Family Practice Notebook Updates

Aka: Family Practice Notebook Updates, Family Practice Notebook Updates 2019, FPN Updates 2019, FPN Updates

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II. Updates: May 2019

  1. Acute Pancreatitis (gi, Pancreas)
    1. AGA as of 2018 recommends NO prophylactic antibiotics regardless of necrosis severity
    2. Prophylactic antibiotics were previously recommended for necrosis of >30% of Pancreas
    3. Initial antibiotic regimens for infected Pancreatic Pseudocyst or Pancreatic Abscess include zosyn, primaxin, meropenem, Moxifloxacin
    4. Obtain cultures of abscess or pseudocyst to direct antibiotic therapy
  2. Nitrous Oxide Abuse (surgery, pharm, anesthesia)
    1. Chronic Nitrous Oxide Abuse (e.g. Whippets) can result in B12 Deficiency and spinal cord degeneration (esp. Posterior Columns)
  3. Spontaneous Bacterial Peritonitis (gi, id, Cirrhosis)
    1. Antibiotic management for mean duration of 5 days with Cefotaxime, zosyn, Ceftriaxone, ertapenem
    2. Prophylaxis with Norfloxacin or Ciprofloxacin daily (or weekly)
  4. Heat Related Illness (er, environ)
    1. Avoid strenuous Exercise on hot, humid days; if unavoidable, then take breaks in the shade, maintain hydration (using electrolytes after first hour)
    2. General measures for Heat Illness include laying patient supine, with legs elevated in cool, shaded environment and initiate re-hydration
    3. Early recognition and intervention of Heat Exhaustion symptoms prevents progression to Heat Stroke
    4. Fever over 105, especially with mental status changes requires emergent management (ABC, cold/ice immersion, IV hydration, rectal temp monitoring)
  5. Nephrolithiasis (urology, renal)
    1. Adequate hydration (2.5 Liters per day), is the single most effective preventive measure
    2. Renal Ultrasound is the first-line study in suspected Renal Colic
    3. Although expectant management without CT imaging is preferred in many cases, exclude Urinary Tract Infection first
  6. Breast Mass (gyn, Breast)
    1. Breast Mass evaluation starts with a good history (including Breast Cancer Risk Factors) and careful Clinical Breast Exam
    2. Breast Mass imaging has been simplified into age <30 (Ultrasound first) and age>30 (Mammogram first) protocols
    3. Core needle biopsy is the preferred biopsy technique (over FNA and open biopsy)
  7. Mastalgia (gyn, Breast)
    1. Most Mastalgia is cyclical and requires no significant testing
    2. Non-cyclical Mastalgia, especially with focal pain, should be evaluated with Ultrasound and if over 30, Mammogram
    3. Consider Chest Wall Pain and referred pain in focal Mastalgia
    4. Adjusting bra fit and NSAIDs are first-line measures (with Tamoxifen, Danazol and goserelin reserved for moderate to severe refractory cases)
  8. Nipple Discharge (gyn, Breast)
    1. Distinguish physiologic discharge (bilateral, non-spontaneous) from Galactorrhea (milky discharge) and pathologic discharge (unilateral, single duct)
    2. Associated Breast Mass, bloody Nipple Discharge or pathologic discharge require imaging and biopsy/excision
    3. Nipple Discharge cytology and culture are not indicated
  9. Interventional Radiology (rad, surgery)
    1. Minimally invasive, imaging-guided procedures have replaced many more invasive surgical procedures
  10. Drug Interactions (pharm, metabolism)
    1. Drugs with numerous interactions: Warfarin Drug Interactions, Direct Oral Anticoagulants, Statins, Drug Interactions due to Chelating Cations
    2. Specific important drug-Drug Interactions: Phosphodiesterase Inhibitor and Nitroglycerin, Beta Blockers and Clonidine, ACE Inhibitors and Potassium supplements
    3. Drug-Induced Syndromes (exacerbated by combinations of agents): Prolonged QT Interval due to Medication, Serotonin Syndrome, CNS Depressants
  11. Myocarditis (cv, Myocardium, id)
    1. Non-sepcific presentations (e.g. flu-like illness)
    2. May present with Tachypnea, retractions and progress rapidly to Cardiogenic Shock (esp. infants)
    3. Exercise caution with fluid administration
  12. Pericarditis (cv, Pericardium, id)
    1. Classically presents with anterior sharp, stabbing, Pleuritic Chest Pain worse lying supine and best when leaning forward
    2. Radiation to the Scapula (from phrenic nerve irritation) is typical
  13. Kawasaki Disease (cv, Vasculitis)
    1. Fever for 5 days, with at least 4 of the following: Conjunctival injection, mucosal changes, polymorphous rash, palms and soles changes, cervical adenopathy
  14. Infective Endocarditis (cv, id, valve)
    1. Uncommon in children outside Congenital Heart Disease and indwelling venous lines
    2. Consider in persistent low grade fever, poor feeding, lethargy
    3. Do not delay antibiotics beyond Blood Cultures in children (rapid decompensation may occur)
  15. DOT Examination (prevent, hme)
    1. Insulin Treated Diabetes is no longer a contraindication to DOT commerical license in U.S. as of 2018
  16. Groin Pain (ortho, hip)
    1. Broad differential of Groin Pain causes including Hernias, hip pathology, nerve entrapments, strains, Stress Fractures and genitourinary referred pain
    2. Consider SCFE, Legg-Calve-Perthes and Congenital Hip Dislocation in children
    3. Consider Femoral Neck Stress Fractures, especially in female athletes
  17. Antiplatelet Therapy for Vascular Disease (hemeonc, pharm, platelet, cv)
    1. Shift to more dual therapy (Plavix and Anticoagulant) instead of triple therapy (with Aspirin) after coronary stenting with Atrial Fibrillation
  18. Aspirin (pharm, Analgesic, platelet)
    1. Not for primary prevention any more (bleeding risk, less benefit in those without vascular disease)
  19. Eskatamine (surgery, sedation, psych)
    1. Expensive ($900/dose) intranasal agent for Refractory Depression Management
    2. Initially dosed twice weekly for 4 weeks with observation for 2 hours for Hypertension, sedation, dissociation
  20. Myocardial Infarction (cv, cad)
    1. Of 5 subtypes, Type 1 (Plaque rupture requiring emergent cath lab) and Type 2 (oxygen supply and demand mismatch) are important to differentiate
  21. Vaccination (id, immune)
    1. Tdap may cause severe injection site pain (20% of adults), flu-like symptoms (10% of children) and low grade fever (<101)
    2. MMR Vaccine rarely causes Encephalitis (<1 in 1-3 million) compared with 1 in 1000 for those with Measles
    3. Varicella Vaccine may cause a vesicular rash in 5% of cases
  22. Active Shooter (prevent, abuse, work)
    1. Run-Hide-Fight may not be the best strategy in the hospital setting, where exits and hiding places are limited, and protecting vulnerable patients is also a priority
    2. Securing areas with removable locks, stocking emergency supplies, training and establishing protocols are key
  23. Synthetic Cannabinoids (psych, cd)
    1. Unpredictable with variable effects (pleasantly intoxicated vs hyperadrenergic vs Agitated Delirium vs Seizures)
    2. Sedation to prevent harm to the patient and others (see Agitated Delirium) and Benzodiazepines are mainstay strategies
  24. Tetanus (id, neuro, Bacteria)
    1. Tetanus in the unvaccinated is associated with high mortality and morbidity
    2. Presents with wound, Trismus, opisthotonus, muscle spasm, autonomic instability
  25. Button Battery Ingestion (gi, esophagus, fb)
    1. For over age 1, Honey 10 ml given every 10 min while awaiting emergent endoscopy may prevent further mucosal erosion, perforation
  26. Rapid Sequence Intubation (lung, procedure)
    1. Avoid intubating a severely hypotensive patient (outside of crash airway without RSI)
    2. Temporize airway and breathing management (Nasal Airway, bipap) during stabilization and Consider awake intubation
    3. Optimize systolic Blood Pressure prior to RSI: Fluid Resuscitation, Vasopressors, Use agents less likely to lower Blood Pressure (Ketamine in 0.25 to 0.5 mg/kg boluses until dissociation)
    4. Can never over-dose paralytics: Best to over-estimate than under-estimate dose (e.g. 2 mg/kg of Succinylcholine or Rocuronium) esp. in decreased Cardiac Output
  27. Incidental Imaging Finding (rad, ct)
    1. Incidental findings on CT are common (4-30%), but ED discharge paperwork fails to mention the findings in 50-90% of cases
    2. Establish a consistent approach for likely normal incidental findings vs uncertain incidental findings vs highly suspicious incidental findings
  28. Fever in the Returning Traveler (id, fever, travel)
    1. Assume Falciparum Malaria in those returning from Malaria endemic regions
    2. Consider other causes, such as Dengue Fever, Chickungunya and Zika Virus
    3. Do not forget about non-travel related infections (Pneumonia, Urinary Tract Infection, Meningitis)
  29. Trauma Evaluation (er, Trauma)
    1. Chest XRay is often sufficient as first-line study (unless mechanism and findings suggest CT)
    2. Although CT may identify additional injuries over Chest XRay, often these injuries require no additional intervention
  30. Actinic Keratosis (derm, hemeonc)
    1. Topical 5-Flourouracil (5-FU) is one of several topical agents used in place of Cryotherapy for numerous Actinic Keratosis (e.g. >15 lesions present)
    2. Fluorouracil cream 5% (Efudex) is applied twice daily for 2-4 weeks until significant inflammation and crusting
    3. It is least expensive (<$100) and more effective, less re-treatement than Imiquimod, ingenol and Phototherapy
  31. Beta Blockers (cv, pharm, htn)
    1. Selective Beta Blockers (e.g. Metoprolol) are safe in COPD and Asthma (but avoid non-selective Beta Blockers)
  32. Parkinsonism (neuro, Tremor)
    1. Inbrija, and inhaled Levodopa, may be effective as needed for "off time" rigidity, Tremor
  33. Treating Family Members (manage, legal)
    1. Do not prescribe controlled substances to family, friends or self
    2. Home treatment of minor symptoms is reasonable
    3. However, major symptoms are best treated with formal evaluations
    4. Notify primary provider of medications prescribed outside of their care
  34. Dry Eyes (eye, lacrimal, dry)
    1. Cequa is another Cyclosporine option for Dry Eyes
  35. Stimulant Medication (peds, pharm, behavior)
    1. Psychosis may occur with ADHD Medications, esp. at higher doses, occurs in 0.1% of patients)
    2. More common with Amphetamines in teens and young adults
    3. Stimulants may also unmask Bipolar Disorder or Schizophrenia
  36. Intravenous Brexanolone (psych, ob, depression)
    1. GABA receptor acgent, indicated in refractory Postpartum Depression
    2. Intravenous infusion over 60 hours with onset of action by 24-48 hours
    3. Risk of sedation and loss of consciousness (REMS program)
    4. Astronomically expensive ($34,000) and unknown safety in Lactation

III. Updates: April 2019

  1. Concussion (ed, neuro, Trauma)
    1. Mild Head Injury accounts for the 85% or more of 2.8 Million (as well as the unreported additional million) U.S. patients per year
    2. No return to play until asymptomatic and medical clearance. Often, symptoms and deficits may persist for months
    3. Well established protocols exist for field and acute medical evaluation (e.g. SCAT5) and for return to play guidelines
  2. Abnormal Uterine Bleeding (gyn, sx, Uterus, bleed)
    1. Age over 45 years with Abnormal Uterine Bleeding indicates Endometrial Biopsy, Ultrasound (prior cutoff was for age >35)
    2. Consider in age >=35, if persistent or refractory Abnormal Uterine Bleeding, or known Unopposed Estrogen
  3. Angioedema (ent, derm, allergy)
    1. Angioedema management is based on whether it is histamine-mediated (e.g. Anaphylaxis) or bradykinin-mediated (e.g. hereditary, ACE Inhibitor)
    2. Bradykinin-Mediated Angioedema does not typically respond to Epinephrine, Antihistamines or Corticosteroids
    3. Management and disposition is based on edema distribution (face/lips vs anterior Tongue vs posterior Tongue vs Larynx)
  4. Cervical Spine Fracture (ortho, c-spine, Fracture)
    1. Vertebral Fractures affect one or more of the anterior, middle or Posterior Columns
    2. Jefferson Fractures (bilateral burst Fractures) are the most common C1 Fractures, and patients are often neurologically intact
    3. C2 Fractures include arch Fractures (Hangman's fracture) and odontoid Fractures
    4. Other cervical Fractures include Wedge compression Fractures, flexion teardrop Fractures, burst Fractures and spinous process Fractures
  5. Post-Intubation Sedation and Analgesia (lung, procedure, airway)
    1. Analgesics (e.g. Fentanyl) are first-line agents and second is sedation (e.g. Propofol) following intubation
  6. Caustic Ingestion (er, toxin, ingestion)
    1. Caustic Ingestions (acids and alkali) may cause significant burns to the GI tract, with risk of perforation
    2. Intentional ingestions are associated with higher risk (larger volumes taken)
    3. Evaluation includes upper endoscopy and CT
  7. Symjepi (cv, pharm, allergy)
    1. Another Epinephrine device for Anaphylaxis, this time a non-autoinjector (simple prefilled syringes)
    2. Pharmacies can compound Epinephrine syringes for $20. Why does Symjepi cost $240. Why are payers satisfied with this?
  8. Prevention of Ischemic Stroke (neuro, prevent)
    1. Combined Aspirin 81 and Plavix 75 are being used after Ischemic CVA and high risk TIA for 3 weeks (then Aspirin alone)
  9. Jailed Patient (prevent, hme)
    1. Patient must consent to blood draw or officer must have a warrant to obtain blood (fourth amendment rights), except in cases of immediate danger to patient
    2. Malingering is common, but start with a reasonable evaluation for presenting concerns (e.g. Chest Pain, Abdominal Pain)
    3. Thoroughly evaluate Trauma patients and have a low threshold for imaging (e.g. Head CT, neck CT) when indicated
    4. Ensure continuation of important chronic medications (Insulin in Diabetes Mellitus, Antiepileptics in Seizure disorder, Antipsychotics in Schizophrenia)
  10. Glimepiride (endo, pharm)
    1. Higher risk for Hypoglycemia (like Glyburide) when compared with Glipizide
  11. Prescription Drug Diversion (psych, pharm. Opioid)
    1. Prescription Drug Diversion is now found in patients using their pet's Opioids
  12. Revefenacin (lung, pharm, copd)
    1. Long-acting Anticholinergic Bronchodilator (LAMA) that is nebulized once daily. Expensive ($1000/month) at the time of release in 2019
    2. Consider inhaled LAMA instead for less than half the cost (e.g. Spiriva, Incruse)
    3. Consider nebulized Ipratropium four times daily at $25/month (or combined with Albuterol in duonebs)
  13. Lokelma (renal, pharm, Potassium)
    1. Another Potassium binder used in chronic Hyperkalemia to allow continuation of ACE Inhibitors or ARB Agents despite elevated Serum Potassium
    2. Valtessa is preferred (less edema risk), and first consider other measures to reduce Serum Potassium
  14. Ulcerative Colitis (gi, ibd)
    1. Consider rectal Hydrocortisone enema (or foam) for distal Ulcerative Colitis refractory to Mesalamine (or other 5-ASA)
  15. Skeletal Muscle Relaxant (Rheum, Pharm)
    1. Lean toward cyclobanzaprine (Flexeril) and avoid use outside acute back pain after the week
  16. Febrile Seizure (neuro, Seizure, fever)
    1. Those with simple Febrile Seizure and who appear well require no diagnostic testing
    2. Acetaminophen may be helpful in reducing Seizure recurrence in first 24 hours (prior studies showed no benefit)
  17. Rett Syndrome (peds, neuro)
    1. Most frequent cause of mental Disability in girls (1 in 10,000 to 15,000)
    2. X-linked trait and affects only girls in the vast majority of cases (very rare in boys) - MECP2 Gene mutation (95% occur at methyl CpG-binding protein)
    3. Presents with regression of previously acquired skills, decreased head growth, speech loss, Gait Abnormality, loss of purposeful hand movement, Seizures
  18. Measles (id, virus)
    1. Measles outbreak in U.S. has affected 387 people in only the first 3 months of 2019
    2. Measles is highly contagious in the unimmunized (90% infection rate), kills 1 in 1000, is safe, and two doses are very effective prevention
  19. Neti Pot (ent, pharm)
    1. Risk of amoebic Meningitis
    2. Use sterile or distilled water (or boiled for 3-5 min) and wash the Neti Pot with soap and water after each use
  20. Medication Causes of Edema (renal, edema)
    1. Common causes include Amlodipine, NSAIDS, hormonal agents, Mirapex, and Diuretic Abuse or Laxative abuse
  21. Left Ventricular Assist Device or LVAD (cv, pharm, device)
    1. Various updates to emergency management of the LVAD patient
  22. Eliquis (hemeonc, pharm)
    1. May be preferred DOAC in Atrial Fibrillation Anticoagulation due to lower risk of bleeding complications
  23. Acne Vulgaris Pharmacologic Management (derm, pharm)
    1. More expensive meds for acne, without compelling reasons for use compared with $10-20/month generic alternatives
    2. Altreno is Tretinoin 0.05% lotion for $120/month (did we not try this 15-20 years ago and was too irritating)
    3. Seysara is Tetracycline. Why does it cost $860/month. Tetracycline is older than I am.
  24. Asthma Management (lung, Asthma, pharm)
    1. Generic proair HFA and Ventolin HFA will finally be generic for $35 per Inhaler (finally a reasonable cost)
    2. Wixela Inhub is fluticasone/Salmeterol at $150/Inhaler, compared with $460 for Advair
  25. Latent Tuberculosis Treatment (lung, Tb, pharm)
    1. Rifampin daily for 4 months or Isoniazid/Rifapentine for 12 doses have higher compliance, safety, and are as effective as INH for 9 months
  26. Peripheral Arterial Disease (surg, cv)
    1. Ask about Claudication in patients at risk and consider ABI
    2. Management includes specific Exercise protocols, Antiplatelet agents, ACE Inhibitors (or ARBs), Statins
  27. Breast Cancer Survivor (gyn, hemeonc, Breast)
    1. Perform a history and exam every 3-6 months for first 3 years, then every 6-12 months for 2 years, and then annually
    2. Repeat Mammogram annually, but only obtain Breast MRI if high risk of recurrence indications
  28. Choosing Wisely (prevent, peds)
    1. Longterm reversible Contraception (IUD, implant) is preferred by teens, cost-effective and safe
    2. Behavior management is key to ADD management (yet >50% are treated with medication alone)
    3. Observation is preferred over antibiotics for Otitis Media in ages 2 to 12 years old
    4. Preparticipation physicals have high false positive and high False Negative Rates and are discouraged by choosing wisely (as a policy stand)
  29. Hospital Acquired Pneumonia (id, Bacteria, Pneumonia)
    1. Hospital Acquired Pneumonia (HAP) replaced the term Heathcare Associated Pneumonia (HCAP) in 2016
    2. HCAP failed to identify multi-drug resistance risk, and resulted in overuse of broad spectrum antibiotics
    3. Hospital Acquired Pneumonia (HAP) refers to onset of Pneumonia after first 48-72 hours of hospitalization (not Nursing Home, home care)
  30. Propofol Infusion Syndrome (surgery, pharm, anesthesia)
    1. Avoid prolonged use of Propofol (>24 hours) esp. in children due to Propofol Infusion Syndrome and its resulting very high morbidty and mortality
  31. Acute Retinal Ischemia (eye, cv)
    1. Management of Retinal artery Occlusion and Amaurosis Fugax should include TIA evaluation (head imaging, carotid imaging, EKG, Zio Monitor, Echo)
  32. Anti-Retroviral Therapy (hiv, pharm)
    1. HIV ART is among the most difficult topics to keep updated. Updated preferred options as of 2018
  33. Acute Cholangitis (surgery, gi)
    1. For mild infections from the community, Third Generation Cephalosporins may be used
    2. For moderate to severe infections, comorbidities, hospital-acquired, start zosyn, ertapenem or Metronidazole with Ceftriaxone (or Fluoroquinolone)
  34. Emergency Psychiatric Evaluation (psych, exam)
    1. In Agitated Delirium, maintain staff and patient safety, and where possible use Verbal De-escalation
    2. Careful history (esp. from those accompanying the patient) and thorough Mental Status Exam and physical exam are key
    3. Consider differential diagnosis of Delirium, Psychosis, Altered Level of Consciousness, Unknown Ingestion
  35. Variceal Bleeding (gi, esophagus, Cirrhosis)
    1. Antibiotics (cipro, Norfloxacin or Ceftriaxone) used for 5-7 days reduces rebleeding, Spontaneous Bacterial Peritonitis (SBP), and mortality rates
    2. Higher infection risk in Child-Pugh Class B-C, longterm Proton Pump Inhibitor, SBP Prophylaxis
  36. Liver Abscess (gi, id, liver)
    1. With the exception of Amebiasis (critical to exclude), most Liver Abscesses are Bacterial, and at least 50% have a GI source
    2. Empiric antibiotic coverage is with Metronidazole and a second agent (e.g. Ceftriaxone, zosyn, cipro or ertapenem)
    3. Definitive management with abscess drainage
  37. Strychnine Poisoning (ed, toxin)
    1. Southeast asian plant whose seed extracts are used as rodenticide, but may also be found in Herbal Medicines and as street drug contaminants
    2. Toxicity manifests as painful, uncontrolled muscles spasms similar to Tetanus
  38. Omadacycline (id, pharm)
    1. Newer Tetracycline approved for soft tissue infections and community acquired infections at $300/pill

IV. Updates: March 2019

  1. Adhesive Capsulitis (ortho, Shoulder)
    1. Diabetes Mellitus and Hypothyroidism are commonly associated with Adhesive Capsulitis
    2. Greatest improvements are made early, and although most patients will have near resolution after 1-2 years, persistent deficits are common
    3. Physiotherapy and Corticosteroid Injections are effective in combination
  2. Musculoskeletal Manipulation (sports, procedure, alternative)
    1. Uses various modalities: Counterstrain, Muscle Energy Technique, Soft Tissue Therapy, Spinal Manipulation
    2. May offer benefit in Neck Pain (with the rare 1:20,000 but devastating risk of vertebrobasilar dissection)
    3. May offer benefit in chronic Tension Headaches, but only small studies are available; no significant benefit in Low Back Pain (acute or chronic)
    4. No good evidence for benefit in infants and children, and generally recommended to avoid
  3. Hand Infection (ortho, id, hand)
    1. Superficial infections finger include Acute Paronychia, felon and Herpetic Whitlow
    2. Deep Finger Infections include Pyogenic Flexor Tenosynovitis and Fight Bite
  4. Hepatitis B (gi, liver, id, virus)
    1. Antivirals are indicated in chronic active Hepatitis B with inflammation and higher viral loads
    2. Prevent Hepatitis B perinatal transmission and after bloodborne exposure
  5. Functional Gastrointestinal Disorders (gi, sx, bowel)
    1. Bloating, Belching and Flatulence are common distressing functional complaints that have specific causes, evaluations and management strategies
    2. Common causes with established diagnostic criteria include Functional Dyspepsia, Irritable Bowel Syndrome and Functional Constipation
    3. Functional symptoms may be broken down into Belching (aerophagia), gastric bloating, Small Bowel bloating and bloating with Constipation
  6. Type II Diabetes Medications (endo, pharm, dm)
    1. Of the more than 40 medications available for Type II Diabetes, many show only modest improved A1c, despite high cost, and adverse effects
    2. Better alternatives likely exist for Gliptins and amylins
  7. Wilderness Trauma (er, sports, Trauma, wild)
    1. Most wilderness injuries are mild (sprains and strains, Lacerations, burns, gastrointestinal illness)
    2. Serious illness and injury are uncommon, but require a systematic approach with modified ATLS and evacuation considerations
    3. Spine evaluation, Pneumothorax evaluation, dislocation reduction, Fracture stabilization and Hemorrhage control are key to best outcomes
  8. Seat Belt Sign (er, exam, peds)
    1. Car Restraints significantly reduce the risk of injury and death, but must be used properly
    2. Car Seats should be used up to age 4 years old (rear facing until age 2 years)
    3. Booster Seats should be used from age 4-8 years old (until height >=57 inches)
    4. Premature use of the adult Shoulder-Lap belt risks neck extension and flexion injuries, head injuries, Chance Fractures, Abdominal Trauma
  9. NIH Stroke Scale (neuro, cv)
    1. Observe for mild changes (esp. facial droop which may be subtle)
    2. Patients may have severe symptoms (e.g. Vertigo in posterior CVA), yet have a low NIH stroke score
  10. Giant Cell Arteritis (neuro, Headache, cv)
    1. Consider Temporal Arteritis in any patient with Diplopia or Vision Loss (even when transient)
  11. Nerve Block (surgery, pharm)
    1. Ultrasound allows for much safer regional blocks (landmarks, visualize fluid dispersion)
    2. Anticoagulation is not a contraindication to Nerve Block
    3. Be aware of LAST Reaction and precalculate toxic dose levels
    4. Dilute anesthetic to lower concentrations and higher volumes for best effect
  12. Bupropion (psych, pharm, depression)
    1. Seizure risk in Overdose (treat with Benzodiazepines)
    2. QRS prolongation may also occur with Overdose (treat with serial doses of bicarbonate)
  13. MAO inhibitor (psych, pharm, depression)
    1. Some drugs we do not identify as MAO inhibitors include Linezolid, St. Johns Wort, Selegeline
    2. May cause Hypertension in Overdose or when taking tyramines; treat with phentolamine (alpha-adrenergic antagonist)
    3. May cause Hypotension in Overdose (treat with IV fluids and direct Vasopressors such as norepinephine)
    4. Risk of Serotonin Syndrome
  14. Massive Hemoptysis
    1. Intubating decompensating patients is challenging
    2. Attempt awake intubation under Ketamine, large bore suction (or via ET Tube) and place large ET (e.g. 8.5)
    3. Consider lung isolation (left or right mainstem Bronchus intubation)
    4. Emergently consult pulmonology, thoracic surgery, Intervention Radiology
  15. Sepsis (id, fever, Bacteria)
    1. In pregnancy, no Sepsis criteria accurately predicts status (SIRS, SOFA, MEWS, MOEWS, SOS)
    2. Blood Pressure, Heart Rate, Respiratory Rate are unreliable markers of serious infection or instability in pregnancy
    3. Lactic Acid cutoffs do not apply well to pregnancy, but higher Lactic Acids are associated with worse outcomes
  16. Postpartum Endometritis (ob, postpartum)
    1. Consider pelvic Thrombophlebitis in those who fail to improve with initial antibiotics
    2. Postpartum Endometritis with hematoma present may respond better to doxycyline AND Gentamicin, Cefoxitin or Unasyn
  17. Appendicitis (surgery, bowel)
    1. Mortality for mothers approaches 4% and for the fetus, up to 45%
    2. Atypical presentations are common in pregnancy; RUQ Abdominal Pain in 20%, Rectal Pain in 45%
  18. Neurologic Anatomy of the Eye (eye, anatomy, neuro)
    1. Completed 2 new diagrams: Extraocular Movement abnormalities and Pupillary defects

V. Updates: February 2019

  1. Patellofemoral Pain Syndrome (ortho, knee)
    1. Exercises are the most effective management strategy
    2. Foot Orthotics may benefit over-pronators, but Knee Braces are unlikely to be of benefit
    3. Patellar Taping may have short-term benefit
  2. Neuropsychological Assessment (neuro, psych)
    1. Consider neuropsychological exam in Mild Cognitive Impairment, concern for driving risk, Decision Making Capacity Evaluation and after Traumatic Brain Injury
  3. Intravenous Drug Abuse (psych, CD)
    1. Drug Abuse Screening Test (or other CD screening) and offer CD treatment
    2. Screen for Viral Hepatitis, HIV Infection, Tuberculosis and immunize (Hepatitis B Vaccine, Hepatitis A Vaccine, Tetanus Vaccine)
    3. Be aware of the many complications from Injection Drug Use
    4. Consider HIV Preexposure Prophylaxis, dispense Naloxone to Opioid Abuse patients and review safer injection methods
  4. Renal Cell Carcinoma (urology, hemeonc)
    1. Incidental Renal Mass and persistent Microscopic Hematuria have replaced Renal Cell Carcinoma late presentations (palpable Renal Mass, Flank Pain, Gross Hematuria)
  5. Pediatric Gastroenteritis (gi, peds, Diarrhea)
    1. Oral Rehydration Solution (ORS) is preferred in moderate dehydration and well described protocols can avoid IV fluids in most cases
    2. Half-strength apple juice followed by preferred fluids is more effective than ORS in mild dehydration due to Diarrhea
  6. First Trimester Bleeding (ob, antepartum)
    1. Excluding Ectopic Pregnancy is top priority in pregnancy of unknown location
    2. Progesterone level <6 is consistent with non-viable pregnancy
    3. Gestational Sac should be seen on Transvaginal Ultrasound by 1800 to 3000
  7. Agitation (psych, behavior)
    1. Identify underlying cause (e.g. Cocaine, meth, Alcohol Withdrawal, Head Trauma, Hypoglycemia, Psychosis, Encephalitis)
    2. De-escalation is preferred in the agitated but non-dangerous patient
    3. Standard approaches exist for each of 3 Agitated Patients: agitated but cooperative, disruptive but not dangerous and Agitated Delirium
  8. Envenomation (er, derm)
    1. Anaphylaxis to Hymenoptera Stings (bees, hornets) are the most common cause of lethal Envenomation in the U.S.
    2. Snake Bite venom vacuum extractors are no longer recommended
    3. Do not use Tourniquets in Snake Bites
    4. Antivenoms may be life saving (e.g. Coral Snake bites, pit viper bites, Scorpion bites) but they risk Anaphylaxis
  9. Lacunar CVA (neuro, cv)
    1. Lacunar Infarcts are named for the latin ("small lakes"), and refer to the resorbed defects after stroke
    2. These strokes are from small penetrating vessels into the Thalamus, pons, Internal Capsule, corona radiata
    3. Several lacunar stroke syndromes exist (e.g. pure motor, pure sensory, ataxic Hemiparesis, Dysarthria-clumsy hand)
  10. Post-Cardiac Arrest Care (er, exam)
    1. Hypotension in post-arrest patients is common and critical to correct and maintain adequate perfusion for best outcomes
    2. Consider possible causes including the initial inciting event for the Cardiac Arrest
    3. Epinephrine is typically a reasonable choice for post-arrest Vasopressor
  11. Abdominal Compartment Syndrome (gi, cv)
    1. Rare condition with very high mortality if missed
    2. Abdominal pressures may be monitored through a Foley Catheter
  12. Local Anesthetic Systemic Toxicity (surgery, pharm)
    1. Toxicity increases with lipophilic drugs (esp. Bupivicaine, Ropivacaine)
    2. Withdraw before injection to prevent injection intravascularly, which can be lethal
    3. Intralipid is the antidote for life threatening LAST Reactions
  13. Newborn Stool Color (gi, nicu, bowel, blood)
    1. In the ill appearing young infant with blood in the stool, consider NEC, malrotation with Midgut Volvulus, Hirschsprung's enterocolitis, Vitamin K Deficiency
    2. In well appearing young infants, with intermittent inconsolable crying, consider intussception
    3. In well appearing young infants, consider Allergic Colitis of Infancy, Anal Fissure, red food or fluid intakes
    4. Acolic stool requires an emergent evaluation for Biliary causes including biliary atresia
  14. Urticaria (ent, derm, allergy)
    1. Differentiate acute hives (<6 weeks) which often has a cause identified from chronic hives (>6 weeks) which often is idiopathic
    2. Consider allergic causes, acute infections, autoimmune causes
    3. Antihistamines are most beneficial (in non-Anaphylaxis), and allergists often use Zyrtec 10 mg orally TWICE daily
    4. Other adjunctive medications include H2 Blockers, leukotriene modifiers, steroids
  15. Acute Flaccid Myelitis (id, neuro)
    1. Viral prodrome followed by Flaccid Paralysis with or without Meningitis, but no encephalopathy
    2. Enterovirus D68 and A71 are identified as common causes
    3. Treated with IVIG and recovery is most often incomplete, with residual deficits
  16. Ulnar Neuropathy at the Wrist (ortho, wrist, neuro)
    1. Consider in differential in a C7-T1 radiculopathy differential
    2. Nerve injury may also cause Ulnar Neuropathy at the Elbow
  17. Brachial Plexus (ortho, anatomy)
    1. At least 38 defined variations exist
  18. Saturday Night Palsy (ortho, Shoulder, neuro)
    1. Radial Nerve injury at the axilla (stereotypically when intoxicated with arm over a chair or bench back rest) resulting in a Wrist Drop
  19. Suprascapular Nerve Injury (ortho, Shoulder, neuro)
    1. Nerve exits high in the Brachial Plexus and can be impinged with overhead overuse (Volleyball Player's Shoulder)
  20. Thoracic Outlet Syndrome (ortho, brachial)
    1. Adson's Test and Elevated Arm Stress Test (EAST) are 2 tests used to identify Thoracic Outlet Syndrome
  21. Fluoroquinolone (id, pharm, Bacteria)
    1. Add aortic complications (Aortic Dissection, aortic aneurysm, Aortic Rupture) to the list of Fluoroquinolone complications
    2. Another reason to avoid in the elderly, vascular disease patients, smokers, Marfan Syndrome, Ehlers Danlos
  22. Acute Kidney Injury (renal, failure)
    1. ACE Inhibitors and ARBs are typically stopped in Acute Kidney Injury
    2. Outcomes appear improved if ACE/ARBs are restarted after Renal Function returns to baseline in high risk conditions (Systolic Dysfunction, recent MI, CKD)
    3. When reintroducing ACE/ARB, start at low dose and slowly increase
  23. Acute Gastroenteritis (gi, Diarrhea)
    1. Lactobacillus (Probiotic) does not significantly modify the Gastroenteritis course
  24. Warfarin Protocol (hemeonc, pharm)
    1. Do not use DOACs for Warfarin bridging (use Lovenox or other LMWH)
    2. Exception: May overlap DOAC and Warfarin when switching from DOAC to Warfarin
  25. Dosing Changes (pharm)
    1. Vitamin D units have been expressed in IU, and will now be in mcg (1000 IU = 25 mcg)
    2. Folic Acid will now be in Dietary Folate Equivalents (DFE), for example, Folate 400 mg = 600 mg DFE
  26. Expensive Medications (pharm)
    1. More expensive medications to extend patents (Tolsura) or me-too (Aemcolo)

VI. Updates: January 2019

  1. Health Maintenance in Adults (prevent, hme)
    1. Screen high risk adults with Ultrasound of AAA, Lung Cancer Screening CT Chest
    2. HPV Vaccine is indicated up to age 26 in men and women (age 45 years in high risk patients)
  2. School Absenteeism (peds, behavior, school)
    1. Truancy is common in U.S. with 14% of students missing more than 10% of school days (18 days)
    2. Truancy is associated with social problems, risky behavior, low academic achievement, school drop out, lower future income
    3. Prevention of Truancy includes pre-kindergarden attendance and addressing specific risk factors and attendance barriers
  3. Migraine Prophylaxis (neuro, Headache)
    1. Prophylaxis is indicated for 4 Headaches per month or 8 Headache days per month, refractory debilitating attacks or complicated Migraine
    2. First-line prophylaxis agents include Divalproex, Topiramate and some Beta Blockers (Metoprolol, Propranol, Timolol)
  4. NSTE-ACS Protocol (cv, cad)
    1. Obtain serial EKGs and Troponins in high clinical suspicion Chest Pain despite non-diagnostic initial findings
    2. Observe EKG for ST depression, T Wave inversion, T Wave flattening
    3. Atypical Chest Pain presentations are common in older women including Dyspnea, weakness, Nausea, Vomiting, Palpitations, Syncope
  5. Inborn Errors of Metabolism (endo, metabolism)
    1. U.S. Universal Newborn Screening differs between states, but typical panels screen 25 inborn error conditions
    2. In suspected inborn errors or metabolism, stop feedings and start D5 or D10 infusion
    3. Consider Inborn Errors of Metabolism in the differential diagnosis of Sepsis
  6. Urine Drug Test (psych, lab)
    1. Immunoassays area Screening Tests with many false negatives and false positives; confirmation tests are available via reference lab
    2. Typical poppy seed intake does not cause false positive Opioid tests and typical Marijuana second hand smoke does not cause positive tests
  7. Downhill Skiing (sports, Skiing)
    1. Start range of motion soon after knee and Shoulder injuries
    2. Evaluate knee injuries for important Fractures (Tibial Plateau Fracture, Tibial Spine Avulsion Fracture)
    3. Lateral talar process Fracture is the most common significant ankle injury in the snowboarder
  8. Labial Fusion (gyn, peds, vagina)
    1. Labia minora fuses in prepubescent girls, blocking the vaginal introitus
    2. Avoid manually separating the fused labia (painful, and typically refuses)
    3. Practice good hygiene with daily baths and frequent diaper changes
    4. Apply daily, a small amount of Topical Estrogen cream to affected labia minora
  9. Urethral Prolapse (urology, peds, Urethra)
    1. Erythematous, friable Urethra
    2. Do not manually reduce
    3. Apply daily, a small amount of Topical Estrogen cream to Urethra
  10. Vaginal Injury in Girls (gyn, peds, vagina, Trauma)
    1. Most cases will be accidental, but observe for signs of pediatric sexual abuse and Nonaccidental Trauma
    2. Blunt injury is typically a superficial Skin Tear between labia majora and minora
    3. Deep Lacerations from blunt injury may require Consultation for repair
    4. Sharp injuries are uncommon, but risk of penetrating injuries (esp .blood in introitus) - consult gynecology, surgery
  11. Carbon Monoxide Poisoning (er, toxin)
    1. Hyperbaric oxygen may be indicated for moderate to severe exposure, esp. if neurologic symptoms are present
  12. Aortic Dissection (cv, aorta)
    1. Symptoms: Chest Pain, back pain or Abdominal Pain that is abrupt onset, severe intensity, ripping or tearing pain
    2. Signs: Pulse deficit or SBP differential, new murmur of Aortic Insufficiency, Hypotension
  13. Thoracic Aortic Aneurysm (cv, aorta)
    1. Relatively uncommon (approximately 15,000 cases per year in U.S.)
    2. Surgical repair is indicated in asymptomatic patients at 4 to 5.5 cm depending on underlying risks (e.g. Marfan Syndrome)
  14. Workplace Violence (prevent, abuse)
    1. Healthcare is second only to law enforcement as a site for Workplace Violence
    2. Emergency department is a frequent site of Workplace Violence
  15. Ultrasound guided peripheral IV
    1. Standard of care is to use a probe cover and single-use sterile gel
  16. Medical Malpractice (manage, legal)
    1. Most common pediatric lawsuits are for Meningitis, arm Fractures, Appendicitis, Testicular Torsion
    2. Age 0 to 2 account for 50% of pediatric Malpractice cases
  17. Penetrating Neck Trauma (er, ent)
    1. Do not be distracted by wound when performing primary Trauma survey and ensuring airway and Hemorrhage Management
  18. Cellulitis (derm, Bacteria)
    1. Aside from Necrotizing Fasciitis and Sepsis, oral antibiotics are preferred and as effective as IV antibiotics
  19. Hyperlipidemia Management (cv, lipid)
    1. Statins are still the only first-line agent for Hyperlipidemia Management, with the only decision high intensity or low intensity
    2. LDL Cholesterol goal for the highest risk patients continues to be 70 mg/dl, and the only indication to add a second agent (e.g. Zetia)
  20. Asthma (lung, Asthma, pharm)
    1. Despite its potential risk, Primatene Mist is back on the OTC market
    2. Educate patients regarding the risk of misuse, and stick with Albuterol as the rescue Inhaler
  21. Angiotensin Receptor Blockers (cv, htn, pharm)
    1. Valsartan, Irbesartan, Losartan are all in the midst of recalls due to a contaminant with cancer risk
  22. SGLT2 Inhibitor (endo, dm, pharm)
    1. Jardiance reduces overall mortality (NNT 39) and cardiovascular death (NNT 45) over 3 years
    2. Other SGLT inhibitors (e.g. Invokana, Farxiga) have weaker CV benefits
    3. SGLT2 Inhibitors are also associated with significant adverse effects (UTI, amputations, Euglycemic ketoacidosis, Acute Kidney Injury)
  23. MRSA (id, emerging, Bacteria)
    1. Most patients do not require MRSA decolonization (instead, prevent spread)
    2. Decolonization is indicated for 2 MRSA Infections at different sites over a 6 month period despite proper hygiene
  24. Opioid Dependence (psych, cd)
    1. Wisdom Tooth Extraction is often an entry for young adults to get hooked on Opioids
  25. Amiodarone (cv, ekg, pharm)
    1. So many Drug Interactions and potential adverse effects, but still loved by many cardiologists
  26. Deep Vein Thrombosis Prevention (hemeonc, coags, prevent, surgery)
    1. DVT Prophylaxis for 10-14 days after knee replacement, 35 days after hip surgery
    2. Also consider DVT Prophylaxis after hospital discharge if prior VTE, extremely limited mobility
    3. Most other patients do not need DVT Prophylaxis after hospital discharge, and serious bleeding risk is typically higher than the DVT Risk

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