II. Updates: December 2017
-
Cardiomyopathy (cv, Myocardium)
- Primary Cardiomyopathy is organized into Acquired (e.g. Myocarditis), Genetic (e.g. ARVD, HCM) and Mixed (dilated, restrictive)
- Secondary Cardiomyopathy are due to extrinsic/systemic causes (e.g. Autoimmune, diabetes, Thyroid, Chagas, cardiotoxins)
- Treat specific underlying causes, as well as Congestive Heart Failure
- Herpes Zoster (id, virus)
-
Diabetes Mellitus Control in Hospital (endo, pharm)
- Glucose goals are 140-180 mg/dl
- Metformin may typically be continued while hospitalized (but Exercise caution with Sulfonylureas, GLP-1 Agonists)
- In hospital protocols exist for initiating basal, bolus and correctional Insulin
-
Liver Function Test Abnormality (gi, liver)
- Nonalcoholic Fatty Liver is the most common cause of asymptomatic mild Liver Function Tests (<5 times normal)
- Other than Alcohol, Hepatotoxins, Hepatitis B, Hepatitis C and Hemochromatosis may also increase Liver Function Tests
- Rare cases include Alpha-1-Antitrypsin Deficiency, Autoimmune Hepatitis, Wilson Disease
-
Hyperosmolar Hyperglycemic State (endo, dm, er)
- Fluid and Potassium Replacement precede Insulin
- Identify precipitating conditions (e.g. Sepsis)
- Exercise caution in overhydration of children (risk of cerebral edema)
-
Beta Blocker Overdose (cv, pharm, adverse)
- Follow Don't Open Eyes Technique for Eye Drop Instillation, to prevent systemic Beta Blocker Toxicity
- Beta Blocker Toxicity presents with Bradycardia and Hypotension
- May respond to Glucagon, hyperinsulinemia-euglycemia, methylene blue, ECMO
-
Emergent Reversal of Anticoagulation (hemeonc, coags, pharm, adverse)
- For life threatening bleeding on Dabigatran, give Idarucizumab if available (otherwise PCC or FFP)
- For bleeding on other NOAC, administer PCC or FFP
-
Acute Pancreatitis (gi, Pancreas)
- Acute Pancreatitis diagnosis is based on 2 of 3 criteria (symptoms, Lipase 3x >normal, imaging c/w Pancreatitis)
- Even mild Acute Pancreatitis improves faster with aggressive Intravenous Fluids (LR 2L bolus to start)
- Early initiation of oral clear fluids, low-fat full liquids and low residue soft-solids prevents bowel atrophy
-
Diabetic Foot Ulcer (surgery, derm, endo, dm)
- Assess patients for systemic illness, Peripheral Arterial Disease, Retained Foreign Body
- Assess for Osteomyelitis (Probe To Bone Test, ESR, XRay changes)
- Chronic Osteomyelitis of diabetes may typically be managed outpatient
-
Testicular Torsion (urology, Testes)
- Frequently misdiagnosed as Epididymitis
- Examination is unreliable
- Abdominal Pain may be only presenting symptom
-
Moderate Risk Acute Coronary Syndrome Management (cv, cad)
- Immediate angiography for refractory Angina with Heart Failure, acute Mitral Regurgitation, hemodynamic instability, sustained VT/VF
-
Sepsis (id, fever, Bacteria)
- SOFA Score and qSOFA Score have been recommended to replace SIRS Criteria in the diagnosis of Sepsis
-
Moderate Acne Vulgaris Management (derm, acne)
- Topical and oral Antibiotic Resistance in acne is increasing (as high as 50% for Topical Antibiotics)
- Benzoyl Peroxide should be used with all Antibiotic regimens to prevent Antibiotic Resistance
- Stop oral Antibiotics after acne improves (after 3-4 months) and continue topical agents
-
Systolic Dysfunction (cv, chf, pharm)
- When maximizing Systolic Dysfunction medical management, include an Aldosterone Antagonist (e.g. Spironolactone, Eplerenone)
-
Hoarseness (ent, Larynx, sx)
- Laryngoscopy is the first-line evaluation of Hoarseness lasting more than 2-4 weeks (esp with risk factors for Laryngeal Cancer)
- Impaired Fasting Glucose (endo, dm)
-
Opioid Induced Constipation (gi, pharm, Constipation, Opioid)
- Gastrointestinal Opioid Antagonist (e.g. Relistor) are third-line, expensive, marginally effective agents in refractory Opioid-Induced Constipation
-
Home Medications Before Colonoscopy (gi, procedure)
- Anticoagulants, antiplatelet agents and diabetes medications need modification before Colonoscopy
- Low dose Aspirin and NSAIDs may often be continued before Colonoscopy
- Most other medications may be taken before Colonoscopy
-
Acute Infectious Diarrhea (gi, Diarrhea)
- Infectious Diarrhea is typically self limited and responds to standard rehydration
- Antibiotics may be considered with Loperamide in severe Dehydration, without Dysentery, fever, bloody Diarrhea
-
Foreign Body Aspiration (lung, airway)
- Aspirated objects are only radioopaque in 10-20% of cases (xray does not exclude aspirated foreign body)
- In a patient maintaining their airway, do not perform back blows or blind finger sweep (risk of complete obstruction)
- Keep Foreign Body Aspiration in the differential in a child with respiratory complaints (one third of aspirations are unwitnessed)
-
Opioid Abuse (psych, cd, Opioid)
- Provide prescription intranasal Naloxone
- Encourage needle exchange program and screening for HIV Infection, Hepatitis C infection
- Users should wash hands before preparing Heroin and use a clean cooker (e.g. spoon), clean water, new cotton filter
- Use new sterile needles, syringe for each injection (do not share needles) and do not spit on or lick the needle or injection site before injection
-
Procedural Sedation (surgery, Anesthesia)
- Ketamine is preferred agent for Conscious Sedation in children and longer procedures in adults
- Propofol is preferred agent for brief Procedural Sedation in adults
- Etomidate or Ketamine may be considered for Procedural Sedation in hypotensive adults
-
Sepsis (id, fever)
- Mortality increases with every hour of Antibiotic delay
-
Pulmonary Embolism (lung, cv)
- YEARS Score is negative if no DVT clinical evidence, PE not the most likely diagnosis, and no Hemoptysis
- If YEARS Score negative (no criteria present), D-Dimer cut-off of 1.0 may be used
-
Corneal Abrasion (eye, Cornea)
- Evidence for safe use of Topical Eye Anesthetic (tetracaine 1%) for 24 hours at home in simple Corneal Abrasion
- Simple, small, non-pentrating, non-lacerating Traumatic Eye Injury onset within prior 2 days
- Not due to chemical or Contact Lens and no infection, contamination or Retained Foreign Body
-
Globe Rupture (eye, Trauma)
- Ocular CT has only a 75% Test Sensitivity for Globe Rupture
-
Self-Talk Incrementalization (manage, legal)
- Break down complicated and high risk situations into manageable tasks
- Concentrate on each single task, with multiple adjustment strategies available if difficult
- Slow down, and perform each task with adequate precision to ensure success
- Self-talk yourself into success at each step (perform each task with confidence of success)
III. Updates: November 2017
-
Chronic Rhinosinusitis (ent, sinus)
- Chronic Rhinosinusitis is an inflammatory condition (analogous to Asthma, Allergic Rhinitis) more than an infectious condition
- Diagnosis is based on 2 of 4 cardinal symptoms, exam or imaging evidence of Sinusitis, and at least 12 weeks of findings
- Primary management is with Nasal Saline and Intranasal Corticosteroids
-
Bladder Cancer (urology, hemeonc)
- Cystoscopy for all patients with Gross Hematuria and Microscopic Hematuria with risk (age >35, symptoms without cause)
- CT Urogram and CT Pelvis should be included in evaluation for Bladder Cancer
- Bladder Cancer screening is not recommended
- Urine cytology and urine Tumor Markers are at the discretion of urology based on risk, evaluation
-
Statin (cv, pharm, lipid)
- Statins remain by far the most effective AntiHyperlipidemic agents to reduce cardiovascular events
- Despite poor compliance, Statins are safe and have an overall low adverse effect rate
-
Chronic Cough (lung, sx)
- Chronic Cough in adults lasts >8 weeks, and is most commonly caused by post-nasal drainage, GERD, Asthma, Eosinophilic Bronchitis
- Chronic Cough in Children lasts >4 weeks and is most commonly caused by Asthma, post-Bronchitic cough, post-nasal drainage
-
Heart Failure with Preserved Ejection Fraction (cv, chf)
- Heart Failure with Preserved Ejection Fraction (HFpEF) is findings of CHF with an LV EF>50%
- Brain Natriuretic Peptide can be used to exclude Heart Failure in Emergency Department, BNP <100, nt-BNP < 300
- Suspected Heart Failure should be evaluated with Echocardiogram as a a first line test
- Disorders of Puberty (endo, sex)
- Consider precococious Puberty evaluation in girls before age 8 and boys before age 9
- Consider Delayed Puberty evaluation in girls without Breast development by age 13 or Menarche by 15, and boys with small Testes at age 14
-
Skin Abrasion (er, environ, derm, Trauma)
- Evaluate Skin Abrasion as a friction burn (including depth of burn, involved BSA)
- Anesthetize area well and remove all particulate matter (scrub, irrigate, scrape)
- Apply Topical Ointment (e.g. Bacitracin, petroleum jelly) and bandage with Absorptive Dressing
- As with Burn Injury, for extensive involvement, replace fluids, and burn center referral
-
Foot Pain (ortho, sx, foot)
- Lisfranc Fracture, Tarsal Navicular Fracture, Talus Fracture and Calcaneus Fracture and Fifth Metatarsal Fracture are the High Risk Fractures of the foot
-
Spontaneous Bacterial Peritonitis (gi, id, liver)
- Keep SBP high on the differential for cirrhotic patients with Ascites (up to 25% of Cirrhotic Ascites patients in the ED)
- Emergently obtain peritoneal fluid (PMNs >250 defines SBP) and start Antibiotics
- Administer albumin for Cr>1, BUN>30, TBili>4
-
Button Battery Ingestion (gi, Esophagus)
- Button batteries leak alkaline agents and cause liquifaction necrosis when in contact with tissue and cause serious burns within first 2 hours
- High risk of Esophageal Perforation in first 6 hours, and may be fatal in unrecognized or delayed presentation ingestions
-
Lumbar Puncture in Infants (neuro, procedure, csf)
- Consider Topical Anesthetic (LMX4 applied 30 minutes before procedure OR EMLA applied 60 minutes before procedure)
- May remove stylet after entering skin (makes it less likely to miss the space)
- May allow for 1 additional CSF WBC for every 1000 CSF RBCs
-
Ascariasis (id, Helminth)
- Ascariasis is most common in Asia, in regions where Defecation is in open, or crops are fertilized with animal feces (esp. pig)
- After 9-11 weeks from time of initial ingestion, Ascariasis starts to lay eggs, and infected patients shed up to 200,000 Ascariasis eggs per day
- Worms are typically 15-30 cm long, live for 10 months to 2 years and do not reproduce within host patient
- In the U.S., treatment is with a single dose of Albendazole 400 mg (or Pyrantel Pamoate in pregnancy)
-
Antiplatelet Therapy for Vascular Disease (hemeomc, cv)
- Platelet ADP Receptor Antagonist for 6-12 months after Drug-eluting Stent placement
- Benefit of Ticagrelor, Prasugrel over Clopidogrel, but at higher bleeding risk and 30x cost
- However, Clopidogrel may offer similar efficacy after the first week post-stenting
- Mydriatic (eye, pharm)
-
Musculoskeletal Injury (ortho, sx, Trauma)
- Do not forget SCIWORA in children with high mechanism injuries (esp. under age 8 years)
- Non-displaced Femoral Neck Fractures are initially missed in 10%, often have negative XRay (but positive MRI or CT), and may present as Knee Pain
- Elbow Ossification Centers should be considered when evaluating the Elbow XRay in a child with Elbow Injury
- First exclude Septic Joint before diagnosing a red, hot, swollen large joint as gout (tap the joint if any level os suspicion)
-
Emergency Department Migraine Headache Care (neuro, Headache)
- Reglan and Compazine are the most effective initial management strategies for Migraine Headache
- Prevent akisthesia by injecting the Antiemetic slowly (over 15-20 minutes); Diphenhydramine does not prevent the akisthesia
- Intravenous Fluids are without added benefit
- Consider Greater Occipital Nerve Block or Transnasal Sphenopalatine Ganglion Block
-
DKA Management (endo, dm, er)
- Lactated Ringers is preferred over Normal Saline, and give initial 20 ml/kg, then 5-10 ml/kg boluses until IVC is not collapsed
- Replace Potassium before Insulin if <3.3, and give maintenance Potassium at 10 meq/h for 3.3 to 5.2 Serum Potassium
- Start Insulin Infusion at 0.1 units/kg/h without bolus, and continue at same rate until acidosis corrects
- Bicarbonate replacement is controversial, but may be helpful in Cardiac Arrest, severe Hyperkalemia with Arrhythmia, and refractory shock
-
Topical NSAID (pharm, Analgesic)
- Topical NSAIDS (e.g. Topical NSAIDs) have low side effect profiles and may be as effective as their oral counterparts
-
Chest Compressions (cv, procedure)
- Ultrasound during pulse checks in CPR, prolongs pulse checks, which should be <10 sec, from 13 sec to 20 sec
- Consider using ETCO2 as marker of ROSC instead of Bedside Ultrasound
-
Drug Withdrawal (psych, cd)
- Severe Medication Withdrawal may occur with intrathecal Baclofen, Clonidine and Venlafaxine
-
Analgesic Medications in Pregnancy (pharm, ob)
- Avoid Opioids in pregnancy as much as possible
- Neural Tube Defects if Opioids used in early pregnancy
- Newborn Opioid Withdrawal (neonatal abstinence syndrome) if maternal Chronic Opioid use
- No evidence of Tramadol safety
-
Eosinophilic Esophagitis (gi, Esophagus)
- Immune mediated Esophagitis (Asthma of the Esophagus) that does not respond to GERD management
- May present with solid Dysphagia, food impaction, anterior Chest Pain, Epigastric Pain and refractory GERD
- Strongly associated with allergic conditions
- If GERD management ineffective, try activating steroid Inhaler MDI (e.g. Flovent HFA) and Swallowing, not inhaling
IV. Updates: October 2017
-
Fall Prevention in the Elderly (geri, prevent)
- Approach falls as a sentinel event, a predictor of future falls with greater injury, and risk for Nursing Home placement
- Over age 65, screen yearly with history (fall in the last year?, How many times?, Injuries?) and if positive, Get Up and Go Test
- Educate patients on Fall Prevention, Vitamin D Supplementation, strength and balance Exercises
- High risk patients warrant medication review, Mental Status Exam, foot evaluation, Syncope evaluation, Vision Screening, formal Fall Prevention program
- Meniscal Tear (ortho, knee)
- Arthroscopy with Debridement offers no longterm benefit in middle aged and older patients (with or without Knee DJD)
- Arthroscopy offers no significant improvement in knee catching or locking in those with meniscal tear
- Exercise therapy is preferred
-
Wound Care (surgery, derm, wound)
- Updated wound care, Chronic Wounds, Decubitus Ulcers, Wound Debridement
- Wound Debridement is important for necrosis or Hematoma (but do not debride if significant periphera arterial disease)
- Attended Wound Care Update conference, Park Nicollet, St Louis Park, MN (very good practical conference)
-
Intensive Lifestyle Change In Type II Diabetes Mellitus (endo, dm)
- National Diabetes Prevention Program can markedly reduce risk of Prediabetes progression to Type II Diabetes
- Similarly, Look Ahead Study protocol results in up to 20% remission of new onset Type II Diabetes present for <2 years
- Goals of intensive programs include weight loss of 7-10% and Exercise gradually increased to 150-175 minutes per week
-
Alopecia (derm, hair)
- Alopecia management is specific for type of Hair Loss, and Alopecia type is typically evident from the history and exam
- Two new Alopecia types are defined: Trichorrhexis Nodosa (hair Trauma or fragile hairs) and Anagen Effluvium (Chemotherapy-Induced Alopecia)
-
Vitamin B12 Deficiency (hememonc, Anemia, Vitamin)
- Risk factors for B12 Deficiency include Metformin, acid suppression, malabsorption (e.g. Celiac Disease, Crohns, Roux-en-Y Bypass), Alcoholism, vegans
- Consider Serum Vitamin B12 with methylmalonic acid for confirmation (if Pernicious Anemia, then xIntrinsic acid, and possibly Gastrin)
- Treat severe deficiency (including neurologic changes) with IM Injections, but otherwise oral and Parenteral have equivalent efficacy
-
Probiotics (pharm, nutrition, gi, id)
- Probiotics are effective in prevention of Antibiotic-Associated Diarrhea, C. difficile, Necrotizing Enterocolitis, Infantile Colic
- Probiotics are effective in management of Hepatic Encephalopathy, Ulcerative Colitis, Irritable Bowel Syndrome
- Probiotics evidence is unclear in NASH, and ineffective in Acute Pancreatitis and Pancreatitis
- Beyond type of Bacteria used in preparation, colony forming units (CFU) >5 Billion is most associated with efficacy
-
CVA Prevention (neuro, cv, prevent)
- After acute period, lower Blood Pressure <140/90
- In those with CVA, TIA, screen for Diabetes Mellitus, Obstructive Sleep Apnea (50-75% Prevalence)
- Encourage Tobacco Cessation, Physical Activity (120-150 min per week)
-
Secondary Hypertension (cv, htn)
- Consider secondary testing in Hypertension under age 30 years, Malignant Hypertension, Refractory Hypertension
- Renal Artery Stenosis is common and is due to fibromuscular dysplasia in younger patients, atherosclerosis in older patients
- Primary Hyperaldosteronism is common, especially with Hypertension and Hypokalemia (although Potassium is normal in 50% of cases)
-
Male Hypogonadism (uro, endo)
- Androgen Replacement is only indicated in symptomatic low Testosterone, confirmed on 2 samples
- Longterm safety of Testosterone Replacement is unknown
- Routinely monitor Serum Total Testosterone, Hematocrit, PSA and adverse effects
-
Stab Wound (er, Trauma)
- Trauma Survey and FAST Exam are often sufficient alone to indicate Unstable Patients requiring emergent surgery
- Cardiac injury and Diaphragmatic Injury may be easily missed
- Avoid speculating in the medical record regarding intent (self-inflicted, Suicide, homicide)
-
Acute Severe Pain (pharm, Analgesic)
- Pain out of proportion to exam, can be more than Malingering, with occult serious causes
- Acute Painful Syncope (e.g. AAA, Aortic Dissection, Subarachnoid Hemorrhage) may immediately be recognized
- Other conditions may be initial diagnostic dilemmas until localizing findings (e.g. Shingles)
-
Acute Pain Management in Children (pharm, peds)
- Topical measures prior to phlebotomy, IV start, Laceration Repair include LET, EMLA, LMX-4, J-Tip, Vapocoolant, Buzzy Bee
- Avoid Codeine and Tramadol
- For adequate parenteral Opioid Analgesic (e.g. long bone Fracture), use Morphine Sulfate 0.1 mg IV
-
Hepatitis C Antiviral Regimen (gi, liver, id)
- Mavyret (glecaprevir/pibrentasavir) is a relative bargain in Hepatitis C (any Genotype) treatment: $26k for 8 weeks, and 95% effective
-
Atenolol (cv, pharm)
- Atenolol is in shortage, and finally time to find a better Beta Blocker (Metoprolol XL in most cases)
-
Influenza Vaccine (id, immunize)
- Reminder to avoid Flumist due to low efficacy
-
Inhaled Corticosteroids (lung, Asthma)
- Yet another CorticosteroidInhaler, ArmonAir, which is nearly as expensive as Flovent (>$200)
-
Post-Cardiac Arrest Care (er, exam)
- Head CT following ROSC may identify Intracranial Hemorrhage (11% of cases), catastrophic anoxic brain injury
- Neurologic outcome is not accurately predictable before 72 hours from ROSC or completion of Temperature targeted management
- Prevent Hypoxia and hypocapnia, Hyperglycemia and Electrolyte disturbances
- Temperature targeted management of 36 C may offer similar benefit in outcomes to 32-33 C
-
Elastic Bougie (lung, procedure, airway)
- Elastic Bougie improves first pass Endotracheal Intubation success from 85 to 95%
- Elastic Bougie is useful when airway is obscured by blood or vomit
-
Low Risk Acute Coronary Syndrome Management (cv, cad)
- As of 2017, HEART Score is the most used for Low Risk Chest Pain management stratification but does not appear to alter management
- Compared to usual care, HEART Score did not result in worse outcomes, but did not decrease resource use, admissions
-
Appendicitis (surgery, gi)
- RLQ Abdominal Ultrasound before Abdominal MRI in children is preferred
- Ultrasound first strategy is faster and more cost-effective, despite RLQ Abdominal Ultrasound being inconclusive in 25% of cases
-
Emergency Psychiatric Evaluation (psych, exam, er)
- Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
- Acute psychiatric symptoms in alert adults do not mandate routine lab testing
- No risk assessment tool can identify those safe for discharge
-
CVA Management (neuro, cv)
- Consider Thrombolysis even in minor NIH stroke scores <5
- Large vessel Occlusion (e.g. Middle Cerebral Artery, cerebellar artery) may have low NIH Stroke Scale
- NIH Stroke Score particularly underestimates deficits from Cerebellar Strokes
- CTA Head and Neck identifies large vessel Occlusion and can help inform decision
V. Updates: September 2017
-
Lower Extremity Abnormalities in Children (ortho, peds)
- Evaluation includes Torsional Profile, gait exam, limb asymmetry as well as Growth Parameters, Neurologic Exam
- In-Toeing may be caused by Metatarsus Adductus, Internal Tibial Torsion, Femoral Anteversion
- Out-toeing may be caused by External Tibial Torsion, Femoral Retroversion and Pes Planus
- Angular variations include Genu Varum and Genu Valgum
-
Exercise Stress Testing (cv, procedure, Exercise)
- Stress testing is uncommonly indicated in asymptomatic patients aside from vascular surgery preop, vigorous Exercise clearance in deconditioned patients at risk
- Exercise Stress Testing is the first-line test for most symptomatic patients
- Stress Imaging is indicated for those with uninterpretable ekg, inability to Exercise, high False Positives or prior revascularization
-
Pleuritic Chest Pain (lung, cv, sx)
- Critical to exclude 6 high risk causes: PE, MI, Pneumothorax, Aortic Dissection, Pneumonia, Pericarditis
-
Bacterial Meningitis (neuro, id, Bacteria)
- Do not hesitate to obtain Lumbar Puncture when clinical suspicion dictates (regardless of Nuchal Rigidity, lab markers, decision rules)
- Delayed Antibiotics in Bacterial meninigitis >6 hours from presentation, is associated with >8 fold Odds Ratio increased mortality
-
Heat Illness (er, environ, heat)
- Exertional Heat Illness is on a spectrum from Heat Stress to Heat Exhaustion to Heat Stroke
- Other Heat Related Illnesses include Heat Rash, Heat Edema and Heat Cramps
- Removal from heat and rapid external cooling are the mainstays of initial care
- Not all patients are volume depleted (avoid over-hydration)
-
Dental Pain (dental, teeth sx)
- In a normal appearing tooth (without exposed root or abscess), Tooth Pain implies exposed dentin or pulp (cavity)
- Antibiotics are not indicated in Pulpitis where infection is absent
-
Parasitic Infection (id, Parasite)
- In the returning traveler, keep Parasitic Disease in the differential diagnosis (esp. Immunocompromised patients)
- Parasitic Infections have the potential for life threatening complications; Exercise prevention for Foodborne Illness, Waterborne Illness, vector-borne disease
-
Methemoglobinemia (hemeonc, Hemolysis)
- Methemoglobin levels >20-30% or significant cardiopulmonary symptoms indicate antidote (methylene blue)
-
Cardiac Risk Factors (cv, prevent, cad)
- Some additional lesser known CAD risk factors (HIV Infection, Alcohol Abuse, Chemotherapy)
-
Intubation Preoxygenation (lung, procedure, airway)
- Nonrebreather Face Mask can deliver >90% FIO2 for preoxygenation if combined with Nasal Cannula at 15 L/min
-
Endotracheal Intubation (lung, procedure, airway)
- In Trauma, in-line stabilization offers little protection yet prolongs intubation attempts and decreases first pass success rates
- In Cardiac Arrest, early intubation (first 15 minutes) is associated with worse outcomes (concentrate on )
-
Dextromethorphan Overdose (lung, pharm)
- Dextromethorphan Abuse is increasing, with dosing 50 fold higher than typical, exceeding 1000 mg for dissociation
- Risks include Serotonin Syndrome, and depending on the abused formulation, Acetaminophen Overdose, Anticholinergic Toxicity
-
Chemical Restraint (psych, behavior)
- Midazolam combined with Droperidol offers safe, rapid sedation (10 min) compared with Droperidol alone (30 min)
- Of course, this study was in Australia, where they can actually use Droperidol
- In the U.S., Olanzapine with Midazolam may be a reasonable option
-
Gastroparesis (gi, Stomach)
- Observational study of ED Acute Pain Management for Diabetic Gastroparesis, in which Haloperidol was effective (additional studies needed)
-
Massive Hemorrhage (er, cv)
- End-Tidal CO2, Lactic Acid and Shock Index all appear to correlate with increasing levels of Hemorrhage
- Critical Administration Threshold (CAT) may be a better marker of Massive Transfusion
- Diabetic Ketoacidosis (endo, dm, er)
-
Tattoo (derm, procedure)
- Prevent infection with new Tattoo sites, by washing twice daily with soap and water, avoiding swimming for 2-4 weeks
-
Vaginal Estrogen (gyn, pharm)
- Intrarosa (another Vaginal Estrogen) indicated for post-menopausal Dyspareunia
-
Multiple Sclerosis (neuro, demyelinating)
- Multiple Sclerosis disease modifying agents with side effects, monitoring, and risks updated
VI. Updates: August 2017
-
Seizure Disorder (neuro, Seizure)
- Seizures are divided into generalized (GTCS, Myotonic, Absence), focal (simple or complex) or spasms
- Focal Seizures involve only one hemisphere and are either with awareness (simple) or without awareness (complex)
- Seizure Prophylaxis medication selection is based on the Seizure type
-
Herbal Medicine (pharm, alternative)
- Drug Interactions may either be pharmacokinetic (ADME Mechanism) or pharmacodynamic (direct effects)
- Pharmacokinetic (ADME Mechanism) are related to competition for Enzyme Activity (CYP, P-g, UGT, OATP)
- Herbals at highest risk for Drug Interaction include Goldenseal and St. John's Wort
-
Refugee Health Exam (prevent, exam)
- All Refugees should have screening exam within first 30 days of U.S. arfrival
- Test or empirically treat for endemic diseases if not already tested (e.g. Malaria, intestinal Parasites)
- Evaluate chronic health conditions (e.g. Diabetes Mellitus)
- Evaluate for mental health conditions including PTSD
-
Shoulder Dislocation Management (ortho, Shoulder, procedure)
- Davos technique is an older Shoulder self-reduction technique
- Patients sits with hands wrapped around knee on affected side and leans backward
- Surprisingly effective without sedation in the emergency department
-
HIV Complications (hiv, exam)
- Antiretroviral Drug Interactions and adverse effects are common
- Screen HIV patients for renal disease at HIV diagnosis and then at least every 6 months
- Screen HIV patients with Lipid profile and Glucose at HIV diagnosis and then periodically
- Cervical Cancer Screening follows similar screening as non-HIV patients, but is continued life long
-
PCP Pneumonia (HIV, lung)
- Septra continue to be a first line agent for PCP Pneumonia (for 21 days) and PCP Prophylaxis
- Alternative combination protocols include Clindamycin and Primaquine, or Atovaquone
-
Pelvic Organ Prolapse (gyn, Uterus)
- Pessaries remain an excellent, well tolerated first-line option for Pelvic Organ Prolapse
- Pelvic Floor Exercises are effective for Urinary Incontinence but do not effect Pelvic Organ Prolapse
- Pelvic Organ Prolapse related inflammation, bleeding, ulcers are not decreased with Topical Estrogen
-
Isovolemic Hypoosmolar Hyponatremia (renal, sports, Sodium)
- Hypertonic Saline bolus 100 ml is preferred in Hyponatremia with severe symptoms
- Even Normal Saline may result in paradoxical Hyponatremia worsening, due to free water retention with Exercise
-
Ultrasound Assessment of Shock (er, rad, Ultrasound, cv)
- Stroke Volume Estimation by Bedside Ultrasound measures pulse wave doppler wave form area (Velocity-Time Integral or VTI)
- Fluid responsiveness is indicated if VTI increases 15% with passive leg raise
-
Urethral Catheterization (urology, procedure)
- External Urethral sphincter between penile and prostatic Urethra is more common than Prostate as site of catheter obstruction
- Male catheterization is eased in a calm patient, with Lidocaine to distend Urethra, traction applied to penis, and with a larger, 20 French catheter\
- Catheterization of a retracted Urethral meatus (e.g. morbid Obesity) requires assistance to retract redundant tissue, apply suprapubic pressure
-
Procedural Sedation (surgery, Anesthesia, pharm)
- Consider intranasal route for Fentanyl, Midazolam, Lidocaine, Dexmedetomidine
- Consider Intramuscular (IM) route for Ketamine, Midazolam, Hydromorphone
- Consider rectal route for Methohexital, Diazepam, Midazolam
-
Migraine Headache (neuro, Headache)
- Most effective medications in Migraine Headache include Metoclopramide, Prochlorperazine, Sumatriptan
- Droperidol (or Haloperidol or Olanzapine if not available) may also be offered
- Dexamethasone may be considered to prevent Rebound Headache
- Avoid Opioids, Lidocaine, Octreotide
-
Hand Foot and Mouth Disease (ent, mouth, id)
- Coxsachievirus A6 is a more virulent strain that is highly contagious, affects adults and teens, associated with fever, myalgias and diffuse vesicular rash
-
Syncope (cv, sx)
- Syncope Plus is Syncope with Headache, Chest Pain, Vomiting, Abdominal Pain, Vaginal Bleeding
- Consider Subarachnoid Hemorrhage, AAA, MI, PE, Aortic Dissection, Ectopic Pregnancy
-
Pulmonary Embolism Management (lung, cv)
- More evidence that sub-massive PE patients as a whole, do not do better with Thrombolysis
-
Prescription Safety (pharm, )
- Opioids are not typically stored safely in the home away from children
-
Low Risk Chest Pain (cv, cad)
- Telemetry is not needed after 8 hours from ED presentation if no current Chest Pain, no significant EKG abnormality and no Arrhythmia
-
Acute Coronary Syndrome Adjunctive Therapy (cv, cad)
- Beta Blockers are typically indicated for the first 3 years after Myocardial Infarction
-
Menopause (gyn, endo, ovary)
- Estrogen Replacement appears a safe option (unless contraindicated) in early Menopause (age <60 years, and <10 years since last Menses)
-
Adolescent Health (peds, teen)
- Remind adolescents to update their Vaccinations (HPV Vaccine, Menactra, Tdap, Influenza Vaccine)
-
Seizure Causes (neuro, Seizure)
- Common Medication Causes of Seizure include Bupropion, Tramadol, Clozapine, Chlorpromazine, Penicillins, Cephalosporins, Quinolones
-
Medication Use in the Elderly (geri, pharm)
- Remember the Beers List and avoid Anticholinergic Medications (Diphenhydramine, Tricyclic Antidepressants, Oxybutynin) in the elderly
VII. Updates: July 2017
-
Evaporative Cooling (er, environ, heat)
- Cold water immersion is the most effective external cooling procedure, but may be logistically difficult
- Evaporative Cooling is highly effective and still allows for monitoring, and without fear of head immersion
-
Botulism (id, neuro)
- As with infants, Botulism spores (e.g. from honey) may germinate in the GI Tract of those status-post Bariatric Surgery or on PPI
-
Priapism (urology, penis)
- Updated after I performed a case successfully using aspiration and Phenylephrine injection (under propofol Anesthesia)
- I was suprised at the large amount of blood aspirated despite low-flow Priapism
-
Dementia Management (neurology, cognitive)
- Still no magic Dementia medication - Cholinesterase Inhibitors and Namenda are marginally effective with GI side effects
- Avoid most other agents (Statins, nsaids, ginkgo, Omega-3 Fatty Acids) for Dementia as they lack benefit or have risks
- Mental stimulation programs, physical Exercise and occupational therapy have quality of life and functional benefits
-
Slipped Capital Femoral Epiphysis (ortho, hip. peds)
- Do not miss SCFE in the Overweight adolescent with vague hip or Knee Pain
- Delayed SCFE diagnosis risks longterm Disability including Hip Avascular Necrosis and premature hip degeneration
-
Immunization (id, immunize, prevent)
- Vaccination is safe, effective and prevents serious illness and Vaccination refusal puts entire communities at risk
- For every 1000 Measles cases, 50 will develop Pneumonia, 1 will develop Encephalitis and 2 will die
- Congenital Rubella (TORCH Virus) affected 20,000 U.S. newborns in 1964-5, prior to Rubella Vaccination
- Orchitis (with Infertility risk) occurs in up to 10% of males with Mumps
-
Insomnia (psych, sleep)
- Non-pharmacologic measures are preferred (Cognitive Behavioral Therapy is very effective in longterm)
- Avoid Benzodiazepines (risk for dependence, associated with poor sleep and Fatigue, Cognitive effects, Fall Risk)
- Consider Melatonin, Gabapentin or Doxepin
-
Paronychia (derm, nails, id)
- In Acute Paronychia, Antibiotics are typically not needed after Incision and Drainage
- In Chronic Paronychia, antiinflammatories (Corticosteroids, calcineuron inhibitors) are the primary treatment (NOT Antifungals)
-
Developmental Evaluation (peds, neuro)
- Early intervention (by age 3 years old) is associated with the best outcomes
- AAP recommends routine screening at 9, 18, 24-30, and 48 months as well as Autism screening at 18 and 24 months
- AAFP and USPTF recommend Developmental Screening in symptomatic children
- Large multi-specialty groups in U.S. are following AAP guidelines for routine screening and have EMR embedded tools
-
Wilderness Medicine (er, environ, geri)
- Geriatric pitfalls include occult soft tissue infections, occult Fractures from minor Trauma, comorbidity exacerbation (e.g. ACS, Hypoglycemia)
-
Alcohol Withdrawal (psych, cd)
- Avoid masking withdrawal signs with Beta Blockers
- Consider differential diagnosis (Altered Level of Consciousness, Sympathomimetic toxicty, Sepsis, Intracranial Hemorrhage)
-
Canagliflozin (endo, dm)
- Associated with increased risk of amputations (RR 2.0, risk of 6 amputations per 1000 on Canagliflozin)
- May be a class effect (unclear mechanism)
-
Statin (cv, pharm, lipid)
- In age over 75 years without significant CAD risk, starting Statin may increase mortality without a decrease in CV risk
-
Corticosteroids (endo, pharm)
- Even short course Corticosteroids (1 week) is associated with increased risk of Fractures, VTE and Sepsis
- Avoid use when not truly indicated (e.g. Sinusitis, Acute Bronchitis, Pharyngitis)
- Avoid Medrol dose pack (replace with Prednisone 30 mg orally daily for 5 days would have similar effect)
-
Advair (lung, pharm, Asthma)
- New generic fluticasone/Salmeterol for $90/month (compared with $475/month for Advair)
- Systolic Dysfunction (cv, chf)
-
Osteoporosis (rheum, pharm)
- Abaloparatide (Tymlos) is another very expensive ($20,000/year) Parathyroid Hormone Analog for Osteoporosis similar to Forteo
-
Medication Patch (pharm, metabolism)
- Patches are heat sensitive and heat may increase absorption, resulting in dangerous drug levels (e.g. Fentanyl)
- Avoid cutting patches unless specifically allowed (non-reservoir, evenly distributed medication such as Lidoderm may be cut)
- Remove patches before entering MRI (many patches have a metallic backing)
- FDA recommends Flushing or Take-Back program for some patches with diversion potential (e.g. Fentanyl)
- Anticoagulation (hemeonc, pharm)
-
Nocturnal Leg Cramps (ortho, sx)
- Identify and treat comorbid conditions (Peripheral Vascular Disease, Peripheral Neuropathy, Restless Leg Syndrome)
- Decrease dose or switch medications from potentially causative agents (Diuretics, Albuterol, Nifedipine)
- Before bed, perform calf stretch, maintain hydration, use warm or cold packs, massage calf
- Consider Diltiazem or Verapamil, Vitamin B12 Supplementation, Magnesium Supplementation, Gabapentin
- Avoid Quinine sulfate (risk outweighs benefit)
- Laceration Repair (surgery, derm)
-
Intubation Preoxygenation (lung, procedure)
- Flush rate oxygenation at 40-70 lpm is optimal for RSI (rather than 15 lpm)
-
Rapid Sequence Intubation (lung, procedure)
- Premedications (Fentanyl, Lidocaine, Atropine) for RSI are nearly never indicated
- In Head Trauma, Lidocaine does not decrease ICP with intubation (Fentanyl may offer benefit, but is associated with Hypotension)
-
Pediatric Fractures (ortho, peds, Fracture)
- Emergent surgery for open Fractures, neurovascular injury (or risk of injury), unreducible joint dislocations
- Removable ankle splints are safe management for possible lateral ankle distal fibular Salter I Fractures
- Removable Wrist Splints have also been used safely for distal radius buckle Fractures
-
Acute Coronary Syndrome (cv, cad)
- Nitroglycerin may be used in ischemic Chest Pain except with Sildenafil, Hypotension, Aortic Stenosis, Pulmonary Hypertension
- Also avoid Nitroglycerin in right sided Myocardial Infarction (in inferior MI, obtain RT sided EKG)
-
Amoxicillin (id, pharm, Bacteria)
- Amoxicillin rash without allergic or systemic symptoms is not an IgE mediated reaction, and does not absolutely contraindicate future Amoxil use
- Amoxicillin may be re-trialed again if rash alone (non-allergic); consider allergy Skin Testing if unclear history
- Diabetes Mellitus Control in Hospital (endo, dm)
-
Pulmonary Embolism Management (lung, cv)
- Hestia Criteria, Troponin, ekg, history (active cancer, pregnancy) risk stratify for inpatient vs outpatient care
-
Gabapentin (neuro, pharm, Seizure)
- Gabapentin and Pregabalin are now used as a common drug of abuse to potentiate the CNS effect of Opioids
-
Pediatric Trauma (er, peds, Trauma)
- Tranexamic Acid is safe and effective in Pediatric Trauma
- Each transfusion bolus is 10 ml/kg and Massive Transfusion is defined as 40 ml/kg (50% of a child's Blood Volume)
-
Deep Vein Thrombosis Prevention (hemeonc, prevent, cv, coags)
- Lower leg cast typically does not require DVT Prophylaxis in most cases (except prior VTE, Achilles Tendon Rupture, prolonged travel >6 hours)
-
Toxin Ingestion (er, toxin)
- Hydrocarbon Ingestion is high risk for aspiration (esp. those with lower viscosity) with devestating complications including ARDS
-
Sepsis (id, fever)
- qSofa is more accurate than SIRS Criteria in predicting inpatient mortality
-
Mild Head Injury Home Management (er, neuro)
- Children recover faster from Concussion with less postconcussive Headache when allowed non-contact light activity while recovering
VIII. Updates: June 2017
-
Laceration Repair (Surgery, Derm)
- Epinephrine may be safely used for Anesthesia of ears, nose, digits, if no vascular compromise
- Irrigating with tap water under a faucet is as effective as sterile saline irrigation by syringe
-
Perioperative Antiplatelet Therapy (hemeonc, surgery)
- Continue Aspirin through perioperative period unless high bleeding risk (e.g. intracranial surgery)
- Continue Dual antiplatelets for 30 days after bare metal stent, 6 months after Drug-eluting Stent, 12 months after ACS
- For urgent or emergent surgery, continue dual antiplatelet agents unless major bleeding risk (e.g. active bleeding, intracranial surgery)
-
Refractive Corneal Surgery (eye, surgery)
- LASIK has a long, well-studied track record for safety and efficacy with 98% with Vision >20/40
- Common complications include Dry Eyes, halos around lights (esp. night) and worsened Presbyopia in the longterm
-
Subclinical Hyperthyroidism (endo, Thyroid)
- Defined as TSH suppressed <0.4 mIU/L, but normal Free T4 and Free T3
- Most significant if TSH persistently <0.1 mIU/L in age over 65 years
- Risk of cardiac adverse effects (esp. Atrial Fibrillation) and Osteoporosis
- Treatment indications include TSH persistently <0.1 mIU/L and age >65 years old or comorbidity, symptoms
-
Newborn Screening (nicu, lab)
- Newborn Screening continues to advance with additional screening recommended in U.S. universal panel
- Disorder ACT sheets from ACMGG cover diagnosis algorithms and initial management
-
Urticaria (ent, allergy, derm)
- Exclude Anaphylaxis and airway angiodema first
- History and exam are most important in the evaluation (labs are rarely indicated)
- Start with Non-Sedating Antihistamines, and may add Sedating Antihistamines, H2 Blockers and Corticosteroids
- Chronic Urticaria is idiopathic in more than 80% of cases
-
Traveler's Diarrhea (gi, id, Diarrhea, travel)
- Fluoroquinolone resistance is high in south Asia (use Azithromycin instead)
- Lab testing including Stool Cultures is not needed in most cases
- Be alert for Dysentery, severe Dehydration, Sepsis
-
Vitamin Deficiency (pharm, Vitamin)
- Vitamin Deficiency is common with subtle, vague presentations (myalgias, weakness, Fatigue) and frequently misdiagnosed
- Predisposing conditions (e.g. Alcoholism, Vegan diet, malabsorption) can help keep specific deficiencies in mind
-
RSV Bronchiolitis (peds, lung)
- Brief minor oxygen desaturation is not a contraindication to emergency department discharge
-
Neutropenic Fever (id, fever, hemeonc)
- CISNE Score is an accurate risk stratification score for Neutropenic Fever emergency department discharge
-
Low Risk Chest Pain (cv, cad)
- Negative Coronary Catheterization without lesions in the last 5 years is reassuring
- Negative coronary CTA in last 6 months is reassuring
- Prior myocardial perfusion scans do not offer reassurance
-
Hypoglycemia (endo, Hypoglycemia)
- D10 is less likely to cause rebound Hypoglycemia than D50
- Lantus, Humalog, Novolog, Metformin are unlikely to cause delayed recurrent Hypoglycemia
- Observe hypoglycemic patients on Levemir for 6-8 hours
- Observe hypoglycemic patients on Sulfonylureas for 6-8 hours
-
Increased Intracranial Pressure in Closed Head Injury (er, neuro)
- Hypertonic Saline with mixed results in lowering Intracranial Pressure
- However, Scott Weingart refutes the study as a misinterpretated meta-analysis
-
Femur Fracture (ortho, hip, Fracture)
- Traction Splint does not appear to offer benefit in Femoral Shaft Fracture in reduced blood loss (may offer comfort)
- Consider traction for associated acute neurovascular compromise (to temporize until definitive management)
-
Sedation in Excited Delirium (psych, behavior)
- Categorize Agitated Patients as cooperative, disruptive without danger and Agitated Delirium
- Treat cooperative patients with non-medication therapy (calming measures)
- Sedate disruptive without danger patients with Zyprexa or B52 (Benadryl, Haldol 5, Midazolam 2)
- Sedate Agitated Delirium patients with Ketamine to gain IV Access, then Benzodiazepines for sedation
-
Preeclampsia (cv, htn, ob)
- Do not forget about postpartum Preeclampsia out to 6 weeks after delivery
- Prevent Seizures with Magnesium, and manage Hypertension with Labetalol, Hydralazine or Nifedipine
-
Cervical Spine Imaging in Acute Traumatic Injury (ortho, rad)
- CT Cervical Spine has excellent sensitivity for C-Spine Injury
- In atypical cases with neurologic symptoms/signs, MRI Cervical Spine may be needed to exclude Central Cord Syndrome
- Acute Pain Management (pharm, Analgesic)
- Pediatric Analgesic (pharm, peds, Analgesic)
-
Penile Zipper Entrapment (surg, derm)
- Mineral Oil is the single most effective measure, followed by cutting the distal zipper end
-
Subarachnoid Hemorrhage (neuro, cv)
- Lumbar Puncture is recommended after negative CT, when SAH is suspected with symptom onset >6 hours
- MRI Brain may be considered when symptom onset >6 hours (high Test Sensitivity for SAH after 6 hours)
-
Anticoagulation in Thromboembolism (hemeonc, pharm)
- In longterm Anticoagulation for those at moderate risk of DVT recurrence, consider lower dose DOAC after first 6 months
-
Tympanostomy Tube (ent, ear, surg)
- Treat Otitis Media with patent PE Tubes with (Ofloxacin, ciprodex or ciloxan) but not cipro HC (not sterile)
- Earplugs are not required for chlorinated pools (except if diving >6 feet)
-
Menstrual Migraine (neuro, Headache, gyn)
- Consider prophylaxis with NSAID scheduled from pre-Menses to completion of Menses
- Consider Seasonal Contraception if no Migraine with Aura
- Consider Migraine Prophylaxis agents (e.g. Propranolol, Tricyclic Antidepressant or Topiramate)
-
Agitation in Dementia (neuro, cognitive)
- Identify and treat underlying causes of Agitation and use non-medication calming measures
- If needed, Antipsychotics (e.g. Risperidone, Aripiprazole) may be considered, but associated with increased mortality
- Avoid Benzodiazepines due to Fall Risk and paradoxical Agitation
-
Tardive Dyskinesia (psych, pharm, adverse)
- Antipsychotics are not the only culprits; Dopamine blockers (e.g. Reglan, Levodopa, tricyclics) can also cause Tardive Dyskinesia
IX. Updates: May 2017
- Severe Asymptomic Hypertension (cv, htn)
- Severe Hypertension (SBP>180 or DBP>110) WITHOUT signs/symptoms of Hypertensive Urgency
- Severe Asymptomic Hypertension may still have mild symptoms, but no target organ injury (cv, neuro, renal)
- Does not require diagnostics, parenteral Antihypertensives, emergency department or inpatient management
- Start (or adjust) oral Antihypertensives with clinic follow-up
-
Peritonsillar Abscess (ent, mouth)
- Most Peritonsillar Abscesses should have attempted drainage
- Failed aspiration may indicate Peritonsillar Cellulitis or deep space infection
- Broad spectrum Antibiotics typically follow aspiration (e.g. Clindamycin, Augmentin or Metronidazole with Cefdinir)
- Corticosteroids (e.g. Dexamethasone) speed recovery and decrease symptoms
-
Zika Virus (id, virus)
- Zika Virus is a Flavivirus similar to Dengue Fever, Yellow Fever and West Nile Virus
- In addition to Congenital Zika Syndrome, Zika may also cause Guillain Barre Syndrome, Thrombocytopenia, Encephalitis
- Testing in pregnant women starts with Zika RNA urine/serum in first 2 weeks or Zika and Dengue IgM if 2-12 weeks after onset/exposure
- Men may sexually transmit Zika Virus for up to 6 months in semen
-
Waterborne Illness (gi, Diarrhea)
- Many waterborne pathogens are Chlorine resistant (Cryptosporidium, Giardia, Adenovirus)
- Rare, but serious infections may occur (e.g. Legionella, Vibrio vulnificus, Primary Amebic Encephalitis, Leptospirosis)
- Live pathogen shedding continues for 1-3 weeks after symptom resolution (avoid swimming pool for at least 1 week after resolution)
-
Postmenopause (gyn,endo)
- Reduce CVA, HFpEF, CAD Risk Factors by controlling Hypertension, Atrial Fibrillation, Diabetes Mellitus, Tobacco Abuse, Obesity
- Screen for Breast Cancer, Colorectal Cancer and Cervical Cancer (until 65 years)
- Screen for Osteoporosis and discuss Fall Prevention
- Women remain sexually active (weekly in 65% ages 51 to 64), with STI Incidence 1% over age 65 years
-
Emergency ECMO (cv, procedure)
- Some tertiary institutions with access to cardiopulmonary bypass have instituted Emergency ECMO protocols for ECPR and ECLS
- Extracorporeal Cardiopulmonary Resuscitation (ECPR) for refractory Cardiac Arrest >10 min
- Extracorporeal Life Support (ECLS) for severe, refractory Cardiogenic Shock, massive PE or undifferentiated Hypotension
-
Infected Animal Bite (er, derm)
- Highest risk of infection: Distal extremity, vascular compromise, Cat Bites, Human Bites, Puncture Wound, DM/Immunodeficiency
- Be suspicious of clenched fist injuries as Fight Bites even if denied by patient (high risk of infection)
- Gunshot Wound (er, Trauma)
-
Laceration Repair (surgery, derm)
- Closure by secondary intention (or delayed primary closure) is indicated for wounds >12 hours (24 hours on face) or high risk of infection
- Highest infection risks include diabetes, wound contamination, length >5 cm and lower extremity wounds
- Intracranial Hypotension (neuro, Headache)
- CSF Leak may occur spontaneously from dura tears (sneezing, coughing)
- MRI with gadolinium contrast is diagnostic (subdural fluid, pachymeninges enhancement, venous engorgement, pituitary hyperemia)
- Caffeine and Epidural Blood Patch are effective (as with Spinal Headache)
-
CVA Management (neuro, cv)
- CT Perfusion imaging may identify patients beyond 3 to 4.5 hours who have large prenumbra at risk, and who might benefit from endovascular procedure
-
Naloxone (pharm, Analgesic)
- Give Naloxone in Opioid Overdose and hypoventilation (consider titrating in small amounts to effect)
- Observe patients for at least 1 hour after Naloxone for short acting Opioids (longer for long-acting Opioids)
-
Atrial Fibrillation Cardioversion (cv,ekg)
- Despite recent literature to the contrary, cardioversion within 48 hours of Atrial Fibrillation onset is safe
-
Transvenous Pacemaker (cv, procedure)
- Emergency Pacemaker placement in the ED for Symptomatic Bradycardia is safe
-
Cellulitis (derm, Bacteria)
- Cellulitis is overdiagnosed, most often with Stasis Dermatitis (although the differential is long)
- Consider other diagnosis in bilateral involvement, pruritic instead of painful, and longterm involvement
-
Thin Slicing (manage, legal)
- Fast, intuitive decision making is often used in the Emergency Department for initial evaluation and management
- Thin Slicing is often accurate for experienced clinicians, but is subject to anchor bias and premature closure
- Checklists (Review of Systems, serious cause differential diagnosis) can act as safety net
-
Bedside Ultrasound (rad, Ultrasound)
- Perform Ultrasound to answer specific questions
- Optimize gain/contrast and start zoomed out
- Image abnormalities in 2 planes
-
Syncope (cv, sx)
- Consider Pulmonary Embolism in differential (esp. if Leg Edema, VTE Risk, Tachypnea)
-
Deep Vein Thrombosis (hemeonc, cv)
- Symptomatic calf clots have similar outcomes with or without Anticoagulation
- Anticoagulation is associated with a 4% bleeding risk
-
Transient Synovitis (ortho, peds)
- Kocher Criteria (inability to walk, Temp >=38.5 C, ESR > 40 mm/h, WBC >12k) may help distinguish from septic hip
- In toxic appearing, febrile children, obtain XRay, labs, Hip Ultrasound (and consider MRI if non-diagnostic)
- If well appearing child with normal XRay walks after Ibuprofen, may disposition home with follow-up
-
Return of Spontaneous Circulation or ROSC (er, exam)
- Defined as return of palpable pulse OR return of Blood Pressure sufficient to perfuse critical organs (e.g. by Arterial Line)
- Near Hanging (er, Trauma)
- Advanced imaging was negative in Near-Hanging survivors with normal GCS and normal exam (without tenderness)
-
Antibiotics in Pregnancy (id, ob)
- Penicillins, Cephalosporins and Clindamycin are safe in pregnancy
- Avoid Fluoroquinolones and Tetracyclines in pregnancy
- Azithromycin and Erythromycin are safe (but Clarithromycin is not)
- Septra is only safe in second trimester and Nitrofurantoin is safe up to 36 weeks
-
Prosthetic Joint Infection Prophylaxis (surgery, prevent)
- Antibiotic prophylaxis is no longer needed around the time of dental procedures for immunocompetent patients
-
Anti-Retroviral Therapy (hiv, pharm)
- Antiretroviral medication errors are common during hospitalizations (affects 86% of patients on Antiretrovirals)
-
Irritable Bowel Syndrome (gi, bowel)
- Viberzi (Eluxadoline) used in Constipation dominant IBS risks life-threatening Pancreatitis (esp. if s/p Cholecystectomy)
-
Anticoagulants (hemeonc, pharm)
- Restarting Anticoagulation after major Hemorrhage (e.g. Hemorrhagic CVA) risks recurrent major bleeding
- However, Prosthetic Heart Valve or CHADS2-VASc Score 4 or higher might warrant restarting Anticoagulation
- If Anticoagulation restarted, wait at least 4 weeks after Intracranial Hemorrhage (8-10 weeks if higher risk)
-
Low Risk Chest Pain (cv, cad)
- After a thorough negative evaluation, in Low Risk Chest Pain patients, consider Anxiety Disorder in differential as diagnosis of exclusion
-
PCSK9 Inhibitor (cv, pharm, lipid)
- At $14,000 per year, are PCSK9 Inhibitors (e.g. Repatha, Praluent) worth the investment
- Repatha added to Statin for 2 years prevents one more CV event per 74 treated ($2,000,000 per CV event prevented)
- Statin alone ($250/year) for 5 years prevents one more fatal CV event per 39 treated ($48,000 per fatal CV event prevented)
X. Updates: April 2017
-
End-Of-Life Care (hemeonc, sx)
- Opiates are first-line agents for the symptomatic management of Shortness of Breath
- Corticosteroids may be effective for malignant Bowel Obstruction
- Start Opioids at low dose and short interval and titrate to effect
- Proactively manage Cancer Symptoms (e.g. Cancer Related Constipation)
-
Preterm Labor (Ob, Antepartum)
- Progesterone supplementation is indicated for history of spontaneous premature delivery and single gestation (or short Cervix)
- Corticosteroids are indicated for confirmed Preterm Labor at 24-34 weeks gestation
- Magnesium Sulfate before preterm delivery decreases Cerebral Palsy risk in infants <32 weeks
- Tocolytics in Preterm Labor are indicated to allow for transport to tertiary care, and Corticosteroid administration
-
Patiromer (renal, pharm, Potassium)
- May be indicated in chronic Hyperkalemia instead of Kayexalate
- Binds Potassium in exchange for Calcium in the Gastrointestinal Tract
- Risk of Hypomagnesemia (monitor Serum Magnesium as well as Potassium)
-
COPD Management (lung, COPD)
- COPD Screening (e.g. in smokers) is not recommended
- COPD diagnosis is Dyspnea, Chronic Cough or Wheezing and post-BronchodilatorFEV1 to FVC <0.7
- Start with Long-acting Bronchodilator or Anticholinergic and advance (per GOLD guidelines)
- Consider home oxygen and Pulmonary Rehabilitation
-
Postpartum Hemorrhage (ob, LD, bleed)
- Active Management of the Third Stage of Labor includes early Oxytocin at anterior Shoulder, cord traction, uterine massage
- Start with Oxytocin, then Methergine 0.2 mg IM, then Hemabate 0.25 to 1 mg IM
- Consider the 4Ts of Postpartum Hemorrhage causes: Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)
-
Procedural Sedation (surgery, Anesthesia)
- Be aware of Intralipid (esp. for intravascular Bupivicaine) in Local Anesthetic Systemic Toxicity (LAST Reaction)
- Laryngospasm Notch Maneuver may relieve laryngospasm with Ketamine
- Also addressed specific topics in Trauma in Pregnancy and Resource Limited Environment
- Propofol and Ketaphol are equivalent in efficacy and safety
-
Exercise in the Elderly (sports, geri)
- Any activity is better than no activity (start with ADLs, Errands)
- Resistance Training preserves Muscle Strength and physical functioning in older patients
- Aim for 150 minutes of Moderate Aerobic Activity weekly
- Perform Stretching and balance training 2-3 times weekly
-
Vomiting in Children (gi, peds, vomit)
- Not all that vomits is Gastroenteritis
- Consider Pyloric Stenosis, intussception, Testicular Torsion, DKA, UTI
- Consider Nonaccidental Trauma
-
Internal Hernia (endo, surgery)
- Catastrophic Abdominal Pain with a history of Roux-en-Y Bypass
-
Vocal Cord Dysfunction (ent, Larynx)
- Paradoxical vocal cord movements that present with Stridor
- Evaluate as airway emergency until Vocal Cord Dysfunction confirmed
- Improves with Ketamine
-
Chest Tube (lung, procedure)
- Small Chest Tubes (28-32 fr) are as effective as large Chest Tubes (36-40 fr) in Trauma
-
Massive Blood Transfusion (hemeonc, pharm)
- Indicated for 4-6 pRBC units (50% adult Blood Volume) required within 4 hours, or 8-12 pRBC units (100% adult Blood Volume)
- Replace Platelets and Fresh Frozen Plasma in 1:1:1 ratio
- Also consider Cryoprecipitate, Tranexamic Acid and PCC4
- Avoid Hypothermia (keep temp >36)
-
Digoxin Toxicity (cv, pharm)
- In chronic Digoxin Toxicity, DigiFab improves Digoxin levels but not Hyperkalemia or Bradycardia
-
Lumbar Puncture (Neuro, procedure)
- Blunt tipped spinal needles result in far fewer post-dural Headaches than sharp needles, and offer same CSF flow
-
Lactic Acid (renal, lab)
- Lactic Acid is helpful in children for disposition of Sepsis and Trauma
-
Coma (neuro, LOC)
- Full Outline of Unresponsiveness (FOUR Score) is a useful evaluation scale for monitoring coma
-
Lung Ultrasound for Pneumothorax (lung, rad)
- Single view Ultrasound per side (at 3rd interspace) has equivalent Test Sensitivity for Pneumothorax as 4 view
-
Pulseless Electrical Activity (CV, EKG)
- In PEA, when PE is strongly suspected, TPA 50 mg IV given in the first ~6 min of CPR, resulted in 85% longterm survival
-
Esophageal Foreign Body (gi, Esophagus)
- Reviewed Foley Catheter technique for extraction of esophageal coins (and other flat, blunt, small objects)
-
Diastolic Heart Failure (CV, CHF)
- Hypertension control is paramount (ACE Inhibitors, Beta Blockers, Thiazide Diuretics)
- Limit Furosemide to when Fluid Overload is present (otherwise risk of decreased Preload and increased symptoms)
-
Hepatitis C Antiviral Regimen (gi, liver)
- Hepatitis B reactivation is a risk when treating Hepatitis C with Antiviral Medications
-
Postpartum Depression (psych, ob)
- Sertraline (Zoloft) and Escitalopram (Lexapro) are preferred first-line SSRI in Lactation (due to safety in Lactation, and low adverse effects)
-
Restless Leg Syndrome (neuro, motor)
- Dopaminergic agents (e.g. premipexole) have fast onset and initial good efficacy, but cause more adverse effects in the longterm
- Gabapentin (or Pregabalin) has a longer delay to effect, but has similar efficacy to Dopaminergic agents and fewer adverse effects
-
Agitated Delirium (psych, behavior)
- Differential diagnosis of Sympathomimetic Toxicity includes Intracranial Hemorrhage, Hypoglycemia, NMS, Heat Stroke, Alcohol Withdrawal, Thyrotoxicosis
-
Laceration Repair (surgery, derm)
- Updated Suture Selection and wound edge eversion techniques
-
Fall Prevention in the Elderly (geri, prevent)
- Screen gait, strength and balance at the Welcome to Medicare Physical
- Review Medications to Avoid in Older Adults (Beers List, STOPP)
-
Asthma Management (lung, Asthma)
- For those with stable Asthma for at least 3 months, consider tapering controller medications
-
Antiplatelet Therapy for Vascular Disease (hemeonc, pharm)
- Limit triple therapy (e.g. Warfarin, Aspirin, Clopidogrel) to the shortest possible duration
-
Hiccup (gi, sx)
- Baclofen and Ganapentin taken for 7-10 days are safe and effective
-
Miralax (gi, pharm)
- Loose association with neuropsychiatric adverse effects in chldren
- Miralax is considered safe in children
XI. Updates: March 2017
-
Acute Coronary Syndrome (cv, cad)
- NSTE-ACS replaces terms NSTEMI and Unstable Angina in Moderate Risk Acute Coronary Syndrome Management
- STEMI goal door to balloon is 90 min (or 120 min if presenting to non-PCI hospital), otherwise Fibrinolysis if not contraindicated
- Reperfusion (PCI preferred) is recommended for STEMI with symptom onset within 12 hours
-
Proteinuria in Children (urology, peds, urine)
- Confirm 1+ Urine Protein with first morning Urine Protein to Creatinine Ratio (Upr/cr) and Urinalysis/microscopy
- Upr/cr >0.2 (or >0.5 in ages 6-24 months) should prompt further evaluation (history, Blood Pressure exam, labs)
- Nephrology consult for positive evaluation or persistent Proteinuria, nephritis, Renal Insufficiency, Hypertension, Vasculitis
-
Neuroblastoma
- Most common extracranial solid tumor in children, with 550 new U.S. cases per year, accounting for 8-10% of all Childhood Cancers (esp. age <2 years)
- Presents most often as adrenal or abdominal lesion, but may also present as chest, cervical or paraspinal lesions
- Metastatic findings include fever, bone pain, limp, Anemia, Raccoon Eyes, Opsoclonus-myoclonus syndrome, Blue Skin Nodules
-
Venous Thromboembolism (hemeonc, coags)
- Direct Factor Xa Inhibitors (Apixaban, Rivaroxaban) may be started without Heparin for both DVT and PE
- Most DVT and select PE patients may be treated as an outpatient
- Directed Thrombolysis indications are limited to massive PE, and ileofemoral DVT with severe symptoms/signs
- VTE (including PE) without thrombopilia is treated for a 3 month course
-
Syncope (cv, sx)
- Presyncope carries the same risk as Syncope and should be evaluated with similar carefulness
- Syncope causes are categorized as cardiac, neural or reflex-mediated and Orthostatic Hypotension
- Obtain a careful history, EKG, Orthostatic Blood Pressure, and select diagnostics tailored to presentation
- In-hospital observation for Syncope with CHF, structural heart disease, abnormal EKG, familial Sudden Cardiac Death
- Outpatient evaluation with Event Monitor, Holter Monitor or loop recorder may be indicated
-
Women Who Have Sex With Women (prevent, hme)
- Lesbian Women are often behind their healthcare screening with increased STI risk, cancer risk, Mood Disorder, and Substance Abuse
- Higher rates of Type II Diabetes Mellitus and cardiovascular disease
- Counsel on safe sex (Condoms over sex toys, dental dams, gloves and lubricants)
- Include Cervical Cancer Screening (many women in same sex relationships have had prior intercourse and HPV is common)
-
Sexual Assault of Male Victim (prevent, abuse, rape)
- Rape lifetime Incidence: 1.4% of U.S. men (typically before at 25 years old)
- Perpetrators of male victim rape are also male in 80% of cases
- Male victims are heterosexual in 68% of rapes
- Same Rape Management approach (with SANE Nurse) as with Female Rape Victim
-
Pneumonia in the Elderly (lung, geri, id)
- Elderly often do not mount fever response or Tachycardia despite serious infection
- SIRS criteria may therefore not be met despite Sepsis
- Pneumonia is the single most common cause of Sepsis in the elderly
- Err on the side of treating as Sepsis (even if SIRS negative), with early directed care and ICU admission
-
Decision Making Strategy - Interruptions (manage, legal)
- Interruptions are frequent in the emergency department (6-7/hour)
- Multi-tasking is a misnomer, and instead tasks are switched
- Task displaced by interruption is returned to after a mean delay of 23 minutes
- High cognitive load and frequent task switching is a risk for errors
-
Decision Making Strategy - Shift Fatigue (manage, legal)
- Energy and focus diminish over the course of a work shift and end of shift Fatigue is common with higher error rate
- Take a 5-10 min break to recharge, walk, eat, drink every 3-4 hours
- Reassess your patient list every 2-3 hours (patients, acuity, barriers to disposition) and complete next tasks needed
- Make an exit plan in the final 1-2 hours of a shift to work towards a disposition for each patient
-
NSAIDs (Pharm, Analgesic)
- Patients may report NSAID allergy with history of Allergic Reaction, pseudoallergic reaction or NSAID intollerance
- Pseudoallergic reaction is a COX reaction, often associated with Asthma, Nasal Polyps, Allergic Rhinitis
- Assume true Allergic Reaction first (unless only intollerance) and do not retrial with any NSAID until allergy evaluation
-
STEMI (cv, cad)
- Morphine may be relatively contraindicated in STEMI due to Drug Interaction with Ticagrelor
- Morphine decreased (35%) and delayed (2 hours) Ticagrelor absorption
- Presumed to apply to other Opioids and possibly other Platelet ADP Receptor Antagonists (e.g. Clopidogrel)
-
Calcaneus Fracture (ortho, Fracture)
- Surgical emergencies include Compartment Syndrome and Tongue-Type (extra-articular Fracture)
- Splint with Bulky Bobby Jones splint with both sugar tong and posterior splint applied and a well padded heel
- DVT Prophylaxis and non-weight bearing for 6-8 weeks
- Subtalar fusion indications include Bohler's Angle <4 degrees or Sanders Type 4 Fracture
-
Erythroderma (derm, exam, Scaling, er)
- Serious to life-threatening dermatosis with generalized skin erythema and Scaling
- Causes include underlying Psoriasis or Eczema, Drug Reaction, infection (HIV, toxic shock) and Cutaneous T-Cell Lymphoma
- Associated with significant morbidity and mortality risk
- Admit all patients suspected of having Erythroderma
-
Acute Pain Management (pharm, Analgesic, Opioid)
- When Opioids are needed, consider Morphine immediate release 10-30 mg orally every 4 hours prn adult moderate to severe pain
- Morphine is less euphoric than Oxycodone and Hydrocodone
-
Bursitis (ortho, sx)
- Bursal aspiration for all suspected Septic Bursitis for diagnosis and Antibiotic sensitivity
- Medications (pharm)
- Updated Hyperlipidemia Management
- Updated Iron Supplementation
- QT Prolongation
XII. Updates: February 2017
-
Hyperlipidemia Management (cv, lipid, prevent)
- A mess of ACC and NICE and USPTF Guidelines re-reviewed from 2013 emphasize Statins (high dose or low dose)
- High dose Statin (e.g. Lipitor 40, Crestor 20) for LDL >190, known CAD, DM 40-75yo if CAD risk >7.5%
- Moderate dose Statin (e.g. Lipitor 20, Crestor 10) for CAD risk >7.5%, DM 40-75 with CAD Risk <7.5%
-
Uterine Fibroid (gyn, Uterus)
- Surgical arsenal includes MRgFUS and IR embolization, as well as the traditional Hysterectomy or myomectomy
- Medical management has changed little (still GnRH Agonists, Mirena IUD, NSAIDs)
- Tranexamic Acid is an interesting option given its other uses (Massive Hemorrhage in Trauma)
-
RSV Bronchiolitis (lung, peds, Bronchi)
- Supportive care, nasal suctioning and maintain hydration (all other measures e.g. nebs, steroids, are defunct)
-
Vertigo (ent, vestibular)
- Distinguish triggered episodic Vertigo VS spontaneous episodic Vertigo VS continuous (Acute Vestibular Syndrome)
- Critical to consider posterior CVA in Acute Vestibular Syndrome (continuous) with HiNTs Exam, and possible imaging
- Positive Dix-Hallpike Maneuver in triggered episodic Vertigo suggests BPPV, which should respond to Epley Maneuver
- Avoid anti-Vertigo medications for longer than 3 days (risk of delaying central compensation)
-
Jaundice (gi, derm)
- Fractionate the Bilirubin, and if Unconjugated Hyperbilirubinemia, exclude Hemolysis
- If direct Hyperbilirubinemia, evaluate for Hepatitis And biliary obstruction
-
Endotracheal Intubation (lung, procedure, airway)
- Anticipate post-intubation Hypotension (related to sedation, PPV, PEEP) esp. children, age >65, Sepsis
- Hypotension occurs in up to 25% of emergency intubations (Cardiac Arrest in 3% of intubations)
- Post-intubation Hypotension is associated with worse outcomes
- Consider Normal Saline 10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI
-
Red Eye (eye, sx)
- In the Acute Red Eye, remember Intraocular Pressure, stain for Dendrites, Slit Lamp for cells and flare
- Visual Acuity should not be affected in Conjunctivitis (consider alternative diagnoses)
- Consider severe causes of Conjunctivitis (e.g. Chlamydia Conjunctivitis, Gonorrhea Conjunctivitis)
-
Pediatric Blunt Abdominal Trauma (er, peds, gi, Trauma)
- Consider intraabdominal injury in hypotensive Pediatric Trauma patients
- CT Abdomen is indicated for Positive Pediatric Blunt Abdominal Trauma Decision Rule or abnormal labs (e.g. AST, ALT, Lipase, UA)
- Emergent surgery if hemodynamic unstable
-
Pelvic Fracture (ortho, Trauma)
- Even seemingly minor Pelvic Fractures on xray may cause life threatening bleeding
- Pelvic Fractures with Hypotension have a very high mortality (>15-40%) and even higher with associated injuries
- Hemodynamically Unstable Patients with Pelvic Fractures need emergent angiography or surgery
- FAST Exam has a high False Negative Rate for missed hemoperitoneum with Pelvic Fractures
-
Pediatric Constipation (gi, peds, bowel)
- Constipation is a clinical diagnoses (use rome criteria) and XRays are not needed for diagnosis
-
Endotracheal Intubation (lung, procedure, airway)
- Peri-Intubation Hypotension is associated with worse outcomes
- Predict patients at risk (e.g. elderly, volume depletion) and prevent Hypotension with fluid Resuscitation
-
Bipolar Disorder in children (psych, mood, peds)
- Children present with Bipolar Disorder atypically (e.g. angry, irritable, Insomnia)
-
Prolonged QT Interval due to Medications (cv, pharm, ekg)
- Ondansetron causes minimal QT Prolongation, but if QT is already prolonged consider Reglan instead
-
Likelihood Ratio (prevent, epi)
- Post-Test Probability may be calculated by adding a 15, 30 or 45% to the pretest probability based on LLR+ of 2, 5 or 10
-
Low Risk Chest Pain (cv, cad)
- Up to 28% of patients with Acute Coronary Syndrome have a normal EKG
- Highest risk history includes Chest Pain radiation to right side or bilateral Shoulders, exertional Chest Pain, Vomiting, sweats
- Stress testing detects 70% stenotic lesions, but MI often occurs with small lesions
-
First Trimester Bleeding (ob, antepartum, bleed)
- Bedside Ultrasound is highly accurate (98% Test Specificity) at identifying intrauterine pregnancy at 5.5 weeks
- Additional testing (unless other indication) is not needed if IUP confirmed
- RhoGAM is not needed for spotting and Quantitative hCG is not needed if IUP is confirmed
- Refractory Ventricular Fibrillation (cv, ekg)
- Esmolol or double sequential external Defibrillation may be considered
-
Intracerebral Hemorrhage (neuro, cva, bleed)
- Target Systolic Blood Pressure <180 mmHg in Spontaneous Intracerebral Hemorrhage
- Target Systolic Blood Pressure <145 mmHg in Subarachnoid Hemorrhage
-
Deep Vein Thrombosis (hemeonc, coags)
- Two options: Observe with serial Ultrasound over 2 weeks OR treat as DVT for 6-12 weeks
- DVT management is preferred in those with Coagulopathy or symptomatic
- Additional evidence that proximal propogation of calf DVT is common
- MRI in pregnancy (rad, mri, ob)
- MRI is safe in pregnancy, but gadolinium is not
- Gadolinium may increase risk of Stillbirth as well as inflammatory conditions
-
Intraosseous Line (er, fen)
- Use the longer IO (4.5 cm, yellow) in obese patients at the Humerus and if tibial tuberosity can not be palpated
-
HIV Postexposure Prophylaxis (hiv, prevent)
- No occupation post-exposure patient has seroconverted with prophylaxis since 2001
- However, we still miss prophylaxing high risk sexual exposures (2% seroconversion rate)
- Fake Xanax (psych, cd)
- Tobacco Cessation (psych, cd)
- NSAIDs (pharm, Analgesic, ortho, Fracture)
-
COPD Management (lung, copd)
- Long acting Bronchodilators (e.g. Spiriva) are preferred over Corticosteroids in COPD
- Muscle Relaxants (rheum, pharm)
XIII. Updates: January 2017
-
Gastrointestinal Manifestations of Diabetes Mellitus (endo, dm, gi)
- Most common DM-related GI complications are Gastroparesis, NASH, GERD, Diabetes Related Intestinal Enteropathy
- If Gastroparesis is suspected, obtain TSH, chem18, upper endoscopy and consider scintigraphy; Trial on Reglan
- Nonalcoholic Fatty Liver Disease is a spectrum from Steatosis to fibrosis (NASH)
- NASH may be identified with Ultrasound and confirmed with various scoring systems, and if needed liver biopsy
-
Esophageal Cancer (gi, hemeonc, cancer, Esophagus)
- 80% of Esophageal Cancer (typically Squamous Cell) cases occur in non-industrialized countries in Asia and Africa
- In The U.S., Esophageal Adenocarcinoma predominates, most often in white males
- Early disease (Stage Ia) responds well to local resection, but 75% of cases present with distant metastases (Stage IV)
-
Carpal Tunnel Syndrome (ortho, wrist, neuro)
- Median Nerve motor deficit suggests severe, longstanding Carpal Tunnel (or alternative condition)
- Neutral Wrist Splint, avoidance of provocative activities and Exercises are beneficial
- Carpal Tunnel Corticosteroid Injection is very effective for more than 10 weeks and >1 year in some cases
- Median Nerve Measurement on Ultrasound may be used instead of EMG prior to surgery
-
Autism Spectrum Disorder (peds, neuro, develop)
- Autism Spectrum Disorder (ASD) Prevalence has increased significantly over time (1 in 68 children as of 2012)
- ASD encompasses four disorders: Autistic disorder, Asperger Disorder, Disintegrative Disorder, Pervasive Developmental Delay NOS
- Screening is with M-CHAT or M-CHAT-R/F followed by detailed evaluation and diagnosis in line with DSM-V Criteria
- Early diagnosis, referral and intensive behavioral management is associated with best outcomes
-
Baclofen Pump Malfunction (neuro, pharm)
- Baclofen Withdrawal results in hemodynamic instability, Seizures, Sepsis-like presentation
- May present with Tachycardia, Tachypnea, fever and confusion (all consistent with Sepsis)
- However, in contrast with Sepsis, Baclofen Withdrawal presents with Hypertension
- Benzodiazepines (or Propofol) until replace Baclofen into pump's side port OR via intrathecal space via spinal needle
-
Beta Blocker Overdose (cv, pharm, adverse)
- Treat on par with full code event as patients decompensate to death quickly
- Consider Gastric Decontamination with Activated Charcoal if patient presents within first hour and lucid
- Typical management includes Epinephrine, Calcium, Glucagon, euglycemic Insulin protocol
- Consider Intralipid for lipophilic agent Overdose
-
Patient-Centered Communication (manage, communication)
- Understand patient's agenda (open ended questions, avoid interrupting, actively listen, something else?)
- Understand patient's perspective (avoid judging and prematurely reassuring, understand patient expectations)
- Shared treatment goals (discuss treatment options without overwhelming)
-
Loperamide Abuse (gi, pharm, adverse, cd, Opioid)
- Loperamide Abuse is increasing with doses 4 fold and more higher than recommended
- Risk of cardiotoxicity and lethal Arrhythmias including Torsades
-
Systolic Dysfunction (cv, chf)
- ACE Inhibitors (or Angiotensin Receptor Blockers) and Beta Blockers remain the mainstay of CHF management
- Entresto (Valsartan with Neprilysin) is also an option, but more expensive, adverse effects, and limited studies
- Second-line options include Diuretics, Digoxin, Aldosterone Antagonists, Bidil, Corlanor
-
Dyspnea in Palliative Care (hemeonc, lung, cancer)
- Provide aggressive palliative Resuscitation to get a patient to maximal possible comfort (DNR does not mean less care)
- Direct symptomatic treatment at Dyspnea not Tachypnea
- Maximize comfort (sitting with family, monitors off) and air-flow (fans, cool room, humidifier, oxygen as tolerated)
- Opioids reduce Dyspnea
-
Complex Regional Pain Syndrome (rheum, neuro, pain)
- Early range of motion, physical therapy and avoiding Splinting
- Effective agents include Corticosteroids, topical Lidocaine
- Other novel agents include Bisphosphonates, topical DMSO, Lidocaine infusion
- DigiFab (cv, pharm, adverse)
- Digoxin Toxicity agent replaces Digibind due to lower risk of Hypersensitivity
-
Vertigo (ent, neuro, Vertigo)
- Subdividing Vertigo by triggers may help differentiate benign causes from those requiring imaging
- Triggered Vestibular Syndrome (TVS) is triggered by head movement (e.g. Dix-Hallpike, body position (e.g. Orthostasis)
- Episodic Vestibular Syndrome (EVS) is distinct episode without obvious trigger with DDx including TIA
- Acute Vestibular Syndrome (AVS) is abrupt onset and persistant without trigger with DDx including posterior CVA (HiNTs Exam)
-
Uterine Bleeding in Pregnancy (ob, antepartum, bleed)
- bHCG below discriminatory values does not exclude Ectopic Pregnancy
- Normal pelvic utrasound does not exclude placenta abruption
-
Trauma in Pregnancy (er, Trauma, ob)
- RSI is typically with Succinylcholine and Etomidate
- Post-intubation sedation typically with Propofol and Fentanyl, or alternatively with Ketamine or Dexmedetomidine
-
Postpartum Headache (neuro, ob, Headache)
- Differential includes Preeclampsia and PRES, Spinal Headache, Cerebral Venous Thrombosis, SAH, Meningitis, Pituitary Adenoma
- Preeclampsia should be at top of differential if within 6 weeks postpartum with Hypertension
-
Hypertensive Encephalopathy (cv, htn, neuro)
- Added
-
Alcohol Intoxication (psych, cd)
- Consider coingestions (e.g. Drugs of Abuse), Closed Head Injury, Hepatic Encephalopathy, Meningitis
- Observe closely and manage Alcohol Withdrawal early if signs develop
- Alcohol Detoxification or early discharge when Clinically Sober
-
Ankle Fracture (ortho, Ankle Fracture)
- Weber A Fractures are stable, transverse fibular Fractures below syndesmosis and are treated non-surgically
- Weber B Fractures are possibly unstable Fractures at the level of joint line and syndesmosis
- Weber C Fractures are unstable syndesmotic ligament ruptures and require surgical repair
-
Increased Intracranial Pressure in Closed Head Injury (ed, neuro, Trauma, icp)
- Improve cerebral venous drainage (head of bed at 20-35 degrees, avoid jugular compression
- Maintain adequate Cerebral Perfusion Pressure (MAP>65-80 mmHg) but keep SBP <140-160 with Nicardipine
- Do not hyperoxygenate or hyperventilate
- Mannitol for impending Brainstem Herniation
-
Comprehensive Advanced Life Support (ER)
- Added Universal Algorithm and protocols
- CALS should update Acute Care 23: Bioagents - anthrax Antibiotics
-
Anthrax (id, Bacteria, weapon)
- Updated Antibiotic regimens
-
DTaP (id, immunize, pregnancy)
- Give DTaP at 27-36 weeks in each and every pregnancy
- Medications (pharm)
- New GLPT-1 me-toos and combos: Adlyxin (Lixisenatide), Soliqua (Insulin Glargin with Lixisenatide), Xultophy (Tresiba with Liraglutide)
- Differin 0.1% gel is generic in 2017
- Patients need Inhaler Education