Month: February 2017

Sore Throat

February 26, 2017 /

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You must know the FOUR emergent causes of sore throat!

Step 1: Apply the Centor Criteria

  • Determines if patients is at risk for Group A strep (“strep throat”)
  • 4 Criteria
    • Fever
    • No cough
    • Tonsiller exudates
    • Lymphadenopathy
  • Interpretation
    • If patient has ALL of the criteria
      • Treat for strep throat
    • If patient has NONE of the criteria
      • Don’t even test for strep throat
    • If patient has SOME of the criteria
      • Consider testing for strep throat

Step 2: Prescribe Antibiotics

  • B-lactams work best
    • Penicillin
    • Amoxicillin
  • If patient has allergy, consider alternative agent
    • Azithromycin
    • Clindamycin

Step 3: Pain Control

  • NSAIDS
  • Steroids

Step 4: Consider EBV (Epstein-Barr Virus)

  • Consider in patients not getting better on antibiotics
  • Examine for splenomegaly
    • If present, no contact sports

Step 5: Consider the FOUR Emergent Causes of Sore Throat

  • Ludwigs angina
    • Airway emergency
    • Infection UNDER the tongue
  • Peritonsillar abscess (PTA)
    • Complication of bacterial pharyngitis
    • Causes “trismus” (difficulty opening mouth)
    • Frequently need to be drained
  • Retropharyngeal abscess
    • Airway emergency
    • Difficult to diagnose by exam alone
      • Infection is BEHIND airway
      • Seen on lateral neck xray
  • Epiglottitis
    • Airway Emergency
    • “The Triad”
      • Drooling
      • Dysphagia
      • Distress (respiratory)
    • Lateral neck xray shows “thumbprint sign”

Additional Reading

  • Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
  • Airway Infectious Disease Emergencies (UNM)

Procedural Sedation

February 19, 2017 /

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Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

  • Cardioversion
  • Orthopedic reductions
  • Painful procedures

Three Step Approach to Procedural Sedation

  • Step 1: Risk stratify the patient
    • Mallampati score (aka “How visible is the uvula?”)
      • Level 1: Can visualize THE WHOLE uvula
      • Level 2: Can visualize MOST of the uvula
      • Level 3: Can visualize SOME of the uvula
      • Level 4: Can NOT visualize the uvula
    • ASA (aka “How healthy are they?”)
      • Level 1: Healthy
      • Level 2: Mild illness
        • Hypertension
        • Hyperlipidemia
        • Anemia
      • Level 3: Major illness
        • Diabetes
        • Coronary disease
        • COPD
        • Chronic renal disease
      • Level 4: Extremely unhealthy
        • Dialysis patient
        • Severe heart failure
        • Chronically debilitated
      • Level 5: Dying
        • Patient needs operation to live
          • Intracranial hemorrhage with midline shift
          • Ruptured aortic aneurysm
          • Ruptured papillary muscle with cariogenic shock
          • Dissecting aortic aneurysm
  • Step 2: Informed consent
    • Patients sign a GENERAL CONSENT to treat when registering to the department
    • Many emergency scenarios require physician to operate with IMPLIED CONSENT
    • Many patients have an ADVANCED DIRECTIVE
    • In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
      • Varies by hospital
      • Typically required for procedural sedation in stable patients
  • Step 3: Gather supplies
    • Nurse and nursing supplies
      • IV
      • Cardiac monitor
    • Respiratory therapy and respiratory supplies
      • Capnography
      • Bag-valve mask
      • Airway box

Top 5 Procedural Sedation Medications

  • Midazolam (“Versed”) – 0.02 mg/kg IV
    • Reduces anxiety prior to procedure
    • Provides no analgesia
  • Fentanyl – 1 mcg/kg IV
    • Reduces pain
    • Useful for painful procedures
      • Incision and drainage
      • Simple reductions
  • Propofol – 0.5-1mg/kg IV
    • General anesthetic
    • Best given “low and slow”
    • Short acting
    • Causes respiratory depression and hypotension
  • Etomidate – 0.15 mg/kg IV
    • General anesthetic
    • Less hypotension than propofol
    • Can cause myoclonus
  • Ketamine – 1-2mg/kg IV
    • “Dissociative”
    • Provides both amnesia AND analgesia
    • Can cause emergence reactions
    • Can cause laryngospasm and secretions

Additional Reading

Back Pain

February 5, 2017 /

Podcast: Play in new window | Download

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses

  • Aortic Dissection and Abdominal Aortic Aneurysm (AAA)
    • Age >50
    • Hypertension
    • “Ripping” or “Tearing” pain
    • Absent pulses in lower extremities
  • Spinal Infections
    • Fever
    • Immunocompromized
      • HIV
      • Diabetes mellitus
      • Transplant patients
  • Spinal cord compression (especially cauda equina)
    • Urinary retention
      • Consider obtaining post-void residual
    • Saddle anesthesia
    • Fecal incontinence/decreased rectal tone
  • Fracture
    • Recent trauma
    • Advanced age
  • Cancer
    • History of cancer
    • Night sweats
    • Weight loss

Step 2: Testing Plan (If Patient Has Red Flags)

  • X-ray or CT scan if concerned for fracture
  • MRI if concerned for infection, cord compression, or cancer

Step 3: Symptom Management

  • NSAIDS
    • Naproxen
    • Ibuprofen
  • “Muscle relaxants”
    • Cyclobenzaprine
  • Other agents
    • Opiates
    • Topical therapy
    • Lidocaine patches

Step 4: Counseling

  • Remain active
  • Avoid heavy lifting
  • Red flags = immediate return to ED

Additional Reading

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