II. Updates: December 2016

  1. Acute Monoarthritis (rheum, joint)
    1. Arthrocentesis is the only absolutely reliable method to exclude Septic Joint
    2. Osteoarthritis, Gouty Arthritis and Trauma are the most common causes in primary care
    3. Although initially causing Migratory Arthritis, Gonorrhea settles in a primary joint
  2. Pet-Borne Infection (id, vector)
    1. Ringworm may be transmitted from dogs and cats to humans
    2. Backyard poultry are particularly ripe with infectious risk (Exercise prevention)
    3. Leptospirosis (from dog or wild animal urine) may cause serious human infections
    4. Salmonellosis is the main risk of reptile/amphibian exposure
    5. Cat Scratch Disease (Bartonellosis) and Toxoplasmosis are the main infectious risks from cats
  3. Erectile Dysfunction (urology, Impotence)
    1. Limit Serum Testosterone testing to signs of Hypogonadism or refractory Erectile Dysfunction
    2. Sildenafil continues to be the only generic PDE-5 Inhibitor (other agents are 30-50x the cost)
    3. Most management strategies for Erectile Dysfunction remain unchanged for the last decade
  4. Unexplained Lymphadenopathy (hemeonc, lymph)
    1. If head and neck imaging is needed in under age 14 years old, Ultrasound is preferred
    2. Consider antibiotics for persistent acute anterior cervical Lymphadenitis with systemic symptoms in children
    3. Avoid Corticosteroids until definitive diagnosis made (may mask Lymphoma or Leukemia diagnosis)
    4. If biopsy is needed, fine needle aspirate may distinguish reactive Lymphadenopathy from malignancy
  5. Estrogen Replacement Therapy (gyn, endo, pharm)
    1. Estrogen Replacement Therapy (ERT) is indicated for symptom control, NOT for prevention of any chronic disease
    2. Estrogen must be used with Progesterone if intact Uterus, but has higher complication rates
    3. No single lifestyle measure is consistently effective for Vasomotor Symptoms of Menopause
    4. Estrogen Replacement options are reviewed with multiple options of agent, delivery and dose
  6. Fever in the Newborn (id, peds, nicu)
    1. Febrile, but well appearing infants >21-28 days old may be evaluated by step-by-step protocol
    2. Child low risk if negative Urinalysis for Leukocytes, and Procalcitonin <0.5, CRP <20, ANC<10,000
  7. Nitrous Induced Subacute Combined Degeneration of the Spinal Cord (surgery, Anesthesia, adverse, psych, cd, neuro)
    1. Nitrous Oxide Abuse is common among 16-17 years olds (and historically of dentists and Anesthesia providers)
    2. Longterm use risks B12 Deficiency and progressive ascending Polyneuropathy (especially sensory)
  8. Urticaria (ent, allergy, derm)
    1. Allergy may be the cause of hives, BUT most hives are not due to allergy
    2. Allergic Reactions occur in close proximity to the inciting agent (typically within minutes)
    3. Most antibiotic reactions that have onset days after starting, are due to the infection, not Allergic Reaction
    4. Cetirizine, Loratidine, Fexofenadine may be dosed twice daily in adults if needed
  9. Acute Brachial Neuritis (ortho, brachial)
    1. Acute severe, sharp Shoulder Pain (or arm and Neck Pain) for 1-2 weeks, then non-dermatomal weakness and sensory loss
    2. Idiopathic Brachial Plexus lesion that resolves in most cases within 2-3 years
  10. STI Screening (id, std, prevent)
    1. Behavioral counseling (proper Condom use, safe sex, difficult sexual situations) for all sexually active teens, adults at STI risk
    2. GC and Chlamydia screening in all sexually active teens <24 years old and women at risk for STI
    3. HIV Screening in all patients ages 15 years old to 65 years old (or if risks) AND all pregnant women
    4. Hepatitis BVirus Screening in all pregnant women and in those at risk of infection
    5. Syphilis Screening in all pregnant women and those at risk of infection
    6. Avoid HSV Serology in asymptomatic patients (per USPTF, AAFP); Per CDC and ACOG, may be considered in women (esp. with multiple partners)
  11. Trauma in the Elderly (er, Trauma, geri)
    1. Geriatric Trauma patients are frequently much more ill than they appear
    2. Maintain a high index of suspicion for serious injury, even in low mechanism injuries
    3. Frail Trauma patients more rapidly decompensate, and remain ill for longer periods of time
  12. Febrile Seizure (neuro, id, peds, fever)
    1. Simple Seizures account for a majority of Febrile Seizures and are generalized, lasting shorter than 15 minutes
    2. Complex Seizures last longer than 15 minutes and may have focal neurologic findings
    3. Healthy children with simple Febrile Seizures, and no red flags, do not require imaging or lab
  13. Field Trauma Assessment and Treatment (er, Trauma)
    1. Equivalent of Primary Survey for the field; follow with Secondary Survey
    2. Control Massive Hemorrhage (Tourniquets, Hemostatic Agents, pressure bandages)
    3. Airway may require Advanced Airway or Cricothyrotomy
    4. Respiration management may require chest decompression for Tension Pneumothorax
    5. Circulation management (assess vitals, rapid transfusions)
    6. Head and Hypothermia (GCS, decreased mental status) and avoid Hypothermia
  14. Foot Fracture (ortho, foot, Fracture)
    1. Includes Tarsal Navicular Fracture, Fifth Metatarsal Fracture, Lisfranc Fracture
  15. Nebulized Lidocaine (lung, sx, cough)
    1. May offer benefit in refractory significant cough
  16. Subarachnoid Hemorrhage (neuro, cv, bleed)
    1. Platelet Transfusion has been historically used for patients with Hemorrhagic CVA who are on antiplatelet agents
    2. Platelet Transfusion in these cases is associated with worse outcomes (death and worse neurologic function)
  17. Thoracolumbar Trauma (ortho, L-Spine, T-Spine, Trauma)
    1. Image if not alert, not able to be evaluated, positive exam, high risk mechanism, age >65 years old
    2. Physical exam and plain xray are inadequate to exclude significant Thoracolumbar Injury
    3. Thoracolumbar CT may be reconstructed from chest and Abdomen, Pelvis imaging
  18. Chest Compressions (er, procedure, cv)
    1. High performance CPR (hard - PETCO2>20, fast and with minimal interruption) is critical to better outcomes
  19. Esophageal Foreign Body (gi, Esophagus)
    1. Glucagon is marginally better than Placebo
  20. Pneumonia Accelerated Diagnostic Protocol (lung, id, Bacteria)
    1. Cam Berg and North Memorial have created another well thought out accelerated diagnostic protocol
    2. EM:Rap this month reviewed this ADP, including CURB-65 for disposition, and MDR Score for HCAP management
  21. Acute Otitis Media Observation (ent, ear, id)
    1. Observation (no antibiotic) protocols are well established for over age 6 months
    2. Consider short (5 day) course antibiotics >6 years old without severe symptoms
  22. HPV Vaccine (id, immunize)
    1. New protocol for HPV Vaccine in ages 9-14 years old will be 2 doses instead of three, each 6-12 months apart
  23. Statins (cv, lipid, pharm)
    1. Lipid control has been reduced to Statin or no Statin (replaces multi-agent), and high dose or low dose (replaces LDL driven)
  24. DVT Prophylaxis in Pregnancy (hemeonc, ob, dvt, prevention)
    1. If increased VTE Risk, consider DVT Prophylaxis with Enoxaparin for pregnancy and 6 weeks postpartum
    2. Enoxaparin dosing is based on starting weight, typically 40 mg SC daily for weight 50-90 kg (q12h if >90 kg)
    3. Do not use Warfarin, Direct Oral Anticoagulants, Aspirin, Compression Stockings for DVT Prophylaxis
  25. Turmeric
    1. Not yet a proven panacea; save your money, until more data is available
  26. Breast Feeding Problems for the Mother
    1. Updated with additional recommendations, including Nipple Soreness in Lactation

III. Updates: November 2016

  1. Travel Medicine (id, travel)
    1. Start international Travel Preparation at least 6 weeks in advance
    2. Be aware of local risks, Air Travel Restrictions, and specific required and recommended Vaccinations
    3. More than 18% of travel related fatalities are due to Motor Vehicle Accidents
    4. Casual sex occurs in 20% of international travelers (encourage Condoms and Contraception)
  2. Mental State Exam (psych, exam)
    1. Exam areas break down into 11 areas of evaluation (e.g. appearance, behavior, activity...)
    2. Many alternatives to the non-free MMSE such as SLUMS Exam, Addenbrooke's Cognitive Exam, Montreal Cognitive Assessment
  3. Intimate Partner Violence (prevent, abuse)
    1. Intimate Partner Violence is common and high risk for morbidity and mortality
    2. There are many validated screening tools (SAFE, WAST, HITS) - Pick one and use it regularly (you may save a life)
    3. Listen respectfully, interact compassionately, and offer resources
  4. Community Acquired Pneumonia (lung, id, Bacteria)
    1. Lung Ultrasound may have higher efficacy than Chest XRay
    2. Five days of antibiotics is sufficient for low severity Pneumonia
    3. Consider Corticosteroids in inpatient Pneumonia Management (less ARDS risk, shorter stays)
    4. Prevention in age over 65 years old includes Prevnar 13, followed in one year by Pneumovax 23
  5. Combination Antiretroviral Therapy (hiv, pharm)
    1. Of the 2.1 M new cases HIV worldwide, U.S. accounted for 44,000 (see HIV Infection)
    2. Disproportionately, Black patients who represent only 12% of the U.S. population, account for 44% of new cases
    3. Triumeq and Genvoya are first line, one pill daily regimens for therapy naive, non-pregnant HIV patients
    4. NNRTI based therapy with Atripla is no longer first-line therapy as of 2015
  6. Epididymitis (uro, Testes)
    1. Treat suspected STD-related Epididymitis with IM Rocephin 250 mg and oral Doxycycline 100 bid for 10 days
    2. Age over 35 and no concern for STD, treat with Levofloxacin or Ofloxacin for 10 days
    3. Insertive anal intercourse history should prompt Rocephin 250 IM, then Levofloxacin or Ofloxacin for 10 days
    4. Ciprofloxacin is inadequate for Epididymitis (Chlamydia resistance)
  7. Tuberculosis (lung, tb)
    1. IGRA (e.g. Quantiferon Gold) is a more accurate, reproducible test regardless of BCG vaccine than Tuberculin Skin Test
    2. Do not treat Latent Tuberculosis with a single drug regimen until Active Tuberculosis is excluded by history, Chest XRay
    3. In suspected Active Tuberculosis, mask patient in negative ariflow room and induce Sputum for AFB x3 samples
    4. Susceptible Tb Treatment has not changed substantially in 10 years, but multi-drug resistance guidelines are lacking
  8. Rapid IJ Access (er, procedure, fen)
    1. Quick central access without Seldinger technique
  9. Syphilis (id, std)
    1. Syphilis Incidence has increased 3-4 fold in the U.S. since 2000 (now at 20,000 cases per year)
    2. Syphilis is typically treated with Penicillin G (or Doxycycline, Tetracycline) for primary and secondry Syphilis
    3. Avoid Zithromax in Syphilis due to resistance
  10. Sickle Cell Disease (hemeonc, Hemoglobin)
    1. Children with SCD have serious morbidity that include high risks for Acute Chest Syndrome and CVA
    2. Musculoskeletal pain causes: Sickle Cell Crisis, AVN of femur/Humerus, Osteomyelitis, Septic Arthritis,Dactylitis
    3. Acute Dyspnea or Chest Pain Causes: Acute Chest Syndrome, PE, symptomatic Anemia (as well as ACS, Pneumonia, Asthma)
    4. Neurologic conditions include CVA (including silent CVA), Headaches (associated with serious causes) and Seizures
  11. Nail Injury
    1. Large Subungual Hematoma >50% may be treated as effectively with trephination as nail removal and Nail Bed Laceration repair
    2. Native nail is best for Nail Replacement (as opposed to nail substitutes/artificial nails) - less risk of infection
    3. Nail Replacement is indicated to hold open the eponychial fold (prevents scarring, closure) and protects the nail bed
  12. Sugammadex
    1. New Rocuronium and Vecuronium reversal agent - onset within 3 minutes, but with a 0.3% Anaphylaxis risk
  13. Rocuronium
    1. Sedation and analgesia is often inadequate during Rocuronium induced paralysis
  14. Penetrating Neck Trauma
    1. Observe the platysma, but avoid probing it
    2. Hard signs of vascular/aerodigestive injury are immediately triaged to the operating room
    3. Soft signs of neck injury (mild bleeding, Hematoma) are sent for CT angiogram of the neck
  15. Advanced Airway
    1. Have a plan for failed airway (e.g. 3 intubation attempts, then LMA, then Cricothyrotomy)
  16. Cardiopulmonary Resuscitation
    1. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
    2. On pausing CPR with rhythm check revealing shockable rhythm, immediate shock can be delivered and CPR resumed
  17. Acute Prostatitis
    1. Non-tender, non-boggy Prostate is unlikely to be Acute Prostatitis
    2. Urinary Tract Infection is uncommon in men without Bladder outlet obstruction (e.g. BPH, neurologic conditions)
    3. In mild Acute Prostatitis, 10 days of antibiotics is sufficient
  18. Splenic Laceration
    1. Grade 4-5 Splenic Lacerations in stable patients may be safely initially observed
  19. Induced Therapeutic Hypothermia
    1. Consider in children s/p non-Traumatic Cardiac Arrest, newborns with hypoxic-ischemic encephalopathy
    2. Goal Temperature of <36 C (prevent fever) appears as effective as <33 C, with fewer adverse effects
    3. Therapeutic Hypothermia is contraindicated in Hemorrhage including CNS and Hypotension requiring Vasopressors
  20. Short Acting Nitroglycerin
    1. Sublingual tablets are now good for up to 2 years from manufacture date if kept at room Temperature with bottle capped
    2. Costs roughly $0.40/tablet, compared with >$1.50/spray or $7/GoNitro powder
  21. Medications
    1. Codeine is finally banned by AAP for under age 18 years old
  22. Transgender Persons
    1. Ask patients their preferred name, gender and pronoun (may differ from medical record)
    2. Preventive health screening should be directed towards their birth gender
    3. Ask about mental health (Anxiety Disorder, Major Depression, Suicidality, Bullying
  23. Cardiac Risk Management
    1. Avoid Aspirin (and other antiplatelet agents) for primary prevention after prior GI Bleed
    2. Limit Aspirin after GI Bleed to secondary prevention (known cardiovascular disease)
  24. Kratom
    1. Derived from tropical tree (within coffee family)
    2. Herbal stimulant at low dose and with Opioid effects at higher dose, and potential for Opioid Abuse
    3. Currently legal in U.S. to purchase (as of 2016) but under DEA review
    4. Kratom withdrawal is similar to Opioid Withdrawal

IV. Updates: October 2016

  1. Vector Borne Disease (id, vector)
    1. Mosquitos transmit West Nile Virus, Dengue Fever, Zika Virus and Chikungunya
    2. Deer Ticks transmit Lyme Disease, Anaplasmosis and Babesiosis
    3. Other ticks transmit Ehrlichiosis, Rocky Mountain Spotted Fever and Tularemia
    4. Fleas, mites/Chiggers and Body Lice transmit Typhus
  2. Brief Resolved Unexplained Event (peds, er, lung)
    1. BRUE replaces term ALTE and describes infants (<1 year) with <1 min episode of unexplained change in color, tone or respirations
    2. Low risk events are initial, isolated in term infant>60 days old with an event lasting <1 minute with reassuring history, exam and no CPR needed
    3. Low risk events do not require hospitalization (or home CV monitor), but these infants should be re-evaluated in 24 hours
  3. Acute Bronchitis (lung, Bronchi, id)
    1. Another infection associated with inappropriate antibiotic use
    2. Chest XRay for Temp>100 F, Dyspnea, rusty or Bloody Sputum, Tachycardia, Tachypnea, Hypoxia, asymmetric lung signs
    3. Caution in the elderly who may present with Pneumonia without red flag findings
    4. Antibiotics clear Pertussis from nasopharynx (lowering Infectivity), but do not shorten course (esp. when given >2 weeks after onset)
  4. Postoperative Fever (id, fever, surgery)
    1. Infectious causes include Cellulitis, Pneumonia, C. Diff, UTI, prosthetic infections, CRBI
    2. Noninfectious causes include Atelectasis, PE, Alcohol Withdrawal and Adrenal Insufficiency
  5. Acute Pain Management (pharm, Analgesic, Opioid)
    1. Non-opioid Acute Pain Management options include Ketamine 0.2 mg/kg IV over 10 min, followed by 0.15 mg/kg/h IV
    2. Opioid Prescription in Acute Pain includes Informed Consent regarding Opioid prescriptions
    3. Updated Pediatric Analgesic to include J-Tip and intranasal Ketamine (?ready for prime time)
  6. Olanzapine (psych, pharm)
    1. Intravenous Olanzapine (Zyprexa) dosing appears safe by large 2016 HCMC ED study
  7. Procalcitonin (hemeonc, lab)
    1. Adds little to the diagnosis of Bacterial Infection
  8. Opioid Withdrawal (psych, cd, Opioid)
    1. Clonidine is first-line agent, often combined with Gabapentin (and consider with Tramadol taper)
    2. Tizanidine and Baclofen may reduce cravings
  9. Gabapentin (neuro, pharm)
    1. Doses above 1800 mg/day are unlikely to be beneficial
    2. Indicated for persistent neuropathic pain as well as Alcohol Dependence (decreases craving)
    3. Most common adverse effects are Dizziness, Somnolence and Ataxia
  10. Delirium (neuro, cognitive)
    1. Infections are responsible for 50% of geriatric Delirium cases, esp. Pneumonia, UTIs, soft tissue infections
    2. Infections in the elderly, even with bacteremia, are often occult without fever or localizing signs or symptoms
    3. Medications, esp. Opioids, Benzodiazepines, Anticholinergics, Dihydropyridines, Diuretics, and Muscle relaxants, are common causes of Delirium
    4. Includes DSM-5 update
  11. Cyanide Poisoning (er, toxin)
    1. Cyanide is found in Prunus Seeds (plums, cherries, peaches, nectarines, apricots and almonds)
    2. Consider Cyanide toxicity when ALOC or acidemia in syncopal lab worker, Smoke Inhalation, Suicide attempt or other suspected ingestion
  12. Sepsis (id, fever, Bacteria)
    1. Aggressive fluid hydration is key to Sepsis management, even in those at risk of Fluid Overload (CHF, CKD)
    2. CHF and CKD patients have decreased mortality with aggressive fluid hydration in Sepsis
    3. Aggressive fluid hydration offers significant benefit even if Lactic Acid 2-4 (intermediate range)
  13. Atrial Fibrillation (cv, ekg)
    1. Paroxysmal Atrial Fib carries the same longterm CVA risk of persistent Atrial Fib (both have 5 fold increased CVA risk)
    2. Goal Heart Rate in Atrial Fib rate control is <80 at rest and <110 with Exercise
    3. Anticoagulation for CHA2DS-VASc >=2 and HAS-BLED <3 with Warfarin, Direct Thrombin Inhibitor or Factor Xa Inhibitors
    4. Invasive management in refractory cases include Cardiac Ablation and left atrial appendage ablation
  14. Pulmonary Hypertension (lung, cv)
    1. Pulmonary Arterial Hypertension is idiopathic or genetic, rare and has specific treatments
    2. Four secondary types include left heart disease, lung disease, chronic PE or miscellaneous (e.g. sickle cell)
    3. Pulmonary Hypertension Diagnosis is often delayed 4 years or more despite multiple evaluations/Consultations
    4. Consider in progressive Dyspnea on exertion or Syncope
    5. Echocardiogram is the first line diagnostic tool, evaluating pulmonary pressures and right ventricular function
    6. Reviewed Pulmonary Arterial Hypertension Crisis
  15. Right Ventricular Strain EKG Pattern (cv, ekg, pe)
    1. Acute Pulmonary Hypertension in PE may be seen in EKG as a right heart strain pattern
    2. EKG findings include S1-Q3-T3, T inversion in V1-V4, ST Elevation aVR, Right Bundle Branch Block, Sinus Tachycardia, Atrial Fibrillation
  16. Asthma Management (lung, Asthma)
    1. Apply a stepped approach to uncontrolled Asthma, stepping up or down therapy every 2-4 weeks until controlled
    2. Steps 1-3 advance from prn Bronchodilator (SABA), adding low dose Inhaled Steroid, then long-acting Bronchodilator (LABA)
    3. Steps 4-6 advance Inhaled Corticosteroid from low dose, to moderate and then high dose, as well as allergy management
  17. Tumor Necrosis Factor Inhibitor (rheum, pharm)
    1. Risk of opportunistic or reactivated infections (e.g. Tb, Fungal Lung Infection, Hepatitis B, CMV)
    2. Risk of Nonmelanoma Skin Cancer
  18. Discharge Instructions (er, manage)
    1. Discuss and document Discharge Instructions with every patient
    2. Do not rely solely on generic or pre-printed Discharge Instructions (or on pharmacy pre-printed information)
    3. Discharge Instructions should be specific regarding follow-up, return precautions and medication instructions
  19. Patient Signout (er, manage, risk)
    1. Patient care hand-offs are high risk for error (e.g. change of shift, from mid-level to physician)
    2. Initial provider should clearly transfer care to the accepting provider (avoiding interruptions)
    3. Accepting provider should "own" the patient (assume full care of the patient)
  20. Assorted Medication Updates (pharm)
    1. Ondansetron (Zofran)
    2. Direct Oral Anticoagulants (DOAC, NOAC)
  21. Influenza Vaccine (id, immunize, virus)
    1. Flumist is not an option in 2016 due to lower efficacy
    2. Quadrivalent Vaccines (includes extra B strain coverage) are preferred over trivalent
    3. Those over 65 years old should consider high dose Fluzone or fluad (but higher risk of skin reactions)
    4. Egg allergy is not a contraindication for Influenza Vaccine
  22. Incretin Mimetic (dm, pharm)
    1. Byetta-like agents increase the risk of gallbladder disease
  23. Hydroxyzine (ent, pharm)
    1. Hydroxyzine is associated with QT Prolongation (join the club)
  24. Meniscus Tear (ortho, knee)
    1. Exercise therapy is preferred over arthroscopy and meniscectomy (similar longterm outcomes)
  25. Knee Osteoarthritis (ortho, knee)
    1. Platelet-rich plasma injections are no better than hyaluronic acid injections (which have questionable efficacy themselves)
  26. Post Myocardial Infarction Medications (cv, cad, pharm)
    1. Beta Blockers do not reduce overall mortality beyond first 30 days after Myocardial Infarction
  27. Perioperative Anticoagulation (surg, coag, pharm)
    1. Perioperative Anticoagulation bridging risks outweigh benefits in Atrial Fibrillation and low risk DVT
  28. Osteoporosis Management (rheum, bone)
    1. Vitamin D supplementation does affect BMD, function, Fall Risk or Muscle Strength in post-Menopause age <75 years
  29. Active Tuberculosis Treatment (lung, tb)
    1. Updated the regimen
  30. Gout (rheum, joint, crystal)
    1. Zurampic is another expensive adjunct for gout and Hyperuricemia

V. Updates: September 2016

  1. Systemic Lupus Erythematosus (rheum, diffuse)
    1. Affects up to 1 in 1000 in U.S. (esp. young black women)
    2. Up to 90% present with Fatigue, weight loss and fever
    3. Symmetric Polyarthritis of small joints is also common, and some present with Psychosis or Seizure
    4. High risk for nephritis (50%), premature coronary disease (52x increase), Pancytopenia
    5. Management and monitoring is complex, and is performed in collaboration with rheumatology
  2. Failure to Thrive
    1. Accurate recording of height and weight at every visit can prompt early evaluation and intervention
    2. Use WHO growth charts up to age 2 years, then CDC charts until age 20 years (or specialized growth charts)
    3. Laboratory testing or hospitalization are rarely indicated in Failure to Thrive
  3. Agitation in Dementia
    1. Non-pharmacologic methods (e.g. No-fail Environment in Dementia) are preferred over medications
    2. Medication risks and benefits should be reviewed with patients and their care Caregivers before starting
    3. Abilify and Risperdal are the most effective Atypical Antipsychotics for Agitation in Dementia
    4. All of the Atypical Antipsychotics have significant risks in the elderly including increased mortality
  4. Babesiosis
    1. Case presented with recent fever, Platelets 45k and mild Diarrhea, malaise
    2. Gradually developed wbc to 3.5k, hgb from 13 to 12 to 11 over 1 week of serial visits
    3. Peripheral Smear for Parasites demonstrated RBC inclusion bodies consistent with Babesiosis
    4. Updated Thrombocytopenia to include Babesiosis
  5. Needle Cricothyrotomy
    1. In failed airway, Needle Cricothyrotomy may temporize in infants and young children for 20-25 min
  6. Hemorrhagic Shock
    1. Covers reversal of specific Coagulation Disorders (e.g. DIC, TTP, Liver disease, renal disease, Anticoagulants)
  7. Live Attenuated Influenza Vaccine or Flumist (id, immunize, Influenza)
    1. Very low efficacy in U.S. as of 2016 (as low as 3%) and will not be used in U.S. per ACIP guidelines
  8. SGLT2 Inhibitor (endo, pharm, dm)
    1. For all its mediocre activity on Glucose lowering and adverse effects (UTI, Vaginitis, acidosis, ARF), there may be a bright spot
    2. Jardiance (empaglifozin) appears to lower cardiovascular death rate and slow Diabetic Nephropathy progression
  9. Naloxone (pharm, Analgesic, Opioid)
    1. Prescribe an emergency home Naloxone packs to families or Caregivers of patients on high dose Opioids
  10. Antacid (gi, pharm)
    1. No surprise, but alka seltzer (and similar) contain Aspirin and are a risk for Gastrointestinal Bleeding
  11. Gastrostomy Tube (gi, procedure)
    1. Unplug with warm water in 60 cc syringe; after water sitting in tube for 20 min, move plunger back and forth
    2. Pancreatic Enzymes with Sodium Bicarbonate in water can open a plugged tube refractory to warm water
    3. Prevent plugging with frequent Flushing (15-30 ml water) at least every 8 hours and before and after medications
  12. MRSA (id, emerging, resistance)
    1. Prevent spread by covering wounds, not sharing personal items, washing linens in hot water, Hand Washing, cleaning surfaces
  13. Pregabalin (neuro, pharm, ob)
    1. Pregabalin (Lyrica) in first trimester has been linked to possible birth defects
  14. Obstructive Sleep Apnea (lung, apnea, sleep)
    1. Home sleep studies are less accurate, but may be adequate in high probability patients without comorbidity
    2. No surgical intervention is effective (except for Bariatric Surgery and possibly hypoglossal neurostimulators)
    3. The STOP-Bang Questionnaire may be a helpful screening tool in preoperative assessment
  15. Obesity Management (endo, Obesity)
    1. Dietary management, activity with monthly clinic follow-up are first-line in the management of Obesity
    2. Caloric deficit of 500 kcal/day is ideal and simple measures are effective (e.g. more fiber and vegetables)
    3. If Obesity Medications are used, Orlistat is first-line due to fewer adverse effects and lower cost
    4. Medications that Exacerbate Obesity may be substituted with other agents that are weight neutral
    5. Obesity Surgery is indicated for refractory Obesity, BMI >40 kg/m2 (>35 kg/m2 if Obesity-related comorbidity)
    6. Adjustable gastric band has been approved for BMI >30 kg/m2
  16. Epiphyseal Fracture (ortho, Fracture, peds)
    1. Children have Growth Plates that are much weaker than ligaments (by a factor of 2-5 fold)
    2. Joint Trauma that would otherwise cause a ligamentous sprain in adults, results in a physeal Fracture in children
    3. Red flags include Growth Plate tenderness, non-weight bearing, joint sprain or instability
    4. Suspect a concurrent type 3-4 physeal Fracture, when children sustain a Ligament Sprain
  17. Ankle Sprain Management in Children (ortho, ankle, peds)
    1. Be suspicious of Growth Plate injury (weaker than ligaments) in children with Ankle Sprains
    2. Rotational injuries are a risk for Tillaux Fracture (with anterior tibial Epiphyseal PlateFracture)
    3. Suspect a Grade I Epiphyseal Fracture (Salter-Harris Fracture) if XRays are negative
    4. Lateral Ankle Sprains with Grade I Epiphyseal Fractures heal well with bracing
  18. Hip Pain (ortho, hip)
    1. Always exclude hip Septic Joint, as well as other serious causes (e.g. AVN, malignancy, Stress Fracture)
    2. Consider referred pain from the Abdomen, back and knee
    3. Intra-articular hip causes are more likely with pain on rotation and axial loading
    4. Posterior Hip Pain is rarely intra-articular (consider Lumbar Radiculopathy, Piriformis Syndrome, SI Joint instead)
    5. Evaluation should include Hip XRay to evaluate for serious causes (e.g. bony lesions, Stress Fractures and AVN)
  19. Acute Valvular Dysfunction (cv, valve, er)
    1. Consider Acute Valvular Disorders in a patient presenting with a new murmur and Dyspnea, Syncope or Chest Pain
    2. Consider Aortic Stenosis, Acute Mitral Valve Regurgitation, Prosthetic Heart Valve complication, Hypertrophic Cardiomyopathy
  20. Decision Making Strategy (manage, risk, cognitive)
    1. Effective emergency decision making is a combination of thin and Thick Slicing
    2. Thin Slicing (fast and intuitive) is used for the initial plan and based on limited information with risk of anchor bias and Confirmation Bias
    3. Thick Slicing (slow and logical) is used before disposition and is a deeper evaluation and analysis of clinical data including subtle findings
  21. Atrial Fibrillation (cv, ekg)
    1. Atrial Fibrillation and Atrial Flutter often co-occur in the same patient, often on the same EKG, and are treated identically
    2. Atrial Flutter is easier to to cardiovert at lower joules (<200 J) and Atrial Fibrillation is easier to rate control
    3. Diltiazem IV appears more effective than IV Metoprolol at acute rate control
    4. Oral Metoprolol appears more effective than oral Diltiazem in chronic Atrial Fibrillation
  22. Chest Tube (lung, procedure)
    1. Place in the triangle of safety (axilla at apex), between the lat dorsi posteriorly, pec major anteriorly, and xiphoid/nipple line inferiorly
    2. When in doubt, place the Chest Tube higher (4-5th intercostal space)
    3. Prepare well in obese patients (good light, wide exposed area, longer incision, reposition Breast/axillary fat/arm)
  23. Vitamin Deficiency in Alcoholism (cd, Alcohol, Vitamin)
    1. Vitamin Deficiency in Alcoholism is common (Vitamins A, C, B1, B3, B6, B9, B12)
    2. Deficiency syndromes include Wernicke's Encephalopathy, Vitamin A Deficiency, Scurvy and Pellegra
  24. Testicular Torsion (urology, Testes)
    1. Prehn's Sign and Cremasteric Reflex are unreliable and should not be used alone to rule-out Testicular Torsion
    2. Ultrasound is the study of choice in torsion evaluation, but Ultrasound can miss Testicular Torsion
    3. Even at 6-48 hours after symptom onset, testicular salvage rates may be as high as 50%
  25. Neonatal Resuscitation (nicu, er)
    1. Do not endotracheal suction infants regardless of thick meconium or non-vigorous infant
    2. Delay cord clamping for 30-60 sec in term infants, with normal tone and breathing, not needing Resuscitation
    3. Prevent Hypothermia and keep infant Temperature 36.5 to 37.5 (monitor with Temperature sticker over liver)
    4. Monitor Heart Rate with 3 lead ekg (cord palpation and auscultation are considered unreliable)
    5. Resuscitate with FIO2 21% in term infants and 21-30% in Preterm Infants
  26. Tenofovir (hiv, pharm)
    1. As if HIV agents were not confusing enough, Tenofovir formulation changes from Disoproxil (TDF) to Alafenamide (TAF)
    2. Results in combination agent name changes Stribild, Truvada and Complera TO Genvoya, Descovy, and Odefsey
  27. Marathon Medical Care (sports, Running, renal, Sodium
    1. Water Intoxication and Isovolemic Hypoosmolar Hyponatremia due to overhydration occurs in up to 50% of endurance event athletes
    2. Most cases are asymptomatic, while mild cases present with Nausea, Light Headedness and severe cases with Headache, Vomiting, Seizures
    3. Obtain Serum Sodium at medical tent if available
    4. Mild cases may be treated at medical tent with 3-4 boullon cubes in 1 cup of water, but severe cases require Hyponatremia Management protocol
    5. In prevention, athletes should drink to thirst, not on schedule, and Electrolyte tablets or solutions may slow Hyponatremia development
  28. Retinal Detachment (eye, Retina, Ultrasound)
    1. Bedside Ultrasound in ED has high accuracy with training (Test Sensitivity 91%, Test Specificity 96%)
  29. Elbow Exam
    1. Full range of motion nearly excludes elbow Fracture (especially in adults)

VI. Updates: August 2016

  1. Vision Loss (eye, Vision, loss)
    1. Macular Degeneration, Glaucoma, Cataracts and Diabetic Retinopathy are the 4 most common causes of Vision Loss in elderly
    2. Intravitreal Vascular Endothelial Growth Factor inhibitors are used in Macular Degeneration and Diabetic Macular Edema
    3. Macular Degeneration progression may be reduced with the use of eye Vitamins (antioxidants from AREDS and AREDS 2 trials)
  2. Painful Diabetic Neuropathy (endo, DM, neuro)
    1. Start with anticonvulsants (e.g. Gabapentin, Pregabalin), Tricyclic Antidepressants or SNRI (e.g. Duloxetine)
    2. Consider adjuncts such as Isosorbide Dinitrate spray on feet at bedtime, or Lidocaine Patch, TENS or Capsaicin
  3. Premenstrual Syndrome (gyn, psych, Menses)
    1. SSRIs (or SNRIs) and Oral Contraceptives are first line agents for PMS and PMDD
    2. Cognitive Behavioral Therapy, Calcium Supplementation and B6 supplementation are also effective
    3. Diagnostic criteria updated for PMS (ACOG) and Premenstrual Dysphoric Disorder (DSM 5)
  4. Syncope (cv, sx)
    1. Careful, directed history can hone Syncope from Dizziness or Seizure and distinguish cardiovascular from benign cause
    2. One third to one half of causes will be idiopathic; the key is to identify the high risk cardiovascular cases
    3. Updated Syncope, Electrocardiogram in Syncope as well as specific Arrhythmia recognition (WPW, Brugada)
  5. Transient Ischemic Attack (neuro, cv)
    1. Patients without ischemic MRI, high grade stenosis, CVA, cardioembolic phenomena or high ABCD2 Score may be discharged home
    2. EKG, vascular imaging (CTA, MRA or US), non-contrast MRI are most acutely important for disposition
    3. MRI Brain demonstrates infarction in 20%, ischemia (high risk for CVA) in 25%
    4. Aspirin 81 mg daily is the preferred antiplatelet agent for most patients TIA patients
  6. Septic Arthritis (ortho, id, Bacteria, joint)
    1. Synovial FluidGram Stain misses 20-40% of Septic Joint cases, and WBC cut-off of 50,000 also misses Septic Arthritis cases
    2. Synovial Fluid culture is best grown in Blood Culture medium bottles
    3. Gouty Arthritis and Septic Arthritis can occur concurrently; only Joint Aspiration can absolutely exclude Septic Arthritis
  7. Sepsis (id, Bacteria)
    1. Phenylephrine should be generally avoided in Septic Shock (Norepinephrine is preferred, even with Tachycardia)
  8. Ring Removal (surgery, derm, finger)
    1. Titanium Ring Removal with a vice grip (gradually tightening and clamping)
    2. Thank you to my ED partners Dr. Dan Johnson, and Dr. Tony Genia for introducing me to the technique
  9. Auricular Hematoma (ent, ear, Trauma, procedure)
    1. Updated Incision and Drainage technique with Ear Field Block and Auricular Bolster technique
  10. Nasal Ala Laceration (ent, nose, Laceration, procedure)
    1. Repair in three layer closure (mucosa, cartilage and skin), and close approximation is critical (analogous to vermilion border)
  11. Rocuronium (surgery, Anesthesia, pharm)
    1. Rocuronium 1.2 mg/kg is equivalent to Succinylcholine full activity onset
    2. Rocuronium long activity may outlast sedation, and result in unsedated paralysis (long acting sedation is critical)
  12. Increased Intracranial Pressure in Trauma (er, neuro, Trauma)
    1. Hypertonic Saline does not improve Intracranial Pressure or benefit mortality in Severe Closed Head Injury
  13. Necrotizing Fasciitis (derm, id, Bacteria)
    1. Watch for pain out of proportion to exam and tenderness beyond the erythematous margin
    2. Fever, crepitation, bullae, skin necrosis may all be absent
    3. Timely diagnosis and surgery within 12 hours is the difference between survival and death
  14. Intussusception (surgery, peds, gi, bowel)
    1. Exercise a high index of suspicion for Abdominal Pain in ages 3-12 months, lethal with delayed diagnosis
    2. Episodic severe, inconsolable pain can prompt ED visit where the child may be transiently well appearing
    3. Have a low threshold for ordering Ultrasound, which has high Test Sensitivity and Test Specificity
  15. Nasogastric Tube (ed, procedure)
    1. Midazolam 2 mg IV before procedure, significantly reduces pain and eases placement
  16. Emergency Department Patient Satisfaction
    1. Christopher Peabody, MD focuses on patient safety and in developing the high functioning organization (standardizing quality)
    2. He shares 3 mantras with his EM teams: "We keep our patient's safe, we get each other's back, have the shift of your life"
  17. Needle Thoracentesis (lung, procedure)
    1. Longer angiocatheter (8 cm) is needed in larger chest walls (compared with the 5 cm needle recommended by ATLS)
  18. DSM5 Updates (psych, exam)
    1. Premenstrual Dysphoric Disorder

VII. Updates: July 2016

  1. Eye Pain (eye, sx)
    1. Eye Pain with Vision Loss should be urgently evaluated by ophthalmology
    2. Evaluate for Fluorescein uptake pattern, IOP, Visual Acuity and photophobia
    3. Distinguish painful Red Eye from the painful, non-Red Eye
  2. Chronic Opioid (rheum, pain)
    1. Chronic Opioids for non-Cancer Pain are fraught with risk of Overdose, misuse/abuse and side effects
    2. Chronic visceral pain (abdominal or Pelvic Pain) and central pain (Headache) respond poorly to Opioids
    3. Exercise caution in initiating Chronic Opioids (consider all other options)
    4. Pre-screen patients with Opioid Risk Tool or DIRE Score and be alert for patients at risk of Overdose, misuse and abuse
  3. Occupational Disorders (sports, work)
    1. Occupational Asthma accounts for 15% of Asthma, with a 70% persistent morbidity despite elimination of triggers
    2. Occupational Dermatitis can range from Contact Dermatitis (>90% of cases) to burns, infections and Skin Cancer
    3. Common occupational injuries include Carpal Tunnel, Lateral Epicondylitis, Shoulder Impingement and Low Back Pain
  4. Vertebral Compression Fracture (ortho, t-spine)
    1. Conservative therapy for initial 3 weeks is preferred in most cases
    2. Consider Vertebroplasty or Kyphoplasty in refractory cases
    3. Evaluate for Osteoporosis with DEXA Scan, and consider secondary Osteoporosis (esp. younger patients)
  5. Bullous Conditions (derm, bullous)
    1. Stevens Johnson Syndrome is more on the spectrum of Toxic Epidermal Necrolysis than Erythema Multiforme
    2. Mucosal involvement and Nikolsky Signs distinguish Steven Johnson (and TEN) from Erythema Multiforme Minor
    3. Staphylococcal Scalded Skin Syndrome has a much higher mortality in adults than children
  6. Syncope in Children (cv, peds)
    1. Most Syncope cases in children are benign
    2. Electrocardiogram and Echocardiogram are used to exclude the most significant Syncope cause
  7. RSV Bronchiolitis (lung, Bronchi, peds)
    1. Another article reiterates everything we were taught in medical school is wrong (no nebs or steroid trials)
    2. Saline and suction and other supportive care are the mainstays of treatment
    3. Added the Clinical Severity Scoring System Tool
  8. Streptococcal Pharyngitis (ent, throat)
    1. Throat Culture is recommended by IDSA for children with negative quick strep tests and intermediate probability for strep
    2. However, adults are at lower risk for strep complications and strep culture is not routinely recommended
  9. Cardiac Rehabilitation (cv, cad)
    1. In addition to standard rehab programs, several intensive, extended cardiac rehab programs are covered by medicare
  10. Rhinosinusitis (ent, sinus, id)
    1. Up to 70% of Acute Sinusitis <14 days resolves without antibiotics
    2. Number Needed to Treat (NNT) for antibiotic in Acute Sinusitis benefit: 11-15
    3. Number needed to harm (NNH) for antibiotic in Acute Sinusitis adverse effects: 8
  11. Polycystic Ovary Syndrome (gyn, endo)
    1. Associated with DM II, Metabolic Syndrome, Obesity, NASH, Sleep Apnea, Dyslipidemia and Mood Disorders
    2. Ultrasound is not required for diagnosis of PCOS (diagnosis can be made clinically)
    3. Rotterdam Criteria 2 of 3 are required for PCOS diagnosis (Hyperandrogenism, Ovulatory Dysfunction, Polycystic Ovaries)
  12. Acute Shoulder Injury (ortho, Shoulder)
    1. Reviewed AC Separation, Clavicle Fracture, Glenohumeral Dislocation, Proximal Humerus Fracture and Rotator Cuff Tear
  13. Trigeminal Neuralgia (neuro, Headache, cn)
    1. Carbamazepine and Oxcarbazepine (or Baclofen in MS) are the most effective agents initially
    2. In the longterm, as medication efficacy wanes, and attacks increase in severity, consider microvascular decompression
  14. Posterior Tibial Nerve Block (ortho, procedure)
    1. Anesthesia of the heel and sole of the foot under Ultrasound guidance
  15. Pentrating Trauma (surgery, Trauma)
    1. In superficial chest injuries, obtain FAST Exam and if negative for Pericardial Effusion, serial Chest XRay x2 at >1 hour apart
    2. In superficial abdominal penetration, CT Abdomen does not have 100% Test Sensitivity for GI Tract injury (better for solid organ)
  16. Carbon Monoxide Poisoning (er, toxin)
    1. Carbon Monoxide diffuses through drywall and may cross through multi-tenant dwellings
    2. Hyperbaric chambers decrease neurotoxicity in severe Poisonings (but do not affect mortality)
    3. Half-Life of Carbon Monoxide decreases from 6 hours on room air to 1 hour on non-rebreather
    4. Consider cyanide Poisoning in structure fires and Smoke Inhalation (ALOC, Lactic Acid >8)
  17. Torticollis (ortho, neck)
    1. Reviewed the multiple causes of Torticollis including Atlantoaxial Rotary Subluxation (in those with Atlantoaxial Instability)
  18. Awake Intubation (lung, airway, procedure)
    1. Fiberoptic Nasotracheal Intubation in cases of impending airway compromise (e.g. Epiglottitis)
    2. Prepare airway with 4% Lidocaine atomized into nose and throat and Lidocaine paste on the back of Tongue
  19. Tibial Plateau Fracture (ortho, knee, Fracture)
    1. High mechanism injuries that may be occult on xray, severe pain and risk of Compartment Syndrome and associated injuries
  20. Lyme Disease (id, vector)
    1. Reviewed management as well as Tick Bite management
  21. Acute Coronary Syndrome (cv, cad)
    1. Exercise a higher level of suspicion for women with atypical cardiopulmonary symptoms (higher ACS miss rate)
    2. Non-occlusive coronary disease is more common in women (making prior stress testing results less reassuring)
  22. Hepatitis C Antiviral Regimen (gi, id, pharm)
    1. Primary care is increasingly prescribing Hepatitis C treatment
  23. Loperamide (psych, cd, Opioid)
    1. Opioid Abuse with Loperamide (Imodium) is increasing, with doses as high as 64 mg with risk of lethal Arrhythmias
  24. Fluouroquinolones (id, pharm)
    1. No longer first-line for UTIs due their adverse effect profile
  25. Rosuvastatin (cv, pharm, lipid)
    1. Now generic (but still $200/month)
  26. Electronic Cigarettes (psych, cd, Tobacco)
    1. Finally the FDA will regulate as Tobacco
  27. Medication-Related Travel Precautions (id, travel, pharm)
    1. Beware of medication homonyms on international travel (e.g. ambyen is Amiodarone in Britain)
    2. You may be arrested if you bring pseudophedrine into Mexico or Adderall into Japan
  28. DSM5 Updates (psych, exam)
    1. Opioid Use Disorder

VIII. Updates: June 2016

  1. Sarcoidosis (lung, rheum)
    1. Often presents with asymptomatic Hilar Adenopathy on Chest XRay
    2. Prednisone is still the first-line agent for symptomatic Stage 2-3 disease
  2. Pediatric Abdominal Pain (surgery, gi, peds)
    1. Do not forget PID/STI and Ectopic Pregnancy in adolescents
    2. History, exam, lab (esp. UA) and Ultrasound are the work horses of acute Pediatric Abdominal Pain
    3. Red flags include Bilious Emesis, fever, bloody Diarrhea, and abdominal peritoneal signs
    4. Ultrafast 3T MRI is a 6 minute appendix evaluation with good sensitivity and Specificity
  3. Peripartum Depression (psych, ob)
    1. Maternal Suicide is only second to PE for most common causes of peripartum maternal death
    2. Screen for depression at perinatal visits and Well Child Visits (months 2, 4 and 6)
    3. Consider home health visits, telephone support for high risk mothers
  4. Antiplatelet Therapy for Vascular Disease (CAD, hemeonc, pharm)
    1. Durations of post-stenting Dual Antiplatelet Therapy are changing
    2. Six months is now the default after DES for Stable Ischemic Heart Disease
    3. Twelve months is needed after Acute Coronary Syndrome (even if no stent placed)
    4. Consider 18 months if DAPT Score (Dual-Antiplatelet Therapy Decision Rule) of 2 or greater
  5. Ovarian Cancer (gyn, hemeonc, ovary)
    1. Not much has changed since last reviewed
    2. Screening is not still not recommended (outside of hereditary syndromes such as BRCA, Lynch II)
    3. Human Epididymis Protein 4 (HE4) is a new Tumor Marker used in combination with CA-125
  6. Genital Herpes (id, std, herpes)
    1. HSV I now accounts for at least 50% of new Genital Herpes cases in U.S.
    2. Genital Herpes is asymptomatic in 65-90% of patients
    3. Asymptomatic viral shedding occurs on 10-20% of all days (regardless of outbreak)
    4. All pregnant women with Genital Herpes outbreak should be prophylaxed with Acyclovir starting at 36 weeks
  7. Painless Acute Vision Loss (eye, Vision)
    1. Causes: Central Retinal artery or vein Occlusion, Retinal Detachment, Vitreous Hemorrhage, Optic Nerve ischemia
    2. Flashes and Floaters are seen with Vitreous Detachment, but Retinal Detachment also has presents with Vision Loss
    3. A good Funduscopic Exam can distinguish Acute Vision Loss causes (urgent to emergent ophthalmology consult)
    4. Fundus is pale with cherry red macula Central Retinal Artery Occlusion, and "blood and thunder" in vein Occlusion
  8. Clostridium difficile (gi, id, Diarrhea)
    1. Highest risk antibiotics are Clindamycin, Fluoroquinolones, broad-spectrum Cephalosporins, Carbapenems
    2. Lowest risk antibiotics are Penicillins, Bactrim, Macrolides and Tetracyclines
  9. Acetaminophen Overdose (pharm, Analgesic, toxin)
    1. Four hour Acetaminophen level is key, but 8 hour level is needed for extended release products
    2. Rumack-Matthew Acetaminophen Nomogram cannot be used in chronic or staggered ingestions
    3. N-Acetylcysteine is best started in first 8-10 hours, but may be effective in delayed presentations >24 hours
    4. Consider Activated Charcoal in an alert patient presenting within 1 hour of ingestion
  10. Tooth Avulsion (dental, tooth, procedure)
    1. Permanent (secondary) Tooth Avulsion is a Dental Emergency with implantation ideal within 5-20 minutes
  11. Childlife Specialist Measures to Calm Children (er, peds, behavior)
    1. Distraction and coaching coping techniques are the mainstays of keeping a child calm and cooperative in the ED
  12. Trauma (er, Trauma)
    1. Minimize crystalloid use in a hemodynamically stable patient without acute blood loss
  13. Coronary Artery Disease Prevention (cad, prevent)
    1. Little has changed. DASH Diet or Mediterranean Diet AND regular Aerobic Exercise and Muscle Strengthening
    2. Salt Restriction appears to matter little in CAD prevention (aside from CHF)
  14. Sickle Cell Anemia (hemeonc, Hemoglobin)
    1. In acute presentations obtain Hemoglobin And Reticulocyte Count to help differentiate cause
    2. Low Hemoglobin (>2 g/dl drop) and high Reticulocyte Count suggests Splenic Sequestration or Hemolysis
    3. Low Hemoglobin And low Reticulocyte Count suggests Transient Red Cell Aplasia (Parvovirus B19)
    4. Normal Hemoglobin And cardiopulmonary findings sugesst Acute Chest Syndrome
    5. Otherwise consider Acute Vaso-Occlusive Episode in Sickle Cell Anemia (Sickle Cell Crisis)
  15. Lead Poisoning (er, toxin)
    1. Acute Lead Chelation is indicated for Acute Encephalopathy (e.g. Seizures, Altered Mental Status) AND Lead Toxicity
    2. Consult poison control
    3. First: British anti-Lewisite (BAL) IM (if not contraindicated due to G6PD or peanut allergy)
    4. Next: Calcium Disodium EDTA IV given 4 hours after BAL
  16. Treating Family Members (pharm, legal, ethics)
    1. Do not write controlled substance prescriptions (e.g. Opioids, Benzodiazepines) for family or friends
    2. Home treatment of minor symptoms is reasonable, but major symptoms are best treated with formal evaluations
    3. Rendered care may be sub-standard of the care you would deliver to others
    4. Clinician may stretch their care beyond their level of expertise
    5. Family members may have misconceptions or unrealistic expectations and perceive a poor outcome
    6. Trying to please a family member may result in altering care from best practice with a worse outcome
  17. Mechanical Ventilation (lung, failure, Asthma)
    1. Most Asthma patients will respond to aggressive management and BiPap
    2. In those intubated, keep Respiratory Rate low enough (e.g. 10) to prevent Breath Stacking, and watch plateau pressure
  18. Topical Analgesics (pharm, Analgesic)
    1. Lidocaine Patches 4% are over the counter and cost $3, one third that of the generic 5% patches
  19. Rheumatoid Arthritis (rheum, ra)
    1. Methotrexate with Sulfasalazine and Hydroxychloroquine is as effective as Methotrexate and a biologic/TNF agent
  20. Quinolones (id, pharm, Bacteria)
    1. Quinolones may cause neurologic symptoms (e.g. Insomnia, confusion or Hallucinations)
  21. Fluconazole (id, pharm, fungus)
    1. Fluconazole even a single dose in second trimester may predispose to Miscarriage
  22. Prothrombin Complex Concentrate (er, Trauma, hemeonc, bleed)
    1. Prothrombin Complex Concentrate (PCC) is not associated with increased thrombosis risk (compared with FFP)
  23. Head Trauma (neuro, Trauma)
    1. Warfarin-related delayed Intracranial Hemorrhage after Minor Head Injury is more uncommon than previously thought
  24. Gliptins (endo, dm)
    1. Saxigliptin or Alogliptin risk of hospitalized CHF exacerbation: 1 in 150 patients/2 years (less likely with Sitagliptin)
    2. Yet another adverse effect for agents that only improve A1C 0.5%
  25. C-Reactive Protein (hemeonc, lab, id)
    1. Is not accurate enough, to alter management in distinguishing Bacterial Infection from other causes (e.g. fever, Septic Joint)
  26. DSM-5 Updates (psych, exam)
    1. Major Depression Diagnosis updated
  27. Drug Updates (pharm)
    1. Viberzi is another expensive ($1000) IBS with Diarrhea agent with marginal efficacy

IX. Updates: May 2016

  1. Brain Abscess (neuro, id, Bacteria)
    1. From Direct Spread (e.g. Mastoiditis, Sinusitis, Dental Infection) or hematogenous (e.g. empyema, endocarditis)
    2. Strep cause up to 70% of cases, and the rest are most Bacteroides, Enterobacteriaciae and Staph aureus
    3. Unilateral Headache is most common presentation, but fever, focal neurologic deficits, Seizures, aloc are variable
    4. Diagnosis is by MRI (preferred) or CT, and fluid is obtained by neurosurgery (avoid Lumbar Puncture)
    5. Initial empiric antibiotic management includes Cephalosporin and Metronidazole and consider Vancomycin
  2. Aseptic Meningitis (neuro, id)
    1. Enteroviruses cause 85% of cases, in addition to Arbovirus, Herpes viruses, HIV
    2. Bacterial causes include Brain Abscess, partially treated Meningitis, Lymes, Tuberculosis
    3. Other causes include fungal Meningitis, medications (esp. Ibuprofen), Leukemia, lumphoma and Autoimmune Conditions
    4. Abnormal brain function (aloc, changed behavior, personality, speech) distinguishes Encephalitis from Meningitis
    5. Seizures may occur with either Meningitis or Encephalitis
  3. Encephalitis (neuro, id)
    1. More than 40% of cases are HSV Encephalitis; other causes VZV, Tb, Listeria, Arbovirus
    2. NMDA Encephalitis is a common cause in age <30 years old (40% of cases in one study)
    3. Start Acyclovir empirically in all cases of suspected Encephalitis until HSV is excluded by PCR
  4. Bacterial Meningitis Management (neuro, id, Bacteria)
    1. For over age 1 month, empiric management includes Vancomycin AND Cefotaxime OR Ceftriaxone (or Meropenem)
    2. Dexamethasone is added for suspected pneumococcus
    3. Ampicillin is added for listeria risk (Immunocompromised, pregnant, over age 50 years or under age 1 month)
  5. Bartonella (id, Bacteria)
    1. Three species of Gram Negative Rod cause Cat Scratch Disease, Bacterial Endocarditis, Trench Fever and Bacillary Angiomatosis
    2. Bartonella is a common cause of culture negative endocarditis (esp. in homeless)
    3. Bacillary Angiomatosis complicates AIDS (CD4 <100) with vascular lesions similar to Kaposi's Sarcoma (may disseminate)
  6. Health Concerns in the Elderly (geri, prevent)
    1. Take Life Expectancy into account when discussing cancer screening
    2. Paradoxically, the healthiest patients are screened less than those in with the lowest Life Expectancy
  7. Adnexal Mass (gyn, ovary)
    1. Most Ovarian Masses are benign, and routine screening for Ovarian Cancer is not recommended in low risk patients
    2. Obtain a Pregnancy Test (to exclude Ectopic Pregnancy) in all women with a Uterus of child bearing age
    3. Ovarian Cancer risk increases after age 40-50, FHx (esp. BRCA, Lynch Syndrome), nulliparity, Obesity
    4. Red flag symptoms with Ovarian Mass include Abdominal Bloating, pelvic or Abdominal Pain, urinary symptoms
  8. Ovarian Torsion (gyn, ovary)
    1. Torsion presents in atypical patients (15% pediatric, 15% Postmenopause, 20% pregnancy, 25% without risk)
    2. Torsion presents with atypical symptoms (not abrupt in 40%) and pelvic exam adds little to the diagnosis
    3. Ultrasound sensitivity is poor (30-85%), not much better than CT, but is sufficient in moderate suspicion
    4. Ultrasound need not follow CT to specifically evaluate torsion in moderate suspicion cases
    5. Only definitive diagnosis tool is laparoscopy in high suspicion cases
  9. Glaucoma (eye, iop)
    1. Glaucoma is a leading cause of blindness, with increased risk especially over age 65 and in black and hispanic patients
    2. Primary Open Angle Glaucoma (POAG) is typically asymptomatic until severe Visual Field or central loss occurs
    3. IOP measurement alone is insufficient for POAG diagnosis (also requires Optic Nerve exam and Visual Field testing)
    4. More than half of POAG patients have normal IOP, and most with high IOP >22 do not develop Glaucoma (nerve injury)
  10. Cervical Radiculopathy (ortho, c-spine)
    1. Spondylosis in older patients is most common cause, especially at C6-7
    2. Loss of Triceps Reflex is most common objective finding
    3. Provocative tests with high efficacy: Spurlings Test, Shoulder Abduction Test, Upper limb Tension Test
    4. Consider red flags including Myelopathy (decreased dexterity, urine urgency, Ataxia, Clonus, hyperreflexia)
    5. MRI has a high False Positive and False Negative Rate in Cervical Radiculopathy
    6. Non-surgical management is preferred in most cases (88% are improved by 4 weeks)
  11. Prostate Cancer Survivor Care (urology, Prostate, hemeonc)
    1. Obtain PSA every 6-12 months for 5 years after treatment and refer if >1.0 after radiation or >0.03 after surgery
    2. Refer for new onset Hematuria (esp. after Radiation Therapy due to secondary cancer risk)
    3. Radiation Therapy and Prostatectomy are both complicated by urinary dysfunction and Erectile Dysfunction
  12. Breast Abscess (gyn, Breast, id)
    1. Needle aspiration under Ultrasound guidance is preferred (consider irrigating through same needle)
    2. Needle aspiration may be repeated as needed (consider Incision and Drainage if more than 3 times)
  13. Abdominal Aortic Aneurysm (surgery, gi, cv)
    1. Cryptic presentations are common
    2. AAA may present with Microscopic Hematuria (leading to mis-diagnosis of Renal Colic)
    3. Misdiagnosis as Diverticulitis, GI Bleed, Musculoskeletal cause is common (60% initial misdiagnosis rate)
  14. Pediatric Trauma (er, Trauma, peds)
    1. Chest XRay is preferred over chest CT in most cases of Pediatric Trauma (including Seat Belt Sign)
  15. Concussion (neuro, Trauma)
    1. No patient should return to play on the same day of a Concussion
    2. Graded Return to Play after Concussion (6 steps) is recommended for sports-related Concussion
    3. Headache, Dizziness, inattention start to improve in first 48 hours, and typically last 1-2 weeks
    4. More than 30% of patients will have Postconcussion Syndrome lasting 3 months
    5. Early cognitive and physical relative rest reduces the risk of long-lasting Concussion symptoms
  16. Severe Head Injury (neuro, Trauma)
    1. Document Neurologic Exam before intubation and use short acting Sedatives
    2. Consider non-convulsive Status Epilepticus (extremity fine Tremor, facial tics)
    3. Elevate the head above 30 degrees
    4. Keep Oxygen Saturation >90% (best 94-97%) and avoid hyperoxygenation
    5. Keep Glucose in normal range
  17. Seat Belt Sign (gi, Trauma)
    1. Abdominal seat belt Ecchymosis is associated with significant Abdominal Injury in 65% of cases (RR 8)
    2. CT Abdomen is indicated in most if not all cases, and laparotomy if positive
    3. Observation for 12-24 hours with serial exams may be indicated even if normal CT Abdomen
  18. Acute Pain Management in Children (pharm, analgesia, peds)
    1. Children's pain is frequently under-treated in the emergency department
    2. Pain Evaluation scales include FLACC Scale and Wong-Baker FACES Pain Rating Scale
    3. Beyond Ibuprofen or Tylenol, oral options include Hydrocodone, Oxycodone and Morphine
    4. Intranasal Fentanyl is an excellent option for children in the emergency department
    5. IV non-Opioids include Ketorolac and Ketamine, and Opioids include Morphine and Hydromorphone
  19. Chest Pain (cv, cad, sx)
    1. Four factors increase the likelihood of Acute Coronary Syndrome
    2. Pain radiation to the right chest or bilateral chest
    3. Exertional Chest Pain
    4. Pain with diaphoresis
    5. Pain associated with Nausea or Vomiting
  20. Shock (cv, er)
    1. Consider intubation if Resuscitation is unlikely to result in early response (within 15 minutes)
    2. Ketamine is an ideal RSI agent for a patient in shock
  21. High Risk Acute Coronary Syndrome Management (cv, cad)
    1. Aggressively decreasing door to balloon time is associated with significant adverse effects
    2. Higher False Positive Rate on angiography (with higher mortality risk)
    3. Missed alternative diagnoses (e.g. Pulmonary Embolism, Aortic Dissection, Sepsis)
    4. Obtain an adequate initial history and examine the EKG carefully
  22. Vasopressor (cv, pharm)
    1. Peripheral Vasopressor delivery appears safe for short-term use (e.g. 2 hours)
    2. Do not use Vasopressors via unreliable, small or deep peripheral site
    3. Monitor peripheral IV closely for Vasopressor Extravasation
    4. In case of extravasation, withdraw residual Vasopressor, and inject Phentolamine SQ
  23. Antivenin for Snake Bite (er, Trauma, bite, toxin)
    1. Antivenin is given as 4-6 vials over 1 hour for advancing swelling or Platelet Count or Fibrinogen <100
    2. Repeat antivenin hourly until advancing swelling ceases
    3. Recheck Platelet Count 7-10 days after Rattlesnake bite (due to delayed Thrombocytopenia risk)
  24. Acute Pain Management (pharm, Analgesic, Opioid)
    1. Limit acute Opioids to 3-7 days (most chronic use or misuse starts with acute pain prescription)
    2. Avoid Chronic Opioid dosing >50 mg/day Morphine Equivalents (and especially >90 mg/day)
    3. Wean Chronic Opioids if function does not improve at least 30% while on Opioids
  25. Metformin (endo, dm, pharm)
    1. Consider serum B12 level q3 years with longterm use, esp. in elderly, PPI use and Vegetarians
    2. Consider B12 Deficiency for new onset Neuropathy in Diabetes Mellitus
  26. Diabetes Mellitus Glucose Management (endo, dm, pharm)
    1. Intensive diabetes control benefits Type I but not Type II
  27. Depression in Older Adults (psych, depression, pharm)
    1. Consider starting low dose Methylphenidate with SSRI for first 2-3 months in severe depression
  28. Streptococcal Pharyngitis (ent, throat, Bacteria)
    1. Strep culture may not be needed, given low risk of Rheumatic Fever, Test Sensitivity of 86% of quick strep test
    2. Preventing each case of Rheumatic Fever in U.S. costs $8 Million
  29. Acute Low Back Pain Management (ortho, l-spine)
    1. NSAIDS alone are as effective as when combined with Opioids or Flexeril
    2. Acetaminophen and early physical therapy adds little additional benefit to Acute Low Back Pain
  30. Antibiotic coverage review (id, pharm, Bacteria)
    1. Reviewed and updated infections: CV, CNS, Febrile Syndromes
    2. Covered Toxic Shock Syndrome, Septic Shock, Typhoid Fever, Enteric Fever
  31. Medication updates (er, pharm, toxin)
    1. Avoid Flumazenil in most cases of Overdose (risk of severe Benzodiazepine Withdrawal, Seizures)
    2. In Digoxin Toxicity and Hyperkalemia, Calcium is unlikely to cause harm (theoretical stone heart)
    3. Direct Oral Anticoagulants (DOACs) have significant Drug Interactions, albeit less than Warfarin
    4. Herbals (e.g. St Johns Wort, Glucosamine, Ginkgo) have significant Drug Interactions
    5. Fasting in Diabates Mellitus updated
    6. Ortho Evra corrected (weekly application, thanks to email from Kyle Walsh)
  32. Pinworms (gi, id, Parasite)
    1. Drug company Impax has significant nerve charging $600-700 for old drugs (Albendazole, Mebendazole)
  33. Emergency Department Active Labor Presentation (ob, ld)
    1. Reviewed history, exam and complication management
  34. G-Tube (gi, procedure)
    1. Insertion procedure updated
  35. Bacterial Infection (id, Bacteria)
    1. Basic list of Bacteria by morphology and staining (side of effect of creating Microbe Hunter game - see Web Apps)

X. Updates: April 2016

  1. Nephrotic Syndrome (renal, urology, Proteinuria)
    1. Although numerous secondary causes (esp. DM, SLE), up to 80-90% of cases are idiopathic
    2. Edema, hypoalbuminemia (<2.5 g/dl) and Proteinuria (>3 g/day) are required for diagnosis
    3. Complications include VTE, Infection, Hyperlipidemia and Renal Failure (ESRD)
    4. May restrict Sodium (<3 g/day) and fluid (<1.5 L/day), and use ACE/ARB, Loop Diuretic and Immunosuppressant
    5. ESRD occurs in 30% of Membranous Nephropathy and >50% of Focal Segmental Glomerulosclerosis
  2. Endometrial Cancer (gyn, hemeonc, Uterus)
    1. Most common gynecologic cancer, with 90% diagnosed after age 50 years old
    2. Majority of cases (75%) are Type I, Endometrioid associated with Endometrial Hyperplasia
    3. Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer, HNPCC) causes 15% of cases, but 40% of mortality
    4. Screen if HNPCC, Postmenopausal Bleeding (or discharge), Anovulatory Bleeding over age 35 years, Pap Smear with AGUS
    5. Staging system was last updated 2009 and directs Hysterectomy, radiation, adjuvant agents
  3. Alcohol Use Disorder (psych, cd)
    1. DSM-V combined abuse and dependence under a single diagnosis (Alcohol Use Disorder)
    2. Preferred Alcohol Abuse Screening tools per USPTF: AUDIT, AUDIT-C and single question screening
    3. Preferred medications for maintaining abstinence are Naltrexone and Acomprosate (Campral), both generic
  4. Recurrent UTI (uro, id, Bacteria)
    1. Confirm Recurrent UTI (2 in 6 months, 3 in 12 months) with at least one Urine Culture
    2. No UTI preventive benefit to wiping front to back, hydrating, cotton underwear, or avoiding hot tub and tampons
    3. Further evaluate Hematuria, multi-drug resistance, recurrent Pyelonephritis, urinary obstructive symptoms
    4. Further evaluate prior GU malignancy, surgery, Trauma, Diverticulitis, urinary calculi
    5. Consider UTI continuous (6 months) or post-coital prophylaxis (within 2 hours) with Macrobid or Septra
    6. Consider self-start antibiotics for classic UTI symptoms in healthy women without red flags (e.g. fever, Vaginitis)
  5. Drowning (sports, water, er)
    1. Drowning is preventable, yet kills >4000 in U.S. per year, most under age 14
    2. Submersion >6 min is associated with poor prognosis, and 0% survival after 60 min
    3. Despite case reports, lung injury is just as severe in cold water and in fresh water
    4. Drownings classified as death, Grade 6 (CPR), Grade 5 (apnea), Grade 4 to 2 (rales), Grade 1 (cough) and rescue
  6. Oppositional Defiant Disorder (peds, behavior, psych)
    1. DSM-5 criteria are nearly identical to DSM-4, but now a patient may have both ODD and Conduct Disorder
    2. On spectrum of distinct disorders from typical teen to ODD to Conduct Disorder, and in adults antisocial disorder
    3. Typical onset in early elementary; distinguish from learning and language disorders, and Mood Disorders
    4. Treatment includes both child and parent training and treatment of comorbid ADHD and Major Depression
  7. Emergency Medical Service Contact (er, manage)
    1. Ambulance diversion should be avoided if possible (esp. hospital owned Ambulances)
    2. Patients may refuse Ambulance transport if they have medical decision making capacity (know risk, benefits, alternatives)
    3. Best to convince a patient to be transported voluntarily (instead of against their will with police)
  8. Difficult Intravenous Access in Children (er, procedure, peds, fen)
    1. Consider peripheral IV at distal saphenous vein, external Jugular Vein or scalp vein (not over Anterior Fontanelle)
    2. Consider Intraosseous Line at anterior tibia or proximal Humerus (or in a newborn, distal femur)
    3. Consider Central Line in failed IV/IO Access; femoral line is preferred central access in children older than 7 days
    4. Consider Umbilical Vein Catheter in newborns under age 7 days
  9. Burn Injury (er, derm, environ)
    1. Burn Injury is frequently overestimated (esp. in children) and may result in significant overestimation of fluid requirements
    2. Only second/Third Degree Burns count toward burn percentage calculation, and Parkland Formula applies to >20% burns
    3. Lactated Ringers is the preferred fluid in burns (due to high volume fluids and Hyperchloremic Metabolic Acidosis risk)
    4. Consider early intubation in Smoke Inhalation, and use ET Tube at least 7.5 mm to allow suctioning, bronchoscopy
    5. Altered Level of Consciousness in Burn Injury or Smoke Inhalation suggests CO or Cyanide Poisoning or Trauma
    6. Compartment Syndrome in Burn Injury does not occur in the first 2 hours (and typically not for 4-6 hours)
  10. Ultrasound Guided Regional Anesthesia (surgery, Anesthesia, Ultrasound)
    1. Ultrasound Guided Regional Anesthesia is preferred with fewer complications and more site options than landmark-based
    2. Local Anesthetic System Toxicity (LAST) from IV Anesthetic injection (esp. Bupivicaine) may cause Seizures, Arrhythmias or Cardiac Arrest
    3. LAST is treated with Intralipid, Benzodiazepines for Seizures and Advanced Airway management
    4. Due to risk of LAST, Intravenous Access and available Intralipid is recommended preparation for regional Nerve Block
  11. Anticholinergic Toxicity (neuro, er, toxin)
    1. Control secondary Agitated Delirium with Benzodiazepines, not with Physical Restraints or Antipsychotics
    2. Control hyperthermia, observe for Rhabdomyolysis and administer intravenous crystalloid
    3. Physostigmine is indicated in cases refractory to Benzodiazepines
  12. Emergency Transvenous Pacing (cv, procedure, ekg)
    1. In Unstable Bradycardia, consider as an alternative to Transcutaneous Pacing (less energy, less sedation)
    2. Place 6 Fr Central Line in pacing kit (instead of 9 Fr) at right internal jugular or left subclavian
    3. Pacer wire is floated with balloon into right ventricle until electrical and mechanical capture is achieved
  13. Push Dose Pressors (cv, pharm, Hypotension)
    1. Consider if Hypotension occurs with intubation in Sepsis
  14. Proton Pump Inhibitors (gi, pharm)
    1. Dementia association with longterm PPI in observational studies
  15. Penetrating Trauma (er, Trauma)
    1. FAST Exam is highest yield (Pericardial Effusion, Pneumothorax, Hemothorax, intraabdominal bleeding)
    2. Decompress Hemothorax or Pneumothorax (Ultrasound is sufficient to make diagnosis)
    3. Immediate Emergency Thoracotomy for Pericardial Effusion and loss of pulses
  16. Atypical Antipsychotics (psych, pharm, Psychosis)
    1. Olanzapine, Ziprasidone, Aripiprazole and Risperidone have been used Parenterally for acute Agitation
    2. Potential for serious adverse effects despite their lower risk than first generation agents (e.g. Haloperidol)
    3. Serious adverse effects include Neuroleptic Malignant Syndrome (NMS) and QTc Prolongation
    4. Extrapyramidal Side Effects and Anticholinergic side effects may also occur with Atypical Antipsychotics
    5. Clozapine has the highest risk of NMS, Agranulocytosis and Myocarditis
  17. Phytophotodermatitis (derm, environ, pharm)
    1. Sunburn precipitated by topical (or ingested) Photosensitizer (e.g. lime or lemon)
    2. Use Sunscreen, eliminate Photosensitizer and if inflamed, Topical Corticosteroid
  18. Subarachnoid Hemorrhage (neuro, cv, bleed)
    1. In suspected SAH, when CT Head is negative, LP is a true positive in 0.4%, and False Positive in 4.2%
  19. Needlestick Injury (id, prevent)
    1. Highest infection risk is for an HBab negative exposed patient (30% risk if source is HBeAg positive)
    2. For a positive source, HCV transmission is 1.8% and HIV Transmission is 0.3%
    3. Post-exposure Prophylaxis is available for HIV and HBV exposures
  20. Methadone in Chronic Pain (pharm, analgesia, Opioid)
    1. Methadone is reponsible for 30% of Opioid prescription related deaths, but accounts for only 2% of the prescriptions
    2. Prescribe Naloxone Auto-Injector, and caution patients not to use Alcohol or Benzodiazepines with Methadone
    3. Methadone has a very long Half-Life with delayed respiratory depression
    4. Sedation that precedes pain relief suggests Methadone dose too high (taper down)
  21. Potassium Supplementation (renal, pharm, Potassium)
    1. Extended release Potassium tablets are preferred over powder (better tasting, $15 instead of $290 per month)
    2. Immediate release Potassium powder is indicated in Feeding Tubes and those with Delayed Gastric Emptying
  22. Massive GI Bleed (gi, sx, bleed, er)
    1. Assume Upper GI Bleed in Unstable Patients
    2. In Massive Hemorrhage, replace blood with blood (initially with Type O, universal donor)
    3. ABC Management, early intubation, reverse Coagulopathy, empiric PPI IV and variceal management
  23. Esophageal Balloon Tamponade (gi, Esophagus, procedure, er)
    1. Balloon tamponade temporizes in 60-90% until emergent endoscopy in exsanguinating Esophageal Varices
    2. Critical that gastric balloon is not inflated within Esophagus (would result in Esophageal Rupture)
  24. Zika Virus (id, virus)
    1. Zika is an Arbovirus in the genus Flavivirus, which also includes Yellow Fever and Dengue Fever
    2. Transmitted by aedes Mosquito which breed in water containers
    3. Mild symptoms (if any) include fever, maculopapular rash, Arthralgia, Conjunctivitis (as well as myalgias and Headache)
    4. Associated with Guillain-Barre Syndrome and thousands of Microcephaly newborn cases in Brazil

XI. Updates: March 2016

  1. Bleeding Disorder (hemeonc, coags, bleed)
    1. Platelet Closure Function Test is no longer recommended for Bleeding Disorder evaluation
    2. When INR, PTT and Platelets are normal, obtain Von Willebrand Factor, activity and Factor VIII levels
    3. ISTH Bleeding Assessment Tool (ISTH-BAT) screens for congenital Bleeding Disorder (but not Platelet function abnormality)
  2. Pediatric Anemia (hemeonc, peds, Anemia)
    1. Anemia Screening (Hgb) is now recommended universally at 12 months by WHO, AAP (but not USPTF)
    2. Mild Microcytic Anemia may be treated empirically as Iron Deficiency Anemia for one month (expect 1 g/dl increase)
    3. In Microcytic Anemia, Mentzer Index (MCV/RBC) is <13 mg/dl in Thalassemia and >13 mg/dl in Iron Deficiency Anemia
  3. Chronic Prostatitis (urology, Prostate, id)
    1. Chronic Prostatitis (symptoms >3 months) are Chronic Bacterial Prostatitis or chronic Nonbacterial Prostatitis
    2. Treat Chronic Bacterial Prostatitis (>3 months, UC positive for same organism) with Fluoroquinolone for 4-6 weeks
    3. Chronic Nonbacterial Prostatitis is treated symptomatically (e.g. Alpha Adrenergic Antagonist, Tricyclic Antidepressants)
  4. Hyperthyroidism (endo, Thyroid)
    1. Graves specific signs include Graves Ophthalmopathy, pretibial swelling, Digital Clubbing and Vitiligo
    2. Thyroiditis is self limited, resolving within 6 months and is NOT an indication for antithyroid medications or ablation
    3. Moderate to Severe Graves Ophthalmopathy is a contraindication for I-131 treatment
    4. Antithyroid agent monitoring is primarily with Free T4 and Free T3 unless symptoms prompt CBC, LFTs
    5. Thyroid Storm may be diagnosed via the Burch Watofsky Score and a specific treatment protocol is established
  5. Mechanical Ventilation (lung, er, failure)
    1. Initial Ventilator settings follow one of two "recipes" per Scott Weingart, MD at EM:Crit
    2. Acute Lung Injury: Set AC with 6 cc/kg TV, 18 RR, FIO2 and PEEP titrated together, and IFR 60-80
    3. Obstructive Lung: Set AC with 8 cc/kg TV, 10-12 RR, start FIO2 at 40%, No PEEP, and IFR 80-100
  6. Skull Trephination (neuro, bleed, surgery)
    1. Acute Subdural Hematoma or Epidural Hematoma are treated with emergent Skull Trephination in
    2. Rapidly decompensating patients with Herniation may require non-neurosurgeon trephination if any delay to neurosurgery
  7. Aortic Stenosis (cv, valve)
    1. Asymptomatic Aortic Stenosis with or without Valve Replacement confers similar mortality to those without Aortic Stenosis
    2. However, once even subtle symptoms arise, mortality risk sky-rockets (>50% in 2 years)
    3. Evaluate undiagnosed Grade 3, harsh, holosystolic or late Systolic Murmurs
  8. Pulmonary Embolism in Pregnancy (lung, cv, hemeonc, ob)
    1. PE Risk in pregnancy was over-estimated due to combining with DVT (accounts for 33% of VTE in Pregnancy)
    2. PE Risk is 3 in 10,000 overall in pregnancy, with highest risk postpartum (esp after Cesarean Section)
    3. Start evaluation with bilateral leg venous doppler, then PERC Rule negative or D-Dimer
    4. If D-Dimer above discriminatory levels adjusted for pregnancy or high suspicion, then CTA (or perfusion only VQ Scan)
  9. Subsegmental Pulmonary Embolism Management (lung, cv, hemeonc)
    1. CT Chest has False Positives (subsegmental PE re-read as negative in as many as 26% of cases)
    2. CT Chest has False Negative (CT read as subsegmental PE, later re-read as segmental in 11% of cases)
    3. Subsegmental Pulmonary Embolism treatment has mixed results on outcomes
  10. ACE Inhibitor Angioedema (er, allergy, pharm)
    1. Icatibant did not show benefit in subsequent Phase III trial (initial trial results were promising)
  11. Burn Injury (er, Trauma, derm, environ)
    1. Estimate burn area only based on second and Third Degree Burns (not red, Sunburn-like injury areas)
    2. Debride large Blisters with thin walls and those over joints (aspirate large Blisters with thick walls)
    3. Silvadene delays healing, increases scar risk and is best avoided in Second Degree Burns (but preferred in third degree)
    4. Foot burn injuries in Diabetes Mellitus have 15% risk for infection and should be re-examined every 3-4 days
  12. Cardiopulmonary Resuscitation (er, cv)
    1. First 2-3 minutes prior to patient arrival is critical to successful Resuscitation and survival
    2. Gather Resuscitation team together prior to Ambulance arrival, assign roles and prepare equipment
    3. Mnemonic AEIOU: Advanced Airway, ETCO2, IO, Organize, Ultrasound
    4. Give Paramedics primary attention to relay history, findings, Resuscitation efforts, and answer team questions
  13. Sepsis (id, fever, er, Bacteria)
    1. Consider initial antibiotics that may be given as IV bolus (beta-lactams, Cephalosporins, Aminoglycosides)
  14. Pediatric Sepsis (id, fever, er, Bacteria)
    1. Epinephrine may be preferred over Dopamine in Cold Shock (if central Intravenous Access) - higher survival rate
  15. Chronic Pelvic Pain in Women (gyn, sx, pain)
    1. Start with systematic approach with thorough history, exam, labs (e.g. hcg, GC/Ch, UA) and Transvaginal Ultrasound
    2. Laparoscopy for persistent, severe idiopathic pain refractory to Analgesics, hormonal and neuropathic agents
  16. Thrombocytopenia (hemeonc, Platelet)
    1. Emergent causes of Thrombocytopenia include HUS, TTP, DIC, HIT and HELLP Syndrome
    2. Hemolytic Uremic Syndrome (HUS) is fever, Hemolytic Anemia, Renal Failure and often preceded by EHEC
    3. Thrombotic Thrombocytopenic Purpura (TTP) is fever, Hemolytic Anemia, Renal Failure, and neurologic signs
    4. Precautions
    5. Distinguishing Grade of sprain is initially difficult in first week (swelling interferes with laxity testing)
    6. If red flags, despite negative xray, safest to posterior splint, Crutches and follow-up in 7-10 days
  17. Ankle Sprain (ortho, ankle, sports)
    1. Treat suspected Grade III Lateral Ankle Sprain with posterior splint, Crutches for 7-10 days, then re-XRay, exam, air splint, PT
    2. For dynamic Splinting, air splint is preferred, allowing for dorsiflexion and plantar flexion, while providing stability
  18. Syncope (cv, sx)
    1. Presyncope has same adverse event risks as Syncope and should be evaluated in similar fashion
    2. Careful history, exam, and ekg should direct limited diagnostics and disposition
    3. Base lab ordering on symptoms, exam risks (chem8, Hgb, hcg, cxr, Troponin are not needed in every case)
    4. Rule of 15s: PE, Dissection, AAA, ectopic, SAH, ACS each have a 15% Incidence as syncopal presentation
    5. EKG may find VT, Brugada Syndrome, WPW (short PR), Prolonged QTc >500, Hypertrophic Cardiomyopathy, ischemia
    6. Abnormal vitals, EKG (including QTc>500) and Syncope WITHOUT prodrome all warrant telemetry admission
  19. Video Laryngoscopy (lung, failure, procedure)
    1. Top devices include Glidescope (hyperangulated), Storz C-Mac (DL with video), McGrath (portable)
    2. All devices offer excellent visualization (Grade I or II) even in difficult airways, and have high success at DL rescue
    3. With Glidescope use hyperangulated stylet or curved Elastic Bougie, and withdraw stylet 5 cm after passing cords
    4. Also with Glidescope, avoid inserting blade too close to cords (too hard to pass ET Tube) - keep view wide
  20. RSV Bronchiolitis (lung, Bronchi, id, peds)
    1. Central apnea risk in RSV is unlikely after 6 weeks of age or birth weight >2.5 kg (unless prior apneic event)
  21. Central Line (er, cv, procedure)
    1. In 2015 study, femoral lines had similar risks to internal jugular: infection rate (1.2%), thrombus rate (1.4%)
    2. Femoral also had the lowest failed placement rate (5%) compared with 9% IJ and 15% subclavian
  22. Intravenous Crystalloid (er, fen)
    1. Either NS or buffered solution (e.g. LR, Plasmalyte) are suitable for non-massive Fluid Replacement
    2. No increased Acute Kidney Injury or mortality with Normal Saline compared with buffered solution
  23. Emergency Management of Asthma Exacerbation (lung, Asthma)
    1. Dexamethasone 0.3 mg/kg x1 dose is as effective as Prednisolone 1 mg/kg for 3 days in moderate exacerbation
  24. Purpura (hemeonc, derm)
    1. In fever with toxicity consider Meningococcus, pneumococcus, DIC, Rocky Mountain Spotted Fever
    2. During or after viral illness or URI, consider EBV, Adenovirus, Pertussis, Strep Throat, HSP
  25. Angiotensin Receptor Blockers (cv, pharm, htn)
    1. Appear as effective as ACE Inhibitors in cardiovascular disease
  26. Anticoagulation in Thromboembolism (hemeonc, cv, pharm)
    1. Chest guidelines give the nod to Direct Oral Anticoagulants (esp. Eliquis, Xarelto)
    2. But, still no reversal agents yet, and use Warfarin instead in GFR<30, Mechanical Heart Valves
  27. CVA Thrombolysis (neuro, cv, pharm)
    1. New push to use TPA in less severe strokes (NIH Stroke Score <5) within 3 hours
    2. Still I worry about the bleeding risks and the weak evidence for better outcomes
  28. Attention Deficit Medication (peds, neuro, learning, pharm)
    1. New (i.e. expensive) and old (i.e. generic) ways to get XR meds to children who will not swallow pills

XII. Updates: February 2016

  1. Acute Bacterial Prostatitis (uro, Prostate, id)
    1. Accounts for only 10% of Prostatitis, but may be associated with bacteremia or Sepsis
    2. Urinalysis and Urine Culture, and PCR for GC and Chlamydia if STI risks (or age<35)
    3. Consider Blood Culture, Lactic Acid, CBC, BMP in fever >101, SIRS, Immunocompromised
    4. Evaluate for Prostate abscess (transrectal Ultrasound or CT or MRI Pelvis) if refractory after 36 hours
    5. Antibiotic selection based on STI risk, outpatient, inpatient, severe (Sepsis), and Antibiotic Resistance risk
    6. Transrectal biopsy, transurethral instrumentation and Fluoroquinolone exposure modify antibiotic selection
  2. Diabetes Screening (endo, dm)
    1. Type II DiabetesPrevalence from 5 M (1980), to now 22 M + 8 M undiagnosed (9% of adults) to 44 M by 2035
    2. Screen obese adults 40-70 (every 1-3 years) and obese children (every 2 years after age 10), or other risk factors
    3. High risk ethnicity (black, native american, native alaskan, asian, hispanic, pacific islander or native hawaiian)
    4. Type II Diabetes is diagnosed with A1C >6.5%, Fasting Glucose >126 mg/dl, OGTT or random Glucose >200 mg/dl
    5. Hemoglobin A1C is modified falsely by Anemia, liver and Kidney disease, Antiretrovirals, Vitamin E and C
  3. Hypertension in Pregnancy (cv, htn, ob)
    1. Blood Pressure is only mildly increased in 30-60% of Eclampsia
    2. HELLP Syndrome may be associated with normal Blood Pressure in 13-18%, and no Proteinuria in 13%
    3. Delivery by 37 weeks gestation is recommended even in non-Severe Preeclampsia
    4. Magnesium Sulfate is recommended only in Severe Preeclampsia or Eclampsia
  4. Foot Fractures (ortho, foot, Fracture)
    1. Non-displaced Metatarsal Fractures (or displaced <3mm, angulation <10 deg) are splinted, then short leg boot, then rigid shoe
    2. Fifth Metatarsal tuberosity avulsion Fractures are in Short Leg Boot for 2 weeks, then gradual transition to ambulation
    3. Fifth Metatarsal Jone's Fracture or Diaphyseal Fracture require non-weight bearing Short Leg Cast for 6-8 weeks minimum
    4. Great Toe Fractures are immobilized in short leg boot for 2-3 weeks and refer for displacement, angulation, rotation
  5. Solid Organ Transplant (surgery, failure)
    1. Immunosuppressants include Calcineurin (e.g. Tacrolimus), mTor (e.g. Sirolimus) and Purine (e.g. Azathioprine) inhibitors
    2. Immunosuppressants have numerous Drug Interactions (CYP3A4) with risk of toxicity and organ rejection
    3. Non-Estrogens (e.g. IUD, depo-Provera, Implanon) are preferred contraceptives post-transplant (fewer Drug Interactions)
    4. Opportunistic infections include CMV, EBV, HSV, VZV, fungus, pneumocystis, Tuberculosis
    5. Preventive care includes screening/management of CKD, DM, lipids, htn, Osteoporosis, Tobacco, cancer (esp. non-Melanoma skin)
    6. Infection prevention includes foodbourne illness prevention, Immunizations (flu, prevnax/Pneumovax), travel precautions
  6. Brain Tumor in Adults (neuro, hemeonc)
    1. High dose ionizing radiation is the only proven non-genetic risk factor for primary brain malignancy in adults
    2. Primary brain malignancies account for <2% of all malignancies in the U.S.
    3. Bifrontal tension-type Headache is most common presentation (followed by Seizure, cognitive change, focal weakness)
    4. Red flag signs include Cranial Nerve 6 Palsy, focal weakness, Gait Abnormality
    5. Benign tumors (esp. meningioma) account for 50% of Brain Tumors and most malignancies are gliomas (astrocytoma, glioblastoma)
    6. Differential Diagnosis includes Multiple Sclerosis and infection (AIDS, Amebiasis, fungi, Cysticercosis, Sarcoidosis, Syphilis, tyberculosis)
  7. Acetaminophen Overdose (pharm, Analgesic, toxin)
    1. Acetaminophen level at 4 hours is the only reliable method to exclude toxicity (unless undetectable at >1 hour post-ingestion)
  8. Tramadol (pharm, Analgesic, Opioid)
    1. Tramadol is as weak as Tylenol 3, with the same schedule IV as Hydrocodone
    2. Addictive potential with risk of Overdose (deaths have occurred) and Serotonin Syndrome
  9. Gum Elastic Bougie (lung, airway, intubation)
    1. Under-rated intubation tool that deserves practice during routine intubations, preparing for the difficult airway
  10. Acute Pulmonary Edema (cv, chf)
    1. NIPPV (Bipap or CPAP) and Nitroglycerin are first-line interventions, followed by possible ACE Inhibitor
    2. IV Furosemide is only indicated in the subset of Pulmonary Edema patients who are volume overloaded
  11. Congestive Heart Failure Exacerbation Management (cv, chf, prevent)
    1. Up to 25% of patients are re-admitted in the first month and 33% rehospitalized or die within first 90 days
    2. Contact by phone or email within 2 days of hospital discharge (symptoms, weights, Medication Compliance)
    3. Clinic follow-up within 7 days and consider medication adjustment (ACE Inhibitor, Beta Blocker, Diuretic, Spironolactone)
  12. Synthetic Drugs of Abuse (psych, cd, toxin)
    1. Synthetic Marijuana (K2, Spice) is a THC analog with unpredictable effects, including acute Psychosis lasting up to months after even a single dose
    2. Synthetic Cathinones (bath salts) are stimulants with risk of Agitated Delirium, Rhabdomyolysis, cva and hyperthermia
    3. NBOMe (N-Bomb) is a synthetic Hallucinogen, with typical stimulant adverse effects (Agitated Delirium, Rhabdomyolysis, hyperthermia)
  13. Atrial Fibrillation Cardioversion (cv, ekg)
    1. Atrial thrombus may form within first 12 hours, however cardioversion still appears safe within first 48 hours
    2. Patients may be safely discharged if Heart Rate <110 bpm, BP >90/60 mmHg and mild symptoms
    3. Diltiazem IV is more effective in initial rate control, whereas Metoprolol is more effective for rate control on discharge
    4. Anticoagulation is recommended for first 3 weeks after cardioversion (due to stunned Myocardium)
  14. Atrial Fibrillation Anticoagulation (cv, ekg, coags)
    1. Restart Anticoagulation 7-14 days after Gastrointestinal Bleeding in CHADS2-VASc Score 2 or more
    2. Risk of stroke related mortality is 4x higher than mortality related to Gastrointestinal Bleeding
    3. Warfarin or Eliquis (Apixaban) have lower risk of Gastrointestinal Bleeding, whereas Pradaxa (Dabigatran) is higher risk
    4. Use Proton Pump Inhibitor for Gastrointestinal Prophylaxis
    5. Avoid combining Anticoagulant with Aspirin and Platelet ADP Receptor Antagonist (e.g. Plavix)
  15. Personal Protection Equipment (er, toxin)
    1. Donning and Doffing PPE includes putting on in order of gown, mask, goggles, gloves and removing in reverse order
    2. Standard Precautions include Hand Hygiene and blood and bodily fluid protection (gowns, gloves, masks, Eye Protection)
    3. Expanded Precautions include Contact Isolation (gown, gloves), Droplet Isolation (Face Mask) and Airborne Isolation (e.g. N95)
  16. Nexus Chest CT Decision Rule in Blunt Trauma (er, lung, Trauma)
    1. Criteria: Abnormal CXR, distracting injury, chest wall/sternal/Scapula/Thoracic Spine tenderness, rapid deceleration
    2. Absent criteria: Negative Likelihood Ratio of 0.04; CT chest not needed unless high pretest probability
  17. Droperidol (pharm, sedation)
    1. Another study demonstrates safety with low risk of QT Prolongation (will FDA ever revise its warning?)
  18. Ketamine (pharm, pain)
    1. As effective as IV Morphine in acute moderate to severe pain
  19. Incision and Drainage (derm, id, procedure)
    1. Wound Irrigation during Incision and Drainage appears to be unnecessary
    2. How Incision and Drainage has changed: No packing (most cases), no irrigation, no antibiotics
  20. Pediatric Limp (ortho, peds, hip, sx)
    1. LIMPSS Mnemonic: Legg-Calve Perthes, Infection/Inflammation, Malignancy, Pain (Trauma), SCFE, Somewhere Else (Referred)
    2. Kocher's Criteria for septic hip: Fever >38.6 C, WBC>12k, ESR>40, child refuses to bear weight
    3. Hip Ultrasound demonstrating >2mm effusion requires aspiration to exclude septic hip
  21. Cervical Spine Injury (ortho, c-spine, Trauma)
    1. Cervical Collar is still standard of care, but no evidence of benefit and may cause harm
  22. Hemorrhage Management (er, surgery, Trauma, bleed)
    1. Direct pressure is first-line management
    2. Tourniquet for up to 1-2 hours may prevent Exsanguination and allows for definitive surgical management
  23. Cardiac Arrest (er, cv, ekg)
    1. Prehospital Resuscitation may be discontinued in Asystole >20 minutes and PEA Arrest >60 minutes (with ET-CO2 5)
    2. Bedside Ultrasound may identify improved chance of survival (e.g. obese with Pseudo-EMD)
    3. PEA with End-Tidal CO2 trending >20 and Heart Rate >40-60 are associated with improved chance of survival
  24. Glucometers (endo, dm)
    1. Glucometers cost $10 to over $100, but the test strips ($0.22 to $1.66 each) cost $84 to $600 per year for once daily testing
    2. Prescribe "Blood Glucose Meter" without specific brand and allow patient to select with pharmacist best option
    3. Meter features change constantly and some have large buttons, audio prompts or exportable data to mobile apps
    4. Test strip directions should include specific testing frequency (Medicare does not accept prn or as directed)
    5. Medicare allows for 100 test strips and 100 lancets every 30 days if on Insulin and every 90 days otherwise
  25. Hepatitis C Antiviral Regimen (gi, liver, id, virus)
    1. Hepatotoxicity with Ombitasvir, Paritaprevir/r (Technivie, Viekira Pak which also includes Dasabuvir) with Ribavirin
    2. Risk of fulminant liver failure (especially in pre-existing Cirrhosis) typically in first 1-4 weeks of treatment
      1. Repeat Liver Function Tests at 4 weeks after starting regimen (or earlier if needed)
      2. Consider stopping regimen if ALT >10 times normal (esp. if increased Bilirubin or INR)
  26. Selective Alpha-1a Antagonist (urology, pharm, Prostate, cv)
    1. Agents include Tamsulosin (Flomax), Alfuzosin (Uroxatral) and Silodosin (Rapaflo) used in BPH
    2. Despite selective nature, still cause Orthostatic Hypotension, Fall Risk, Head Trauma and Fractures
    3. Number needed to harm (NNH): 600 for fall-related hospitalizations, and 1600 for fall-related Fractures
    4. Welk (2015) BMJ 351:h5398 +PMID:26502947 [PubMed]
  27. Buprenorphine (pharm, pain, Opioid)
    1. Yet still more Opioids for Chronic Pain: Buprenorphine patch (Butrans) and buccal film (Belbuca)
    2. Are these really that much safer to warrant one more Opioid, or is this another free market, legal niche?
  28. Depression in Pregnancy (psych, ob, pharm)
    1. SSRIs have shown mixed or weak associations with Autism (as one of many contributing factors)
    2. Sertraline (Zoloft) is the preferred SSRI in pregnancy (although psychotherapy is preferred over medication)
  29. Cervical Cytology (gyn, Cervix, lab)
    1. Approach to ASC-US, ASC-H, LSIL, HSIL, Inadequate Pap Smear have changed dramatically in the last few years
    2. Extensive updates based on the 2014 ASCCP Guidelines
  30. Musculoskeletal Ultrasound (rad, Ultrasound, ortho, sports)
    1. Attended another GCUS Ultrasound course, but Musculoskeletal Ultrasound is new to me and overwhelming
    2. Covered Shoulder Ultrasound, Elbow Ultrasound, Wrist Ultrasound, Hip Ultrasound, Knee Ultrasound, Ankle Ultrasound
    3. Still I am mystified with Bedside Ultrasound as pure magic (appropriately known as POCUS, should be prefixed with hocus)

XIII. Updates: January 2016

  1. Fluoroquinolones (id, pharm)
    1. Increased risk of Peripheral Neuropathy, Tendinopathy and growing Antibiotic Resistance
    2. Pushed to third-line agent in Acute Sinusitis, Urinary Tract Infection, acute exacerbation Chronic Bronchitis
  2. Sinusitis (ent)
    1. Limit antibiotics to those with symptoms >10-14 days, fever or severe presentation (most cases are viral)
    2. High dose Amoxicillin in children and Augmentin in adults are first-line antibiotics
    3. In non-anaphylactic allergy to Penicillin, Cephalosporins are alternative agents
    4. Other agents in Penicillin Allergy include Clindamycin in children and doxycyline and Fluoroquinolones in adults
    5. Avoid Macrolides and TMP-SMZ due to high resistance rates
  3. Topical Analgesics (pharm, pain, rheum)
    1. Topical Analgesics include Topical NSAIDs and Lidoderm patch (as well as topical Capsaicin)
    2. Topical Diclofenac (gel, solution, patch) may be effective, but is expensive, and should not be used with oral NSAIDs
    3. Exercise same precautions for topicals as for oral NSAIDs (avoid in cardiovascular and renal disease)
  4. Emergency Thoracotomy (ed, Trauma, cv)
    1. Indicated in refractory Massive Hemothorax or refractory penetrating Cardiac Tamponade
    2. Avoid if no signs of life in field, Asystole, loss of Vital Signs >15 minutes (Penetrating Trauma)
    3. Sequence: Intubate, IV/Fluids, left thoracotomy, control bleeding, restart heart, right Chest Tube
  5. Cardiogenic Shock (cv, chf, cad)
    1. Most commonly from large anterior Myocardial Infarction, right MI, papillary Muscle rupture
    2. Involve early cardiology, cath lab, cardiothoracic surgery, intensivists to expedite disposition
    3. Treat Cardiogenic Shock with Dobutamine, Norepinephrine, Fluid Replacement to adequate LV volume
    4. Consider Endotracheal Intubation to reduce work of breathing
  6. Modified Valsalva for Supraventricular Tachycardia (cv, ekg)
    1. Postural modification significantly increases efficacy in PSVT cardioversion
    2. Valsalva is initially performed for 15 seconds sitting with head of bed at 30-45 degrees
    3. Patient repositioned immediately after Valsalva Maneuver to supine with legs raised
    4. Modified valsalva resulted in 43% of SVT patients converting at 1 minute, compared with 17% with standard valsalva
  7. Diaphragmatic Injury (er, lung)
    1. Penetrating Trauma (Gunshot Wound, Stab Wound) or blunt Trauma to anterior Abdomen (MVA, fall from height)
    2. Blunt Trauma is associated with 37% mortality due to multi-system Trauma (esp. CHI, large vessel rupture, Fractures)
    3. Penetrating Trauma is associated with a higher risk of occult Diaphragmatic Injury with delayed complications
    4. CT is insufficient to exclude Diaphragmatic Injury (False Negative Rate 18%)
    5. Laparoscopy and thoracoscopy are indicated in high suspicion cases (despite negative imaging)
  8. Tick Borne Illness (id, vector)
    1. Rocky Mountain Spotted Fever does not typically develop a rash until day 6 and may be fatal by day 8
    2. Alpha-Gal Reaction results in hives or Anaphylaxis to red meat (after tick-mediated sensitization)
    3. Consider tick-borne illness even without Tick Bite history in Fever Without Source, focal neurologic deficits (e.g. Bell Palsy)
    4. Tick Borne Illness is a clinical diagnosis, not a lab diagnosis (except Peripheral Smear in Babesiosis and Anaplasmosis)
    5. Do not delay treatment of suspected Tick Borne Illness (esp. Rocky Mountain Spotted Fever)
    6. Doxycyline is the treatment of choice for Lyme Disease (except for children under age 8 years who are treated with Amoxil)
    7. Doxycyline is the treatment of choice for Anaplasmosis, Ehrlichiosis, Rocky Mountain Spotted Fever (regardless of age)
    8. Babesiosis presents similarly to Malaria and is treated with Atovaquone and Azithromycin
  9. Congenital Heart Disease (cv, peds, chd)
    1. Up to 60% of Congenital Heart Disease has a delayed diagnosis (associated with worse outcomes)
    2. Nonstructural causes of cardiac emergencies in infants include Arrhythmias and myocardial dysfunction
    3. Structural causes of cardiac emergencies are volume overload and pressure overload (obstruction)
    4. Volume Overload causes include VSD, ASD, PDA, TAPVR, Truncus, AV Canal
    5. Pressure overload causes are ductal dependent - Left-sided obstruction (e.g. coarct) or right-sided (e.g. pulmonic stenosis)
  10. Bariatric Surgery (endo, Obesity, surgery)
    1. Of 179,000 bariatric surgeries performed in 2013 in U.S., most were Gastric Sleeves (42%), followed by Roux-en-Y (34%)
    2. Excess body weight lost is 50% even at 7-10 years, remission of diabetes of 30% at 15 years, and 30-50% overall reduction in mortality
    3. However, patient assumes increased short-term complications including death, and longterm monitoring
  11. Acute Pelvic Pain (gyn, pain)
    1. Avoid tests that are low yield or do not alter management (C-RP, abdominal XRay)
    2. Abdominal Ultrasound has utility beyond the Uterus and Adnexa (e.g. Hydronephrosis, Appendicitis)
    3. Consider MRI Abdomen and Pelvis for pregnancy-related Pelvic Pain and suspected Appendicitis
  12. Asymptomatic Bacteriuria (urology, id)
    1. Very common, esp. older patients (15-20% in community and 40-50% in Longterm Care)
    2. Most Asymptomatic Bacteriuria resolves without treatment (including catheterized patients)
    3. Less than 3% of simple cystitis progresses to Pyelonephritis
    4. Urinalysis has poor Test Specificity for UTI in the absence of urinary tract symptoms
  13. Amiodarone Pulmonary Toxicity (cv, pharm, lung)
    1. Diffuse pneumonitis in 1-2% of patients on Amiodarone per year
    2. May present as refractory Pneumonia or CHF
    3. Early discontinuation and Prednisone for 4-12 months has best prognosis
    4. Obtain baseline Chest XRay and PFTs with DLCO when starting Amiodarone (in addition to TSH, transaminases)
  14. Juvenile Idiopathic Arthritis Exacerbation (rheum, peds)
    1. For exacerbations, obtain CBC, ESR and CRP
    2. Consider systemic infection (esp. if on Rituxamab or similar mab) or Septic Joint
    3. Be aware of Macrophage Activation Syndrome (Cytokine Storm) with risk of DIC, Acute Renal Failure, Pancytopenia
  15. Chemical Restraint alternatives (psych, er, violent)
    1. But be prepared with strong, large, burly security guards at the ready in case of dangerous Agitation
    2. Provide a calm, quieter, comfortable setting with dimmed lights to help de-escalate Agitation
    3. Offer food, drink, warm blanket , phone call and other comforts to those able to reason
    4. Offer Nicotine Replacement as needed and Benzodiazepines for Alcohol Withdrawal Protocol or anxiety
    5. Express empathy and compassion
  16. Neuroimaging after First Seizure - Urgent Indications (neuro, Seizure)
    1. All patients under age 1 year
    2. Cognitive or Motor Developmental Delay
    3. Partial Seizure (Focal Seizure), postictal neurologic deficit that persists, mental status changes persist
    4. Malignancy, Brain Tumor
    5. Prior Cerebrovascular Accident
    6. Coagulopathy, Sickle Cell Disease
    7. Head Trauma, Prior CNS surgery with shunt
  17. Umbilical Vein Catheter (nicu, er)
    1. Remains patent for the first week of life and may be used as a Central Line
    2. After preparing the umbilical stump and vein, advance 1-2 cm beyond free flow of blood (4-7 cm total)
  18. Abdominal Compartment Syndrome (gi, er, Trauma)
    1. Decreased abdominal perfusion pressure from rapidly expanding pressure within the abdominal cavity
    2. Critically ill patients with Abdominal Trauma or hemoperitoneum, massive fluid third spacing or Ascites
    3. Intraabdominal pressures (measured via Foley Catheter) >20-25 mmHg are consistent with Compartment Syndrome
    4. Definitive management with surgical decompression (NG and Foley Catheter may temporize)
  19. PIP Extensor Tendon Injury or Central Slip Extensor Tendon Injury (ortho, hand)
    1. Missed diagnosis risks secondary Boutonniere Deformity
    2. Elson Extensor Tendon Test evaluates PIP extension against resistance
  20. Home Naloxone Rescue Kits (pharm, Analgesic, adverse)
    1. Home rescue Naloxone may curb the >40 daily lethal Opioid Overdoses in the U.S.
    2. Naloxone autoinjector and intranasal spray are now commercially available intended for families to administer
    3. Home rescue kits may also be prepared for IM (Naloxone vials and syringes) or Nasal (prefilled syringes with atomizer)
  21. Hepatitis C Antiviral Regimen (gi, id, hepatitis)
    1. All genomes qualify for treatment (albeit with 3-4 drugs that cost over $100,000)
    2. Many adverse effects and Drug Interactions with treatment agents
  22. Asthma Exacerbation
    1. Dexamethasone 0.3 to 0.6 mg/kg/day PO/IV/IM up to 10-16 mg/dose for 1-2 days
    2. As effective as a 3 day Prednisolone course in preventing hospitalization and improving symptoms
  23. Somatic Symptom Disorder (psych, Somatization)
    1. Previously known as Somatoform Disorder or Somatization Disorder (the names have changed, but...)
    2. Now, nearly everyone will qualify for this diagnosis (the DSM-IV criteria were more stringent)
    3. Two scales can help make the diagnosis and assess severity (PHQ-15, SSS-8)
    4. Schedule monthly visits with primary provider to replace frequent phone calls and emergency visits
    5. Main provider role at the encounter: Empathic listening
  24. Impulse control behaviors and Dopamine Agonists (neuro, psych, pharm)
    1. Behaviors seen with Dopamine Agonists include Compulsive Gambling, hypersexuality, shopping, eating
    2. Now reported with Aripiprazole (Abilify), a partial Dopamine Agonist
  25. Tromethamine or THAM (renal, acidBase, er)
    1. Indicated in severe Metabolic Acidosis from Cardiac Arrest as an alternative to Sodium Bicarbonate
    2. THAM is a weak base that binds Hydrogen Ions and is excreted renally, unlike bicarbonate which is exhaled as CO2
    3. As with Sodium Bicarbonate, no evidence of outcome benefit in correction of Metabolic Acidosis
  26. Insulin Degludec (Tresiba)
    1. Yet another long acting Insulin; Lantus is generic and pricing should be on its way down

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