II. 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

III. 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

IV. 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

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window