Author: Zack (Page 5 of 9)

NBME Shelf Review (Part 3) – Pediatrics

October 14, 2018 / Zack

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Febrile Seizures

Simple (All features must be present)
- Age 6 months – 5 years
- Febrile
- Lasts less than 15 minutes
- Only one seizure in 24 hour period
- No focal neuro deficits on exam
- Generalized seizure (must have LOC)
  - Treat with acetaminophen and reassurance
Complex
- Does not meet ALL of the criteria for a simple febrile seizure
  - Consider full workup including lumbar puncture

Pediatric Abdominal Pain

Intussusception
- Classic history
  - Severe emesis
  - INTERMITTENT severe abdominal pain
- Common causes
  - Meckles diverticulum
  - Henoch-Schonlein purpura
- Diagnose with abdominal ultrasound
  - Look for target sign
- Treat with air enema
Malrotation with Volvulus
- Classic symptoms
  - Bilious emesis
  - Projectile
  - CONSTANT severe abdominal pain
  - Peritonitic abdominal exam
- Common tests (if stable)
  - Upper GI Series
    - Corkscrew sign
    - Coffee-bean sign
Necrotizing Enterocolitis
- Classic symptoms
  - Premature neonate
  - Bloody stool
- X-Ray shows pneumotosis intestinalis
  - (Air in the bowel wall)
Hirschsprungs Disease
- Delayed passage of meconium
- Diagnosis
  - Contrast enema (not typically done in ED)
    - Look for distal transition point
  - Rectal suction biopsy (DEFINITELY not done in the ED)
    - Gold standard for diagnosis

Bronchiolitis

Commonly caused by RSV
Initial fever and URI
- Progresses to respiratory distress

Croup (laryngotrachealbronchitis)

Commonly caused by parainfluenza
Initial fever and URI
- Progresses to stridor
- Barky cough
Neck xray will show “steeple sign” (subglottic narrowing)
Treatment
- Steroids
- Nebulized epinephrine

Epiglottitis

Commonly caused by Haemophilus influenzae
Classic symptoms
- Fever
- Sore throat
- Drooling
- Muffled voice
Treatment
- Keep the child calm
- Intubation in a controlled environment
- Antibiotics

Additional Reading

Pediatric Abdominal Pain (EM Clerkship)
Peds O – Oxygen, Airway, and Respiratory Disorders (EM Clerkship)

NBME Shelf Review (Part 2) – Trauma

October 7, 2018 / Zack

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Penetrating Abdominal Trauma

Anything below the 4th intercostal space (nipple) is potentially an abdominal injury
- Gunshot wounds to the abdomen
  - Needs immediate exploratory laparotomy
- Stab wounds to the abdomen
  - Needs immediate exploratory laparotomy IF…
    - Hemodynamically unstable
    - Peritonitis on exam (rebound, rigidity, guarding)
    - Organs hanging out of abdomen

Blunt Abdominal Trauma

If the patient is unstable
- Perform FAST exam
If the patient is stable
- CT scan of the abdomen/pelvis with contrast

Basilar Skull Fracture

Bilateral post-auricular ecchymosis (Battle’s Sign)
Raccoon eyes
Hemotympanum
Otorrhea/Rhinorrhea

Tension Pneumothorax

Classic findings
- Hypotension
- Obstructive shock
- Absent breath sounds
- Jugular vein distension (JVD)
Treatment
- Needle decompression
  - 2nd intercostal space
  - Mid-clavicular line
- Tube thoracostomy

Hemothorax

Hypotension
- Hemorrhagic shock
Absent breath sounds
NO jugular vein distension

Cardiac Tamponade

Beck’s Triad
- Hypotension
  - Obstructive shock
- Jugular vein distension
- Muffled heart sounds
Perform bedside ultrasound
- Diastolic collapse of right ventricle (RV)
EKG
- Electrical alterans

Traumatic Aortic Rupture

Rapid deceleration injuries
Tears at ligamentum arteriosum
Widened mediastinum on chest X-Ray

Pulmonary Contusion

Blunt chest trauma
Respiratory distress
- NO paradoxical chest movement with breathing
Chest X-Ray
- Shows non-lobar infiltrates
- Located near location of injury

Additional Reading

Abdominal Trauma (EM Clerkship)
Head Trauma (EM Clerkship)
Thoracic Trauma (EM Clerkship)

NBME Shelf Review (Part 1) – General Concepts

September 30, 2018 / Zack

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General Approach to a Test Question

Read the last sentence of the question
Read the answer choices
THEN read the vignette

Common Scenarios with Quick Answers

Hypotensive patients
- Give a fluid bolus
Altered mental status
- Check a blood glucose
Hypoglycemia
- Orange juice if can swallow safely
- D50 if patient cannot swallow and mildly altered
- IM glucagon if unresponsive
Patient with altered mental status and possible drug overdose
- Give empiric naloxone
Female patients of childbearing age
- Get a pregnancy test
If you need to give contrast for a CT scan (example CTA for pulmonary embolism)
- Need renal function

Hyperkalemia

Common scenarios
- Crush injury
- Severe burns
- End stage renal disease
- Especially if missed dialysis
- Leukemia on chemotherapy
Remember: Don’t give succinylcholine to a patient with hyperkalemia
Common EKG findings on test
- Hyperacute T waves
- Sinusoidal waves
Treatment
- Stabilizes cardiac cell membranes
  - Calcium
- Shifts potassium into the cells
  - Insulin/Glucose
  - Albuterol
  - Sodium Bicarbonate
- Removes potassium
  - Furosemide
  - Dialysis
  - Kayexalate

Hypokalemia

EKG findings
- Flattened T waves
- QTC prolongation
- U waves
At risk for ventricular arrhythmias
Treatment
- Oral potassium replacement
- IV potassium replacement
- Consider magnesium replacement

Hyponatremia

Hypertonic saline IF
- Comatose
- Actively seizing
Otherwise treat with normal saline
Pseuohyponatremia
- Correct the sodium if patient has severe hyperglycemia
- Add 1.6 to sodium for every 100 glucose above normal limit

Hypercalcemia

Symptoms
- “Stones, bones, groans, psychiatric overtones”
Treatment
- IV fluids (promotes excretion) FIRST
- Then calcitonin/bisphosphates

Torsade de Pointes

Common in patients with prolonged QTc
- Hypokalemia
- Hypocalcemia
Treat with magnesium

Additional Reading

Hyperkalemia (EM Clerkship)

When to Stop CPR

September 9, 2018 / Zack

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Why is this Important?

It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal.
Hospitals need to steward their resources to distribute equitable care between its patients

When is it Appropriate to Stop CPR on a Pulseless Patient?

Patient shows signs of irreversible death
- Rigor mortis
- Decapitation
- Rotting/decaying
Patient has dismal prognosis (3 studies discuss this)
- Implementation of the universal BLS termination of resuscitation rule in a rural EMS system
  - Non-EMS witnessed arrest
  - No return of spontaneous circulation prior to transport
  - Only non-shockable rhythms present
- Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation
  - Non-EM witnessed arrest
  - Non-shockable INITIAL rhythm
  - No ROSC despite 3 doses of epinepherine
Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study
- Less than 1% chance of recovery after 46 minutes of resuscitation

Additional Reading

Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.
Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.
Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Abdominal Aortic Aneurysm

September 2, 2018 / Zack

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Kidney Stones are a Diagnosis of Exclusion!!!

History

Risk factors
- Age >60
- Tobacco use
Classic presentations
- Stable with sudden flank/back/abdominal pain or syncope
- Unstable with pallor, hypotension, and ill appearance

Exam

Pulsatile abdominal mass
Unstable vitals

Testing Plan

Labs
- TYPE AND SCREEN
- CBC
- Electrolytes
- Coagulation studies
- Lactic acid
Imaging
- Bedside ultrasound (optimal)
  - Aorta protocol
    - Look for aorta >3cm
  - RUSH protocol
    - Mnemonic: HI-MAP
    - Heart
    - IVC
    - Morrisons Pouch (RUQ)
    - Aorta
    - Pulmonary
- CT scan with IV contrast (less optimal)

Treatment Plan

2 Large bore IVs (16G)
Massive transfusion protocol
- PRBCs
- Platelets
- Fresh Frozen Plasma
Blood pressure management
- Goal Systolic ~100
- Goal MAP ~60-65

Clerkship Pearls

Put AAA in your differential during your presentation for all older patients with back/flank pain
Attempt to perform a bedside ultrasound of the aorta OR find recent CT of the abdomen with normal sized aorta

Additional Reading

Abdominal Aortic Aneurysm Review (Medscape)

Testicular Torsion

August 26, 2018 / Zack

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Kidney Stones are a Diagnosis of Exclusion!!!

Introduction

Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)
Commonly mimics kidney stones

History

Sudden onset pain
- Epididymitis tends to be slower in onset
Flank/lower abdomen/scrotal pain
Frequently causes vomiting
Uncommon in geriatric patients

Exam

Perform a GU exam and look for
- Unequal/horizontal “lie”
- Testicular tenderness
- Swelling
- Absent cremasteric reflex

Testing Plan

Testicular/Scrotal Ultrasound
Urinalysis

Treatment Plan

Consult urology when suspected (even if ultrasound hasn’t returned yet)
Manual detorsion
- “Open the Book”
- Twist medial to lateral
  - Switch directions if no pain relief

Additional Reading

Flank Pain Practice Case (EM Clerkship)
Pediatric Abdominal Pain (EM Clerkship)

Flank Pain and Kidney Stones

August 19, 2018 / Zack

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Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain

Appendicitis
Abdominal Aortic Aneurysm
Ectopic Pregnancy
Testicular/Ovarian Torsion
Kidney Stone

Step 2: Diagnose the Kidney Stone

Option 1- Renal Ultrasound
- Findings consistent with kidney stone diagnosis
  - Hydronephrosis
  - Lack of ureteral jets (in bladder)
  - Kidney stones (poor sensitivity for this)
- Benefits
  - Can be performed at bedside
  - No radiation
Option 2- Non-contrast CT scan
- Great for identifying alternative diagnoses

Step 3: Rule Out Infection

Fevers
Urinalysis with nitrites or bacteria
- If present, patient needs antibiotics

Step 4: Control Symptoms

Analgesics
- NSAIDS (such as ketorolac)
- Opiates
Antiemetics
- Zofran

Step 5: Rule Out Kidney Injury

Elevated creatinine
Solitary kidney

Admission Criteria for Kidney Stones

Coexisting Urinary Tract Infection
Unable to Control Symptoms
Renal Injury/Solitary Kidney

Additional Reading

How to Interpret a Urinalysis (EM Clerkship)

Ventilator Basics

July 8, 2018 / Zack

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Step 1: Start Patient on Volume Assist-Control Ventilation

The most basic mode of ventilation
- Provides a FIXED VOLUME at a FIXED RATE
If the patient over-breaths…
- The ventilator will give another FULL breath
  - Can cause breath stacking and be uncomfortable in patients who are poorly sedated
  - This is not a problem in the ED because patients are typically deeply sedated

Step 2: Know your oxygenation and ventilation goals

Oxygenation (getting oxygen in)
- Try to keep O2 saturation >92%
Ventilation (getting CO2 out)
- Try to keep pCO2 <40

Step 3: Know the 4 Most Important Settings on a Ventilator

FiO2
- The concentration of oxygen
  - Room air is 21% oxygen (or 0.21 on the vent)
  - Maximum is 100% oxygen (or 1.0 on the vent)
PEEP
- The pressure applied during exhalation
  - Typical starting point is 5 (but can be increased significantly)
- “Recruits” and opens alveoli
Tidal Volume
- The volume of air moved during each cycle of the vent
Respiratory Rate
- How fast the ventilator cycles/breaths for the patient

Step 4: Improving the patient’s OXYGENATION

FiO2
- Increases the amount of oxygen present for exchange in non-damaged alveoli
PEEP
- Increases the number of alveoli available to exchange oxygen

Step 5: Improving the patient’s VENTILATION

FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)
Increasing either of these will improve ventilation

BONUS

Patients with COPD/asthma
- Have tendency to not get full breath out (“breath stacking”)
  - “Plateau pressures” will increase above 30
    - Can damage alveoli
    - Can cause pneumothorax
- Treat by increasing the I:E ratio
  - Quick inhalation
  - Longggggggggggggg exhalation

Additional Reading

Breathing (EM Clerkship)
Dominating the Vent Part 1 (EMCrit)
Dominating the Vent Part 2 (EMCrit)

Rabies Prophylaxis

June 24, 2018 / Zack

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Introduction

What is rabies?
- A very rare and aggressive encephalitis
- Global impact with exception of UK/Australia
Animals whose bites/scratches may require prophylaxis
- Bats
- Dogs, Cats, Ferrits
- Other carnivorous animals
- Foxes, Coyotes, Skunks, Raccoons
Post exposure prophylaxis
- Both Rabies vaccine and immunoglobulin

When Do You Give Rabies Prophylaxis?

Step 1: Bitten or scratched by domesticated pet?
- Immunization status of pet does not matter
- Animal must be monitored
- Give prophylaxis if animal develops encephalitis
Step 2: Bitten or scratched by wild animal?
- If animal is captured it can be sacrificed and tested
- Give prophylaxis the animal is not captured and is a potential carrier
Step 3: Possible bat scratch/bite?
- Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”
Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)
- Reptiles
- Birds
- Small rodents
- Rabbits/Hares
- Livestock
Step 5: How to give prophylaxis
- Only contraindication is severe egg allergy
- Can be given to babies/pregnant women/etc
- Rabies immunoglobulin
  - Give ONCE in the department
  - Inject as much as possible around wound
- Rabies vaccine
  - Give first day
  - Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)

Pearls

It doesn’t matter if the bite/scratch was provoked or unprovoked
It doesn’t matter where on the body the patient received the bite/scratch
It’s a universally fatal disease
No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits
The NNT is >300,000 (but we still do it)

Additional Reading

Rabies Guidelines (CDC)

Occupational Exposures

June 17, 2018 / Zack

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The only chief complaint that you are guaranteed to eventually have to manage in a colleague

Respiratory Exposures

Meningococcus (meningococcemia, meningitis, etc)
- Give prophylaxis (ceftriaxone) if…
  - Intubated a pt without a mask
  - Suctioned a pt without a mask
  - Performed mouth to mouth resuscitation
Tuberculosis
- CDC recommends testing if exposed
  - Treat if positive
- CDC recommends prophylaxis in..
  - Little children, HIV positive, immunosuppressed

Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)

Hepatitis B
- Test source patient
  - If positive, 1-30% risk of transmission with needle stick exposure
    - (Mucous membrane/broken skin exposures are much lower risk)
- Test exposed colleague for anti-HepB surface antibody level
- If source patient is positive and coworker is not fully immunized…
  - Treatment
    - Hep B Vaccine
    - Hep B Immunoglobulin
Hepatitis C
- Test source patient
  - If positive, 2% risk of transmission with needle stick exposure
    - (Mucous membrane/broken skin exposures are much lower risk)
- Get baseline hepatic function labs (LFTs) in coworker
- Follow-up on outpatient basis, no prophylaxis available
HIV
- Test source patient with rapid HIV test
  - If positive, 1/300 risk of transmission with needle stick exposure
    - Transmission risk increases if: bloody exposure, large needle bore
    - (Mucous membrane/broken skin exposures are much lower risk)
- Generally recommend prophylaxis if source is positive
  - Prophylaxis is potentially curative if given at exposure
  - Counsel on safe sex practices
  - Counsel on common treatment side effects
    - GI symptoms, headaches, fatigue

Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Breast Complaints

June 10, 2018 / Zack

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All breast complaints are cancer until proven otherwise!!!

History

Increased risk of breast cancer
- Family history of breast cancer (especially 1st degree)
- Delayed childbearing (no children until after 30)
- Age >50
Associated with menstrual cycle

Exam

Asymmetric appearance of breasts
Palpable mass
- Red Flags
  - Non-mobile
  - Overlying skin changes
  - Lymphadenopathy
  - Located in upper/outer quadrant of breast

Differential Diagnoses

Red/inflamed/painful breast
- Postpartum engorgement
  - Treat with warm compresses, continue breastfeeding/pumping, massage
- Infection (“Mastitis”)
  - Treat with antibiotics and continue breastfeeding
- Abscess
  - Treat with needle aspiration
  - Refer to breast surgeon
Non-inflamed breast pain
- Fibrocystic changes
  - Associated with menses
  - Treat with supportive bra
Breast mass
- Fibroadenoma
  - Slippery/mobile
- Fibrocystic changes
Nipple discharge
- Red flags
  - Unilateral discharge
  - Bloody discharge

Additional Reading

Breast Cancer Screening Guidelines (CDC)

Neonatal Conjunctivitis

June 3, 2018 / Zack

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The 3 Worst Causes of Neonatal Conjunctivitis

Gonorrhea
- Causes corneal ulcers and sepsis
- Red flags
  - 1st week of life
  - Copious purulent drainage
- Diagnose with cultures
- Treatment
  - Cefotaxime (3rd generation cephalosporin)
  - Admit
Chlamydia
- Occurs in 1st month of life
- Treat with PO erythromycin
HSV
- Can disseminate to the brain
- Red flags
  - Mother tested positive (or had active lesions)
  - Vesicles on baby
- Treatment
  - IV acyclovir
  - Admit

Other Causes of Conjunctivitis

Viral/other bacterial
- Treat with erythromycin ointment
Chemical conjunctivitis
- Caused by eye drops given after birth
Dacryostenosis (closed eye ducts)
- Watery eyes from tears not draining

Additional Reading

Neonatal Conjunctivitis (CDC)

Subarachnoid Hemorrhage

May 20, 2018 / Zack

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History

Sudden and maximal in onset
Compared to previous headaches
Family history of aneurysm
Associated Symptoms
- Photophobia
- Visual Changes
- Neck Stiffness

Exam

Full neuro examination
- Cranial nerves
- Visual fields
- Speech
- Cerebellar (finger-nose)
- Motor
- Sensation
- Gait

Testing Plan

Non-contrast head CT
- Excellent sensitivity <6 hours from onset
Lumbar puncture
- >100 RBCs in tube 4
  - Can be difficult to interpret after a traumatic lumbar puncture
- Xanthochromia

Treatment Plan

Prevent rebleeding
- Keep SBP <140
  - Nicardipine
- Reverse any anticoagulants
  - Vitamin K
  - Prothrombin complex concentrate
  - Fresh frozen plasma
Prevent vasospasm
- Nimodipine PO
Prevent delayed ischemia
- Avoid hyperthermia
- Avoid hyper/hypoglycemia
Prevent seizures
- Levetiracetam (aka Keppra)

Additional Reading

Ottawa Subarachnoid Hemorrhage (MDCalc)

Blood in the Diaper

May 13, 2018 / Zack

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The 4 Most Common Causes of Blood in Diaper

Urinary crystals
- Will be guaiac negative
- Common in first few weeks of life
Vaginal bleeding
- Common in newborn females as they withdraw from maternal estrogen
Maternal blood
- Swallowed during birthing process
- Breastfeeding with cracked/bleeding nipples
Anal fissures
- Common and will improve on its own

Basic Approach

Step 1: Check if guaiac positive
- If negative, it’s not blood
- Urinary crystals, food coloring, etc
Step 2: Consider vaginal bleeding
Step 3: Perform apt test
- Diagnoses maternal blood
Step 4: Check for anal fissure
- Self resolve
Step 5: Expand the differential diagnosis
- Necrotizing enterocolitis
- Intussusception
- Cow’s milk allergy
- Colitis
- Red Food Dye

Additional Reading

Neonate With Bloody Stool (Pediatric EM Morsels)

Nutritional Emergencies

May 6, 2018 / Zack

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Consider In High Risk Patients

Alcoholics
GI disorders
Eating disorders
Starvation/poor diet
Extremes of age

Thiamine (B1) deficiency

Causes damage to neurons and cardiac myocytes
Manifestations
- Dry beriberi
  - Neuropathy
  - Paresthesias
- Wernicke’s encephalopathy
  - Ophthalmoplegia
  - Ataxia
  - Altered mental status
- Korsakoff syndrome
  - Ophthalmoplegia, ataxia, altered mental status
  - PLUS
  - Confabulation
  - Memory loss
- Wet beriberi
  - Heart failure from cardiac damage
Treatment
- High dose thiamine

Niacin (B3) Deficiency

“Pellagra”
Clinical Triad
- Diarrhea
- Dementia
- Dermatitis
  - Scaly rash
    - Neck
    - Dorsum of hands
Treatment
- Vitamin B3

Folate (B9) Deficiency

Megaloblastic anemia
Treatment
- Folate

B12 Deficiency

Classically occurs in vegans (in addition to the previous high risk groups)
Manifestations
- Megaloblastic anemia
- PLUS
- Neurologic complaints
  - Subacute combined (posterior and lateral column) degeneration of spinal cord
    - Posterior columns
      - Impaired vibratory sensation and propioception
    - Lateral columns
      - Sensory loss
      - Motor weakness

Additional Reading

Thiamine Deficiency: Pearls and Pitfalls (emDOCs)

Complications of Myocardial Infarction

April 29, 2018 / Zack

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Mnemonic: DARTH VADER

Death

Arrhythmia

ACS patients need to be placed on cardiac monitor
Frequently degenerate into non-perfusing rhythms

Rupture of Ventricle

Occur within a few days of myocardial infarction
Rapid decompensation
Bedside ultrasound will show pericardial effusion and tamponade

Tamponade

Multiple etiologies
- Rupture of ventricle (see above)
- Pericarditis
Becks Triad
- Jugular vein distension
- Muffled heart sounds
- Hypotension
Diagnosed with bedside ultrasound
Treatment is pericardiocentesis

Heart Failure

Occurs in approximately 1/3 post-MI patients
Leads to cardiogenic shock
Treatment
- Fluid bolus
- Vasopressors (esp. norepinephrine)
- Inotropes (milrinone, dobutimine)
- Left ventricular assist devices
- Intra-aortic balloon pumps

Valve Failure/Rupture

Rapid decompensation (similar to ventricular wall rupture)
PLUS
New heart murmur
Surgical emergency

Aneurysm

A classic STEMI mimic
Large Q waves with ST segment elevation (IN ASYMPTOMATIC PATIENT)

Dresslers Syndrome/Pericarditis

Rule out cardiac tamponade
Treatment
- NSAIDS/colchicine

Embolism

Occur in damaged ventricles and in cardiac aneurysms
Require anticoagulation

Recurrence

Emphasize lifestyle management

Additional Reading

Approach to STEMI (EM Clerkship)

tPA Basics

April 15, 2018 / Zack

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My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.

Introduction

tPA is one of the core treatments for acute ischemic stroke
The history of tPA is filled with controversy
Mechanism
- Activates plasminogen to plasmin
- Plasmin breaks down fibrin

Contraindications to tPA

Objective contraindications
- Hypoglycemia
- Blood pressure (>185/110)
- Hemorrhagic CVA seen on head CT
Other common contraindications
- Mnemonic: ABCDE
  - A– History of Aneurysm, AVMs (or other intracranial structural problems)
  - B– Actively Bleeding
  - C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months
  - D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)
  - E– Endocarditis
Relative Contraindications (Discuss with neurology)
- Minimal or resolving symptoms
- Recent surgery or major trauma
- Seizure
- Recent lumbar puncture
- Pregnancy
- Active pericarditis
3-4.5 Hour Contraindication Addons
- A- Age >80
- B- Bad Stroke (NIH >25)
- C- CT shows multilobar stroke
- D- Bleeding diasthesis (even if coagulation studies normal)
- E- Ever had old stroke or diabetes

Additional Reading

tPA Contraindications for Ischemic Stoke (MDCalc)
2018 Stroke Management Guidelines (AHA/ASA)

Sepsis

April 1, 2018 / Zack

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Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

Introduction

Sepsis is bad and needs to be treated aggressively
Confusion around multiple conflicting guidelines and requirements
- Surviving Sepsis Campaign recommendations
- CMS requirements
- Sepsis-3
- SOFA/SIRS/qSOFA
- Institutional protocols

Sepsis-3 Proposed Recommendations

Screen for sepsis by applying qSOFA instead of SIRS criteria
- qSOFA criteria
  - Altered mental status
  - Tachypnea
  - Hypotension
- SIRS criteria
  - Tachycardia
  - Tachypnea
  - Leukocytosis
  - Hyper/hypothermia
- qSOFA criteria miss cases of sepsis (too specific)
- SIRS calls everything “sepsis” even if the patient is fine (too sensitive)
Change definition of “Sepsis” (no more SIRS plus source)
- New definition
  - Source of infection
  - PLUS
  - Organ disfunction
    - Determined by SOFA score (different purpose than qSOFA)
Eliminate the term “severe sepsis” completely
Redefine “septic shock”
- Persistent hypotension
- OR
- Lactic acid >4

Current Approach to Sepsis

Step 1- If the patient has SIRS plus source
- Get labs including a lactic acid
Step 2- If the patient has organ dysfunction
- Diagnose sepsis
Step 3- If the patient has sepsis
- Order broad spectrum antibiotics
- Order blood cultures
- Needs to be completed in <3 hours
Step 4- If the patient has persistent hypotension or lactate >4
- Diagnose septic shock
Step 5- If they have septic shock
- Give 30ml/kg crystalloid bolus
- Start vasopressers if hypotension doesn’t improve with bolus

Additional Reading

CMS Sepsis Core Measures (ACEP)
Sepsis-3 Recommendations (EMJ)
Surviving Sepsis Campaign (SCCM)

Neonatal Jaundice

March 25, 2018 / Zack

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Physiology

RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin
Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin
Conjugated (direct) bilirubin -> Eliminated in stool

Causes of Hyperbilirubinemia

Increased RBC turnover
- Sepsis
- Rh incompatibility
- RBC disorders
- Maternal diabetes
- Scalp hematoma
Decreased/slow conjugation by the liver
- Peaks around day 5 of life
- Congenital liver disorders
  - Gilbert/Crigler Najjar Syndromes
- Breast milk jaundice
  - Breast milk inhibits conjugation of bilirubin
Decreased excretion
- Bowel obstruction
- Breast feeding failure (dehydration)
  - Decreased stool output results in reabsorbed bilirubin

Kernicterus

Brain damage from severe hyperbilirubinemia (>25 mg/dL)
Compare measured bilirubin to established nomogram
Treatment is phototherapy
- (Worst case scenarios require exchange transfusion)

Additional Reading

Approach to Neonatal Jaundice (emDOCs)

Thrombocytopenia

March 11, 2018 / Zack

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Clinical Presentation

Incidental finding on routing CBC
Petechiae/purpura
Mucosal bleeding
Epistaxis
Gingival bleeding
Hematuria
Vaginal bleeding

5 Major Causes of Thrombocytopenia

Thrombotic Thrombocytopenic Purpura (TTP)
- Clinical presentation (pentad)
  - Thrombocytopenia
  - Fever
  - Microangiopathic hemolytic anemia
    - “schistocytes”
  - Neurologic abnormalities
  - Renal dysfunction
- Physiology
  - Low ADAMTS13 results in impaired vWF breakdown
    - Widespread “platelet plugs”
- Treatment
  - Plasma exchange
Hemolytic Uremic Syndrome (HUS)
- Clinical presentation
  - Pediatric patient with bloody diarrhea
  - Renal dysfunction
  - Thrombocytopenia
- Treatment
  - Supportive care
Heparin Induced Thrombocytopenia (HIT)
- Clinical presentation
  - Recent heparin administration
  - Acute thrombocytopenia (<150) or 50% decrease in platelets
- Treatment
  - Stop heparin and choose different anticoagulant
Disseminated Intravascular Coagulation (DIC)
- Clinical presentation
  - Patient septic, severe trauma, or otherwise critically ill/injured
  - Multiple abnormal labs
    - Increased PT/PTT
    - Increased D-dimer
    - Increased fibrinogen degradation products
- Treat underlying trigger
Immune/Idiopathic Thrombocytopenic Purpura (ITP)
Common condition
- Relatively benign
Treatment
- Steroids
- Occasionally platelet transfusion
Other causes
- HIV
- Hepatitis
- Heavy alcohol use

Additional Reading

Thrombocytopenia: An ED Approach (emDOCs)

Febrile Seizures

Pediatric Abdominal Pain

Bronchiolitis

Croup (laryngotrachealbronchitis)

Epiglottitis

Additional Reading

Penetrating Abdominal Trauma

Blunt Abdominal Trauma

Basilar Skull Fracture

Tension Pneumothorax

Hemothorax

Cardiac Tamponade

Traumatic Aortic Rupture

Pulmonary Contusion

Additional Reading

General Approach to a Test Question

Common Scenarios with Quick Answers

Hyperkalemia

Hypokalemia

Hyponatremia

Hypercalcemia

Torsade de Pointes

Additional Reading

Why is this Important?

When is it Appropriate to Stop CPR on a Pulseless Patient?

Additional Reading

Kidney Stones are a Diagnosis of Exclusion!!!

History

Exam

Testing Plan

Treatment Plan

Clerkship Pearls

Additional Reading

Kidney Stones are a Diagnosis of Exclusion!!!

Introduction

History

Exam

Testing Plan

Treatment Plan

Additional Reading

Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain

Step 2: Diagnose the Kidney Stone

Step 3: Rule Out Infection

Step 4: Control Symptoms

Step 5: Rule Out Kidney Injury

Admission Criteria for Kidney Stones

Additional Reading

Step 1: Start Patient on Volume Assist-Control Ventilation

Step 2: Know your oxygenation and ventilation goals

Step 3: Know the 4 Most Important Settings on a Ventilator

Step 4: Improving the patient’s OXYGENATION

Step 5: Improving the patient’s VENTILATION

BONUS

Additional Reading

The only chief complaint that you are guaranteed to eventually have to manage in a colleague

All breast complaints are cancer until proven otherwise!!!

Mnemonic: DARTH VADER

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

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