Much less common in the U.S. with the over-treatment of Otitis Media
Has been primarily a complication of Otitis Media seen in children, most often due to Streptococcus acutely, and staph and Pseudomonas in chornic infections
Newer cardiac devices (Pacemakers and Implantable Defibrillators) are defined as MRI Conditional (whereas legacy devices do not carry the designation)
Adverse Effects related to legacy devices in MRI include Power-On Reset Event, False Positive shocks or pacing, altered sensing and pacing thresholds, generator failure, device battery depletion
Legacy cardiac devices appear to be safe in MRI if safety protocols in place
Specific learning disabilities include dyslexia, dysgraphia and dyscalculia, which are difficult to diagnose before second grade and with best outcome if treatment started by third grade
Response to Intervention is an early intervention initiated by school in response to Academic Underachievement, before Individualized Education Program (IEP) evaluation is needed
Medical providers play an important role in identifying medical conditions that may be impacting learning
Wilderness Evacuation is indicated when readily available definitive care is unavailable and the risk of evacuation is more than the risk of deterioration
Improvised litter may be fashioned from two 8 ft poles/skis/branches and an 8x8 ft tarp/blanket, secured with tape/rope
Many satellite messengers (e.g. InReach Mini) and Personal Locator Beacons are available for emergency wilderness travel
Global warming impacts human health in many ways including air quality, vectorborne disease, waterborne disease, food security, extreme events and their mental health impacts
Even a seemingly minor trigger, may precipitate the appearance of a hyperadrenergic state, especially in younger patients who may present with circulatory collapse
Elderly patients may present with Apathetic Thyroid Storm, in which they are not hyperadrenergic, but rather weak, Fatigued and depressed
Submandibular Space Infection with secondary airway compromise that is polymicrobial and typically results from mandibular tooth with periapical infection
Emergent surgical drainage of Ludwig Angina with abscess decreases the risk of airway compromise by 10 fold
Also known as Cancrum oris or gangenous Stomatitis, results from severe ANUG progression with mucous membrane gangrene seen in malnourished patients, especially children
Causes facial soft tissue and bone destruction and facial disfigurement
Pilonidal Disease forms when skin injured (often by loose hairs) forms pit at skin disruption in gluteal fold
Pit plugs with hair and keratin with secondary Pilonidal Cysts, and abscess forms when infected, and sinus tracts may also develop
When abscess is present, the treatment is Incision and Drainage and consider surgical excision for recurrence
When abscess is not present, hair removal from the gluteal cleft with weekly shaving, or periodic laser Epilation, topical phenol or Fibrin glue (with or without surgical excision - see below)
For maximal ear drop penetration, clear visible debris from ear canal, instill while lying in decubitus position, and pull tragus back and down several times after instilling drops
Do not use Cipro HC Otic (not sterile) and of course avoid all cortisporin products (including suspension)
Combination drops with steroid result in faster resolution but are much more expensive
Heavy lifting (esp. >55 lb or 25 kg), Bending or twisting frequently, Whole body vibration are among higher risks for Workplace Injury
Risk for prolonged recovery include Poor pain coping skills, Fear avoidance (avoiding activities due to fear that they will cause pain), Baseline functional Impairment, Psychiatric illness, Low general health status
Perform Start Back Screening Tool, address fear avoidance beliefs, encourage early functional return to work, provide physicial therapy, consider behavioral health follow-up
Congenital Heart surgical repairs (e.g. Norwood Procedure, Glenn Procedure, Fontan Procedure, BT Shunt) have allowed children to survive CHD that would otherwise be fatal
However, the repairs re-route blood to mimic physiologic flow, but these hearts have unique physiology with Pulmonary Hypertension, chronic Hypoxia, Dysrhythmia risk, thrombosis risk
Homeostasis is an easily disrupted tight balance between Preload dependence and Cardiogenic Shock
Consult Cardiology in all cardiopulmonary presentations and new medications with possible hemodynamic effects
J-Tip (transdermal Lidocaine device) creates eraser sized wheel of Lidocaine that has been shot through the skin without needle, with onset of Anesthesia within 3 minutes
Topical Lidocaine (LMX4 - topical liposomal Lidocaine 4%) occluded 30 min. before procedure
Ethicists make no moral distinction between witholding treatment and withdrawing treatment
Patients often present to the Emergency Department without Advanced Directives and Resuscitation is continued, and as relatives and power of attorney arrive, patient's wishes for no life sustaining measures may become known
Withdrawing treatment at this time may be the most ethical and humane path, and consistent with patient wishes
Consider this to be the transition "from cure to care", in the active management of the dying process
Nasal mucosa is well vascularized with rapid medication absorption and ideal intranasal medications are lipophilic and small in molecular size
Intranasal medications are best tolerated and absorbed at pH 4.5 to 6.5 with a maximal absorption amount 0.3 ml (+ 0.1 ml for dead space in MAD atomizer)
Vaginal ring (Ethinyl Estradiol/Segesterone) similar to NuvaRing which is inserted each cycle into vagina for 21 days, removed for 7 days, and may be re-used for up to 13 cycles
Avoid in BMI >29 (lower efficacy) and backup Contraception if the ring is out more than 2 hours during the 21 days of cycle
Efficacy may be reduced by oil or silicone based vaginal products or lubricants
Expensive at $2000 per ring, especially if lost (but $160/month similar to NuvaRing)
Knee spontaneous reduction may occur prior to presentation; Do not dismiss patient report of "popping out and in Sensation" simply as Patella subluxation
Multidirectional instability may be only finding if knee spontaneously reduced prior to presentation
Knee Dislocation may occur with low energy mechanism and confers much higher risk than Patella subluxation
Follow the same vascular evaluation and monitoring if Knee Dislocation is suspected
Graded Compression Stockings (e.g. TED Stockings) are insufficient alone and these and Intermittent pneumatic compression (IPC) add little benefit when added to pharmacologic prophylaxis
Preschool children normally display speech disfluency as they are learning to speak
Those with Childhood-Onset Fluency Disorder display CNS imaging changes affecting speech related pathways; requires concious monitoring by those who Stutter, in contrast to unconscious fluent speech
Early interventions are most effective (plastic brain) and less likely to develop complications (see below)
Complications include decreased self esteem and negative Perception by others, word avoidance, mannerisms, social withdrawal, Anxiety Disorder
Sports Hernia (Athletic Pubalgia) is a lower abdominal or inguinal pain, outside the ball and socket Hip Joint, in athletes (esp. males in kicking, cutting, twisting sports)
Hernia is through a weakened posterior Inguinal Canal wall in most cases, resulting in an occult, non-palpable Hernia
Electricity travels a path until it meets resistance and skin offers resistance to low current
However, with enough current a burn hole through the skin is established, and this allows current to pass bypass intact skin via Electrolytes into nerves, Muscles, vascular structures
Skin resistance is lowered by a factor of 100 when it is wet (i.e. wet skin is a much reduced barrier to Electrical Injury)
FDA approved for reversal in adult surgery cases, to speed recovery after case completion and is also used to follow neurologic status in neurologic catastrophe (e.g. Intracranial Hemorrhage) or Status Epilepticus
However emergency paralytic reversal is off-label use and may not be ideal as a patient who requires emergent Endotracheal Intubation still needs an airway
Can't Intubate but CAN ventilate scenarios may be treated with temporarily with BVM or LMA, and Can't Intubate, Can't Ventilate scenarios require emergency Cricothyrotomy
CT Contrast and MRI Contrast (Gadolinium) are not required for Necrotizing Fasciitis diagnosis, but do assist with complication evaluation and differential diagnosis
Consider Ultrasound in children, and for guided fluid aspiration
Blue-gray or muddy brown Hyperpigmentation resulting from Minocycline-iron complex skin deposition, especially on the face, arms, legs
Highest risk in long-term dosing for chronic infection or Rheumatoid Arthritis (risk increases with longer duration) and uncommon with Acne Vulgaris dosing
Counseling is effective and recommended by USPTF in the prevention of perinatal depression for those at risk
Start screening in the second trimester
Risk factors include history of depression or depressive symptoms not meeting Major Depression criteria, socioeconomic risks, Intimate Partner Violence, stressful events
Drospirenone (Slynd) was released in 2019 in U.S. at $200/month as a minipill and marketed as having more maintained efficacy after a missed pill than Norethindrone
Does not require back-up Contraception if missed pill is taken within 24 hours
Risk of Hyperkalemia (anti-mineralcorticoid effect)
Degree to which radiocontrast causes nephropathy is controversial
Most recent studies find no significant impact on Acute Kidney Injury with radiocontrast if GFR>30 ml/min (however, Serum Creatinine may transiently increase in 2-3% of patients)
ACR recommends no baseline Creatinine before scan if age <60, no renal disease, Hypertension, diabetes
Flibanserin (Addyi, oral) and Bremelanotide (Vyleesi, SQ) are medications that may be considered in low sexual desire in premenopausal women
They are minimally effective and expensive ($400 to $900 per month in 2019)
Bremelanotide (Vyleesi) is injected SQ prn 45 minutes before sexual activity and causes Vomiting in 1 of 8 women, and potentially irreversible Hyperpigmentation
In the U.S., Polio has not occurred in wild since 1979, or been imported since 1993, but it still exists in parts of Africa, Middle East and New Guinea
Most patients will be asymptomatic or have mild viral syndromes, but 1% will have asymmetric, Acute Flaccid Paralysis, and children ages <15 years old are most at risk
Tafenoquine (Arakoda) is a new Malaria Prophylaxis agent taken 100 mg daily for 3 days before travel, weekly while traveling, then once on return from travel
Contraindicated in children and pregnancy (including for conception up to 3 months after last dose)
Also contraindicated in G6PD Deficiency (requires testing before use) and if history of Psychosis
Focal Seizure followed by contralateral weakness (or other neurological deficits such as Aphasia, Gaze Palsy, sensory deficit) lasting up to 24 to 36 hours
Syringomyelia is chronic expanding central cavity in the spinal cord resulting in progressive loss of pain and Temperature sense and motor atrophy and weakness
Acneiform Facial Eruption more often in young women with perioral Papules and Pustules, that may also involve the perinasalm periorbital, forehead, cheeks, chin and neck
Presents with Diarrhea onset 6-16 hours after meat or gravy ingestion and in-vivo toxin production, unlike Staph Aureus, which presents in first 6 hours with Vomiting from preformed toxin
Affects 1 in 500 live births, and results in Midgut Volvulus in 75% of cases (most within the first week if not first month of life)
Presents with Bilious Emesis in a toxic infant, and requires emergent surgical intervention to prevent the bowel necrosis starting within first 3 hours
Innominate artery erosion is a rare but catastrophic complication presenting from bleeding at Tracheostomy site
Any significant bleeding, even if stopped, requires careful evaluation
Initial bleeding event may transiently stop, but herald masssive bleeding when clot is displaced
Emergent surgical intervention is needed, but temporizing maneuvers include hyperinflating Tracheostomy cuff ballon, and ET intubation from above and compressive inominate artery against Sternum with inserted finger
Face Presentation occurs in 1 in 550 live births when the fetal head is hyperextended back, and is associated with a 2-3% perinatal mortality, as well as Anencephaly
Brow Presentation is with a partially extended head, occurring in 1 in 1400 live births, and with a 1-8% perinatal mortality
Uncommon, but life-threatening infection and abscess of the prevertebral space with risk of airway obstruction, local infection spread (e.g. mediastinitis, meningoencephalitis, Carotid Artery erosions)
Despite regulatory changes in 1978 and 1986, Lead Poisoning still effects 500,000 children each year
Although universal lead screening is no longer done in U.S., targeted screening in medicaid children, Immigrants and other high risk groups is important
No lead level is considered safe, and permanent neurotoxicity occurs at levels of 5 mcg/dl in children
Of those adults requiring Longterm Care, 80% live in the community, with the assistance of unpaid Caregivers who provide 90% of the care for these patients (nearly 25 hours/week on average)
Caregiving is associated with significant persistent, uncontrollable and unpredictable stressors and physical, psychological and financial burdens
Caregiver Support is critical to helping them sustain their care, while still maintaining their own well being
HEART Score 0-3 and 2 normal serial Troponins 3 hours apart (2 hours if using High Sensitivity Troponin) are sufficient to disposition low risk patients home with major adverse cardiac events <1%
Provide adequate sedation and Anesthesia for the procedure
Adequately expose landmarks (clavicle, Sternum, axilla, costal margin) and make an adequate skin incision (e.g. 3 cm) for access, wider in larger patients
Take your time after the pleura is penetrated; any risk of Tension Pneumothorax is eliminated
On lateral gaze, Cranial Nerve 6 abducts the ipsilateral eye, and to maintain Conjugate Gaze,, a signal is passed via MLF to the contralateral eye's CN 3 to adduct (medially) in parallel
With a MLF lesion, the adducting eye via CN 3 fails to adduct and in response, the abducting eye (via CN 6) demonstrates Nystagmus
In older adults (esp. unilateral involvement), consider vascular disease and in children consider pontine glioma
In young adults (esp. bilateral involvement), consider Multiple Sclerosis
Romosozumab (Evenity) Injection is a SQ Injectable Monoclonal Antibody, sclerositin inhibitor that costs $22,000 per year in 2019 (covered under Medicare Part B)
Increases bone growth and decreases bone breakdown
Indicated for high risk women with Fractures despite bisphosphonate or multiple Vertebral Fractures
Contraindicated if MI or CVA in last year (associated with increased Cardiovascular Risk)
Early initiation of highly active HIV Antiretrovirals have significantly reduced MAC Incidence
MAC prophylaxis is now indicated for CD4 Cell Count < 50 cells/mm3 (previously <100 cells/mm3) and patients have delay in starting Antiretrovirals or optimized regimen cannot be used
Fever for 5 days, with at least 4 of the following: Conjunctival injection, mucosal changes, polymorphous rash, palms and soles changes, cervical adenopathy
Run-Hide-Fight may not be the best strategy in the hospital setting, where exits and hiding places are limited, and protecting vulnerable patients is also a priority
Securing areas with removable locks, stocking emergency supplies, training and establishing protocols are key
Can never over-dose paralytics: Best to over-estimate than under-estimate dose (e.g. 2 mg/kg of Succinylcholine or Rocuronium) esp. in decreased Cardiac Output
Patient must consent to blood draw or officer must have a warrant to obtain blood (fourth amendment rights), except in cases of immediate danger to patient
Most frequent cause of mental Disability in girls (1 in 10,000 to 15,000)
X-linked trait and affects only girls in the vast majority of cases (very rare in boys) - MECP2 Gene mutation (95% occur at methyl CpG-binding Protein)
Presents with regression of previously acquired skills, decreased head growth, speech loss, Gait Abnormality, loss of purposeful hand movement, Seizures
In the ill appearing young infant with blood in the stool, consider NEC, malrotation with Midgut Volvulus, Hirschsprung's enterocolitis, Vitamin K Deficiency
In well appearing young infants, with intermittent inconsolable crying, consider intussception
Outcomes appear improved if ACE/ARBs are restarted after Renal Function returns to baseline in high risk conditions (Systolic Dysfunction, recent MI, CKD)
When reintroducing ACE/ARB, start at low dose and slowly increase