Family Practice Notebook Updates 2018

See Also

Updates
December 2018

Hemorrhagic Shock (er, cv, bleed)
1. Primary priority is the identification of Hemorrhage as shock cause, localizing Hemorrhage site, and rapidly stopping further bleeding
2. Avoid overly aggressive crystaloid infusion, and aside from Traumatic Brain Injury, allow permissive Hypotension with SBP 80-100 mmHg
3. Rapidly transfer to Trauma Center and operating room for definitive management for persistent compartment Hemorrhage
4. Consider TXA (Tranexamic Acid) within first 3 hours of onset
Conduct Disorder (peds, psych, behavior)
1. Lifetime Prevalence approaches 10% and diagnosis has remained virtually unchanged through DSM-4 and 5
2. Diagnosis is based on characteristic behaviors within 4 categories: Aggression, Property Destruction, Lying or theft, rule violation
3. Management focuses on non-pharmacologic measures and comorbidity management (esp. ADHD), although Risperidone may be used in refractory cases
4. As many as 65% will develop Antisocial Personality disorder, and other risks include criminality, Substance Abuse and failure to complete school
Healthcare of the Incarcerated Patient (prevent, Health Maintenance)
1. At any one time in the U.S., 720,000 persons are incarcerated, roughly the population size of San Francisco
2. Prisoners are at higher risk for nearly every medical and psychiatric condition, especially communicable disease and Substance Abuse
3. Most Prisoners undergo an initial brief evaluation to confirm that they are fit for incarceration, and later undergo a more complete intake health evaluation
Crohn's Disease (gi, ibd)
1. Consider Fecal Calprotectin as an initial test to rule-out Crohn's Disease, then confirm with endoscopy or CT or MRI enterography
2. Biologic Agents are first-line management, with high efficacy, but with the risk associated with Immunosuppression
Human Sex Trafficking (prevent, abuse)
1. Human Sex Trafficking is increasing in Incidence and acute care settings are a common contact point for trafficking victims
2. Keep a high index of suspicion in teens and young adults who are accompanied by companions who dominate the encounter
3. Use Medical Interpreters and interview patients alone
Dental Health (dental, exam)
1. Dental Caries lead to Reversible Pulpitis, Irreversible Pulpitis and ultimately dental abscess or dental Cellulitis
2. Periodontal Disease may progress from Gingivitis to Periodontitis
3. Dental Trauma includes Tooth Fracture, Tooth Luxation and Tooth Avulsion
4. Prevention includes reducing Xerostomia, fewer Simple Sugars, Tobacco Cessation, regular brushing and flossing, regular dental care
Diplopia (eye, sx)
1. Monocular Diplopia persists regardless of whether the unaffected eye is open or closed. Monocular Diplopia is due to primary eye problems
2. Binocular Diplopia resolves when one eye is closed and is caused by eye malalignment typically from a Cranial Nerve deficit
3. Cranial Nerve 3 deficts (eye looks down and out, Mydriasis, Ptosis) should prompt emergent CT and CTA to exclude Posterior Communicating Artery aneurysm
Gonococcal Arthritis (id, rheum)
1. Joint Pain in acute Gonorrhea may be due to Disseminated Gonorrhea dermatitis syndrome or to septic Monoarthritis
2. Obtain Gonorrhea Cultures from all sources (blood, Rectum, pharynx, Urethra, Cervix) including Joint Aspiration
3. Empiric initial management with Ceftriaxone and Azithromycin
Alcohol Withdrawal (psych, cd)
1. Consider Ketamine 0.2 mg/kg/hour in Benzodiazepine refractory Alcohol Withdrawal
Rabies Postexposure Prophylaxis (id, immunize)
1. In the U.S., Human Rabies is rare (31 cases 2003-2016), and bats are the most common Rabies exposures
2. Worldwide, Rabies is responsible for 59,000 human deaths per year, and dogs are a common source
Fall on Outstretched Hand (ortho, sx, hand)
1. Consider Carpal Tunnel view if concern for Pisiform or hook of hamate Fracture, or Scaphoid tubercle Fracture
2. Consider clenched fist view to evaluate for Scapholunate Dislocation
3. Consider radial head-capitellum view to evaluate for Radial Head Fracture
High Flow Nasal Oxygen (lung, procedure)
1. Although it offers some NIPPV, a large part of its mechanism is in oxygenating the proportionately large airway dead space in young children
Transgender (prevent, HME)
1. Train clinicians and staff on culturally sensitive terms and topics
2. Be aware of hormonal therapy and surgical management of Transgender Persons and potential complications, monitoring
3. Avoid attempting to convert person's Gender Identity to that of their birth sex is considered unethical
Influenza (id, virus)
1. In adults, the classic triad is fever, cough and Pharyngitis with a 80-85% Test Sensitivity and 75-80% Test Specificity
2. In children, the classic triad is present 60% of the time, and they have gastrointestinal symptoms in up to 30% of cases
Adolescent History (peds, exam)
1. HEADSS Psychosocial Interview of teen patients broadly reviews important topics including drugs, sex and Suicidality
Orthotics (ortho, procedure)
1. Updated Knee Braces, Ankle Braces, Wrist Splints
Anatomy Images
1. Five new images completed: sensory Dermatomes, Rule of 9s (adult and infant), Cardiomyopathy, wrist supinators and pronators
Baloxavir Marboxil (id, pharm, virus)
1. Another Antiviral for Influenza that may shorten course by one day, but may not offer significant benefit in the highest risk groups
Xarelto (hemeonc, pharm)
1. May be used for vascular prevention (CAD or PAD) by adding Xarelto 2.5 mg twice daily added to Aspirin 81 mg in stable chronic CAD or PAD
2. However, NNT 71 for serious CAD related event, NNT 147 for PAD related amputation and the NNH 80 to cause one major bleeding event
Gardasil-9 (id, immunize, virus)
1. As of 2018, Gardasil is approved for use in 27-45 year old women and men at risk
Raynaud's Phenomenon (rheum, cv)
1. Avoid Vasoconstrictors and consider vasodilators (e.g. Norvasc, Nifedipine, or in refractory cases, Sildenafil)
Activated Charcoal (er, pharm, toxin)
1. Expect to see it in toothpaste, mouthwash cleansers and oral supplements
2. No evidence of benefit in consumer products and risks of prescribed medication malabsorption, Tooth Erosions, Constipation
Migraine Prophylaxis (neuro, Headache)
1. Migraine Prophylaxis cost grows to $6900 for CGRP Antagonists with similar efficacy to their cheaper counterparts (e.g. TCA, Propranolol, topomax)
Biosimilars (id, pharm)
1. Biosimilar agents are similar but not identical to their reference Biologic Agents (e.g. Nivestym is biosimilar to Neupogen)

Updates
November 2018

Hypertension in Children (cv, htn, peds)
1. Hypertension diagnostic criteria in children have changed as of 2017 AAP guidelines
2. Hypertension is underdiagnosed in children (only 26% are formally diagnosed)
3. Essential Hypertension is the most common cause of Hypertension in Children (previously Secondary Hypertension was most common)
Urinary Retention (urology, sx, Bladder)
1. Acute Urinary Retention is a urologic emergency, requiring immediate Bladder decompression with Urinary Catheterization (or Suprapubic Catheter)
2. Acute Urinary Retention is often treated with indwelling catheter for 3-7 days, initiate Flomax, and follow-up urology for post-void residual
3. On acute Urinary Retention, assess for Medication Causes of Urinary Retention, neurologic causes, post-void residual
Major Depression (psych, depression)
1. Major Depression Prevalence is as high as 8% (16 Million adults), and esp. in elderly and in Nursing Homes where depression Prevalence approaches 50%
2. Yet, only 5% of the clinic population is screened for Major Depression
3. Depression in women may present with Headaches, myalgias and gastrointestinal complaints
4. Depression in men may present with anger, aggression, Substance Use Disorder and risky behavior
Knee Pain (ortho, Knee)
1. Rapid onset of Knee Effusion after Trauma suggests internal knee derangement (e.g. meniscal tear, ACL or PCL Tear)
2. Thessaly Test is more accurate for meniscal tear than McMurray Testing
3. Knee MRI has limited indications in the acute setting, and mechanical symptoms are generally referred to rehabilitation first prior to MRI
Hyperemesis Gravidarum (ob, gi)
1. Onset before 4 weeks and after 12 weeks should prompt consideration of other causes of Nausea and Vomiting in Pregnancy
2. Primary treatments include non-pharmacologic measures, Vitamin B6, Doxylamine and Reglan
Urinary Tract Infection in Pregnancy (uro, ob)
1. Bacteriuria is associated with Preterm Labor
Seizure (neuro, Seizure)
1. Status Epilepticus is now defined as 5 minutes of continued Seizure (instead of the prior 30 min duration)
2. First line management of Status Epilepticus is ABC Management, reversible cause treatment (e.g. Glucose), and Benzodiazepines
3. Laboratory testing and imaging for a single Seizure has specific indications, and many will not require testing (beyond fingerstick Glucose)
Sickle Cell Anemia (hemeonc, Hemoglobin)
1. Febrile Sickle Cell Anemia patients are management as Asplenic and Immunocompromised
2. Treat vaso-occlusive crisis aggressively and rapidly and evaluate for other causes if pain pattern is not typical for patient
3. Acute Chest Syndrome and Splenic Sequestration are medical emergencies
Low Back Pain in Pregnancy (ortho, ob)
1. Symptomatic management includes Exercise, PT, Acupuncture, support devices, epidural Corticosteroids
2. Exclude Placental Abruption, labor, Ureterolithiasis, Pyelonephritis
Type 2 Diabetes Mellitus in Children (endo, dm, peds)
1. Type II Diabetes accounts for 1 in 3 diabetes diagnoses in children in the U.S.
2. Type II Diabetes may present with Ketoacidosis as well as positive Glutamic Acid decarboxylase or islet Antigen-2 Antibody
3. Screen diabetes in children age >10, if Overweight and at least 2 other risks (FHx, maternal Gestational Diabetes, high risk ethnicity, signs Insulin Resistance)
4. Metformin and Insulin are the only FDA approved medications for Type 2 Diabetes in children
Cerumen Impaction (ent, ear)
1. Avoid cotton tipped swabs, candling and olive oil drops
2. Home Cerumen Softening Agents are as effective and safe as office removal techniques (as long as TM is intact)
Endotracheal Intubation (lung, procedure)
1. Preventing aspiration is key
2. Raise the head of bed and avoid excessive Positive Pressure Ventilation
3. Consider Nasogastric Tube prior to intubation in Bowel Obstruction
4. Have adequate suction (there are much better suction tips than Yankauer)
Push Dose Pressor (cv, pharm)
1. In addition to Phenylephrine and Epinephrine, Norepinephrine can be used as a Push Dose Pressor without dilution at 0.5-1 cc (8-16 mcg)
Rectal Foreign Body (gi, Rectum)
1. Patients with peritonitis should be consulted for emergent surgery
2. Some rectal foreign bodies may be removed in the ED, with Procedural Sedation, speculum, and using fingers or swab sticks to manipulate the object out
Biologic Agents (id, pharm)
1. These agents include monoclonal antibodies, and have numerous potential adverse effects
2. Standardized naming conventions can help decipher these agents source, target and mechanism
Medications in Lactation (ob, pharm)
1. Pumping and Dumping is not benign, especially in early pregnancy, as this risks discontinuation of Breast Feeding
2. CT IV Contrast is compatible with Lactation and needs no pumping and dumping
3. Ibuprofen is the preferred NSAID in Lactation
4. All maternal Opioids sedate lactating infants, but especially avoid Demerol, Codeine, Oxycodone
Urinary Tract Infection (urology, id)
1. Consider single dose Fosfomycin in the emergency department for noncompliant patients (but has a 58% cure rate compared with 70% for Nitrofurantoin)
2. In children, when planning catheterization, consider Bedside Ultrasound first to confirm adequate urine to prevent dry catheterization (30% of cases)
Drug Resistance in Pneumonia Score (lung, exam)
1. Another tool to evaluate for drug resistant Pneumonia (as HCAP is phased out since 2016 in favor of other criteria)
Epidural Blood Patch (neuro, procedure)
1. Performed by injecting 20-30 cc into a patient's epidural space and allowing it to spread and coagulate along the dura, plugging CSF Leaks
Severe Asymptomatic Hypertension (cv, htn)
1. Most patients may follow-up with their primary providers for medication adjustments and additions
2. Patients with systolic Blood Pressure >180, or >160/110 with comorbidities may benefit from initiation of Blood Pressure management in the ED
3. No Labs are typically needed until follow-up (although consider Creatinine and Potassium if starting an ACE or ARB)
Cardiac Risk Management (cv, prevent)
1. Aspirin is out as primary prevention due to lower efficacy even with most risk factors and risk of GI Bleeding
2. However Aspirin remains a critical part of secondary and tertiary prevention
3. Benefit of Aspirin Use in Diabetes marginally outweighs the risk of GI Bleeding
SGLT Inhibitor (endo, pharm, dm)
1. SGLT Inhibitors are now associated with Fournier's Gangrene and Pancreatitis
Endocarditis (cv, valve, id)
1. Some patients with left sided endocarditis (mitral valve, aortic valve), may be considered for oral Antibiotics after initial first 2 weeks of IV Antibiotics
Corticosteroid Associated Osteoporosis (endo, pharm)
1. Greatest effect on Bone Mineral Density with chronic Corticosteroids is in the first 3-6 months
2. Men and women >50 years old on Prednisone 5 mg/day for 3 months, or three steroid bursts in 6 months should undergo DEXA Scan
Electronic Cigarette (psych, cd)
1. Increasing use by teens (up to 1 in 9 in high school), and associated with 4 fold increased risk of Tobacco Abuse
2. More than 80% of teens believe e-cigs are harmless
Hyperhidrosis (derm, sweat)
1. OTC Aluminum Chloride is as effective as prescription items
2. Obrexza is an expensive ($550/month) second-line adjunct for axillary sweating refractory to other topicals

Updates
October 2018

Well Child Visit (prevent, hme, peds)
1. Screen for Postpartum Depression at visits for infants <6 months of age
2. Perform Developmental Screening at 9, 18 and 30 months (minimum) and Autism screening at 18 and 24 months
3. Visual Acuity screening at least once at age 3-5 years
Hemolytic Anemia (hemeonc, Hemolysis)
1. Mechanisms include immune (AIHA), microangiopathic (MAHA), oxidative (e.g. G6PD Deficiency)
2. Initial testing includes a CBC, Peripheral Smear, Direct Coombs, Total and Indirect Bilirubin, Basic metabolic panel, Lactate Dehydrogenase, Urinalysis
3. Plasmic Score may be useful in suspected Thrombotic Thrombocytopenic Purpura
Small Bowel Obstruction (surgery, bowel)
1. Closed loop obstruction, Volvulus, Strangulated Hernia are surgical emergencies
2. CT Abdomen is a first line study over plain XRay for high suspicion obstruction
Lactation (ob, Lactation)
1. Breast Feeding is recommended for 1-2 years (exclusively for the first 6 months) with decreased infection risks, higher IQ for infants
2. Most common causes of Lactation cessation are insufficient milk supply, inadequate latching and painful nipples or Breasts
3. Effective Breast Feeding Signs may be monitored to ensure adequate intake
Low Back Pain (ortho, L-spine, sx)
1. Most Low Back Pain resolves with conservative therapy and most measures are ineffective beyond NSAIDS and non-medication management
2. Imaging is not indicated unless Low Back Pain Red Flags or persistent and significant pain at 6 weeks
3. McKenzie Method entails an initial assessment by methodology trained PT and then individualized self treatment
Abdominal Wall Pain (surgery, gi, pain, Muscle)
1. Abdominal Wall Pain is under-recognized as a common cause of persistent or recurrent Abdominal Pain
2. Nerve entrapment is a common cause of Abdominal Wall Pain
3. Consider Trigger Point Injection with or without Corticosteroid
Anemia in Older Adults (hemeonc, geri, Anemia)
1. Low Serum Ferritin is consistent with Iron Deficiency Anemia, but a high Serum Ferritin may be increased as an acute phase reactant
2. Consider endoscopy in older adults with Iron Deficiency Anemia
3. For those with Iron Deficiency but intolerant to Iron Supplementation, consider 15 mg elemental iron suspension dissolved in orange juice
Cervical Spine Injury (ortho, c-spine)
1. Follow ATLS protocol with inline spinal immobilization, ABC Management, Primary Survey and Secondary Survey
2. Use decision rules (e.g. NEXUS, Canadian C-Spine Rule) to determine imaging indications (see Cervical Spine Imaging in Acute Traumatic Injury)
3. Consider Neck Vascular Injury in Blunt Force Trauma
4. Be aware of Neuropraxia (Stingers and Transient Quadriplegia) as diagnoses of exclusion, and keep other Cervical Spine Injury causes in mind
Sepsis (id, fever)
1. Surviving Sepsis 2018 is being criticized for squeezing the 3 hour and 6 hour bundles into 1 hour without much evidence to support the change
Medications in Pregnancy (OB, pharm)
1. As you know by now, FDA Pregnancy Categories will be replaced on medication bottles with specific warnings and precautions by 2020 in U.S.
2. As of 2018, succinct guidance (to replace ABCDX) on specific drugs in pregnancy is lacking
3. In pregnancy, balance medication risks with drug benefits and the risk of untreated conditions (e.g. Diabetes Mellitus, Asthma, Seizure Disorder)
Exercise-Induced Anaphylaxis (ent, sports)
1. Exercise with or without food triggers can result in Urticaria as well as Anaphylaxis
Immune Complex Inhibitors (hemeonc, pharm)
1. Another class of monoclonal antibodies for cancer
2. Includes CTLA-4 (e.g. Ipilimumab), PD-1 (e.g. Pembrolizumab), PDL-1 (e.g. Atezolizumab )
3. Adverse effects include potentially serious toxicity, Autoimmune Conditions, Diarrhea and rashes
Esophageal Foreign Body (gi, Esophagus, fb)
1. Esophageal Bougie has become a first-line measure in children to push single coins from the Esophagus into the Stomach
Diaper Rash (derm, peds)
1. Keep the diaper area dry, and clean with hypoallergenic wipes at diaper changes
2. Use barriers such as petroleum jelly, Zinc Oxide or aquaphor
3. If Topical Corticosteroids are used, limit to level 6-7, low potency agents
4. Consider Antifungals if persistent rash >5 days consistent with Candida Diaper Dermatitis
Depression Management in Cardiovascular Disease (psych, cv, depression)
1. Major Depression Prevalence after MI may approach 50% and increases risk of future cardiovascular events and increases mortality
Essential Oils (pharm, alternative)
1. Limited evidence of benefit when used for Aromatherapy, and unlikely to cause harm when inhaled
2. Topical use can cause local reactions and systemic effects on absorption, and oils should be diluted before application
3. Avoid ingestion (esp. in children)
Actinic Purpura (derm, environ, sun)
1. Sun Damaged Skin in the elderly develop purple patches and Ecchymosis
Mass Casualty Incident (er, Trauma)
1. Prepare before patients arrive, by moving as many patients out of the ED as possible (admitted patients to ward, ESI 4-5 home with follow-up appts)
Hypertensive Emergency (cv, htn, er)
1. Lower systolic Blood Pressure to <140 mmHg in Subarachnoid Hemorrhage and <180 mmHg in Intracerebral Hemorrhage
2. Lower systolic Blood Pressure to <220 mmHg in Cerebrovascular Accident and <185 mmHgif using tPA for CVA
3. Keep systolic Blood Pressure >100-110 mmHg in Closed Head Injury
Pediatric Emergency Care (er, peds)
1. Children may have longer lasting behavioral change after even minor ED procedures with or without sedation
Agitated Delirium (psych, behavior)
1. Physical Restraints are a high risk procedure that should be run like a code and kept briefly until Sedation of the Violent Patient is adequate
Laceration Repair (surgery, derm)
1. Avoid loose wound closure
2. If closing a potentially contaminated wound, choose either primary closure or by second intention
Placenta Previa (ob, bleed)
1. Painless Vaginal Bleeding after 18-20 weeks is Placenta Previa until proven otherwise
Liposuction (surgery, procedure)
1. High volume Liposuction >5 liters may result in significant Fluid Shifts, Syncope, Pulmonary Edema
Breast Implant (surgery, procedure)
1. Bleeding after implant placement may occur in the first 24 hours requiring return to surgery

Updates
September 2018

Bone Cancer (hemeonc, cancer, bone, Sarcoma)
1. Bone Cancers include Osteosarcoma, Ewing Sarcoma, and much less common, Chondrosarcoma
2. Osteosarcoma is most common, affects age 5-25 years old, more common in black males, and is treated with Chemotherapy and resection
3. Ewing Sarcoma is most common in mid-teen years and is more common in white or asian males
4. Chondrosarcoma is the least common Bone Cancer, affects ages 45-75 years and is treated with surgical resection, and Radiation Therapy in some cases
Preoperative Examination in Older Adults (surgery, Anesthesia, geri)
1. Always consider whether surgical benefits outweigh the risks in older patients with major comorbidities, low functional capacity, reduced Life Expectancy
2. Evaluate neurologic status (Dementia, Delirium, decision making capacity, Major Depression)
3. Evaluate Activities of Daily Living, Fall Risk, Frailty, nutritional status
4. Review Medication Use in the Elderly for inappropriate medications (e.g. Beers List, STOPP)
Nutrition in Toddlers (pharm, peds, nutrition)
1. Do not limit fat intake under age 1 year (but may limit to 30-40% of total kcals at age 1-3 years)
2. At ages 1-2 years, whole milk 16 oz/day, limit 100% Juice to 4 oz/day and the rest water (avoid sugar drinks)
3. Avoid special diets (e.g. gluten free) unless medically indicated
Lithium Toxicity (psych, pharm, adverse)
1. May present with Nausea, Vomiting, Diarrhea and sluggishness, Ataxia, confusion, Agitation or Tremors, esp. in chronic Lithium Toxicity
2. Peak levels may not be reached for >12 hours after Overdose
3. For a given level, symptoms may be more mild in acute toxicity than in chronic toxicity
4. First-line management is IV hydration; severe cases may require Hemodialysis
Annular Lesion (derm, exam)
1. Common causes include Tinea Corporis, nummular Eczema, Urticaria, Erythema Multiforme, Erythema Migrans, Lichen Planus
Foot Pain (ortho, sx, foot)
1. Plantar Fasciitis is a condition of micro-tears, not of inflammation; NSAIDs and steroid injections are unlikely to offer significant benefit
2. Salicylic acid is as effective for Plantar Warts as Cryotherapy and as Sharp Debridement for corns
3. Proper Shoe Fit is a key preventive strategy for overall foot conditions
Long-Acting Reversible Contraception (gyn, pharm)
1. Nexplanon is the only Contraceptive Implants (Etonogestrel Progesterone Implants) available in the U.S.
2. Intrauterine Devices (IUD) include the Copper T IUD, as well as Mirena and Kyleena (5 year), Liletta (4 year) and Skyla (3 year)
3. Difficult IUD Removal (Missing IUD Strings, embedded IUD) and difficult implant removal techniques are explored
Geriatric Emergency Care (geri, er)
1. Every emergency visit and hospitalization are high risk events
2. Elderly are undertriaged in at least one third of cases in the Emergency Department
3. Delirium is often missed on initial emergency department triage and on medical provider evaluation (use bCAM)
Valsartan (cv, pharm, htn)
1. Valsartan is recalled for contamination by NDMA, a known carcinogen
Drowning (sports, er, water)
1. Avoid using antiquated terms (e.g. near Drowning, wet Drowning, dry Drowning)
2. Immediately get patient to land, lay supine, and initate CPR, starting with ventilations (do not perform heimlich to "clear the lungs")
3. Manage Hypothermia with rewarming, and do not cease Resuscitation attempts until warmed to >34-35 C
Fascia Iliaca Block (ortho, procedure, hip)
1. Consider in isolated Femoral Neck Fracture
Opioid Withdrawal (psych, cd, Opioid)
1. Consider Emergency department initiated Buprenorphine (single dose) with follow-up scheduled within days in those seeking treatment
2. Patient should be experiencing at least moderate Opioid Withdrawal at time of dose
3. Buprenorphine may be administered for up to 3 dose over 72 hours in the Emergency Department without a FDA X-Waiver
Big Pharma (pharm, manage)
1. Pharmaceutical companies have decades of work, billions of dollars of potential sales hinging on study results
2. Newly introduced drugs are typically backed by studies that overestimate benefit and underestimate risk
3. Negative studies are not published and adverse outcomes are suppressed in published reports
4. Manipulation of control groups, statistical techniques, study duration
Acute Coronary Syndrome Immediate Management (cv, cad)
1. Up to 30-30% with NSTEMI may have complete coronary Occlusion and would benefit from PCI
2. ST Elevation criteria for leads V2 and V3 are age and gender dependent (2.5 mm for man <40, 2 mm for man>40, 1.5 mm for woman)
3. ST depression >1mm in 8 or more leads and ST Elevation in aVR or V1 suggests left main obstruction or multi-vessel disease
Bradycardia (cv, ekg)
1. BRASH Syndrome is Bradycardia, Renal Failure, AV Blocker (e.g. Beta Blocker, Calcium Channel Blocker), Shock, Hyperkalemia
2. Type 2 Diabetes Preparations (endo, dm, pharm)
  1. Mild benefit in albuminuria reduction with Jardiance and Victoza
ASCVD Risk Calculator (cv, exam, cad, prevent)
1. Since 2013, ACC/AHA ASCVD Risk Calculator has replaced Framingham Calculator
Gout (rheum, joint)
1. Febuxostat may increase mortality from cardiovascular disease in those with known CAD
Quinolone (id, pharm, Bacteria)
1. More warnings about Quinolones
2. Hypoglyemia in those using Quinolones with Sulfonylureas or Insulin, especially in the elderly, renal Impairment
Recurrent Urinary Tract Infection (urology, id, Bladder)
1. Methenamine may be effective for short term UTI prophylaxis in patients without renal tract abnormalities
2. Cranberry Juice appears less effective than originally found in initial studies (may reduce symptomatic Recurrent UTI in women)
Prescription Cannabinoid (gi, pharm)
1. Epidiolex is a purified Cannabidiol indicated for rare Seizure Disorders at $32,500 per year
Lice (derm, Parasite)
1. The OTC agents are still worth a try (despite resistance) along with combing

Updates
August 2018

Stimulant Use Disorder (psych, cd)
1. Methamphetamines, MDMA, Cocaine and Bath Salts continue to present to emergency departments with serious stimulant effects
2. Consider Stimulant Use Disorder in those with altered behavior, neuropsychiatric changes, labile Vital Signs
3. Almost half of Chemical Dependency goes undiagnosed in primary care
Breaking Bad News (hemeonc, psych)
1. Several mnemonics are available to guide an approach to Breaking Bad News
Type I Diabetes Mellitus (endo, dm)
1. Early aggressive Insulin management with A1C maintained<7% reduces morbidity and mortality rates, sustained for decades
2. Self-monitoring of Blood Glucose is associated with better Glucose control
3. Insulin Pump is selected by more than half of type I diabetics, but multiple daily basal and bolus injections offers similar efficacy
Connective Tissue Disease (diffuse, rheum)
1. Limit rheumatologic testing (e.g. ANA, RF) to cases of higher clinical suspicion given the high rate of positives in the unaffected population
2. When higher suspicion for Connective Tissue Disease, only obtain specific Antibody testing when ANA is positive
Chronic Nonallergic Rhinitis (ent, nose)
1. Reclassification of non-allergic non-Infectious Rhinitis of which subtypes include Vasomotor Rhinitis and Nonallergic Rhinitis with Eosinophilia
2. Rhinorrhea predominant symptoms are treated with intranasal Atrovent first
3. Congestion predominant symptoms are treated with Intranasal Corticosteroids and/or intranasal Antihistamines
Congestive Heart Failure Exacerbation Management (cv, chf, er)
1. Consider causes of acute CHF decompensation (e.g. medication or dietary non-compliance, ACS, Arrhythmia)
2. Start with NIPPV and Nitroglycerin in hypertensive CHF, and consider ACE Inhibitor, Diuretics
3. History, exam and Bedside Ultrasound are typically more effective as diagnostic tools than BNP
4. Consider Ottawa Heart Failure Risk Score to risk stratify very low risk patients to discharge (most will require admission)
Fever in the Returning Traveler (id, fever, travel)
1. Careful history of travel timing, regions, exposures is critical to identifying likely causes
2. Be vigilant and consider personal protection, when evaluating a febrile traveler who may need isolation (e.g. hemorrhagic fever, MERS)
3. Excluding Malaria is key, even in mild illness, even in those who took chemoprophylaxis
Pericarditis (cv, Pericardium)
1. Children with significant Pericarditis (large Pericardial Effusion, Myocarditis) may present with subtle findings (e.g. Sinus Tachycardia, Puffy Eyelids)
Hypokalemia (renal, Potassium)
1. Obtain EKG for Potassium <3.0 mEq/L and observe for QTc Prolongation
2. For every Serum Potassium drop of 0.3 mEq/L, total body Potassium deficit increases 100 mEq
3. Consider empiric Magnesium Replacement with Potassium Replacement (e.g. 400-500 mg twice daily for 3 days)
Chronic Kidney Disease (renal, failure)
1. CKD patients die of Coronary Artery Disease. Prescribe a Statin, ACE Inhibitor, Aspirin
2. Significant medication adjustments start at Creatinine Clearance <30 mg/dl
Nitrofurantoin (id, pharm, Antibiotic)
1. Short-term Nitrofurantoin use (<14 days) is safe down to GFR 30 ml/min
Flumist (id, immunize, virus)
1. In 2018, Flumist is once again an option for influenza Vaccination, albeit likely still less effective than other influenza Vaccination options
2. Consider Flumist in healthy, non-pregnant patient aged 2 to 49 years who would otherwise refuse Influenza Vaccine
Migraine Prophylaxis (neuro, Headache)
1. Erenumab (Aimovig) is a new, expensive ($7000/year) biologic, monthly SQ Injection for Migraine Prophylaxis
2. Indicated when other first-line Migraine Prophylaxis options have been exhausted
Sunburn (derm, environ)
1. Treat as minor Burn Injury with cool compresses and inert Skin Lubricants (e.g. eucerin)
2. Avoid benzocaine, Corticosteroids and home remedies (e.g. butter, apple cider vinegar, buttermilk, lavender oil)
Procedural Sedation and Anesthesia (surgery, Anesthesia)
1. Prepare to protect the airway against closure and pulmonary aspiration and to recognize early Hypotension, Hypoxia, and apnea
2. Hypotension and apnea most often occur with Propofol and with Benzodiazepines (esp. with Opiates)
3. Be prepared for specific Sedative (e.g. Ketamine) adverse effects (e.g. larygospasm, emergence)
Methotrexate (rheum, ra, dmaard)
1. Methotrexate Overdose or toxicity is potentially lethal if not treated
2. Optimize Urine Output and alkalinize the urine
3. Administer folinic acid or Leucovorin to bypass Methotrexate induced blockade of dihydrofolate reductase and supply active Folate
4. Administer Glucarpidase (if available), an expensive enzyme that breaks down Methotrexate (and unfortunately Leuocovorin)
Serum Magnesium (renal, Magnesium)
1. Serum Magnesium represents only 1 to 1.5% of total body Magnesium (of which only 50% is active, ionized)
2. Magnesium levels tend to vary widely (e.g. with respiration) and single values are unlikely to be useful
3. Serum Potassium tends to be a surrogate marker for Serum Magnesium
4. Hypokalemia is typically accompanied by Hypomagnesemia (consider empiric Magnesium Replacement at the time of Potassium Replacement)
Provider Burnout (manage, psych)
1. Acute stress may us more effective in emergencies, but chronic stress is maladaptive and leads to burnout
2. Consider self actualization pyramid of needs (physiologic, safety, love and belonging and self esteem)
3. Maintain Exercise, Healthy Diet, adequate sleep, and get together with colleagues, family and friends
Peripheral IV Access (er, procedure)
1. Two additional techniques for difficult Peripheral IV Access
2. Tourniquet Infusion Technique uses an already placed small IV to infuse 100 cc NS and a Tourniquet above the elbow results in Forearm venous engorgement for second IV
3. Central Vein Placement of peripheral IV targets an internal Jugular Vein under Ultrasound guidance with a peripheral IV (48 mm long is ideal if available)

Updates
July 2018

Appendicitis (surg, gi)
1. Cefotetan and Unasyn with Clindamycin are no longer considered adequate pre-surgical Antibiotics due to resistance
2. Skilled bedside Appendix Ultrasound is a first-line test in the evaluation of Appendicitis in children and pregnant women
Recurrent Abdominal Pain Syndrome (surg, peds, gi)
1. Functional Abdominal Pain is a clinical diagnosis and diagnostic testing is not needed unless red flag findings are present
2. Consider Cognitive Behavioral Therapy and Probiotic supplementation
Localized Prostate Cancer (urology, hemeonc, Prostate)
1. Reviewed active surveillance of localized Prostate Cancer
Health Concerns in the Elderly (geri, prevent)
1. Review Beers Criteria and STOPP Criteria, as well as medication indications before starting a new medication
2. Preventive evaluations should include Fall Risk, Major Depression, Hearing Loss, Cognitive Impairment and Immunization updating
Allergy Testing (ent, lab, allergy)
1. Skin Testing for Penicillin Allergy can prevent the overuse of broader spectrum Antibiotics
2. Food Allergy testing has a high False Positive Rate and should only be performed based on a specific history
Medical Decision-Making Capacity (neuro, cognitive)
1. Ability to communicate, understand the information they are given
2. Ability to make logical decisions based on given information
3. Ability to understand their current medical status or condition
4. Ability to understand options for medical care
Compartment Syndrome (ortho, neuro)
1. Have a high index of suspicion to check Compartment Pressures when pain is out of proportion to findings
2. Pulse loss and weakness are late findings and their absence does not exclude limb threatening pressures
3. Emergency Fasciotomy delayed >4-6 hours may result in permanent injury or even limb loss
Anticoagulant Overdose (hemeonc, pharm, coags, adverse)
1. Consider Activated Charcoal if ingestion within 1-2 hours (may be effective with DOACs up to 8 hours)
2. Intentional Overdose: Observe for bleeding for 24 hours (or per poison control) before medically cleared to psychiatry
3. Unintentional Overdose: If small quantity (e.g. one extra dose) may discharge home with bleeding precautions
4. Risk of significant bleeding 5% after Anticoagulant Overdose
Emergency Department Observation Unit (ed, cv)
1. Established protocols exist for Atrial Fibrillation, CHF and PE that are cost effective, safe, shorter duration, with added quality and consistency
2. Observation protocols have clear inclusion, exclusion and discharge criteria to ensure good patient selection and best outcomes
Emergency Psychiatric Evaluation (psych, exam)
1. Reviewed strategies for emergency mental health evaluation in children
2. Consider HEADS-ED as a disposition tool
Gonorrhea (id, std)
1. Gonorrhea has growing Incidence and resistance, and dual coverage with Ceftriaxone and Zithromax is preferred
2. Retest all patients in 3 months for new, reinfection
Andexxa (hemeonc, pharm, coags)
1. Inactivated Factor Xa, reversal agent for Eliquis and Xarelto, to be released in 2018
Oxycontin (pharm, Analgesic, Opioid)
1. Oxycontin true duration of action approaches 6 hours (instead of 12 hours) in many patients
2. Oxycontin was released as MS Contin (8 hour duration) patent was expiring
3. The exaggerated duration may add to misuse and abuse of Opioids
Acute Pain Management (pharm, Analgesic)
1. Limit Opioids for acute pain to 3 days in most patients (7 days in nearly all patients)
2. Avoid non-cancer Chronic Opioids
Ketamine (surgery, pharm)
1. Ketamine is often used as a very effective and safe pre-hospital Chemical Restraint
2. Ketamine at high dose (4-5 mg/kg) results in GCS 3, but typically maintained respiratory drive (GCS-3K)
3. Many providers prematurely intubate based on ED arrival GCS 3 (despite Ketamine induced)
4. However, with close monitoring, Ketamine sedated patients may be safely observed without intubation
Supraventricular Tachycardia Management in the Adult (cv, ekg)
1. Adenosine and Diltiazem have similar efficacy in PSVT
2. Some patients may prefer the risk of Hypotension with Diltiazem to the pause Sensation of Adenosine
Sunscreen (derm, pharm, environ)
1. Two chemical Sunscreens (Oxybenzone, Octinoxate) will be banned in Hawaii as of 2021 due to adverse effects to ocean wildlife (coral bleaching, reproduction)
2. Physical Sunscreens (Titanium Dioxide, Zinc Oxide) are nanoparticle products despite labeling ("non-nano")
3. None of the physical Sunscreens are absorbed through the skin regardless of size (nano or "non-nano")
4. Nanoparticle Sunscreens are typically easier to apply
Genetic Test (lab, gene)
1. Home Genetic Tests (e.g. 23andMe) are becoming more available in which patients mail in a cheek swab sample for DNA analysis
2. Tests only a subset of available Genetic Tests at a cost of several hundred dollars and risk of both False Positives and false reassurance when testing is incomplete
3. Genetic Counseling is preferred for test interpretation and test selection based on patient history
Crohns Disease (gi, ibd)
1. TNF Agents are becoming first-line over Sulfasalazine, Mesalamine, Corticosteroids

Updates
June 2018

Discipline (peds, prevent)
1. Provide anticipatory guidance at visits on positive parenting
2. Assist with effective behavior changing approaches
Developmental Disorder in Adults (prevent, hme)
1. Speak directly to patients using the communication methods they are able to use
2. Focus on adaptive interventions that allow patients to live in their home or community
3. Specific approaches to common problems include Constipation, Osteoporosis, aspiration, Decubitus Ulcer, behavior changes
Colorectal Cancer Prevention (gi, prevent, hemeonc, bowel)
1. Screening options include Colonoscopy every 10 years or FOBT (guiaic-based or FIT immunochemical) annually
2. Although Virtual Colonoscopy and Flexible Sigmoidoscopy are other screening options, they have significant disadvantages
3. For average risk patients, screening starts at age 50 years and ends at 75-85 years old
4. The only significantly effective lifestyle changes that have impact on CRC are weight loss, Physical Activity, and avoiding red meat
Oncologic Emergency (hemeonc, sx, er)
1. Consider Tumor Lysis Syndrome esp. in hematologic malignancies following Chemotherapy or Radiation Therapy
2. Consider Hypercalcemia of Malignancy esp. in Multiple Myeloma and Breast Cancer in those with confusion, weakness, Vomiting
3. Consider SIADH esp. in Small Cell Lung Cancer with often asymptomatic Hyponatremia
4. Exercise caution in Febrile Neutropenia, and start early empiric Antibiotic management for best outcomes
Hyperhidrosis (derm, sweat)
1. Exclude secondary Hyperhidrosis Causes (including Medication Causes of Hyperhidrosis)
2. Aluminum hydroxide 20% (Drysol) is a first-line therapy for all regions of primary Hyperhidrosis
3. Iontophoresis is effective for palmar and planter Hyperhidrosis
4. Onabotulinum Toxin A intradermal injection is effective for Hyperhidrosis on the palms, soles, axilla and face
Atrial Fibrillation Anticoagulation (cv, ekg, atrialfib coags)
1. Apixaban (Eliquis) may be the preferred DOAC with best Atrial Fib efficacy and lowest adverse effect profile
2. Andexxa, a factor 10a Inhibitor reversal agent is pending release in 2018
EMS Transport (er, manage, ems)
1. Air transport (aside from rescue helicopters) offer mobile ICU level care typically staffed by an ICU nurse, advanced Paramedic or physician
2. Helicopters travel at 100-150 mph, at <3000 feet and are limited by visibility
3. Fixed wing aircraft are preferred for >100 mile distance and travel at 250 to 600 mph, at high altitude with cabins pressurized to 7000 feet
Pneumaturia (urology, sx)
1. May be due to Bladder instrumentation (cystoscopy), fistula from bowel or vagina, renal tumor infarction, urinary diversion or Scuba Diving with p-valve
2. However, it is critical to exclude UTI with gas forming organisms (e.g. Proteus, E. coli, Klebsiella, Candida, Clostridium)
3. UTI with gas forming organisms may result in Emphysematous Cystitis or Emphysematous Pyelonephritis which are associated with high mortality
4. Staghorn calculi and low Urine pH may indicate the presence of gas forming organisms
Abdominal Aortic Aneurysm (surgery, gi)
1. The classic triad of Abdominal Pain or back pain, Hypotension and pulsatile abdominal mass is present <50% of the time
2. Keep a high index of suspicion for AAA in >50-60 year old patients (esp. men) with back pain or abominal pain
3. Consider bedside abdominal aortic Ultrasound (turn color doppler on, apply pressure and be patient to allow gas to settle)
CVA Management (neuro, cv)
1. DAWN study shows benefit for endovascular intervention in selected patients with CVA up to 24 hours after onset
Syncope (cv, sx)
1. All Syncope patients should have an EKG; additional testing is directed by a thorough history and physical
2. Emergency department evaluation identifies 80% of syncopal causes
3. In the absence of high risk criteria, syncopal patients may be discharged from the ED with follow-up
Loperamide Abuse (gi, pharm)
1. Loperamide crosses the blood brain barrier when taken in very high dose or when in combination with P-Glycoprotein Inhibitor (e.g. Cimetidine)
2. Loperamide Overdose is associated with QTc Prolongation and risk of fatal Arrhythmia
Emergency Psychiatric Evaluation (psych, exam)
1. As with adults undergoing Emergency Psychiatric Evaluation, lab testing in children should be targeted by history and exam
2. Use Verbal De-escalation techniques in children to prevent the need for escalation to Chemical Restraints and Physical Restraints
Clinical Decision Rule (manage, legal, risk)
1. Decision rules allow risk stratification, standardization of risky presentations, and limit testing with adverse effects (e.g. radiation exposure)
2. Use decision rules that have been prospectively validated, refined and used in clinical practice and in combination with clinical gestalt
3. Avoid applying the decision tool to patients outside the population studied (inclusion and exclusion criteria)
4. Avoid mashing multiple decision tools together (use each decision tool individually, in the way it was validated)
Postoperative Bleeding after Tonsillectomy (Ent, Surgery, Mouth, Bleed)
1. Tonsillar bleeding occurs with sloughing of Fibrin clot day 5-10 in 2-7% of post-Tonsillectomy patients
2. Bleeding control can be challenging especially in children
3. Consider nebulized Tranexamic Acid (TXA)
Ketamine (surgery, pharm)
1. Ketamine 0.1 to 0.2 mg/kg offers excellent analgesia for acute pain in the emergency department (if expected to improve during ED course)
2. For adults, 50 to 150 kg, a single dose Ketamine 10 mg IV offers good effect, without risk of emergence reaction
Syphilis (id, std)
1. Incidence continues to rise in U.S. (now 8 per 100,000)
2. Review primary, secondary and tertiary presentations, esp. dermatologic findings
Asthma Biologic (lung, Asthma, pharm)
1. Consider Biologic Agents for Severe Persistent Asthma
Depression in Children (psych, peds, depression)
1. Depression is common in teens (1 in 5) - screen each year for depression with PHQ-2 and advance to full PHQ-9 as needed
2. Cognitive therapy is the most effective first line treatment for Childhood Depression
3. Most effective Antidepressants include Fluoxetine, Escitalopram, Sertraline
More expensive drugs (pharm)
1. Vitamin K costs $50 per 5 mg tablet
2. Naloxone autoinjectors are still $125, and $4900 if your device is to speak to you
3. Epinephrine Autoinjectors are still $600 and up to $4900
4. Another HIV Treatment me-too drug (Biktarvy)
5. Lonhala Magnair is a new LAMA for COPD at $1100 per month
Synthetic Cannabinoid (psych, cd)
1. Anticoagulant-laced Synthetic Cannabinoids have resulted in life threatening bleeding

Updates
May 2018

Running Injury (sports, Running)
1. Most common Running injuries include Patellar Tendinopathy, Patellofemoral Syndrome, Achilles Tendonitis, Iliotibial Band Syndrome
2. Keep Tibial Stress Fractures in the differential diagnosis (esp. with Shin Splints)
Osteoarthritis (rheum, Osteoarthritis)
1. Diagnosis is typically clinical with onset after age 50 years, pain with activity (esp. late in the day), and pain in fingers, Shoulders, hips, knees
2. Analgesics, avoiding provocative activity and in some cases joint replacement are effective treatments
3. Unfortunately Glucosamine and joint steroid and viscoreplacement injections offer minimal to no benefit
Group A Streptococcus (id, Bacteria)
1. Numerous complications (which are now much less common in the U.S.) including Rheumatic Fever, PSGN, PANDAS, Poststreptococcal Reactive Arthritis
2. Keep Rheumatic Fever in the differential when seeing children with Reactive Arthritis or neuropsychiatric symptoms (Sydenham Chorea)
Croup (lung, airway)
1. Humidified oxygen offers no benefit over standard oxygen
2. Administer Corticosteroids to croup of any severity
3. Nebulized Epinephrine for moderate to severe croup and observe for 2-3 hours
Charcot Foot (rheum, neuro)
1. Consider Charcot Foot in the >40 year old with Peripheral Neuropathy, Obesity, and minimally painful swollen, red, warm foot without fever
2. Charcot Foot is misdiagnosed on average for 7 months, delaying diagnosis, and risking deformity and amputation
Pediatric Limp (rheum, sx, peds)
1. Consider Nonaccidental Trauma in nonambulatory or developmentally delayed children with Fractures
2. Limp is not always a lower extremity problem (consider back, hip and Pelvis causes)
3. AP Pelvis may miss hip pathology (nearly always obtain frog-leg Pelvis)
4. Back pain is rare in children (consider serious causes such as Discitis, referred abdominal source, Nonaccidental Trauma)
Medication Use in the Elderly (geri, pharm)
1. Consider noncompliance, OTC Medications and Herbals when evaluating adverse drug events
2. Consider taking a medication away, instead of starting a new medication, in older patients
3. Anticoagulants (esp. Warfarin), diabetic medications (esp. Insulin) and Digoxin account for the most common adverse drug events in elderly
Pediatric Congestive Heart Failure (cv, peds, chf)
1. Viral Myocarditis (e.g. Parvovirus B19, HH6, Kawasaki's, enterovirus) can be life threatening in infants
2. Acute presentations for "URI" may reveal a sicker infant with Tachycardia out of proportion progressing to Acute Respiratory Failure
Necrotizing Fasciitis (derm, id)
1. Necrotizing Fasciitis is a life threatening infection with an insidious, occult presentation
2. Do not ignore pain out of proportion, Sinus Tachycardia or unexplained fever
3. Do not delay surgical exploration when Necrotizing Fasciitis is suspected
ST Elevation (cv, exam, ekg)
1. Consider alternative causes of ST Elevation, including neurologic catastrophe (e.g. Subarachnoid Hemorrhage)
Marijuana Toxicity (psych, cd)
1. Children (esp. <6 years old) are at high risk of toxicity from accidental Marijuana ingestion
2. CNS depression (somnolent to obtunded) and Cerebellar dysfunction (e.g. Ataxia) are most common findings
3. Effects do not peak until 2-4 hours after ingestion and may persist for 6-12 hours
Hypertension in Diabetes Mellitus (dv, endo, htn)
1. Diabetes Mellitus targets move once again to <130/80 for everyone per ACC/AHA, but <140/90 per ADA in non-high risk patients
Cocaine-Induced Coronary Vasospasm (cv, cad)
1. MI Relative Risk increases to 24 fold over baseline (risk increases within first hour of use and persists for 4-7 hours)
2. Acute Cocaine Intoxication causes tachyarrhythmias, Hypertension, prothrombotic state, QT Prolongation, QRS Widening
3. Chronic Cocaine use increases coronary atherosclerosis, Cardiomyopathy, Pulmonary Hypertension and stroke risk
Drugs of Abuse (psych, cd)
1. Substances of abuse are difficult to distinguish by sight
2. White powder could be Cocaine, Methamphetamine, synthetic Opioids, NBOMe or bath salts
3. Crystals could be Crystal Meth, U-47700
4. Many substances of abuse are reformulated into tablets (e.g. Fentanyl may be formed in tablets similar to Oxycodone or Hydrocodone)
Gastric Lavage (er, pharm, toxin)
1. Rarely indicated in modern Emergency Medicine
2. Consider in Overdoses that approach 100% mortality (consult poison control) such as Colchicine Overdose, Paraquat Poisoning (herbacide used outside the U.S.)
3. May also consider in Hydrofluoric Acid ingestion due to risk of lethal Hyperkalemia and Hypocalcemia
Rhus Dermatitis (ent, allergy, derm)
1. Corticosteroid course of 14-18 days is preferred due to risk of rebound with shorter courses
Emergency Department Triage System (er, exam)
1. ESI 3 is the achilles heal of the Emergency Severity Index (50% are triaged to ESI 3)
2. Techniques to optimize ESI 3 flow include provider in triage, split flow, vertical triage and most recently, electronic triage
Limited Ultrasound for Acute Renal Colic (uro, renal)
1. More evidence that Ultrasound is a safe, effective approach to Renal Colic
Nocturia (uro, Bladder, sx)
1. Noctiva (low dose Desmopressin) - another expensive drug with marginal efficacy, real risk (Hyponatremia)
2. Treat Nocturia instead by identifying, treating and optimizing the underlying causes of Nocturia
Ottawa Aggressive Atrial Fibrillation Protocol (cv, ekg)
1. In stable patients with Atrial Fibrillation <48 hours, consider Procainamide 1 g over 1 hour, then electrical cardioversion if fails

Updates
April 2018

Stable Coronary Artery Disease (cv, cad)
1. High intensity Statin for age <75 years
2. Blood Pressure control with Beta Blocker, ACE Inhibitor, Thiazide Diuretic, optimally <130/80 and keep <140/90
3. Low dose Aspirin 81 mg is sufficient for most patients
4. Encourage aerobic Exercise, Tobacco Cessation, Influenza Vaccine
Chronic Pancreatitis (gi, Pancreas)
1. CT Abdomen is first line imaging followed by MR/MRCP, then EUS, and finally ERCP if other testing non-diagnostic
2. Malabsorbtion and steatorrhea occur when <10% pancreatic exocrine function remains, at which point enzyme replacement is indicated
Dementia (neuro, cognitive)
1. Dementia Screening with Mini-Cog, GPCOG, or Ascertain Questionnaire, and diagnosis with SLUMS, Addenbrooke or MMSE
2. Evaluation includes CBC, TSH, Vitamin B12, Serum Glucose and MRI Brain
3. Exclude Major Depression, medications, infections and other causes of Delirium
Cervical Cancer (gyn, hemeonc)
1. Cervical Cancer Screening has eased with no screening before age 21 years, and cytology and/or HPV screening at 3-5 year intervals
2. Except for Stage IA1, Cervical Cancer management typically involves radical Hysterectomy, pelvic lymphadenectomy and chemoradiation
Rheumatoid Arthritis (rheum, ra)
1. Methotrexate is the preferred first line DMARD in most cases
2. Do not start Biologic Agent (e.g. tnf agent) before a trial on Methotrexate or similar DMARD
3. Screen for Tuberculosis, Hepatitis B, Hepatitis C and Skin Cancer before starting a Biologic Agent
4. Consider tapering DMARD if in remission for at least 6 months (esp. if anti-citrullinated Protein negative)
Rheumatoid Arthritis in the Emergency Department (rheum, ra)
1. CV presentations - MI, CHF, Atrial Fibrillation, Pulmonary Hypertension, PE, Pleural Effusion, Pericardial Effusion
2. ID presentations due to RA, TNF agents, steroids, such as Pneumonia, opportunistic infections
3. In Joint Pain presentation, exclude Septic Arthritis, even if underwhelming signs
4. Treat Rheumatoid Arthritis flare after excluding Septic Joint with Prednisone taper, 60-10 mg over 2 weeks
Clarithromycin (id, pharm)
1. Observational studies find possible increase in cardiovascular deaths while on Clarithromycin
Clostridium difficile (gi, Diarrhea)
1. Vancomycin is becoming first-line for C. Diff over Flagyl even in first episode except in mild cases
Fentanyl Patch (pharm, Analgesic)
1. Fentanyl Patches should only be used for Chronic Pain with patients using at least 60 mg Morphine per day
Prescription Cannabinoids (gi, pharm)
1. Consider in wasting, Anorexia, intractable Nausea for patients with AIDS, cancer, Chemotherapy
Lactic Acid (renal, lab)
1. Lactic Acid is primarily used as a Sepsis marker and tissue ischemia marker, e.g. Ischemic Bowel, but differential diagnosis of Lactic Acidosis is broad
2. Avoid ordering Lactic Acid in low risk patients, non-toxic, previously healthy
3. Lactic Acid clearance outside Sepsis does not uniformly improve with Intravenous Fluids
4. Cardiogenic Shock can also increase Lactic Acid and will worsen with excess fluids
Abdominal Trauma in Pregnancy (er, ob)
1. Abdominal tenderness and maternal Vital Sign changes are often absent despite significant hemoperitoneum
2. Maternal stabilization and needed imaging, even if requiring ionizing radiation, takes precedence
3. Give RhoGAM even in minor Trauma in Rh Negative women
Transesophageal Echocardiogram (cv, rad)
1. Consider in Cardiac Arrest, as may be monitored without interruption and not interfere with Resuscitation efforts
2. Heart function, compression quality and Great Vessels are seen without chest wall or epigastric bowel gas obstruction
3. Distinguishes cardiac standstill, true PEA or Asystole, from ineffective contraction and may identify Cardiac Tamponade, PE with RV strain, vascular rupture
Sickle Cell Anemia (hemeonc, Hemoglobin)
1. Treat sickle cell vaso-occlusive crisis aggressively with early IV Opioids
2. Have a high index of suspicion for serious Bacterial Infection in febrile children <5 years old
3. Always consider Acute Chest Syndrome in "Pneumonia" in Sickle Cell Anemia
4. Splenic Sequestration is a life threatening complication
Chance Fracture (Ortho, L-spine, Fracture, Trauma)
1. High velocity Traumatic Injury, e.g. MVA with Lap belt only, causes flexion and distraction of the thoracolumbar spine
2. Results in unstable, transverse Fracture through the anterior, middle and posterior Vertebral body, that typically requires surgical repair
3. Associated with cord injury, aorta injury, Liver Laceration, Splenic Rupture and mesentary and Small Bowel injury Pediatric Cervical Spine Injury (ortho, peds, c-spine)
4. New radiculopathy or Myelopathy (hyperreflexia, Clonus, babinski, weakness), esp. if bilateral, requires MRI prior to discharge (even if negative CT)
5. MRI for ligamentous instability with subluxation, Central Cord Syndrome, Vertebral Fracture

Updates
March 2018

Nutrition Guidelines (pharm, nutrition)
1. Healthy Kitchens, Healthy Lives conferences emphasizes delicious, plant forward food choices
2. Vegetables and fruits should be 50% of diet and whole grains 25%
3. Replace red meat with nuts, legumes, fish and poultry; limit dairy, and use monounsaturated fats
Sexual Assault of Male Victim (prevent, abuse)
1. Woods lamp is ineffective at visualizing semen (but UV light is effective)
Migraine Headache (neuro, Headache)
1. NSAIDS are first-line for mild-moderate Migraines and Triptans are first-line for mild-moderate Migraines
2. Dopamine Antagonists (e.g. Reglan, Compazine) are preferred Antiemetics in Migraine Headache
3. Acetaminophen and Metoclopramide are preferred agents in pregnancy
4. Acetaminophen, NSAIDs and Triptans are preferred in children
Testicular Cancer (urology, hemeonc, Testes)
1. Testicular Cancer screening is not recommended in asymptomatic men (USPTF)
2. Testicular Cancer peaks at age 30-34 years
3. Thorough update of staging, management and surveillance
Vitamin D (pharm, Vitamin)
1. Vitamin D Deficiency is defined as Vitamin D <12-20 ng/ml
2. Vitamin D screening is not routinely recommended
3. Vitamin D testing or supplementation is not indicated in Major Depression, Fatigue, Osteoarthritis or Chronic Pain
Opioid Use Disorder (psych, cd)
1. Buprenorphine is a common partial opioid Agonist used in Medication-Assisted Treatment
2. Combined Buprenorphine/Naloxone agents are preferred over Buprenorphine alone for lower abuse potential
3. Buprenorphine prescribers requires special DEA licensing
Colorectal Cancer (gi, hemeonc)
1. Follow-up after resection is typically every 3-6 months for 2-3 years, then every 6 months until 5 years post-resection
2. CEA is tested at each follow-up visit
3. CT chest, Abdomen and Pelvis is done every year for 5 years in Stage 3-4, and high risk Stage 1-2
4. Colonoscopy is at 1 and 3 years after resection and then every 5 years (unless advanced adenoma is found)
Intimate Partner Violence (prevent, abuse)
1. Screen all patients with atypical presentations for abuse regardless of gender, race, age or LGBT
2. Provide abuse victims with the resources and help they are willing to accept, with an open offer for additional help as they are willing to accept it
3. Help patients develop a safety plan (emergency shelter and point person, emergency bag, important papers)
Electrocardiogram (cv, exam)
1. Do not rely on computerized EKG Interpretation (aside from interval measurement)
2. There is no standardization for software quality across EKG manufacturers and accuracy varies widely
3. Computer interpretations miss STEMIs in up to 23-41% of cases
4. Atrial Fibrillation is a frequent False Positive on computer interpretations
Vaginitis (gyn, vagina)
1. Symptoms do not distinguish Vaginitis cause (history, exam and labs are best used for accurate diagnosis)
2. Single DNA tests (e.g. BD Affirm) are available to test for Trichomonas, Bacterial Vaginosis and candida infection
3. DNA Testing is preferred for Trichomonas diagnosis, and can be added to DNA probe and liquid pap
4. Bacterial Vaginosis treatment in pregnancy improves symptoms, but does not lower risk of Preterm Labor
Drug Activity in Women (pharm, gyn)
1. Women are higher risk for Torsades, Opioid-induced respiratory depression, insufficient Propofol dosing
Musculoskeletal Injuries in Women (sports, gyn)
1. Women athletes are higher risk for ACL Tears, PFS, Patellar Subluxations, Stress Fractures, elbow and Shoulder Dislocations and Concussions
Sulfonylurea Drug Interactions Causing Hypoglycemia (endo, pharm)
1. Sulfonyureas (esp. Glyburide) are a risk for Hypoglycemia
2. Drug Interactions (e.g. Fluoroquinolones, Clarithromycin, sulondamides, Fibrates) can increase the risk of drug-induced Hypoglycemia
Mediastinal Widening (lung, rad)
1. Emergent causes include Aortic Dissection, Aortic Rupture, Pneumomediastinum, Thoracic Aortic Aneurysm, Vertebral Fracture with Hematoma
2. Other causes include lung or Mediastinal Mass or adenopathy, Hiatal Hernia, Atelectasis, Thymus or Thyroid mass or anatomic variant
3. Imaging technique (rotation, supine position, AP view, poor inspiration) commonly results in wide mediastium appearance
Procedural Sedation and Analgesia (surgery, Anesthesia)
1. Ketamine is the preferred procedural Anesthetic in children with the least adverse effects
MMR Vaccine (id, immunize)
1. MMR Vaccine booster (3rd dose) is indicated in outbreaks if directed by local public health (esp. in dormitories, barracks)
2. As always, avoid MMR in pregnancy and Immunocompromised
3. Give a second dose, if never immunized (or unknown status), at 4 weeks after the first
Urinary Tract Infection in Pregnancy (urology, ob, id)
1. Cephalexin, Cefuroxime, and Fosfomycin (expensive) may be used in any trimester (as well as Amoxicillin, which has higher resistance)
2. Nitrofurantoin should not be used in late third trimester (Hemolytic Anemia risk) and may be very weakly associated with heart defects, Cleft Lip
3. Trimethoprim-Sulfamethoxazole may only be used in second and early third trimester
Steroid-Induced Hyperglycemia (endo, pharm)
1. Blood Glucose will typically increase with Systemic Corticosteroids
2. Most diabetes patients do not require significant changes to regimen when on short courses of Corticosteroids
3. Risk of Hypoglycemia as steroid is tapered outweighs benefit of transiently increased regimen
4. Closer monitoring and tighter Glucose management on Corticosteroids in Type I Diabetes Mellitus, uncontrolled Type 2 Diabetes Mellitus
Rhabdomyolysis (renal, failure)
1. Rhabdomyolysis is divided into exertional (typically benign) and non-exertional (worse outcome)
2. Initial Creatinine kinase level does not predict outcome unless >40,000
3. Acute Kidney Injury is associated with a worse outcome
4. Aggressive fluid hydration is key within first 6 hours (urine out >250 cc/h), but crystalloid type and alkalinization have not been shown to matter for outcome
Influenza (id, virus)
1. Avoid Elderberry and Oscillococcinum (unlikely to be helpful)
Low Back Pain Management (ortho, L-Spine)
1. Valium does not add benefit over Naprosyn alone for Low Back Pain
2. Most will improve within 3 months of Acute Low Back Pain onset (but 20% will still have a functional deficit)
Tympanic Membrane Perforation (ent, ear)
1. Do not use cortisporin with a perforated Ear Drum
2. ENT referral for most cases, esp. for large perforation, suspected ossicle disruption, Vertigo
3. Use Antibiotic drops (e.g. Ofloxacin, Ciprofloxacin) which are at 100x oral concentrations, for associated Otitis Media with or without oral Antibiotics
Neonatal Circulation Assessment (nicu, exam, cv)
1. Minimize blood loss in newborns
2. Newborn Blood Volume: 85 ml/kg
3. Newborn weighing 4 kg has only 340 ml total Blood Volume
4. Every 34 ml (slightly more than 2 Tbs or 1 oz) is 10% of total Blood Volume
Alcohol Intoxication (psych, cd)
1. Hypoglycemia, Abnormal Vital Signs or chemical sedation needed are markers of underlying Critical Illness in the intoxicated patient
Appendix Ultrasound (surgery, rad)
1. Appendicitis Ultrasound accuracy is improving
2. Test Sensitivity is as high as 92% in radiology (80% at ED bedside)
3. Test Specificity is as high as 97% in radiology (92% at ED bedside)
Surfer Spine (sports, water)
1. Atraumatic Spinal Myelopathy from cord infarction is an uncommon condition seen primarily in warm water Surfing (e.g. Hawaii) by amateur surfers
2. May be associated with prolonged hyperextended position
3. Presents with sudden onset of back pain, bilateral leg weakness, Paresthesias

Updates
February 2018

Penile Lesion (urology, penis, derm)
1. Papulosquamous lesions include Psoriasis and pearly Papules
2. Inflammatory lesions include Lichen Sclerosus, Lichen Nitidus, Lichen Planus
3. Vascular lesions include Angiokeratomas
4. Neoplastic lesions include Penile Carcinoma in Situ, penile squamous cell cancer
Heel Pain (ortho, ankle, foot)
1. Midfoot lateral pain includes Peroneal Tendinopathy and Sinus Tarsi Syndrome
2. Midfoot medial pain includes flexor digitorum Tendinopathy or tibialis posterior Tendinopathy
3. Posterior plantar Foot Pain includes Plantar Fasciitis, Heel Pad Syndrome, Tarsal Tunnel Syndrome, Calcaneal Stress Fracture
4. Posterior Heel Pain includes Achilles Tendinopathy, Retrocalcaneal Bursitis, Haglund Deformity and in children, Severe Disease
Colorectal Cancer Screening (gi, procedure, hemeonc)
1. Standard Colorectal Cancer Screening starts at age 50, but for those meeting Family History criteria, start at age 40 (or 10 years before youngest relative)
2. Specific screening protocols are defined for high risk syndromes: HNPCC, IBD, adenomatous polyposis, Peutz-Jeghers Syndrome, Sessile serrated polyposis
Hemorrhoid (gi, Rectum)
1. Fiber supplementation with adequate hydration is first-line management of Hemorrhoids
2. Excise Thrombosed Hemorrhoids in the first 48-72 hours; Nifedipine or Nitroglycerin may be adjunctive for pain
3. Most effective surgical interventions include Rubber band ligation (grade I-III) and surgical excision (grade III-IV)
4. Exercise caution when attributing Rectal Bleeding to Hemorrhoids (esp. in age >40 years or other Colon Cancer or Inflammatory Bowel Disease risks)
Tremor (neuro, Tremor)
1. Essential Tremor is the most common pathologic Tremor, an Action Tremor progressive with age, a diagnosis of exclusion made clinically
2. Most Rest Tremors are Parkinsonism (although other causes include drug-induced and psychogenic can cause similar findings)
3. Urgently refer children with Tremor
Bullying (peds, behavior)
1. Bullying is much more common than previously reported (each year, 20% in schools and 16% online)
2. Start discussing Bullying at the 6 year old well child check
3. Bullying victims commonly have Insomnia, Abdominal Pain, Headaches as well as Major Depression, Suicidality, poor school performance, Eating Disorders
Hypothermia (er, environ)
1. In Frostbite, do not massage or apply dry heat
2. In Hypothermia, measure a core Temperature with a Thermometer with adequate lower range, and consider Secondary Hypothermia causes
3. In severe Hypothermia, ECMO continues to offer better outcomes when core Temperature is <28 C or if hemodynamic instability
Abdominal Ultrasound (gi, rad)
1. Several protocols exist for evaluating the Abdomen with Ultrasound including for free air, Small Bowel Obstruction and localizing Epigastric Pain
STEMI (cv, cad)
1. STEMI with Hypotension mayh be due to right ventricular infarct, Aortic Dissection, massive Pulmonary Embolism, Cardiac Tamponade, ventricular rupture
Head Injury (er, neuro)
1. Warfarin-related delayed CNS bleeding after Head Injury is uncommon (<2%) and typically does not warrant intervention
Cardiac Arrest (er, exam)
1. Consider a brief moment of silence at the end of code in which the patient expired
Chlorine (er, toxin)
1. Chlorine gas may form with use of cleaners (e.g. bleech solutions) and may cause ARDS and other life threatening lung injury
Ketorolac (pharm, Analgesic)
1. Ketorolac 10 mg IV is as effective for analgesia as 15 or 30 mg
Fever Without Focus Management Birth to 3 Months (id, peds)
1. Well appearing febrile infants at 60 days of age have a 1.8% Prevalence of bacteremia
Cannabinoid Hyperemesis Syndrome (psych, cd)
1. Capsaicin cream applied to Abdomen (palm-sized amount) is effective
Sudden Sensorineural Hearing Loss (ent, Hearing)
1. Prednisone 50-60 mg orally daily while awaiting ENT followup
Traumatic Cardiopulmonary Arrest (er, cv)
1. Unless medical Cardiac Arrest, immediate interventions (chest Ultrasound, Finger Thoracostomy) take precedence over CPR in Traumatic Arrest
2. Consider Finger Thoracostomy instead of Needle Thoracostomy (both of which are best done at the 5-6th intercostal space axillary line)
Oral Contraceptives (gyn, pharm)
1. Even low dose Estrogen increases Breast Cancer risk by RR 1.2
Biotin (pharm, Vitamin)
1. Biotin supplementation for hair, nails... has little data of efficacy
2. High dose Biotin (>5000 mcg) falsely lowers Thyroid Stimulating Hormone, Troponin and Procalcitonin
Altitude sickness (er, environ)
1. Consider prophlaxis with Diamox if traveling to >11,000 feet in one day (or 9000 if prior history of altitude sickness)
Medications (pharm)
1. Many new, expensive, copy-cat drugs
2. Do we really need more GLP-1, SGLT2 Inhibitor agents for diabetes or biologics for Psoriasis or combo HIV agents?
3. Who is working on new Antibiotics or reasonably priced cancer regimens?
Long Acting Beta Agonist (lung, Asthma, pharm)
1. FDA takes away a black box warning on LABAs (apparently mortality was no worse than with Inhaled Corticosteroids)

Updates
January 2018

Chronic Kidney Disease (renal, failure)
1. Serum Cystatin C may be used in place of Serum Creatinine to estimate Glomerular Filtration Rate
2. Urine Albumin to Creatinine Ratio is the preferred method to evaluate for Proteinuria
3. Use Urine Protein to Creatinine Ratio in severe Proteinuria (>300 mg/g)
Pigmentation Disorder (derm, pigment)
1. Several Hyperpigmentation disorders (e.g. Melasma, Solar Lentigines, Postinflammatory Hyperpigmentation) respond to tri-luma
2. Start with Topical Corticosteroids for Localized Vitiligo, and UVB for generalized Vitiligo
3. Sun protection and Sunscreen are a key to the management of Pigmentation Disorders
Palpitations (cv, sx)
1. Most Palpitations will be due to psychosomatic disorders, Atrial Fibrillation, SVT
2. Every person with Palpitations should have an EKG at minimum
3. Supraventricular Premature Complexes (SVPCs) are associated with risk of Atrial Fibrillation and cardiac events
Hypertension Criteria (cv, htn)
1. Once again ACC/AHA has moved the targets on Blood Pressure goals based on new studies
2. Is this sound, given Blood Pressure reading inaccuracies, prescriber confusion, medication and lifestyle noncompliance
Hypothyroidism (endo, Thyroid, pharm)
1. Subclinical Hypothyroidism may be treated if TSH >10, persistent symptoms (Fatigue, Constipation, cold intolerance) or pregnancy
2. Avoid desiccated Thyroid and Liothyronine (T3) in most cases
Automobile Safety (prevent, car, pharm)
1. Ilicit drugs and prescribed Benzodiazepines and other Sedative-Hypnotics, Muscle relaxants, Opioids, Anticholinergics may cause Impaired Driving
Opioid Dependency (psych, cd, pharm)
1. Naltrexone is revisted for maintenance of Opioid sobriety
Topical Corticosteroids (derm, pharm)
1. Once again, pharmaceutical companies have found a way to double prices on Generic Drugs (e.g. Topical Clobetasol)
Long-Acting Beta Agonist (copd, pharm)
1. Trelegy Ellipta for severe COPD combines a LAMA, LABA and Corticosteroid
Bronchiolitis (lung, Bronchi)
1. Hypertonic Saline does not reduce hospitalization rates in Bronchiolitis
Nonphysiologic Neonatal Jaundice (nicu, gi)
1. Not much has changed in Hyperbilirubinemia management in the last couple of decades
2. Use calculators (e.g. BiliTool.com) to assess the need for Phototherapy
3. Consider secondary causes (e.g. Neonatal Sepsis)
Idarucizumab (hemonc, pharm, coags)
1. Idarucizumab reverses Dabigatran (Pradaxa) rapidly (minutes) and effectively
Low Risk Chest Pain (cv, cad)
1. Stress testing in Low Risk Chest Pain increases angiograms and revascularization without reducing MI related admissions
Cardiac Arrest (er, exam)
1. Bedside Ultrasound increases the delays to restarting Chest Compressions
Delayed Sequence Intubation (lung, procedure)
1. Prevent aspiration, by keeping CPAP or Bipap inspiratory pressures <15 cm H2O
2. Small Ketamine doses in adults for DSI are sufficient (20-30 mg)
Hyperemesis Gravidarum (ob, gi)
1. Fewer labs needed (No Thyroid tests unless symptoms of Hyperthyroidism, Urine Ketones are not markers of illness severity)
2. Metoclopramide and Ondansetron are first line Antiemetics
Endotracheal Intubation Preoxygenation (lung, procedure)
1. Oops Mnemonic (Levitan): Oxygen On, Apply 15 lpm by Nasal Cannula for Apneic Oxygenation, Pull Mandible forward, Sit patient up (to 20 degrees)
Acromioclavicular Separation (ortho, Shoulder)
1. Obtain comparison view of unaffected side, but weighted films are not needed
Ankle Fracture (ortho, ankle, Fracture)
1. Weber B Ankle Fracture stability is predicted by <2 mm posterior fragment displacement and only 2 Fracture fragments
Noninvasive Urine Collection (urology, lab)
1. Alternative techniques to stimulate urination in young children (pre-Toilet Training) are highly effective
2. Quick-Wee Method (forceps with cold saline soaked gauze rubbed on suptrapubic area)
3. Bladder stimulation technique (infants <1 month), with infant suspended by axilla, tap on Bladder, than circular massage low back
Brown Recluse Spider Bite (er, derm, bite)
1. Immediately ice bite wounds to deactivate toxin
2. Skin necrosis starts at 72 hours after bite
3. NOT RECLUSE mnemonic is used to exclude brown recluse bites as wound cause in endemic areas
Informed Consent (neuro, cognitive)
1. Provider performing the procedure should also perform the Informed Consent
Otitis Externa (ent, ear)
1. Combine Topical Antibiotic with a Topical Corticosteroid (e.g. cipro-hc, cipro-dex, Ofloxacin and Dexamethasone)
Insulin Dosing in Type 2 Diabetes (endo, pharm)
1. Updated protocol for initiating Basal insulin only and advancing to basal and Bolus Insulin (Insulin augmentation)
2. Updated protocol for initiating and advancing to basal and Bolus Insulin (Insulin replacement)
Ear Pain (ent, sx, ear)
1. Consider referred Ear Pain, esp. cancer risk, CAD risk and Temporal Arteritis risk
Pityriasis Rosea (derm, hyperplasia)
1. Likely HHV-6 (Roseola) and HHV-7 mediated rash, which may respond to Acyclovir