II. Updates: December 2013 Highlights

  1. Prothrombin Complex Concentrate 4 factor (PCC4)
    1. PCC4 is now available in the United States (trade name Kcentra)
    2. Now recommended in CHEST guidelines for Warfarin Reversal in life threatening bleeding
    3. Very effective, but at 20 times the cost ($4500 per dose)
  2. Microscopic Hematuria in Adults
    1. Updated the evaluation protocol (significant changes, with more detailed approach)
    2. Don't ignore persistent Microscopic Hematuria <3 cells/hpf
    3. Urine cytology and Bladder Cancer markers are not recommended for primary care use (cystoscopy is a better tool)
  3. Onychomycosis
    1. General update reinforcing that there is still no magic bullet to treat nail fungus
    2. Another expensive therapy (Nd:YAG laser) finds a niche with no better efficacy than the $4/month oral Terbinafine
  4. Acute Headache
    1. Not all new and different Headaches need head imaging
      1. New location or Headache not relieved with typical home Headache regimen does not necessarily warrant head imaging
      2. Head imaging is indicated in a new Headache in age over 50 years old even with a normal Neurologic Exam
    2. Thunderclap Headache presenting within 6 hours of onset, normal neuro exam, no Neck Pain
      1. CT read by radiologist may be sufficient without LP in a reliable patient who understands the SAH miss rate of at least 1 in 700
  5. Testicular Torsion
    1. Nothing has changed: Time is Testicle and consider attempt at manual detorsion if surgical delay
    2. As good as Ultrasound is, there is a 1% False Negative Rate (negative Ultrasound does not trump high clinical suspicion)
  6. Smell Dysfunction and Taste Dysfunction
    1. Olfactory Dysfunction causes 95% of altered Taste Sensation and nasal and sinus disease is the most common cause
  7. Arthropod Bites
    1. Updated Tick Bite, Spider Bite, Diptera, Chigger Bite and various other Arthropod Bites
    2. Another benefit of vegetarian lifestyle: No risk of Anaphylaxis from alpha-gal sensitivity (induced by Lone Star Tick)
  8. Post-Traumatic Stress Disorder (PTSD)
    1. New DSM-V diagnostic criteria are similar to the old (except helplessness is no longer required criteria)
    2. Screen for Suicidality early in the evaluation
    3. SSRI and SNRI along with CBT are still first-line treatment with little evidence for mood stabilizers and avoid Benzodiazepines
  9. Digital Nerve Block
    1. One injection (using a modified Transthecal Digital Block) is as effective as the typical multiple injection Digital Block
  10. Ventilator Troubleshooting
    1. Following the DOTTS Mnemonic on intervening with Ventilator problems
  11. BIPAP or NIPPV (Bilevel Positive Airway Pressure, Non-Invasive Positive Pressure Ventilation)
    1. Reviewed parameters and adjustment
    2. Ordered Marino, Owens and Nourbakhsh books to review Ventilators - expect updates on this in the coming year
  12. Emergency Pediatric Dosing (i.e. Broselow Tape)
    1. Created 13 pages with pre-calculated pediatric emergency doses (bringing together multiple sources)
    2. Expanding on pre-calculated pediatric weight and length based RSI, Advanced Airway and Resuscitation medications/devices
    3. In the future, will add Status Epilepticus dosing and other emergency medications
  13. Intraosseous Line (EZ-IO)
    1. Two alternative sites to the proximal tibia: Superior to medial malleolus at distal tibia or into greater tuberosity of anterolateral Shoulder
    2. Updated the technique for insertion and removal
    3. Don't forget: 5 mm mark should be visible when needle adjacent to bone prior to using needle driver
  14. ResQPOD (impedance threshold device)
    1. Lowering intrathoracic pressure seems like a great idea for increasing venous return
    2. Unfortunately the follow-up studies did not show as much benefit as the inital studies
  15. Status Epilepticus
    1. Re-reviewed pediatic Status Epilepticus protocols - same as before with alternative options
    2. Consider Keppra instead of Phenytoin/phosphenytoin
    3. Consider Valproic Acid instead of phenobarbital
    4. Consider Ketamine or Propofol
  16. Hydrocodone
    1. Acetaminophen combinations (Vicodin) change to have 300 mg Acetaminophen max
    2. Hydrocodone will likely be Schedule II by spring 2014
  17. Influenza
    1. Influenza Vaccine has greatest efficacy in children and COPD
    2. Tamiflu does NOT reduce Influenza complications (Pneumonia, mortality) including in the elderly and chronically ill
  18. Bariatric Surgery
    1. Detailed guidelines added on medications following Obesity Surgery
  19. Bedside Ultrasound
    1. Re-reviewed emergency Ultrasound and protocols (e.g. Blue Protocol, RUSH Protocol, Emergency Echocardiogram)
    2. On Bedside Ultrasound, 85% of PEA patients have mechanical cardiac contractions (Pseudo-EMD)
  20. Medical Cognitive Errors
    1. Prevent diagnostic errors with the mnemonic "When U RACE, tie your LACES"
  21. HIV Postexposure Prophylaxis
    1. Simplified regimen is 3 drugs for all regimens (regardless of exposure volume or source viral load)
    2. Preferred regimen (for 4 weeks)
      1. Raltegravir (Isentress or RAL) 400 mg orally twice daily AND
      2. Truvada (Tenofovir/Viread/TDF 300 mg and Emtricitabine/Emtriva/FTC 200 mg) one orally once daily
  22. Topical Hemostatic Agents
    1. Updated with the old standbys for procedural bleeding (Drysol, monsel's solution, Silver Nitrate, Surgicel)
    2. Split out these individual products for minor bleeding and the newer agents in major bleeding
  23. Smoke Inhalation
    1. Carboxyhemoglobin is a reflex lab for Smoke Inhalation, but don't forget Lactic Acid as a surrogate for cyanide Poisoning
  24. Added Clinical Images
    1. Added images to IJ Line, IO Line, Endotracheal Intubation Preparation, Bag Valve Mask, Chest Tube, Small Caliber Chest Tube
    2. Also added images to Oral Airway, Aerochamber with Mask

III. Updates: November 2013 Highlights

  1. Primary Care
    1. Post Myocardial Infarction Evaluation
    2. Outpatient Alcohol Withdrawal Protocol
    3. Polymyalgia Rheumatica (and Giant Cell Arteritis)
  2. Emergency Medicine
    1. Orthostatic Blood Pressures are worthless
      1. Inferior Vena Cava Ultrasound for Volume Status is a better gauge of fluid Resuscitation response
      2. Passive Leg Raise Maneuver is a clever way to predict fluid bolus responsiveness
    2. Endovascular CVA Management is not better than TPA (three studies in 2013)
    3. Rapid Sequence Induction without paralysis (significant cautionary notes)
    4. Ultrasensitive Troponin T (with interpretation protocol)
    5. Delirium

IV. Updates: October 2013 Highlights

  1. Pearls for common topics
    1. Acute Otitis Media
      1. Antibiotic courses are 10 days for every one under 2 years old
      2. Effective antibiotics are limited to Amoxicillin, Augmentin, Cephalosporins (2nd and 3rd gen.) and Clindamycin
      3. Observation Protocol for Acute Otitis Media Management
        1. Indicated for 6 months and older without severe symptoms and 2 years and older regardless of symptoms
    2. Subarachnoid Hemorrhage
      1. Women 40-60 years old with new or atypical, severe, unrelenting Headache with occipital or orbital Headache and neck spasm
        1. How often Tension Headaches present in a similar manner
      2. Subarachnoid Hemorrhage frequently presents as initial days to weeks of severe, persistent or Recurrent Headache (herald bleed)
        1. Often followed by a severe catastrophic bleed with much worse outcomes if not diagnosed at initial herald bleed
  2. Primary care updates (highlights)
    1. Fever in the Returning Traveler
    2. Eye Injury
    3. Retinal Detachment
  3. Emergency Medicine Updates (highlights)
    1. Cancer Emergencies
    2. Dialysis Emergencies
    3. Enterostomy Tubes
    4. Delayed Sequence Intubation
  4. Pharmacology Updates (highlights)
    1. Drug warnings about Fluoroquinolones, Mefloquine, and Acetaminophen skin reactions
    2. P-Glycoprotein drug interactions

V. Updates: September 2013 Highlights

  1. Advanced Airway, Endotracheal Intubation
    1. Attended Practical Airway Course (Levitan, Baltimore)
  2. Pituitary Adenomas
    1. September 1, 2013 issue of American Family Physician
  3. Hernias
    1. September 2013 Critical Decisions in Emergency Medicine
  4. Congenital Heart Defects and the Crashing Newborn
    1. September 2013 EM:Rap
  5. Assorted risks regarding multiple medications (Prescriber's Letter)
    1. Strong risks - Ketoconazole
    2. Warnings - Mefloquine (Lariam), Plavix after CVA
    3. Uproven risks - Amlodipine, Fish Oil

VI. Updates: August 2013 Highlights

  1. Tourniquets and Topical Hemostatic Agents
    1. August 2013 Critical Decisions in Emergency Medicine
  2. Hypocalcemia, Hypercalcemia and Hyperparathyroidism associated with Parathyroid disorders
    1. August issue of American Family Physician
  3. Acidity of IV fluids (Crystalloid acidity)
    1. Scott Weingart of the EMCrit blog describes this on EM:Rap

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