Family Practice Notebook Updates 2017

Aka: Family Practice Notebook Updates 2017, FPN Updates 2017

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II. Updates: December 2017

  1. Cardiomyopathy (cv, Myocardium)
    1. Primary Cardiomyopathy is organized into Acquired (e.g. Myocarditis), Genetic (e.g. ARVD, HCM) and Mixed (dilated, restrictive)
    2. Secondary Cardiomyopathy are due to extrinsic/systemic causes (e.g. Autoimmune, diabetes, Thyroid, Chagas, cardiotoxins)
    3. Treat specific underlying causes, as well as Congestive Heart Failure
  2. Herpes Zoster (id, virus)
    1. Shingles lifetime risk is 30%, with onset peaking at 50-79 years old
    2. May involve more than 1 Dermatome and may cross the mid-line (esp. on the back)
  3. Diabetes Mellitus Control in Hospital (endo, pharm)
    1. Glucose goals are 140-180 mg/dl
    2. Metformin may typically be continued while hospitalized (but Exercise caution with Sulfonylureas, GLP-1 Agonists)
    3. In hospital protocols exist for initiating basal, bolus and correctional Insulin
  4. Liver Function Test Abnormality (gi, liver)
    1. Nonalcoholic Fatty Liver is the most common cause of asymptomatic mild Liver Function Tests (<5 times normal)
    2. Other than Alcohol, Hepatotoxins, Hepatitis B, Hepatitis C and Hemochromatosis may also increase Liver Function Tests
    3. Rare cases include Alpha-1-Antitrypsin Deficiency, Autoimmune Hepatitis, Wilson Disease
  5. Hyperosmolar Hyperglycemic State (endo, dm, er)
    1. Fluid and Potassium Replacement precede Insulin
    2. Identify precipitating conditions (e.g. Sepsis)
    3. Exercise caution in overhydration of children (risk of cerebral edema)
  6. Beta Blocker Overdose (cv, pharm, adverse)
    1. Follow Don't Open Eyes Technique for Eye Drop Instillation, to prevent systemic Beta Blocker Toxicity
    2. Beta Blocker Toxicity presents with Bradycardia and Hypotension
    3. May respond to Glucagon, hyperinsulinemia-euglycemia, methylene blue, ECMO
  7. Emergent Reversal of Anticoagulation (hemeonc, coags, pharm, adverse)
    1. For life threatening bleeding on Dabigatran, give Idarucizumab if available (otherwise PCC or FFP)
    2. For bleeding on other NOAC, administer PCC or FFP
  8. Acute Pancreatitis (gi, Pancreas)
    1. Acute Pancreatitis diagnosis is based on 2 of 3 criteria (symptoms, Lipase 3x >normal, imaging c/w Pancreatitis)
    2. Even mild Acute Pancreatitis improves faster with aggressive Intravenous Fluids (LR 2L bolus to start)
    3. Early initiation of oral clear fluids, low-fat full liquids and low residue soft-solids prevents bowel atrophy
  9. Diabetic Foot Ulcer (surgery, derm, endo, dm)
    1. Assess patients for systemic illness, Peripheral Arterial Disease, Retained Foreign Body
    2. Assess for Osteomyelitis (Probe To Bone Test, ESR, XRay changes)
    3. Chronic Osteomyelitis of diabetes may typically be managed outpatient
  10. Testicular Torsion (urology, Testes)
    1. Frequently misdiagnosed as Epididymitis
    2. Examination is unreliable
    3. Abdominal Pain may be only presenting symptom
  11. Moderate Risk Acute Coronary Syndrome Management (cv, cad)
    1. Immediate angiography for refractory Angina with Heart Failure, acute Mitral Regurgitation, hemodynamic instability, sustained VT/VF
  12. Sepsis (id, fever, Bacteria)
    1. SOFA Score and qSOFA Score have been recommended to replace SIRS Criteria in the diagnosis of Sepsis
  13. Moderate Acne Vulgaris Management (derm, acne)
    1. Topical and oral Antibiotic Resistance in acne is increasing (as high as 50% for Topical Antibiotics)
    2. Benzoyl Peroxide should be used with all Antibiotic regimens to prevent Antibiotic Resistance
    3. Stop oral Antibiotics after acne improves (after 3-4 months) and continue topical agents
  14. Systolic Dysfunction (cv, chf, pharm)
    1. When maximizing Systolic Dysfunction medical management, include an Aldosterone Antagonist (e.g. Spironolactone, Eplerenone)
  15. Hoarseness (ent, Larynx, sx)
    1. Laryngoscopy is the first-line evaluation of Hoarseness lasting more than 2-4 weeks (esp with risk factors for Laryngeal Cancer)
  16. Impaired Fasting Glucose (endo, dm)
    1. Cassia cinnamon at 1-3 g/day may decrease Fasting Glucose by as much as 25 mg/dl
  17. Opioid Induced Constipation (gi, pharm, Constipation, Opioid)
    1. Gastrointestinal Opioid Antagonist (e.g. Relistor) are third-line, expensive, marginally effective agents in refractory Opioid-Induced Constipation
  18. Home Medications Before Colonoscopy (gi, procedure)
    1. Anticoagulants, antiplatelet agents and diabetes medications need modification before Colonoscopy
    2. Low dose Aspirin and NSAIDs may often be continued before Colonoscopy
    3. Most other medications may be taken before Colonoscopy
  19. Acute Infectious Diarrhea (gi, Diarrhea)
    1. Infectious Diarrhea is typically self limited and responds to standard rehydration
    2. Antibiotics may be considered with Loperamide in severe Dehydration, without Dysentery, fever, bloody Diarrhea
  20. Foreign Body Aspiration (lung, airway)
    1. Aspirated objects are only radioopaque in 10-20% of cases (xray does not exclude aspirated foreign body)
    2. In a patient maintaining their airway, do not perform back blows or blind finger sweep (risk of complete obstruction)
    3. Keep Foreign Body Aspiration in the differential in a child with respiratory complaints (one third of aspirations are unwitnessed)
  21. Opioid Abuse (psych, cd, Opioid)
    1. Provide prescription intranasal Naloxone
    2. Encourage needle exchange program and screening for HIV Infection, Hepatitis C infection
    3. Users should wash hands before preparing Heroin and use a clean cooker (e.g. spoon), clean water, new cotton filter
    4. 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
  22. Procedural Sedation (surgery, Anesthesia)
    1. Ketamine is preferred agent for Conscious Sedation in children and longer procedures in adults
    2. Propofol is preferred agent for brief Procedural Sedation in adults
    3. Etomidate or Ketamine may be considered for Procedural Sedation in hypotensive adults
  23. Sepsis (id, fever)
    1. Mortality increases with every hour of Antibiotic delay
  24. Pulmonary Embolism (lung, cv)
    1. YEARS Score is negative if no DVT clinical evidence, PE not the most likely diagnosis, and no Hemoptysis
    2. If YEARS Score negative (no criteria present), D-Dimer cut-off of 1.0 may be used
  25. Corneal Abrasion (eye, Cornea)
    1. Evidence for safe use of Topical Eye Anesthetic (tetracaine 1%) for 24 hours at home in simple Corneal Abrasion
    2. Simple, small, non-pentrating, non-lacerating Traumatic Eye Injury onset within prior 2 days
    3. Not due to chemical or Contact Lens and no infection, contamination or Retained Foreign Body
  26. Globe Rupture (eye, Trauma)
    1. Ocular CT has only a 75% Test Sensitivity for Globe Rupture
  27. Self-Talk Incrementalization (manage, legal)
    1. Break down complicated and high risk situations into manageable tasks
    2. Concentrate on each single task, with multiple adjustment strategies available if difficult
    3. Slow down, and perform each task with adequate precision to ensure success
    4. Self-talk yourself into success at each step (perform each task with confidence of success)

III. Updates: November 2017

  1. Chronic Rhinosinusitis (ent, sinus)
    1. Chronic Rhinosinusitis is an inflammatory condition (analogous to Asthma, Allergic Rhinitis) more than an infectious condition
    2. Diagnosis is based on 2 of 4 cardinal symptoms, exam or imaging evidence of Sinusitis, and at least 12 weeks of findings
    3. Primary management is with Nasal Saline and Intranasal Corticosteroids
  2. Bladder Cancer (urology, hemeonc)
    1. Cystoscopy for all patients with Gross Hematuria and Microscopic Hematuria with risk (age >35, symptoms without cause)
    2. CT Urogram and CT Pelvis should be included in evaluation for Bladder Cancer
    3. Bladder Cancer screening is not recommended
    4. Urine cytology and urine Tumor Markers are at the discretion of urology based on risk, evaluation
  3. Statin (cv, pharm, lipid)
    1. Statins remain by far the most effective AntiHyperlipidemic agents to reduce cardiovascular events
    2. Despite poor compliance, Statins are safe and have an overall low adverse effect rate
  4. Chronic Cough (lung, sx)
    1. Chronic Cough in adults lasts >8 weeks, and is most commonly caused by post-nasal drainage, GERD, Asthma, Eosinophilic Bronchitis
    2. Chronic Cough in Children lasts >4 weeks and is most commonly caused by Asthma, post-Bronchitic cough, post-nasal drainage
  5. Heart Failure with Preserved Ejection Fraction (cv, chf)
    1. Heart Failure with Preserved Ejection Fraction (HFpEF) is findings of CHF with an LV EF>50%
    2. Brain Natriuretic Peptide can be used to exclude Heart Failure in Emergency Department, BNP <100, nt-BNP < 300
    3. Suspected Heart Failure should be evaluated with Echocardiogram as a a first line test
  6. Disorders of Puberty (endo, sex)
    1. Consider precococious Puberty evaluation in girls before age 8 and boys before age 9
    2. Consider Delayed Puberty evaluation in girls without Breast development by age 13 or Menarche by 15, and boys with small Testes at age 14
  7. Skin Abrasion (er, environ, derm, Trauma)
    1. Evaluate Skin Abrasion as a friction burn (including depth of burn, involved BSA)
    2. Anesthetize area well and remove all particulate matter (scrub, irrigate, scrape)
    3. Apply Topical Ointment (e.g. Bacitracin, petroleum jelly) and bandage with Absorptive Dressing
    4. As with Burn Injury, for extensive involvement, replace fluids, and burn center referral
  8. Foot Pain (ortho, sx, foot)
    1. Lisfranc Fracture, Tarsal Navicular Fracture, Talus Fracture and Calcaneus Fracture and Fifth Metatarsal Fracture are the High Risk Fractures of the foot
  9. Spontaneous Bacterial Peritonitis (gi, id, liver)
    1. Keep SBP high on the differential for cirrhotic patients with Ascites (up to 25% of Cirrhotic Ascites patients in the ED)
    2. Emergently obtain peritoneal fluid (PMNs >250 defines SBP) and start Antibiotics
    3. Administer albumin for Cr>1, BUN>30, TBili>4
  10. Button Battery Ingestion (gi, Esophagus)
    1. Button batteries leak alkaline agents and cause liquifaction necrosis when in contact with tissue and cause serious burns within first 2 hours
    2. High risk of Esophageal Perforation in first 6 hours, and may be fatal in unrecognized or delayed presentation ingestions
  11. Lumbar Puncture in Infants (neuro, procedure, csf)
    1. Consider Topical Anesthetic (LMX4 applied 30 minutes before procedure OR EMLA applied 60 minutes before procedure)
    2. May remove stylet after entering skin (makes it less likely to miss the space)
    3. May allow for 1 additional CSF WBC for every 1000 CSF RBCs
  12. Ascariasis (id, Helminth)
    1. Ascariasis is most common in Asia, in regions where Defecation is in open, or crops are fertilized with animal feces (esp. pig)
    2. 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
    3. Worms are typically 15-30 cm long, live for 10 months to 2 years and do not reproduce within host patient
    4. In the U.S., treatment is with a single dose of Albendazole 400 mg (or Pyrantel Pamoate in pregnancy)
  13. Antiplatelet Therapy for Vascular Disease (hemeomc, cv)
    1. Platelet ADP Receptor Antagonist for 6-12 months after Drug-eluting Stent placement
    2. Benefit of Ticagrelor, Prasugrel over Clopidogrel, but at higher bleeding risk and 30x cost
    3. However, Clopidogrel may offer similar efficacy after the first week post-stenting
  14. Mydriatic (eye, pharm)
    1. Adequate fundoscopic exam relies on Mydriatic use
    2. Mydriatics are safe to use in emergency department eye evaluation (with caveats regarding contraindications)
  15. Musculoskeletal Injury (ortho, sx, Trauma)
    1. Do not forget SCIWORA in children with high mechanism injuries (esp. under age 8 years)
    2. 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
    3. Elbow Ossification Centers should be considered when evaluating the Elbow XRay in a child with Elbow Injury
    4. First exclude Septic Joint before diagnosing a red, hot, swollen large joint as gout (tap the joint if any level os suspicion)
  16. Emergency Department Migraine Headache Care (neuro, Headache)
    1. Reglan and Compazine are the most effective initial management strategies for Migraine Headache
    2. Prevent akisthesia by injecting the Antiemetic slowly (over 15-20 minutes); Diphenhydramine does not prevent the akisthesia
    3. Intravenous Fluids are without added benefit
    4. Consider Greater Occipital Nerve Block or Transnasal Sphenopalatine Ganglion Block
  17. DKA Management (endo, dm, er)
    1. Lactated Ringers is preferred over Normal Saline, and give initial 20 ml/kg, then 5-10 ml/kg boluses until IVC is not collapsed
    2. Replace Potassium before Insulin if <3.3, and give maintenance Potassium at 10 meq/h for 3.3 to 5.2 Serum Potassium
    3. Start Insulin Infusion at 0.1 units/kg/h without bolus, and continue at same rate until acidosis corrects
    4. Bicarbonate replacement is controversial, but may be helpful in Cardiac Arrest, severe Hyperkalemia with Arrhythmia, and refractory shock
  18. Topical NSAID (pharm, Analgesic)
    1. Topical NSAIDS (e.g. Topical NSAIDs) have low side effect profiles and may be as effective as their oral counterparts
  19. Chest Compressions (cv, procedure)
    1. Ultrasound during pulse checks in CPR, prolongs pulse checks, which should be <10 sec, from 13 sec to 20 sec
    2. Consider using ETCO2 as marker of ROSC instead of Bedside Ultrasound
  20. Drug Withdrawal (psych, cd)
    1. Severe Medication Withdrawal may occur with intrathecal Baclofen, Clonidine and Venlafaxine
  21. Analgesic Medications in Pregnancy (pharm, ob)
    1. Avoid Opioids in pregnancy as much as possible
    2. Neural Tube Defects if Opioids used in early pregnancy
    3. Newborn Opioid Withdrawal (neonatal abstinence syndrome) if maternal Chronic Opioid use
    4. No evidence of Tramadol safety
  22. Eosinophilic Esophagitis (gi, Esophagus)
    1. Immune mediated Esophagitis (Asthma of the Esophagus) that does not respond to GERD management
    2. May present with solid Dysphagia, food impaction, anterior Chest Pain, Epigastric Pain and refractory GERD
    3. Strongly associated with allergic conditions
    4. If GERD management ineffective, try activating steroid Inhaler MDI (e.g. Flovent HFA) and Swallowing, not inhaling

IV. Updates: October 2017

  1. Fall Prevention in the Elderly (geri, prevent)
    1. Approach falls as a sentinel event, a predictor of future falls with greater injury, and risk for Nursing Home placement
    2. Over age 65, screen yearly with history (fall in the last year?, How many times?, Injuries?) and if positive, Get Up and Go Test
    3. Educate patients on Fall Prevention, Vitamin D Supplementation, strength and balance Exercises
    4. High risk patients warrant medication review, Mental Status Exam, foot evaluation, Syncope evaluation, Vision Screening, formal Fall Prevention program
  2. Meniscal Tear (ortho, knee)
    1. Arthroscopy with Debridement offers no longterm benefit in middle aged and older patients (with or without Knee DJD)
    2. Arthroscopy offers no significant improvement in knee catching or locking in those with meniscal tear
    3. Exercise therapy is preferred
  3. Wound Care (surgery, derm, wound)
    1. Updated wound care, Chronic Wounds, Decubitus Ulcers, Wound Debridement
    2. Wound Debridement is important for necrosis or Hematoma (but do not debride if significant periphera arterial disease)
    3. Attended Wound Care Update conference, Park Nicollet, St Louis Park, MN (very good practical conference)
      1. http://www.parknicollet.com/~/media/Files/Events/CME/WoundCareUpdate2017.ashx?la=en
  4. Intensive Lifestyle Change In Type II Diabetes Mellitus (endo, dm)
    1. National Diabetes Prevention Program can markedly reduce risk of Prediabetes progression to Type II Diabetes
    2. Similarly, Look Ahead Study protocol results in up to 20% remission of new onset Type II Diabetes present for <2 years
    3. Goals of intensive programs include weight loss of 7-10% and Exercise gradually increased to 150-175 minutes per week
  5. Alopecia (derm, hair)
    1. Alopecia management is specific for type of Hair Loss, and Alopecia type is typically evident from the history and exam
    2. Two new Alopecia types are defined: Trichorrhexis Nodosa (hair Trauma or fragile hairs) and Anagen Effluvium (Chemotherapy-Induced Alopecia)
  6. Vitamin B12 Deficiency (hememonc, Anemia, Vitamin)
    1. Risk factors for B12 Deficiency include Metformin, acid suppression, malabsorption (e.g. Celiac Disease, Crohns, Roux-en-Y Bypass), Alcoholism, vegans
    2. Consider Serum Vitamin B12 with methylmalonic acid for confirmation (if Pernicious Anemia, then xIntrinsic acid, and possibly Gastrin)
    3. Treat severe deficiency (including neurologic changes) with IM Injections, but otherwise oral and Parenteral have equivalent efficacy
  7. Probiotics (pharm, nutrition, gi, id)
    1. Probiotics are effective in prevention of Antibiotic-Associated Diarrhea, C. difficile, Necrotizing Enterocolitis, Infantile Colic
    2. Probiotics are effective in management of Hepatic Encephalopathy, Ulcerative Colitis, Irritable Bowel Syndrome
    3. Probiotics evidence is unclear in NASH, and ineffective in Acute Pancreatitis and Pancreatitis
    4. Beyond type of Bacteria used in preparation, colony forming units (CFU) >5 Billion is most associated with efficacy
  8. CVA Prevention (neuro, cv, prevent)
    1. After acute period, lower Blood Pressure <140/90
    2. In those with CVA, TIA, screen for Diabetes Mellitus, Obstructive Sleep Apnea (50-75% Prevalence)
    3. Encourage Tobacco Cessation, Physical Activity (120-150 min per week)
  9. Secondary Hypertension (cv, htn)
    1. Consider secondary testing in Hypertension under age 30 years, Malignant Hypertension, Refractory Hypertension
    2. Renal Artery Stenosis is common and is due to fibromuscular dysplasia in younger patients, atherosclerosis in older patients
    3. Primary Hyperaldosteronism is common, especially with Hypertension and Hypokalemia (although Potassium is normal in 50% of cases)
  10. Male Hypogonadism (uro, endo)
    1. Androgen Replacement is only indicated in symptomatic low Testosterone, confirmed on 2 samples
    2. Longterm safety of Testosterone Replacement is unknown
    3. Routinely monitor Serum Total Testosterone, Hematocrit, PSA and adverse effects
  11. Stab Wound (er, Trauma)
    1. Trauma Survey and FAST Exam are often sufficient alone to indicate Unstable Patients requiring emergent surgery
    2. Cardiac injury and Diaphragmatic Injury may be easily missed
    3. Avoid speculating in the medical record regarding intent (self-inflicted, Suicide, homicide)
  12. Acute Severe Pain (pharm, Analgesic)
    1. Pain out of proportion to exam, can be more than Malingering, with occult serious causes
    2. Acute Painful Syncope (e.g. AAA, Aortic Dissection, Subarachnoid Hemorrhage) may immediately be recognized
    3. Other conditions may be initial diagnostic dilemmas until localizing findings (e.g. Shingles)
  13. Acute Pain Management in Children (pharm, peds)
    1. Topical measures prior to phlebotomy, IV start, Laceration Repair include LET, EMLA, LMX-4, J-Tip, Vapocoolant, Buzzy Bee
    2. Avoid Codeine and Tramadol
    3. For adequate parenteral Opioid Analgesic (e.g. long bone Fracture), use Morphine Sulfate 0.1 mg IV
  14. Hepatitis C Antiviral Regimen (gi, liver, id)
    1. Mavyret (glecaprevir/pibrentasavir) is a relative bargain in Hepatitis C (any Genotype) treatment: $26k for 8 weeks, and 95% effective
  15. Atenolol (cv, pharm)
    1. Atenolol is in shortage, and finally time to find a better Beta Blocker (Metoprolol XL in most cases)
  16. Influenza Vaccine (id, immunize)
    1. Reminder to avoid Flumist due to low efficacy
  17. Inhaled Corticosteroids (lung, Asthma)
    1. Yet another CorticosteroidInhaler, ArmonAir, which is nearly as expensive as Flovent (>$200)
  18. Post-Cardiac Arrest Care (er, exam)
    1. Head CT following ROSC may identify Intracranial Hemorrhage (11% of cases), catastrophic anoxic brain injury
    2. Neurologic outcome is not accurately predictable before 72 hours from ROSC or completion of Temperature targeted management
    3. Prevent Hypoxia and hypocapnia, Hyperglycemia and Electrolyte disturbances
    4. Temperature targeted management of 36 C may offer similar benefit in outcomes to 32-33 C
  19. Elastic Bougie (lung, procedure, airway)
    1. Elastic Bougie improves first pass Endotracheal Intubation success from 85 to 95%
    2. Elastic Bougie is useful when airway is obscured by blood or vomit
  20. Low Risk Acute Coronary Syndrome Management (cv, cad)
    1. As of 2017, HEART Score is the most used for Low Risk Chest Pain management stratification but does not appear to alter management
    2. Compared to usual care, HEART Score did not result in worse outcomes, but did not decrease resource use, admissions
  21. Appendicitis (surgery, gi)
    1. RLQ Abdominal Ultrasound before Abdominal MRI in children is preferred
    2. Ultrasound first strategy is faster and more cost-effective, despite RLQ Abdominal Ultrasound being inconclusive in 25% of cases
  22. Emergency Psychiatric Evaluation (psych, exam, er)
    1. Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
    2. Acute psychiatric symptoms in alert adults do not mandate routine lab testing
    3. No risk assessment tool can identify those safe for discharge
  23. CVA Management (neuro, cv)
    1. Consider Thrombolysis even in minor NIH stroke scores <5
    2. Large vessel Occlusion (e.g. Middle Cerebral Artery, cerebellar artery) may have low NIH Stroke Scale
    3. NIH Stroke Score particularly underestimates deficits from Cerebellar Strokes
    4. CTA Head and Neck identifies large vessel Occlusion and can help inform decision

V. Updates: September 2017

  1. Lower Extremity Abnormalities in Children (ortho, peds)
    1. Evaluation includes Torsional Profile, gait exam, limb asymmetry as well as Growth Parameters, Neurologic Exam
    2. In-Toeing may be caused by Metatarsus Adductus, Internal Tibial Torsion, Femoral Anteversion
    3. Out-toeing may be caused by External Tibial Torsion, Femoral Retroversion and Pes Planus
    4. Angular variations include Genu Varum and Genu Valgum
  2. Exercise Stress Testing (cv, procedure, Exercise)
    1. Stress testing is uncommonly indicated in asymptomatic patients aside from vascular surgery preop, vigorous Exercise clearance in deconditioned patients at risk
    2. Exercise Stress Testing is the first-line test for most symptomatic patients
    3. Stress Imaging is indicated for those with uninterpretable ekg, inability to Exercise, high False Positives or prior revascularization
  3. Pleuritic Chest Pain (lung, cv, sx)
    1. Critical to exclude 6 high risk causes: PE, MI, Pneumothorax, Aortic Dissection, Pneumonia, Pericarditis
  4. Bacterial Meningitis (neuro, id, Bacteria)
    1. Do not hesitate to obtain Lumbar Puncture when clinical suspicion dictates (regardless of Nuchal Rigidity, lab markers, decision rules)
    2. Delayed Antibiotics in Bacterial meninigitis >6 hours from presentation, is associated with >8 fold Odds Ratio increased mortality
  5. Heat Illness (er, environ, heat)
    1. Exertional Heat Illness is on a spectrum from Heat Stress to Heat Exhaustion to Heat Stroke
    2. Other Heat Related Illnesses include Heat Rash, Heat Edema and Heat Cramps
    3. Removal from heat and rapid external cooling are the mainstays of initial care
    4. Not all patients are volume depleted (avoid over-hydration)
  6. Dental Pain (dental, teeth sx)
    1. In a normal appearing tooth (without exposed root or abscess), Tooth Pain implies exposed dentin or pulp (cavity)
    2. Antibiotics are not indicated in Pulpitis where infection is absent
  7. Parasitic Infection (id, Parasite)
    1. In the returning traveler, keep Parasitic Disease in the differential diagnosis (esp. Immunocompromised patients)
    2. Parasitic Infections have the potential for life threatening complications; Exercise prevention for Foodborne Illness, Waterborne Illness, vector-borne disease
  8. Methemoglobinemia (hemeonc, Hemolysis)
    1. Methemoglobin levels >20-30% or significant cardiopulmonary symptoms indicate antidote (methylene blue)
  9. Cardiac Risk Factors (cv, prevent, cad)
    1. Some additional lesser known CAD risk factors (HIV Infection, Alcohol Abuse, Chemotherapy)
  10. Intubation Preoxygenation (lung, procedure, airway)
    1. Nonrebreather Face Mask can deliver >90% FIO2 for preoxygenation if combined with Nasal Cannula at 15 L/min
  11. Endotracheal Intubation (lung, procedure, airway)
    1. In Trauma, in-line stabilization offers little protection yet prolongs intubation attempts and decreases first pass success rates
    2. In Cardiac Arrest, early intubation (first 15 minutes) is associated with worse outcomes (concentrate on )
  12. Dextromethorphan Overdose (lung, pharm)
    1. Dextromethorphan Abuse is increasing, with dosing 50 fold higher than typical, exceeding 1000 mg for dissociation
    2. Risks include Serotonin Syndrome, and depending on the abused formulation, Acetaminophen Overdose, Anticholinergic Toxicity
  13. Chemical Restraint (psych, behavior)
    1. Midazolam combined with Droperidol offers safe, rapid sedation (10 min) compared with Droperidol alone (30 min)
    2. Of course, this study was in Australia, where they can actually use Droperidol
    3. In the U.S., Olanzapine with Midazolam may be a reasonable option
  14. Gastroparesis (gi, Stomach)
    1. Observational Study of ED Acute Pain Management for Diabetic Gastroparesis, in which Haloperidol was effective (additional studies needed)
  15. Massive Hemorrhage (er, cv)
    1. End-Tidal CO2, Lactic Acid and Shock Index all appear to correlate with increasing levels of Hemorrhage
    2. Critical Administration Threshold (CAT) may be a better marker of Massive Transfusion
  16. Diabetic Ketoacidosis (endo, dm, er)
    1. Some patients may be able to return home from ED (instead of ICU)
    2. Criteria for ED discharge include CO2 >18-20, resolved Ketones, Anion Gap <17, Glucose <250 mg/dl, taking oral fluids and normal mentation
  17. Tattoo (derm, procedure)
    1. Prevent infection with new Tattoo sites, by washing twice daily with soap and water, avoiding swimming for 2-4 weeks
  18. Vaginal Estrogen (gyn, pharm)
    1. Intrarosa (another Vaginal Estrogen) indicated for post-menopausal Dyspareunia
  19. Multiple Sclerosis (neuro, demyelinating)
    1. Multiple Sclerosis disease modifying agents with side effects, monitoring, and risks updated

VI. Updates: August 2017

  1. Seizure Disorder (neuro, Seizure)
    1. Seizures are divided into generalized (GTCS, Myotonic, Absence), focal (simple or complex) or spasms
    2. Focal Seizures involve only one hemisphere and are either with awareness (simple) or without awareness (complex)
    3. Seizure Prophylaxis medication selection is based on the Seizure type
  2. Herbal Medicine (pharm, alternative)
    1. Drug Interactions may either be pharmacokinetic (ADME Mechanism) or pharmacodynamic (direct effects)
    2. Pharmacokinetic (ADME Mechanism) are related to competition for Enzyme Activity (CYP, P-g, UGT, OATP)
    3. Herbals at highest risk for Drug Interaction include Goldenseal and St. John's Wort
  3. Refugee Health Exam (prevent, exam)
    1. All Refugees should have screening exam within first 30 days of U.S. arfrival
    2. Test or empirically treat for endemic diseases if not already tested (e.g. Malaria, intestinal Parasites)
    3. Evaluate chronic health conditions (e.g. Diabetes Mellitus)
    4. Evaluate for mental health conditions including PTSD
  4. Shoulder Dislocation Management (ortho, Shoulder, procedure)
    1. Davos technique is an older Shoulder self-reduction technique
    2. Patients sits with hands wrapped around knee on affected side and leans backward
    3. Surprisingly effective without sedation in the emergency department
  5. HIV Complications (hiv, exam)
    1. Antiretroviral Drug Interactions and adverse effects are common
    2. Screen HIV patients for renal disease at HIV diagnosis and then at least every 6 months
    3. Screen HIV patients with Lipid profile and Glucose at HIV diagnosis and then periodically
    4. Cervical Cancer Screening follows similar screening as non-HIV patients, but is continued life long
  6. PCP Pneumonia (HIV, lung)
    1. Septra continue to be a first line agent for PCP Pneumonia (for 21 days) and PCP Prophylaxis
    2. Alternative combination protocols include Clindamycin and Primaquine, or Atovaquone
  7. Pelvic Organ Prolapse (gyn, Uterus)
    1. Pessaries remain an excellent, well tolerated first-line option for Pelvic Organ Prolapse
    2. Pelvic Floor Exercises are effective for Urinary Incontinence but do not effect Pelvic Organ Prolapse
    3. Pelvic Organ Prolapse related inflammation, bleeding, ulcers are not decreased with Topical Estrogen
  8. Isovolemic Hypoosmolar Hyponatremia (renal, sports, Sodium)
    1. Hypertonic Saline bolus 100 ml is preferred in Hyponatremia with severe symptoms
    2. Even Normal Saline may result in paradoxical Hyponatremia worsening, due to free water retention with Exercise
  9. Ultrasound Assessment of Shock (er, rad, Ultrasound, cv)
    1. Stroke Volume Estimation by Bedside Ultrasound measures pulse wave doppler wave form area (Velocity-Time Integral or VTI)
    2. Fluid responsiveness is indicated if VTI increases 15% with passive leg raise
  10. Urethral Catheterization (urology, procedure)
    1. External Urethral sphincter between penile and prostatic Urethra is more common than Prostate as site of catheter obstruction
    2. Male catheterization is eased in a calm patient, with Lidocaine to distend Urethra, traction applied to penis, and with a larger, 20 French catheter\
    3. Catheterization of a retracted Urethral meatus (e.g. morbid Obesity) requires assistance to retract redundant tissue, apply suprapubic pressure
  11. Procedural Sedation (surgery, Anesthesia, pharm)
    1. Consider intranasal route for Fentanyl, Midazolam, Lidocaine, Dexmedetomidine
    2. Consider Intramuscular (IM) route for Ketamine, Midazolam, Hydromorphone
    3. Consider rectal route for Methohexital, Diazepam, Midazolam
  12. Migraine Headache (neuro, Headache)
    1. Most effective medications in Migraine Headache include Metoclopramide, Prochlorperazine, Sumatriptan
    2. Droperidol (or Haloperidol or Olanzapine if not available) may also be offered
    3. Dexamethasone may be considered to prevent Rebound Headache
    4. Avoid Opioids, Lidocaine, Octreotide
  13. Hand Foot and Mouth Disease (ent, mouth, id)
    1. Coxsachievirus A6 is a more virulent strain that is highly contagious, affects adults and teens, associated with fever, myalgias and diffuse vesicular rash
  14. Syncope (cv, sx)
    1. Syncope Plus is Syncope with Headache, Chest Pain, Vomiting, Abdominal Pain, Vaginal Bleeding
    2. Consider Subarachnoid Hemorrhage, AAA, MI, PE, Aortic Dissection, Ectopic Pregnancy
  15. Pulmonary Embolism Management (lung, cv)
    1. More evidence that sub-massive PE patients as a whole, do not do better with Thrombolysis
  16. Prescription Safety (pharm, )
    1. Opioids are not typically stored safely in the home away from children
  17. Low Risk Chest Pain (cv, cad)
    1. Telemetry is not needed after 8 hours from ED presentation if no current Chest Pain, no significant EKG abnormality and no Arrhythmia
  18. Acute Coronary Syndrome Adjunctive Therapy (cv, cad)
    1. Beta Blockers are typically indicated for the first 3 years after Myocardial Infarction
  19. Menopause (gyn, endo, ovary)
    1. Estrogen Replacement appears a safe option (unless contraindicated) in early Menopause (age <60 years, and <10 years since last Menses)
  20. Adolescent Health (peds, teen)
    1. Remind adolescents to update their Vaccinations (HPV Vaccine, Menactra, Tdap, Influenza Vaccine)
  21. Seizure Causes (neuro, Seizure)
    1. Common Medication Causes of Seizure include Bupropion, Tramadol, Clozapine, Chlorpromazine, Penicillins, Cephalosporins, Quinolones
  22. Medication Use in the Elderly (geri, pharm)
    1. Remember the Beers List and avoid Anticholinergic Medications (Diphenhydramine, Tricyclic Antidepressants, Oxybutynin) in the elderly

VII. Updates: July 2017

  1. Evaporative Cooling (er, environ, heat)
    1. Cold water immersion is the most effective external cooling procedure, but may be logistically difficult
    2. Evaporative Cooling is highly effective and still allows for monitoring, and without fear of head immersion
  2. Botulism (id, neuro)
    1. As with infants, Botulism spores (e.g. from honey) may germinate in the GI Tract of those status-post Bariatric Surgery or on PPI
  3. Priapism (urology, penis)
    1. Updated after I performed a case successfully using aspiration and Phenylephrine injection (under propofol Anesthesia)
    2. I was suprised at the large amount of blood aspirated despite low-flow Priapism
  4. Dementia Management (neurology, cognitive)
    1. Still no magic Dementia medication - Cholinesterase Inhibitors and Namenda are marginally effective with GI side effects
    2. Avoid most other agents (Statins, nsaids, ginkgo, Omega-3 Fatty Acids) for Dementia as they lack benefit or have risks
    3. Mental stimulation programs, physical Exercise and occupational therapy have quality of life and functional benefits
  5. Slipped Capital Femoral Epiphysis (ortho, hip. peds)
    1. Do not miss SCFE in the Overweight adolescent with vague hip or Knee Pain
    2. Delayed SCFE diagnosis risks longterm Disability including Hip Avascular Necrosis and premature hip degeneration
  6. Immunization (id, immunize, prevent)
    1. Vaccination is safe, effective and prevents serious illness and Vaccination refusal puts entire communities at risk
    2. For every 1000 Measles cases, 50 will develop Pneumonia, 1 will develop Encephalitis and 2 will die
    3. Congenital Rubella (TORCH Virus) affected 20,000 U.S. newborns in 1964-5, prior to Rubella Vaccination
    4. Orchitis (with Infertility risk) occurs in up to 10% of males with Mumps
  7. Insomnia (psych, sleep)
    1. Non-pharmacologic measures are preferred (Cognitive Behavioral Therapy is very effective in longterm)
    2. Avoid Benzodiazepines (risk for dependence, associated with poor sleep and Fatigue, Cognitive effects, Fall Risk)
    3. Consider Melatonin, Gabapentin or Doxepin
  8. Paronychia (derm, nails, id)
    1. In Acute Paronychia, Antibiotics are typically not needed after Incision and Drainage
    2. In Chronic Paronychia, antiinflammatories (Corticosteroids, calcineuron inhibitors) are the primary treatment (NOT Antifungals)
  9. Developmental Evaluation (peds, neuro)
    1. Early intervention (by age 3 years old) is associated with the best outcomes
    2. AAP recommends routine screening at 9, 18, 24-30, and 48 months as well as Autism screening at 18 and 24 months
    3. AAFP and USPTF recommend Developmental Screening in symptomatic children
    4. Large multi-specialty groups in U.S. are following AAP guidelines for routine screening and have EMR embedded tools
  10. Wilderness Medicine (er, environ, geri)
    1. Geriatric pitfalls include occult soft tissue infections, occult Fractures from minor Trauma, comorbidity exacerbation (e.g. ACS, Hypoglycemia)
  11. Alcohol Withdrawal (psych, cd)
    1. Avoid masking withdrawal signs with Beta Blockers
    2. Consider differential diagnosis (Altered Level of Consciousness, Sympathomimetic toxicty, Sepsis, Intracranial Hemorrhage)
  12. Canagliflozin (endo, dm)
    1. Associated with increased risk of amputations (RR 2.0, risk of 6 amputations per 1000 on Canagliflozin)
    2. May be a class effect (unclear mechanism)
  13. Statin (cv, pharm, lipid)
    1. In age over 75 years without significant CAD risk, starting Statin may increase mortality without a decrease in CV risk
  14. Corticosteroids (endo, pharm)
    1. Even short course Corticosteroids (1 week) is associated with increased risk of Fractures, VTE and Sepsis
    2. Avoid use when not truly indicated (e.g. Sinusitis, Acute Bronchitis, Pharyngitis)
    3. Avoid Medrol dose pack (replace with Prednisone 30 mg orally daily for 5 days would have similar effect)
  15. Advair (lung, pharm, Asthma)
    1. New generic fluticasone/Salmeterol for $90/month (compared with $475/month for Advair)
  16. Systolic Dysfunction (cv, chf)
    1. Updated 2 expensive (>$400/month) CHF adjunctive medications: Entresto and Corlanor
  17. Osteoporosis (rheum, pharm)
    1. Abaloparatide (Tymlos) is another very expensive ($20,000/year) Parathyroid Hormone Analog for Osteoporosis similar to Forteo
  18. Medication Patch (pharm, metabolism)
    1. Patches are heat sensitive and heat may increase absorption, resulting in dangerous drug levels (e.g. Fentanyl)
    2. Avoid cutting patches unless specifically allowed (non-reservoir, evenly distributed medication such as Lidoderm may be cut)
    3. Remove patches before entering MRI (many patches have a metallic backing)
    4. FDA recommends Flushing or Take-Back program for some patches with diversion potential (e.g. Fentanyl)
  19. Anticoagulation (hemeonc, pharm)
    1. For Obese patients (weight >120 kg or BMI >40), Warfarin is preferred, and Apixaban and Rivaroxaban may be considered
    2. For low body weight (<60 kg) Apixaban (Eliquis) may be considered
    3. For Dialysis patients, Apixaban (Eliquis) may be considered
  20. Nocturnal Leg Cramps (ortho, sx)
    1. Identify and treat comorbid conditions (Peripheral Vascular Disease, Peripheral Neuropathy, Restless Leg Syndrome)
    2. Decrease dose or switch medications from potentially causative agents (Diuretics, Albuterol, Nifedipine)
    3. Before bed, perform calf stretch, maintain hydration, use warm or cold packs, massage calf
    4. Consider Diltiazem or Verapamil, Vitamin B12 Supplementation, Magnesium Supplementation, Gabapentin
    5. Avoid Quinine sulfate (risk outweighs benefit)
  21. Laceration Repair (surgery, derm)
    1. Consider deep Sutures to reduce skin tension
    2. Avoid subcuticular Suture as a sole method of skin closure
  22. Intubation Preoxygenation (lung, procedure)
    1. Flush rate oxygenation at 40-70 lpm is optimal for RSI (rather than 15 lpm)
  23. Rapid Sequence Intubation (lung, procedure)
    1. Premedications (Fentanyl, Lidocaine, Atropine) for RSI are nearly never indicated
    2. In Head Trauma, Lidocaine does not decrease ICP with intubation (Fentanyl may offer benefit, but is associated with Hypotension)
  24. Pediatric Fractures (ortho, peds, Fracture)
    1. Emergent surgery for open Fractures, neurovascular injury (or risk of injury), unreducible joint dislocations
    2. Removable ankle splints are safe management for possible lateral ankle distal fibular Salter I Fractures
    3. Removable Wrist Splints have also been used safely for distal radius buckle Fractures
  25. Acute Coronary Syndrome (cv, cad)
    1. Nitroglycerin may be used in ischemic Chest Pain except with Sildenafil, Hypotension, Aortic Stenosis, Pulmonary Hypertension
    2. Also avoid Nitroglycerin in right sided Myocardial Infarction (in inferior MI, obtain RT sided EKG)
  26. Amoxicillin (id, pharm, Bacteria)
    1. Amoxicillin rash without allergic or systemic symptoms is not an IgE mediated reaction, and does not absolutely contraindicate future Amoxil use
    2. Amoxicillin may be re-trialed again if rash alone (non-allergic); consider allergy Skin Testing if unclear history
  27. Diabetes Mellitus Control in Hospital (endo, dm)
    1. In ED, in absence of DKA and HHS, Hyperglycemia need only be managed enough to lower Glucose to readable on meter (<500-600 mg/dl)
    2. If lowering Glucose in ED (e.g. Glucose >600 mg/dl) without DKA/HHS, administer 1-2 L LR and Insulin 10 units IV and monitor Glucose, Potassium
  28. Pulmonary Embolism Management (lung, cv)
    1. Hestia Criteria, Troponin, ekg, history (active cancer, pregnancy) risk stratify for inpatient vs outpatient care
  29. Gabapentin (neuro, pharm, Seizure)
    1. Gabapentin and Pregabalin are now used as a common drug of abuse to potentiate the CNS effect of Opioids
  30. Pediatric Trauma (er, peds, Trauma)
    1. Tranexamic Acid is safe and effective in Pediatric Trauma
    2. Each transfusion bolus is 10 ml/kg and Massive Transfusion is defined as 40 ml/kg (50% of a child's Blood Volume)
  31. Deep Vein Thrombosis Prevention (hemeonc, prevent, cv, coags)
    1. Lower leg cast typically does not require DVT Prophylaxis in most cases (except prior VTE, Achilles Tendon Rupture, prolonged travel >6 hours)
  32. Toxin Ingestion (er, toxin)
    1. Hydrocarbon Ingestion is high risk for aspiration (esp. those with lower viscosity) with devestating complications including ARDS
  33. Sepsis (id, fever)
    1. qSofa is more accurate than SIRS Criteria in predicting inpatient mortality
  34. Mild Head Injury Home Management (er, neuro)
    1. Children recover faster from Concussion with less postconcussive Headache when allowed non-contact light activity while recovering

VIII. Updates: June 2017

  1. Laceration Repair (Surgery, Derm)
    1. Epinephrine may be safely used for Anesthesia of ears, nose, digits, if no vascular compromise
    2. Irrigating with tap water under a faucet is as effective as sterile saline irrigation by syringe
  2. Perioperative Antiplatelet Therapy (hemeonc, surgery)
    1. Continue Aspirin through perioperative period unless high bleeding risk (e.g. intracranial surgery)
    2. Continue Dual antiplatelets for 30 days after bare metal stent, 6 months after Drug-eluting Stent, 12 months after ACS
    3. For urgent or emergent surgery, continue dual antiplatelet agents unless major bleeding risk (e.g. active bleeding, intracranial surgery)
  3. Refractive Corneal Surgery (eye, surgery)
    1. LASIK has a long, well-studied track record for safety and efficacy with 98% with Vision >20/40
    2. Common complications include Dry Eyes, halos around lights (esp. night) and worsened Presbyopia in the longterm
  4. Subclinical Hyperthyroidism (endo, Thyroid)
    1. Defined as TSH suppressed <0.4 mIU/L, but normal Free T4 and Free T3
    2. Most significant if TSH persistently <0.1 mIU/L in age over 65 years
    3. Risk of cardiac adverse effects (esp. Atrial Fibrillation) and Osteoporosis
    4. Treatment indications include TSH persistently <0.1 mIU/L and age >65 years old or comorbidity, symptoms
  5. Newborn Screening (nicu, lab)
    1. Newborn Screening continues to advance with additional screening recommended in U.S. universal panel
    2. Disorder ACT sheets from ACMGG cover diagnosis algorithms and initial management
  6. Urticaria (ent, allergy, derm)
    1. Exclude Anaphylaxis and airway angiodema first
    2. History and exam are most important in the evaluation (labs are rarely indicated)
    3. Start with Non-Sedating Antihistamines, and may add Sedating Antihistamines, H2 Blockers and Corticosteroids
    4. Chronic Urticaria is idiopathic in more than 80% of cases
  7. Traveler's Diarrhea (gi, id, Diarrhea, travel)
    1. Fluoroquinolone resistance is high in south Asia (use Azithromycin instead)
    2. Lab testing including Stool Cultures is not needed in most cases
    3. Be alert for Dysentery, severe Dehydration, Sepsis
  8. Vitamin Deficiency (pharm, Vitamin)
    1. Vitamin Deficiency is common with subtle, vague presentations (myalgias, weakness, Fatigue) and frequently misdiagnosed
    2. Predisposing conditions (e.g. Alcoholism, Vegan diet, malabsorption) can help keep specific deficiencies in mind
  9. RSV Bronchiolitis (peds, lung)
    1. Brief minor oxygen desaturation is not a contraindication to emergency department discharge
  10. Neutropenic Fever (id, fever, hemeonc)
    1. CISNE Score is an accurate risk stratification score for Neutropenic Fever emergency department discharge
  11. Low Risk Chest Pain (cv, cad)
    1. Negative Coronary Catheterization without lesions in the last 5 years is reassuring
    2. Negative coronary CTA in last 6 months is reassuring
    3. Prior myocardial perfusion scans do not offer reassurance
  12. Hypoglycemia (endo, Hypoglycemia)
    1. D10 is less likely to cause rebound Hypoglycemia than D50
    2. Lantus, Humalog, Novolog, Metformin are unlikely to cause delayed recurrent Hypoglycemia
    3. Observe hypoglycemic patients on Levemir for 6-8 hours
    4. Observe hypoglycemic patients on Sulfonylureas for 6-8 hours
  13. Increased Intracranial Pressure in Closed Head Injury (er, neuro)
    1. Hypertonic Saline with mixed results in lowering Intracranial Pressure
    2. However, Scott Weingart refutes the study as a misinterpretated meta-analysis
  14. Femur Fracture (ortho, hip, Fracture)
    1. Traction Splint does not appear to offer benefit in Femoral Shaft Fracture in reduced blood loss (may offer comfort)
    2. Consider traction for associated acute neurovascular compromise (to temporize until definitive management)
  15. Sedation in Excited Delirium (psych, behavior)
    1. Categorize Agitated Patients as cooperative, disruptive without danger and Agitated Delirium
    2. Treat cooperative patients with non-medication therapy (calming measures)
    3. Sedate disruptive without danger patients with Zyprexa or B52 (Benadryl, Haldol 5, Midazolam 2)
    4. Sedate Agitated Delirium patients with Ketamine to gain IV Access, then Benzodiazepines for sedation
  16. Preeclampsia (cv, htn, ob)
    1. Do not forget about postpartum Preeclampsia out to 6 weeks after delivery
    2. Prevent Seizures with Magnesium, and manage Hypertension with Labetalol, Hydralazine or Nifedipine
  17. Cervical Spine Imaging in Acute Traumatic Injury (ortho, rad)
    1. CT Cervical Spine has excellent sensitivity for C-Spine Injury
    2. In atypical cases with neurologic symptoms/signs, MRI Cervical Spine may be needed to exclude Central Cord Syndrome
  18. Acute Pain Management (pharm, Analgesic)
    1. Emergency department patients were more likely to use longterm Opioids when seen by a high intensity Opioid prescriber
    2. Toradol IM is no better than oral NSAIDS
  19. Pediatric Analgesic (pharm, peds, Analgesic)
    1. FDA now officially contraindicates Tramadol and Codeine under age 12-18 years old (finally)
  20. Penile Zipper Entrapment (surg, derm)
    1. Mineral Oil is the single most effective measure, followed by cutting the distal zipper end
  21. Subarachnoid Hemorrhage (neuro, cv)
    1. Lumbar Puncture is recommended after negative CT, when SAH is suspected with symptom onset >6 hours
    2. MRI Brain may be considered when symptom onset >6 hours (high Test Sensitivity for SAH after 6 hours)
  22. Anticoagulation in Thromboembolism (hemeonc, pharm)
    1. In longterm Anticoagulation for those at moderate risk of DVT recurrence, consider lower dose DOAC after first 6 months
  23. Tympanostomy Tube (ent, ear, surg)
    1. Treat Otitis Media with patent PE Tubes with (Ofloxacin, ciprodex or ciloxan) but not cipro HC (not sterile)
    2. Earplugs are not required for chlorinated pools (except if diving >6 feet)
  24. Menstrual Migraine (neuro, Headache, gyn)
    1. Consider prophylaxis with NSAID scheduled from pre-Menses to completion of Menses
    2. Consider Seasonal Contraception if no Migraine with Aura
    3. Consider Migraine Prophylaxis agents (e.g. Propranolol, Tricyclic Antidepressant or Topiramate)
  25. Agitation in Dementia (neuro, cognitive)
    1. Identify and treat underlying causes of Agitation and use non-medication calming measures
    2. If needed, Antipsychotics (e.g. Risperidone, Aripiprazole) may be considered, but associated with increased mortality
    3. Avoid Benzodiazepines due to Fall Risk and paradoxical Agitation
  26. Tardive Dyskinesia (psych, pharm, adverse)
    1. Antipsychotics are not the only culprits; Dopamine blockers (e.g. Reglan, Levodopa, tricyclics) can also cause Tardive Dyskinesia

IX. Updates: May 2017

  1. Severe Asymptomic Hypertension (cv, htn)
    1. Severe Hypertension (SBP>180 or DBP>110) WITHOUT signs/symptoms of Hypertensive Urgency
    2. Severe Asymptomic Hypertension may still have mild symptoms, but no target organ injury (cv, neuro, renal)
    3. Does not require diagnostics, parenteral Antihypertensives, emergency department or inpatient management
    4. Start (or adjust) oral Antihypertensives with clinic follow-up
  2. Peritonsillar Abscess (ent, mouth)
    1. Most Peritonsillar Abscesses should have attempted drainage
    2. Failed aspiration may indicate Peritonsillar Cellulitis or deep space infection
    3. Broad spectrum Antibiotics typically follow aspiration (e.g. Clindamycin, Augmentin or Metronidazole with Cefdinir)
    4. Corticosteroids (e.g. Dexamethasone) speed recovery and decrease symptoms
  3. Zika Virus (id, virus)
    1. Zika Virus is a Flavivirus similar to Dengue Fever, Yellow Fever and West Nile Virus
    2. In addition to Congenital Zika Syndrome, Zika may also cause Guillain Barre Syndrome, Thrombocytopenia, Encephalitis
    3. 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
    4. Men may sexually transmit Zika Virus for up to 6 months in semen
  4. Waterborne Illness (gi, Diarrhea)
    1. Many waterborne pathogens are Chlorine resistant (Cryptosporidium, Giardia, Adenovirus)
    2. Rare, but serious infections may occur (e.g. Legionella, Vibrio vulnificus, Primary Amebic Encephalitis, Leptospirosis)
    3. Live pathogen shedding continues for 1-3 weeks after symptom resolution (avoid swimming pool for at least 1 week after resolution)
  5. Postmenopause (gyn,endo)
    1. Reduce CVA, HFpEF, CAD Risk Factors by controlling Hypertension, Atrial Fibrillation, Diabetes Mellitus, Tobacco Abuse, Obesity
    2. Screen for Breast Cancer, Colorectal Cancer and Cervical Cancer (until 65 years)
    3. Screen for Osteoporosis and discuss Fall Prevention
    4. Women remain sexually active (weekly in 65% ages 51 to 64), with STI Incidence 1% over age 65 years
  6. Emergency ECMO (cv, procedure)
    1. Some tertiary institutions with access to cardiopulmonary bypass have instituted Emergency ECMO protocols for ECPR and ECLS
    2. Extracorporeal Cardiopulmonary Resuscitation (ECPR) for refractory Cardiac Arrest >10 min
    3. Extracorporeal Life Support (ECLS) for severe, refractory Cardiogenic Shock, massive PE or undifferentiated Hypotension
  7. Infected Animal Bite (er, derm)
    1. Highest risk of infection: Distal extremity, vascular compromise, Cat Bites, Human Bites, Puncture Wound, DM/Immunodeficiency
    2. Be suspicious of clenched fist injuries as Fight Bites even if denied by patient (high risk of infection)
  8. Gunshot Wound (er, Trauma)
    1. Hard signs of vascular injury (e.g. pulsatile bleeding, expanding Hematoma, pulseless extremity) require emergent surgery
    2. Soft signs of vascular injury (e.g. oozing, small Hematoma, pulse differential) require imaging (e.g. CT angiogram)
  9. Laceration Repair (surgery, derm)
    1. Closure by secondary intention (or delayed primary closure) is indicated for wounds >12 hours (24 hours on face) or high risk of infection
    2. Highest infection risks include diabetes, wound contamination, length >5 cm and lower extremity wounds
  10. Intracranial Hypotension (neuro, Headache)
    1. CSF Leak may occur spontaneously from dura tears (sneezing, coughing)
    2. MRI with gadolinium contrast is diagnostic (subdural fluid, pachymeninges enhancement, venous engorgement, pituitary hyperemia)
    3. Caffeine and Epidural Blood Patch are effective (as with Spinal Headache)
  11. CVA Management (neuro, cv)
    1. 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
  12. Naloxone (pharm, Analgesic)
    1. Give Naloxone in Opioid Overdose and hypoventilation (consider titrating in small amounts to effect)
    2. Observe patients for at least 1 hour after Naloxone for short acting Opioids (longer for long-acting Opioids)
  13. Atrial Fibrillation Cardioversion (cv,ekg)
    1. Despite recent literature to the contrary, cardioversion within 48 hours of Atrial Fibrillation onset is safe
  14. Transvenous Pacemaker (cv, procedure)
    1. Emergency Pacemaker placement in the ED for Symptomatic Bradycardia is safe
  15. Cellulitis (derm, Bacteria)
    1. Cellulitis is overdiagnosed, most often with Stasis Dermatitis (although the differential is long)
    2. Consider other diagnosis in bilateral involvement, pruritic instead of painful, and longterm involvement
  16. Thin Slicing (manage, legal)
    1. Fast, intuitive decision making is often used in the Emergency Department for initial evaluation and management
    2. Thin Slicing is often accurate for experienced clinicians, but is subject to anchor bias and premature closure
    3. Checklists (Review of Systems, serious cause differential diagnosis) can act as safety net
  17. Bedside Ultrasound (rad, Ultrasound)
    1. Perform Ultrasound to answer specific questions
    2. Optimize gain/contrast and start zoomed out
    3. Image abnormalities in 2 planes
  18. Syncope (cv, sx)
    1. Consider Pulmonary Embolism in differential (esp. if Leg Edema, VTE Risk, Tachypnea)
  19. Deep Vein Thrombosis (hemeonc, cv)
    1. Symptomatic calf clots have similar outcomes with or without Anticoagulation
    2. Anticoagulation is associated with a 4% bleeding risk
  20. Transient Synovitis (ortho, peds)
    1. Kocher Criteria (inability to walk, Temp >=38.5 C, ESR > 40 mm/h, WBC >12k) may help distinguish from septic hip
    2. In toxic appearing, febrile children, obtain XRay, labs, Hip Ultrasound (and consider MRI if non-diagnostic)
    3. If well appearing child with normal XRay walks after Ibuprofen, may disposition home with follow-up
  21. Return of Spontaneous Circulation or ROSC (er, exam)
    1. Defined as return of palpable pulse OR return of Blood Pressure sufficient to perfuse critical organs (e.g. by Arterial Line)
  22. Near Hanging (er, Trauma)
    1. Advanced imaging was negative in Near-Hanging survivors with normal GCS and normal exam (without tenderness)
  23. Antibiotics in Pregnancy (id, ob)
    1. Penicillins, Cephalosporins and Clindamycin are safe in pregnancy
    2. Avoid Fluoroquinolones and Tetracyclines in pregnancy
    3. Azithromycin and Erythromycin are safe (but Clarithromycin is not)
    4. Septra is only safe in second trimester and Nitrofurantoin is safe up to 36 weeks
  24. Prosthetic Joint Infection Prophylaxis (surgery, prevent)
    1. Antibiotic prophylaxis is no longer needed around the time of dental procedures for immunocompetent patients
  25. Anti-Retroviral Therapy (hiv, pharm)
    1. Antiretroviral medication errors are common during hospitalizations (affects 86% of patients on Antiretrovirals)
  26. Irritable Bowel Syndrome (gi, bowel)
    1. Viberzi (Eluxadoline) used in Constipation dominant IBS risks life-threatening Pancreatitis (esp. if s/p Cholecystectomy)
  27. Anticoagulants (hemeonc, pharm)
    1. Restarting Anticoagulation after major Hemorrhage (e.g. Hemorrhagic CVA) risks recurrent major bleeding
    2. However, Prosthetic Heart Valve or CHADS2-VASc Score 4 or higher might warrant restarting Anticoagulation
    3. If Anticoagulation restarted, wait at least 4 weeks after Intracranial Hemorrhage (8-10 weeks if higher risk)
  28. Low Risk Chest Pain (cv, cad)
    1. After a thorough negative evaluation, in Low Risk Chest Pain patients, consider Anxiety Disorder in differential as diagnosis of exclusion
  29. PCSK9 Inhibitor (cv, pharm, lipid)
    1. At $14,000 per year, are PCSK9 Inhibitors (e.g. Repatha, Praluent) worth the investment
    2. Repatha added to Statin for 2 years prevents one more CV event per 74 treated ($2,000,000 per CV event prevented)
    3. 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

  1. End-Of-Life Care (hemeonc, sx)
    1. Opiates are first-line agents for the symptomatic management of Shortness of Breath
    2. Corticosteroids may be effective for malignant Bowel Obstruction
    3. Start Opioids at low dose and short interval and titrate to effect
    4. Proactively manage Cancer Symptoms (e.g. Cancer Related Constipation)
  2. Preterm Labor (Ob, Antepartum)
    1. Progesterone supplementation is indicated for history of spontaneous premature delivery and single gestation (or short Cervix)
    2. Corticosteroids are indicated for confirmed Preterm Labor at 24-34 weeks gestation
    3. Magnesium Sulfate before preterm delivery decreases Cerebral Palsy risk in infants <32 weeks
    4. Tocolytics in Preterm Labor are indicated to allow for transport to tertiary care, and Corticosteroid administration
  3. Patiromer (renal, pharm, Potassium)
    1. May be indicated in chronic Hyperkalemia instead of Kayexalate
    2. Binds Potassium in exchange for Calcium in the Gastrointestinal Tract
    3. Risk of Hypomagnesemia (monitor Serum Magnesium as well as Potassium)
  4. COPD Management (lung, COPD)
    1. COPD Screening (e.g. in smokers) is not recommended
    2. COPD diagnosis is Dyspnea, Chronic Cough or Wheezing and post-BronchodilatorFEV1 to FVC <0.7
    3. Start with Long-acting Bronchodilator or Anticholinergic and advance (per GOLD guidelines)
    4. Consider home oxygen and Pulmonary Rehabilitation
  5. Postpartum Hemorrhage (ob, LD, bleed)
    1. Active Management of the Third Stage of Labor includes early Oxytocin at anterior Shoulder, cord traction, uterine massage
    2. Start with Oxytocin, then Methergine 0.2 mg IM, then Hemabate 0.25 to 1 mg IM
    3. Consider the 4Ts of Postpartum Hemorrhage causes: Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)
  6. Procedural Sedation (surgery, Anesthesia)
    1. Be aware of Intralipid (esp. for intravascular Bupivicaine) in Local Anesthetic Systemic Toxicity (LAST Reaction)
    2. Laryngospasm Notch Maneuver may relieve laryngospasm with Ketamine
    3. Also addressed specific topics in Trauma in Pregnancy and Resource Limited Environment
    4. Propofol and Ketaphol are equivalent in efficacy and safety
  7. Exercise in the Elderly (sports, geri)
    1. Any activity is better than no activity (start with ADLs, Errands)
    2. Resistance Training preserves Muscle Strength and physical functioning in older patients
    3. Aim for 150 minutes of Moderate Aerobic Activity weekly
    4. Perform Stretching and balance training 2-3 times weekly
  8. Vomiting in Children (gi, peds, vomit)
    1. Not all that vomits is Gastroenteritis
    2. Consider Pyloric Stenosis, intussception, Testicular Torsion, DKA, UTI
    3. Consider Nonaccidental Trauma
  9. Internal Hernia (endo, surgery)
    1. Catastrophic Abdominal Pain with a history of Roux-en-Y Bypass
  10. Vocal Cord Dysfunction (ent, Larynx)
    1. Paradoxical vocal cord movements that present with Stridor
    2. Evaluate as airway emergency until Vocal Cord Dysfunction confirmed
    3. Improves with Ketamine
  11. Chest Tube (lung, procedure)
    1. Small Chest Tubes (28-32 fr) are as effective as large Chest Tubes (36-40 fr) in Trauma
  12. Massive Blood Transfusion (hemeonc, pharm)
    1. Indicated for 4-6 pRBC units (50% adult Blood Volume) required within 4 hours, or 8-12 pRBC units (100% adult Blood Volume)
    2. Replace Platelets and Fresh Frozen Plasma in 1:1:1 ratio
    3. Also consider Cryoprecipitate, Tranexamic Acid and PCC4
    4. Avoid Hypothermia (keep temp >36)
  13. Digoxin Toxicity (cv, pharm)
    1. In chronic Digoxin Toxicity, DigiFab improves Digoxin levels but not Hyperkalemia or Bradycardia
  14. Lumbar Puncture (Neuro, procedure)
    1. Blunt tipped spinal needles result in far fewer post-dural Headaches than sharp needles, and offer same CSF flow
  15. Lactic Acid (renal, lab)
    1. Lactic Acid is helpful in children for disposition of Sepsis and Trauma
  16. Coma (neuro, LOC)
    1. Full Outline of Unresponsiveness (FOUR Score) is a useful evaluation scale for monitoring coma
  17. Lung Ultrasound for Pneumothorax (lung, rad)
    1. Single view Ultrasound per side (at 3rd interspace) has equivalent Test Sensitivity for Pneumothorax as 4 view
  18. Pulseless Electrical Activity (CV, EKG)
    1. In PEA, when PE is strongly suspected, TPA 50 mg IV given in the first ~6 min of CPR, resulted in 85% longterm survival
  19. Esophageal Foreign Body (gi, Esophagus)
    1. Reviewed Foley Catheter technique for extraction of esophageal coins (and other flat, blunt, small objects)
  20. Diastolic Heart Failure (CV, CHF)
    1. Hypertension control is paramount (ACE Inhibitors, Beta Blockers, Thiazide Diuretics)
    2. Limit Furosemide to when Fluid Overload is present (otherwise risk of decreased Preload and increased symptoms)
  21. Hepatitis C Antiviral Regimen (gi, liver)
    1. Hepatitis B reactivation is a risk when treating Hepatitis C with Antiviral Medications
  22. Postpartum Depression (psych, ob)
    1. Sertraline (Zoloft) and Escitalopram (Lexapro) are preferred first-line SSRI in Lactation (due to safety in Lactation, and low adverse effects)
  23. Restless Leg Syndrome (neuro, motor)
    1. Dopaminergic agents (e.g. premipexole) have fast onset and initial good efficacy, but cause more adverse effects in the longterm
    2. Gabapentin (or Pregabalin) has a longer delay to effect, but has similar efficacy to Dopaminergic agents and fewer adverse effects
  24. Agitated Delirium (psych, behavior)
    1. Differential diagnosis of Sympathomimetic Toxicity includes Intracranial Hemorrhage, Hypoglycemia, NMS, Heat Stroke, Alcohol Withdrawal, Thyrotoxicosis
  25. Laceration Repair (surgery, derm)
    1. Updated Suture Selection and wound edge eversion techniques
  26. Fall Prevention in the Elderly (geri, prevent)
    1. Screen gait, strength and balance at the Welcome to Medicare Physical
    2. Review Medications to Avoid in Older Adults (Beers List, STOPP)
  27. Asthma Management (lung, Asthma)
    1. For those with stable Asthma for at least 3 months, consider tapering controller medications
  28. Antiplatelet Therapy for Vascular Disease (hemeonc, pharm)
    1. Limit triple therapy (e.g. Warfarin, Aspirin, Clopidogrel) to the shortest possible duration
  29. Hiccup (gi, sx)
    1. Baclofen and Ganapentin taken for 7-10 days are safe and effective
  30. Miralax (gi, pharm)
    1. Loose association with neuropsychiatric adverse effects in chldren
    2. Miralax is considered safe in children

XI. Updates: March 2017

  1. Acute Coronary Syndrome (cv, cad)
    1. NSTE-ACS replaces terms NSTEMI and Unstable Angina in Moderate Risk Acute Coronary Syndrome Management
    2. STEMI goal door to balloon is 90 min (or 120 min if presenting to non-PCI hospital), otherwise Fibrinolysis if not contraindicated
    3. Reperfusion (PCI preferred) is recommended for STEMI with symptom onset within 12 hours
  2. Proteinuria in Children (urology, peds, urine)
    1. Confirm 1+ Urine Protein with first morning Urine Protein to Creatinine Ratio (Upr/cr) and Urinalysis/microscopy
    2. Upr/cr >0.2 (or >0.5 in ages 6-24 months) should prompt further evaluation (history, Blood Pressure exam, labs)
    3. Nephrology consult for positive evaluation or persistent Proteinuria, nephritis, Renal Insufficiency, Hypertension, Vasculitis
  3. Neuroblastoma
    1. 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)
    2. Presents most often as adrenal or abdominal lesion, but may also present as chest, cervical or paraspinal lesions
    3. Metastatic findings include fever, bone pain, limp, Anemia, Raccoon Eyes, Opsoclonus-myoclonus syndrome, Blue Skin Nodules
  4. Venous Thromboembolism (hemeonc, coags)
    1. Direct Factor Xa Inhibitors (Apixaban, Rivaroxaban) may be started without Heparin for both DVT and PE
    2. Most DVT and select PE patients may be treated as an outpatient
    3. Directed Thrombolysis indications are limited to massive PE, and ileofemoral DVT with severe symptoms/signs
    4. VTE (including PE) without thrombopilia is treated for a 3 month course
  5. Syncope (cv, sx)
    1. Presyncope carries the same risk as Syncope and should be evaluated with similar carefulness
    2. Syncope causes are categorized as cardiac, neural or reflex-mediated and Orthostatic Hypotension
    3. Obtain a careful history, EKG, Orthostatic Blood Pressure, and select diagnostics tailored to presentation
    4. In-hospital observation for Syncope with CHF, structural heart disease, abnormal EKG, familial Sudden Cardiac Death
    5. Outpatient evaluation with Event Monitor, Holter Monitor or loop recorder may be indicated
  6. Women Who Have Sex With Women (prevent, hme)
    1. Lesbian Women are often behind their healthcare screening with increased STI risk, cancer risk, Mood Disorder, and Substance Abuse
    2. Higher rates of Type II Diabetes Mellitus and cardiovascular disease
    3. Counsel on safe sex (Condoms over sex toys, dental dams, gloves and lubricants)
    4. Include Cervical Cancer Screening (many women in same sex relationships have had prior intercourse and HPV is common)
  7. Sexual Assault of Male Victim (prevent, abuse, rape)
    1. Rape lifetime Incidence: 1.4% of U.S. men (typically before at 25 years old)
    2. Perpetrators of male victim rape are also male in 80% of cases
    3. Male victims are heterosexual in 68% of rapes
    4. Same Rape Management approach (with SANE Nurse) as with Female Rape Victim
  8. Pneumonia in the Elderly (lung, geri, id)
    1. Elderly often do not mount fever response or Tachycardia despite serious infection
    2. SIRS criteria may therefore not be met despite Sepsis
    3. Pneumonia is the single most common cause of Sepsis in the elderly
    4. Err on the side of treating as Sepsis (even if SIRS negative), with early directed care and ICU admission
  9. Decision Making Strategy - Interruptions (manage, legal)
    1. Interruptions are frequent in the emergency department (6-7/hour)
    2. Multi-tasking is a misnomer, and instead tasks are switched
    3. Task displaced by interruption is returned to after a mean delay of 23 minutes
    4. High cognitive load and frequent task switching is a risk for errors
  10. Decision Making Strategy - Shift Fatigue (manage, legal)
    1. Energy and focus diminish over the course of a work shift and end of shift Fatigue is common with higher error rate
    2. Take a 5-10 min break to recharge, walk, eat, drink every 3-4 hours
    3. Reassess your patient list every 2-3 hours (patients, acuity, barriers to disposition) and complete next tasks needed
    4. Make an exit plan in the final 1-2 hours of a shift to work towards a disposition for each patient
  11. NSAIDs (Pharm, Analgesic)
    1. Patients may report NSAID allergy with history of Allergic Reaction, pseudoallergic reaction or NSAID intollerance
    2. Pseudoallergic reaction is a COX reaction, often associated with Asthma, Nasal Polyps, Allergic Rhinitis
    3. Assume true Allergic Reaction first (unless only intollerance) and do not retrial with any NSAID until allergy evaluation
  12. STEMI (cv, cad)
    1. Morphine may be relatively contraindicated in STEMI due to Drug Interaction with Ticagrelor
    2. Morphine decreased (35%) and delayed (2 hours) Ticagrelor absorption
    3. Presumed to apply to other Opioids and possibly other Platelet ADP Receptor Antagonists (e.g. Clopidogrel)
  13. Calcaneus Fracture (ortho, Fracture)
    1. Surgical emergencies include Compartment Syndrome and Tongue-Type (extra-articular Fracture)
    2. Splint with Bulky Bobby Jones splint with both sugar tong and posterior splint applied and a well padded heel
    3. DVT Prophylaxis and non-weight bearing for 6-8 weeks
    4. Subtalar fusion indications include Bohler's Angle <4 degrees or Sanders Type 4 Fracture
  14. Erythroderma (derm, exam, Scaling, er)
    1. Serious to life-threatening dermatosis with generalized skin erythema and Scaling
    2. Causes include underlying Psoriasis or Eczema, Drug Reaction, infection (HIV, toxic shock) and Cutaneous T-Cell Lymphoma
    3. Associated with significant morbidity and mortality risk
    4. Admit all patients suspected of having Erythroderma
  15. Acute Pain Management (pharm, Analgesic, Opioid)
    1. When Opioids are needed, consider Morphine immediate release 10-30 mg orally every 4 hours prn adult moderate to severe pain
    2. Morphine is less euphoric than Oxycodone and Hydrocodone
  16. Bursitis (ortho, sx)
    1. Bursal aspiration for all suspected Septic Bursitis for diagnosis and Antibiotic sensitivity
  17. Medications (pharm)
    1. Updated Hyperlipidemia Management
    2. Updated Iron Supplementation
    3. QT Prolongation

XII. Updates: February 2017

  1. Hyperlipidemia Management (cv, lipid, prevent)
    1. A mess of ACC and NICE and USPTF Guidelines re-reviewed from 2013 emphasize Statins (high dose or low dose)
    2. High dose Statin (e.g. Lipitor 40, Crestor 20) for LDL >190, known CAD, DM 40-75yo if CAD risk >7.5%
    3. Moderate dose Statin (e.g. Lipitor 20, Crestor 10) for CAD risk >7.5%, DM 40-75 with CAD Risk <7.5%
  2. Uterine Fibroid (gyn, Uterus)
    1. Surgical arsenal includes MRgFUS and IR embolization, as well as the traditional Hysterectomy or myomectomy
    2. Medical management has changed little (still GnRH Agonists, Mirena IUD, NSAIDs)
    3. Tranexamic Acid is an interesting option given its other uses (Massive Hemorrhage in Trauma)
  3. RSV Bronchiolitis (lung, peds, Bronchi)
    1. Supportive care, nasal suctioning and maintain hydration (all other measures e.g. nebs, steroids, are defunct)
  4. Vertigo (ent, vestibular)
    1. Distinguish triggered episodic Vertigo VS spontaneous episodic Vertigo VS continuous (Acute Vestibular Syndrome)
    2. Critical to consider posterior CVA in Acute Vestibular Syndrome (continuous) with HiNTs Exam, and possible imaging
    3. Positive Dix-Hallpike Maneuver in triggered episodic Vertigo suggests BPPV, which should respond to Epley Maneuver
    4. Avoid anti-Vertigo medications for longer than 3 days (risk of delaying central compensation)
  5. Jaundice (gi, derm)
    1. Fractionate the Bilirubin, and if Unconjugated Hyperbilirubinemia, exclude Hemolysis
    2. If direct Hyperbilirubinemia, evaluate for Hepatitis And biliary obstruction
  6. Endotracheal Intubation (lung, procedure, airway)
    1. Anticipate post-intubation Hypotension (related to sedation, PPV, PEEP) esp. children, age >65, Sepsis
    2. Hypotension occurs in up to 25% of emergency intubations (Cardiac Arrest in 3% of intubations)
    3. Post-intubation Hypotension is associated with worse outcomes
    4. Consider Normal Saline 10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI
  7. Red Eye (eye, sx)
    1. In the Acute Red Eye, remember Intraocular Pressure, stain for Dendrites, Slit Lamp for cells and flare
    2. Visual Acuity should not be affected in Conjunctivitis (consider alternative diagnoses)
    3. Consider severe causes of Conjunctivitis (e.g. Chlamydia Conjunctivitis, Gonorrhea Conjunctivitis)
  8. Pediatric Blunt Abdominal Trauma (er, peds, gi, Trauma)
    1. Consider intraabdominal injury in hypotensive Pediatric Trauma patients
    2. CT Abdomen is indicated for Positive Pediatric Blunt Abdominal Trauma Decision Rule or abnormal labs (e.g. AST, ALT, Lipase, UA)
    3. Emergent surgery if hemodynamic unstable
  9. Pelvic Fracture (ortho, Trauma)
    1. Even seemingly minor Pelvic Fractures on xray may cause life threatening bleeding
    2. Pelvic Fractures with Hypotension have a very high mortality (>15-40%) and even higher with associated injuries
    3. Hemodynamically Unstable Patients with Pelvic Fractures need emergent angiography or surgery
    4. FAST Exam has a high False Negative Rate for missed hemoperitoneum with Pelvic Fractures
  10. Pediatric Constipation (gi, peds, bowel)
    1. Constipation is a clinical diagnoses (use rome criteria) and XRays are not needed for diagnosis
  11. Endotracheal Intubation (lung, procedure, airway)
    1. Peri-Intubation Hypotension is associated with worse outcomes
    2. Predict patients at risk (e.g. elderly, volume depletion) and prevent Hypotension with fluid Resuscitation
  12. Bipolar Disorder in children (psych, mood, peds)
    1. Children present with Bipolar Disorder atypically (e.g. angry, irritable, Insomnia)
  13. Prolonged QT Interval due to Medications (cv, pharm, ekg)
    1. Ondansetron causes minimal QT Prolongation, but if QT is already prolonged consider Reglan instead
  14. Likelihood Ratio (prevent, epi)
    1. 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
  15. Low Risk Chest Pain (cv, cad)
    1. Up to 28% of patients with Acute Coronary Syndrome have a normal EKG
    2. Highest risk history includes Chest Pain radiation to right side or bilateral Shoulders, exertional Chest Pain, Vomiting, sweats
    3. Stress testing detects 70% stenotic lesions, but MI often occurs with small lesions
  16. First Trimester Bleeding (ob, antepartum, bleed)
    1. Bedside Ultrasound is highly accurate (98% Test Specificity) at identifying intrauterine pregnancy at 5.5 weeks
    2. Additional testing (unless other indication) is not needed if IUP confirmed
    3. RhoGAM is not needed for spotting and Quantitative hCG is not needed if IUP is confirmed
  17. Refractory Ventricular Fibrillation (cv, ekg)
    1. Esmolol or double sequential external Defibrillation may be considered
  18. Intracerebral Hemorrhage (neuro, cva, bleed)
    1. Target Systolic Blood Pressure <180 mmHg in Spontaneous Intracerebral Hemorrhage
    2. Target Systolic Blood Pressure <145 mmHg in Subarachnoid Hemorrhage
  19. Deep Vein Thrombosis (hemeonc, coags)
    1. Two options: Observe with serial Ultrasound over 2 weeks OR treat as DVT for 6-12 weeks
    2. DVT management is preferred in those with Coagulopathy or symptomatic
    3. Additional evidence that proximal propogation of calf DVT is common
  20. MRI in pregnancy (rad, mri, ob)
    1. MRI is safe in pregnancy, but gadolinium is not
    2. Gadolinium may increase risk of Stillbirth as well as inflammatory conditions
  21. Intraosseous Line (er, fen)
    1. Use the longer IO (4.5 cm, yellow) in obese patients at the Humerus and if tibial tuberosity can not be palpated
  22. HIV Postexposure Prophylaxis (hiv, prevent)
    1. No occupation post-exposure patient has seroconverted with prophylaxis since 2001
    2. However, we still miss prophylaxing high risk sexual exposures (2% seroconversion rate)
  23. Fake Xanax (psych, cd)
    1. Mix of Fentanyl and etizolam has presented with significant Overdoses (similar to Opioids) and deaths
  24. Tobacco Cessation (psych, cd)
    1. Chantix and Bupropion lose their black box warnings for psychiatric adverse effects
  25. NSAIDs (pharm, Analgesic, ortho, Fracture)
    1. NSAIDs in the short-term do not significantly impact Fracture healing time
  26. COPD Management (lung, copd)
    1. Long acting Bronchodilators (e.g. Spiriva) are preferred over Corticosteroids in COPD
  27. Muscle Relaxants (rheum, pharm)
    1. Primary action is as Sedative and do not truly relax Muscles
    2. Flexeril appears beneficial in Acute Low Back Pain and Neck Pain
    3. However, limit toi short-term use , and primarily as an adjunct to Analgesics to aid sleep

XIII. Updates: January 2017

  1. Gastrointestinal Manifestations of Diabetes Mellitus (endo, dm, gi)
    1. Most common DM-related GI complications are Gastroparesis, NASH, GERD, Diabetes Related Intestinal Enteropathy
    2. If Gastroparesis is suspected, obtain TSH, chem18, upper endoscopy and consider scintigraphy; Trial on Reglan
    3. Nonalcoholic Fatty Liver Disease is a spectrum from Steatosis to fibrosis (NASH)
    4. NASH may be identified with Ultrasound and confirmed with various scoring systems, and if needed liver biopsy
  2. Esophageal Cancer (gi, hemeonc, cancer, Esophagus)
    1. 80% of Esophageal Cancer (typically Squamous Cell) cases occur in non-industrialized countries in Asia and Africa
    2. In The U.S., Esophageal Adenocarcinoma predominates, most often in white males
    3. Early disease (Stage Ia) responds well to local resection, but 75% of cases present with distant metastases (Stage IV)
  3. Carpal Tunnel Syndrome (ortho, wrist, neuro)
    1. Median Nerve motor deficit suggests severe, longstanding Carpal Tunnel (or alternative condition)
    2. Neutral Wrist Splint, avoidance of provocative activities and Exercises are beneficial
    3. Carpal Tunnel Corticosteroid Injection is very effective for more than 10 weeks and >1 year in some cases
    4. Median Nerve Measurement on Ultrasound may be used instead of EMG prior to surgery
  4. Autism Spectrum Disorder (peds, neuro, develop)
    1. Autism Spectrum Disorder (ASD) Prevalence has increased significantly over time (1 in 68 children as of 2012)
    2. ASD encompasses four disorders: Autistic disorder, Asperger Disorder, Disintegrative Disorder, Pervasive Developmental Delay NOS
    3. Screening is with M-CHAT or M-CHAT-R/F followed by detailed evaluation and diagnosis in line with DSM-V Criteria
    4. Early diagnosis, referral and intensive behavioral management is associated with best outcomes
  5. Baclofen Pump Malfunction (neuro, pharm)
    1. Baclofen Withdrawal results in hemodynamic instability, Seizures, Sepsis-like presentation
    2. May present with Tachycardia, Tachypnea, fever and confusion (all consistent with Sepsis)
    3. However, in contrast with Sepsis, Baclofen Withdrawal presents with Hypertension
    4. Benzodiazepines (or Propofol) until replace Baclofen into pump's side port OR via intrathecal space via spinal needle
  6. Beta Blocker Overdose (cv, pharm, adverse)
    1. Treat on par with full code event as patients decompensate to death quickly
    2. Consider Gastric Decontamination with Activated Charcoal if patient presents within first hour and lucid
    3. Typical management includes Epinephrine, Calcium, Glucagon, euglycemic Insulin protocol
    4. Consider Intralipid for lipophilic agent Overdose
  7. Patient-Centered Communication (manage, communication)
    1. Understand patient's agenda (open ended questions, avoid interrupting, actively listen, something else?)
    2. Understand patient's perspective (avoid judging and prematurely reassuring, understand patient expectations)
    3. Shared treatment goals (discuss treatment options without overwhelming)
  8. Loperamide Abuse (gi, pharm, adverse, cd, Opioid)
    1. Loperamide Abuse is increasing with doses 4 fold and more higher than recommended
    2. Risk of cardiotoxicity and lethal Arrhythmias including Torsades
  9. Systolic Dysfunction (cv, chf)
    1. ACE Inhibitors (or Angiotensin Receptor Blockers) and Beta Blockers remain the mainstay of CHF management
    2. Entresto (Valsartan with Neprilysin) is also an option, but more expensive, adverse effects, and limited studies
    3. Second-line options include Diuretics, Digoxin, Aldosterone Antagonists, Bidil, Corlanor
  10. Dyspnea in Palliative Care (hemeonc, lung, cancer)
    1. Provide aggressive palliative Resuscitation to get a patient to maximal possible comfort (DNR does not mean less care)
    2. Direct symptomatic treatment at Dyspnea not Tachypnea
    3. Maximize comfort (sitting with family, monitors off) and air-flow (fans, cool room, humidifier, oxygen as tolerated)
    4. Opioids reduce Dyspnea
  11. Complex Regional Pain Syndrome (rheum, neuro, pain)
    1. Early range of motion, physical therapy and avoiding Splinting
    2. Effective agents include Corticosteroids, topical Lidocaine
    3. Other novel agents include Bisphosphonates, topical DMSO, Lidocaine infusion
  12. DigiFab (cv, pharm, adverse)
    1. Digoxin Toxicity agent replaces Digibind due to lower risk of Hypersensitivity
  13. Vertigo (ent, neuro, Vertigo)
    1. Subdividing Vertigo by triggers may help differentiate benign causes from those requiring imaging
    2. Triggered Vestibular Syndrome (TVS) is triggered by head movement (e.g. Dix-Hallpike, body position (e.g. Orthostasis)
    3. Episodic Vestibular Syndrome (EVS) is distinct episode without obvious trigger with DDx including TIA
    4. Acute Vestibular Syndrome (AVS) is abrupt onset and persistant without trigger with DDx including posterior CVA (HiNTs Exam)
  14. Uterine Bleeding in Pregnancy (ob, antepartum, bleed)
    1. bHCG below discriminatory values does not exclude Ectopic Pregnancy
    2. Normal pelvic utrasound does not exclude placenta abruption
  15. Trauma in Pregnancy (er, Trauma, ob)
    1. RSI is typically with Succinylcholine and Etomidate
    2. Post-intubation sedation typically with Propofol and Fentanyl, or alternatively with Ketamine or Dexmedetomidine
  16. Postpartum Headache (neuro, ob, Headache)
    1. Differential includes Preeclampsia and PRES, Spinal Headache, Cerebral Venous Thrombosis, SAH, Meningitis, Pituitary Adenoma
    2. Preeclampsia should be at top of differential if within 6 weeks postpartum with Hypertension
  17. Hypertensive Encephalopathy (cv, htn, neuro)
    1. Added
  18. Alcohol Intoxication (psych, cd)
    1. Consider coingestions (e.g. Drugs of Abuse), Closed Head Injury, Hepatic Encephalopathy, Meningitis
    2. Observe closely and manage Alcohol Withdrawal early if signs develop
    3. Alcohol Detoxification or early discharge when Clinically Sober
  19. Ankle Fracture (ortho, Ankle Fracture)
    1. Weber A Fractures are stable, transverse fibular Fractures below syndesmosis and are treated non-surgically
    2. Weber B Fractures are possibly unstable Fractures at the level of joint line and syndesmosis
    3. Weber C Fractures are unstable syndesmotic ligament ruptures and require surgical repair
  20. Increased Intracranial Pressure in Closed Head Injury (ed, neuro, Trauma, icp)
    1. Improve cerebral venous drainage (head of bed at 20-35 degrees, avoid jugular compression
    2. Maintain adequate Cerebral Perfusion Pressure (MAP>65-80 mmHg) but keep SBP <140-160 with Nicardipine
    3. Do not hyperoxygenate or hyperventilate
    4. Mannitol for impending Brainstem Herniation
  21. Comprehensive Advanced Life Support (ER)
    1. Added Universal Algorithm and protocols
    2. CALS should update Acute Care 23: Bioagents - anthrax Antibiotics
  22. Anthrax (id, Bacteria, weapon)
    1. Updated Antibiotic regimens
  23. DTaP (id, immunize, pregnancy)
    1. Give DTaP at 27-36 weeks in each and every pregnancy
  24. Medications (pharm)
    1. New GLPT-1 me-toos and combos: Adlyxin (Lixisenatide), Soliqua (Insulin Glargin with Lixisenatide), Xultophy (Tresiba with Liraglutide)
    2. Differin 0.1% gel is generic in 2017
    3. Patients need Inhaler Education

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