Harbor:RME Manual

RME Provider Manual

Patient Flow

• Quick team huddle at beginning of shift
  • Physician, NP's, RME charge, LVN
  • Determine team roles (who will primarily screen/discharge)
  • Write names with spectralink numbers on the whiteboard (there are 4 phones!)

• Patient presents at router desk for check-in

1. Quick registration occurs
2. Called to Triage 1 by NA for full set of vitals
3. Patient then called to Triage 2-5 for provider MSE concurrent with RN triage
   1. Limit of one family member with patient
   2. After intake interview, family member may be asked to go back to WR as limited space in tasking area
4. Patient then goes to RME 4-6 for tasking (phlebotomy, medications, transport to radiology)
   1. If tasking rooms are at capacity, patient goes back to WR and LVN's will call the patient back in for tasking

• Triage Priority is to provide MSE to all patients presenting to the ED

1. Patients who appear ill or have unstable vitals should be seen immediately
   1. Critical patients straight to the back; immediate verbal notification to green or purple teams senior or attending
2. Chest Pain (door to ECG <10 min)
   1. To “review” the ECG: Double click eyeglasses, write “NO STEMI Activation”, and click “ED review and close”
   2. NP may review if read is “Normal Sinus” otherwise the physician needs to review in ORCHID
3. Focal neuro deficit (door to eval <10 min, door to code stroke activation <15 min)
4. ESI 2 then 3
5. ESI 4 & 5 based on overall length of stay
6. Once all the patients that have been triaged have had a MSE exam initiated, continue performing MSE on patients in WR who have not yet been triaged
   1. RME Provider may concurrently see patient with NA in Triage 1 if triage RN's are backed up
   2. If pulling patients in from WR, assign to appropriate MSE room on the tracking board so Triage RN knows where patient is if they call the patient during your screening exam
   3. Once MSE initiated and orders placed, patient should go back to WR until called in by Triage nurse UNLESS:
   4. DO NOT assign an ESI number to patients who have not yet been triaged so the Triage nurses know who still needs the nursing triage task performed

• If door to MSE is >30 minutes, NP to assist with screening; if >90 min, second NP to assist with MSE until <60 min wait time

1. Many of the ESI 4 & 5 Patients may be seen and discharged concurrently
   1. If additional workup is needed on these patients, place orders and they should be placed in rooms 7 & 8 for the Fast Track NP/resident

• Fast Track Priority:

1. Simple discharges in independent scope
2. Patients with completed workups and likely discharge home
3. Any other completed workups with high probability of Gold/CORE or admission; once this decision is made, patient needs to be kept in internal WR (RME 7, 8, or 12)

• Communicate with RME charge for patient flow - they will find a bed for critical patients

• Registration: x2075, 2076

Process Improvement

• Router Desk: RN directs traffic to 2 clerks, 1 for adult, 1 for peds/visitor/info
  • 3 separate lines - adult, peds, visitors/info (send to spine visitor desk if note ED patient during regular visiting hours)
  • RN designates CC and HIGH, routine, or CARDIAC (add STROKE???)
    • Cardiac goes straight back to 11 for ECG; triage team goes to 11 to see the patient ... need to follow current process
    • Stroke goes to next triage for immediate assessment

• Patient goes to triage queue (designated seating - hard chairs from far side of WR or orange ones from peds WR)

• Team Triage (double coverage 9a-9p ... target D2 Triage 15 min)
  • RN gets VS during Doc interview (3 min)
  • Doc Scripting: I'm Dr. Chappell, one of the physicians in triage. This is Aurora, the triage nurse working with me today. We are going to ask a few questions to get your workup started.
    • CC, focused HPI, med history, allergies, focused physical exam
  • Doc places orders and writes MSE note while RN completes triage
  • limit POCT in triage - do in tasking unless urgent

• • Triage Note
    • Extended reason for visit: CC and <10 work HPI (ie, pleuritic CP x 3 days)
    • weight - patient stated or estimated - 2 fields
    • Temp, HR, RR, O2, BP - 6 fields
    • Pain assessment - 1 click
    • RIPT - 15 questions/clicks
    • Abuse/violence - 1 click
    • LMP - 1 field
    • Risks
      • Suicide: 2 clicks
      • Falls: typically 1-2 clicks
      • Abuse/violence
    • ??? Histories → social → smoking???
    • Triage Treatments: hard c-collar, dressing, ice, heat, POCT, other
      • need close central location for these items - not running to central supply!
    • ESI - 2 clicks unless using calculator; more appropriate level given direct physician input

• NA to assist with reassessment, filling triage queue, moving patients to XR

• Tasking: Scripting - we are going to move you to the next treatment area to get your lab work and medications
  • need phlebotomy 7a to 10p
    • consider using IA from lab or RN
  • LVN or RN x 2 7a to MN
  • ECG tech - for 10 min ECG
• Radiology
  • Take patients to XR WR - tech checks q15-30 min, afterward takes back to AWR
  • CT: we call when ready to take patient
  • US: Jeremy to discuss inconsistencies with Candy - in ED vs radiology

• AWR (ideally designate as results waiting area)

• Provider D/C vs RME charge

• Clerk
• RME Charge RN - for IV pushes, communicate with AED charge and router
• Reassessment RN - repeat VS, pain score, and give meds (do not take back to tasking)
• Martee: look at router process, review compliance with CP policy
  • Triage Process workgroup: Brad, Regina, Martee, triage RN (Aurora?), LVN, ECG tech, +/- radiology
• Jeremy: what is required for meaningful use for tobacco; med rec on ESI 1-3 with secondary triage, review and acknowledge for ESI 4-5? Linda (lab) - can we use IA employees?
  • Susana Su - med rec should be done but can be in secondary triage
• Brad: review CP policy
• Wilson: D2ECG #'s, Susan (USC) to reorganize triage note
• Metric Goals
  • Door to Triage 15 min
  • D2Doc 25 min
  • LWBS <3%
  • LWTC <7%
  • Decrease dispo to discharge times (provider discharge?)
• How to address the boarding issue
  • Fully staff Gold/Upstairs Gold Overflow
  • Admitted patients to floor hallways (round robin)
• Secondary Triage for ESI 1-3
  • Home meds
  • medical, surgical, social history
• Secondary triage for ESI 4-5
  • Tobacco for meaningless use
• slow transfer outs for OOP
• PCU and ICU at 90% capacity, ward can flex staffing ratios

Patient Screening Process

• Optimal flow is to concurrently see the patients with the triage nurses (move between rooms)
• Once the patient is seen:
  • Click MSE Note:
    • "screening provider" unless you are dispositioning the patient from RME (then "definitive provider")
    • "stable to wait" or "needs room now"
    • Place orders that need to be done now (labs, imaging, medications); do NOT order things such as cardiac monitor, IVF, etc unless it needs to be performed immediately
    • If patient needs IV simply for contrast for imaging, they will need to be placed in room 12 until the test is completed and patient either has a room assigned or IV can be removed
  • On tracking board, label patient as:
    • RME/AWR (to be dispositioned by express provider, stable for WR)
    • RME/8 (simple discharge with no additional resources needed (med refill, clinic follow upp)
    • AED/AWR (dispo per AED team but stable for WR)
    • AED/12 (next back or needs intervention requiring monitoring (IV, antibiotics, etc) - verbally notify RME Charge RN of your concern
• Scripting
  • Seeing provider in triage to expedite workup and make you feel better sooner
  • We will start your workup and you will see one of my partners in the main ED

RME Phones

• RME Charge x23930
• Martee x23973
• Chappell x23203
• MSE Resident x23208
• MSE NP x23209
• FT Resident x23210
• FT NP x23220
• FT NP #2 x23220
• Extra x23213

NP Independent Workup Guidelines

• Nurse practitioners may independently order any imaging study listed below. Other studies not listed require physician consultation prior to test being ordered.
  • Standard X-rays, keeping in mind evaluation of joints above and below for concomitant injury
  • Non-contrast CT of the brain for symptoms of “sudden onset” headache or “worst headache of life”
    • consider CTA Brain for aneurysm if patient is unwilling to have lumbar puncture (discuss CTA with attending)
  • Non-contrast CT of the brain for patients who have minor head trauma following ACEP Clinical Policy Statement:
    • Loss of consciousness or post-traumatic amnesia PLUS one of the following
      • Headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication)
    • Consider if no loss of consciousness but presence of:
      • focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
  • CT brain with IV contrast – for patients being evaluated for mass/tumor or those with HIV and new onset headache
  • Non-contrast CT of cervical spine if any of the NEXUS criteria is present:
    • Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
  • Non-contrast CT of the abdomen/pelvis for patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
    • If previous CT confirms stone, consider renal ultrasound to evaluate for hydronephrosis or pyelonephritis
  • Limited Right upper quadrant ultrasound for patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
  • Abdominal ultrasound for patients with high suspicion for first episode of pancreatitis
  • Pelvic ultrasound for patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding.
  • Risk Stratification for DVT
    • Well’s Criteria: Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous DVT(+1), and alternative diagnosis as likely (-2)
      • If low-risk Well’s (score of 0-1), order d-dimer
      • If score greater than 1, order formal (not bedside) Lower Extremity Doppler US
  • Risk Stratification for PE
    • If low pre-test probability and PERC negative, no further testing for PE necessary
      • PERC measures: Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks
    • If patient falls out of PERC, then apply Well’s criteria:
      • Clinical signs and symptoms of DVT(+3), PE #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
        • If score <2, order d-dimer
        • If Score 2 or greater, CTA or VQ scan (if contra-indication to CTA)
        • If pregnant, discuss with attending
  • Chest Pain: NP should obtain a brief history on any patient with signs or symptoms of cardiac ischemia or with ECG read that is not “normal sinus rhythm” then present the ECG to the Attending

Being Seen by Consultants Prior to ED Evaluation

• ED Policy 3.3
  • A consultant may request from RME/AED attending or senior resident to see or take a patient to clinic
  • Once the specialty evaluation is completed, documentation of both exam and assessment/plan should be in ORCHID and communicated to the ED provider
  • ED to disposition the patient after evaluating for any other needs (full chart)
• Alternately, if the patient has already been evaluated in the ED and found to have an isolated problem that is best cared for by the consulting specialist, care of the patient should be transferred from the ED to the specialist who should discharge them from clinic unless there are extenuating circumstances

NP Consultation Guidelines

• Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult

1. If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.
2. If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and alpha-page the consult service.

• Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending
  • If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation

NP Independent Discharge Guidelines

NPs may independently discharge patients whose complaints are limited to the following and only if they feel physician consultation is not warranted: • Allergic reactions (without signs of anaphylaxis) • Asthma exacerbation that responds to Albuterol, not immune compromised • Bell’s Palsy with complete unilateral facial paralysis and no other focal neurological deficits • Breast Complaints • Superficial (1st) and Partial Thickness (2nd) Burns which do not meet Burn Center Referral Criteria (3rd degree, 2nd degree with greater than 10% total body surface area, burns of eyes, face, hands, feet, perineum, electrical injuries, inhalation injuries) • Chest pain (low risk – HEART Score <4, age < 30, no syncope/shortness of breath, no drugs, no significant family history of early cardiac disease or sudden death, no tachycardia, normal ECG without arrhythmia) • Conjunctivitis • Constipation without signs of obstruction • Dental Complaints • Dizziness consistent with Peripheral Vertigo (normal HiNTS exam, no cerebellar findings) • Ear, Nose and Throat (no angioedema, drooling, phonation changes, or stridor) • Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin) • Genitourinary, minor complaints (male and female, no torsion) • Gynecological, minor complaints (not pregnant, no active bleed, hemoglobin >8) • Hemorrhoids • Hyperglycemia (asymptomatic, no DKA/HHS) • Hypertension (asymptomatic) • Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury) • Low back pain without associated fever or neurologic deficits • Medication Refill • Minor head or facial trauma • Musculoskeletal injuries/musculoskeletal pain • Nausea and vomiting without significant abdominal pain • Ocular complaints (no significant acute decreased vision, no trauma) • Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can overbook into orthopedic fracture clinic): o Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks o Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week o Humerus:  Proximal: non-displaced; sling, ortho in 1 week  Shaft: non-displaced; sugar tong/sling, ortho 1 week o Radius:  Non-displaced distal or shaft; volar splint, ortho 2 weeks  Non-displaced head with good ROM: sling, ortho in 2 weeks o Ulna: non-displaced; volar splint, ortho 2 weeks

o Metacarpal: non-displaced shaft and neck  MCP 4&5: Ulnar gutter splint, ortho 3 weeks  MCP 2&3: Radial gutter splint, ortho 3 weeks o PIP/DIP dislocations: simple, no fracture; buddy tape/splint, ortho 1 week o Hand Distal Phalanx: buddy tape/alumiform splint, ortho in 3 weeks o Occult Scaphoid: thumb spica splint, ortho in 3 weeks o Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks o Foot Non-displaced phalanx fracture: buddy tape, ortho in 2 weeks o Chronic or non-healing fracture: e-consult or CCC (call ortho if needs closer follow-up) • Palpitations • Psychiatric Patients without psychosis, homicidal ideation, or suicidality (but these patient may be screened for medical conditions and sent directly to the Psychiatric ED if it is deemed no other medical workup is necessary prior to psychiatric evaluation) • Rash (no petechiae/purpura) • Seizures (known disorder, no new trauma) • Soft tissue infection or simple abscess • Simple UTI • STI exposure • URI • Exclusion: o Any cases not specifically listed on the inclusion list o Prior to discharge of any patient with a persistent vital sign abnormality needs consultation with a physician.  Temperature >38F  HR > 110 or <50  RR> 20, Pox <92% on room air  SBP >210 or <100, DBP >120 or <50

Ortho Follow-ups

• Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can overbook into orthopedic fracture clinic): o Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks o Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week o Humerus:  Proximal: non-displaced; sling, ortho in 1 week  Shaft: non-displaced; sugar tong/sling, ortho 1 week o Radius:  Non-displaced distal or shaft; volar splint, ortho 2 weeks  Non-displaced head with good ROM: sling, ortho in 2 weeks o Ulna: non-displaced; volar splint, ortho 2 weeks

o Metacarpal: non-displaced shaft and neck  MCP 4&5: Ulnar gutter splint, ortho 3 weeks  MCP 2&3: Radial gutter splint, ortho 3 weeks o PIP/DIP dislocations: simple, no fracture; buddy tape/splint, ortho 1 week o Hand Distal Phalanx: buddy tape/alumiform splint, ortho in 3 weeks o Occult Scaphoid: thumb spica splint, ortho in 3 weeks o Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks o Foot Non-displaced phalanx fracture: buddy tape, ortho in 2 weeks o Chronic or non-healing fracture: e-consult or CCC (call ortho if needs closer follow-up)

Documentation

• Consults
  • When simply asking a doc if it is appropriate to consult X service, just put in your documentation something to the effect of “Dr. Chappell agreed with consulting ortho for displaced fx”
  • If you are reviewing a case with a physician and asking for advice on management, you should forward the chart to the physician for signature - “Case discussed with Dr. Chappell who agrees with X plan.”
    • Under no circumstance other than approval for consultation should you write “case discussed with Dr. X” without forwarding the chart to the aforementioned physician.

Timesheets

• Daytime (099) - 6am, 9am, 10am
• Evening bonus (517) - 12n, 2pm, 4pm
• Night Bonus (504) - 6pm or 8pm
• Weekend Bonus (539) - Friday 6pm through
• 703-843: accrued OT (any work over 12 hour shift or 40 hour week; maximum of 81 hours); use this for Staff meetings or elective trainings such as ultrasound
• 701-843: Paid OT (only when offered by director or Lead NP) or Part-time accrued
• 037: mandatory training (computer modules, skills lab)
• 024: Military time

RME Rounds

• Please post/edit after presenting to NP's at rounds

ACLS Review

CODE

• Intubate: ET drugs (LidoEpiAtropineNarcan; valium (NAVEL)…2-3x IV dose)
• Line: labs, ABG
• H’s: O2, IVF, bicarb (H+), accucheck, Temp, Ca (K+)
• T’s: charcoal/lavage, tamponade (trauma), pneumothorax, MI/PE
• DOPE: displaced, obstruction (suction/bronch), pneumothorax, equipment (try bagging)

PEA/Asystole

• Epi 1mg . . . q3 min
• +/- Atropine 1mg; 0.04mg/kg max … NO atropine if tachycardic!

Bradycardia

• Variable with 1 drop=mobitz 1 … responds to atropine
• Fixed PR=mobitz 2 (2p:1qrs); may worsen with atropine; pace with ant MI
• Consider 3rd degree block
• Atropine, Pacer – transcutaneous/transvenous (versed!), Dopamine gtt, Epi gtt
• Check TSH

VF/VT Pulseless

• CPR x 2 min; recheck pulse, shock, give meds
• SHOCK 200J ASAP; may increase subsequent
• EITHER Lido or Amio
• --Amio 300mg x 1, 150mg x 1
• --Lido 1.5mg/kg, 0.5mg/kg , 0.5mg/kg
• Shock – CPR – EPI – shock – CPR – Amio
• Consider Mag 2g IV for torsades; then 2g/hr gtt
• Amio gtt 1mg/kg/min x 6 hrs, 0.5mg/kg/min x 18hrs

UNSTABLE Tachy with pulses

• Versed 0.05 -0.1mg/kg
• SYNC cardiovert 50-100-200J;
• --RESET sync after each shock
• BIPHASIC . . . A-fib/SVT: 100-200-300-360
• A-flutter: 50-100-200-300-360

STABLE tachy with pulses, WIDE complex (75% VTach)

• Amio 150/10 min; 1mg/min x 6hrs, 0.5 x 18hrs (2.2g max)
• REGULAR: Amio 150; elective sync cardiovert
• IRREGULAR: afib, WPW, polymorphic VT
• Amio; NO dig, CA, adenosine
• Mag for torsades

STABLE tachy with pulses, NARROW complex

• CARDIZEM .25mg/kg, then .35mg/kg; gtt 5-15mg/hr
• REGULAR: SVT
• Vagal; adenosine 6,12,12; cardizem
• IRREGULAR: a-fib, a-flutter, MAT … check TSH
• Cardizem
• WPW: short PR and upsloping delta wave before QRS
• --Procainamide 15mg/kg/30min, 1-6mg/min
• --or amiodarone …. NO BB or CCB!!!

Post resuscitation

• Target MAP 80-100
  • Pressors portend higher mortality (sicker patients); no benefit to steroids in ROSC, but low risk if refractory shock

• Cooling
  • VF or TBI -- CPR within 15 min, ROSC<60 min; RAPID cooling (<6 hours from event) to 32-34 degrees for 12-24 hours post arrest
    • Expand to Asystole/PEA
    • 36 degrees non-inferior to 32 degrees
• Cool for at least 24 hours; slow re-warming helps prevent rebound increased ICP (0.25 deg C per hour); for TBI, need to keep cool for 48-72 hours to reduce brain edema
• check K, Ca, Mg; monitor hypotension when rewarming

• ECMO: short-term bridge

• Cath lab if consistent with cardiac cause
  • AHA looking at keeping separate registry of ROSC patients so cardiologists are not as hesitant to take to the cath lab as higher mortality

• Prognosis relatively clear 72 hours after ROSC or rewarming; lack of pupillary response and myoclonus bad

PALS

• 78% mortality if coded >20 minutes; peds need pre-hospital ventilation!

BROSLOW TAPE

• <1 week old, umbilical line
• consider IO for access
• Tube size: age/4 +4, depth=3x diameter
• Adenosine 0.1mg/kg, then 0.2mg/kg (12 max)
• Amiodarone 5mg/kg, repeat up to 15mg/kg, 300mg max
• Atropine 0.02mg/kgIV, 0.03mg/kg ET; 0.1mg min, 0.5mg max
• Bicarb 1meq/kg with adequate ventilations
• CaCl 20mg/kg slowly
• Epi: 0.01mg/kg IV (0.1ml/kg) of 1:10k, 1mg max; 0.1mg/KG ET of 1:1k, 10mg max
• Glucose 1g/kg (25% … 50/50 mix of D50 + water); Peds 2ml/kg of D25, infant 5ml/kg of D10
• Lido 1mg/kg, 100max; infuse at 20-50mcg/kg/min; 3mg/kg ET
• Magnesium 25-50mg/kg, 2gram max
• Narcan 0.1mg/kg, 2mg max
• Procainamide 15mg/kg over 30 min

Pressors

• Levophed 0.1-2mcg/kg/min
• Dopamine 2-20 mcg/kg.min
• Epinephine0.1-1mcg/kg/min
• Dobutamine 2-20mcg/kg/min
• Milrinone 75mcg/kg over 30min, then 0.5-0.75mcg/kg/min
• Inamrinone 1mg/kg over 5 min x 2-3 doses then 2-20mcg/kg/min
• Nitroprusside 1-8mcg/kg/min

Asystole/PEA

• H’s (HYPOXIA, hypovemia, H+, hyperkalemia, hypothermia)
• T’s (Toxins, pneumothorax, tamponade, thrombosis)
• Epi 0.01mg/kg 1:10k (0.1ml/kg); use 1:1000 via ET tube (10x IV dose)

Bradycardia

• Consider: CHI, toxins, hypothermia, heart block, hypoxia
• CPR when HR<60
• Epi 0.01mg/kg 1:10k (0.1ml/kg); use 1:1000 via ET tube (.1mg/kg)
• If increased vagal tone or AV block, atropine 0.02mg/kg, 0.5mg max x 2 doses – 0.1mg minimum; Consider pacing

Pulseless VT/VF

• 1-8 y/o, peds pads and shock at 2J/kg → 2min CPR → check rhythm
  • re-shock at 4J/kg, then give EPI; pulse check every 2 minutes, drugs q3 min
• Amiodarone 5mg/kg OR Lidocaine 1mg/kg
• Mag 50mg/kg, 2g max for torsades

Tachy with pulses, NARROW

• Consider: hypovolemia, hypoxia, sepsis/fever, pain, toxins
• Sinus=variable R-R, constant P-R; infant<220, child<180
• SVT – constant HR, abrupt change, infant >220, child>180
  • Vagal – ICE to face
  • Adenosine 0.1mg/kg, then 0.2, 0.2
  • Cardiovert: Versed 0.1mg/kg then SYNC 1J/kg, then 2J/kg
  • AMIO 5mg/kg/1hr OR Procainamide 15mg/kg/1hr

Tachy with Pulses, WIDE

• AMIO 5mg/kg/1hr OR Procainamide 15mg/kg/1hr
• Versed 0.1mg/kg then SYNC 1J/kg, then 2J/kg

RSI

• O2 during apnea keeps SpO2>95~5 min (NC during tube in kids and difficult airways)
• AIRWAY: Look, Eval (3/2/2), Mallampatti, Obstruction, Neck
• PEDS:
  • +/- Atropine 0.02mg/kg IM
  • <2 = miller 1; >2 = mac2
• Pre Treatment
• Lidocaine 1mg - 1.5mg/kg – decrease sympathetics, ICP (theoretical)
• Fentanyl: 3mcg/kg if inc ICP or hypertension; 1mcg/kg asthma, epilepticus, difficult



Induction agents

• Etomidate .3mg/kg
• Ketamine (PCP) 1-2mg/kg (for hypotension, asthma); increases sympathetics (good for shock); potentially increases ICP
• Propofol 1mg/kg (give with lido to decrease burning … for hypertension, ICP, difficult)
  • SE: infusion syndrome when prolonged use >mg/kg/hr - ARF, rhabdo, MI
• Thiopental 3-5mg/kg (decreases ICP, neuroprotective … for hypertension, ICP)
• Versed 0.05-0.1mg/kg (for status epilepticus, hypertension, ICP)



Paralytics

• Succinylcholine 1.5mg/kg; increases MAP, ICP, K+ (amputee/crush), neuro disorder; brady in peds
  • increased mortality in brain injury patients with more hypotension-- keep them down
• Rocuronium .9-1.2mg/kg
• Vecuronium .1mg/kg
• Pavulon: 0.1mg/kg, then 0.01mg/kg q30-60 min (decrease in ARF); low BP effect
• Nimbex (brain stimulator protocol): 0.2mg/kg then 3mcg/kg/min; ok with ARF
  • Reversal Agents (non-depolarizers: roc, vec, pan)
    • Neostigmine 1mg, 5mg total; + glycopyrolate .2mg per 1mg neostigmine
    • Sugammadex 16mg/kg actual weight - full reversal in 3 minutes, only for ROC & VEC

Rapid Takedown

• Versed 5-10mg faster and shorter acting than Zyprexa or Haldol
• Get ECG if using Haldol or inapsine

VENT Settings

• Minute Ventilation=RR x TV (~450 based on predicted body weight)
  • I:E ratio ~1:5
  • Keep PaO2<200 (high= inc mortality due to increased oxidative stress)
  • Rate x CO2=new rate x desired CO2
• Vent Modes
  • AC (Assist/Volume control) - guarantees minte ventilation, decreases work of breathing
    • Failure to work: AC 12 / 6-8ml/kg / 5 / 30%; SIMV when stable
    • Failure to ventilate (COPD): AC 8 / 6ml/kg / 5 / 35%; increase 1i:5e
      • These patient are prne to auto-PEEP with subsequent pneumothorax, decreased preload, and RV failure due to high pulmonary vasc pressure
      • Will see high airway pressures or decreased volumes
      • May need to slow rate and allow permissive hypercapnea
  • PCV (Pressure Control) - set insp time and RR; control i:e ratio, decrease peak insp pressure
    • Tidal volume thus minute ventilation may change with lung compliance
    • ARDS: titrate PEEP-FiO2 table, keep plateau pressure <30
      • dec TV, pneumothorax suction, inc exp time
      • prone to increase posterior ventilation (the good alveoli); paralyze with Nimbex; consider ECMO
  • SIMV (sync intermittent mandatory vent) - augments pressure for patient's spontaneous breaths and will mandate breathing if rate too slow
    • Failure to oxygenate: SIMV 14 / 8mg/kg / 10 / 50%; PS~15
    • Failure to maintain airway: SIMV 12 / 8ml/kg / 5 / 30; PS~10
    • PEDS: SIMV / 8-10ml/kg / PIP=16+2prn / PS=16 /PEEP 3-5
  • PSV (pressure support) - patient alone triggers breath



Procedural Sedation

• combos potentiate side effects!
• Use capnography – watch for ETCO2>50 or 10% increase from baseline
  • Etomidate 0.15mg/kg (myoclonus 22%); low CV effect; not FDA approved <10y/o
  • Propofol 0.5-1mg/kg then 0.1mg/min maintenance during procedure (slow titration); Not with egg allergy
    • amnestic, no analgesia (pretreat with Fentanyl), quick recovery; decreases nausea, HR, and breathing
    • Propofol infusion syndrome: ARF, rhabdo, MI when >5mg/kg/hr; 1Cal/mg of fat
  • KETOFOL IV: Ketamine 0.75mg/kg + propofol 0.75mg/kg; aliquots of propofol if additional sedation needed (ACEP recommended)
  • Ketamine: 1-2mg/kg IV over 2 minutes, 4-5mg/kg IM; re-dose at 0.5-1mg/kg IV, 1-2mg/kg IM
    • Analgesic/dissociative; little resp/CV effect; SE: inc ICP, BP; laryngospasm & increased emergence in adults)
    • give zofran 0.15mg/kg during sedation to avoid vomiting
    • IM~2hr recovery, IV~80min (IV preferred – over 2 min)
  • Fentanyl: 1 mcg/kg (up to 5mcg/kg); in kids can cause chest wall/glottic rigidity
  • Morphine 0.1-.2mg/kg IV/IM; then 0.05mg/kg q15 min; dilaudid 1mg=7-10mg of MS
  • Versed: 0.05 - 0.1mg/kg + Fentanyl (increased respiratory depression)
    • flumazenil .01mg/kg (0.2 x 5) for reversal

Sedation

• B52 (Benadryl 50mg, haldol 5mg, ativan 2mg in 1 IM shot)
• Ativan 1-4mg IM/IV per hour
• Haldol 1-5mg IM; check ECG for QT prolongation; Decreases seizure threshold - should not be used in DT’s
  • cogentin 2mg or Benadryl for EPS (antiparkinsonian)
• Inapsine (droperidol) 1.25mg IV/IM (2.5mg max dose): watch QT interval
• Geodon 10-20mg IM, 40mg max daily

Pediatrics

• +/-glycopyrrolate 4mcg/kg IM OR atropine 0.02mg/kg;
• ACEP Pediatric Sedation:
  • Do NOT need NPO; safe with recent oral intake, 1:2000 aspirate, takes 6 hours for solids to clear the stomach, higher failure of sedation in fasted kids
  • N20: onset<5min, safe at 50%, must use gas scavenging system, minimal CV effects, only 10% emesis rate in 24hrs; do not mix with CH or BZD
• Pentobarbital
• Chloral Hydrate safe: oral or rectal for painless diagnostic studies; 75mg/kg, may repeat x 1 (max 2gram or 100mg/kg)
  • May have re-sedation effect up to 24 hours! Not in neurologic pts (decreases seizure threshold); Does not work if fasted
• INFANTS: if <6mo, anesthesia consult!
  • Sweet-ease (24% sucrose) 2 min before procedure with pacifier
    • premie=.1-.2ml
    • 1-6mo, .5-2ml
    • slight risk of necrotizing enterocolitis
  • methohexital 10mg/kg IM or 25mg/kg PR

Anesthetics

• Neutral Bicarb + Lido (1:10 ratio) … slow, warm
  • Most common reaction is vasovagal; Can increase max dose by 33% if mixed with epi
• Esthers: procaine 7mg/kg, tetracaine, cocaine; Cross sensitivity among class
• Amides: lidocaine 5mg/kg (10 min-2 hrs), bupivicaine 2mg/kg (6-8 hours), mepivicaine; Slower onset, last longer
  • Intra-lipid 1.5mg/kg for systemic absorption/cardiovascular collapse
• Methemoglobinemia: oral BENZOCAINE, lidocaine, tetracaine, prilocaine; cardiac monitoring; treatment: methylene blue
• Blocks: Supraorbital, infraorbital, mental, auricular (diamond-shaped), digital (4cc max, MCP crease)

Shock

Sepsis

• SCCM - Jama Feb 2016
  • Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
  • Septic Shock
    • Vasopressor requirement to maintain a mean arterial pressure > 65 mm Hg
    • Serum lactate level greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia.
• ProCESS
• ProMISE - antibiotics & IVF
• ARISE

• Monitoring
  • Lactic acid should clear 10% in 1st 6 hours
  • Urine output: 0.5-1ml/kg/hr
• US of IVC – if IVC collapses >50% with sniffing, give IVF
• art line – if art waveform varies more than 10% with inspiration, increase IVF
• CVP – only good to monitor volume DEFICIT (not excess)

• Old Definitions
  • SIRS: T>38 or<36, HR>90, RR>20, ALOC, glucose>140, WBC<4k or >12K, bands>10%
  • Severe=end organ damage (hypotension - narrow pulse pressure, poor cap refills, ALI/ARDS, oliguria/AKI, thrombocytopenia, INR>1.5, bili>2, lactate>2
  • Shock=hypotense after 30ml/kg, lactate>4

Pressors

• Push Dose Pressors (blog.emcrit.org)
  • Epi: 1ml (100mcg/ml) into 9cc syringe → 10mcg/ml (0.5-2ml q5-10 min)
  • Phenylephrine: 1ml (10mg/ml) into 100ml bag → 100mcg/ml (0.5-2ml q2-5 minutes)

Pressor Dosing (ml : mcg) – keep MAP>65

• 1 - Levophed 2-20 mcg/min (4:1); inc SVR & CO for PE, Sepsis, TCA
  • Alpha1, beta1; inc MAP, reflex brady
• 2 - Vasopressin: 0.01-0.04 units/min (3:1); Reduces stroke volume
  • Start at 0.03unit/min; Synergistic with levophed; use for 24 hours, wean of levophed then wean the VPH
• 3 - Epi: 1-10mcg/min; B1>>B2, a1; inc CO, dec SVR (10:1)
  • SE: splanchnic constriction & arrhythmias
• 4 - Phenylephrine: 40-180 mcg/min (.1-.5mcg/kg/min); inc SVR
  • Alpha only; min cardiac effect; use when tachy
• 5 - Dobutamine: 2-20 mcg/kg/min (pump failure) … not if tachy
  • B1 (inotrope); inc CO with reflex dec SVR – may need levophed
    • Milrinone: 50mcg/kg x 1 dose (at .75mcg/kg/min) then gtt @ 0.375-0.75mcg/kg/min; watch for thrombocytopenia
      • Similar to dobutamine; PDE inhibitor; low dysrhythmia rate
    • Isoproteranol: 2-10mcg/min; B1&B2
      • For bradycardia (atropine resistant) with hypotension
• 6 - Dopamine: 1-2mcg (dopa, renal); 5-10mcg (beta1, inc SVR) (3:1)
  • 10-20mcg/kg/min (dopa>alpha … inc SVR) Cardio(CHF), Neuro

• Colloids
  • Require less volume to expand the intravascular space; they do NOT improve outcomes (albumin 6% increased mortality)
    • Hetastarch 6%: 500cc up to 20ml/kg; inc mortality, dec factor 8
    • Plasmonate: can have hypersensitivity reaction
    • Albumin: low side effects but expensive

• Hypovolemic
  • Medical – 250cc q 15 min
  • Trauma – 20cc/kg over 20 min, repeat x 1 (+/- blood)
• Cardiogenic – pump failure
  • DOBUTAMINE +/- LEVOPHED; dopamine (inc mortality & arrhythmias NEJM 2010) and epinephrine 2nd/3rd line
  • increased MAP feeds the coronaries
  • revascularization or intra-aortic balloon pump (inc CO, dec myocardial O2 demand)
• PE: LEVOPHED (dopamine increases pulmonary hypertension, slightly higher mortality); not responsive to IVF (typically makes it worse)
• Septic – decreased tissue perfusion with decreased SVR
  • NS 20cc/kg x 2; then colloid/blood (HCG of 10 in 1st 6 hrs)
  • Low SBP, high SVO2: LEVOPHED and dopamine are equivalent
  • if SCVO2<70, start DOBUTAMINE or milrinone (improves CO)
    • When SCVO2 and LACTATE normalize, reduce pressors (tissue is perfusing)
    • If stressed random cortisol <16, SOLU-CORTEF 2mg/kg (100mg max) TID; no more xigris for MODS (APCHCE II >25)
• Anaphylactic – histamine release causes decreased SVR; cocktail+/-epinephrine gtt
• Neurogenic – loss of sympathetic tone results in Brady + decreased SVR

Cardiology

Chest Pain

• Chest pain: rule out CAD, PE, pneumothorax, Tamponade, Boearhave, TAD
• HEART SCORE: <4= LR of 0.15, >6=LR of 5.2
• TIMI SCORE: Age >65, 3 risk factors (smoker, FmHx, hypertension, DM, lipids), >50% stenosis, ASA<7d, <24hrs angina, inc TI, ST>.5mm
  • 14d Death Risk: 0-2 (3%), 3-4 (13-20%), 5-7 (25-40%)
• Increased troponins in PE, sepsis, ARF . . . trend to rule out MI … CKMB (r/in CAD)
• USA/NSTEMI TX: ASA 81mg decreases mortality 25%; NTG @ 10mcg/min; oral b-blocker within 24 hours (long-term improved mortality, not needed acutely – COMMIT trial), heparin, plavix 300mg (600mg if no chance of CABG), ACEi (remodeling); +/- integrillin (GPIIb/IIIa) 180u/kg then 2u/kg/min x 96hrs
• Infarct size: 25% loss=CHF, 40%=shock
  • 2% of MI's missed in ED, 25% of those are straight ECG mis-interpretation
• Remote Ischemic Conditioning: protects myocardium from reperfusion injury (Lancet 3/10); 4 x 10-minute cycles of inflation/deflation of BP cuff (20% greater slavage index)
• Pericarditis: 20% in 2-4 days
• Dressler’s seen 2-10 weeks post-MI
  • NSAIDs +/ steroids

• CTCoronaryAngiogram
  • CTCA better than stress stest in low & intermediate category, but high radiation for “low-risk”
  • Low coronary calcium score does NOT exclude obstructive CAD
• Persantine stress test requires a focal defect; looks normal if global ischemia

STEMI treatment

• STEMI – door to balloon 90 min, door to needle (fibrinolysis) 30 min; 5% false activation
• TRANSFERS: Only 4% of transfers get PCI in <90 min;
• Minimal Delay for PCI: lysis contraindications, shock, old, inferior MI, delayed presentation

• TREATMENT
  • ASA
  • NTG
  • Prasurgel (Effient) 60mg PO - faster than plavix (1 hr)
    • Age <75, >70kg, no hx of Stroke/TIA EVER (increased risk of ICH)!
    • Ticagrelor (Brillinta) 180mg (not with hx of hemorrhagic stroke)
    • Clopidigrel (Plavix) as alternate 600mg - not with active ICH or GI bleed
    • Bivalirudin 0.75mg/kg IV (direct thrombin inhibitor) better than plavix
    • Integrillin (G2b3a inhibitor) - 180mcg/kg bolus then 2 mcg/kg/min
  • Lovenox 30mg IV (or 1mg/kg SQ OR heparin)
    • EXTRACT Trial: lovenox 1mg/kg better than heparin; 0.75mg/kg if >75 y/o
      • 17% drop in 30d mortality, 2% inc bleed
    • Arixtra 2.5mg SQ for HIT
    • Cyclosporin with PCI: 2.5mg/kg bolus at the time of PCI decreased median infarct volume by 20

• • Alteplase 15mg IVP, then 0.75mg/kg (50mg max) / 30min, then 0.5mg/kg (35mg max) / 60 min; Use left femoral line (compressible)

• • • tPA INCLUSION:
      • STEMI in 2 contiguous chest leads >2mm or limb leads>1mm
      • New onset LBBB (based on clinical picture), consider ST depression V1-3 (POST MI)
        • Best in young patients, anterior MI, <3 hours of CP, high ST elevation with no Q’s
        • HOLD tPA for small INFERIOR STEMI when ST decreases with NTG, ASA; discuss with cardio
        • High Risk (PCI better): HR>100 + SBP<100, pulmonary edema, shock
        • Symptoms 20 min to 3 hrs best, but acceptable for INFERIOR within 4 hours, ANTERIOR within 16 hrs
        • <24 hrs: 1-2% head bleed, 5-10% GI bleed … FFP, Cryo, Vit K, Platelets
        • ST should decrease 50% in <90 min after tPA

• • • tPA CONTRAINDICATIONS:
      • Active bleed, suspected of TAD/AAA (CXR, R vs. left BP off 15mmHg), any prior intracranial hemorrhage, ischemic CVI<3mo, any intracranial AVM/neoplasm, major facial/head trauma or surgery <3mo
      • RELATIVE: BP>180/110, CPR>10min, major surgery<3wks, INR>1.7 (higher number=bigger bleed risk - consider vit K), pregnancy, non-compressible vascular punctures, recent internal bleeding (2-4 weeks), active PUD, prior TPA, pericardial tamponade, severe thrombocytopenia, coag disorder (vWF, hemophilia)

STEMI ECGs

• 2012 updates: 1mm in all leads except V2-3; V2-3: female 1.5mm, male<40 2.5mm, male>40 2mm
  • STEMI: hyperacute T’s, T inversion, Q-waves, reciprocal ST depression
  • Q-waves indicate infarct >4 hrs; 1mm wide (.04sec) or 1/3 of QRS amplitude; Q’s with inverted T’s=NSTEMI >4 hrs old
  • RBBB does not effect diagnosis of STEMI
  • Do not activate new LBBB unless meets Sgarbossa criteria
    • Sgarbossa Criteria (modified) (suspected ACS with LBBB or paced rhythms – GUSTO-1)
      • 1mm ST elevation with QRS concordance in any lead – 73% Sens
      • 1mm ST depression V1-3 with concordance – 25% Sens
      • 5mm ST elevation with QRS discordance (not enough by itself) – 31% Sens
      • Modified Sgarbossa: Discordant ST to S wave amplitude (discordance)
        • S-wave below base=negative, above=positive; compare number of boxes: ST/S <-0.25 - 91% Sens
  • T-wave inversion (decreased coronary flow with infarct); always pathological in V2-6
  • Reciprocal changes: PAILS (move down one - post has reciprocal in anterior)
  • STEMI DDX: ventricular aneurysm, pericarditis (flat or concave up, entire T elevated above baseline)
  • ST DEPRESSION DDX: angina, digoxin, subendocardial/non-transmural MI

• POSTERIOR: Dominant R in V1-V2, ST depression V1-3, +/-upright T, > 0.5mm ELEVATION in V7-9

• ANTERIOR
  • V2-4 = ANT (mid LAD); often have tachyarrhythmia, mobitz 2 or 3rd AVB
  • ELEVATION V1-4 = anteroseptal (LAD proximal to first diagonal)
  • ELEVATION aVR>V1 with lateral ST depression = left main/proximal LAD lesion
  • Wellen’s Sign (critical LAD stenosis in USA)
    • V2-4: Greater than 2mm T-wave inversions (76%) or biphasic T’s (24%)
    • R-waves remain present as opposed to LV aneurysm or septal/ant STEMI
    • Typically anterior MI with 85% stenosis and infarct at ~8 days

• INFERIOR: ELEVATION 2,3,aVF; 80% have reciprocal change in aVL+V1-4; (RCA 70%, circumflex 30%)
  • Evolution of ECG:
    • T-wave inversion in aVL (not early repol, can be normal in LBBB or LVH - will be flipped in I & aVL)
    • Then ST depression followed by inf elevation
  • RIGHT VENTRICULAR
    • RIGHT-sided ECG: V3-6R ELEVATION (V4R most sensitive)=INF+right ventricle (30%)
    • Inf + V1 elevation likely RV infarct
    • No NTG or Lopressor; IVF to inc preload!
      • Watch for 2nd(mobitz 1) & 3rd degree AVB

• LATERAL: ELEVATION 1, aVL, V5-6; first diag, circumflex, or obtuse marginal
  • +/- DEPRESSION in V1-6 = inferolateral (dominant circumflex, RCA)

• SEPTAL
  • V1-V2

• TPA

• STEMI Mimics
  • Pericarditis - PR shortening or depression, diffuse ST elevation
  • PE - tachy, RAD, S1Q3T3
  • LBBB - discordance
  • Hypercalcemia - ST elevation
  • Ventricular aneurysm - T in V1-4 / QRS in V1-4 <.22 = MI
    • V2-4 – LV aneurysm – may throw clots; check US
    • Only 35% have reciprocal inf changes
  • inc ICP/SAH - diffusely inverted deep T's across precordial leads (vs Wellen's - decipher with hx)
  • spiked helmet appearance -- inferior=abdominal, V1-6=intrathoracic
  • Paced
  • Brugada
  • LVH - many calculations;
  • Hypotehrmia

• Brugada (genetic sodium channel mutation, sudden death)
  • V1-V3 with a RBBB appearance +/- terminal S waves in the lateral leads; prolongation of the PR interval is frequently seen
  • Type 1: coved 2mm ST elevation with negative T-wave (gradually descending ST segment)
  • Type 2: saddle back pattern with 2 mm J-point elevation and at least 1 mm ST elevation with a positive or biphasic T-wave
  • Type 3: saddle back pattern with less than 2 mm J-point elevation and less than 1 mm ST elevation with a positive T-wave
  • Typically, when the heart rate decreases, the ST segment elevation increases and when the heart rate increases the ST segment elevation decreases
  • TX: ICD

 RVH can give R in V1 o RCA involvement (III>II) can interrupt the AV node resulting in AVB o 2nd degree AVB/Mobitz 1 (Wenckebach): progressive prolongation of PR until dropped beat  ... measure the pr after the drop...if the one after the drop is shorter than the preceding, type 1...increased vagal tone o 2nd degree AVB/Mobitz 2...structural defect (2-3p’s for every QRS)  Non-conducted atrial impulses o 3rd degree AVB ... atria must be faster  if ventricle beating faster, it is AV dissociation

• ACEP CHF: most often due to CAD or hypertension

o BNP<100 negative; >500 likely; increased with age, obesity, CKD  BNP - higher=poor prognosis; Unreliable in ARF, PE, elderly, females, cirrhosis  CXR: cephalization, CM, edema/ Kerley B, effusion o NTG 60mcg/min most important treatment! o NIPPV: CPAP 7-10 is best; BiPAP 12/8 (possible higher NSTEMI rate) o Lasix 40 q8 or BUMEX (may worsen renal function if >60mg daily) o Vasotec decreases wedge pressure by 7, MAP by 20! (not if hypotensive) o Nitroprusside for severe hypertension (pre & afterload), Digoxin (delayed inotropy) o Dobutamine, milrinone, IABP for refractory cases (or cardiogenic shock) o Hypotensionwith CHF – albumin with lasix btw units  A-fib: cardizem .25mg/kg, repeat at .35mk/kg; gtt 5-15mg/hr; o stop cardizem gtt 4 hrs after starting multaq o RISK: DM, hypertension, TSH, COPD/OSA

• CHADS2 score: CHF, hypertension(controlled), age>75, DM, prior CVI(2 pts)

 Score=0, only ASA; >1=coumadin o >48 hrs=high VTE risk; anticoagulate x 1mo, Coumadin x 1 mo, then TEE o ibutilide (corvert – 4% get torsades, not with CHF) or flecanaide o amiodarone 150mg +/- gtt o digoxin .5mg IV then 0.25mg q6hrs x 2 o shock if unstable or new  dabigatrum (pradaxa): equal efficacy to coumadin, no lab monitoring, not with CKD

• Endocarditis:

o Strep viridians #1; Risk: IVDA, prosthetic valve, rheumatic heart disease, dental procedures, GI instrumentation o Fever (85%), murmur (60%); JONES: joints/janeway lesions, osler nodes, erythema nodosum, syndenham’s chorea o o Endocarditis Prophylaxis – with prosthetic heart valves, previous endocarditis, congenital malformations, MVP, IVDA . . . for dental cleaning or extraction, tonsillectomy, bronchoscopy, sclerosing of varices, biliary procedures, ERCP, prostatectomy (not for delivery/C-Section)  General – amoxicillin 2g 1 hr before procedure; ampicillin 2g IV 30 min before  penicillin allergy – clinda 600mg (PO or IV) , keflex 2g, azithro 500mg 1 hr before or ancef 1g IV/IM  GI/GU procedures – amp 2g + gentamicin 1.5mg/kg 1 hr before + amox 1g 6 hr after  GI/GU with penicillin allergy – vanc 1g + gentamicin 1.5mg/kg 30 min before  Murantic endocarditis: non-bcaterial thrombotic endocarditis; deposits of fibrin on L>R leaflets with 1-5mm sterile vegetations; seen in autoimmune and neoplastic patients, in 2% of population & 10% of CVA patients o Endocarditis: 3 BCX, TEE  native valve: nafcillin 2g q6 + ampicillin2g q4 + gentamicin 1mg/kg q8  prosthetic valve: vancomycin + gentamicin q8 + rifampin 300 PO q8  IVDA: vanco; daptomycin 6mg/kg daily (can be used for penicillin allg)  prophylaxis: amoxicillin 2g PO 2 hrs before procedure o • Random

• PE: tachy, large S in 1, ST depression in 2, Q-wave and T-inversion in 3, transient RBBB (RSR’) with T inversions in V1-4 • R-wave in AVR – consider Na channel blockade (TCA) – treatment: bicarb 2 amps +/- gtt o Amio may increase QT  torsades; treatment: overdrive pacing o NO STRESS TEST • COPD: low voltage with RAD; can have MAT (secondary to theophylline) • HyperKalemia: peaked T, wide QRS, flat P … severe  bradycardia • HypoKalemia: flat T with U-wave; makes dig toxicity worse • HyperCalcemia: short QT interval • Hypocalcemia: long QT interval • Digitalis: downsloping ST (mustache/ski-jump AFTER QRS); parasympathetic effect; AV blocks can cause increased junctional and ventricular irritability • Quinidine: wide, notched P-wave, wide QRS, ST depression, QT prolonged, U-waves; torsades • Pacer: AVB, SSS; overdrive suppressed by rate, PVC’s, etc; leads should be in apex of RV – will cause LBBB with left axis • Heart TPX: native (does not cross the suture line—ineffective) and donor SA node • If patient less than 40, had non-diagnostic ECG, 2 neg trops 6 hrs apart, routine stress testing is not clinically useful • Coronary sinus empties venous coronary circulation to right atrium

ECG's

• Adrenergic (increased contractility, AV conduction, & foci irritability) blocked by Vagus nerve (parasympathetic); carotid massage increases parasympathetics; decreases irritable focus; SA slows, arteries dilate  hypotension and syncope
  • SA node to left atrium via Bachman’s bundle
• Autonomic foci
  • Atrial 60-80 (SA node inherently >100 but limited by Vagus); overrides and suppresses slower foci;
    • minimally varies with respiration (sinus arrhythmia)
  • Junctional 40-60 (no p-wave); Ventricular 20-40
    • Accelerated Junctional if no p’s but rate >60
• Axis
  • RAD – 1 down, aVF up; lat MI, post hemiblock, slender body, ventilator hypertrophy, pul disease, vertical heart
  • LAD – 1 up, aVF down; left hemiblock, LVH, inf MI, horizontal heart
  • aVL isoelectric at -30, aVF at 90
  • LVH: deep QS; R in V2-5>35mm
• S in V1 + R in V5 or V6 ≥ 35 mm; R in aVL ≥ 11 mm
• R or S in limb leads≥20 mm; S in V1-2 or R in V5-6 ≥30 mm
  • RVH: high R (>7 boxes, R>=S) in V1, RAD
  • RAE: Lead V2 P>2mm
  • LAE: wide, notched P in V1
• PR interval is the AV conduction pause
• R-wave progressively increases across precordial leads; QRS neg in V1, pos in V6
• BBB often secondary to ischemia (bundle=HIS + purkinge fibers)
  • RBBB – LAD lesion
    • RSR’ V1-3, deep S in lat leads (V5-6); dominant R in V1;
    • Ant MI – RBBB + left ant hemiblock; right axis

o LBBB – RSR’ in lat leads

• • • Ant fascicle – LAD lesion (V1-4); left axis deviation + neg QRS in INF leads; Q in 1, deep S in 3; deep QS in V1
    • Post fascicle – LCA (often dual blood supply); inf MI, right axis deviation; deep/wide S in 1, Q in 3
  • Mixed blocks
    • RBBB+Post hemiblock can quickly progress to 3rd degree AVB!!!
    • Mobits 2 (2:1) likely to progress to 3rd degree AVB
    • Ventricular focus paces the heart (slowpacer); intermittent block will change QRS morphology … NEED PACER!!!
• Tachycardia
  • V-tach criteria (if positive → v-tach)
    • Concordance of ALL V1-6 (neg>>pos)
    • Brugada V-tach criteria:
      1. No RS complex V1-6
      2. RS>100msec
      3. AV dissociation (atrial slower than ventricular)

• Physiologic, pharmacologic/cocaine, pathologic (hypovolemic, TSH)
• Treat with AMIODARONE IF UNKNOWN RHYTHM
  • • SVT: rate~160-180
    • A-flutter: rate~150, 2:1 AVB (regular); sawtooth P’s
    • PAT: rate~120
  • Irregular
    • A-fib: rate >100; no discernable P’s
    • MAT: rate ~140; varying height of P and PR interval

Derm

Basic Dermatology Definitions

• Macule – flat and circumscribed
• Papule – solid and elevated; forms plaques (wart, SK, melanoma, angioma)
• Plaque – solid, circumscribed, elevated (psoriasis, tinea, eczema)
• Nodules – elevated, circumscribed, solid (BCC, SCC, hemangioma, NF, melanoma)
• Pustule – collection of leukocytes (pox, milia, acne, herpes, impetigo)
• Vessicle < .5cm, Bullae >.5cm; check Nicolsky’s (varicella, herpes, impetigo)
• Wheals (hives) – fluid infiltrates the dermis (angioedema, urticaria)
• Scales – excessive keratinization; psoriasis, tinea, Kawasaki, scalded skin
• Crusts – dried serumen cells (scab) – impetigo (honey), tinea
• Ulcer - epidermis & dermis; will leave a scar (chancroid)
• Excoriation – lesion from scratching
• Comedone – plugged hair follicle (open-blackhead, closed=whitehead)

Sutures

• Wound Care: tap water, explore for FB, non-sterile gloves, keep wound moist
  • Prophylactic abx: deep wounds, punctures, pseudomonal coverage for shoes, bites

• connect the “Lines of Langer”
• Scalp 4-0 in 7 days
• Face/Lips/Ears: 6-0/5-0 in 5 days, or plain RAPID gut; then steristrips
• Eyelid with no levator involvement: 6-0/7-0 nylon or silk
• Fast absorbing gut for face; dissolves in 5-12 days; can be removed earlier (5d)
• Oral Mucosa 5-0 gut or vicryl
• Torso: 4-0 in 10-12 days
• Hand: 5-0 in 10 days
• Nailbed: 4-0/6-0 in 7 days
• Foot: 3-0/4-0 in 12 days
• Extremity: 4-0/3-0 in 12 days
• Extensor Tendon – 4-0
• Vagina – 4-0 absorbable (gut or vicryl)

• Dermabond ~5-0 strength: should not be used on wound >4cm; can be removed with petroleum jelly (or neosporin) … should remove tar as well

• Td prophylaxis: 0.5ml IM (for >7 y/o); TIG 250-500U IM if not fully immunized
  • Low risk wounds need to be updated every 10 years
  • High risk: puncture/crush, IVDA, dirt contamination, >1cm deep, saliva; update every 5 years
    • high risk wounds without prev. immunizations require Td +TIG (passive)
  • Age 11-12 should get one dose of Tdap (Adacel)

• Any lacs up to 12 hours, face up to 72 hours
  • Infection risk: face=2%, arm=7%, leg=15%
  • NO CLOSURE for fight bite, crush injury, bite to hands & feet, or infected
  • Bites: Primary closure for head, face, neck <12 hrs
  • Bites: Delayed primary if >12 hrs or signs of infection
  • Animal: DICLOXACILLIN, augmentin, or e-mycin; Human=augmentin or cefuroxime



Conditions

• ACNE: clindamycin + claron, differin cream + microderm abrasion; tazarac for scarring + very oily; DUAC=clinda + peroxide
  • Non-inflammatory (open, closed)
  • Inflammatory (papule, pustule, nodule (>5mm))
  • Mild: rennin-A, benzoyl peroxide, topical sulfa/clinda
  • Moderate: sulfa, topical antibiotic, peroxide, oral antibiotic x 3mo or retin-A
  • Severe: accutane
    • Retinoids: differinretin-Atazorac (strongest); thin layer nightly after washing face x 2mo
    • Peroxide: benzaclin, triaz
    • Topical antibiotic: clindagel, plexion (sulfa)
    • Oral antibiotic: tetracycline, doxycycline, minocycline
    • Isotretinoin: accutane 1mg/kg/day x 120days; double contraceptives
• Actinic Keratoses: retin A x 2 weeks, then aldera>effudex
• Brown spots: obagi nu-derm system … 6 products daily ($350) + retin A ($75)
• Bullous Pemphigoid – nicolsky sign, elderly
• Pemphigous Vulgaris – friable lesions, middle age, watch for bacterial superinfection; not in mouth
• Candida: thrush, balantitis, vulvovaginitis – fluconazole (cancidas IV for non-albicans)
  • Diaper rash: hytone + bactroban
    • keep dry, anti-fungal (lomotrin), Vaseline/silicone spray
• Chapped hands: locoid lipocream + bactroban
• Dandruff: selsun blue, loprox
• Epi Pen to finger: NTG paste or phentolamine SQ; safe with no treatment
• Erisypelas - keflex
• Erythema Nodosum: nodules to shins; inflammatory, drug rxn; self-resolving <6 weeks, NSAIDs
• Folliculitis: evoclen (clinda foam) or carmal shampoo (sulfa)
  • Ketaconazole shampoo + 200mg PO daily x 1 month
• Keratosis pilaris – retin A to unclog pores
• Necrotizing Fasciitis
  • LRINEC Score Crit Care Med 2004

1. CRP (mg/L) ≥150: 4 points
2. WBC count (×10³/mm³)
   • <15: 0 points
   • 15–25: 1 point
   • >25: 2 points
3. Hemoglobin (g/dL)
   • >13.5: 0 points
   • 11–13.5: 1 point
   • <11: 2 points
4. Sodium (mmol/L) <135: 2 points
5. Creatinine (umol/L) >141: 2 points
6. Glucose (mmol/L) >10: 1 point

• Low Risk: score 5 (10% of pts with score < 6 still had nec fasc)
• Moderate Risk: score 6– 7
  • Score > 6 has PPV of 92% and NPV of 96% for necrotizing fasciitis
• High Risk: score >8
• Toxic shock/necrotizing fasciitis - use clindamycin as it suppresses toxin elaboration by bacteria

• Onchyolysis (nail separation) & pitting
  • TX: topical steroid x 2 weeks, lubrication x 1 wk; moderate=tar + UVB; severe=methotrexate (hepatotoxic) + UVB
• Orbital (NOT periorbital) cellulites is an EMERGENCY (no valves in the facial veins)
• Photosentitivity: tetracyclines, sulfa, Compazine
• Psoriasis – A&D ointment, phototherapy, cyclosporin/methotrexate, dermatologist for T-cell or TNF-inhibiting agents
• Poison Ivy (uroshiol): prednisone 60mg x 14d then taper x 7
• Scarlet fever – strawberry tongue, sandpaper rash
• Sensitive skin: oil of olay
• Steroid Creams (Gel dries, cream moisturizes):
  • Class 1 (eczema, psoriasis) – clobetasol 0.05% x 14d
  • Class 2/3 (adults) – fluocinonide0.05%/betamethasone 0.5% x 21d
  • Class 4/5 (peds) – fluocinolone 0.025%/locoid 0.1%
  • Class 6 (eyelid) – kenalog 0.05% x 28d
  • Class 7 (diaper rash) – hydrocortisone 1% x 28d
• SJS/TEN
• Swimmer's Itch (cercarial dermatitis) - supportive care
• Tinea
  • Versicolor: sun + selson 2.5% 10min daily x 1 week + lamisil bid x 7d +/- ketaconazole 400mg daily x 1 month
  • Corporis: itraconazole 200 PO daily x 7d
    • Griseofulvin drug of choice for PEDS: 20mg/kg/day x 6 weeks
  • Pedis: lamisil q12 x 1 week; terbafine 250 qd x 6 weeks if refractory
  • Cruris: miconazole daily x 6 weeks or fluconazole 100 daily x 3 weeks
• Toenail Fungus – penlac polish, terbafine (penetrates nails to SQ fat), itraconazole (with meals … lasts 3 months post treatment in the nails)
• Wound care: vit A 10,000u, vit C 500mg BID, MVI QD, Zinc sulfate 220mg QD
  • Scars: myderma decreases the redness

Endocrine

• Addison’s Disease
• Cushing’s Disease

• Diabetes mellitus
  • decreased c-peptide (no endogenous plasma insulin) – type 1
  • exogenous insulin has high plasma with normal to low CP
  • Insulinoma has increased plasma insulin and C-peptide level
  • HbA1C: levels correlate as follows: 6 ~ BS of 130; increases by 35 for every one above it (8 ~ BS=200, 12 ~BS=340)
  • O’Riain wrinkle test for sympathetic function – skin should wrinkle in H2O for 20 minutes … if not, poor sympathetic function!
  • “Correction Factor”: check preprandial glucose and give 1u per 50g over 100 + 1u per 10g carbs in meal
  • Starting Insulin: 0.3 – 0.5 units/kg; 50% lantus, 50% novolog (QAC&HS)

• DKA (usually Type 1=5% of all DM); HHS (Type 2)
  • Not enough insulin, so no glucose in the cells; catabolize protein and fat for gluconeogenesis  ketone production
  • HHS – slower onset, higher mortality (5-20 vs <2%), normal pH, 8-10L loss
  • VBG, acetone, UA, BHB  ketones . . . ketones increase as patient improves
  • NS 2 liter bolus, 500cc/hr x 2, then 250cc/hr; typically 3-6L deficit, 150-200cc/hr (+20 kcl when K<5)
    • BS<250 x2, change to D5 ½ NS@ 125cc/hr
  • Insulin gtt: NO BOLUS; 0.1 – 0.14 u/kg/hr; lower BS 75/hr; once BS<250, gap closed, no acetone, and bicarb>20, feed and give .3-.5 u/kg insulin (1/2 lantus, ½ novolog with meals); stop gtt in 1 hr
    • Chem. 7, phos, mag q2 hrs; keep K>3.5meq/L
  • Peds cerebral edema: mannitol 1-2g/kg over 20 min; 5-10ml/kg of 3% NS

• AKA: use D5NS; no ketones in urine but very high BHB (no NAD but High HADH+ from ETOH); very high lactate

• Corrected Na: add 1.8 per 100 over glucose=100

• Hyperkalemia: check ECG!!!
  • Peaked T, QRS widening, prolonged PR, RBBB, sine wave, asystole
    • Calcium Chloride 20mg/kg IV (preferred to Ca gluconate 50-100mg/kg)
    • Kayexalate 1g/kg PO (preferred to PR)
    • Albuterol LVN (continuous 10ml/1hr)
    • Bicarb 1meq/kg IV; Insulin .1U/kg IV + Glucose D50 1ml/kg



• Hyperthyroid/Thyroid storm
  • Check TSH, free T4 (?T3); consider other endocrine tests (?ACTH, cortisol???)

1. Propranolol – 1mg IV q15 min, 5mg max; +/- gtt
2. Methimazole 5-30mg PO, 20mg max if pregnant
3. PTU – 600mg; give 1 hour after propranolol; 100-900mg daily, divided TID; 200 daily if pregnant
4. Iodine 131 10-15mCi (this is ABLATION!!! – consult endocrine 1st!!!)

• Hyponatremia: 3% saline if seizing (100ml)
  • correct at 2 mEq/L/hr (NS=154 mEq/L)
• Myxedema Coma



• DI
  • SG<1.005, UNa<20, Uosm<200  DDAVP 0.05mg PO q12, fluid restrict, consider HCTZ, stop lithium
• SIADH
  • SG>1.030, UNa>20, Uosm>200  fluid restrict, consider 3% NS

 

ENT

Ear

• Ear FB: try small ENT suction tip
• Otitis media: 10d treatment if <2; 7d treatment if >2 y/o; less than 6mo, always treat!
  • Amoxicillin 90mg/kg divided q12; azithro 10m/k, then 5m/k x 5d
• Otitis externa: ofloxacin 0.3% 5gtt q12 x 7d; use suspension (NOT solution) if risk of TM rupture; +/- HC drops; auralgam for pain
  • Prevention: No q-tips; 2% acetic acid or white vinegar
  • Malignant Otitis externa: ciprofloxacin 750 q12
• Mastoiditis: rocephin 2g qd

Nose

• Nasal FB: Fogarty catheter
• Epistaxis
  • Afrin spray + PAC with nose clip, silver nitrate, merocel, thrombin spray, rhinorocket, foley tamponade
  • Td, augmentin/keflex
  • Admit/obs if double packing (risk of asphyxia)
• Sinusitis
  • Acute <4wk; subacute 4-12 weeks; chronic >12 wks - ENT consult
  • Viral: NSAID, antihistamine, decongestant (oral+nasal);
  • Antibiotics if worse after 10 days; consider fungal if immunocompromised
    • Moderate: bactrim 1 q12 x 10d; cefdinir 300 q 12 x 10d
    • Severe (antibiotic failure): levaquin 750 x 10d; augmentin XR 2 q12 x10d
    • Peds: amoxicillin (or augmentin) 45mg/kg q12 x 10d; cefdinir 14mg/kg x 10d; bactrim 5mg/kg q12 x 10d

Throat

• BLADE:
  • bacterial tracheitis
  • laryngeobronchitis (croup) – CXR (steeple sign)
  • aspiration/paratracheal/retropharyngeal abscess (ST lat neck)
  • diphtheria
  • epiglottitis – lat neck (thumbprint)

• • Centor Criteria: fever, exudate, tender ant cervical adenopathy, no cough; 0-1 no culture, no antibiotic; 2-3 culture; 4=antibiotic
  • Mono: lymphadenopathy, palatine petechiae, fatigue, >50% lymphocytes and 10% atypical lymphocytes (JAMA. 2016;315(14):1502-1509. doi:10.1001/jama.2016.2111)

o Parotitis: mainly viral (mumps); massage gland and stimulate with OJ or lemon drops (sialogues);  augmentin 875 q12; clinda 300mg q6; keflex 500mg q6

• Pharyngitis … consider mono (steroid, hydration, no contact sports)

 penicillin G 1.2mill units IM x 1; penicillin VK 500 q12 x 10d; clinda 300 q8 x 10d  Peds: penicillin G 25k units/kg IM; penicillin VK 12.5mg/kg q6 x 10d; clarithromycin 7.5mg/kg q12 x 10d

 o Parapharyngeal abscess (peritonsilar/retropharyngeal) – CT neck with IV  Clinda 900mg q8, zosyn 4.5g q8, steroids  o Thrush  Nystatin swish and swallow100k units/ml 5ml q6 x 14d; fluconazole 200mg PO + 100mg x 13d; STOP 2 days after lesions clear  Infants: 1ml to each side of mouth q6; peds 5ml q6; if breastfeeding, must treat the nipple as well o

DENTAL

• Incisors (2), canine (1), premolars (2), molars (2+1); adult=32, peds=20
  • Enamel - dentin - pulp - periodontal ligament - alveolar bone
• Dental Pain – most often pulpitis (likely bacrterial from caries)
  • No antibiotic if no overt infection; however, without good radiographic evidence and good follow-up, benefit> risk
    • Dental block, NSAIDs, narcotics
    • If pain due to deep caries, dental block + cover it (temrex, dermabond, bone wax)
• Dental Abscess: Pen VK (or amoxyl) or erythromycin 500 q6 x 10d
• Ludwing's Angina: clinda 600 q6
• ANUG (nec ulcerative gingivitis) penicillin 500 q6 + Flagyl 500 q8 x 10d

• Trauma
  • Find missing tooth parts – xray for aspiration
  • Bleeding: irrigate, lido with epinephrine, gauze, gelfoam/surgical +/- thrombin (sew in gelfoam with “X” stitch)
  • Close mucosa if >0.5cm (vicryl)
  • antibiotics for mucosal lacs, avulsed/fx teeth … amoxyl, clinda

• Subluxation – loose only
  • Luxation – tooth displacement (extrusive, intrusive, laterally)
    • X-ray for intruded teeth if not brought in
    • Intruded teeth need to be re-positioned & splinted by dentist … often alveolar bone fx
  • Avulsion – complete displacement of tooth out of socket
    • Hank’s solution or milk; do NOT wipe the ligaments!!!
    • Irrigate tooth & socket, re-implant, splint
    • Tooth displacement – stabilize with COE-PAK (mix base + catalyst); Liquid diet, 48 hr follow upp
    • Do NOT replace primary teeth (peds)

• Alveolar osteitis (dry socket -- loss of clot -- after tooth removal)
  • Block, irrigate & suction, pack (gelfoam or dry socket paste)

• Dental fracture
  • Ellis 1 – enamel fx … dental restoration; <3% pulp necrosis
  • Ellis 2 – crown fracture with enamel & dentin … very sensitive … 10% pulp necrosis; dry tooth & cover with CaOH paste
  • Ellis 3 – crown fracture with enamel, dentin, & pulp
  • Root fracture; block, dry, CaOH, immediate dental referral
    • Likely pulp necrosis  root canal!



ENVIRONMENTAL

• Mosquito repellant: DEET on skin, permethrin spray on clothes • Fire ant stings: cool, baking soda paste, antihistamines, steroid burst • Swimmer’s itch: schistosome cercarval dermatitis; cool, calamine, class 2-5 steroids • • Radiation exposure o acute radiation syndrome – key factors are time of exposure, distance from exposure, & duration of exposure o Decon: use radiation meter, remove clothing, wash until <2x background radiation level  Time of onset of vomiting is key • <10 min = >8Gy … lethal • 10-30 min = 6-8 Gy … very severe • <1hr = 4-6 Gy … severe • >2 hours = <2 Gy … mild  Serial CBC for progressive decline in lymphocyte levels • At 2 days: >1500=normal, <1000 severe, <100 lethal  Consider internal contamination if levels remain high • Gastric lavagem Prussian blue  Consider using neupogen o Cutaneous radiation injury – may be delayed presentation o • • • Anthrax: aerosolized; 1-6 day incubation; flu-like, wide mediastinum o ciprofloxacin 15mg/kg q12 or doxy 2.2 (2.5 PO)mg/kg; prophylaxis x 60 days! • Pneumonic Plague (yersenia pestis); aerosolized; 2-3 day incubation o High fever, consolidating pneumonia, hemoptysis, DIC, shock; g- bacilli o ciprofloxacin 15mg/kg q12 or doxy 2.2mg/kg … high mortality! • Tularemia: aerosolized or food-borne transmission; hilar adenopathy; ciprofloxacin or doxy • Botulism: aerosolized or food-borne transmission; onset 12-72 hours after exposure o Vent + CDC for anti-toxin • Smallpox: airborne; 7-14d incubation; synchronous vessiculopustular rash across entire body2-4 days after fever (face→ ext→ palms→ trunk) … give vaccine <4 days of exposure •

GI

• Cholangitis

1. Charcot’s Triad – fever, WBC, RUQ pain
2. Reynold’s Pentad … +hypotension & ALOC

• Choledocholithiasis – should have increased LFT’s (AP, AST/ALT)

1. Need ERCP/MRCP
2. Unasyn 3g q6; primaxin 500mg q6; rocephin + cipro/flagyl

• Constipation … milk of molasses + mag citrate; colace, senokot, Citrucel (less gas than Metamucil), go-lytely

• Food bolus impaction
  • NTG or Cardizem for muscle relaxation; glucagon 1mg IV (+/- Zofran)

• GI Bleed/Varicosities
  • Type & cross ... pRBCs +/-
  • Protonix 80mg IV + 8mg/hr gtt
  • Octreotide 50mcgIV + 50mcg/hr gtt or Somatostatin 250mg + 250mg/hr
  • Rocephin or Levaquin, erythromycin for gastric emptying (mortality benefit)
  • If lavage does not clear, call GI
    • Banding, IR, TIPS, BLAKEMORE tube last resort
    • Bleeding scan, angiography
  • PPI: ACCP says to consider them; no mortality benefit

• Eosinophilic esophagitis



• Hepatic Encephalopathy: for NH4
  • consider mannitol (do ocular US to look for increased ICP)
  • Lactulose -- higher rectal dose (200g)???
  • L-carnitine 1g IV q8 hrs; IV arginine?
  • Midodrine 100mg PO q8 hrs
  • Zinc sulfate 220mg PO q8 hrs

• Liver Failure
  • avoid hypotonic fluids, albumin is good
  • Ascites
    • Secondary to Cirrhosis (85%)
    • SAAG (serum-ascitic albumin):
      • >1.1 (cirrhosis or cardiac); if >2.5=cardiac
      • <1.1 – nephrotic, carcnomatosis, pancreatitis, Tb
  • HepatoRenal Syndrome (NASH)
  • Kings College Criteria for tPX:
  • Child-Pugh Classification:
  • MELD SCORE for transplant: AST>1000 is liver failure; pH<7.3 at 24 hrs, INR>6.5, encephalopathy, Cr>3.4, lactate >3.0 after resuscitation

• • Paracentis – not if INR>2, plt<20
    • Albumin + serum albumin, total protein, cell count, gram stain
    • Infraumbilical with empty bladder or lateral to rectus sheath; insert z-track and at angle
    • Give albumin if >5L take off
    • SBP:
      • Diagnostic tap if no other source of fever
      • Rocephin + albumin 1.5g/kg
      • Only get gram stain if PMN’s >250

 o Bud-Chiari: hepatic vein occlusion  Abd pain, ascites, hepatomegaly  75% hepatic vein thrombosis, 25% dues to tumor compression of vein  treatment: TIPS; watch for hepatorenal

• Advance dobhoff with reglan and place patient on right side for 30 min

• TPN: 30 cal/kg, pro 1g/kg, sugar 300 cal, water 100cc, fat 150 cal

  

  Hemorrhoids o Anusol-HC suppositories; steroid cream (Prep H) better than suppositories o o Thrombosed: inject lido at base and into hemorrhoid; elliptical incision, pack & dress wound  may need silver nitrate or cautery   Pancreatitis o I GET SMASHED (idiopathic [microlithiasis], gallstone (40%; especially if ALT>150), ETOH (40%), trauma, steroids, mumps, autoimmune [SLE], scorpion, hyper- [Ca, lipids] /hypothermia, ERCP, drugs [sulfa, NSAIDs, diuretics]) o DX Criteria: 3x lipase, epigastric pain, confirmatory US (need 2 of 3) o Ranson Initial: Glucose>200, Age>55, LDH>350, AST>250, WBC>16 o Ranson 48 hour:Ca<8 (fat saponification), hematocrit drop 10%, pO2<60, BUN+5 from baseline, Base deficit >4, Sequestration >6L IVF  Score >2 … likely to develop severe pancreatitis o Mortality: 0-2=2%, 3-4=15%, 5-6=40%, 7-8=fatal o TX: 3L bolus then 250ml/hr o No antibiotic needed; if septic or suspicion of abscess, primaxin or merrem   Diarrhea . . . ciprofloxacin 500 bid x 5d; bactrim q12 x 5d o Camphylobacter: ciprofloxacin 500 q12 x 3d; azithro 500 x 3d o C. diff: vanco/flagyl PO o E.Coli: antibiotic increases chance of HUS o Salmonella: ciprofloxacin 500 q12 x 5d; azithro 1g then 500 x 6d o Shigella: cipro/azithro 500 x 3d o Vibrio cholera: doxy 300mg x 1; ciprofloxacin 1g x 1 o Yersinia enterocolitica: ciprofloxacin 500q12 x 3d; bactrim q12 x 3d o Emtamoeba histolytica: flagyl 750 q8 x 10d o Giardia: flagyl 750 q8 x 5d

Hematology

• Hypercoaguability work-up: CBC, INR, ANA, Factor 5 Leiden, Prothrombin G20210A, Homocysteine, Lupus Anticoagulant
  • EXTRA’s: Protein C & S, Anti-thrombin III, Anti-phospholipid, anti-cardiolipin
  • AFFECTED by Heparin: Protein C&S, antithrombin 3, Lupus anticoag

Bleeding

• • Uncontrolled bleeding: thrombin powder/spray, thrombin gel foam, surgi-cel, actifuse: like gelfoam but does not expand, cauterize/stitch
  • Anticoagulant reversals
    • Heparin/lovenox -- protamine
    • ASA/Plavix – platelets +/- DDAVP
    • Coumadin decreases Proteins C & S, thus hypercoaguable state (start with heparin); Reversal:
      • PO vitamin K: takes 4 days to increase INR>2; INR 5-9=2.5mg PO; INR>9=5mg PO
      • Active bleed: Vit K 10mg IV + FFP 10-20ml/kg (1unit=200ml)
      • PCC 50units/kg, 5000 max
    • Arixtra -- factor 7a
    • 10a inhibitors: xarelto, eliquis, savayasa
    • Direct thrombin inhibitors
      • Praxibind may be useful for big brain bleeds, but otherwise expensive with little true evidence of efficacy

• Lovenox steady state at 3 hours; No Lovenox if Cr>2.0
• When replacing blood, use NS (not LR – clots); 1u=325 ml (count as 3:1 fluid replacement – colloid); 1u FFP per 4u pRBC’s
• DIC: d-dimer/fibrin split products high, fibrinogen<200, INR, thrombocytopenia, low factor 8
  • 1 pRBC : 1 FFP; Platelets – 6pk per 3 RBC’s; Factor 7 4mg IV q20 min
  • Cryoprecipitate; DDAVP;
  • Amicar (aminocaproic acid) 5g/1hr then 1g/hr x 8 … last ditch effort
• HIT: Thrombocytopenia= platelet drop more than 50 pct; platelets will stay around 60K in cardiac surgert pts, platelet will drop 50 percent immediately ... but if it falls after day 4, look for HIT!
  • lovenox less than 1pct, UFH less 5 pct; use arixtra (fondiparinox)
  • Argatroban for confirmed HIT
  • check immunoassays (99 sensitive, not specific... 0.4-1 is 5 pct chance of HIT...1.4 is 50 pct chance of HIT... more than 2 is 90 pct chance of HIT) and PF4 levels ... platelet serotonin release assay (gold standard-send out)
• ITP: <20k platelets
  • treatment: IVIG
• Sickle Cell – trait ~40% HbS, disease >50% HbS;
  • Vaso-occlusive episodes: AChestS (infiltrate on CXR, consider PE), Pulm hypertension (stress ECHO), CVI (transcranial Doppler or MRA), joint necrosis, splenic sequestration (Hgb drop 2g), ARF, priapism; parvo B-19 causes aplastic crisis
  • CBC, peripheral smear, retic count (normal=sequestration, low (<0.5%)=aplastic – likely parvo); LFTs, BCX
  • TX: Hydrate, O2, toradol +/- morphine; hydroxyurea if chronic pain
  • Transfuse: sequestration with severe anemia (retic count <3%)
  • Exchange TFX to keep HbS<30%: CVI, ACS with O2<90%, priapism
• TTP

ONCOLOGY

• ALL – highest cancer in peds; FEVER; lymphadenopathy (mediastinal), anemia, thrombocytopenia, neutropenia; check uric acid, watch for ARF
• CML – 20% of all leukemia; 30-50 y/o; BCR/ABL 9/22 translocation – Philadelphia Cr; Leukocytosis, thrombocytosis; peripheral smear; after 3-5 yrs, blast crisis
• CLL – BCL-2; >55 y/o; large lymphadenopathy (in 87% on Dx); check clonality by flow cytometry; smudge cells on peripheral smear
• AML – >20% blasts; in all ages – incidence increases with age (median=70); auer rods; Anemia, neutropenia, thrombocytopenia; schistocytes with DIC; Negative myeloperoxidase stain and + TdT
• Hemophilia
• Hyperviscosity Syndrome: seen in MM, CML  rouleaux formation
• Multiple Myeloma
• Myelodysplastic syndrome – often progresses to AML; macrocytic anemia, mild thrombocytopenia
• Neutropenic patient: zosyn 4.5 q6 + tobra 5mg/kg
• NHL -
• Tumor Lysis Syndrome:
• Tumor Markers:
  • AFP: Liver, ovaries/testes; elevated during pregnancy
  • B2M (Beta-2 microglobulin): Multiple myeloma and lymphomas; also present with Crohn¦s disease and hepatitis
  • BTA (Bladder tumor antigen -- UA) – diagnose recurrence
  • CA 15-3: breast, lung, ovarian; stage & monitor recurrence
  • CA 19-9: Pancreatic, colorectal; stage & monitor recurrence
  • CA 72-4 + CA-125: ovarian Ca; also elevated with endometriosis
  • Calcitonin: thyromedullary carcinoma, pernicious anemia, thyroiditis
  • CEA: colorectal, lung, breast, thyroid, pancreatic, liver, cervix, and bladder; also in hepatitis, COPD, colitis, pancreatitis, and smokers
  • EGFR (Her-1): solid tumors (NSC lung, colon, pancreas, breast
  • hCG: Testicular and trophoblastic; Elevated in pregnancy
  • Her-2/neu: Oncogene in 20-30% of invasive breast
  • Monoclonal immunoglobulins: Multiple myeloma and Waldenstrom’s
  • NSE (Neuron-specific enolase): Neuroblastoma, small cell lung cancer (better than CEA)
  • NMP22 (UA): Bladder; diagnose and determine recurrence
  • Progesterone receptors: breast; increased in hormone-dependent cancer
  • PSA, total and free: prostate Ca; BPH, prostatitis, & with age; screen for, monitor treatment, and determine recurrence
  • Prostatic acid phosphatase (PAP): Metastatic prostate cancer, myeloma, lung cancer
  • S-100: Metastatic melanoma
  • TA-90: Metastatic melanoma
  • Thyroglobulin: Thyroid; after surgery to determine recurrence

ID

• Sepsis
  • WBC/bands, RR, HR, Temperature
    • 7.5% inc mortality for each hour of delayed antibiotic
    • 30ml/kg LR preferred; foley for I/O
    • Jama 2010: 10% lactate clearance analogous to ScVO2
    • IVC diameter variability over CVP
    • start antibiotic in first hour – not necessary to find source (Urine, Lung, abdomen, & skin)
    • solu-cortef 50 q6 if refractory hypotension/2 pressors
  • PROCESS: avg ~5L, no mortality change (20%) or ICU LOS, but only 55% central line vs 93% in EGDT group

• BUGS (best susceptibility listed first):
  • CDC: 404-639-3670

• • Acinetobacter baumanni: tobra (28%!!!)
  • Aeromonas hydrophilia - fresh water lake
  • Botulism: IgG from Ca Health department; 20% serum sickness; descending paralysis with CN (esp eye) involvement
  • Chagas: reduvid kissing bugs; dysrhythmias
  • Citrobacter: cipro/avelox
  • Dengue – in carribean; arthralgias, high fever within 14d of travel, transient macular rash, peyechaie/thrombocytopenia, inc LFTs; ddx malaria
  • E. Coli: rocephin, gent/tobra
  • Enterobacter: gent/tobra, cipro, bactrim
  • Enterovirus (EV-D68): focal limb weakness; suspected to cause acute flaccid myelitis (AFM), an inflammation of the spinal cord with unique clinical and MRI features. MRI predominantly found in the gray matter of the spinal cord. Recent cases have primarily affected children under the age of 18
  • Giardia: camping/spring water; bloating, cramping, flatulence
  • HIV
    • Seroconversion 3-4 weeks after infection – 50% flu-like
    • PJP – IV Bactrim 20mg/kg/day div q6
    • CD4<50 – MAC, CMV retinitis, Toxoplasmosis
    • HAART – causes hepatotoxicity, lactic acidosis, obesity
      • Sexual assault or high resk encounter – PEP witin 72 hours; <2hrs is best; for 28 days; check for STDs, give zofran
      • Needlestick=0.3%, mucous=.1%
  • Klebsiella: rocephin, gent, bactrim
  • Leishmaniasis: snad fly; neutropenia, hepatosplenomegaly
  • Malaria: thick and thin smears, irregularly high fevers
    • quinine + doxy for chloroquine resistance
  • MERS: fever and pneumonia or ARDS, travel from Saudi Arabia within 14d
  • Measles: cough, coyza, conjunctivitis, Koplick spots, fever followed by rash 2-4 days later
  • Morganella: rocephin, tobra
  • Naglaeria/Acanthamoeba: freshwater amoeba; invade via corneal abrasion and cause meningoencephalitis; amphoteracin and miconazole
  • Serratia: bactrim, gent
  • Pinworm: scotch tape test; mebendazole
  • Proteus: rocephin, tobra
  • Providencia stuartii: bactrim, cipro/rocephin
  • Pseudomonas: tobra, fortaz
    • Highly resistant – colistin 2.5mg/kg QD div over 2-4 doses; (synergy with rifampin or ceftazidine); only 3% resistance, but very nephrotoxic
  • Staph: vanco, gent
  • Strep: vanco, rocephin (Strep D - enterococcus: zosyn + gent, vanco)
  • Swimmer’s Itch: avian schistosome dermatitis; spontaneous resolution
  • Trypanosomiasis: tsetse fly; cervical lymphadenopathy
  • VRE: zyvox; Resistant – tygacil (no pseudomonas coverage)

• Bites – prophylactic antibiotic x 5 days (if >72 hrs & no infection, no antibiotic); 14d if infected
  • Dog – augmentin to cover pasturella, capnocytophagia canimorsus
    • Consider crush injury (up to 450 psi!)
    • 4% facial infection, ~30-50% elsewhere
    • Doxy and flagyl if pcn allergic
  • Cat - augmentin to cover pasturella – 30-50% infection rate
    • If penicillin allergic, Adult: clinda & cipro, peds clinda + bactrim
  • Human - augmentin to cover eikenella; 10-20% infection rate; consider HIV/hepatitis
    • Fight bites look for tendon lac, extensor tenosynovitis
    • Penicillin allg Adults: clinda 450 q8 + bactrim DS q12
    • Penicillin allg peds: clinda 10mg/kg q8 + bactrim 5mg/kg of TMP (160 max) q12
  • Monkey – acyclovir 800mg 5x/d x 14 d for herpes B
  • Rat bite – streptobacillus; endocarditis, meningitis, penicillin or e-mycin
  • Ticks: doxy 100bid x 3 wks for lyme (need attachment for several days)
  • Rabies: raccoon, skunk, fox, bat, rabid dog – immediate vaccination; all others consult public health; local paresthesia, fever, HA, myalgias
    • Furious (laryngospasm/hydrophobia) vs paralytic (limb weakness)
    • Clean wound with soap, water, iodine, and SUNLIGHT
      • PEP (PASSIVE + ACTIVE) for indoor exposures (aerosolized guano)
        • HRIG 20IU/kg at site then IM + Vaccine 1ml IM at 0, 3, 7, & 14d
        • If previously vaccinated, vaccine at 0 & 3 days

• Random Facts:
  • penicillin – amoxicillin is best oral PCN
  • Gent cheaper than tobra

• Pregnancy Rx

Nephrology

• ARF: Creatine increase by >0.3 or 50% baseline; urine sodium, creatine (FeNa), eosinophils
  • PRE-renal: FeNa < 1, Bun: creatinine > 20:1; give IVF
  • RENAL: FENA > 1 = ATN, eosinophils=interstitial nephritis
  • POST-renal – start with a foley
• If oliguric (<200cc/day), try small dose of lasix
• In CHF, do NOT hold the ACE/ARB; only hold ACE if Creatine acutely increases by 30%

• CKD (GFR): >90 stage 1, 61-90 stage 2, 31-60 stage 3 (failure), 16-30 stage 4, 0-15 stage 5
  • Renin activates angiotensin (constricts blood flow); activates aldosterone (retains water) – end result is increased blood pressure
  • Anemia – give EPO
  • Hyperparathyroidism – check PTH, ionized Ca, Vit D
  • Give ACE/ARB
  • If GFR>60, give lasix (volume overloaded)

Max renal Troponin ~1.1

• Dialysis
  • If US normal but decreased flow from graft for HD, need IR fistulogram
  • PD - if diasylate WBC>100, initiate antibiotic

• Rhabdo
  • IVF=NS + 3amps bicarb @ 200cc/hr until urine output > 1-2ml/kg/hr
  • Consider dialysis if not improving

ELECTROLYTES

• If electrolytes are off, check: Urine na, cr, osm
• K+ falsely elevated with increased glucose
• Increased bicarb, decreased K+ = diuretic use until proven otherwise

o SIADH/diuretics: increased NA, increased osmolarity o Pre-renal (Diet/polydipsia): decreased sodium, increased osmolarity o Thiazide, loop, psych (check volume status): decreased Na, decreased osmolarity o NSAIDs – increase PGE which increases ADH; water is retained, thus urine sodium decreases o Na/K is proportional to osmolarity; correct K and Na will follow (and osmolarity will increase) – Na/K cotransporter • Adrenal Insufficiency – typically due to chronic steroid use; causes hypotension and hyponatremia

• Intravascular fluid retention per 1 liter:
  • NS=250cc
  • D5W=80cc
• Comparison of Loop Diuretics
  • Demadex T1/2=24 hrs 100% oral bioavailabiity
  • Bumex T1/2=12 hrs 80% oral bioavailability
  • Lasix T1/2=6 hrs 40-50% oral bioavailability
  • Ethacrinic acid – weaker, but only loop that is not sulfa-based



• Wegner’s -- elderly
• Goodpasture’s -- youth

   

Hypertension

• JNC 8

• JNC 7: o Stage 1 140/90 (confirm in 2 months) o Stage 2 160/100 (treat within 1 week) o >210/120, PO treatment and immediate follow upp

• Risk Factors: smoking, dyslipidemia, DM, >60y/o, male, post-menopausal, obesity, fm history; essential hypertension most common, renovascular most prevalent

 Peds: renal or pheochromocytoma; DDx: hyperthyroid

• Dx: fundoscopic disk edema/cotton-wool exudates, bruits/murmurs, UA (protein, rbc casts) most cost-effective test
• Accelerated hypertension: Significant elevation over baseline; HA, nausea and vomiting, visual disturbance, ALOC, seizure, and retinopathy with papilledema
  • Reduce MAP by 20-25% over 1 hour
  • Organ damage: LVH, angina, CHF, CKD, PAD, TIA
  • CVI (25%), Encephalopathy (16%), CHF (14%), ACS (12%), SAH (5%), AAA (2%)
• Meds
  • Nitroprusside: 0.3-10 mcg/kg/min; most potent; arteriolar and venous dilator
    • CN toxity after 24hrs; mix with Na thiosulfate and check thiocyanate levels
  • Labetalol: 20-80mg q 10 min; 300mg IVP max; gtt 0.5 - 3mg/kg/hr
    • alpha & beta (B=5x*A; B1:B2 = 7:1)
    • Contraindicated in bradycardia, heart block, asthma, CHF
  • Nicardipine: 5mg + 5-15mg/hr; first line treatment
  • Diltiazem: 0.25mg/kg, then 0.35mg/kg; gtt at 5-15mg/hr; great for tachycardia, Sick Sinus Syndrome
  • Fenoldopam: 0.1-1.6 mcg/kg/min; titrate q15min; dopa-1 receptor -- vasodilator
    • maintains renal perfusion (good in ARF/CKD)
  • NTG: 5-100 mcg/min; venodilator>>arteriolar; SE: tachycardia (reflex sympathetics)
  • Clevidipine: 1-2mg/hr, double q 2 min; max 32mg/hr; arteriolar vasodilation
    • ultra-short acting; Good for cardiac surgery patients
  • Esmolol: 0.5mg/kg + 50-300mcg/kg/min; may repeat bolus q 5min x 4, and increase drip rate by 25-50 each time; 9 min half life; B1-selective (90% blockade in 5 min)
    • Not with PAD, ca-blockers, ARF; causes skin necrosis
  • Hydralizine: 10-20mg IV/IM q30 min; 4:1 PO to IV dose; arteriolar dilator
  • Enalaprilat: 0.625-2.5mg q6; peaks in ~4 hours; ACEi, CHF
  • Phentolamine: 5-15mg q 15 min; alpha blocker; for cocaine or pheochromocytoma

• Stroke
  • For TPA: Must keep below 185/110 for 24 hours
    • Labetalol 10-20mg x 2 doses or cardene gtt
  • After TPA: 180-230/105-120
    • Labetalol up to 300mg
    • If >230/120: Cardene 5mg then 5-15mg/hr
  • NO TPA – goal to decrease 10-15% of MAP
    • Labetalol or nicardipine; NTG if DBP>140

• ICH/SAH/Aneurysm
  • Keep SBP<180, MAP>90 but <130
  • nimodipine PO for vasospasm
  • Cardene 2mg IVP, gtt 5-15mg/hr (may reverse vasospasm)
• MI: NTG, labetalol 20mg q10 min (double to 80mg), metoprolol 5mg q5 min, vasotec
• AAA: Esmolol gtt then Nipride gtt to SBP 100-120
• Cocaine: benzodiazepine+/- labetalol; Alt: phentolamine, niprode, NTG
• Pregnancy: pre-eclampsia (HELLP, DTR)
  • Mag 6g/20 min + 2g/hr; reverse with Ca gluconate
  • Hydralizine: Keep <160/110; Alt: Cardizem or labetalol

• PO Options: Asymptomatic >210/120
  • HCTZ 25mg qd (FIRST line)
  • Captopril 25 q8 (2nd … CHF, DM)
  • labetalol 200-400mg q6
  • metoprolol 50mg q12 (CAD)
  • Ca-blocker (cardizem, nicardipene)
  • clonidine 0.2mg patch
  • hydralizine 25q12
  • tekturna (renin-i)

NEURO

Headache

• Cephalgia: dilaudid + reglan 10 + mag 2g; decadron, toradol, phenergan, compazine, Benadryl, propranolol; zofran 30 min before DHE 45 1mg IV/IM, may repeat x 1 (2 hours to effect); Rx for fioricet 1 PO q4 x 10
  • Caffeine
  • Ketamine 0.2mg/kg, Haldol 5mg IV (inhibits serotonin uptake and norepi release)
  • Sphenopalatine and Occipital Nerve blocks
  • Magnesium over 15 min

• • Naprosyn 500mg & sumatriptan 100mg PO equally effective

o Compazine 10+Benadryl 12.5 IV >> triptan 6mg SQ (annals 7/10) o Cluster: high flow O2 (NRB), triptan, DHE45, avoid vasodilators o Tension: massage, OMT, NSAIDs o Migraine: DO NOT use triptan + ergot in 24 hours of each other; o Refractory: ativan + fentanyl ; stadol for rescue therapy o scintillating scotomas – most common aura – zigzag flickering light • • Temp Arteritis: >50, new HA, temp art tender, ESR>50, biopsy (3=93% sensitive) • • Post-dural HA: caffeine 500mg/1L NS over 1 hour; cosyntropin (ACTH) 1mg IV; blood patch • • Chiari Malformation (MRI): Chronic HA, inc with valsalva; balance, dizzy, nystagmus; Cerebellar tonsils and medulla through foramen magnum; +/-hydrocephalus • • Cavernous sinus thrombosis

Back Pain

• Cervical radiculopathy - Spurling test • • Back Pain with radiculopathy: motrin, vicodin, valium, Decadron + prednisone x 5d; robaxin >> norflex IM (non-sedating) o neurontin if peripheral/radicular pain 100-300mg TID; Lyrica if tingling o Lumbars affect nerve below unless central herniation (same level) • • LBP with new weakness – MRI + neurosurg; decadron 10mg + 6mg q6 o Sharp=radiculopathy o Weak=compression (surgery) o Achy (worse upright)=stenosis (PT) + epidurals • • Epidural/intracranial abscess: rocephin 2g q12 + flagyl 500mg q6

Stroke

TIA to CVI: Age Bp Clinical Duration Predictor • Age >60, BP>140/90, speech deficit=1…unilateral weakness=2; <60 min=1…>60min=2; <4=0.4%, 5=12%, 6=35% CVI at 1 week • Get stat carotid US, ASA +/- aggrenox/plavix, ECHO • CEA after age 70 increases stroke risk

NIHSS: 1. LOC: AOx3, follow commands 2. Gaze – palsy, forced deviation; Visual fields – any hemianopsia 3. Facial palsy 4. Motor – ARM & LEG – drift, gravity, paralysis 5. Ataxia … +/- rhomberg 6. Sensory - pinprick 7. Language – aphasia … severe … mute 8. Dysarthria – slurring 9. Extinction & Inattention – inattention … full neglect

• TPA up to 4.5 hrs … Alteplase .9mg/kg (90max); 10% bolus, 90% over 60 min o Need consent if >3 hours (not FDA approved) • Contraindications: head trauma or CVI <3mo, symptoms suggestive of SAH, recent intra-cranial/spinal surgery, active internal bleed, non-compressible arterial puncture <7d, Plt<100k, heparin <48 hours with inc ptt, direct thrombin or 10a inhibitor o Intracranial neoplasm, AVM, aneurysm, previous ICH o Glucose<50, BP > 185/110 • Relative Contraindications: minor or rapidly improving, pregnancy, seizure at onset, major surgery or trauma < 14d, recent GI/GU hemorrhage, MI < 3mo • 3 – 4.5 hr Contraindications: >80 y/o, NIHSS > 25, oral anticoagulants regardless of INR, dx of DM & prior CVI • Symptomatic hemorrhage by NIHSS: 0-5 (x%), 6-10 (x%), 11-15 (x%), 16-20 (x%), >20 (xx%) • bleed on CT, minor or rapidly improving, story consistent with SAH, active internal bleeding, PLT<100k, recent heparin or coumadin (elevated INR), major surgery or trauma <2wks, brain surgery or head trauma or CVI <3mo, GI bleed<3 wks, recent non-compressible art puncture or LP, BP>220/120; >185/110 after labetalol 20mg x 2, any intracranial bleed hx, glucose <50 or >400, seizure at time of stroke, known AVM or aneurysm o Do not give ASA, heparin, or coumadin!!! o NOT ACEP Standard of Care; 6.4% of large stroke pts had significant intracranial bleed!!! o Hemorrhage: CT, neurosurg, CBC, INR, fibrinogen, 6U plt + cryo • Intra-arterial TPA: within 6 hours of onset • Thrombectomy: up to 8 hours from onset • • Imaging: o CT: look for ICH, 1/3MCA, hyperdense MCA, midline shift, multifocal hypodensities o CTA: NIHSS>10; misses <3mm aneurysms o CTP: core <70ml may benefit from intervention; dec CBF with normal CBV is favorable o • Endovascular: o SWIFT-PRIME o REVASCAT o MR CLEAN o EXTEND IA o ESCAPE • ICH Risk o GRASPS Score (get with the guidelines calculator, AHA.org) • Mild Stroke (NISS <5) o Excludes complete emianopsia, severe aphasia, weakness to gravity • Current FDA tPA contraindications (2015) … however ASA guidelines unchanged!: o ICH, active internal bleed, intracranial or spine surgery or head trauma<3mo, intracranial neoplasm/AVM/aneurysm, severe uncontrolled HTN, bleeding diatheses (?anticoagulants?)

first imaging study should be a noncontrast CT (NCCT), followed by a CTA if a proximal occlusion is accessible and the patient is eligible for MRI. If the NCCT does not demonstrate a hemorrhage or large hypodensity, and the patient is within the time window, TPA is prepared while the CTA is performed, and the infusion is started. If the patient has a distal internal carotid artery and/or proximal middle cerebral artery occlusion, he will undergo diffusion-weighted imaging (DWI). Patients with DWI lesions less than 70 mL in volume are sent for intra-arterial therapy as long as they meet clinical and medical criteria. "DWI is really the only method we have to determine the core volume with sufficient precision to be able to make good clinical decisions,"

"For many years, radiologists thought you could substitute DWI with CT perfusion. We came to the conclusion that you cannot,

no or poor evidence that CTP could be used for early estimation of the infarct core or penumbra, and had no proven role in selecting ACO patients for IV thrombolysis or endovascular therapy. Similarly, they found the evidence indicated that MRP had no proven role in selecting ACO patients for endovascular therapy. Perfusion imaging may be appropriate if patients cannot be scanned by an MRI or are not otherwise eligible for intra-arterial therapy, or if perfusion data are needed for another reason.

A little more than a year of testing at the Cleveland Clinic showed that the algorithm resulted in a significant reduction in mortality and improvement of modified Rankin Scale scores independent of the treatment received. Interestingly, the number of interventions for stroke decreased by 40% as patient selection through imaging targeted patients more likely to benefit and excluded those not suitable for intra-arterial therapy (Stroke 2012

• Paresis r/o CVI (any weakness from baseline) • • Vertigo vs CVI o Vertigo: recurrent, lasts minutes; 50% BPPV (no vomiting) o Vestibular Neuronitis: decreases significantly in 48 hrs; menierre’s episodes last hours; need vestibular PT/exercises (Epley maneuver) o CVI: confusion, speech deficit, no nausea, often ATAXIC o HA with cerebellar deficit: CTA head & neck to r/o VBI;  MRI with DWI to r/o CVI • • SAH/ICH: lidocaine+fentanyl+etomidate+thiopental; o Cardene gtt 5-15mg/hr for BP control o Nimodipine 60mg PO + simvastatin 80mg for vasospasm; o elevate HOB, mannitol 50g, mild hyperventilation o Keppra or dilantin for seizure prophylaxis o Consult neurosurg to place ventriculostomy for ICP monitoring  CPP=MAP-ICP;  keep CPP~60-80, keep MAP>90, ICP is ~12-20  MAP<110 unless ventriculostomy with known ICP • Ottowa SAH Rules (100%sens, 15% spec) o Age>40, thunderclap headache, neck pain/stiff, +LOC, and exertional onset • Cushing effect from increased ICP: HTN, bradycardia, irregular breathing pattern • Craniotomy: GCS<8, hematoma with midline shift, no NS available o Have cautery available

Meningitis

• Meningitis: 2g rocephin q12 o Decadron 0.15mg/kg (10mg max) just before 1st dose of abx if:  Peds: highly suspicious for H. Influenza  Adults: concern for pneumococcal o Neonate: vanco 15 mg/kg q6 + ampicillin 50mg/kg q6 (listeria) + cefotaxime (claforan) 100mg/kg q8 (dec risk of cholestasis) + acyclovir 20mg/kg q8 o Peds: rocephin 100mg/kg x 1 then 50mg/kg q12 o Adult: Vanco + rocephin OR vanco + levaquin + bactrim o Add ampicillin: >50, pregnant, immunocompromised, ANC<1000 o Gram Stain: gram pos diplococci (strep pna - rocephin), gram neg diplococci (neiserria – rocephin), gram positive bacilli/coccobacilli (listeria - amp + gent), gram neg bacilli (H. inf, e.coli, kleb, pseudo – fortaz + gent) o CT needed if immunocompromised/HIV, hx of mass/CVI, new seizure, ALOC, neuro deficit, papilledema o <5WBC ok; if traumatic: 500 RBC : 1 WBC is ok  Admit on abx until cultures negative

Seizures

ACEP Seizures/Status Epilepticus (must get stat EEG) o CT: hx of trauma, cancer, fever, immunocompromised, persistent HA, anti-coagulated, >40, focal deficit, focalgeneralized seizure  23% have tumor or CVI! o LP after CT if ALOC, fever, immunocompromised o #1 - Benzo’s: ativan (long) .03mg/kg q3min IV/IM (peds .05-.1mg/kg)  Versed (better than valium) .5mg/kg buccal or .2mg/kg IM  Valium (fast): .2mg/kg IV; 0.5mg/kg PR (1dose-50% recur) o (#2) – fosphenytoin: 20PE/kg @ 150PE/min; arrhythmia, ARF, CLD, preg o (#2) – dilantin: 20mg/kg @ 1mg/kg/min; Not in ARF, cirrhosis, pregnancy  FAST; (separate line from D5 or benzo); Propylene glycol base – hypotension, arrhythmias; “purple glove” syndrome o (#3) – Valproic Acid: 20mg/kg @5mg/kg/min; not with preg, CLD, low plt o #3 – Phenobarbital 20mg/kg at 1mg/kg/min o #4 – RSI  Propofol 1-3mg/kg +1-15mg/kg/kr (anti-seizure properties)  Pentobarbital 10-20mg/kg @100mg/min + 1-5mg/kg/hr  Versed .2mg/kg + .5mg/kg/hr; small SBP effect o #4 – Keppra 500-1000mg load

Peds Status Epilepticus o 1 - Benzo o 2 - Phenobarb

Vertigo

• • BPPV: meclizine, valium
  • Central: ataxia, HiNTS
    • Head Impulse Testing - record on phone, tilt head forward 20 degrees, thrust head side to side ~20 degrees slowly & rapidly, cannot focus on camera if peripheral (lose vestibule-occulcar reflex); if intact (eyes stay fixed centrally), higher concern for central
    • Nystagmus - vertical is bad, direction changing (ie, look to left, nystagmus to left; look right, nystagmus to right); benign goes unilateral to one direction (ie, always to right regardless of direction patient looks)
    • Test of Skew - vertical dysconjugate gaze (can be overcome by fixation, so must alternately cover one eye to prevent fixation -- when uncovered, the misaligned eye will move back into alignment)
      • concern with bilat diplopia
    • 100% specific, 96% sensitive for stroke -- more sensitive than early MRI with DWI! Stroke Oct 2010.

===Syncope===

• ACEP Syncope (brief LOC unable to retain postural tone, transient dec cerebral perfusion)
  • Key DDX: dysrhythmia, PE, AAA, SAH, MI, bradycardia, seizure, ectopic
  • Situational Yvasovagal Neuro Cardio Orthostatic Psych Everything else (AlcoholEpilepsyInsulinOverdoseUnderdose/uremiaTraumaIinfectionPsychStroke) – check abg for prolactin within 20 min of event to r/in seizure
  • RISK Stratification for pts who are ASYMPTOMATIC after episode
    • Predictors of arrhythmia: age>45, abnormal ECG, history of ventilator arrhythmia or CHF, lack of prodrome
    • 0% 1 yr mortality if no risk, 30% mort with 4 risk factors
    • Cardiac – seated or reclining, few seconds
    • Neural – good prognosis, longer lasting, nausea and vomiting
    • Convulsive syncope – short period of tonic-clonic activity after event
• SFSR (syncope rules) – increased risk of adverse event in 7 days (ADMIT FOR ANY of these HIGH-RISK criteria (+CAD or age>45)
  • CHF, hematocrit<30, ECG abnormal (q-waves), SBP<90, shortness of breath (O2<94%)
    • Ottowa Modified ECG Criteria (SAEM) – increase sens to 87%, spec 75%, 99.5% neg predictive value
      • Abnormal ECG=non-sinus, bifascicular block, 1deg AVB+BBB, 2&3deg AVB, LAD, sinus pause
  • If exertional syncope age<35, consider IHSAS, hypertrophic cardiomyopathy, long QT, pre-excitation syndromes … ECHO + cardio
  • ECHO if history of CAD, abnormal ECG, or suspected aortic stenosis
  • Annals of IM 7/09: 40% undetermined cause
    • Orthostatic – dec 20/10, or HR inc 10; recurrence of symptoms more important than actual numbers; most cost-effective and highest yield (20% of dx)
    • Head CT, carotid US, EEG, TI~5% of dx

Cord Syndromes

• • Ant cord: decreased motor, pain, temp
  • Central cord: upper>lower weakness; distal loss>proximal; cape-like decrease in pain/temp
  • Brown-sequard: ipsilateral decreased motor, contralateral decreased pain & temp
  • Cauda Equina – central lumbar disk herniation with nerve root injury; bowel/bladder, variable motor and sensory loss in the lower limbs – areflic
    • Post void residual >200ml
  • Conus Medularis -- sacral cord; areflexia in the bladder, bowel, and to a lesser degree, lower limbs; motor and sensory loss in the lower limbs is variable
• Partial cord syndromes
  • 45% MVA, 16% recreational
  • DCML – ascending – ipsilateral vibration (cross in the brain)
  • Lateral spinothalamic – ascending – contralateral (cross 2 levels above) pain and temp
  • Corticospinal – descending; cross at medulla – ispilateral??? cervical medial, lumbar lateral; thus, central injury affects upper>> lower body
    • Complete Transection – involves entire spinal cord causing equal bilat deficits
    • partial – effects very location dependent
• SCIWORA – better outcome than pts with radiologic findings; 2/3 of cervical injuries age<8

Neuro Exam

www.neuroexam.com GCS/Peds MS: AOx3, fluent speech, logical thought, no delusions/hallucinations • E 4 spont opening o 3 verbal o 2 pain • V 5 oriented … babbles, consolable o 4 disoriented but conversive … irritable, unconsolable o 3 inappropriate … cries o 2 incomprehensible sounds … moans • M 6 obeys commands … movement o 5 localizes pain … withdraws to touch o 4 withdraws from pain o 3 decorticate/flexes o 2 decerebrate/extends Cranial Nerves • 1 – Olfactory – smell • 2 – optic – visual acuity/fields, PERRLA, fundoscope, blink to confrontation • 3/4/6 – occu, troch, abducens; eye opening, EOMI, nystagmus, vert/hor saccades • 5 – trigeminal – corneal reflex, face sensation • 7 – facial – face movement • 8 – vestibulocochlear – hearing, rinne (air>bone)/weber, doll’s eyes, caloric stimulation; hall-pike: vertigo +/- nystagmus • 9/10 – glossopharyngeal/vagus – swallow/gag (15% no gag reflex) • 11 – accessory – shoulder shrug (SCM/traps) • 12 – hypoglossal – tongue protrusion Strength/motor: tremor, wasting, pronator drift, rapid movement • 5 – against gravity with full resistance • 4 – against gravity with some resistance • 3 – against gravity only • 1 – contraction with no mvmt Reflexes: 4+=clonus, 3+=hyperactive 1+=hypoactive • Bicep=C5/musculocutaneous • Brachioradialis=C6/radial • Tricep=C7/radial • Patellar=L4/femoral • Achilles=S1/tibial • Babinski sign; Hoffman’s (flick 3rd finger, watch for thumb spasm) Coordination/gait … Cerebellar (dysdiadokinesia) • Finger/nose, rapid hand alternation, heel/shin • Gait: tandem, heels, toes Sensation • ALS – pain/deep touch, temperature (lateral) … contralateral loss • DCML – fine touch (anterior -- incomplete loss + paralysis), vibration, proprioreception, 2-pt discrimination … ipsilateral loss • Proprioception: rhomberg, joint position (finger up/down); stereognosis, graphesthesia (writing)

Nerve Roots motor sensation reflex • C5 shoulder (axillary) lateral arm biceps • C6 wrist ext (radial) thumb/index brachio • C7 wrist flex (musc/median) middle finger triceps • C8 finger flexion 4th/5th digits • T1 finger abd/add (ulnar) medial arm • L1 hip flex (obturator) med thigh • L2 hip add mid thigh • L3 knee ext (femoral) distal thigh • L4 foot dorsi/invert (peroneal) med leg/heel patellar • L5 toe ext (sciatic) lat leg/med foot/big toe • S1 foot plant/evert (tibial) lat/dorsal foot Achilles Reticular Activiating System: controls consciousness • Unilateral dilated pupil is herniation until proven otherwise • Doll’s eyes – should look opposite of head turning direction • Fixed gaze toward side of mass/lesion • Caloric testing: slow to stimulus, fast away = no coma; one or no eye mvmt=brainstem lesion

Random Neuro

• Bell's palsy: send lyme titer; steroids in 1st 72 hours

o valacyclovir 1g q8 x 10d

• Encephalitis

o HSV – acyclovir 10mg/kg q8 x 14-21 days o CMV – ganciclovir 5mg/kg q12 o WEST NILE

• Encephalopathy (metabolic, rule out CVI) • • Cognitive Impairment vs dementia: amnestic (short-term memory); multifactorial

• Parkinson’s -- Asymmetric tone, bradykinesia, hypophonic voice;

o Glabellar reflex: tap forehead and they keep blinking (normally stops) 

• Myasthenia Gravis CRISIS – 4% mortality; admit to ICU

o Typically precipitated by infection, surgery, or tapering Rx o respiratory insufficiency (dysphagia, dysarthria) disproportionate to limb/bulbar weakness o withdraw anticholinergics until after plasmapheresis or IVIG (with response!); give atropine, but watch for ileus, constipation, & delirium o solumedrol 60-80mg QD, IVIG 1g/kg x 1 dose is most effective (alternative in ARI or CHF: 400mg/kg x 5 days); o plasmapheresis (PE) is treatment of Choice; removes Ach receptor Ab’s & lasts 3-4 weeks – do 5 exchanges of 3-5 liters each QoD (~2 weeks)  restart anticholinesterase meds after response to PE or IVIG 

• Multiple Sclerosis: solumedrol 1000mg daily for 3-5d

o Often, initial presentation is for optic neuritis 

Opthomology

• General Exam:
  • PERRLA, EOMI, nystagmus, evert lid
  • visual acuity
  • fluorescein
  • tonometry (normal <22 or US 3mm post from optic disc, optic nerve sheath <5mm)
• slit lamp
  • US (retinal detachment)



• Acute angle closure glaucoma: sudden eye pain, blurred vision, frontal HA, nausea and vomiting, mid-dilated fixed pupil; check IOP (typically>40)!!!
  • Decrease aqueous production: timolol 0.5% q30min, dorzolamide 2% 2gtts (COSOPT=combo)
  • Decrease inflammation: prednisolone 1% q 15min
  • Osmotic gradient: mannitol 1g/kg IV
  • Acute: DIAMOX 500mg IV + dorzolamide 2% gtt TID
  • Constrict pupil: pilocarpine 4% q15 min (only after pressure is down)
  • Maintenance: combigan + XALATAN; ALPHAGAN, Cosopt, travatan, trusopt

• Inflammatory pseudotumor or hematoma (s/p trauma): retrobulbar inflammation, conjunctival injection, proptosis, disk edema; check IOP, CT orbits; decrease IOP, high dose steroids

• Blepharitis: inflammation of eyelid margins; warm compress 15 min, scrub lid margins with baby soap, artificial tears; bacitracin q4 x 1mo after symptoms resolve; e-mycin q6 x 2 weeks, then nightly for 8 weeks
• Chalazion: inflammation of meibomian gland with sub-q nodule; warm compress and massage nodule
  • Hordeolum (stye): eyelash abscess; external – warm compress + bacitracin q12; internal – warm compress + Bactrim



• Corneal Abrasion
  • Non contact: e-mycin ointment q6 x 5d; ofloxacin/ciprofloxacin 0.3% solution 2gtts q6 x 5d
  • Contacts: levo/moxi/gati floxacin 0.5/0.5/0.3% 2gtts q2 while awake x 2d, then q4 x 5d; optho follow upp within 24 hrs for possible ulceration



• Conjunctivitis (mostly viral): e-mycin ointment ½ inch q6 x 7d; moxifloxacin 0.5% 2gtt q2 hrs while awake x 2d, then q4hrs x 5 days ($75) or ofloxacin ($15)
  • No contacts until resolved; 3rd gen (preferred) quinolone for contacts
  • Caustic Conjunctivitis: acid 2L min, alkali 4L min irrigation with morgan lens; check pH 30 min after irrigation; fluorescein for ulceration (antibiotic); optho in AM
  • Bacterial Conjunctivitis: purulent discharge, unilateral; infants: polymyxin B + trimethoprim ointment; adults: gentamycin gtts (ciprofloxacin for contact users) x 10 days OU
  • Gonococcal: rocephin 1g IM/IV x 1
  • Viral conjunctivitis: bilat injection with lid cobblestoning, crusting in AM; artificial tears, naphazoline, or ketorolac gtts
  • Chlamydia conjunctivitis: neonates, concurrent STD; rocephin+erythromycin PO x 14d
  • Peds – azithro 20mg/kg x 1; adult: doxy 100 q12 x14d
  • Allergic conjunctivitis: follicular cobblestoning of inner lid; naphazoline gtts

• Dacrocystitis: eye tearing, lower lid inflammation/redness; rule out periorbital cellulites, inspect for obstruction of punctum; culture if pus expressed; warm compress, massage canthal area, augmentin

• Keratitis: abrasion or UV; FB sensation, fluorescein uptake
  • Check for corneal penetration (seidel’s sign)

o Superficial punctuate keratitis – stipling of the corneal surface o Td, topical anesthetic, polymixin/bacitracin, PO motrin o Ulceration from contacts too long – ciprofloxacin q15min x 4, q1hr x 4, then q4hrs  optho in AM

• Herpetic: corneal dendrites under fluorescein; Trifluridine 1% q2 hrs x 7d or acyclovir ointment 5x daily; taper over 2 weeks

 Keratoconjunctivitis: pain, decreased vision, halos; consider prednisolone 1% per optho

• Scleritis: eye pain with radiation to ipsilateral face, decreased vision; NSAIDs PO +/-steroid gtts

 Episcleritis: rapid onset of localized pain and injection; artificial tears and ketorolac gtts

• Uveitis: pain, photophobia, conjunctival injection, cell and flare in ant chamber; if IOP<20, ok to dilate; often seen with +HLA-B27, sarcoid, crohn’s/UC

 Iritis:

• • Uveitis/iritis – pred(nisolone) forte 1% q6 hrs + cyclogyl 0.5% q6hrs



• Endophthalmitis: pain, dec vision, cell & clare, possible hypopyon, chemosis, eyelid edema; Admit for IV vanc+rocephin



• Orbital Cellulitis: fever, proptosis, limited/painful EOMI, disk edema, retinal engorgement
  • CT orbits to eval for peri-osteal/retrobulbar abscesses, cavernouse sinus thrombosis (typically get LR6 deficit)
  • Admit; Vanco, unasyn/zosyn, cleocin/rocephin, cover fungal for immunocompromised
  • Consider mucormycosis if refractory

• Periorbital outpatient: augmentin q12 x14d; clinda 300 q6 + levaquin 750 x 14d
  • Periorbital inpatient – clinda 900 q6 + rocephin 1g; vanco; zosyn 4.5g IV q8

• Retrobulbar abscess: orbital cellulites with increased IOP; if IOP>30, emergent needle aspiration or lateral canthotomy; CT  admit



• Retinal detachment – “curtain coming down”
• Vitreous detachment – floater in visual field

 

• Hypopyon – layering of WBCs in ant chamber; prednisolone; typically admit
  • Hyphema: blood in ant chamber s/p trauma; may have fixed, dilated pupil; measure vertical percentage of blood; US – rule out globe rupture; if IOP<20, cycloplegics to prevent iris motion; +/- steroids; bed rest, head elevation; eye shield at night only; NSAIDs PO
    • 7% get glaucoma – watch for increased pain
• Subconjunctival hemorrhage: exclude coagulopathy or thrombocytopenia; self resolving in 2-3 weeks
• Vitreous hemorrhage -
• Globe rupture – sidel’s sign (eye is soft); eye SHIELD
  • Teardrop pupil points to rupture site, most have hyphemas
  • antibiotic, Td, CT
  • Scleral penetration: teardrop pupil, blood in ant chamber; Td, IV antibiotic, optho in ED



• Pingueculum (yellow) or pterygium (white): at limbal margins;

 ketorolac gtts x 2 wks o DM: floaters may be vitreous hemorrhage o Tearing is typically secondary to dry eyes – lacrilube, gtt’s o S/p cataract surgery – ofloxacin qid x 10d, omnipred + nevanac bid x 14d   Meds o Nevanac: NSAID gtt   Anisocoria: o Horner’s: secondary to pancoast tumor o 3rd nerve palsy: PICA infarct 

• Central retinal artery occlusion

o Massage eyeball  Central retinal artery occlusion o   Macular degeneration – loss of central vision – slow & progressive   Pheochromocytoma, sheehan’s – bilat temporal hemianopsia???

Orthopedics

• fracture Descriptors:
  • Skeletally (im)mature;
    • Salter Harris 1 – SEPARATED; tender with swelling over epiphysis; epiphysis weaker than ligament in peds, thus sprain less likely
    • Salter Harris 2 – ABOVE; fx extends into metaphysic
      • Thurston-Holland fragment – triangular metaphyseal fragment with epiphysis of SH2 fx
    • Salter Harris 3 – LOWER; through epiphysis involving articular surface; may disrupt growth
    • Salter Harris 4 – THROUGH; epiphysis and metaphysic ORIF; may disrupt growth
    • Salter Harris 5 – RUINED; crush of epiphyseal plate; mRI if suspected compression injury
  • Closed vs. open;
  • Prox, mid, distal;
  • Transverse, oblique, spiral, comminuted, incomplete (cortex only – greenstick, buckle [torus]);
  • Intra-articular (SALTR Harris -- epiphysis, metaphysic, diaphysis);
  • Aligned, displaced, angulation/translation (distal fragment in relationship to proximal – valgus/varus, dorsal/volar);
  • Shortening: appositioning or bayoneting

• If suspicious but NO OBVIOUS FX, splint and x-ray in 7-10 days as margins appear with fx absorption;
• ALWAYS LOOK FOR 2nd FX; consider comparison and stress views
• IF UNSURE, GET COMPARISON VIEWS

Bone & Joint, Soft Tissue

• Arthrocentesis: monoarticular pain (gout, pseudogout, septic)
  • Check INR, do not needle through cellulitis
  • Elbow: at 90deg, btw olecranon, radial head, & lat epicondyle
• Bites: unasyn 3g q8; clinda 600 q8 + levaquin 500 qd
• Blood Loss: Tibia~500cc, Femur~1L, Pelvis 1.5-3L
• Bursitis: olecranon (posterior over the bony point)
  • Septic bursitis WBC>10k; dicloxacillin 500mg q6, nafcillin 2g iV q6, +/-vanco
  • Traumatic bursitis: <1000 WBCs/mm
• Compartment Syndrome: Pain, Pallor, Pulseless, Paresthesia, Paralysis
  • Check lactate, CPK, myoglobin; if Stryker pressure >30 or <30 below DBP, need immediate fasciotomy
  • give benadryl to decrease histamine mediated leakage; do NOT elevate the limb
• Diabetes
  • Cellulitis- augmentin
  • Foot Ulcer: rocephin 1g daily + flagyl 500 q6
• Flexor Tenosynovitis: Kanavel Signs - held in flexion, pain with passive ROM, fusiform swelling, pain with flexor extension
  • DeQuervain’s Tenosynovitis – finkelstein test
  • Ancef 1g q6; clinda 600 q8;
• Foot puncture: ciprofloxacin 750 PO q12
• Open fracture: splint, reduce if nausea and vomiting compromise, irrigate and cover with NS gauze, ANCEF + Td (add gentamycin 7mk/kg if >5cm lac; add penicillin 4M units if farm wound)
  • Ancef 2g Ivq8; zosyn 4.5g q8 (or gent) if soil contamination
• Osteomyelitis: vancomycin + rocephin 2g qd; with DM: vancomycin + zosyn 4.5g
• Septic joint (arthritis): WBC >50k
  • vancomycin + rocephin 2g; prosthesis: rifampin 600 PO + vanco
• Tendonitis: from repetitive muscle motion; RICE +/- splint

Immobilization

• Casting: stockinette, padding (double on pressure points), cold water with fiberglass (warm with plaster); use plaster under fiberglass when pushing
• Splinting: orthoglass OR 10 layers of plaster
• Thumb spica - thumb, scaphoid
• Short Arm - wrist
• Long arm (for distal rad/ulna) – volar tilt with supracondylar compression
• Post arm: elbow at 90deg, ext wrist 20deg, neutral supination – have patient hold roll of ace wrap
• Sugar tong – for humerus (or simple sling)
• Ulnar gutter: have patient hold a can; only cast bottom half (U-shaped)
• Short leg – patient prone with knee flexed; aim for 90-100 deg dorsiflexion
• Patellar Tendon Bearing
• Cylinder Cast – mid thigh to mid calf
• Long-leg cast: hockey puck medially with slight inversion; increase dorsiflexion with post fx



Face

• LeFort 1 – floating palate – transverse through maxilla
• LeFort 2 – nasal bridge, inf orbital rim
• LeFort 3 – craniofacial dissociation (zygomatic arch); often CSF leaks
• Mandible – all fx exept condyl are open – give antibiotic
  • Condyle, ramus, angle, budy, mental symphysis
• Midface tripod
• Nasal
• Teardrop/Occular blowout

Spine

• C2 pseudosubluxation in peds -- posterior line <2mm, especially in extension
• Clay shoveler’s: tip of spinous process C6-7 from lifting
• Chance: typically lumbar; flexion and distraction (lap belt)
• Hangman’s – hyperextension; fx/dislocation; C2 pars with AP dislocation C2-3
  • Hanging: judicial=high cervical fracture; non-judicial=strangulation; cxr appears similar to ARDS
• Jefferson – burst of C1 (compression fx) – UNSTABLE!
• Teardrop: wedge of ant/inf vert body  lig injury

• http://emedicine.medscape.com/article/824380-overview



Shoulder

• AC Separation – fall directly on acromion
  • type 1-2=sling
  • type 3 (space btw coracoids and clavicle)=sling with ortho follow upp
  • type 4-5 (>2cm)=surgery

o Clavical fracture  Midshaft displaced 23% non-union (pieces don’t touch, >2cm bayoneting, comminuted) o Sterno-clavicular dislocation: 90% anterior; reduce  clavicle strap  Posterior: CT for associated injuried; typically reduced in OR; arm outstretched laterally with downward counter-traction then pull up on clavicle

• DISLOCATION – check axillary view; head should be in the “Y”
  • Bankart lesion – tear of labrum (inf glenohumeral lig); delayed OR to prevent recurrent dislocations
  • Hill-Sachs deformity – cortical depression in head of humerus due to impaction on glenoid rim during ant dislocation; divot on xray – lateral portion of humeral head
    • Anterior dislocation – abducted and EROT; check axillay nerve/artery; immobilize immediately after reduction (before x-ray) – immobilize for 3 weeks
      • Hippocratic --
      • Kocher --
      • Scapular manipulation --
      • FARES Method – lower pain (no sedation!)
    • Post dislocation – patient unable to EROT; seizure, electrocution, MVA, falls
      • IROT, abduction

Arm

o Humerus fx: radial nerve injury; sling o Supracondylar: ant humeral line through mid-capitulum; blood in joint gives fat pads; check brachial artery, median nerve  Must be TRUE lateral for neg fat pad (figure 8 shape)  Humeral & radial lines bisect capitulum – fx, line moves ant  carrying angle >12 degrees likely fx (ant humerus and ulna transections)  Kids: extraarticular; adults: intraarticular o o Colles: dorsal dinnerfork; reduce if displaced/angulated; sugar tong splint  Distal radius +/- ulna; most common if adult FOOSH o Smith (reverse colles) – distal radius with volar displacement; fall with force to back of hand o Radius/Ulna – watch for displacement; if 1, then look for #2  Radius: 12mm past ulna, radial incline 23 degrees, lateral view=12 degree volar tilt o Chauffeur fx: radial styloid; may cause dislocation of lunate o Piedmont – fx of mid to distal 1/3 of radius alone (isolated) o Essex-Lopresti: radial head fx with distal radio-ulnar dislocation; forearm axial compression o Nightstick – midshaft ulna, radius, OR both! o o

• MONTEGGIA (MuGr): prox ½ of ulna fx with ant or post radial head dislocation (UofM); radius should intersect capitulum; FOOSH with pronation

 Long arm, 90deg, full supination

• GALLEIZI: radial shaft fx with distal radioulnar dislocation (gap at carpals); head of ulna displaced; pronation with wrist extended, FOOSH

 Median nerve o  Radial nerve o Coronoidd fx: seen with elbow dislocations; brachialis/radial notch, flexors, & pronators attachment site o Carpal tunnel: med nerve; recurrent to thenar; prayer/phalen test o Cubital tunnel: ulnar nerve; may be from non-union of medial epicondyle o Radial head fx: FOOSH in adult; painful pronation/supination – sling o Peds distal radius buckle fx: removable volar splint x 4 weeks (no sports) o o o Elbow dislocation: 1/3 associated with fx; POST LONG-arm splint  Regional block: aspirate blood from joint then 5ml of lido  POST: FOOSH backwards; cannot extend elbow • Prone on bed, arm 90deg with weight on wrist • Post pressure to humerus, distract forearm • Brachial artery and median nerve  ANT: brachial artery, median nerve (+/- ulnar) • Traction on wrist then post pressure on forearm o Med epicondylitis – golf (flexion); short-arm wrist splint o Lat epicondylitis – tennis (extension); short-arm wrist splint o Floating elbow; supracondylar + forearm fx o Lat humeral condyle fx: 5-10 y/o; <2mm displacement  long arm cast; >3mm displacement  OR for K-wires o Med condyle fx: RARE; violent flexion/pronation or direct impact from fall on olecranon; ORIF if >2mm displacement; OR if fragment in joint or open fx o Elbow growth plates: COME (capitellum), RUB (radial head), MY (med condyle), TREE (trochlea), OF (olecranon), LOVE (lat condyle) o Nursemaid elbow – child not splinting after reduction; no xray if clear story o Olecranon bursitis: 2/3 aseptic; only 40% get fever;  60% of septic have surrounding cellulitis, 25% of aseptic have surrounding cellulitis  Septic: >100K WBC’s, >neutrophils, bursa/serum glucose <50%  Use post/lat insertion site to avoid nerve (through non-infected skin) o Olecranon fx: intramedullary screw with tension wiring o Humerus: check radial nerve  

Wrist

o Chauffeur’s: radial styloid; ulnar deviation & supination o Dequervain Tenosynovitis: Finkelstein test; thumb spica splint o Barton’s: intra-articular fx/dislocation of wrist (UNSTABLE – ORIF)  Dorsal: oblique dorsal rim of dist. Radius with carpal dislocation; dorsiflexion at impact  Volar: wedge sheared off volar rim with displaced carpal; volar flexion (rare injury) o Barton’s (dorsal . . . colles with dislocation) - distal radius fracture with dislocation of radiocarpal joint; most common fx dislocation of the wrist joint; often with radial styloid fx; stability of reduction of dorsal Barton frx is best obtained with wrist extension to take advantaage of intact volar carpal ligament; will likely need ORIF but may tolerate immobilization for 6 weeks in short arm plaster cast; o Barton’s (volar . . . smith with dislocation); characterized by frx of volar margin of the carpal surface of the radius which is associated with subluxation of radiocarpal joint; usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; Needs ORIF -- be sure to immobilize the wrist palmar flexed which will tip the carpi away from the fractured volar surface; o Carpal Tunnel: phalen test, Hand numbness in AM o Hamate fx – get carpal tunnel view; check ulnar nerve  

Hand

o FDP: from hyperextension; can’t flex DIP; surgical repair within 1 week o Flexor tendon lac: splint in full flexion o Skier Thumb – ulnar collateral ligament o Bennett’s: oblique fx/dislocation at base of thumb (1st MC) with dislocation of radial articular portion o Rolando: intraarticular fx at base of thumb (1st MC); Y-shaped, comminuted; axial load with partial flexion; worse than Bennet’s, rarer o Stener – avulsion of ulnar corner of base of thumb; similar to …  Gamekeeper o Boxer – metacarpal neck (typically 4th or 5th); metacarpal head tilts volarly causing joint to lie in hyperextension & collateral ligaments become slack; if joint is allowed to remain in hyperextension, collateral ligaments will shorten, leading to limited MCP flexion;  Reduction: MP joint is flexed 90 deg to produce tightening of MP collateral ligaments; flexed metacarpal is directed dorsally, which effects reduction of metacarpal head by correction of volar angulation  acceptable reduction: 10deg 2nd & 3rd, 20deg on 4th, 30deg on 5th; on lateral, >30-40 deg will need pinning; 30 deg of angulation results in loss of 22% of finger ROM; on AP view, NO (rotational) anglation is accepted  CAST: ulnar gutter short arm; "buddy tape" the little and ring fingers; extend wrist 40deg, flex mcp 90 deg • For 2nd/3rd, radial gutter splint with U on top o Metacarpal head fx: infrequent variant of boxer's frx; requires ORIF o High Pressure Injection Injury – STAT hand consult o Scaphoid: max tenderness in snuffbox; proximal=AVN; short arm cast o Intercarpal space ~2mm o Check the 3 arches: 1st row, prox and distal 2nd row o Capitate, lunate, and radius line up  Perilunate dislocation: capitate dorsal to the saucer (lunate)  Lunate dislocation: saucer posterior to the cup (& radius)  Scapholunate dislocation: increased joint space (Terry Thomas or David Letterman sign) o Lunate: #1 fracture; proximal break has highest risk of AVN o Any hand injury – open fx or tendon lac – give one dose of IM ancef at time of repair decreases risk of infection; no benefit of continued antibiotic 

Pelvis

o Consider angio if significant bleed/hypotensive o If bone in rectum, treat open FX (antibiotics) o Open Book fracture: pubic symphysis and SI joints; >2.5cm is bad  Consider MAST or TPOD pelvic binders o o Dashboard: post rim of acetabulum o Malgagne – ilium fx near SI joint with symphysis displacement OR SI dislocation with fx of ipsilateral pubic rami  UNSTABLE o ?iscial? o Femur fracture: gentle traction (watch for hip dislocation); check for compartment syndrome o Femoral neck – if unable to walk on it an xray neg, check CT  Look at shenton’s line (should be curved and contiguous) o Intertrochanteric – short, EROT o Subtrochanteric – o In peds, apophyseal injury (avulsion of bone) – look for SCFE; rest & PT  Hip o Post dislocation – use your knee as fulcrum to re-locate; check sciatic nerve

Leg

o Ottowa Knee: age>55, isolated patellar tenderness, fibular head tenderness, unable to flex to 90 degrees, unable to bear weight immediately and 4 steps in the ED o o Segond fracture: lateral knee capsule avulsion; 70% tear ACL o Bosworth: fx dislocation with fibula trapped behind tibia; due to severe EROT o Toddler’s fx: spiral of tibia from minor injury; can’t walk (NOT ABUSE) o Aviator: vertical fx neck of talus; forced dorsiflexion (MVA) o Pott’s fx: bimall or distal fib, 4-7 cm above lat mall; usually associated with other fx or ankle dislocation; increased mortise o Distal tibia: short leg cast, NWB o Distal Fibula: Weber A (below joint line) – posterior splint  Weber B (joint line) or C (above joint) – short leg cast due to risk of ligamentous disruption o Proximal fibula fx: hinged knee brace, WBAT o Peroneal Palsy: tarsal tunnel, compartment syndrome, L5 neuropathy, s/p knee surgery  

Ankle

o Ottowa Ankle: TTP distal 6cm of med/lat malleolus, unable to bear weight immediately and 4 steps in the ED o o Sprain: 3rd deg often audible pop; short leg cast for faster recovery  If recurrent, tape, proceptive exercises, peroneal weights o Dislocation: post most common (Talus post); check for lat mall fx  Post reduction: plantar flex, traction, then anterior pull  Ant reduction: plantar flex, traction, then push post  Lateral dislocation – bilat malleoli fx’s  Superior – from fall; check for spine fx  LONG-Leg splint post reduction o Bimall and Trimall (post) – UNSTABLE  ORIF; lat + post +/-medial (deltoid lig disruption leads to widened mortise  Always check nausea and vomiting before redcution  Immediate reduction if skin tenting or nausea and vomiting compromise  Med space <4mm; tib tuberosity line up with 2nd MT o Pilon fracture: distal tibia into the articular surface; +/- fibula  Ligaments avulse “chopart fragments”  Check compartment syndrome; OR for external fixation  o Snowboarder’s fx (lateral talus) – from impact  ORIF if displaced; ddx of ankle sprains o Chopart joints: talonavicular, calcaneocuboid o Maisonneuve: EROT; fx prox 1/3 of fibula; delt lig +/- med mall; disruption of syndesmosis; increased mortise space with fibular head fx  Check peroneal nerve: eversion, 1st webspace sensation o Dupuytren’s: EROT; deltoid lig +/- med mall, diastasis of inf tib/fib, fib shaft fx o Tillaux – avulsion of ant/lat distal tibial epiphysis; external rotation force on ATF in 12-15 y/o (medial portion fuses 1st, thus lateral tearing) o LeFort-Waystaffe: anterior avulsion of lat mall (from ATF) o Tillaux fx: adolescent ant/lat tibial epiphysis (ligament avulses the bone)  Due to EROT; often widens mortise  NWB short-leg cast; OR if >2mm displaced fragment  For reduction, knee at 90 deg, dorsiflex, then IROT • Long leg cast with knee flexed to 30 deg o Sever disease: inflammation of calcaneal aponeurosis (9 y/o male)  Repetitive microtrauma at Achilles insertion  splint 8wks

Foot

o Ottowa Foot: midfoot pain + {TTP at Navicular or base of 5th MT, unable to bear weight + 4 steps in ED} o o Bunion: hallux valgus of 1st MTP; distal MT angle >10deg o Bunionette: at 5th MT o Corns: shave/pare, pumices stone after bath, padding o Lisfranc: fx/dislocation of tarsometatarsal joint (1st MCP interspace)  Downward force on plantar-flexed foot  Stress XR with comparison, CT, MRI  MT 1-3 line up with med, mid, & lat cuneiforms; 4-5 with cuboids; mostly btw 1-2, 2-3; 2-5mm widening  OR  Midfoot echymosis;  NWB short leg cast; delay OR until swelling reduced o Cuboid & cuneiform fx: check for tarsometatarsal dislocations o Subtalar dislocation: from plantar flexion/inversion; closed reduction o Talus dislocation: talus medial (out of mortise); check fibula for Weber C o Calcaneus fx: fall from >6ft – talus driven into calcaneous  Short-leg cast, NWB x 2 weeks  All intra-articular fx’s to OR regardless of displacement (bulky-jones dressing until there); no surgery if severely comminuted  check bohler’s angle???  10% have L-spine fx (Don Juan) o Jones fx: transverse fx of 5th MT base >15mm distal to prox end of bone (peroneus brevis insertion);  ???intra-articular??? NWB o Pseudo Jones – posterior splint o Avulsion of 5th MT o 4th MT fracture: NWB + post-op shoe o Charcot arthropathy: unilateral swelling, inc temp, red, dec sensation; NWB with cast x 6mo o Charcot-marie-tooth: progressive distal limb weakness; foot drop, tripping, multiple sprains, pes cavus o Clavus (“callous”): orthotics & padding o Hallux valgus=bunion … Hallux varus=toe pointing outward o Kohler Disease: avascular necrosis of navicular ossification center; medial tenderness – limp with weight on lateral side  WBAT, short leg cast, 15deg varus (invert) + equinus (plant) o Morton Neuroma: irritation of nerve (compression)3/4th MT heads – get wide shoes o Pes Cavus – PT, orthotics; OR for fascial release o Pes Planus – orthotics o Plantar fasciitis: 83% get relief from simply stretching (tennis ball, can);  RICE, arch & heel support, tape foot; 90deg night splint o Turf Toe: hyperdorsiflexion of 1st MTP; short leg cast with toe spica

OB/GYN

• you cannot rely on one BHCG to rule out ectopic!
• • Pregnancy Q’s: GTPAL, LMP, EDC via US @ xx weeks

o FM, VB, LOF, CTX (cramping, pain) o PNC with OB, complications include (DM, hypertension, PTL, eclampsia) o Check DTR’s o Hx: recent intercourse, low placenta, surgery, procedures (LEEP), GBS o FHT: rate, variability, accel/decels … scan for head position o CTX: reactivity, variability (accel/45olch) o TOCO: contractions q xx min; Montevideo units (200-240 is goal) o Sterile spec exam (SSE): pooling, nitrazine, ferning o Sterile Vag Exam (SVE): cervix (closed  xx cm); effacement (thick  50%  complete); station (high . . . -3 to +3) o A/P: IUP@ xx wks; active labor, SROM, PTL • Hyperemesis Gravidarum: B6 + unisom, reglan, zofran (+/- picc line) • • TAB o B-HCG, Rh, US if significant pain (R/O Ectopic), CBC for significant bleed, SSE o Bedside US for FHT •

• PIH/Pre-Eclampsia: Labetalol 25-50mg PO BID; Hydralizine 10-25mg PO QID

o Always check CBC, chem18, uric acid, 24hr urine (spot pro/cr ratio) • • Eclampsia . . . give Mg (check HA, DTR’s, clonus) o 4g bolus, then 2g per hour with goal of serum level ~4g/dl  Ca gluconate to reverse hyporeflexia/resp depression

• placentia previa • • placenta abruption • • vasa previa • • placenta accretia •

• Preterm Labor

o Fetal Fibronectin: at 24-34 weeks; tells chance of delivery within the next 2 weeks; invalid test if intercourse within the past 24 hours o IVF (1 liter) may help reduce contractions o Pitocin (stimulate contractions) – 20 units/L, titrate to Montevideo Units (MVU) of 200-240 (area under contraction curve over 10 minutes)

• Delivery Note

o Delivered #/oz BB/BG in ROA/LOA/OP position over intact perineum (xx cm MLE/tear @ xx; repaired with chromic gut) o APGAR @ 1 & 5 min o Bulb suction/delee @ perineum and after delivery o +/- nuchal cord reduced; 3-vessel cord clamped and cut o Spontaneous delivery of placenta @ xx; EBL ~500cc

• Post-partum bleeding

o Bimanual fndal massage o Methergine 0.2mg IM x 5 o Hemabate 250mcg IM o Pitocin 10units IM or 40units per liter at 200ml/hour IV

• Amniotic fluid embolism

o Maternal immune response leading to anaphylaxis o 50% 1-hr mortality: seizure, ARDS, DIC

• Heterotopic: 1:4000 (circa 2009); 1:100 with assisted reproduction!

• Methotrexate: no evidence of rupture/hemoperitoneum, HD stable, <8wk gestation, BHCG<5k, adenexal mass <4cm, no cardiac activity, confirmed ectopic not requiring surgical confirmation

• Meds o GBS + . . . penicillin or Clindamycin if allergic o Preterm: Betamethasone 12.5mg IM QD x 2d for lung development o Tocolysis to slow contractions: Procardia 20mg PO q6; Terbutaline 0.25mg SQ q1 or gtt, titrate to CTX<q10min o UTI: macrobid, keflex

OMT

• Somatic Dysfunction 739.x
  • Head (0), cervical (1), thoracic (2), lumbar (3), sacrum/sacroiliac (4), hip/pelvis (5), LE (6), UE (7), rib (8), abdomen (9)
• Procedure codes 9892x per treatment area:
  • 1-2 (5), 3-4 (6), 5-6 (7), 7-8 (8), 9-10 (9)
• Autonomics
  • Sympathetics increase inotropy (like pressors) -- T1-L2
    • 1-4 heart & lungs; right=SVT, left=VF/VT
    • 5-9 liver, GB, stomach, duodenum, pancrease, spleen
    • 10-12 jejunum, ileum, kidneys, gonads, right colon
    • 12-L2 left colon
    • L1-2
  • Parasympathetics (CN3, 7, 9, 10)
    • CN: vagus/OA
    • Right vagus slow HR via SA node
    • Left vagus slow heart via AV (block)
    • S2-4 – pelvic splanchnic; descending colon down
  • Migraine, Head then upper cervical
    • OA release/suboccipital decompression, CV4, Cervical MFR/ME, SCM/traps; check for TMJ; SBS decompression, V-spread fluid wave
  • Lymphatics
    • Dependent on respiratory drive; Thoracic duct must be open
    • Work from core to periphery, Head to sacrum: Inlet – ribs and pecs; Diaphragms – redome (thoracic, abdominal, & pelvic), Pumps – thoracic, pedal
  • Thorax: clavicle, shoulder, thoracics
  • Lumbars – if present standing and seated flexion test, then LS/SI; if gone in seated, limb problem
  • GI – celiac ganglion at xiphoid, superior menenteric btw xiphoid and umbilicus, inferior mesenteric at umbilicus
  • pneumonia/COPD – rib raising, lymphatics, pec lift
  • hypertension – T11-L1
  • Diarrhea – mesenteric lift/ganglion release
  • LBP – HVLA, MFR, ME

PEDS

Vitals

• ..................Weight.......HR.............SBP...........RR......Bld....NG.....Chest Tube....Fem Line
• ......Newborn.....4kg..........130-150........70+(age*2)....40......1......6......10............3F/8cm
•  1 y/o (2*age)+8 120 (80-200) 90 26 1 8 14 4F/8cm
•  2-3 y/o 12-15 115 90 24 2 10 20 4F/15cm
•  4 y/o 17 100 90 24 2 10 24 4F/15cm
•  6 y/o 20 100 95 20 2 12 26 5F/15cm
•  8 y/o 25 90 95 20 2 12 30 5F/18cm
•  10-12 y/o 30-40 85 100 20 3 12 32 6F/20cm

IVF

• NS 20ml/kg bolus x 2
• Maint 40/20/10
  • <2y/o= D5 .2NS
  • >2y/o = D5 .45NS



Anaphylaxis

• Benadryl 2mg/kg
• decadron .6mg/kg
• zantac 1.5mg/kg
• epinephrine .01ml/kg 1:1k
• d/c with referral to allergist and Rx for EpiPen Jr x 2



Febrile workups

• 0-8 weeks – septic workup
• 8-12 weeks – discretionary septic w/up

• Febrile Seizure: consider LP if <1 y/o (unresponsive, appear ill)
  • No LP if look well, high vaccination rate, no previous antibiotic; NEED 24 hr follow upp

• ALTE: Color change, flaccidity, associated with SIDS
  • HIGH RISK: during sleep, longer than 10 seconds, seizure activity, trauma/abuse#idiopathic

1. sepsis
2. GERD
3. Others: seizure, hypoglycemia, ICH, botulism, airway obstruction, electrolytes

•  SIDS: 1 mo – 1 yr; Increased risk with: low mother age, large number of kids, prematurity, history in siblings, sleeping face down/with parents



URI

• Resp distress: tachypnea  grunt/flare/retract  ALOC, bradycardia, cyanosis
• BLADE
• RSV bronchiolitis: Ribavirin inhaled, racemic epi; heliox if severe distress

 Contagious for ~10 days; back to daycare when no cough

• Croup: Cool mist; nebulized racemic epinephrine (watch 4 hours for rebound or have return if reliable parents)

 Decadron 0.6mg/kg IM, orapred 2mg/kg PO, nebulized budesonide if bad; steroids x 5 days

• Pneumonia: strep pneumonia #1, GBS, Chlamydia, pertussis (erythromycin)
• Cough

 <2: booger sucker, humidified O2, TLC  Age 2-5 – Tylenol with codeine, Rondec  Age >5 – robitussin AC

• Nasal foreign body: biliary t-tube, 30 degree incline and bag with open nare occluded, alligator forceps
• AOM: use pneumatic otoscopy, antibiotic if >48 hours of symptoms; no auralgan if perforated

 6-23 months: antibiotic if bilat or unilateral with temp>102 

GI Issues

•  Newborns should gain 0.5-1 ounce daily
•  Colic: 3wks to 3 mo: ~1 hr at night; should grow out of it; zantac may help
•  GI Bleed
  • Neonate: necrotizing enterocolitis, infection, anal fissure, milk allergy
  • Upper: AVM, GB, PUD, Mallory-Weiss
  • Lower: Fissure, intussusception, HUS, swallowed maternal blood, AVM, IBD, tics, HSP
  • Blood in stool: cows milk, anal fissures, salmonella/shigella … check FOB
•  Constipation: Glycerine suppository, Mineral oil – 1 tsp daily
•  Vomiting
  • Bilious vomiting is always BAD --- must rule out malrotation
  • Hepatobiliary Disease: Vomiting + Jaundiced
  • Inborn Errors of Metabolism: Vomiting, hypoglycemia, metabolic acidosis
  • Increased ICP … Meningitis
  • Obstruction: stenosis, ileus, malrotation, imperforate anus, hirschsprung’s
  • Pyloric Stenosis: presents ~ 1month; non-bilious projectile vomiting after feeding; associated with e-mycin in infants; US > 0.3 cm, 1.4cm long; Failure to gain weight; palpable olive at LES
• ROTAVIRUS in winter; summer: salmonella, shigella (high fever, seizure), staph aureus; Norwalk=HA, fever, myalgias

 +Fecal Leuk  consider bactrim or rocephin  Cap refill >2sec, no tears=dehydration

• •  ORS – pedialyte 5ml q3 min (10-100ml/kg /4hrs --?OG tube)
•  Appy: pain, fever, anorexia; <2y/o often septic due to perf
  • With low body fat, US>CT sensitifity
  • DDX: mesenteric lymphadenitis

•  Henoch Schonlein Purpura (HSP) – fever, fatigue, arthralgia, palpable purpura on buttocks and LE (IGA depositions);
  • Watch for hypertension & seizures
  • UA for RBC, if +protein  glomerulonephritis (IVF!!!)

•  Hirschsprung’s: aganglionic colon; chronic constipation, thin stools, bilious vomiting, infrequent explosive BM’s … dx AXR
•  Incarcerated hernia: male, poor feeding, vomit, inguinal/scrotal mass
  • 90% indirect inguinal; examine upright and with abdominal pressure; watch for palpable thickened spermatic cord
  • flex & EROT hips to reduce; needs repair (recurrence)

•  Intusseception – 3mo-3yr; sudden intermittent pain + vomit + bloody stool
  • Sausage mass (small in large bowel, right sided); currant jelly=late finding (due to tissue strangulation)
  • Target sign on US; air contrast enema
  • Lead point typically ileocecal: peyer’s patch, Meckel’s, HSP, rotovirus immunization, incarcerated hernia

 Malrotation with volvulus (1mo): intermittent bilious vomiting, abdominal dist/RUQ dist bowel, blood streaked stool, KUB=double bubble  Surgery

•  Meckel’s Diverticulum: incomplete closure of vitelline duct;
  • 2% of population, 2-8 y/o
  • Complications include: SBO (35%), GIB (32%), Tics (22%), fistula (10%)
  • Get Meckel’s scan!!! CT not ideal
  • Amp, gent, clinda, or cefotetan

•  Necrotizing Enterocolitis: after transition from tube feeding; pneumatosis intestinale, portal v. air, walls thick; acidosis, DIC; NG tube + amp/gent

•  Pancreatitis: cystic fibrosis, post-viral, toxin/ingestion
• Abd Tumors: wilm’s (intrarenal); neuroblastoma (adrenal); rhabdomyosarcoma (psoas)



•  Neonatal Jaundice
  • Physiologic: Immature liver (esp if premature) – cannot handle conjugating RBC breakdown (increased mass from fetal/ delivery process)
  • Pathologic: sepsis, breastfeeding (breast milk inhibits bili conjugation)
  • UV light recommendations; Combs test: check for hemolysis

Congenital Heart Disease (CHD)

• if pt looks sick and you give PGE, worst case scenario is apnea → intubate

• Pulm HTN - ductus arteriosus typically closes within 48 hours; right to left shunting through PDA or PFO
  • preductal R hand >10% higher than post-ductal foot oxygenation
  • need ECHO
  • Intubate, +/- paralyze, IVF/pressors, nitrous oxide

• Cyanotic heart lesions: depend on PDA
  • place infant on 100% NRB, draw ABG - PaO2 < 100 shows right to left shunting
  • Oxygen, ventilation, inotropes, and PGE1 infusion 0.05 - 0.1 mcg/kg/min to O2 sat

•  Fetal Anatomy

o Fetus oxygenated by placenta to umbilical vein  bypass liver via ductus venosus  IVC to left atrium via PFO; SVC to RV to PA then PDA (high pulmonary vascular resistance – bypassing lungs) to descending aorta  circulation then out to umbilical artery o Ductus arteriosus (pulmonary artery to aorta … closes ~ 3 weeks) o Foramen ovale (RA  LA … closes ~ 3 months) o Cutting umbilical cord decreases peripheral vascular resistance; increased pulmonary blood flow promotes closure of PFO  Cyanotic: central (lips, mucous membranes); Cyanosis correlates to O2 sat ~80-85% o acrocyanosis (peripheral – due to cold weather or vasoconstriction) o right to left shunting will minimally improve with O2 o pulmonic cyanosis will significantly improve (10% O2 sat) with O2  Tetrology of Fallot (10%) – birth to 12 weeks; Cyanosis not relieved by O2; boot shaped heart on CXR  Transposition (5%); CXR= eggs on a string  Tricuspid/Pulmonary Atresia (2%)  Total Anomalous Pulm Venous Return (1%); CXR==figure 8/snowman shape  Hypoplastic Right/Left Heart • Acyanotic o VSD (25%) – after 4 weeks; murmur=LLSB S3 o ASD (10%); LUSB=widely split and fixed S2 o PDA (10%) – after 4 weeks; murmur=LUSB continuous machinery o Coarctation (8%); Murmur=RUSB  Measure BP in both arms (if left lower, consider pre-subclavian coarctation; if LE lower or same as upper, consider more distal coarctation) o Aortic (murmur=RUSB) / Pulmonic Stenosis (Murmur=LUSB) (5%) o Require PDA for Aorto-pulmonic circulation  ToF, tricuspid/pulmonic atresia, transposition, hypoplastic right heart o Require PDA for systemic circulation  Coarctation, Aortic stenosis, left hypoplastic heart o TX: PGE1 (alprostadil 0.1-.2 mcg/kg/min gtt) • BNP correlates to CHF in kids •

Peds Rashes/Viral Exanthems

• Deadly Rashes: palms/soles, blistering/mucosal involvement, purpura/petechiae
  • • MRS TECK: meningiocococcemia, RMSF, Syphillis/SJS/SSSS, TSST/TEN, erythema multiforme, coxsackie, Kawasaki
• Bullous impetigo: honey crusting; watch for post-strep glomerulonephritis (hematuria, proteinuria, edema … hypertension, erythrocyte casts)
• Erythema infectiosum (Parvo B- 9, 5th disease) … slapped cheek appearance with erythema to trunk 2 days after facial rah; gone 7d
• Erythema multiforme - hands and soles
• Kawasaki Disease: diffuse urticarial maculopapular rash with desqumation @ 5-7d strawberry tongue, conjunctivitis, high fever > 5d, pharyngitis, swollen hands & feet, cervical lymphadenopathy (>1.5cm);
  • Thrombocytosis, ESR elevated x 6-8wks; ECHO at day 7-28 after fever starts for coronary aneurysm/thrombosis
  • ASA 100mg/kg/day div q6hrs; serum ASA>20mg/dl IVIG 2g/kg x over 2hrs
• Hand-foot-mouth – coxsackie A 6, enterovirus 7 … no TX
• Herpangina - vessivles to post oropharynx
• HSP: vasculitis, joint pain, abd pain (intussusception),
• Lichens Planus: age>40; clears in -4 years, 50% recurrence; flexors of arm, wrist, ankle, lumbars; pruritic papules with wickham’s stria within lesions; darken with time
  • TX: steroid burst, clobex, tacrolimus, azothioprine (last resort)
• Measles (rubeola) – cough, cooryza, conjunctivitis, koplik spots then blanchable rash (face trunk ext)
  • treatment: Vit A <6mo50k IU, 6m-2y 00k IU, >2y 200k IU x 2d
  • Live vaccine … not during pregnancy
• Mononucleosis – prominent lymphadenopathy, rash with amoxyl
• Pityriasis rosea – salmon (herald) patch becomes diffuse over trunk (x-mas tree) with scaly borders over several weeks; often, URI prior to outbreak; clears in -3 months
  • TX: erythromycin q6 x 2-6 weeks, group 5 steroids, antihistamine, steroid burst
• Pityriasis Rubra Pilaris (PRP) – age>40, plaques with skip lesions on face and back, non-pruritic, looks like psoriasis
  • treatment: moisturizer, oral retinoids & methotrexate
• Roseola Infantum (HHV 6&7) … exanthema subitum; most have high fever (103-106) without rash but appear well … RASH AFTER fever breaks
  • treatment: gancyclovir or foscarnet
• Rubella (german measles) – post auriculat & sub-occipital lymphadenopathy; pinpoint lesions to face trunk ext in hours; gone in 2-

3 days

• Scarlet fever (Strep) … fever, pharyngitis, abdominal pain, red tongue, red sandpaper rash (face trunk ext in 48 hrs; hands & feet spared)
  • treatment: PCN, ofloxacin
• Staph Scalded skin - sunburn, nikolsky's sign

Pharmacology

• Narcotic Equivalents
  • MS 10IV=30PO=100mcg fentanyl=dilaudid 1.5mg IV=8mgPO=oxycodone 30mg PO

Psych

• Suicidal
  • RISK: Specific plan, previous attempts, access to lethal means, impulsivity, triggering event (abuse, family death)
  • Protective factors: social/family support, good coping skills, strong religious beliefs
  • Prior to discharge: home with family/friend, corroborate the story, sober, specific follow-up appt
  • Provide resources, contract with patient to return if feeling bad

Pulmonology

PE

• • PIETHO, TOPCOAT, MAPPET-3 - full dose tPA - increased major bleeding and decreased HD decompensation
  • MOPETT - 1/2 dose tPA for sub-massive PE, 0.6mg/kg (50mgmax), (only 121 pts); no negatives, increased exercise tolerance, but decreased HD decompensation; no heparin bolus but gtt (decreased ICH risk)
  • PERFECT, SEATTLE-2 (no comparison/placebo) - catheter directed tPA
  • PEAPETT Study: diagnosed PE, then PEA→ 50mg tPA in 1 minute (CPR to lytic time 7 minutes) followed by heparin, 87% (20/23) alive at 2 years!

• Key Recommendations ACCP 2016
  • Outpatient management:

In patients with low-risk PE, outpatient treatment or early discharge are suggested, rather than hospitalization.

• Choice of anticoagulant drug:
  • In patients with DVTof the leg or PE (and no cancer) the suggestion is to use one of the direct oral anticoagulants (DOAC; apixaban, dabigatran, edoxaban, or rivaroxaban) rather than warfarin therapy!
• Sub-segmental PE:
  • Patients with sub-segmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT:

◦Anticoagulation is suggested for patients at higher risk for recurrence, i.e. patients who are hospitalized, have reduced mobility, have cancer, had unprovoked sub-segmental PE, have low pulmonary reserve, or marked respiratory symptoms. ◦No anticoagulation is suggested but simply surveillance in patients who are at low risk of VTE recurrence (e.g. patients with recent surgery or other transient risk factor •Cancer patients with VTE:

In cancer patients with DVTof the leg or PE LMWH is suggested rather than a DOAC.

•How long to treat with Anticoagulants? 1.VTE (proximal DVTor PE) provoked by surgery: recommend 3 months. 2.VTE (proximal DVTor PE) provoked by non-surgical transient risk factor (e.g. estrogens, pregnancy, leg injury, flight > 8 hrs): suggest 3 months. 3.Unprovoked VTE (proximal DVTor PE): suggest long-term. 4.Distal DVT: ◾ if not severely symptomatic : suggest no anticoagulation, but f/u Doppler ultrasound; ◾if severely symptomatic: suggest 3 months.

• pneumonia antibiotic: CAP: healthy – azithro 5d or avelox/levaquin  comorbidity – avelox or rocephin + azithro o Aspiration: clinda 600 q8 + avelox o ICU: rocephin/aztreonam (2gq8) + avelelox/azithro o ICU/Pseudomonas: zosyn(4.5gq6) (good GI, 95% pseudomonal) /fortaz/aztreonam/rocephin/merrem + (tobra7mg/kg&azithro/avelox OR cipro/levaquin/amikacin) + vancomycin 1g/zyvox(better)  albuterol and steroids may reduce severity of pneumonia • Order Urine strep/legionella if: ICU, failed outpatient, ETOH, liver disease, asplenia, travel<2wks, pleural effusion, encephalopathic • SMART-COP: score >2 predicts 92% of people who need ICU (vent or pressors) for pneumonia o low SBP (2 points); multilobar CXR (1 point) o low albumin (1 point); tachypnea (1 point); tachycardia (1 point) o confusion (1 point); poor oxygenation (2 points); low arterial pH (2 points) • • PE Common causes: age>65, pregnancy, estrogens, surgery, trauma, sepsis, malignancy, lipids, SLE, nephrotic syndrome, unilateral LE edema/swelling o PERC (PE rule-out Criteria)--if all 8 criteria negative, <1.4% risk of PE: Age<50, HR<100, RA sat>94%, no history of DVT/PE, no trauma or surgery (<4weeks), no hemoptysis, no exogenous estrogen, no clinical signs of DVT o Well’s PE: S/S: DVT(3), PE#1 Dx (3), HR>100 (1.5), immobilization or surgery last 1 month (1.5), previous DVT/PE (1.5), hemoptysis (1), malignancy last 6 months (1); 2-6=moderate probability (20%)  VQ intermediate: serial US at 1 week o Well’s DVT(all 1 patient ) 0=low (3%), 1-2=moderate (17%), >2=US (75%)  Ca<6mo, immobilization, bedridden>3d, surgery<4 weeks, homan’s/deep vein tenderness, LE edema, >3cm swelling at 10cm below tib tubercle, pitting edema, previous DVT, collateral superficial veins; alt dx more likely (--2pts)  ++D-dimer or mod-high probability, repeat US in 4-7d o PE: heparin x 5 days + coumadin; Lovenox: decreased HIT  Outpt treatment if compliant, good access to follow upp o TPA for shock: 2% intracranial bleed; inc TI with PE mortality ~6%  Alteplase (TPA) 100mg IV over 2 hours then heparin gtt  Catheter retrieval only if lysis is contraindicated!!! o DVT: lovenox; outpatient treatment if possible; with ARF must use heparin  Arixtra 7.5mg daily  If d-dimer normal after 6 months, stop treatment!  Phlegmasia cerulea albicans/dolens • • COPD: SVN + solumedrol 40 q8-12; +/- avelox o OSA – increase EPAP (12/8) • Status Asthmaticus: o albuterol (10ml LVN) o steroids (decadron 10mg) o terbutaline 2-10 mcg/kg loaf (5mg max) then .08-.4mcg/kg/hr o theophylline/aminophylline (5-7mg/kg, only when severe; SE: vomit, HA) o heliox (70/30 mix) – use with BiPAP o magnesium (50mg/kg, 2g max) o atrovent (anti-cholinergic) o singulair/montelukast (anti-lkt) – not in acute setting o Epi – q5-15 min for severe o ketamine (1-2mg/kg IV for intubation) – give slowly, watch for laryngospasm o VENT: SIMV 6ml/kg, RR 10-12, 1:3 I/E ratio, PEEP 3-5 o Get PEAK FLOWS >6 y/o: >70%=mild, 40-70% moderate o Rule of 2’s – rescue meds 2x/wk, night symptoms 2x/mo, refill meds 2x/yr •  URI o Dextromethorphan and pseudoephedrine not recommended under 6 y/o o Cough suppression at night only: codeine is best; honey as effective as DMX (not age <12, may cause insomnia) o Nasal congestion: afrin, sudaphed, nasal irrigation (nasal saline, neti pot – shrinks mucosal swelling and removed antigens), flonase, Claritin/ALLEGRA o ORAL zinc (not nasal), Vit C x 5 days (8g), Echinacea (not root) o Phenergan/Tylenol with codeine, rondec for peds, tessalon pearls  Intractable cough – alb svn with 2cc lidocaine  Flu: treat high risk pts (<2, >65, pregnant, COPD, immunocompromised); o treatment: ICU admission regardless of onset time; send Flu swab  High risk: <2, >65, pregnant, COPD, immunosuppressed o Tamiflu/relenza x 5d; cuts 17 hrs of signs and symptoms; EUA: premavir … 600mg IV x 5d o 2015: H3N2 predominance o Do NOT prophylax exposures – treat early onset symptoms instead o If symptomatic after prophylaxis, add amantadine; Flu shot: 2 doses if <3yr   Bordatella Pertussis: paroxysmal cough >2 weeks +/- “whoop +/- post-tussive vomiting o Looks viral during first week, but then cough persists for a month or more o NP swab for PCR o Need to update Td with one-time Adacel (Tdap) o Peds: Azithro  <6mo, 10mg/kg x 5d; >6mo, 10mg/kg then 5mg/kg x 4d; or e-mycin 10mg/kg q6 x 14d, biaxin 15mg/kg x 7d, bactrim 8mg/kg x 14d o adult=z-pack, bactrim 1 q12 x 14d, or emycin 500 q6 x 14d   Croup: try albuterol, racemic epinephrine … only continue treatment if it helps • • Hiccoughs – chlorpromazine (thorazine) 25 to 50mg IV, with a repeated dose in 2 to 4 h if needed … effectiveness usually evident within 30 min; PO 25 to 50mg tid or qid o reglan 10mg IV or IM and, if effective, followed by 10 to 20mg qid for 10 days o Chronic: Nifedipine 10 to 20mg PO tid, valproic acid 15mg/kg per day divided, or baclofen 10mg tid

Radiology

• Indications for MRI:
  • Head: MRV for venous sinus thrombosis, suspected encephalitis, diffuse axonal injury, suspected AVM with bleed, stroke with neg CT in therapeutic window, <48 hours post-op brain tumor, suspected brain tumor with ALOC, child with slowly progressive visual loss, proptosis
  • Chest: suspected dissection when unable to do IV contrast
  • Spine: epidural abscess/discitis, cord compression, suspected ligamentous injury, traumatic cord injury
  • Abd: pregnant appy

Contrast

• Reactions (Critical Decisions, Jan 2010):
  • Anaphylactoid: most common, immediately after administration; histamine mediated; more common with high-osmolar contrast
  • Chemotoxic: dependent on dose, osmolality, ionicity;
  • Risk Factors: previous rxn (6x), asthma (5x), CAD (2-5x), B-blockers (3x), atopy (2x), age 20-50 (increased immune response), multiple co-morbidities
  • Prevention: low-osmolarity, non-ionic (ie, Iohexol) - reactions <1%; pre-treatemnt takes to long to have an affect in the ED
  • Tx: Epi, benadryl, steroid for rebound (most delayed reactions are self-limited), albuterol
• Contrast Induced Nephropathy
  • Increase in Cr 0.5 or 25% above baseline, often peaks 3-5 days after contrast (most studies done on cardiac angio - high dye load)
  • <2% of population, but >30% if GFR<60! ~10% of ARF cases from CIN; renal flow 30% less up to 2 hours after contrast
  • Risk: CKD, DM (5-30% CIN), CHF due to low EF
  • Prevention: low-osmolar contrast, lower volume (each 100ml of contrast ~12% risk of CIN), IVF (dilution, Na decreases renin-angiotensin so increased renal blood flow, and volume deccreases CIN decrease of nitrous oxide production); avoid NSAIDs after contrast (decreases the PGE mediated renal arteriole tone)
  • Metformin use can cause lactic acidosis - hold 48 hours
    • Options: D5W + 3 amps bicarb @ 3ml/kg 1 hr before, 1ml/kg 6 hrs after + NAC IV: 150mg/kg 1 hr before, 50mg/kg over 4 hours after contrast (NAC PO: 1000mg PO 1 hr before and 4 hrs after)
• Atheroembolic syndrome (AES) – up to 1 week post-contrast ARF; check urine eosinophils to rule out interstitial nephritis

SURGERY

• Post-Op Fever
  • Wind (pneumonia 48hr)
  • Water (UTI 72hrs)
  • Wound (abscess 7 d)
  • Walk (DVT – 10d)
• APPENDICITIS – Alvarado Score (MANTRELS)
  • 1 point: pain migration, anorexia, nausea and vomiting, RLQ rebound, temp, bandemia
  • 2 points: RLQ TTP, leukocytosis
    • 1-4 unlikely; 5-6 possible; 7-8 probable; 9-10 definite
  • Peds: unasyn 75mg/kg q6; cefoxitin 40mg/kg q6
  • Perforated: merrem 1g q8; zosyn 4.5g q6; ciprofloxacin + flagyl
  • Abscess >3cm needs US drainage
  • Non-pregant adult: CT with IV only contrast (rectal contrast if BMI<20)
  • Pregnant: serial compression US
  • Pediatrics: US (if equivocal, CT with IV and Rectal contrast)
  • Antibiotics (6 European studies): no mortality change, lower perforation rate, slightly longer LOS (in studies, but questionable need for this), decrease initial pain, decrease WBC, return to work faster (5 vs 10 days)
    • 10% fail initially, 15-25% within a year
    • for acute, uncomplicated patients
    • Harbor part of 1500 patient CODA study (ABEST was the trial)
      • Pilot 120 pts, 30 participated; ertapenem x 2d (came back to ED on day 2 for re-eval and 2nd dose IV antibiotic), omnicef + flagly x 8d
      • Can repeat antibiotic if failure (like diverticulitis)
• Biliary Colic
  • Cholecystitis
  • HIDA: no CCK if stones present or if s/p chole looking for bile leak
• Diverticulitis
  • Outpt: flagyl 500 + ciprofloxacin 750 q6
  • Inpt mild: flagyl 500 q6 + ciprofloxacin 400 q12; zosyn 4.5g q8
  • Inpt ICU: ampicillin 2g q6 + flagyl 500 q6 + gentamicin 5mg/kg/day
• Infectious
  • Abd Moderate: rocephin 1g qd or ciprofloxacin 400mg q12 + flagyl 500 q6
  • Abd Severe: ampicillin 1g q6 + flagyl 500 q6 + tobra 7mg/kg (ciprofloxacin 400 for ARF)
• Perforated bowel/Intra-abdominal abscess
  • Merrem 1g q8; zosyn 4.5g q8; amp 2g q6 + flagyl 500 q8 + ciprofloxacin 400 q12
• Mesenteric Ischemia: lactic acid, CTA
• Pneumatosis intestinalis – often a sign of local ischemia
• Thoracic dissection
  • CTA to TEE (not TTE); neg d-dimer does not exclude dx
  • Risk Factors: ripping/tearing, mediastinal widening, pulse or BP differential, aortic murmur
  • No specific target for BP/HR … goal SBP<120, HR=60

TOXICOLOGY

KEY: VS, CNS, ECG, pupils, skin; route of exposure, time since exposure, intentional vs accidental; consider ABG, lactate

Toxidromes

• Anticholinergic -- tachy, red (flushed), hot, mad (hallucinations, seizures; agitation, picking mvmts, babbling speech), blind (mydriasis), dry (urine retention, armpits), ileus

o anti’s: histamine, psychotics, depressant (TCA), parkinsonian (benztropine/amantadine), flexeril, jimson weed, NMS, SS o CPK, lactate, DIC labs, APAP (delayed peak – slow GI), ECG o WBI with PEG at 2L/hr if no ileus; MDAC with prolonged symptoms; aggressive cooling, lots of IVF (prevent rhabdo), benzo’s, bicarb to ph 7.45 if increased QRS, lido for ventricular arrhythmia o PHYSOSTIGMINE: for intractable seizure, unstable arrhythmia, delirium  1-2mg in 10cc NS over 10 minutes (0.02mg/kg in peds)  have atropine at the bedside  inclusion: normal axis and QRS, no coingestions or cardiac toxins, no bradycardia or GI blockage, no recent succinylcholine  may cause asystole with TCA toxicity or any QRS widening, seizures, cholinergic crisis (SLUDGE)  Do not use with asthma or non-sinus tachycardia

• Antipsychotics: cogentin (benztropine) for the EPS – 2mg IV then PO q12

o Seroquel (long QT); if >3gram ingestion  ICU; TX: fluids, +/- levophed o Compazine (delayed EPS), phenergan/reglan (methemoglobinemia), trazodone (priapism, SS) o Buproprione (wellbutrin): seizures, SS; treatment: cyproheptadine 4mg PO TID

• Cholinergic (anticholinesterases)

o Muscarinic (DUMBELS/SLUDGE (diarrhea, urination, mydriasis [dilation], brady, bronchorrhea, emesis, lacrimation, salivation) o Nicotinic (MTWRF: mydriasis, tachy, weak, hypertension, fasciculations/flaccid) o From: Organophosphate, carbamate, mushrooms, cholinesterase inhibitirs (tacrine/donepezil), nerve gas (Sarin, Soman, Tabun, VX ) -- vapor exposure give miosis, physiostigmine, nicotine (pesticides) o Atropine 2mg IV and double q5min until resolution of pulmonary edema, MAP>65, HR>80 (typically need ~75mg in 1st hour);  Gtt 20-50% loading dose; .02-.8mg/kg/hr (typically <5mg/hr)… stop if they become anticholinergic o Pralidoxime (2-PAM – if repeat atropine given) 30mg/kg (up to 2g IV over 30 min) then 8mg/kg/hr for 48 hrs; treat until muscarinic symptoms gone  synergistic (decrease atropine doses once 2-PAM started) o Valium 10mg prophylaxis, 5-10mg boluses for seizures

• Sympathomimetic/stimulants (fight or flight)

o Tachy, hypertension, hyperthermia; combative, seizures, mydriasis, delirium o Cocaine, amphetamine, ecstasy, tryptamines, hallucinogens, MAOi, WITHDRAWAL (sedative-hypnotic – opioid, ETOH, benzo, barb … librium long acting), nicotine, sudaphed, Ritalin, meth, ma huang, thyroid, methylxanthine (caffeine, theophylline), DXM/PCP, buproprion, o treatment: aggressive IVF, valium, active cooling, dantrolene for rigidity

• Sedative/Hypnotic: Miosis, lethargic, decreased bowel sounds, respiratory depression, hypotension, brady, hypothermia, hyporeflexia, ileus

o ETOH, benzo, barb, clonidine, opioids (narcan), GHB, valproic acid, propofol, etomidate, GABA agonists, SOMA

• Bradycardia: alpha agonist (clonidine), beta-blocker, Ca2+ blocker, digitalis, opioid, GHB, organophosphate, sedative-hypnotic OD, hyper K+
• Tachycardia: sympathomimetics, ANTI’s, withdrawal
  • Tachy + Hypotension: TCA, coke, theophylline, iron, MAOi, CN, CO, HS

 Hypotension: ANTI’s, CCB/BB, clonidine, cyanide, toxic ETOH, heavy metals, GHB, nitrates, opioid, organophosphate, phenothiazine, sedative, theophylline

• hypertension: sympathomimetics, anticholinergic, lead, MAOi
• Tachypnea: toxic ETOH, nicotine, organophosphate, salicylate, sympathomimetics
• Bradypnea: sedatives, botulism, clonidine, organophosphates
• Hypothermia– sedative-hypnotic, hypoglycemia, CO, phenothiazines
• Hyperthermia – sympathomimetic, ANTI’s, antipsychotic (NMS/SS), anesthetics (MH), salicylates, arsenic, phenothiazines, sedatives, thyroxine
• Miosis – opiate, clonidine, cholinergic, PCP, pontine hemorrhage, anticholinesterase, nicotine, barbiturates, benzo, ETOH
• Mydriasis – sympathomimetic, ANTI’s, anoxia, withdrawal
• Seizures: sympathomimetics, ANTI’s, BB, camphor, ETOH withdrawal, INH, lead, Li, organophosphates, TCA, buproprione; NMS=rigid; SS=hyperreflexic
• Ataxia: dilantin, VPA, carbamazepine; ETOH, DMX, sedative-hypnotics
• Agitated delirium: withdrawal, SS

Specific Interventions

• HemoDialysis – I STUMBLE (isopropyl ETOH, salicylates>80, theophylline, uremia, methanol, barbiturate, lithium>4, ethylene glycol); anything with low protein binding
• WBI – sustained release, drug packets, iron, enteric coated products
• GoLytely 1L/hr “to clear rectal effluent” (typically ~4 hrs)
• No charcoal to CHAMP (C, heavy metals, A, M, P ...)
• MDAC – CT PDQ (carbamazepine, theophylline, phenobarbital, dapsone, quinidine)
  • 1mg/kg then 25g q 4hrs; no sorbitol if MDAC, + zofran; stop if ileus/SBO



Acid/Base

• Vitals, chem. 7, ABG: Acid or base (7.4) o Metabolic (CO2 & pH in same direction…CO2 of 40)  met acidosis (winter’s): CO2=1.5 HCO3 +8 (+/-2)  met alkalosis: CO2=0.7 HCO3 +20 (+/-5) o Respiratory (opposite directions)  change of 10 CO2 changes pH 0.08 • AG (>12) … AMUDPILES o ARF, Methanol/metformin, Uremia, DKA (diabetic, alcoholic, starvation), Paraldehyde, Isoniazid. Iron, Ibuprophen (NSAIDs), Lactic acid, ETOH, EG, Salicylates; rhabdo, nitroprusside o Ketoacidosis: BHB high initially, ketones increase as the acidosis clears; can follow serum acetone; D5NS • •

• Delta gap – expected HCO3 too high, secondary alkalosis; HCO3 too low, non-AG secondary acidosis

o anion gap-10=delta gap; if delta gap + bicarb=normal HCO3 (22-26), then it is a simple acid base disorder; if it does not normalize it, it is mixed acid base (use calculator) o pH increases .08 for every CO2 increase of 10 o dec NA 1.6 for every 100 over 100 (dilutional) o o AG-10 / 24-HCO3 = 1-1.6; <1= non-gap met acid; >1.6= met alk o corrected bicarb: AG-12 + HCO3; serum & ABG HCO3 should be close  <24 non-AG acidosis (loss of bicarb – diarrhea)  >24=met alkalosis – volume depletion, hypokalemia, base ingestion, mineralocorticoid excess

• OSMOLAR GAP: 2Na + gluc/18 + BUN/2.8 = -2 to 10

 ETOH/4.6, MeOH/3.2, EG/6.2, IsOH/6  Toxic ETOH, mannitol, acetone, propylene glycol, paraldehyde  Small gaps in AKA (give D5 – need carbs), lactic acid, & cirrhosis  Non-Gap: Diarrhea, small bowel/pancreatic fistula, hyperparathyroidism, ingestions: sulful, chlorine, HCL, ammonia, Ca, Mag, lysine/arginine,     

Specific Treatments

• Animals
  • Snake bites
    • 25% dry bites: watch for 6 hours; leave hemorrhagic bleb intact
    • Croataline - Triangle head, heat sensing pit, front fangs, elliptical eyes; 50% coagulopathy, 33% thrombocytopenia, rhabdo
      • Antivenom: rapid progression of swelling, inc INR, plt<50; Start 4-6 vials … typically 12-18 ($3k each)
      • Avoid fasciotomies!!!
  • Gila Monster – local wound care
  • Brow Recluse
  • Black Widow

• Benzos: flumazenil 0.2mg IV q1min, 1mg max; not if chronic (known single ingestion)
• Beta Blockers (low BS) & Calcium channel blockers (high BS): Treat HR <35
  • Watch for QRS widening and torsades
    • Atropine: 0.04mg/kg adult, 0.02mg/k peds, 0.1mg minimum
    • CaCl: 10-20ml (central); Ca gluconate: 30-60ml; gtt up to 3g/hr for SBP; K+ q2 hr; No CA if on DIGOXIN (get level) – theoretical stone heart
    • Glucagon 2-5mgIV x 2; 2-10mg/hr infusion if patient responds to IV bolus; give with zofran; peds 150mcg/kg bolus then 50-100mcg/kg/hr
    • Transcutaneous or transvenous pacing may be needed (versed .05-.1mg/kg)
    • HIET: Insulin gtt bolus 1u/kg; titrate gtt up .5u/kg q 20 min to 6u/kg/hr max
      • Give ½ amp of D50 with bolus; D10 gtt at 200ml/hr; accuchcek q30min; try to wean down at 12-24 hr point (decrease .5u/kg/hr)
    • Consider Epi/isoproteranol, milrinone (PDEi – peripheral vasodilation, inc HR), digibind, narcan
    • Intra-lipid bolus
    • Intra-aortic balloon pump (last effort)
• Buproprione
  • WBI if <1 hr and sustained release tablets; admit if >450mg ingestion
• Carbamazepine
  • False positive TCA on UDS; watch QRS width; discharge if <15mcg/ml
• Carbon Monoxide (CO)
  • VBG for carboxyhemoglobin
• Clonidine: narcan may help; use short acting agents for hypertension -- nipride, esmolol
• Cocaine
  • Stuffer (butt); packer (oral)
  • No BB for CP or hypertension; NTG, phentolamine
  • Bicarb to pH 7.5 for widened QRS
• Cyanide: avoid nitrates if suspected CO (form methemoglobin); consider in house fires (from plastics), especially if LACTATE >10; bitter almond aroma
  • TX: immediately (before levels) if hypotension, headache, vomiting
    • Hydroxycobalamin (vit B-12) 70mg/kg (5gm max) in 100cc of NS over 15 min; peds=70mg/kg
    • Amyl nitrate: 1 ampule inhaled for 30 seconds, then 30 seconds O2 x 3 min; repeat until IV established (each amp should last ~3 min)
    • Sodium Nitrite: 300mg IV over 5 minutes; peds=0.3ml/kg
    • Sodium Thiosulfate: 12.5g IV over 10 min; peds=400mg/kg ... safe with CO poisoning
• Digoxin – digibind if ingestion of >10g in adult or 4mg in peds, unstable arrhythmias, or K+ >5 acutely (not if chronic user) … no CaCl (stone heart)
  • Empiric treatment: 10 vials IV over 30 min if acute, 2-3 vials if chronic
    • Patient must be urinating to excrete the bound dig … otherwise it dissociates back into the blood!
      1. of vials =dig dose taken*0.5 OR =(serum dig *ideal kg)/100
    • For plant ingestions, MDAC and empiric Digibind (cannot follow dig level)
  • Resultant a-fib with RVR: treatment with cardizem or esmolol
    • Lidocaine is anti-arrhythmic of choice

• Dilantin

o Hypotension& bradycardia, ataxia, neuropathy o

• ETOH: dec 20-30mg/dl/hr; 1oz whiskey=6oz wine=12oz beer; 25ml/dl for 70kg M; 1/5 =25oz

 Mellanby effect – at same ETOH level, more intoxicated on level up than on the way down  Withdrawal – 6-12 hrs: anxious, hypertension, tremor; hallucinations 12-24 hrs, seizures 7-48 hrs, DT’s 48-72 hrs o Banana Bag: MVI 10ml, thiamine 100mg, folate 1mg, mag sulfate 2g in 1L D5 1/2NS over 4 hrs o Valium (10mg PO/IV) has a longer lasting metabolite … if needing large amounts, add low doses of phenobarb (30-60mg) o Librium (25-100 PO) has long duration of action o Phenobarb 260mg + 130mgq10 min … intubate o Adjuncts: Clonidine .1 to .5; Atenolol 25-100mg PO

• Toxic ETOH -- Anion Gap & Osmolar Gap; as OG decreases, AG increases

o IF HIGH GAP but NO LACTATE, treat with Fomepizole – gives 12 hours of blocking while awaiting levels!

• Ethylene glycol -- CNS, renal (Ca oxylate crystals in UA … may fluoresce under wood lamp if contains fluorescein) – within 24-72 hrs; HD (for weeks!)

o Early osm gap, late AG; Inc lactate & Cr, dec Ca o Est EG level: OSM Gap x 6.2; Peak levels in ~4 hrs o Replace bicarb, pyridoxime, thiamine o Dialyze at level >25

• Methanol (formic acid) -- CNS (uncoordinated; edema, hemorrhage & necrosis on MRI), ocular (snowstorm, blind, mydriasis), pancreatitis/abdominal pain

o Level >50 or severe acidosis=dialysis o AG after 8-24 hrs; est MeOH level= OSM Gap x 3.2 o Replace bicarb; give folate 50 IV q4 hrs

• Propylene Glycol: level > 70mg/dl; AG + OG acidosis

• Isopropyl alcohol: creates acetone; windex; OSM gap, but no AG (low)

o Supportive care; only dialyze if levels >400mg/dl

• Fomepizole: give while awaiting labs if high suspicion for ingestion(or labs >6hrs)

o 15mg/kg IV, then 10mg/kg q 12 x 4 doses, then 15mg/kg q12 until toxic ETOH cleared and acidosis resolved $100/dose o prolongs elimination half-life to protect kidneys while awaiting dialysis; GIVE Q4 hrs during dialysis (as it is dialyzed!!!) • ETOH gtt: 40 proof (20% best absorption rate) or 100 proof and dilute with juice or D5W o MUST INTUBATE!!! … 5ml/kg of 20% solution to ETOH level of 150; titrate gtt of 1ml/kg/hr and check ETOH level q1hr o Hemodialysis: start with 6-8 hrs; to level <20 and Osm gap <5 o Folate 50mg q4 (Me), thiamine 100mg q12 & pyridoxime 50mg q6 (EG) o If pH <7 consider bicarb + vent; monitor Ca levels

• EPS (extrapyramidal side effects): cogentin or benadryl

• Gasses

o Bleach + ammonia=chloramines; flush eyes o Bleach + toilet cleaner=chlorine gas; RESP; heave gas, effects kids more o CO: tachy, hypotensive; hyperbaric oxygen for ANY neuro symptoms  T ½ = 4 hrs; 60 min with NRB, 15 min with HBO

• Heparin: protamine 1mg for every 100 units of heparin given; may help with LMWH

o If SQ given, need multiple small doses of protamine

• Hydrocarbons – sensitizes myocardium to catecholamines  V-TACH

o Benzos, lidocaine (NO AMIODARONE), beta-blocker, vasopressin

• Hydrofluoric Acid: concentration is important

o <10% concentration delayed up to 24 hrs; <5% TBSA or less than 30ml ok o >40% -- 1% TBSA can cause systemic toxicity– requires cardiac monitoring, ECG, serial Ca levels o arrhythmia, dec SBP, hypocalcemia, met acidosis, dec mag, inc K, inc INR o If QT prolonged, give Ca 1gram over 20 min; Check Ca q30 for 3 hours  If normal Ca level after 6 hours, discharge home o Dermal exposure must be irrigated for 30 min; If pain despite irrigation, topical Ca 2.5% gel (place in latex gloves if hands are exposed; o If refractory pain, SQ injection 27g needle of 0.5ml/cm2 of Ca Gluconate o If STILL refractory, try regional perfusion -- Exsanguinate and tourniquet the extremity, then infuse 50ml into vein of 2.5% Ca Gluconate -- admit o If refractory, art line with 100ml of 2.5% Ca Gluc over 1 hour – to ICU

• Iron Toxicity – get KUB to see pills … Surgery for bezoar!
  • Iron toxicity at 20mg/kg; take dose of pill taken and multiply by .2 - .33 (ie, 325mg pill=60-100mg iron)
  • AG acidosis will NOT resolve

o Go-Lytely 25ml/kg/hr o Deferoxamine ... causes vin rose urine (red from the ferroxamine)

• Isoniazid (INH): pyridoxine gram for gram of INH in 50ml of NS, max 1 g/min

o Empiric dose is 70mg/kg, to 5 grams … if seizing, 5g IV o Synergistic with diazepam; repeat dose (5g) if still seizing

o pyridoxime also used for gyromitra mushrooms (mono-methylhydrazine) o Stop when seizures resolve, mental status improves, acidosis normalizes o If chronic (not OD) & ALT 3-5x normal, hold INH and give PO NAC

• Lithium: inc IVF (Na); HD if >4meq/L or not decreasing 20% q6hrs  goal<1meq/L

o ECG: inc QT, brady, U-waves; anion & osmolar gaps o Ataxia, agitation, weakness, neuropathy, GI (acute), ALOC (chronic) o Benzo/phenobarb, NO charcoal; lavage if >4g ingestion

• MAOi’s

o >1mg/kg to ICU o Phentolamine 2-5mg q15 min for hypertension; NTG, nipride, fenoldopam o Lido or procainamide for dysrhythmias o Benzos or paralyze for seizures (Roc, Vec, Pancuronium) o Dantrolene 1-2.5mg/kg q6 hrs for hyperthermia

• Malignant Hyperthermia

o Rapid cooling measures; Stop succinylcholine; Give O2 (no gasses) o Dantrolene 2.5mg/kg q15 min (10mg max); bromocryptine 2.5mg PO q6 o Bicarb 1-2mg/kg (check ABG) o Treat hyperkalemia (CaCl, insulin 10u + D50, kayexalate) o Increase urine output to 2ml/kg/hr (mannitol, lasix if necessary)

• Neuroleptic Malignant Syndrome

o Fever, rigidity, CPK, ALOC,tachy, diaphoresis, acidotic o Benzos, levophed, bicarb/lidocaine, watch QTc – mag, dantrolene 1-2.5mg/kg for rigidity

• Serotonin Syndrome

• Metformin: watch for lactic acidosis; continuous hemofiltration recommended

• Methemoglobinemia: chocolate-brown blood, shortness of breath/DOE, tachy, grey (10%), blue (20%), 15-50%: HA, weak; 50-60%: severe hypoxia, arrhythmia, MI, ALOC, death (70%)

o treatment: methylene blue 1-2mg/kg over 10 min; see results in <30 min (not if G6PD deficiency… May need exchange transfusion) o Indication: >20% symptomatic; >30% asymptomatic + symptoms o Causes blue-green urine for days, hypertension, CP, HA, fever, ok in pregnancy

• Methotrexate: folinic acid (leucovorin) 100mg/m^2 q3hrs

• Mushrooms: ID it -- gills underneath, patchy color cap, spore color (come out of gills), girth of the stem, skirt on the stem, cup at the base (may be under the soil)=amanita

o Activated charcoal (MDAC), LFT’s, Cr, consider NAC for liver failure o TX: Pyridoxine for seizure/coma: 25mg/kg over 30 min, up to 20g daily

• Opioids: narcan 0.4mg IM/IV q2min, 10mg max; small dose if chronic user!

o titrate gtt to respiratory depression, not awakefulness (hourly dose should be 2/3 the amount needed for initial reversal) o Seizures from darvocet, demerol, & tramadol; watch heroine OD 6 hours o Withdrawal: yawning, anxiety, piloerection, rhinorrhea, nausea and vomiting/D, diaphoresis  Clonidine: 5-6mcg/kg/day (ie, 0.3mg); watch after first dose o Monitor 3 hours after last narcan dose; admit if sustained release

• Phenobarbital: urinary alkalinization to increase renal elimination

• Propylene glycol – acidosis form excessive ativan or valium (preservative)

• Salicylates: IVF with 3amps bicarb +40KCl at 200/hr to alkalinize urine; HD if level>100 (acute); >50 (chronic)

o if urine pH not >7.0 after 1 hr, repeat bolus; check ASA level q1hr o watch for low K+ o if still elevating despite alkalinization, HD necessary o stop when level <30mg.dl

• SNRI’s

o Venlafaxine, duloxetine o Phenylephrine for hypotension (pure alpha)

• SSRI’s

o Hyperthermia, clonus, seizures – check CPK o Benzos, cyproheptadine 4-12mg q2 hrs

• Sodium channel openers (hypotension, brady, dysrhythmias, GI)

o From monkshood, rhodendron, azaleas, death camas, hellebore o treatment: amiodarone, atropine

• Sodium Channel blockade: bicarb gtt for any QRS widening; TCA’s, darvocet, cocaine, carbamazepine, antihistamine, phenothiazine, beta-blockers , tegretol; possibly with high dose: benadryl, carbamazepine, darvocet, cyclobenzaprine

o 1-2 amps of bicarb up front (1meq/kg) + gtt at 250ml/hr (3 amps in D5W)  if no qrs change, repeat bolus  if pH >7.55, bicarb is ineffective – try 3% NS 5ml/kg  lido gtt is fast-acting on the Na Channels o recheck ECG within 30 min of treatment; treat until normal QRS (<120) o bicarb gtt used for urinary alkalinization for ASA (>30mg/dl), phenobarb, HFA, EG/MeOH

• Sulfonylurea: octreotide 50-100mcg IV/SQ q6 if persistent hypoglycemia; no glucagon

 Check K+ when using octreotide gtts (100-125mcg/hr) o D50W in adults, D25W in peds, D10W in infants – 1g/kg … caution: prolonged use of dextrose gtts increases endogenous insulin production o Confused, agitated, weak, tachy, diaphoretic o SE: brady, hypertension, dizzy, anaphylaxis o If asymptomatic after 12 hours, discharge; if intentional OD, monitor for 24 hrs  

• Theophylline: seizure if >90mcg/ml (40mcg/ml if chronic); MDAC, HD

o Benzo’s/propofol for seizures; lido/amio for arrhythmias

• TCA’s

o Bicarb for widening or arrhythmia, levophed for hypotension, benzodiazepines then phenobarb for seizures

• Tylenol (ACEP): NAC best if within 8 hours of ingestion; ok if <24 hrs

o Acute ingestion: Rumack-Matthews Nomogram after 4 hrs (peak time)

 Anticholinergics (benadryl) & opioids (immodium) delay absorption

 NAPQI is toxic metabolite; NAC conjugates it o Risk of hepatotoxicity: possible=5%; probable is time dependent:  <10 hrs=6-7%; 10-16 hrs=26-29%; 16-24 hrs=41-62% o NO HEPATIC FAILURE SEEN IF AST NORMAL ON PRESENTATION

• Toxic: >10g/24 hrs; 140mg/kg adult, 200mg/kg in peds

 Max level=dose/Vd (.8*Kg); T ½ = 4 hrs o Normal dosing is expected to peak <30mcg/dl at 90min, <10 mcg/dl at 6 hrs o Repeated supratheraputic doses have worse prognosis (10g or 200mg/kg in 24 hrs, 6g or 150mg/kg in 48 hrs)  Hepatotoxic (AST>50 likely heading toward sever hepatotoxicity [>1000])  Hepatic failute= hepatotoxicity + hepatic encephalopathy

• Chronic ingestion: treat level >20 or LFT elevated (+/-encephalopathy)

 stop when APAP and LFT wnl (treatment 24 hrs then stop if <200)

• High Dose PO/NG – 140mg/kg then 70mg/kg q4hrs x 17 doses; give with zofran; high 1st pass metabolism (that is the goal)

 Ok to give activated charcoal; for oral NAC (PO, NG), give reglan 10mg IV before

• High Dose IV 140 then 70 q4hr in 250ml D5W; for peds mix in NS

 pregnant (avoid 1st pass effect get to placenta), GI bleed, shock, vomiting after 2 anti-emetics, ALT>1000, SBO  give with benadryl IV (prurutis common)  IV NAC - slows progression of hepatic failure regardless of ingestion time (21% decrease mortality, 24% decrease encephalopathy, 16% decreased dialysis)  Risk of anaphylaxis (if reaction, switch to PO) o Low Dose IV (Acetadote): 150mg/kg over 1 hr, 50mg/kg over 4 hours, 100mg/kg over 16 hours;  <8hrs from acute ingestion, single item, normal LFT’s  not in pregnant or peds  May slightly elevate the INR; higher risk of anaphylaxis o Tylenol level should be --ve at 24 hrs when LFT’s begin to elevate!  STOP NAC if >24 hrs AND Tylenol level negative AND LFT’s trending down (<1000) AND INR <2

• Valproic Acid: watch LFT’s and Na, pH, ARF

o ALOC, hyopotension, hypoglycemia, hypernatremia, AG acidosis, LFTs o MDAC & WBI for extended release; hemoperfusion for severe OD o L-Carnitine 100mg/kg, 6g max; then 50mg/kg/d divided q8hrs; + lactulose for ammonia;

• Warfarin: Serious bleeding -- vit K 10mg IV, FFP 15ml/kg, activated prothrombin 50 IU/kg IV, factor 7a 20mcg/kg IV

o INR>9: Vit K 5mg PO o INR>5: Vit K 2mg PO o Superwarfarins (rat poison – brodifacoum): – start with 100mg PO q6; high dose vit K for months

TRAUMA/ATLS

Activations

• LEVEL 1 – GCS<13, unstable vitals, penetrating, blunt neck with airway compromise, flail chest, foot/hand amputation, multiple long-bone fx’s, open book pelvis, paralysis, major burns, transfers receiving blood
• LEVEL 2 – ejection, death in vehicle, MVA >60mph, intrusion>20”, auto vs ped/bike, motorcycle>20mph OR separation, extrication>20min, unrestrained rollover, fall>20 feet, penetrating extremity injuries, traumatic pelvic fx, open long bone fx
• LEVEL 3 – all traumas needing forther observation

Massive Transfusion Guidelines

• activate when anticipate or give >4u pRBC in 1 hour; must be returned within 30 minutes and cannot be >10 degrees warmer
• Predictive factors: tachy, hypotensive, +ve fast, & penetrating wound
  • Target whole blood; PROPPR 1pRBC:1FFP:1PLT (PROPPR trial - was underpowered)
    • 1st box 6 pRBC (O), 6 FFP (A)
    • 2nd box 6 pRBC, 6 FFP (30 min to thaw), 1 Platelet, +/- cryo based on fibrinogen level

• Give through level 1 warmer
  • 1u=325 ml (count as 3:1 fluid replacement – colloid); 1u FFP per 4u pRBC’s
  • citrate will increase pH and decrease Ca

• Tranexamic acid 1g/10 min then 1g over 8 hrs decreases risk of mortality (10% reduction of hemorrhage, no change in occlusive disease); ** CRASH-2 (NNT=67) & MATTERs (NNT-15, NNT=7 when also using MTP) trials; $10/dose

• TEG (or ROTEM)
  • long R=FFP
  • big MA=platelet
  • big angle=cryo
  • long tail=TXA

ABCDE

• Solid organ injuries more common in peds – bones malleable and transmit forces; adults break

• Head
  • Subdural: evacuate if acute and >1cm or with 5mm midline shift regardless of GCS
  • SAH: watch for hydrocephalus or CVI from vasospasm
  • DAI from acceleration/deceleration forces
  • Massive scalp bleeds: consider lido+epinephrine (max of 7mg/kg~50cc); penrose drain like a headband or Raney clips (neurosurgery)

• Neck
  • Nexus: midline tenderness, ALOC, ETOH, neuro deficit, distracting injury
  • Canadian C-spine rules: image if >65, paresthesia, previous c-spine surgery, or dangerous mechanism of injury (3’, 5 steps, axial head load, 60 mph, ATV, car vs bike)
    • If simple rear-end collision, sitting, ambulatory, delayed onset neck pain, no midline tenderness → test ROM 45 degrees, no pain or instability, no imaging
  • CT, flex/ext, Miami-J
  • If positive c-spine fx, check CTA for possible vertebral artery defect (treatment: ASA)

• Chest
  • Nexus Chest: Age>60, rapid deceleration, CP, ETOH, dec LOC, distracting injury
  • CXR underestimates pulmonary contusion by 60%; often delayed presentation
  • Tracheobronchial Disruption: intubate in OR to avoid worsening tears
  • Aortic Injury – most frequently lose aortic knob
  • Blunt thoracic injury with neg TI – low risk of cardiac contusion/arrhythmia
  • Tachy and hypotense – consider contusion  ECHO, TIx3
  • Commotio Cordis: hit on upstroke of T-wave  VT

• Extremities
  • Concern for vascular injury – ABI >0.9; if less, surgery <6 hours ideal

Decision Rules

• Pan Scan ~25 mSEV (5, 2, 5, 10)
  • REACT-2: no difference in pan-scan vs selective imaging

• Peds
  • PECARN Head
    • <2y/o: most sensitive to radiation; CT vs OBS if GCS<15, palpable skull fx, non-frontal scalp hematoma, not acting normally, LOC > 5 sec, severe mechanism
      • No CT (trivial mechanism): ground level fall, hitting stationary object, no lac or abrasion
    • >2y/o: CT if GCS<15 on eval by DR, LOC, vomiting, severe mechanism, severe HA, signs of basilar skull fx
      • Risk of delayed bleed in minor head injury: ~.03% if normal GCS
      • GCS<14=20% chance of bleed

• • PECARN Abd
    • CT neg, ok for discharge
    • FAST - most commonly find fluid in suprapubic region

• CT for TBI
  • Traumatic Brain Injury/Concussion guidelines (ACEP/CDC)
    • CT if: LOC + 1 item (HA, vomit, >60, ETOH, amnesia, trauma above clavicle, post-traumatic seizure, GCS<15, focal deficit, coagulopathy
    • CT if no LOC but MVA ejection, MVA vs Ped, fall>3 feet
  • New Orleans Criteria for CT: HA, vomit, >60, ETOH, persistent amnesia, trauma above clavicle, seizure
  • Canadian CT Head Rule: GCS <15 2 hrs after event, suspected skull or basilar skull fx, >2 vomit, >65 y/o, amnesia >30 min, mechanism (ejection/MVA vs peds, fall>3’ or 5 stairs)

• Concussion
  • Expect: confusion, trouble concentrating, groggy, HA, dizzy, nausea and vomiting, irritability, difficulty sleeping
  • TX: rest, avoid ETOH, slow return to routine once symptoms resolved
  • Return to hospital: repeat vomiting, worsening HA, confusion, unable to stay awake, difficulty with balance, visual changes, seizures, numbness
  • If not better in 1 week, follow upp with neurologist
• Sports Guidelines (Mild Traumatic Brain Injury)
  • Grade 1 – transient confusion (<15 min), no LOC; May return immediately if no symptoms after 15 min (neuro check q5 min x 3); 1 week if multiple Grade 1’s
  • Grade 2 – transient confusion (>15 min), no LOC; remove from game follow upp next day; PCP may clear after 1 week of no symptoms at rest and with exertion; 2 weeks if multiple Grade 2’s
  • Grade 3 – ANY LOC; if remains unconscious, c-spine and EMS to ED; return at 1 week if brief LOC, 2 weeks if more than seconds; with multiple Grade 3’s off at least 1 month
  • AAN Sideline Eval: AOx3, months/numbers backwards, last team played; Exertional testing: push-ups, sit-ups, squats
  • Red Flags: worsening HA, seizure, focal deficit/speech/behavioral changes, stuporous/ALOC, intractable vomiting, neck pain

• • NEXUS: midline TTP, ALOC, focal deficit, ETOH, distracting injury
• Canadian:

• Denver Blunt Cerebrovascular Injury Screening Guidelines
  • Vertebral artery injuries: ASA +/- heparin

• Nexus Chest

Burns

• Superficial, partial thickness (superficial=blister, deep=ruptured blister), full
  • intact blisters heal faster and get infected less often
• Wash with room temperature water – cold constricts and inc burn depth
• Bacitracin or silvadene (sulfa…transient neutropenia) - synthetic dressings are best
• Non-stick dressing (Vaseline/xeroform/kerlix)
• Update Td, keep warm, protect airway (stridor, CO>10%, prone patient if too much IVF)

• Parkland formula – only if >20% TBSA (use Lactated Ringers)

1. 2-4cc/kg *TBSA; half over 8 hours, half over 16
2. After 24 hrs, ~1.5x maintenance IVF; Titrate to urine of 0.5cc/kg/hr; decrease IVF when>1cc/kg/hr
3. Only add maintenance fluids to peds (if <20kg use D5LR @ 3ml/kg*TBSA; titrate to urine 1-1.5ml/kg/hr)
4. ARF – bicarb, mannitol, dopamine, CRRT
5. Nebulized heparin for pulmonary burns 5,000 – 10,000 IU q4 hours x 7 days + MUCOMYST + albuterol•

• Burn center transfers:

1. Partial thickness >10% TBSA, any full thickness;
2. face, hand/foot, genitals, joints;
3. electrical, chemical, or inhalation
4. Consider escharatomy (lateral sides of ext, especially at joints … not deep fasciotomy)

  

UROLOGY

Kidney Stones

• White male>20y/o, female>60y/o
  • Ca=75%; check PTH, thiazide diuretics; citrate prevents crystal formation
  • Struvite=15%; alkaline urine + NH4 (recurrent UTI’s) – vit C to acidify
  • Uric Acid = 6%; acidic urine, low urine output, high uric acid levels
  • 1-2 liters of water daily to prevent stones; IVF does not help acutely
• Pain and Stone Locations: Prox ureter=back, mid ureter=ant flank; UVJ=groin+ frequency
  • DDX: 50% of flank pain NOT stones; chole 5%, appy 4%, pyelo 3%, ovarian 2%, AAA 2%; pneumonia, renal vein thrombosis, ectopic, SBO, pancreas, musculoskeletal, tics, zoster; Indinavir stones not seen on CT
• Workup: UA + Creatine
  • Persistent pain= CT/KUB+US … >7mm = urology
    • CT ~100% sens; 1.5-2.5mm cuts T12 through pubes – 15mSEV, best when 6-8 hours after pain onset
    • IVP – 94% sens, 90% specific; able to see full anatomy but nephrotoxic
    • KUB (60% visible) + US (98% sens, 100% specific) – for pregnancy, peds, or recurrent stone … should see hydro +/- stone
    • Preg: consider MRI (no gadolinium if increased Cr)
    • Peds: 1st stone – chem. 10, uric acid, PTH, urine culture; if KUB/US neg, get CT
  • No stone = consider contrast for infarct
• Treatment
  • Narcotic + NSAID (decreases ureteral contractility), low salt/protein diet (Ca stones)
    • Flomax: may benefit distal stones <7mm
  • Infection=CT + antibiotic
  • ADMIT: 1 kidney, uncontrolled pain, , ARF, not taking PO’s, +/- hydro/UTI/>5mm

UTI’s

o Uncomplicated: keflex 500 q6; bactrim DS q12 o Complicated: ampicillin 1g q6 (vancomycin 1g if pcn allg) + gentamicin 5mg/kg o Pyelonephritis o o Pyridium x 3 days; urispas as needed o Chronic UTI: mandelamine + vit C; metabolized to formaldehyde in urine

STI’s

o Chlamydia o Gonorrhea o Syphilis o Chancroid

Random

• Fournier's Gangrene: vancomycin, clinda 900q8, rocephin 2g qd
• Bladder rupture
• Hematuria

Procedures

• Airway

1. Elevate head of bed, nasal cannula
2. Bougie, fiberoptic, retrograde
3. Needle Cricothyroidotomy
4. Surgical Cric

• Arthrocentesis: gram stain/culture, cell count with diff, crystal analysis, glucose, LDH

• Burr Hole (Cranial trephination)

• Central Venous Access

1. IJ
2. Subclavian
3. Femoral
4. Venous Cutdown

• IO unless cellulites or fracture
  • adult for tibia, long needle for humerus (preferred location); If needle to bone and cannot see black line, get next size needle
  • IO Labs: hemoglobin/hematocrit, Platlet lower, Bun, Cr, glucose, K higher, CO2 lower, Ca, Protein, Albumin
  • Must use pressure bag

• LP
• Need CT if: age>60, immunocompromised (with contrast), history of CNS mass/CVI, seizures in past week, ALOC/focal deficit/drift/gaze palsy (NEJM 2001)

1. 1 cultures, stain, sens
2. 2 glucose, protein, LDH
3. 3 cell count/diff
4. 4special tests: cryptococcal, oligoclonal bands, VDRL, HSV, fungal cultures, varicella, west nile, TB

• Paracentesis: cell count/differential, albumin, gram stain, cultures, glucose, LDH (LIGHT’s criteria)

• Pericardiocentesis: 18g, 7cm, insert with sheath; use parasternal long US

• Thoracentesis: upright position, post axillary line, above the rib; total pro, pH, cell count with diff, glucose, LDH, gram stain, cultures, cytology?
  • Pleurodesis: talc 500mg, lidocaine 10ml, NS 60ml

• Thoracostomy

• Thoracotomy: penetrating trauma, <5 min CPR, consider if >1500ml out initially from chest tube

1. mainstem right lung to dec left lung volume
2. cut above 5th rib
3. 10-50J defib with internal paddles

• Transvenous Pacer 6 or 8 French Cordis

1. Through right IJ or left subclavian
2. Once 10 cm in, inflate balloon

• Ultrasound

1. e-FAST
2. Fracture: uneven cortical surface
3. Nerve: use color flow to rule out vascular bundle
4. Occular: 3mm down, <5mm wide
5. RUSH
   1. effusion/contraction (looking for strain)
   2. IVC contracture, JVD overload
   3. Caval index (exp to insp) 50% change = CVP<8
   4. pneumothorax (linear probe, long axis 3rd intercostals anterior then 5th lateral chest wall); parietal pleura slides on the visceral pleura giving comet tail artifacts … air between pleura eliminates the sliding and comet tail effect
   5. suprasternal, parasternal, epigastric, and supraumbilical aorta
6. SBO - small bowel >25mm highly suggestive
7. Soft Tissue: consider using NS bag or water bath for superficial structures
   1. FB 93% sens at 5mm, 87% sens for 2.5mm; inject lido to enhance visualization
8. Tendon: visualize mvmt

Billing

• ER Fees: E/M Code, ICD-10 (Dx), CPT (RVU’s)
  • CMS Conversion Factor=$36 (2010); $25 (2012)
    • Work RVU*GeograPhic Cost Index*CF= $ paid
    • [(Work RVUs x Work GPCI) + (Practice Expense RVUs x Practice Expense GPCI) + (Malpractice RVUs x Malpractice GPCI)] = Total RVU
    • Total RVU x Conversion Factor = Medicare Allowable Payment

• Documentation
• https://www.wikem.org/wiki/Harbor:_Macros_and_Autotext
  • HPI: location, severity, time, quality, duration, context, modifying factors, associated symptoms
  • ROS & PFSH (note important co-morbidities) may be reviewed from RN note: constitutional, eyes, ENT, CV, Resp, GI, GU, Musc, Skin, Neuro, Psych, Endocrine, Heme/lymph, allg/immune
    • “Positives and pertinent negatives per HPI; all other (or an additiona X) systems were reviewed and are negative.” Can be reviewed from RN sheet
  • PE: Constitutional/VS, eyes, ENT, CV, resp, GI, GU, Musc, Skin, Neuro, Psych/mood/affect, Heme/Lymph/immune … may be “normal”

• Good Supervisory note: “Patient evaluated in the ED for [CC; initial history and physical exam information was obtained by MLP [name], who also documented a record of this visit. I independently examined and evaluated this patient and made all diagnostic, treatment and disposition decisions. The patient had [key history]. Physical examination revealed [key findings]. [Key lab, x-ray, ECG findings, specifying if these are your interpretations.] [Any key treatment measures administered in the ED.] [Key aspects of the disposition.] Clinical Impression [ dx].”
  • "I performed a history and physical examination of the patient and discussed his management with the resident. I agree with the documented findings and plan of care. See resident's note for details."
  • Med students can only contribute to PMFSH & ROS
  • CANNOT bill for student services (procedures) but them may “participate” in the service

• • • CPT RVU’s $$$
    • 99281 0 HX 1 ROS/HPI 1PE 0.45
    • 99282 0 HX 1 ROS/HPI 2PE 0.88
    • 99283 0 HX 1 ROS/HPI 2PE 1.34
    • 99284 1PMFSH 2ROS/4HPI 5PE 2.56
    • 99285 2PMFSH 10 ROS/4HPI 8PE 3.8 $166
    • OBS 3PMFSH
    • 99291 Critical Care (1st 74 min) 4.5 $213
    • 99292 (addition 30 minute increments) 2.25 $107
    • 99293 (peds CC initial)
    • 99294 (peds CC +30)
    • 99295 (neonatal CC initial)
    • 92950 CPR $181
    • 31500 intubation
    • 36556 central line
    • 93010 ekg interpretation
    • 99218 initial obs 1.92
    • 99219 initial obs 2.60
    • 99220 initial obs 3.56
    • 99217 obs discharge 1.28
    • 10060 abscess drainage 1.22
    • 10061 abscess 2.45
    • 11740 subungal hematoma drainage 0.37
    • 12001-12018 laceration repairs 0.84-3.61
    • fracture +/- reduction
    • FB removal +/- incision or slit lamp
    • ECG or xray interpretation
    • Lip $95, half thickness $508, Full thickness $616 (BCBS)

• • Critical Care Time: High probability of sudden, clinically significant deterioration of condition requiring urgent intervention; does not have to be contiguous;
    • Must document “30 min of CC, exclusive of separately billable procedures”
    • Includes CXR, ABG, NG, transcutaneous pacing, ventilator mgt, pulse ox, computer chart review, peripheral line
    • Does NOT include resident time … only when attending present
      • Time Elements
      • H&P 15 min
      • Orders/RN discussion 10min
      • Lit Review 5 min
      • Rechecks 30 min
      • Family discussion (must document need for discussion – unable to give history, POA) 5min
      • x/ray, lab interpretation 5 min
      • discussion with radiologist 5 min
      • PCP/consultant calls 5 min
      • Review old records 5 min
      • Documentation/dictation 5 min
    • What to include
      • General: high probability of imminent or life threatening deterioration in the patient’s condition; Anyone with initially unstable VS, impairment to 1 or more organ systems + direct physician intervention/management; severe electrolyte abnormalities
      • Resp: multiple nebulizers
      • Cardio: Stemi, USA
      • GI: NS boluses, protonix gtt, transfusion, DKA
      • Neuro: GCS<14, status epilepticus, CVI (significant), TPA
      • Psych: suicidal, psychosis, overdose
      • Sepsis
      • Trauma: pneumothorax, major burns, ETOH, multiple lacs
      • Surgery: anyone going straight to the OR (perf, appy, chole, etc)
      • Subtracts time from:
    • Separately Billed Procedures: CPR, ET tube, central lines, chest tube, ECG, pericardiocentesis, procedural sedation

• SEDATION time does NOT include setup/recovery
• Medicaid pays ~59% Medicare rate
• GRMC: MC 27%, BCBS 23%, GHP 18%, no pay 8%
• Lab or xray $400; lab + xray +/- procedure $800; ICU $3k
• IV $100; meds: IM $100, IV $150

• PQRS Measures: Medicare will keep track of these measures and if they physician reports at least 3 quality measures 50% of the time they may be eligible for a 1% bonus
  • Acute MI
  • Chest Pain
  • Syncope
  • Pneumonia

Med Legal

• The eye does not see what the mind does not know

• Top Malpractice
  • knowledge deficit, failure to take adequate history, failure to perform adequate exam, failure to consider DDX, failure to order/interpret diagnostic studies, failure to diagnose, failure to treat/consult/communicate/admit
  • Missed FB

• Caution with these diagnoses:
  • atypical CP
  • Anxiety
  • Constipation ... peds intussusception, hirschsprung, appy; caution in elderly
  • atypical migraine
  • gastroenteritis

• Need contractual exemption to abandon your ED post to go to the floor; need right to refuse (ie, ED too busy)
  • no covered by good Samaritan laws (IL Supreme Court)

• Clinical Impression, not Dx
• Ambulate before discharge
• APP Supervision: note chart discrepancies, document the discussion with APP
  • Signing charts on patients you have not seen -- Quality Assurance function
    • APP supervisory policy -- docs need to follow it, but sets hospitals up for negligent policy
    • Chart Review: "based on the care documented, care appears appropriate"
  • CMS must document face to face can bill at 100%, not the 85%
  • Curbside consult: should be documented by the APP

• document informed refusal, AMA form does nothing

• Negligence can include poor hiring, poor training

• Asset protection
  • C-corp and s-corp can be viewed as "closely held" and not protect your personal assets
  • CA can garnish wages for 7 years
  • Entity Assets - LLC business, equipment
  • Inside assets - anything purchased under your SSN
  • W2 Employee - highest taxed and audited
  • S-corp: best for taxes and protection
  • LLC - cannot protect the business and assets that create the laswuit
    • Create a corporation with individual LLC's for building, equipment, vehicle, real estate
    • law of disregarded entities ... but Judges can dissolve the LLC's
      • Delaware and Alaska allow you to create holding companies -- cannot dissolve the LLC!
  • Family Limited partnerships
    • 1% ownership by general partner (S-corp: has total control), 99% ownership by limited partnership
      • so only 1% of total assets are at risk - bank accounts, stocks, real-estate investment - supreme court upheld in 1974
      • charging order: pro-rata distribution clause; forces distribution of your portion of the profits of your business until
        • must re-write distribution clause so only the general partner can order a distribution of company funds (non-pro-rata) - so nothing is paid even if they win the judgement ... in which case the they must pay taxes on the judgement even if there is no distribution (IRS ruling 77-137)

• Living Trust ($1200) - avoids probate
  • Management company ($1200)for W2 (bank account with very little money in it) -- FLP ($1200) - only 1% at risk
  • Holding company ($1200) - (in Alaska - can't be dissolved) ... with multiple LLC's ($1200 each - house, condo)
  • non-pro-rata clause so nothing is due even if there is a judgement, but plaintiff will get tax bill for the judgement amount)

• Tax Savings
  • Distribution from FLP - no 15% FICA tax
  • Rent house out to S-corp for board meeting - can rent out for 14 days a year tax-free; at dollar per square foot
  • Paying for college - make kid a member of FLP and give a distribution - writ off for corp, and they will be taxed at very low tax rate

$150/month fee -- blueprint ... $6k for unlimited entities for life; guarantee tax savings of that amount for 1st year

FLP for cash, stocks, etc LLC (individual for each asset (home, investments, etc) MI Homestead law - only protects small amount of equity; FL and TX are completely safe primary residences

Admin

• 40% of new physicians change jobs in the first 2 years
• Bedside Teaching
  • Make the DX: H&P 57%, PE 74%, labs & imaging 25%
  • Bedside teaching must extract the critical elements of the case from the learner
  • Thinking styles
    • Reflective - Why
    • Creative - What
    • Practical - Facts
    • Conceptual - understand the whole
  • RIME
    • Reporter - regurgitate
    • Interpreter - form ddx
    • Manager - risk analysis based on individual circumstances (active process)
    • Educator - mastered above and can scrutinize the literature
  • Competence
    • Unconsciously incompetent - dangerous
    • consciously incompetent - ask for help
    • consciously competent - still have to think about it
    • unconsciously competent - natural
  • SPIT (DDX)
    • Serious
    • Probable
    • Interesting
    • Treatable
  • 1-minute preceptor

1. Get commitment - what do you think is going on
2. Probe for supporting evidence - how did you get there
3. Apply general concepts to the case
4. Reinforce what was done correctly - specifics, not general
5. Correct mistakes - give feedback

• top apps: epocrates, figure 1 - medical images, Medscape, UTDOL, QxMD ($, articles), NEJM this week, Isabel (DDX creator),

See Also

• Harbor:Main
• Harbor:Operations manual

Authors

Bradley Chappell, Neil Young, Ross Donaldson, Daniel Ostermayer, Michael O'Brien, MD, Michael Holtz