II. 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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