticasone or other Inhaled Corticosteroid in stable COPD patients
  20. Antiepileptic agents
    1. Perampanel (Fycompa) and Eslicarbazepine (Apticom) added
  21. Drug Disposal
    1. Added additional options
  22. Ebola Virus
    1. Extensive updates
  23. Miscellaneous
    1. Abdominal CT with IV contrast alone (no Oral Contrast) is sufficient in the diagnosis of Appendicitis
    2. Capnography in Procedural Sedation more rapidly identifies apnea, but may not alter outcomes
    3. Ketamine use for RSI and Procedural Sedation does not increase Intracranial Pressure
    4. Femur Fractures (especially metaphyseal Fractures) in age under 12 months are associated with Child Abuse in one third of cases

IV. Updates: October 2014

  1. Head CT Indications in Adults with Mild Head Injury
    1. Added New Orleans Head CT Indications (for Mild Head Injury)
  2. Health Care-Associated Infections
    1. Urinary Catheter associated Urinary Tract Infection, Central Line-Associated Bloodstream Infection and Ventilator-Associated Pneumonia
    2. Surgical Site Infection, Clostridium difficile, Antibiotic Resistant Infection
  3. Thyroiditis
    1. Painful Thyroiditis: Subacute Thyroiditis, Suppurative Thyroiditis, Radiation-Induced Thyroiditis, Traumatic Thyroiditis, Thyroid Hemorrhage
    2. Painless Thyroiditis: Hashimoto's Thyroiditis, Postpartum Thyroiditis, Drug-Induced Thyroiditis, Silent Thyroiditis, Riedel's Thyroiditis
  4. Acute Vestibular Syndrome (AVS)
    1. HiNTs Exam (Three-Step Bedside Oculomotor Examination)
    2. Distinguishes peripheral vestibulopathy from posterior circulation Cerebrovascular Accident (Cerebellar CVA or Brainstem CVA)
    3. HiNTs is a mnemonic for a battery of three oculomotor tests: Head Impulse, Nystagmus and Test of Skew
  5. Attention Deficit Disorder
    1. Updated Attention Deficit Disorder and its differential diagnosis, diagnosis and management
  6. Dyspareunia
    1. Updated and added Dyspareunia, Vulvodynia, Vaginismus, Atrophic Vaginitis, and Vaginal Dryness
  7. Medical Interpreter
    1. Added pearls to working with Language Interpreters
  8. CT Intravenous Contrast
    1. Updated approach to history of contrast reactions
  9. Pulmonary Embolism
    1. PE Thrombolysis benefits and harms reviewed in the case of intermediate-risk Pulmonary Embolism (RV dysfunction, but hemodynamically stable)
  10. Long-Acting Hydrocodone (Zohydro)
    1. Another long-acting Opioid without abuse-resistant controls and with all the risks of abuse and Opioid Overdose
  11. Left Ventricular Assist Device (LVAD)
    1. Updated an approach to LVAD patient related emergency presentations
  12. Pacemaker and Implantable Defibrillator (AICD)
    1. Updated
  13. Hemodialysis
    1. Revised the shunt type definitions, and updated the approach to complications (Dialysis Emergencies, Bloodstream Infections in Hemodialysis)
  14. Epiglottitis
    1. Since the Hib Vaccine, adults are now the chief cohort, albeit uncommon
  15. Pacemaker Troubleshooting
    1. Updated Pacemakers and automatic inplantable cardioverter Defibrillators (AICDs)
  16. Mobile Medical Applications
    1. Updated the resources
  17. Altered Level of Consciousness (ALOC)
    1. Cleaned this up and added expert opinion on empiric strategies
    2. Still needs an extensive updating based on good review articles
  18. Systemic Lupus Erythematosus
    1. Extensive updates including acute evaluation, management and pitfalls
  19. Over-The-Counter Medications in Pregnancy
    1. Added OTC GI and ENT medications, Analgesics, Herbals and topicals
  20. Urinalysis Interpretation
    1. Updated Microscopic Hematuria
    2. Added Ureteral Stent
  21. Enuresis
    1. Updated Nocturnal Enuresis
  22. Miscellaneous Updates
    1. Post-Intubation Sedation and Analgesia
    2. Dexmedetomidine
    3. High flow nasal oxygen rates per age

V. Updates: September 2014

  1. Impetigo
    1. Updated Impetigo and Bullous Impetigo
  2. Animal Bite
    1. Updated Dog Bite, Cat Bite, Rabies Postexposure Prophylaxis
  3. Preterm Infant
    1. Updated approach to the Preterm Infant for post-hospital care
  4. Newborn Exam
    1. Extensive updates to Newborn Exam in general
    2. Updated Newborn Head and Neck Exam, Newborn Eye Exam, Newborn Gestational Age Exam
    3. Updated Newborn Cardiopulmonary Exam, Newborn Abdominal Exam, Newborn Genitalia Exam
    4. Updated Newborn Orthopedic Exam, Newborn Neurologic Exam, Newborn Skin Exam
  5. External Genital Warts
    1. Updated management details
  6. Autosomal Dominant Polycystic Kidney Disease (ADPKD)
    1. Extensive updates on evaluation and management
  7. Toxin Antidotes
    1. Brief update and reorganization
  8. Against Medical Advice (Leaving AMA, Informed Refusal)
    1. Updated with additional protocol information
    2. Risk of lawsuit is increased 10-100 fold in AMA cases (rate as high as 1 lawsuit in every 300 AMA cases)
  9. Post-Intubation Sedation and Analgesia
    1. Updated with studies related to the high number of cases where sedation and analgesia was not used or used at inadequate dose
  10. Low Risk Chest Pain
    1. Updated the algorithms
  11. Skin and subcutaneous Infections (SSTI)
    1. Updated Cellulitis, Skin Abscess and Incision and Drainage
  12. Flight Medicine
    1. Updated Contraindications to Air Travel
    2. Updated DVT Prevention in Travelers
  13. Ankle
    1. Updated Ankle Anatomy and Ankle Exam
  14. Congestive Heart Failure
    1. Updated Acute Decompensated Congestive Heart Failure (Cardiogenic Shock) and Brain Natriuretic Peptide (BNP)
  15. Patient Satisfaction
    1. Understand an ED patient's needs (diagnosis, advice or education) and you help them navigate the uncertainty that resulted in the visit
  16. Anti-hyperlipidemics
    1. Both Niacin and Statins are associated with increased risk of worsening glycemic control
    2. Unlike Statins, however, Niacin's benefits appear minimal and are unlikely to outweigh the risks
  17. Influenza Vaccine
    1. The Influenza Vaccine for 2014 in the U.S. is the same as the 2013 Vaccine (but everyone should still be immunized again due to waning Immunity)
    2. Healthy children ages 2-8 years old will benefit more from Flumist (better efficacy) if available and not contraindicated
  18. Refractory Depression Management
    1. Updated management
  19. Tobacco Cessation
    1. Updated management
  20. Electronic Prescriptions
    1. Added information on Electronic Prescriptions
  21. Chlorthalidone
    1. Added strategies to prevent Hypokalemia
  22. Oral Health
    1. Updated with a section on the electronic ToothBrush
  23. Added new agents (I am unlikely to use)
    1. Sitavig (buccal Acyclovir) - single dose Cold Sore regimen ($300 for 2 tabs with mediocre efficacy)
    2. Vorapaxar (Zontivity) - new antiplatelet agent for adjunctive therapy in high risk vascular patients (another agent with no antidote)
  24. Research
    1. Evidence-Based Medicine
    2. Information Retrieval
    3. Medical Cognitive Errors (e.g. Anchoring Bias, Availability Bias, Value-Induced Bias, Blois' Funnel)
  25. Information Technology
    1. Computer Science
    2. Database and Relational Database
    3. Computer System Infrastructure
    4. Computer Network (Open Systems Interconnection Model, ISO Network Communications Model, Wireless Network)
    5. Computer Software, Programming Language and Software Development Life Cycle
    6. Software Usability (Software User Experience, Human Computer Interaction)
  26. Healthcare Delivery
    1. U.S. Department of Health and Human Services (DHHS)
    2. Office of the National Coordinator for Health Information Technology (ONC for Health IT)
      1. Health IT Policy Committee (HITPC) and Health IT Standards Committee (HITSC)
      2. Nationwide Health Information Exchange (HwHIN, eHealth Exchange)
      3. Standards and Interoperability Framework (S&l Framework)
    3. Patient Protection and Affordable Care Act (Affordable Care Act, Health Insurance Marketplace)
    4. Public Health
  27. Healthcare Quality Improvement
    1. Control Chart (Shewhart Chart, Process-Behavior Chart)
    2. Failure Mode and Effects Analysis
    3. Donabedian Quality Framework (Donabedian Model)
    4. Clinical Workflow Analysis (Workflow Re-Engineering, Process Redesign, High Reliability in Healthcare)
  28. Information Security (Data Security, Protected Health Information)
    1. Patient Privacy (Information Confidentiality)
    2. Health Insurance Portability and Accountability Act (HIPAA)
  29. Health Information (Clinical Data)
    1. Healthcare Terminology Standard (Standard Medical Vocabulary)
    2. Health Level 7 (HL7)
    3. Unique Patient Identifier
    4. International Classification of Diseases (ICD9, ICD10)
    5. Systematized Nomenclature of Medicine (SNOMED Clinical Terms or SNOMED CT)
    6. Unified Medical Language System (UMLS)
  30. Biomedical Informatics (Clinical Informatics)
    1. Health Information System (Clinical Information System)
    2. Health Information Technology (Health IT, ARRA, HITECH Act)
    3. Telemedicine
  31. Computerized Medical Record (Electronic Medical Record, Electronic Health Record, EMR, EHR)
    1. Clinical Decision Support (CDSS)
    2. Clinical Practice Guideline
    3. Knowledge Representation Syntax (Clinical Guideline Modeling Method)
    4. Medical Documentation (Encounter Documentation)
    5. Meaningful Use of the Electronic Health Record
    6. Electronic Prescription (E-Prescribe, e-Rx)
  32. General Statistics
    1. Statistical Terms (Statistical Significance, P-Value, Confidence Interval, Clinical Significance, Statistical Heterogeneity)
    2. Systems Evaluation
    3. Treatment Effect
  33. Epidemiology Rates
    1. Disease Attack Rate
    2. Disease Incidence Rate (Incidence)
    3. Disease Prevalence Rate (Prevalence)
    4. Mortality Statistics (Leading Causes of Death, Mortality Vital Statistics)
  34. Risks
    1. Odds Ratio
    2. Relative Risk
    3. Weighted Mean Difference
  35. Decision Analysis (Decision Tree, Chance Graph)
    1. Incremental Cost Effectiveness Ratio (ICER)
    2. Expected Value Theory (Expected Utility Theory, Time Trade Off, Standard Gamble, Visual Analogue)
    3. Quality Adjusted Life Year ( QALY)
  36. Screening Test
    1. Contingency Grid or Cross Tab (includes Statistics Example)
    2. Bayes Theorem (Bayesian Statistics)
    3. Fagan Nomogram
    4. Experimental Error (Experimental Bias)
    5. Lead-Time Bias
    6. Length Bias
    7. Selection Bias (Screening Bias)
    8. Likelihood Ratio (Positive Likelihood Ratio, Negative Likelihood Ratio)
    9. Number Needed to Screen (Number Needed to Treat, Absolute Risk Reduction, Relative Risk Reduction)
    10. Negative Predictive Value
    11. Positive Predictive Value
    12. Pre-Test Odds or Post-Test Odds
    13. Receiver Operating Characteristic
    14. Test Sensitivity (False Negative Rate)
    15. Test Specificity (False Positive Rate)
    16. U.S. Preventive Services Task Force Recommendations
  37. Leadership Models, Processes, and Practices
    1. Negotiation
    2. Collaboration
    3. Motivation
    4. Decision-Making
    5. Conflict Management (and Conflict Resolution)
    6. Human Resource Management
  38. Effective Interdisciplinary Teams
    1. Group Management
    2. Group Meeting
    3. Group Presentation
    4. Effective Communications Communication
  39. Project Management
    1. Project Management
    2. Change Management
  40. Strategic and Financial Planning for Clinical Information Systems
    1. Business Financial Planning
    2. Health Information Technology Governance
    3. Clinical Information System Strategic Plan
    4. Clinical Informatics Board Certification Added this entry that links to the topics expected on the Clinical Informatics Board Certification Exam

VI. Updates: August 2014

  1. Myasthenia Gravis
    1. Extensive updates to Myasthenia Gravis
  2. Delirium
    1. Yet another article reviewed to update Delirium
  3. Late-Term Pregnancy
    1. Case for induction at 41 weeks based on an article by my FP residency program director, Dr. Fontaine
  4. Bronchiolitis
    1. More updates on Bronchiolitis (who needs an admit, do I really need an RSV test and Urinalysis)
  5. Sepsis
    1. ProCESS Trial results are released
    2. Pragmatic aggressive care (fluids, Antibiotics, pressors) was as effective as Early Goal Directed Therapy (with Svo2 monitoring)
    3. Emphasizes aggressive fluid hydration (4.4 Liters on average), early Antibiotics, Vasopressors (44%), Central Lines (>50% of cases)
    4. However, specialized Sepsis catheters with Svo2 monitoring is not required, and did not improve outcomes beyond otherwise aggressive care
  6. Emergency Contraception
    1. Remember Plan B (Levonorgestrel) can now be given as a single 1.5 mg dose within 5 days of intercourse (best with 72 hours)
    2. However Levonorgestrel is less effective for intercourse near the time of Ovulation or whose BMI > 25 (and especially if weight >165 lb)
      1. In these cases offer additionally, the copper-T IUD and Ulipristal
  7. Medical Photography
    1. I summarized the salient points from Michelle Lin's very nice review of Medical Photography on EM:Rap
    2. Reminded me that I'd like to share more techniques of generating medical image content (both photography and illustration)
  8. Single Seizure Evaluation
    1. Provoked first-time Seizures do not require antiepileptics
    2. First time Seizures do not need admission
    3. After Benzodiazepines, Status Epilepticus may be treated with any of the typical agents (no evidence-based, preferred option)
  9. Ocular Ultrasound
    1. Astounding how much can be seen with Eye Ultrasound (e.g. Retinal Detachment, Optic Nerve Sheath Diameter, Pupil Exam with Ultrasound)
  10. Video Laryngoscopy (VL)
    1. Another study shows VL superior to Direct Laryngoscopy for successful first-pass intubation (by Odds Ratio >2)
    2. Video Laryngoscopy is also associated with reduced risk of esophageal intubation
    3. However, no difference in bad outcomes when compared with Direct Laryngoscopy
    4. In addition, Direct Laryngoscopy is the number one rescue of unsuccessful Video Laryngoscopy
  11. EKG and ST Elevation MI (STEMI)
    1. Nondiagnostic EKGs occur in 11% of STEMI patients (and first Troponin Is normal in 55% of STEMI cases)
    2. Obtain serial EKGs
  12. Acute Pulmonary Edema Management
    1. Management focus on fluid redistribution rather than Fluid Overload
    2. Initial management is Preload reduction (Nitroglycerin, Bipap)
    3. Next management is Afterload reduction (ACE Inhibitor)
    4. Consider Diuretics following Afterload reduction
  13. New agents for MRSA (similar activity, very expensive)
    1. Vancomycin-like, longer-acting agents: Dalbavancin (Dalvance) and Oritavancin (Orbactiv)
    2. Linezolid (Zyvox) like agent: Tedizolid (Sivextro)
  14. MMR Vaccine
    1. Push for adequate Vaccination in those born after 1956 in U.S.
    2. History of at least 1 dose (2 doses for Primary Series, college students, healthcare workers, high risk travel)
  15. GLP-1 Agonist
    1. More Byetta-like injectable agents (GLP-1 Agonists) for overweight Type II Diabetes Management for additional control
    2. Tanzeum (Albiglutide) released in 2014
  16. Quinolones in children
    1. Despite cartilage effects in study young dogs, no strong evidence of similar effects in children (followed for 5 years)
    2. May be considered in for specific infections (Pseudomonas aeruginosa) or resistant infections (e.g. Pneumonia, Sinusitis)
    3. Transient myalgias and Arthralgias may occur (however Quinolone induced Tendinopathy is rare in children)
  17. Benzodiazepines
    1. Updated Benzodiazepine risks of misuse and abuse
    2. Documented a specific taper schedule
    3. Consolidated Benzodiazepine Abuse and Benzodiazepine Overdose
  18. Obstructive Sleep Apnea and CPAP
    1. Updated strategies to improve compliance
  19. Onychomycosis
    1. Efinaconazole (Jublia) 10%
      1. Topical agent for Onychomycosis that appears more effective than Penlac, but less effective than oral agents
      2. Very expensive ($450 per large Toenail per 6 weeks)
  20. Antibiotic Drug Interactions and adverse effects
    1. Updated Osteomyelitis oral Antibiotics: Quinolones, Trimethoprim Sulfamethoxazole (Septra), Rifampin and Linezolid
  21. Tramadol
    1. Will be reclassified as FDA Schedule IV Opioid in United States as of August 2014
  22. Hospice
    1. Updated Emergency Department approach based on Pediatric Hospice article

VII. Updates: July 2014

  1. Hip Fracture
    1. Updated Hip Fracture
  2. Vomiting in Pregnancy
    1. Updated Vomiting in Pregnancy, Hyperemesis Gravidarum
  3. Local Skin Anesthesia
    1. Updated Digital Block, Supraorbital Nerve Block, Infraorbital Nerve Block, Mental Nerve Block
    2. Added Field Block and Lip Field Block
  4. Ectopic Pregnancy
    1. Updated the diagnostic approach
  5. Pain Management at the End of Life
    1. Updated the approach to pain management in terminally ill patients
  6. Motion Sickness
    1. Extensive update on prevention and management
  7. Cardiac Arrest and Antibiotics
    1. Following ROSC, consider Blood Cultures and broad spectrum Antibiotics
    2. Bacteremia has been identified in up to 38% of ROSC cases (postulated Sepsis as underlying Cardiac Arrest etiology in these cases)
  8. Bronchiolitis
    1. Update including an approach to rapid disposition in the emergency department
    2. Emphasis on the simple (frequent Nasal Saline and suctioning, followed by a trial of Albuterol)
  9. Wide Complex Tachycardia
    1. Assume Wide Complex Tachycardia is Ventricular Tachycardia (not SVT with aberrancy)
    2. Algorithms (e.g. Griffith, Brugada, Bayesian) to distinguish Ventricular Tachycardia from SVT with aberrancy (or RBBB) have miss rates of 6-7% at best
    3. Consequence of treating Ventricular Tachycardia as SVT (e.g. with Calcium Channel Blocker) can be lethal
  10. Pulmonary Embolism Diagnosis
    1. Added Shared Decision Making protocol in Pulmonary Embolism Low Probability Evaluation AND D-Dimer 0.5 to 1.0
  11. Pediatric Sepsis
    1. Updated pressor indications and protocol
  12. Emergency Psychiatric Evaluation
    1. Extensive updates to Mental Status Exam and suicidal risk
  13. Emergency Management of Asthma Exacerbation
    1. Updated management, highlighting the most beneficial interventions
  14. Nephrolithiasis Imaging
    1. Updated with additional precautions related to CT-associated Radiation Exposure
    2. Added approaches that minimize ionizing radiation exposure
  15. Low Risk Chest Pain
    1. Added Vancouver Chest Pain Rule to help triage patients to an earlier disposition
  16. Left Ventricular Assist Device (LVAD)
    1. Extensive update of LVAD related emergencies
  17. Fever in the Returning Traveler
    1. Updates to overall approach including specific updates to Malaria, Leptospirosis, Dengue Fever, Typhoid Fever
  18. Evzio
    1. Naloxone Auto-Injector for treatment of home Opioid Overdoses
  19. Middle East Respiratory Syndrome (MERS)
    1. Coronavirus similar to the virus associated with SARS
  20. Acetaminophen and pregnancy
    1. Yes, it is still safe in pregnancy (despite very weak associations with ADHD in one study)
  21. Antidepressant Selection
    1. Updated Depression Medical Management, Refractory Depression Management, and Antidepressant Adverse Effects
  22. Use of ARBs after Angioedema with ACE Inhibitor
    1. Bradykinin related reaction (not allergic) that recurs with ARBs in 2% of patients who had Angioedema on ACE Inhibitor
    2. Do not use ARB if ACE inhibitor Induced Angioedema was severe
    3. Precautions given to patient to stop ARB immediately and seak emergency care for signs of Angioedema recurrence
    4. Wait at least 4 weeks between stopping ACE Inhibitor and starting ARB
    5. (2013) J Allergy Clin Immunol 131:1491-3 [PubMed]
  23. Insulin-Related Errors
    1. Added approach to preventing Insulin-Related Errors
  24. Tinea Versicolor
    1. Updated Tinea Versicolor including recommendations to avoid oral Ketoconazole
  25. HIV Preexposure Prophylaxis
    1. Updated
  26. Benzodiazepine Receptor Agonist agents for Insomnia (e.g. Ambien, Lunesta)
    1. FDA released a safety warning to limit maximum dosing of Lunesta and to start at 1 mg in all patients (similar to the 2013 Ambien warning)
  27. Pediatric Constipation
    1. Updated Pediatric Constipation, Pediatric Constipation Causes, Pediatric Constipation Management and Constipation in Infants
  28. Pleural Effusion
    1. Updated Pleural Effusion, Pleural Effusion Causes, Thoracentesis and Pleural Fluid Examination
  29. Fever of Unknown Origin
    1. Updated Fever of Unknown Origin, Fever of Unknown Origin Causes, Fever of Unknown Origin Examination, Fever of Unknown Origin History, Drug Fever

VIII. Updates: June 2014

  1. Splenic Injury
    1. Added Splenic Injury management with grading and a management protocol
  2. Spinal Cord Syndromes
    1. Added Complete Cord Syndrome, Central Cord Syndrome, Anterior Cord Syndrome and Spinal Cord Hemisection
  3. Delirium
    1. Added the CAM-S (Confusion Assessment Method Short Form)
  4. Neonatal Hyperbilirubinemia
    1. Updated an approach to Nonphysiologic Neonatal Jaundice and the Risk Score for Neonatal Hyperbilirubinemia
    2. Updated Bilirubin Encephalopathy and Neonatal Bilirubin
  5. Salivary Gland Update
    1. Updated Sialadenitis (Acute Suppurative Sialoadenitis, Viral Sialoadenitis, Chronic Sialoadenitis, Sialolithiasis, Salivary Gland Tumor)
    2. Added Recurrent Parotitis of Childhood
  6. Tuberculosis
    1. Updated Tuberculosis Risk Factors (Tuberculosis Screening Indications)
    2. Added Tuberculosis Risk Factors for progression from Latent to Active Disease (Latent Tuberculosis Treatment Indications)
    3. Added Tuberculosis Related Chest XRay Changes
    4. Updated Tuberculosis Testing (including TST/PPD and IGRA)
    5. Updated Latent Tuberculosis Treatment
  7. Choosing Wisely Campaign
    1. Reviewed Best Practices by Specialty (Choosing Wisely Campaign)
      1. http://www.choosingwisely.org/doctor-patient-lists/
  8. NMDA Receptor Antibody Encephalitis (NMDARE)
    1. NMDA Receptor Antibody Encephalitis occurs in patients under age 30 years (especially women with Ovarian Teratomas)
    2. NMDARE appears to be more common than HSV Encephalitis in young patients
  9. Procedural Sedation pearls
    1. Emergency Department Procedures can be performed safely under sedation despite recent meals
    2. End-Tidal CO2 reduces Hypoxia risk by 10-20%
    3. Asthma Exacerbation Management in the ER (C0349790)
  10. Asthma Exacerbation
    1. Updated Emergency Management of Asthma Exacerbation and Status Asthmaticus
  11. Spasmodic Cough
    1. Added causes
  12. Bronchiolitis
    1. Various updates included nasal cpap for severe Bronchiolitis
  13. Marijuana update
    1. Concentrated Hemp Oil (THC Wax and THC Honey Oil) and butane related explosions
  14. Cardiac Arrest
    1. Guidelines for Emergency Cardiovascular Care remain unchanged (Epinephrine is still standard of care)
    2. However, Epinephrine updated with a summary of research in Cardiac Arrest that calls its benefit in Cardiac Arrest into question
  15. Neurologic Exam
    1. Added Corneal Reflex and Optical Reflex (Orbicularis Oculi Reflex)
    2. Added Finger-Nose-Finger
  16. Trauma in Pregnancy
    1. Updated Trauma in Pregnancy and Radiation Exposure in Pregnancy
  17. Abdominal Pain in Older Adults
    1. Updated Abdominal Pain in Older Adults
  18. Acute Knee Pain
    1. Added Knee Dislocation, Tibial Plateau Fracture
    2. Updated Patella Fracture
  19. E-Cigarette (Electronic Cigarette)
    1. Added including associated toxicity and its management
  20. Pneumothorax
    1. Added guidelines for return to air travel after Pneumothorax
  21. Delayed Sequence Intubation
    1. Updated with additional clarification
  22. ACE Inhibitors and Angiotensin Receptor Blockers
    1. Precautions and monitoring in Chronic Kidney Disease
  23. DVT Prophylaxis
    1. Apixiban and Rivaroxaban in DVT Prophylaxis after total hip arthroplasty and total knee arthroplasty
  24. Drug Dosing in Chronic Kidney Disease
    1. ACE Inhibitor and Angiotensin Receptor Blocker Adjustments in Impaired Renal Function
  25. Insulin Dosing in Type 2 Diabetes
    1. Updated Advancing Basal/Bolus Dosing in Type II Diabetes
  26. Oral Contraceptive
    1. Updated the missed pill protocol
  27. Antepartum Depression
    1. Avoid Paroxetine in pregnancy and avoid Fluoxetine in Lactation
    2. Sertraline (Zoloft) is still safe (and much safer than untreated depression) throughout pregnancy and Lactation
  28. Medication Compliance
    1. Not all medications should be placed in Pillboxes
    2. Sublingual, orally disintegrating medications and other medications may be degraded by moisture and light
  29. Allergy Immunotherapy
    1. Sublingual Immunotherapy for grass and ragweed allergy (Grastek, Oralair, Ragwitek) to the rescue for those with needle Phobia
  30. Bacterial Otitis Externa
    1. Cortisporin suspension is now contraindicated if TM Perforation
    2. Aurodex should be avoided under age 2 years (methhemoglobinemia risk) and with caution in others (Contact Dermatitis risk)
  31. Noninvasive Blood Gas monitoring
    1. Updated Oxygen Saturation
    2. Added End-Tidal CO2 (Capnography)
    3. Added Colorimetric Capnometry
  32. Cardiac Physiology
    1. Added Preload, Afterload, Blood Volume and Cardiac Output (and Stroke Volume), and Central Venous Pressure (CVP)
    2. Added Delayed Tachycardia
  33. Advanced Trauma Life Support (ATLS)
    1. Added Trauma Team Activation (TTA) protocols, Trauma Triage in the Field protocols and Trauma Center Levels
    2. Updated Trauma Primary Survey and Trauma Secondary Survey
    3. Updated Primary Survey Airway Evaluation, Primary Survey Breathing Evaluation, Primary Survey Circulation Evaluation
    4. Updated Primary Survey Disability Evaluation, Primary Survey Exposure Evaluation
    5. Updated Diagnostic Testing in Trauma and EKG monitoring in Trauma
    6. Updated Hemorrhagic Shock and Fluid Resuscitation in Trauma
    7. Updated Pneumothorax, Tension Pneumothorax and Needle Thoracentesis
    8. Updated Esophageal Rupture and added Hamman's Crunch
    9. Added Trauma in the Elderly

IX. Updates: May 2014

  1. Unintentional Weight Loss in the elderly
    1. Updated causes and a rational approach
  2. Pediatric Arrhythmias
    1. Reviewed Supraventricular Tachycardia in children
    2. Practical approach to Vagal Maneuvers
    3. Practical approach to pediatric SVT chemical and electrical cardioversion
  3. Skin Abscess management
    1. Further evidence for Incision and Drainage without packing and primary loose closure
    2. Standard packing is still recommended for larger abscesses (>5 cm) and those in Immunocompromised patients
  4. Leukemia
    1. Significant update to Leukemia, Acute Leukemia (AML and ALL), Chronic Leukemia (CML, CLL) including surveillance
  5. Scrotal Masses
    1. Updates to Scrotal Pain and Scrotal Masses and an overall approach
  6. Pediatric Appendicitis Pathway
    1. Combines the Pediatric Appendicitis Score with Appendix Ultrasound for a reasonable Appendicitis approach in children
  7. Procedural Sedation
    1. Update on assorted issues in Procedural Sedation
    2. Per ACEP, recent food intake is not a contraindication to Procedural Sedation
  8. Intraosseous Access
    1. Labs drawn via IO that are reliable (on i-stat): Serum Sodium, Serum Calcium, Serum Glucose, Serum Bicarbonate (and Base Excess)
  9. Phlegmasia (Milk Leg)
    1. Just when I thought DVT was not typically acutely painful, I learn of ileo-femoral vein obstruction
    2. Add Phlegmasia Alba Dolens and Phegmasia Cerulea Dolens to the differential of the painful lower extremity
  10. MDMA (Molly, Ecstasy)
    1. MDMA is unsafe at any dose (hyperthermia may occur at low dose)
    2. MDMA, whether in "pure" form or contaminated (e.g. bath salts) has been associated with numerous deaths and ED visits since introduced in 2004
  11. Shoulder Pain
    1. Updated various aspects of Shoulder Pain, Shoulder Exam, Frozen Shoulder and Shoulder Injection
  12. Pneumothorax management
    1. Small Caliber Chest Tubes are as effective and significantly less painful than standard Chest Tubes in Pneumothorax
    2. Outside of Hemothorax (or hemopneumothorax), Small Caliber Chest Tubes appear safe in uncomplicated Traumatic Pneumothorax
  13. Atrial Fibrillation Anticoagulation
    1. Added the CHADS2-VASc Score - as a more accurate scoring system then the CHADS2 score
  14. Cerebrovasacular Accident
    1. Significant update
    2. Added Hemorrhagic CVA and Intracerebral Hemorrhage
    3. Updated Subarachnoid Hemorrhage
    4. Updated ischemic Cerebrovascular Accident
    5. Updated CVA Thrombolysis
  15. Central Line Placement
    1. Focus on updating Ultrasound-guided Central Line Placement and on site selection (with links to 4 online demonstration videos)
  16. Gallstones
    1. Extensive updates to Cholelithiasis, Biliary Colic, Acute Cholecystitis, Choledocholithiasis, Ascending Cholangitis
  17. Laparoscopic Adjustable Gastric Banding
    1. Numerous complications with more than 50% of patients requiring repeat surgery and 75% who would not choose the procedure again
  18. Parasitic Infection
    1. Added and updated information about Chagas Disease, Neurocysticercosis, Toxocariasis and Toxoplasmosis
  19. Medications (assorted pearls)
    1. Medications Predisposing to Diabetes Mellitus
    2. Topical Antifungal agents
    3. Opioid Abuse Deterrent Agents
    4. Melatonin
    5. Vitamin Supplement

X. Updates: April 2014

  1. Overhead Athlete Injuries
    1. In addition to updating the common SLAP Lesions and labral tears, SICK Scapula Syndrome and PASTA Injury are added
  2. Emergency Contraception
    1. Multiple effective options: Levonorgestrel only, combination Oral Contraceptives, Ulipristal and Copper T IUD
    2. Levonorgestrel is over the counter for all ages (and behind the counter for generic)
  3. Pericarditis
    1. Updated focusing on diagnosis, distinguishing findings and specific management strategies
  4. Cirrhosis (or other End-stage liver disease) and Coagulopathy
    1. End-stage liver disease patients have mixed Coagulation Disorders (both hypocoagulable and Hypercoagulable)
    2. INR is a poor marker for bleeding risk in liver failure
    3. In active bleeding, consider Cryoprecipitate 10 units for Fibrinogen <150 mg/dl, and Platelet Transfusion for Platelet Count <50,000
  5. Addison Disease
    1. Substantial update including diagnostic approach and management
  6. Medicolegal updates
    1. Safer Patient Signouts with the SIGNOUT Mnemonic
    2. Updated Risk Management and Against Medical Advice
  7. Acute Renal Failure, Chronic Renal Failure updates
    1. Updates included Emergency Care in ESRD and Dialysis-Related Spontaneous Bacterial Peritonitis
  8. Atrial Fibrillation
    1. Extensive updates with additional protocols and reorganization of the material
    2. Surprised by the Atrial Fibrillation Cardioversion precautions (e.g. risk of Thromboembolism for under 48 hours duration)
    3. I am interested in the Ottawa Aggressive Protocol in Atrial Fibrillation Cardioversion
  9. Severe Hypertension
    1. Asymptomatic Severe Hypertension does not require emergency management (modify oral management and arrange close follow-up)
  10. Intertrigo
    1. Evaluation and management including extended differential diagnosis
  11. Acute Limb Ischemia
    1. Updated the overall approach
  12. Hyperkalemia Management
    1. Expanded evaluation and management
  13. Peritonsillar Abscess
    1. Pearls to Peritonsillar Abscess aspiration
  14. Diabetes Management
    1. Updated the overall approach to Type 2 Diabetes Mellitus as well as Diabetes Mellitus Glucose Management, and preventive strategies
  15. Pelvic Fracture
    1. Hemorrhage Management strategy
  16. Post-Intubation Sedation
    1. Propofol and Fentanyl infusions are appropriate for all but the most severe, refractory Hypotension
  17. Therapeutic Hypothermia (post-arrest)
    1. Target Temperature of 36 C may be as beneficial as 33 C (and with lower risk of complications such as Arrhythmia)
  18. Acetaminophen (Tylenol)
    1. Prolonged use in pregnancy may be associated with ADHD in children
  19. Dexamethasone in Asthma
    1. Dexamethasone 0.3 to 0.6 mg/kg/day PO/IV/IM up to 15 mg for 1-2 days is equivalent to Predisolone for a longer course in Asthma Exacerbation
  20. Phosphodiesterase Inhibitors
    1. Updated and reorganized
  21. Digoxin
    1. Updated dosing regimens, precautions
  22. Cerebrovascular Accident Risk in Women
    1. Also updated medications in Pregnancy Related Hypertension
  23. Stress Ulcer prophylaxis (in the ICU)
    1. High risk ICU patients have a 25% risk of Stress Ulcer related GI Bleeding
    2. Protocols may revert to H2 Blockers (over PPIs) for prophylaxis agent of choice (fewer adverse effects, ?similar efficacy)
  24. Elbow Pain
    1. Added differential diagnosis of Elbow Pain by location
    2. Added Distal Biceps Tendinopathy, Elbow UCL Injury (and related tests Elbow Moving Valgus Stress Test, Elbow Milking Test)
    3. Expanded Medial Epicondylitis, Lateral Epicondylitis, Ulnar Tunnel, Radial Tunnel, Elbow Osteochondritis Dissecans, Olecranon Bursitis
  25. Health Care of the Homeless
    1. An approach to medical care of a homeless patients
    2. This adds to the list of Health Maintenance topics focusing on the directed care of a specific population
  26. Chronic Daily Headache
    1. Expanded the evaluation, differential diagnosis and management of Chronic Daily Headache
    2. Added topics related to the brief Headache syndromes and Cluster Headache like conditions seen in Chronic Daily Headache
  27. Pancreatic Cancer
    1. Updated approach
  28. Dietary Potassium
    1. Corrected Potassium calculations in salt substitute
    2. Added additional high Potassium foods and calculated meq per small increment (e.g. per dried apricot, date, inch banana)

XI. Updates: March 2014

  1. Images added
    1. Knee Exam (16 images)
    2. QRS Axis image
  2. Miscellaneous updates
    1. Dacryocystitis and Dacryoadenitis
    2. NEXUS Criteria and the distracting injury defined
    3. Emergency Medicine Links
  3. Secondary Trauma Survey (ATLS)
    1. Modified Mantra: Fingers and tubes in every orifice has changed to applying selective Rectal Exams and Nasogastric Tubes
    2. Added how to perform a bedside Retrograde Urethrogram when Urethral Trauma is suspected
  4. Incision and Drainage
    1. Irrigate abscesses with saline
    2. Gently pack (NOT tightly) larger Skin Abscesses (or loop a penrose drain)
    3. Culture only if Antibiotics used and then only use Antibiotics for Cellulitis, Immunocompromised patient, Diabetes Mellitus
  5. Cerebrovascular Accident in Children
    1. Pediatric CVAs are rare (3-15 out of 100k), but they are devastating, and TPA has been used
  6. Epistaxis management
    1. Topical Tranexamic Acid (IV form) applied topically to nasal septum via inserted cotton pledgets appears effective in refractory bleeding
  7. Dog Bite wounds
    1. Primary closure within 8 hours of wound is safe at all sites
    2. For primary versus secondary closure, infection rates are similar (6-9%) but cosmetic results are significantly better for primary closure
    3. Antibiotics are indicated if primary closure is performed and for all hand wounds (as well as other indications per clinical assessment)
  8. Dysmenorrhea
    1. The management remains largely unchanged
    2. Fleshed out the overall step-wise approach and differential diagnosis
  9. Sleep Problems in Children
    1. Updated Night Awakening in Infants, Night Terrors and Nightmares, Parasomnias (e.g. Sleep Walking) and Pediatric Insomnia
  10. Cognitive Behavioral Therapy for Insomnia
    1. Updated the Sleep Stimulus Control and Sleep Restriction Therapy topics
    2. Based this on a CBT-I course I attended in Minneapolis in 2012 (by Drs Perlis and Schmitz)
  11. Pulmonary Function Tests
    1. Updated the step by step interpretation of Pulmonary Function Tests
    2. Added the new approach per ATS of incorporating Spirometry Lower Limit of Normal (far more accurate than GOLD Criteria)
    3. Added Exercise Spirometry as well as the root nodes for Obstructive Lung Disease and Restrictive Lung Disease (with causes)
  12. Spinal Epidural Abscess
    1. Keep a high index of suspicion, especially in IV Drug Abuse and Immunocompromised patients
    2. Fever may occur in as few as 30% of cases
    3. Neurologic deficits are common, but may initially be subtle
  13. Neck Masses in Children
    1. Highlighted an approach to evaluation and management
    2. Expanded the Lymphadenopathy of the Head and Neck list of causes
  14. Mononucleosis
    1. Overall update including an in depth look at complications
    2. Incredible (and scary) that more than half of Splenic Ruptures in Mononucleosis are spontaneous (no Trauma)
  15. Urine Drug Screen
    1. Updated False Positives and times for detection
  16. Clostridium difficile
    1. General update on management
  17. Elder Abuse
    1. Common and commony missed (as with Domestic Abuse and Child Abuse)
  18. Musculoskeletal Injury
    1. Added Contusion and updated Muscle Strain and Ligament Sprain
  19. Intrauterine Devices
    1. Updated with newer devices (e.g. Skyla) and guidelines
  20. Miscellaneous Topics
    1. Green tea Drug Interactions
    2. Urine drug testing update
    3. Childhood Poisoning update

XII. Updates: February 2014

  1. Hypokalemia
    1. Cleaned up causes and links
  2. CPAP and BIPAP
    1. Similar effects in respiratory distress
    2. CPAP may be better tolerated as patient does not need to synchronize breathing with CPAP
  3. Procedural Sedation and Induction agents
    1. Propofol or Ketamine (or Etomidate) for procedures
    2. Etomidate as a single dose for RSI is unlikely to impact outcomes in Sepsis
      1. However avoid repeat or prolonged dosing due to risk of adrenal suppression and associated increased mortality in Sepsis
  4. Chest XRay Interpretation
    1. Updated the systematic approach
  5. Cyanosis
    1. Cyanosis will be absent until 5 g/dl Hemoglobin is desaturated (and therefore anemic patients will not typically appear cyanotic)
  6. Community Acquired Pneumonia
    1. Updated with the IDSA/ATA guidelines for which tests are indicated in Community Acquired Pneumonia
  7. Shoulder Dislocation
    1. Pre-reduction XRay is not needed in low energy mechanisms and classic anterior dislocation (obtain post-reduction films in all cases)
  8. Acute Diarrhea
    1. Extensive updates of Acute Diarrhea and its causes
  9. Bell's Palsy
    1. Corticosteroids are still a mainstay, but Antiviral Agents (e.g. Valtrex) are not
  10. Scoliosis
    1. With skeletal immaturity (Risser Grade<4-5) Xrays every 6 months for Cobb Angle >20 degrees, bracing at 25 degrees, surgery at 40 degrees
    2. Watch for the red flags (S Curve - convex left thoracic curve, severe pain, spinal disraphism, Neurofibromatosis)
  11. Exertional Syncope
    1. Syncope during Exercise is transient sudden death in contrast to Syncope after Exercise which is typically benign (e.g. Vasovagal Syncope)
  12. Advanced Directives in the Emergency Department
    1. A protocol for family discussions at the end of life
  13. Prenatal Care
    1. Guidelines on Nutrition in Pregnancy, Teratogen Exposure, Quad Screen and Prenatal Visits
  14. Low Risk Chest Pain
    1. Protocol updated
  15. Hypertension Criteria
    1. JNC-8 moves the goal line for Hypertension Management again
    2. Aim for BP <140/90 in age under age 60, or in renal disease or Diabetes Mellitus under age 80, otherwise BP <150/90
  16. Emergency Management of Asthma Exacerbation
    1. Updated Asthma Exacerbation Management in the ER and Status Asthmaticus
  17. Human Immunodeficiency Virus
    1. Combination Antiretroviral Therapy (CART) is constantly changing as well as its indications (earlier start)
    2. HIV Preexposure Prophylaxis (long-term) is being offered to high risk patients
    3. HIV Screening has evolved to fourth generation testing (more sensitive and earlier detection thanks to p24 Antigen testing)
    4. HIV Western Blot has largely been replaced for HIV confirmation
      1. Confirmation is now via Multispot and HIV 1 Nucleic Acid amplification test (NAAT) for HIV RNA Viral Activity
  18. Thyroid Disorders in Pregnancy
    1. Reviewed Hypothyroidism in Pregnancy, Hyperthyroidism in Pregnancy and Postpartum Thyroiditis
  19. Miscellaneous general topic review updates
    1. Soft tissue injuries and Lacerations
    2. Headaches
    3. Cervical Spine Injury
    4. Viral Exanthems
    5. Sexually Transmitted Infections
    6. Musculoskeletal Injury
    7. Cerebrovascular Accident and TIA
    8. QRS Axis (as well as Left Axis Deviation and Right Axis Deviation)
    9. Pacemaker and Cardiac Resynchronization Implantable Device indications

XIII. Updates: January 2014

  1. Penetrating Injury (e.g. Gunshot Wound)
    1. Reviewed the topic in general, prompted after learning of the Arterial Pressure Index (API) in extremity Gunshot Wounds
  2. Spine Board Clearance
    1. Remove Spine Boards within 20 minutes of ED arrival and maintain spinal precautions until fully cleared by history, exam and imaging
  3. Emergency Department Patient Satisfaction
    1. Courtesy and compassion, listening and lay speak, get started early and come back often
  4. Vital Signs
    1. Review and explain Vital Signs at presentation, throughout encounter and at discharge
  5. Encounter Documentation (with medical-legal pearls)
    1. Updated E/M History Criteria and fleshed out a comprehensive Review of Systems
  6. Skull Fracture
    1. Fleshed out the basic approach to Skull Fracture
  7. Gastrointestinal conditions
    1. Assorted updates including Esophageal Foreign Body and Radiopaque Foreign Body
  8. Eye Conditions
    1. Assorted updates including added Slit Lamp exam
  9. Interstitial Infiltrate (includes Kerley B Lines)
    1. Updated as a side effect of updating CHF diagnosis
    2. Refresher on an approach to lung infiltrates (are they interstitial or are they alveolar?)
  10. Chest XRay in Congestive Heart Failure
    1. A hole is filled in my Medical Education: The three stages of CHF progression on Chest XRay
  11. Pediatric Emergency Care
    1. Consent for Treating Minors
    2. Pyloric Stenosis
  12. Accidental Hypothermia Management
    1. ECMO is preferred management for severe Hypothermia (<28 C) or severe Cardiac Dysrhythmia (e.g. Asystole)
  13. Workplace Injury
    1. Early return to work is ideal - of those off work due to restriction for >3 months, only 50% return to regular employment
    2. Low Back Pain treated early with Opioids is associated with prolonged use of Opioids, longer recovery period and higher surgery rate
  14. Anaphylaxis Management
    1. Epinephrine drip preparation and indications
  15. Cellulitis Management
    1. An emergency department protocol
  16. Cardiopulmonary Resuscitation
    1. Therapeutic Hypothermia in the Trauma patient (and bleeding risk at core Temperatures <35 C or 95 F)
    2. Primary Survey Breathing Evaluation and what to do for ventilations when a mechanically ventilated patient has a Cardiac Arrest
  17. Hip Exam
    1. Expanded on examination tools and Hip Pain Differential Diagnosis and added multiple images for various Hip Exam components
  18. Child Abuse (Non-accidental Trauma)
    1. Consider every injury and illness in a child in the context of the reported history and mechanism
    2. Child Abuse is a commonly missed diagnosis (30% of abusive head injuries, 20% of abusive Fractures)
      1. Identify Child Abuse early, when it is still associated with minor injury
  19. Noonan Syndrome
    1. Similar Phenotype to Turner Syndrome, but with a normal karyotype and not limited to females
    2. Delayed diagnosis (or never diagnosed) is typical at the risk of missing serious associated conditions (e.g. Congenital Heart Disease)
  20. Neonatal Resuscitation
    1. Three core questions to determine if Resuscitation is indicated: Term? Breathing? Tone?
    2. Only two markers guide resusictation: Respiratory status and Heart Rate
    3. Only two medications are used in Neonatal Resuscitation: Epinephrine and volume expanders (NS, Blood)
    4. Ventilations are the single most important measure in Neonatal Resuscitation
    5. Perineal suctioning for meconium is no longer recommended
    6. Do not endotracheal suction vigorous infants despite thick meconium presence
    7. Consider Therapeutic Hypothermia protocol in newborns >36 weeks with developing severe hypoxic-ischemic encephalopathy
  21. Adolescent Drug Abuse
    1. Updated individual Drugs of Abuse, Chemical Dependency, Toxin Ingestion
  22. Hyperlipidemia Management
    1. Updated to account for new ACC/AHA 2013 Guidelines
    2. Statins are the preferred AntiHyperlipidemic and combinations are not recommended in most cases
    3. Patients are risk stratified to high or low risk Statin dose without the chasing of specific LDL Cholesterol goals
    4. Framingham calculator is replaced with a new 10 year Cardiovascular Risk calculator to help risk stratify (including Statin dosing)
  23. COPD Action Plan
    1. COPD equivalent to an Asthma Action Plan can help prevent COPD admissions
  24. Barrett Esophagus
    1. Guidelines on who with GERD needs upper endoscopy and how often is unchanged
    2. For those with high grade esophageal dysplasia there are new, less invasive, highly effective treatments
  25. Celiac Disease
    1. Screening protocols continue to change: Now obtain Total IgA and IgA Tissue Transglutaminase (TTG)
  26. Tinnitus
    1. Red flags include unilateral Tinnitus (Acoustic Neuroma), low pitched Tinnitus (Meniere Disease) and pulsatile Tinnitus (vascular lesions)
    2. Audiometry in most patients (especially if >3 weeks of symptoms)
    3. MRI Brain with contrast (and including IAC) for focal neurologic deficits, persistent unilateral Tinnitus
  27. Medication precautions
    1. Ondansetron
      1. May be associated with Congenital Heart Defects and Cleft Palate when used in first trimester (e.g. Hyperemesis Gravidarum)
      2. The first-line Antiemetic in the emergency department (but can also cause Serotonin Syndrome and QT Prolongation)
    2. Emergency Contraception
      1. Levonorgestrel (Morning After Pill) has decreased efficacy in women over 165 pounds and is ineffective over 175 pounds
      2. Consider Ella (Ulipristal) or copper IUD Placement within 5 days of intercourse for obese women who want Emergency Contraception
    3. Clarithromycin
      1. Increases Calcium Channel Blocker levels (via CYP3A4 inhibition) and cause Hypotension and Acute Kidney Injury (especially over age 65 years)

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