II. 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 dysentary, 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

III. 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)

IV. 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-Bronchodilator FEV1 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

V. 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

VI. 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

VII. 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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