123 - BUKU SUDIRMAN(SIRS) and Sepsis SIRS diagnosis requires two or more to be present Body...

Quick Hits in Emergency Medicine

Brandon AllenLatha GantiBobby Desai

123

Brandon Allen • Latha Ganti Bobby Desai


Brandon Allen , MD Department of Emergency MedicineUniversity of Florida College of Medicine Gainesville , Florida USA

Latha Ganti , MD, MS, MBA, FACEP Departments of Emergency Medicine and Neurological Surgery Center for Brain Injury Research and Education University of Florida College of Medicine Gainesville , Florida USA

Bobby Desai , MD, FACEP Department of Emergency MedicineUniversity of Florida College of Medicine Gainesville , Florida USA

ISBN 978-1-4614-7036-6 ISBN 978-1-4614-7037-3 (eBook) DOI 10.1007/978-1-4614-7037-3 Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2013943125

© Springer Science+Business Media New York 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of transla-tion, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimi-lar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accu-rate at the date of publication, neither the authors nor the editors nor the pub-lisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

To our families— Nila, Owen, and Katie [Brandon Allen] Thor, Tej, Trilok, Karthik, Pratik, Mom and Dad [Latha Ganti] Jayden, Dylan, Shayan, and Alpa [Bobby Desai]

for the time this endeavor took away from them

To our patients and colleagues— from whom we learn everyday

vii

Contents

1 ACLS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1ACLS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2ACLS Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . 3ACLS PEA and Asystole . . . . . . . . . . . . . . . . . . . . . . 4ACLS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2 Intubation, Airway, and Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . 7Intubation/Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . 11

3 Sepsis and Resuscitation . . . . . . . . . . . . . . . . . . . . . . . 13Systemic Inflammatory Response Syndrome (SIRS) and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Early Goal-Directed Therapy . . . . . . . . . . . . . . . . . . 15Hemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

4 Pulmonary Decision Rules and COPD . . . . . . . . . . 17CURB + CURB-65 Community-Acquired Pneumonia (CAP) Scores. . . . . . . . . . . . . . . . . . . . . . 18Pulmonary Embolism Rule-Out Criteria (PERC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Wells Criteria (Pulmonary Embolism) . . . . . . . . . . . 20COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

5 Fluid and Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . 23Hyperkalemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

viii Contents

Hypernatremia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Electrolyte Equations . . . . . . . . . . . . . . . . . . . . . . . . . 30

6 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31CSF Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32San Francisco Syncope Rule . . . . . . . . . . . . . . . . . . . 33TPA for Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Stroke and Headache . . . . . . . . . . . . . . . . . . . . . . . . . 35Vertigo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

7 Trauma and ATLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ATLS Primary Survey. . . . . . . . . . . . . . . . . . . . . . . . . 38ATLS History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Lethal Triad of Trauma . . . . . . . . . . . . . . . . . . . . . . . . 40GCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Trauma Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Shock in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Hemorrhage Classifications . . . . . . . . . . . . . . . . . . . . 44Burn Classifications . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

8 Head CT Decision Rules and Intracranial Hemorrhage . . . . . . . . . . . . . . . . . . 47Mild Head Injury/TBI. . . . . . . . . . . . . . . . . . . . . . . . . 48Nexus-II Head CT Decision Rule . . . . . . . . . . . . . . . 49Canadian Head CT Decision Rule . . . . . . . . . . . . . . 50New Orleans Criteria . . . . . . . . . . . . . . . . . . . . . . . . . 51Reading a Head CT. . . . . . . . . . . . . . . . . . . . . . . . . . . 52Epidural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . 53Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . 54Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . 55

9 Cervical Spine Injury and Decision Rules . . . . . . . . 57Cervical Spine Alignment and Allowable Distances . . . . . . . . . . . . . . . . . . . . . . 58NEXUS Criteria for C-Spine . . . . . . . . . . . . . . . . . . . 59Canadian C-Spine Rule . . . . . . . . . . . . . . . . . . . . . . . 60

10 CXR Interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . 61CXR Interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . 62

ixContents

11 Orthopedics and Decision Rules . . . . . . . . . . . . . . . . 65Ottawa Ankle and Foot Rules . . . . . . . . . . . . . . . . . . 66Ottawa Knee Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Orthopedic Disposition. . . . . . . . . . . . . . . . . . . . . . . . 69

12 Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Differential Diagnosis of Chest Pain. . . . . . . . . . . . . 72Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . 73STEMI vs Benign Early Repolarization (BER) . . . . 74Left Ventricular Hypertrophy (LVH) . . . . . . . . . . . . 75New Onset A-fib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Left Atrial Hypertrophy (LAH) . . . . . . . . . . . . . . . . 77Sgarbossa’s Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Brugada Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Brugada Criteria for V-Tach. . . . . . . . . . . . . . . . . . . . 81Wellens’ Sign/Syndrome . . . . . . . . . . . . . . . . . . . . . . . 82

13 GI Bleeding/Hemorrhage. . . . . . . . . . . . . . . . . . . . . . 83GI Bleeding/Hemorrhage. . . . . . . . . . . . . . . . . . . . . . 84Glasgow-Blatchford Score for Upper GI Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . 85

14 Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87ITP/TTP/DIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

15 Toxicology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Toxidromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Ingestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Acetaminophen Nomogram. . . . . . . . . . . . . . . . . . . . 92Toxicology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Serotonin Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 96Coma “AEIOU TIPS”. . . . . . . . . . . . . . . . . . . . . . . . . 97

16 Ultrasound and Pregnancy . . . . . . . . . . . . . . . . . . . . . 99Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

17 The Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103The Red Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

x Contents

18 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Pediatric Vital Signs. . . . . . . . . . . . . . . . . . . . . . . . . . . 106Kocher Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Salter-Harris Fractures (SALTR) . . . . . . . . . . . . . . . 109Pediatric Ossification Centers . . . . . . . . . . . . . . . . . . 110Pediatric GCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Bilirubin Nomogram . . . . . . . . . . . . . . . . . . . . . . . . . . 112Pediatric Head CT Criteria . . . . . . . . . . . . . . . . . . . . 113Sick Neonate “THE MISFITS” . . . . . . . . . . . . . . . . . 114Pediatric Fever Neonate . . . . . . . . . . . . . . . . . . . . . . . 115Pediatric Fever (1–2 Month Old Infant). . . . . . . . . . 116Pediatric Fever (2–3 Month Old Infant). . . . . . . . . . 117Pediatric Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . 118

19 Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Modified Centor (McIsaac) Criteria for Evaluation of Pharyngitis . . . . . . . . . . . . . . . . . . . 120Retropharyngeal Abscess . . . . . . . . . . . . . . . . . . . . . . 121Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

20 Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

21 Infusions, Pressors, and RSI . . . . . . . . . . . . . . . . . . . . 125Medications and Infusions . . . . . . . . . . . . . . . . . . . . . 126

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

1B. Allen et al., Quick Hits in Emergency Medicine, DOI 10.1007/978-1-4614-7037-3_1, © Springer Science+Business Media New York 2013

ACLS

ACLS .............................................................. 2

ACLS Bradycardia .............................................. 3

ACLS PEA and Asystole ................................... 4

ACLS ..................................................................... 5

1

2 ACLS

AC

LS

Yes

. . .

Def

ibril

late

!

Uns

tabl

e

Ven

tric

ular

fibr

illat

ion

puls

eles

s ve

ntric

ular

tach

ycar

dia?

No.

. .

2´ C

PR

+m

eds

+/–

defib

rilla

te

Sta

ble

vent

ricul

arta

chyc

ardi

a

Car

diov

ersi

on:

med

s or

joul

es

PS

VT

Vag

alm

aneu

vers

?A

deno

sine

6, 1

2, 1

2 m

g

Alte

red

men

tal s

tatu

sch

est p

ain

hypo

tens

ion

dysp

nea

O2

to v

ital

orga

ns=

==

3ACLS Bradycardia

AC

LS

Bra

dyca

rdia

HR

< 6

0?1˚

AV

blo

ck?

2˚ A

V b

lock

?3˚

AV

blo

ck?

Bra

dyca

rdia

Obs

erve

Tra

nscu

tane

ous

paci

ng

Whi

le w

aitin

gco

nsid

er:

Atr

opin

eE

pine

prin

eD

opam

ine

Isop

rote

reno

l

Alte

red

men

tal s

tatu

sch

est p

ain

hypo

tens

ion

dysp

nea

=O

2 to

vita

l or

gans

Asy

mpt

omat

icor

ade

quat

epe

rfus

ion

?

Con

side

rS

ympt

omat

icor

poo

rpe

rfus

ion?

PA

CE

=

4 ACLS PEA and Asystole

ACLS PEA and Asystole

No pulse orrhythm notshockable?

PEAasystole

Begin post-resuscitation

care andconsider therapeutic

hypothermia

Search fortreatable causes

(H’s and T’s)

No pulse? Pulse?

Resume CPR for 5 cyclesgive

Epinephrine (every 5 min)or

Vasopressin (1st dose)

Resume CPR for 5 cyclesgive

Epinephrine (every 5 min)or

Vasopressin (1st dose)

=

5ACLS

V-F

ib•

Wit

ness

ed—

shoc

k

− U

nwit

ness

ed—

2 m

in C

PR

+

−

med

s→sh

ock

Ven

tric

ular

tac

hyca

rdia

/par

oxys

mal

•

supr

aven

tric

ular

tac

hyca

rdia

: sta

ble

or

unst

able

? E

lect

rom

echa

nica

l dis

soci

atio

n/pu

lsel

ess

• el

ectr

ical

act

ivit

y? T

hink

H’s

and

T’s

H

eart

blo

ck/b

rady

card

ia: h

ypot

ensi

ve?

• T

hree

thi

ngs

that

impr

ove

surv

ival

:•

Ear

ly s

hock

in V

F

−

Goo

d co

mpr

essi

ons

−

Les

s ve

ntila

tion

−

Ade

nosi

ne Q

uick

Hit

s:•

Nev

er g

ive

if H

R <

150

− N

ever

giv

e if

irre

gula

r (A

- fi b)

− N

ever

giv

e if

vag

al m

aneu

vers

wor

k to

−sl

ow H

R

Bew

are

h/o

CH

F, C

OP

D, W

PW

−

H’s

T

’s

Hyp

ovol

emia

C

ardi

ac t

ampo

nade

Hyp

oxia

To

xins

Hyp

er o

r hy

poka

lem

ia

Thr

ombo

sis

(car

diac

or

pulm

onar

y)

Hyd

roge

n io

n (a

cido

sis)

Te

nsio

n pn

eum

otho

rax

Hyp

ogly

cem

ia

Trau

ma

AC

LS


Intubation, Airway, and Mechanical Ventilation

Intubation/Airway .......................................... 8

Mechanical Ventilation ....................................... 11

2

8 Intubation/Airway

Intu

bati

on/A

irw

ay

7 P

’ s

−P

repa

re =

equ

ipm

ent

−

P re

trea

t =

dru

gs

−

P os

itio

n =

sni

f fi ng

pos

itio

n (i

f po

ssib

le)

−

P re

oxyg

enat

e =

100

% p

ulse

ox

(con

side

r ap

neic

ox

ygen

atio

n du

ring

dir

ect

lary

ngos

copy

) [1

]

−P

aral

yze

= d

rugs

−P

lace

men

t =

tub

e th

roug

h co

rds

−

P os

itio

n =

con

fi rm

wit

h E

TC

02 t

hen

CX

R

1.

Wei

ngar

t, S

and

Lev

itan

, R. P

reox

ygen

atio

n an

d pr

even

tion

of

desa

tura

tion

dur

ing

emer

genc

y ai

rway

man

agem

ent.

Ann

Em

erg

Med

. 201

2 M

ar; 5

9(3)

:165

–175

9Intubation/Airway

Intu

bati

on/A

irw

ay

Dif

fi cul

t to

Bag

Obe

sity

•

Bea

rd

• N

o te

eth

• O

ld/e

lder

ly (

>55

) •

Dif

fi cul

t to

Int

ubat

e (L

EM

ON

S)

•

L oo

k ex

tern

ally

Bea

rd?

Trau

ma?

Obe

sity

?

− •

E va

luat

e

3 fi n

gers

mou

th o

peni

ng

−

3 fi n

gers

chi

n to

hyo

id

−

2 fi n

gers

hyo

id t

o th

yroi

d

− •

M al

lam

pati

Cla

sses

I–I

V

−

• O

bstr

ucti

on

•

N ec

k m

obili

ty

Cer

vica

l pre

caut

ions

− •

S atu

rati

ons

Oxy

gen

rese

rve

−

10 Intubation/Airway

Intu

bati

on/A

irw

ay

Gra

de I

Gra

de II

Gra

de II

IG

rade

IV

Cor

mac

k-Le

hane

airw

ay g

rade

s

Ada

pted

fro

m: C

orm

ack

RS,

Leh

ane

J. D

if fi c

ult

trac

heal

int

uba-

tion

in

obst

etri

cs. C

orm

ack-

Leh

ane

Air

way

Gra

des

Ana

esth

esia

19

84; 3

9: 1

105–

11

Ada

pted

fro

m:

Mal

lam

pati

SR

, G

att

SP,

Gug

ino

LD

, et

al.

A c

linic

al s

ign

to p

redi

ct d

if fi c

ult t

rach

eal i

ntub

atio

n: a

pro

spec

-ti

ve s

tudy

. Can

Ana

esth

Soc

J 1

985;

32:4

29–3

4

III

IIIIV

Mal

lam

pati

scor

e

11Mechanical Ventilation

Mec

hani

cal V

enti

lati

on

Nor

mal

lu

ngs

Ast

hma/

CO

PD

A

RD

S H

ypov

olem

ia

Tid

al v

olum

e (m

L/k

g)

8.0

6.0

6.0

8.0

RR

10

–12

5–8

10–1

2 10

–12

I/E

rat

io

1:2

1:4

1:2

1:2

PE

EP

4.

0 4.

0 4–

15

0–4

FiO

2 1.

0 1.

0 1.

0 1.

0


Sepsis and Resuscitation

Systemic Inflammatory Response Syndrome (SIRS) and Sepsis ............................. 14

Early Goal-Directed Therapy ............................ 15

Hemodynamics .................................................... 16

3

14 Systemic Inflammatory Response Syndrome

Syst

emic

In fl

amm

ator

y R

espo

nse

Synd

rom

e (S

IRS)

and

Sep

sis

SIR

S di

agno

sis

requ

ires

tw

o or

mor

e to

be

pres

ent

Bod

y te

mpe

ratu

re <

36 o

r >

38

HR

>90

RR

>20

or

PaC

O 2 <

32

WB

C <

4,00

0 or

>12

,000

OR

ban

ds >

10 %

Seps

is is

SIR

S w

ith

clin

ical

con

fi rm

ed / s

uspe

cted

infe

ctio

n

Seve

re s

epsi

s is

sep

sis

and

hypo

tens

ion

( tha

t re

spon

ds t

o fl u

ids )

, or

gan

dysf

x , h

ypop

erfu

sion

Sept

ic s

hock

is s

ever

e se

psis

wit

h re

frac

tory

hyp

oten

sion

aft

er fl

uid

resu

scit

atio

n

15Early Goal-Directed Therapy

Ear

ly G

oal-

Dir

ecte

d T

hera

py

Giv

e A

ntib

ioti

cs E

arly

!

Goa

l T

hera

py

CV

P 8

–12

Flu

id b

olus

500

cc

Q30

min

CV

P g

oal 1

2–15

if m

echa

nica

lly v

enti

late

d

MA

P >

65

Beg

in p

ross

ors/

vaso

acti

ve a

gent

s Sc

vO 2 >

70

Tran

sfus

e to

Hct

>30

Star

t in

otro

pe (

dobu

tam

ine)

A

dapt

ed f

rom

Riv

ers

E e

t al

. Ear

ly g

oal-

dire

cted

the

rapy

in t

he t

reat

men

t of

sev

ere

seps

is a

nd s

epti

c sh

ock.

N E

ngl J

. Med

. 20

01 N

ov 8

;345

(19)

:136

8–77

16 Hemodynamics

Hem

odyn

amic

s

•

Art

eria

l con

tent

= (

1.34

)(H

gb)(

arte

rial

sat

.)

Ven

ous

cont

ent

= (

1.34

)(H

gb)(

SVO

•

2 %)

A-V

O

• 2 D

iff.

= A

rt. C

onte

nt −

Ven

ous

cont

ent

O

• 2 -

Del

iver

y =

(A

rt. C

onte

nt)(

C.O

.)(1

0)

O

• 2 -

Con

sum

ptio

n =

(A

-V O

2 Dif

f)(C

.O.)

(10)

Ext

ract

ion

= A

-V O

•

2 Dif

f/A

rter

ial C

onte

nt ×

100


Pulmonary Decision Rules and COPD

CURB + CURB-65 Community-Acquired Pneumonia (CAP) Scores .................................... 18

Pulmonary Embolism Rule-Out Criteria (PERC) ................................................... 19

Wells Criteria (Pulmonary Embolism) .............. 20

COPD .................................................................... 21

4

18 CURB + CURB-65 Community-Acquired Pneumonia

CU

RB

+ C

UR

B-6

5 C

omm

unit

y-A

cqui

red

Pne

umon

ia (

CA

P)

Scor

es

Cha

ract

eris

tic

CU

RB

-65

poin

ts

CU

RB

poi

nts

C on

fusi

on

1 1

U re

a (B

UN

>19

) 1

1

R es

pira

tory

rat

e >

30/m

in

1 1

B lo

od p

ress

ure

(sys

tolic

B

P<

90 o

r di

asto

lic B

P <

60)

1 1

Age

>65

1

N/A

Ada

pted

fro

m L

im W

S, v

an d

er E

erde

n M

M, L

aing

R, e

t al

. (20

03)

De fi

ning

com

mun

ity

acqu

ired

pne

umon

ia S

ever

ity

on

pres

enta

tion

to

hosp

ital

: a in

tern

atio

nal d

eriv

atio

n an

d va

lidat

ion

stud

y. T

hora

x 58

(5):

377–

82. N

P

atie

nts

wit

h C

UR

B-6

5 =

2 o

r C

UR

B =

1 s

houl

d be

con

side

red

for

inpa

tien

t car

e or

inte

nsiv

e ou

tpat

ient

tx; i

f hyp

oxia

or

hyp

oten

sion

, adm

it r

egar

dles

s of

sco

re

19Pulmonary Embolism Rule-Out Criteria (PERC)

Pul

mon

ary

Em

bolis

m R

ule-

Out

Cri

teri

a (P

ER

C)

PE

RC

( B

RE

AT

HS )

cri

teri

a

B—

Blo

od in

spu

tum

R—

Roo

m a

ir s

at <

95 %

E—

Est

roge

n or

hor

mon

e us

e

A—

Age

>50

yea

rs

T—

Thr

ombo

sis

in p

ast

(DV

T, P

E)

or p

ossi

ble

DV

T/s

wol

len

calf

H—

Hea

rt r

ate

>10

0 be

ats/

min

S—Su

rger

y in

pas

t 4

wee

ks

Incl

usio

n cr

iter

ia

Susp

icio

n of

PE

low

eno

ugh

that

clin

icia

n w

ould

be

con fi

dent

eno

ugh

to e

xclu

de if

the

y ha

d no

rmal

D

-dim

er (

low

-ris

k gr

oup

whi

ch c

ompr

ises

a p

opul

atio

n w

ith

8 %

PE

ris

k)

Pat

ient

(s)

wit

h dy

spne

a B

UT

PE

was

not

fel

t to

be

the

mos

t lik

ely

diag

nosi

s (v

ery

low

-ris

k gr

oup—

2 %

ove

rall

PE

ris

k)

Exc

lusi

on c

rite

ria

DO

NO

T u

se t

his

rule

if P

E s

uspi

cion

hig

h en

ough

tha

t yo

u w

ould

not

be

con fi

dent

in e

xclu

ding

PE

w

ith

a no

rmal

D-d

imer

Ada

pted

fro

m K

line

JA, e

t al

. Pro

spec

tive

mul

tice

nter

eva

luat

ion

of t

he p

ulm

onar

y em

bolis

m r

ule-

out

crit

eria

. J T

hrom

b H

aem

ost

2008

; 6; 7

72–8

0 If

all

PE

RC

BR

EA

TH

S cr

iter

ia a

re a

bsen

t, no

D-d

imer

20 Wells Criteria (Pulmonary Embolism)

Wel

ls C

rite

ria

(Pul

mon

ary

Em

bolis

m)

Var

iabl

e P

oint

s

Clin

ical

sig

ns a

nd s

ympt

oms

of D

VT

3

Pre

viou

s P

E o

r D

VT

1.

5

Mal

igna

ncy

w/t

reat

men

t w

ithi

n 6

mon

ths

or p

allia

tive

1

Hem

opty

sis

1

HR

>10

0 bp

m

1.5

PE

is #

1 di

agno

sis

or e

qual

ly li

kely

3

Imm

obili

zati

on a

t le

ast

3 da

ys o

r su

rger

y w

ithi

n pr

evio

us 4

wee

ks

1.5

Scor

e C

ateg

ory

1–1.

5 po

ints

L

ow p

roba

bilit

y

2–6

poin

ts

Inte

rmed

iate

pro

babi

lity

6.5

and

abov

e po

ints

H

igh

prob

abili

ty

Ada

pted

fro

m: W

ells

PS,

And

erso

n D

R, R

odge

r M

, Sti

ell

I, D

reye

r JF

, Bar

nes

D, F

orgi

e M

, Kov

acs

G, W

ard

J, K

ovac

s M

J. E

xclu

ding

pul

mon

ary

embo

lism

at

the

beds

ide

wit

hout

dia

gnos

tic

imag

ing:

man

agem

ent

of p

atie

nts

wit

h su

spec

ted

pulm

o-na

ry e

mbo

lism

pre

sent

ing

to t

he e

mer

genc

y de

part

men

t by

usi

ng a

sim

ple

clin

ical

mod

el a

nd d

-dim

er.

Ann

Int

ern

Med

13

5(2)

:98–

107.

(20

01)

21COPD

CO

PD

Hos

pita

l Adm

issi

on C

rite

ria

Mar

ked

• ↑

inte

nsit

y of

sx

Seve

re u

nder

lyin

g C

OP

D

• (F

EV

1 <

50 %

pre

dict

ed

or o

n ho

me

O 2 )

N

ew s

igns

of

cyan

osis

, ede

ma

• Fa

ilure

to

resp

ond

to t

x •

Com

orbi

diti

es, n

ew

• ar

rhyt

hmia

s Fr

eque

nt e

xace

rbat

ions

•

Dia

gnos

tic

unce

rtai

nty

• In

suf fi

cien

t ho

me

supp

ort

•

ICU

Adm

issi

on C

rite

ria

Seve

re d

yspn

ea t

hat

• in

adeq

uate

ly r

espo

nds

to in

itia

l ED

tx

Cha

nges

in m

enta

l sta

tus

• P

ersi

sten

t or

wor

seni

ng

• hy

poxi

a (P

aO 2 <

40),

hype

rcap

-ni

a (P

aCO

2 >60

), or

aci

dosi

s (p

H <

7.25

) de

spit

e tr

eatm

ent

Nee

d fo

r m

echa

nica

l •

vent

ilati

on

Hem

odyn

amic

ally

uns

tabl

e •

(on

vaso

pres

sors

)


Fluid and Electrolytes

Hyperkalemia ....................................................... 24

Hypokalemia ........................................................ 25

Hyponatremia ...................................................... 26

Hypernatremia ..................................................... 28

Hypercalcemia ..................................................... 29

Electrolyte Equations ......................................... 30

5

24 Hyperkalemia

Hyp

erka

lem

ia

•

Hyp

er-K

? C

heck

EK

G

Wid

e Q

RS

>10

0 m

s (m

ost

sens

itiv

e)

• →

Giv

e C

a++

T

x:•

Insu

lin +

glu

cose

− B

eta-

agon

ist

−

Bic

arbo

nate

(on

ly if

aci

doti

c)

−

Ion

exch

ange

res

in (

cont

rove

rsia

l

−du

e to

bow

el n

ecro

sis)

5 E

CG

cha

nges

:•

Pea

ked

T

−

Pro

long

ed P

-R in

terv

al

−

Los

t P

wav

es

−

Wid

e Q

RS

>10

0 m

s

− Si

ne w

ave

−

Qui

ck H

its

for

etio

logy

of

Hyp

er-K

•

Not

Hyp

er-K

(re

peat

it!)

− C

RF

− A

cido

sis

−

Dru

gs

(AC

E+

AR

B,

K-s

pari

ng

−

diu

reti

c,

NS

AID

s,

Co

x-2

inhi

bito

rs)

Cel

l dea

th

−

Tum

or ly

sis

(hem

atol

ogic

°

mal

igna

ncy?

) R

habd

omyo

lysi

s or

cru

sh in

jury

°

Bur

n °

Hem

olys

is

°

25Hypokalemia

Hyp

okal

emia

•

Hyp

o-K

? L

ikel

y H

ypom

ag

Wat

ch f

or p

rolo

nged

Q-T

! Q

uick

H

its

for

etio

logy

of

•

Hyp

o-K

:

Diu

reti

cs

(th

iazi

de

s/

−fu

rose

mid

e)

Mal

nutr

itio

n

− E

tOH

− L

axat

ive

abus

e

− V

omit

ing

− E

CG

cha

nges

to lo

ok fo

r: lo

ss o

f T

• w

aves

, U

wav

es,

prol

onge

d Q

Tc,

T

orsa

des-

VT

-VF,

di

ffus

e ST

ch

ange

s

Key

fac

ts:

•

Usu

ally

asy

mpt

omat

ic

−

Rep

leti

on t

akes

mor

e th

an y

ou

−

thin

k 10

–20

meq

/h P

IV is

saf

e

− U

se P

O t

oo

−

10 m

eq K

Cl

incr

ease

s K

by

0.1

−

mm

ol/d

L

26 Hyponatremia

Hyp

onat

rem

ia

Usu

ally

sta

ble

•

Mos

t co

mm

on c

ause

: diu

reti

c •

use

and

low

-sal

t di

et

Giv

e hy

pert

onic

sal

ine

to a

•

seiz

ing

hypo

natr

emic

pat

ient

B

ut r

emem

ber

norm

al s

alin

e •

is

hype

rton

ic

rela

tive

to

pa

tien

t’s

hypo

natr

emia

C

orre

ct a

t 0.5

meq

/h o

r le

ss…

•

NE

VE

R

mor

e th

an

10–1

2 m

eq/d

ay

Onl

y gi

ve h

yper

toni

c sa

line:

•

Seiz

ures

, ac

ute

com

a, n

ew

−

foca

l fi nd

ings

Se

rum

Na

100–

110

(alw

ays

−

<12

0)

3 %

hyp

erto

nic

salin

e

−

27Hyponatremia

Serum sodium<135 mEq/L

Plasmaosmolality

Hypotonichyponatremia

Urineosmolality

ECFV

Hypotonichyponatremia • Hyperglycemia• Mannitol therapy• Glycerol therapy

Isotonichyponatremia

• Paraproteinemia• Hypertriglyceridemia

Excess water intake• Primary polydipsia• Excessive tap water in infant feedings• Tap water enemas in infants• Excess water ingestion during swimming

Renal solute loss• Diuretics• Osmotic diuresis • Addison’s disease• RTA with bicarbonaturia• Salt losing nephritis

Extrarenal solute loss• Skin• GIT(GastrointestinalTract)

Impaired renalconcentrating ability

Urinarysodium

Renal failure

Edematous disorders• CHF• Cirrhosis• Nephrotic syndrome

Urinarysodium

DecreasedECFV

IncreasedECFV

NormalECFV

SIADH• Drugs• Tumors• CNS disorders• Nausea, pain, stress • Others

Endocrinopathies• Hypothyroidism• Glucocorticoid deficiency

Reset osmostat Potassiumdepletion • Diuretic use

280−295 msom/kg >295 msom/kg

<100 msom/kg >100 msom/kg

>20 mEq/L <10 mEq/L >20 mEq/L <10 mEq/L

Hyponatremia

28 Hypernatremia

Hyp

erna

trem

ia

Hyp

erna

trem

ia?

Thi

nk

dehy

-•

drat

ion

and

wat

er d

e fi ci

t G

ive

fl uid

s, bu

t…•

Cor

rect

slo

wly

!

−

Thi

ngs

to k

eep

in m

ind:

•

Usu

ally

ger

iatr

ic d

isea

se

−

Com

mon

wit

h A

MS

−

Incr

ease

s m

orta

lity

for

coex

-

−is

ting

dis

ease

R

apid

co

rrec

tion

in

crea

ses

−

mor

talit

y

(

)(

)(

)W

ater

defi

cit

liter

s0.

6W

tin

kgN

a/14

01

=´

´é

-ù

ëû

29Hypercalcemia

Hyp

erca

lcem

ia

Mild

and

asy

mpt

omat

ic:

•

Thi

azid

es

−

Oth

er m

eds

−

Mild

ove

rdiu

resi

s

− Seve

re b

ut a

sym

ptom

atic

:•

Thi

nk h

yper

para

thyr

oid

− Sy

mpt

omat

ic:

•

Thi

nk m

alig

nanc

y an

d pa

rane

opla

stic

−sy

ndro

me

Hyp

erca

lcem

ia?

Giv

e sa

line

• T

x:•

AB

C’s

− Sa

line

(fol

low

I/O

)

− L

asix

(fo

rced

diu

resi

s)

−

Follo

w K

and

Mag

− M

nem

onic

: “ P

AM

P S

CH

MID

T ”

hype

r P ar

athy

roid

ism

A

ddis

on’s

dis

ease

M

ilk-a

lkal

i syn

drom

e P

aget

’s d

isea

se

S arc

oido

sis

C an

cer

(par

aneo

plas

tic)

H

yper

thyr

oidi

sm

M ye

lom

a I m

mob

iliza

tion

D

(vi

tam

in)

T hi

azid

es

(

)C

alci

um4

seru

mal

bum

ing/

dL0.

8se

rum

calc

ium

=-

´+

30 Electrolyte Equations

Ele

ctro

lyte

Equ

atio

ns

Uri

neN

a/U

rine

Cr

FeN

aSe

rum

Na/

Seru

mC

r

*Fe

Na

1Pr

eren

al

*Fe

Na

2In

trin

sic

Ren

al

=

<®

>®

Seru

m O

smol

arit

y :

2N

aB

UN

/2.8

Glu

cose

/18

ET

OH

/4.6

Spot

Uri

neN

a20

likel

yde

hydr

atio

n

++

+

<=


Neurology

CSF Analysis .................................................. 32

San Francisco Syncope Rule ......................... 33

TPA for Stroke .............................................. 34

Stroke and Headache .................................... 35

Vertigo ........................................................... 36

6

32 CSF Analysis

CSF

Ana

lysi

s

Nor

mal

Pre

term

te

rm

child

B

acte

rial

V

iral

F

unga

l T

B

Abs

cess

WB

C

0–5

0–25

>

1,00

0 <

1,00

0 10

0–50

0 10

0–50

0 10

–1,0

00

7.3

± 1

3.9

0–7

% P

MN

0–

15

57

>80

<

50

<50

<

50

<50

61–8

4

5

% L

ymph

>

50

<50

>

50

>80

In

c. m

ono

Var

ies

Glu

cose

45

–65

24–6

3 <

40

45–6

5 30

–45

30–4

5 45

–60

51.2

± 1

2.9

40–8

0

Rat

io

0.6

<0.

4 0.

6 <

0.4

<0.

4 0.

6

Pro

tein

20

–45

65–1

20

>15

0 50

–100

10

0–50

0 10

0–50

0 >

50

64.2

± 2

4.2

5–40

Pre

ssur

e 6–

20

8–11

>

25–3

0 V

aria

ble

>20

>

20

Var

iabl

e

<20

<20

33San Francisco Syncope Rule

San

Fran

cisc

o Sy

ncop

e R

ule

Seri

ous

outc

ome

at 7

day

s is

mor

e lik

ely

if A

NY

of

the

follo

win

g ar

e pr

esen

t

Hx

of C

HF

Hct

<30

EK

G a

bnor

mal

itie

s (v

ague

)

Shor

tnes

s of

bre

ath/

dysp

nea

SBP

<90

Fur

ther

wor

kup

and/

or a

dmis

sion

MA

Y b

e in

dica

ted

if a

ny o

f th

ese

high

-ris

k fe

atur

es a

re p

rese

nt

Ada

pted

fro

m Q

uinn

J, M

cDer

mot

t D

, Sti

ell

I, K

ohn

M, W

ells

G (

May

200

6) P

rosp

ecti

ve v

alid

atio

n of

the

San

Fra

ncis

co

Sync

ope

Rul

e to

pre

dict

pat

ient

s w

ith

seri

ous

outc

omes

. Ann

Em

erg

Med

47

(5):

448–

54

34 TPA for Stroke

TP

A f

or S

trok

e

•

0.9

mg/

kg o

ver

90 m

in w

ith

10 %

of

dose

as

a bo

lus

over

1 m

in

Adm

it t

o IC

U o

r st

roke

uni

t •

BP

and

Neu

ro c

heck

s q1

5 m

in ×

2 h

•

The

n q3

0 m

in f

or n

ext

6 h

−

The

n q

hour

for

tot

al o

f 24

h

− A

void

NG

tub

e, F

oley

and

A-l

ine

• R

epea

t C

T s

can

in 2

4 h

• *I

f na

usea

, vom

itin

g, s

ever

e H

A, a

nd s

ever

e B

P e

leva

tion

occ

ur –

ST

OP

•

infu

sion

and

get

em

erge

nt n

on-c

ontr

ast

head

CT

A

dapt

ed f

rom

Ada

ms,

Har

old

P. e

t al

. Gui

delin

es f

or t

he E

arly

Man

agem

ent

of A

dults

With

Isc

hem

ic S

trok

e: A

Gui

delin

e Fr

om

the

Am

eric

an H

eart

Ass

ocia

tion

Stro

ke C

ounc

il. S

trok

e M

ay 2

007

35Stroke and Headache

Stro

ke a

nd H

eada

che

Stro

ke M

imic

s (C

2 H 2 A

OS)

•

C on

vers

ion

diso

rder

• C

ompl

icat

ed m

igra

ine

•

H yp

ogly

cem

ia

•

H yp

erte

nsiv

e E

ncep

halo

path

y

• A

orti

c di

ssec

tion

• O

ld C

VA

de fi

cits

• S e

izur

e L

ist

is n

ot a

ll-in

clus

ive

Can

’t M

iss

HA

(PA

C 3 T

S)

•

P se

udot

umor

cer

ebri

• A

cute

ang

le c

losu

re g

lauc

oma

•

C er

vica

l art

ery

diss

ecti

on

•

C er

ebra

l ven

ous

thro

mbo

sis

•

C O

poi

soni

ng

•

T em

pora

l art

erit

is

S AH

• Fr

om S

tead

et a

l. Fi

rst A

id fo

r E

mer

genc

y M

edic

ine,

3r

d E

d.

36 Vertigo

Ver

tigo

“ SP

INN

ED

” P

erip

hera

l ver

tigo

C

entr

al v

erti

go

Sudd

en (

onse

t )

Yes

Sl

ow, g

radu

al

Pos

ition

al

Yes

N

o

Inte

nsity

Se

vere

Il

l de fi

ned

Nau

sea /

diap

hore

sis

Freq

uent

In

freq

uent

Nys

tagm

us

Hor

izon

tal

Ver

tica

l

Ear

( he

arin

g lo

ss )

Can

be

pres

ent

Abs

ent

Dur

atio

n P

arox

ysm

al

Con

stan

t C

NS

sign

s A

bsen

t U

sual

ly p

rese

nt


Trauma and ATLS

ATLS Primary Survey ................................... 38

ATLS History ..................................................... 39

Lethal Triad of Trauma ..................................... 40

GCS ..................................................................... 41

Trauma Checklist ............................................... 42

Shock in Trauma ................................................ 43

Hemorrhage Classifications .............................. 44

Burn Classifications ........................................... 45

7

38 ATLS Primary Survey

AT

LS

Pri

mar

y Su

rvey

•

A : A

irw

ay C

an p

t. ta

lk?

Voi

ce n

orm

al?

−

Stri

dor?

Gag

re fl

ex?

Fore

ign

body

?

−B

leed

ing/

secr

etio

ns?

Bur

ns?

−

• B

: Bre

athi

ng E

qual

che

st r

ise/

fall?

− B

reat

h so

unds

bila

t.? S

Q a

ir?

−

Dev

iate

d tr

ache

a? J

VD

? F

lail

ches

t/

−fr

actu

re?

•

C : C

ircu

lati

on H

eart

sou

nds,

puls

es in

all

ext.

−

Loo

k fo

r ex

tern

al b

leed

ing

−

Get

vas

cula

r ac

cess

− •

D : D

isab

ility

Ale

rt, v

erba

l, pa

infu

l sti

mul

i, un

resp

on-

−

sive

(A

VP

U)

GC

S, g

ross

mot

or/s

enso

ry, p

upils

− •

E : E

xpos

ure

(get

all

clot

hes

off)

•

F : F

inge

r

Rec

tal e

xam

(co

ntro

vers

ial b

ut s

till A

TL

S)

−

• F

: FA

ST

Loo

king

for

hem

oper

itone

um a

nd/o

r

−pe

rica

rdia

l eff

usio

n

•

F : F

oley

Con

trai

ndic

ated

for

bloo

d at

mea

tus

and

−

high

-rid

ing

pros

tate

•

F : F

amily

Not

ify

next

of

kin

ASA

P

−

• F

: Fen

tany

l

App

ropr

iate

pai

n co

ntro

l

− Fe

ntan

yl m

ost

hem

odyn

amic

ally

sta

ble

−

narc

otic

P

reve

nt h

ypot

herm

ia

− A

dapt

ed f

rom

San

jay

Aro

ra “

Trau

ma

Rev

iew

200

9”

USC

Ess

enti

als

2009

39ATLS History

AT

LS

His

tory

“AM

PL

E-F

”

A

Alle

rgie

s

M

Med

icat

ions

P

PM

H

L

Las

t m

eal/L

MP

E

Eve

nts

of t

raum

a (w

hat

happ

ened

) F

Fa

mily

, fri

ends

, fi el

d pe

rson

nel

Ada

pted

fro

m S

anja

y A

rora

“Tr

aum

a R

evie

w 2

009”

USC

Ess

enti

als

2009

40 Lethal Triad of Trauma

Let

hal T

riad

of T

raum

a

Aci

dosi

s

Coa

gulo

path

yH

ypot

herm

ia

Hem

orrh

age

Hyp

oxia

Con

tam

inat

ion

SIR

S/s

epsi

sR

esus

cita

tion

41GCS

GC

S

Eye

ope

ning

B

est

verb

al

Bes

t m

otor

4—Sp

onta

neou

s 5—

Ori

ente

d/co

nver

ses

6—O

beys

3—V

erba

l com

man

d 4—

Dis

orie

nted

/con

vers

es

5—L

ocal

izes

pai

n

2—P

ain

3—In

appr

opri

ate

wor

ds

4—W

ithd

raw

to

stim

1—

No

resp

onse

2—

Inco

mpr

ehen

sibl

e 3—

Abn

fl ex

/dec

ort

1—N

o re

spon

se

2—A

bn e

xt/d

ecer

1—N

o re

spon

se

42 Trauma Checklist

Hgb

(se

rial

) •

Init

ial a

nd r

epea

t VS

• FA

ST (

seri

al)

• E

xter

nal b

leed

ers

• co

ntro

lled?

L

abs

sent

•

(typ

e sc

reen

/cro

ss?)

A

irw

ay s

ecur

ed

• (p

rese

nt/f

utur

e)

Lif

e/lim

b th

reat

s •

addr

esse

d Sp

ine

imm

obili

zed

• L

arge

bor

e ac

cess

× 2

•

Pai

n m

eds

• “A

MP

LE

-F”

hist

ory

• co

mor

bidi

ties

?

Trau

ma

Che

cklis

t

43Shock in Trauma

Shoc

k in

Tra

uma

Type

of

shoc

k P

hysi

cal fi

ndin

gs/c

lues

Hem

orrh

agic

sho

ck

(hyp

ovol

emic

sho

ck)

Nar

row

pul

se p

ress

ure,

ext

erna

l ble

edin

g, fl

at n

eck

vein

s

Tens

ion

pneu

mot

hora

x (o

bstr

ucti

ve s

hock

) A

bsen

t uni

late

ral b

reat

h so

unds

, dev

iate

d tr

ache

a, J

VD

, na

rrow

pul

se p

ress

ure,

pulsu

s par

adox

us

Car

diac

tam

pona

de

(obs

truc

tive

sho

ck)

JVD

, muf

fl ed

hear

t sou

nds,

narr

ow p

ulse

pre

ssur

e, p

ulsu

s pa

rado

xus

Myo

card

ial c

ontu

sion

(c

ardi

ogen

ic s

hock

) P

ersi

sten

t ta

chyc

ardi

a, a

bnor

mal

EC

G, a

nd/o

r ca

rdia

c en

zym

es

Neu

roge

nic

shoc

k H

ypot

ensi

on a

nd b

rady

card

ia, w

arm

ext

rem

itie

s, in

jury

ab

ove

T6

44 Hemorrhage Classifications

Hem

orrh

age

Cla

ssi fi

cati

ons

Cla

ss I

C

lass

II

Cla

ss I

II

Cla

ss I

V

Blo

od lo

ss (

ml)

£ 7

50

750–

1,50

0 1,

500–

2,00

0 ³ 2

,000

Blo

od lo

ss (

% b

old

volu

me)

£ 1

5 15

–30

30–4

0 ³ 4

0

Pul

se r

ate

(per

min

) <

100

>10

0 >

120

³ 140

Blo

od p

ress

ure

Nor

mal

N

orm

al

Dec

reas

ed

Dec

reas

ed

Pul

se p

ress

ure

Nor

mal

or

incr

ease

d D

ecre

ased

D

ecre

ased

D

ecre

ased

Cap

illar

y re

fi ll t

est

Nor

mal

Po

siti

ve

Posi

tive

Po

siti

ve

Res

pira

tory

rat

e (b

reat

hs ·

min

−1 )

14

–20

20–3

0 30

–40

<35

Uri

ne o

utpu

t (m

l · h

−1 )

³ 3

0 20

–30

5–15

N

eglig

ible

CN

S m

enta

l sta

tus

Slig

htly

anx

ious

M

ildly

anx

ious

A

nxio

us a

nd c

onfu

sed

Con

fuse

d, le

thar

gic

Flui

d re

plac

emen

t (3:

1 ru

le)

Cry

stal

loid

C

ryst

allo

id

Cry

stal

loid

+ b

lood

C

ryst

allo

id +

blo

od

45Burn Classifications

Burn Classi fi cations

Adult Child

Left leg =13.5 %

Right leg =13.5 %

Left leg =18 %

Right leg =18 %

Left arm =9 %

Chest =18 %

Chest = 18 %

Left arm =9 %

Right arm= 9 %

Right arm= 9 %

Back =18 %

Back =18 %

Head = 18 %(front and

back)

Head = 9 %(front and back)

Perineum =1 %

Perineum =1 %

Parkland Formula = LR 4ml/kg/% burn TBSA in first 24 h + maintain fluids w/half in first 8 h + second half in last 16 h

47B. Allen et al., Quick Hits in Emergency Medicine, DOI 10.1007/978-1-4614-7037-3_8,© Springer Science+Business Media New York 2013

Head CT Decision Rules and Intracranial Hemorrhage

Mild Head Injury/TBI ....................................... 48

Nexus-II Head CT Decision Rule ....................... 49

Canadian Head CT Decision Rule ..................... 50

New Orleans Criteria .......................................... 51

Reading a Head CT ............................................. 52

Epidural Hematoma ........................................... 53

Subdural Hematoma .......................................... 54

Subarachnoid Hemorrhage ............................... 55

8

48 Mild Head Injury/TBI

Mild

Hea

d In

jury

/TB

I

Can

be

dire

ct i

mpa

ct t

o sk

ull

•

or b

rain

tha

t re

sult

s in

dis

turb

ance

of

brai

n fu

ncti

on

(thi

nk f

alls

, syn

cope

, MV

C, a

ssau

lt)

Do

not

unde

rest

imat

e pr

eval

ence

or

asso

ciat

ed m

orbi

dity

•

25 %

of

GC

S 15

hea

d tr

aum

a w

ill h

ave

abno

rmal

CT

•

LO

C, A

OC

, PT

A, a

nd S

z al

l ass

ocia

ted

wit

h w

orse

TB

I se

veri

ty a

nd o

utco

mes

•

25 %

dev

elop

pos

t-co

ncus

sive

syn

drom

e (s

leep

dif

fi cul

ties

, fa

tigu

e, i

rrit

abili

ty,

poor

•

conc

entr

atio

n, h

eada

che)

P

atie

nts

on a

ntic

oagu

lant

s ha

ve h

ighe

r ri

sk o

f po

or o

utco

me

• N

o si

ngle

bes

t w

ay t

o di

agno

se—

CT,

MR

I, E

EG

, neu

roco

gnit

ive

test

s—no

ne p

erfe

ct

• Im

age,

che

ck v

isio

n, r

x an

tiem

etic

, and

non

-opi

ate

anal

gesi

a pr

ovid

e f/

u •

Mos

t im

port

ant

inst

ruct

ion

is c

ompl

ete

brai

n re

st f

or 5

–7 d

ays:

• <

1 h

scre

en t

ime

per

day:

incl

udes

tex

ting

, vid

eo g

ames

, TV

Res

t in

a lo

w-s

tim

ulat

ion

envi

ronm

ent:

no b

righ

t lig

hts,

no lo

ud s

ound

s G

RA

DU

AL

ret

urn

to d

aily

act

ivit

ies

49Nexus-II Head CT Decision Rule

Nex

us-I

I H

ead

CT

Dec

isio

n R

ule

Nex

us-I

I (1

00 %

sen

siti

vity

)•

1. A

lter

ed (

AM

S)

2. S

uspi

cion

of

frac

ture

3.

Cur

rent

vom

itin

g 4.

Age

>65

5.

Neu

rolo

gic

de fi c

its

6. C

oagu

lopa

thy

7. S

calp

hem

atom

a L

OC

is n

ot a

bsol

ute

indi

cati

on f

or H

ead

CT

– V

alid

for

imm

edia

te p

rese

ntat

ion

only

–

Ada

pted

fro

m: M

ower

et

al. N

EX

US

II (

the

Nat

iona

l Em

erge

ncy

X-R

adio

grap

hy U

tiliz

atio

n St

udy:

J T

raum

a 20

05;5

9[4]

:954

; Ann

Em

erg

Med

200

2;40

[5]:5

05)

50 Canadian Head CT Decision Rule

Can

adia

n H

ead

CT

Dec

isio

n R

ule

Hig

h - ri

sk f

eatu

res

pred

icti

ve o

f ne

ed f

or n

euro

surg

ical

inte

rven

tion

GC

S <

15 a

t 2

h af

ter

inju

ry

• Su

spec

ted

open

or

depr

esse

d sk

ull f

ract

ure

• Si

gns

of b

asal

sku

ll fr

actu

re

• A

t le

ast

2 ep

isod

es o

f vo

mit

ing

• A

ge

• ³ 6

5 ye

ars

old

Med

ium

- ris

k fe

atur

es f

or b

rain

inju

ry d

etec

tion

on

CT

Am

nesi

a be

fore

impa

ct o

f

• ³ 3

0 m

in

Dan

gero

us m

echa

nism

(pe

dest

rian

vs

auto

, an

occu

pant

eje

cted

fro

m a

mot

or v

ehic

le,

• or

a f

all f

rom

an

elev

atio

n of

³ 3

ft o

r 5

stai

rs)

→ C

T in

dica

ted

if a

ny o

f th

e ab

ove

are

pres

ent

Ada

pted

fro

m: S

tiel

l IG

, Wel

ls G

A, V

ande

mhe

en K

, Cle

men

t C

, Les

iuk

H, L

aupa

cis

A, M

cKni

ght

RD

, Ver

beek

R, B

riso

n R

, Cas

s D

, Eis

enha

uer

ME

, Gre

enbe

rg G

, Wor

thin

gton

J. T

he C

anad

ian

CT

Hea

d R

ule

for

pati

ents

wit

h m

inor

hea

d in

jury

. L

ance

t. 20

01 M

ay 5

;357

(926

6):1

391–

6

51New Orleans Criteria

New

Orl

eans

Cri

teri

a

Hea

d C

T D

ecis

ion

Rul

e

1. H

A

2. V

omit

ing

3. A

ge >

60

4. I

ntox

icat

ion

5. P

ersi

sten

t ant

erog

rade

am

nesi

a 6.

Tra

uma

abov

e cl

avic

les

7. S

eizu

re P

rese

nce

of a

ny =

hea

d C

T

Stat

s an

d ca

veat

s:•

100

% s

ens

and

5 %

spe

c fo

r bo

th

−

requ

irin

g su

rger

y an

d fo

r an

y in

trac

rani

al le

sion

C

an’t

app

ly t

o pe

ds o

r pt

s on

−an

tico

agul

ants

Ada

pted

fro

m: H

ayde

l M

J, P

rest

on C

A, M

ills

TJ,

Lub

er S

, Bla

udea

u E

, DeB

lieux

PM

. Ind

icat

ions

for

com

pute

d to

mo-

grap

hy in

pat

ient

s w

ith

min

or h

ead

inju

ry. N

Eng

l J M

ed. 2

000

Jul 1

3;34

3(2)

:100

–5.

52 Reading a Head CT

Blo

od C

an B

e V

ery

Bad

•

B: B

lood

(lo

ok f

or b

lood

): su

bdur

al, E

pi, S

AH

•

C: C

iste

rns

•

Key

vie

w #

1: b

asal

cis

tern

at

leve

l of

pons

− K

ey v

iew

#2:

qua

drig

emin

al c

iste

rns

(fro

wn

= b

ad)

− B

: Bra

in (

look

for

asy

mm

etry

)•

Dif

fuse

axo

nal i

njur

y, S

AH

, non

trau

mat

ic le

sion

s, co

ntus

ions

− V: V

entr

icle

s•

Blo

od?

− B

: Bon

e•

Loo

k fo

r fx

or

air

adja

cent

to

bone

− H

emot

ympa

num

on

exam

? L

ook

for

mas

toid

fx

−

Rea

ding

a H

ead

CT

53Epidural Hematoma

Epi

dura

l Hem

atom

a

Use

d w

ith

perm

issi

on f

rom

Ste

ad e

t al

., Fi

rst A

id f

or t

he R

adio

logy

Cle

rksh

ip, M

cGra

w H

ill

54 Subdural Hematoma

Subdural Hematoma

Used with permission from Stead et al., First Aid for the Radiology Clerkship, McGraw Hill

a c

db

55Subarachnoid Hemorrhage

Suba

rach

noid

Hem

orrh

age

U

sed

wit

h pe

rmis

sion

fro

m S

tead

et

al.,

Firs

t Aid

for

the

Rad

iolo

gy C

lerk

ship

, McG

raw

Hill


Cervical Spine Injury and Decision Rules

Cervical Spine Alignment and Allowable Distances .......................................... 58

NEXUS Criteria for C-Spine .................................. 59

Canadian C-Spine Rule ........................................... 60

9

58 Cervical Spine Alignment and Allowable Distances

Cer

vica

l Spi

ne A

lignm

ent

and

Allo

wab

le D

ista

nces

Pos

terio

rla

min

allin

e

Pos

terio

r as

pect

s of

spin

ous

proc

esse

s lin

e

Spi

nous

pro

cess

Spi

nola

min

al li

neP

oste

rior

vert

ebra

l bod

y lin

e

Ant

erio

rve

rteb

ral

body

line

Ver

tebr

al b

ody

Pre

dent

al s

pace

< 3

mm

in a

dults

< 5

mm

in c

hild

ren

< 22

mm

in a

dults

< 14

mm

in c

hild

ren

< 7

mm

< 5

mm

C1

C2

C3

C4 C5 C

6 C7

Use

d w

ith

perm

issi

on f

rom

Fir

st a

id f

or e

mer

genc

y m

edic

ine

cler

kshi

p by

Ste

ad e

t al

., M

cGra

w H

ill

59NEXUS Criteria for C-Spine

NE

XU

S C

rite

ria

for

C-S

pine

Yes

No

radi

ogra

phy

Mee

t all

the

low

ris

k cr

iteri

a: 1

. N

o po

ster

ior

mid

line

ce

rvic

al-s

pine

tend

erne

ss 2

. N

o ev

iden

ce o

f int

oxic

atio

n 3

. A

nor

mal

leve

l of a

lert

ness

4.

No

foca

l neu

rolo

gic

defic

it 5

. N

o pa

infu

l dis

trac

ting

inju

ries

No

Rad

iogr

aphy

Ada

pted

from

: Hof

fman

JR

, Wol

fson

AB

, Tod

d K

, Mow

er W

R. S

elec

tive

cer

vica

l spi

ne r

adio

grap

hy in

blu

nt tr

aum

a: m

etho

d-ol

ogy

of t

he N

atio

nal E

mer

genc

y X

-Rad

iogr

aphy

Uti

lizat

ion

Stud

y (N

EX

US)

. Ann

Em

erg

Med

. 199

8 O

ct;3

2(4)

:461

–9

60 Canadian C-Spine Rule

Canadian C-Spine Rule

Yes

Yes

Yes

No radiography

Any high risk factor that mandates radiography? 1. Age >65 years 2. Dangerous mechanism 3. Paresthesias in extremities

Any low risk factor that allowssafe range of motion assessment? 1. Simple rear-end MVC 2. Sitting position in the ED 3. Ambulatory at any time 4. Delayed neck pain onset 5. No midline cervical tenderness

Able to rotate neck actively(45° left and right)

No

Radiography

Dangerous Mechanisms • Fall from ≥3 ft or 5 stairs • An axial load to the head • A motor vehicle collision At high speed (>100 km/h) Rollover Ejection • A collision involving a motorized recreational vehicle • A bicycle collision

No

No

Adapted from: Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–1848


CXR Interpretation

CXR Interpretation ........................................... 62

10

62 CXR Interpretation

Org

aniz

ed a

ppro

ach

• O

utsi

de t

he c

hest

•

Soft

tis

sues

, bon

es,

• ab

dom

en

Che

st

• D

iaph

ragm

s, ai

rway

, •

aort

a, +

med

iast

inum

, pe

rica

rdiu

m a

nd h

eart

, pl

eura

and

lung

s

Pne

umot

hora

x in

•

trau

ma:

look

for

dee

p su

lcus

sig

n an

d sh

arp

diap

hrag

m o

r do

uble

di

aphr

agm

(of

ten

mis

sed)

CX

R I

nter

pret

atio

n

63CXR Interpretation

CX

R I

nter

pret

atio

n

A B C D E

HF G

A A

irw

ay ,

B B

ones

, C

Car

diac

silh

ouet

te/s

ize,

D

Dia

phra

gm,

E E

dges

(H

eart

bor

ders

), F

Fie

lds

(Lun

gs),

G G

astr

ic b

ubbl

e,

H H

ilum

, I

Inst

rum

enta

tion

(Tu

bes

and

lines

)


Orthopedics and Decision Rules

Ottawa Ankle and Foot Rules .......................... 66

Ottawa Knee Rules ............................................ 67

Orthopedics ......................................................... 68

Orthopedic Disposition ..................................... 69

11

66 Ottawa Ankle and Foot Rules

Ott

awa

Ank

le a

nd F

oot

Rul

es

X - r

ays

are

requ

ired

onl

y if

the

re is

bon

y pa

in o

ver

the

mal

leol

ar o

r m

idfo

ot a

rea

and

any

one

of t

he f

ollo

win

g :

Bon

e te

nder

ness

alo

ng t

he d

ista

l 6 c

m o

f th

e po

ster

ior

edge

of

the

tibi

a or

tip

of

the

med

ial m

alle

olus

Bon

e te

nder

ness

alo

ng t

he d

ista

l 6 c

m o

f th

e po

ster

ior

edge

of

the

fi bul

a or

tip

of

the

late

ral m

alle

olus

Bon

e te

nder

ness

at

the

base

of

the

fi fth

met

atar

sal (

foot

inju

ries

and

con

cern

for

Jo

nes

frac

ture

)

Bon

e te

nder

ness

at

the

navi

cula

r bo

ne (

foot

inju

ry)

Inab

ility

to

bear

wei

ght

both

imm

edia

tely

aft

er t

he in

jury

and

for

4 s

teps

in t

he

ED

(w

ithi

n 10

day

s of

inju

ry)

Ada

pted

fro

m S

tiel

l IG

, McK

nigh

t R

D, G

reen

berg

GH

, et

al.:

Impl

emen

tati

on o

f th

e O

ttaw

a R

ules

. JA

MA

271

:827

, 199

4

67Ottawa Knee Rules

Ott

awa

Kne

e R

ules

Kne

e X

- ray

s ar

e in

dica

ted

if A

NY

of

the

follo

win

g ar

e pr

esen

t ( 9

7 – 10

0 %

sen

s fo

r fr

actu

re )

Age

³ 55

Pai

n at

the

hea

d of

the

fi bu

la

Isol

ated

pat

ella

ten

dern

ess

Can

’t fl

ex k

nee

90°

Inab

ility

to

wal

k 4

wei

ght-

bear

ing

step

s B

OT

H im

med

iate

ly A

ND

in E

D

(reg

ardl

ess

of li

mp)

Ada

pted

fro

m S

tiel

l IG

, Wel

ls G

A, H

oag

RH

, et

al.:

Impl

emen

tati

on o

f th

e O

ttaw

a K

nee

Rul

es f

or t

he u

se o

f ra

diog

raph

y in

ac

ute

knee

inju

ries

. JA

MA

278

:207

5, 1

997

68 Orthopedics

Ort

hope

dics

Com

part

men

t Sy

ndro

me

6 P

’s:

•

Pai

n

− P

allo

r

− P

ares

thes

ia

−

Pul

sele

ssne

ss (

late

)

− Po

ikilo

ther

mia

− P

aral

ysis

− Del

ta P

:•

Dia

stol

ic B

P-c

ompa

rtm

ent

−

Del

ta

−

P <

30

= F

asci

otom

y

Fle

xor

Teno

syno

viti

s

Kan

avel

’s 4

sig

ns:

•

Fus

ifor

m s

wel

ling

−

Fle

xed

posi

tion

− P

ain

wit

h pa

ssiv

e fl e

xion

/

−ex

tens

ion

Pro

xim

al

tend

erne

ss

alon

g

−th

e te

ndon

she

ath

69Orthopedic Disposition

Ort

hope

dic

Dis

posi

tion

OR

TH

O N

OW

N

euro

vasc

ular

com

prom

ise

• an

d co

mpa

rtm

ent

sx

Ope

n fr

actu

re o

r no

n-re

duce

d •

disl

ocat

ions

Se

vere

infx

(ne

crot

izin

g •

fasc

iitis

, fl ex

or t

enos

ynov

itis

, cl

osed

spa

ce in

fx, a

bsce

ss,

post

-op

infx

) “M

ajor

Ort

ho T

raum

a” (

pelv

ic,

• fe

mur

, tib

ial p

late

au, t

ibia

l sh

aft)

A

mpu

tati

ons

(dep

ends

on

• lo

cati

on)

OR

TH

O F

ollo

w-u

p Fr

actu

re li

kely

req

uiri

ng

• su

rger

y (a

nkle

, wri

st, e

lbow

, pr

ox. h

umer

us, e

tc.)

Seve

re c

omm

inut

ion

or

−

intr

a-ar

ticu

lar

Tend

on la

cera

tion

/rup

ture

•

Infe

ctio

n fo

llow

-ups

(48

–72

h)

•


Cardiology

Differential Diagnosis of Chest Pain ............... 72

Acute Coronary Syndrome ............................... 73

STEMI vs Benign Early Repol ......................... 74

Left Ventricular Hypertrophy (LVH) .............. 75

New Onset A-fib ................................................. 76

Left Atrial Hypertrophy (LAH) ...................... 77

Sgarbossa’s Criteria ............................................ 78

Brugada Syndrome ............................................. 80

Brugada Criteria for V-Tach ............................. 81

Wellens’ Sign/Syndrome .................................... 82

12

72 Differential Diagnosis of Chest Pain

Dif

fere

ntia

l Dia

gnos

is o

f C

hest

Pai

n

Lif

e-th

reat

enin

g ca

uses

of

ches

t pa

in

Non

-lif

e-th

reat

enin

g ca

uses

of

ches

t pa

in

Acu

te c

oron

ary

synd

rom

e (A

CS)

P

eric

ardi

tis

Eso

phag

eal r

uptu

re

Eso

phag

eal s

pasm

Per

icar

dial

tam

pona

de

Eso

phag

eal r

e fl ux

(G

ER

D)

Pne

umot

hora

x C

hest

wal

l pai

n P

ulm

onar

y em

bolis

m

Ple

uris

y

Pep

tic

ulce

r di

seas

e (P

UD

)

Bili

ary

dise

ase

Pan

ic a

ttac

k (a

nxie

ty d

isor

der)

Cer

vica

l art

hrit

is (

radi

culo

path

y)

73Acute Coronary Syndrome

Acu

te C

oron

ary

Synd

rom

e

Indi

cato

rs o

f ac

ute

MI

•

1 m

m o

r m

ore

ST s

egm

ent

−

elev

atio

n in

2 c

onti

guou

s le

ads

Rec

ipro

cal S

T d

epre

ssio

n

− Q

wav

es

−

Alw

ays

com

pare

to

old

−

EC

G’s

R

epea

t E

CG

in 1

5–30

min

−

1. A

typi

cal i

s ty

pica

l—at

ypic

al

CP

doe

sn’t

r/o

MI

2. B

ewar

e th

e ge

riat

ric

pati

ent

wit

h at

ypic

al s

ympt

oms

3. D

elta

enz

yme

anal

ysis

4.

Use

obj

ecti

ve te

st o

r pr

ovoc

ativ

e st

udy

74 STEMI vs Benign Early Repolarization (BER)

STE

MI

vs B

enig

n E

arly

Rep

olar

izat

ion

(BE

R)

“Fro

wny

”

J po

int

notc

hing

Cov

ed (

conv

ex d

own)

Con

cave

up

ST

EM

I BE

R

“Sm

iley”

ST

ele

vati

on

var

iati

on

IaV

LV

4V

5V

6

75Left Ventricular Hypertrophy (LVH)

Lef

t Ven

tric

ular

Hyp

ertr

ophy

(LV

H)

S in

V1

+ R

in V

5 or

V6

> 3

5 m

m

• or

S in

V1

−or

V2

+ R

in V

5 or

V6

> 3

5 m

m

R in

aV

L >

11

mm

•

R in

V4–

6 >

25m

m

• S

in V

1–3

> 2

5 m

m

• R

in I

+ S

in I

II >

25

mm

•

76 New Onset A-fib

Rat

e

Fast

>10

0 bp

m

Slo

w<

60 b

pm

Dilt

iaze

m

Esm

olol

No

acut

em

eds

Ons

et

<48

h

>48

h

Can

car

diov

ert

50 J

syn

chro

nize

d

Ant

icoa

gula

te

Cau

ses

of

A-f

ib:

P -

PE

I -

Isc

hem

ia (

AC

S)

R -

Rhe

umat

ic/

valv

ular

HD

A -

Atr

ial m

yxom

aT

- T

hyot

oxic

osis

E -

Eth

anol

S -

Sep

sis

New

Ons

et A

- fi b

77Left Atrial Hypertrophy (LAH)

Lef

t Atr

ial H

yper

trop

hy (

LA

H)

Not

ched

P w

ave

wit

h >

40 m

s be

twee

n th

e tw

o pe

aks

wit

h to

tal

• P

wav

e du

rati

on >

110

ms

•

In V

1

Bip

hasi

c P

wav

e w

ith

term

inal

neg

ativ

e po

rtio

n >

40 m

s

−du

rati

on

Bip

hasi

c P

wav

e w

ith

term

inal

neg

ativ

e po

rtio

n >

1 m

m d

eep

−

78 Sgarbossa’s Criteria

Sgar

boss

a’s

Cri

teri

a

Dia

gnos

is o

f ac

ute

MI

in t

he p

rese

nce

of le

ft b

undl

e br

anch

bl

ock

( LB

BB

)

Cri

teri

a fo

r di

agno

sis

of a

cute

MI

(Sga

rbos

sa’s

cri

teri

a)

PO

INT

S

ST e

leva

tion

>1

mm

con

cord

ant

(sam

e di

rect

ion)

as

QR

S 5

ST d

epre

ssio

n >

1 m

m in

lead

s V

1, V

2, o

r V

3 3

ST e

leva

tion

>5

mm

and

dis

cord

ant

(opp

osit

e) w

ith

QR

S 2

Tota

l > 3

is 3

6 – 78

% s

ensi

tive

, 90 –

96 %

spe

ci fi c

for

acu

te M

I

Ada

pted

fro

m E

lena

. B. S

garb

ossa

et

al.;

New

Eng

land

Jou

rnal

of

Med

icin

e, V

olum

e 33

4; N

umbe

r 8,

Feb

22,

199

6

79Sgarbossa’s Criteria

Sgar

boss

a’s

Cri

teri

a

≥ 5

mm

V1,

V2,

V3

LBB

B/p

aced

rhy

thm

80 Brugada Syndrome

Dia

gnos

tic

crit

eria

for

Bru

gada

syn

drom

e ST

-seg

men

t ab

norm

alit

ies

in le

ads

V1–

V3

Type

1

Type

2

Type

3

J-po

int

³ 2 m

m

³ 2 m

m

³ 2 m

m

T w

ave

Neg

ativ

e Po

siti

ve o

r bi

phas

ic

Posi

tive

ST

-T c

on fi g

urat

ion

Cov

ed t

ype

Sadd

leba

ck

Sadd

leba

ck

ST s

egm

ent

(ter

min

al p

orti

on)

Gra

dual

ly d

esce

ndin

g E

leva

ted

³ 1 m

m

Ele

vate

d <

1 m

m

1 m

m =

0.1

mV

; the

ter

min

al p

orti

on o

f th

e ST

seg

men

t re

fers

to

the

latt

er h

alf

of t

he S

T s

egm

ent

(Fro

m W

ilde

et a

l. w

ith

perm

issi

on)

ab

V1

V2

V1

I II III aVr

aVL

aVF

V1

V2

V3

V4

V5

V6

Bru

gada

Syn

drom

e

81Brugada Criteria for V-Tach

Bru

gada

Cri

teri

a fo

r V

-Tac

h

No

RS

com

plex

in th

e pr

ecor

dial

lead

s?

No?

No?

No?

No?

SV

T

No

to a

ll of

the

abov

e?

Mor

phol

ogy

crite

ria fo

r V-T

ach

pres

ent i

n V

1–V

2 an

d V

6?

AV

dis

soci

atio

n?

R a

nd S

inte

rval

>10

0 m

s in

one

pre

cord

ial l

ead?

Yes?

VT

Yes?

VT

Yes?

VT

Yes?

VT

82 Wellens’ Sign/Syndrome

Wel

lens

’ Sig

n/Sy

ndro

me

Cri

teri

a of

Wel

lens

’ Syn

drom

e P

rior

his

tory

of

ches

t pa

in

• C

hest

pai

n w

ith

norm

al E

CG

•

Nor

mal

or

min

imal

ly e

leva

ted

card

iac

enzy

mes

•

No

path

olog

ic p

reco

rdia

l Q w

aves

or

loss

of

R w

aves

•

St s

egm

ent

in V

2 an

d V

3 th

at is

isoe

lect

ric

or m

inim

ally

ele

vate

d (1

mm

), co

ncav

e, o

r st

raig

ht

• Sy

mm

etri

c an

d de

ep T

wav

e in

vers

ion

or b

ypha

sic

T w

aves

in V

2–V

5 or

V6

in p

ain

free

per

iods

•

Tig

ht p

roxi

mal

LA

D s

teno

sis

•

I II III II

aVR

aVI

aVF

V1

V2 V3

V4

V5 V6


GI Bleeding/Hemorrhage

GI Bleeding/Hemorrhage .................................. 84

Glasgow-Blatchford Score for Upper GI Hemorrhage ...................................... 85

13

84 GI Bleeding/Hemorrhage

GI Bleeding/Hemorrhage

Vitalsigns

Stable

Coagulationissues?

Dispositionbased on

clinical scenario

Considerplatelets, FFPand/or PCC’s

Obtainlabs

Immediateresuscitation

ConsiderNG lavage

• Location (upper vs lower)• Severity• Duration• Risk factors

FocusedH & P

• ABC’s• 2 large bore IV’s• Fluids• Consider tranfusion

• CBC• Chemistry• Type and screen• Liver function• Coagulation

studies

Unstable

Upper

85Glasgow-Blatchford Score for Upper GI Hemorrhage

Gla

sgow

-Bla

tchf

ord

Scor

e fo

r U

pper

GI

Hem

orrh

age

A s

core

of

zero

and

Pt

is lo

w r

isk

for

seri

ous

outc

ome

if a

ll be

low

are

pre

sent

:

Hgb

>12

.9 (

men

) or

>11

.9 (

wom

en)

SBP

>10

9 m

mH

g

HR

<10

0 bp

m

BU

N <

18.2

mg/

dL

No

mel

ena

No

sync

ope

No

past

or

pres

ent

liver

dis

ease

No

past

or

pres

ent

hear

t fa

ilure

St

anle

y A

, Ash

ley

D, D

alto

n H

, et

al. O

utpa

tien

t m

anag

emen

t of

pat

ient

s w

ith

low

-ris

k up

per-

gast

roin

test

inal

hae

mor

rhag

e:

mul

tice

ntre

val

idat

ion

and

pros

pect

ive

eval

uati

on. L

ance

t Ja

nuar

y 3,

200

9;37

3(96

57):

42–4

7


Hematology

ITP/TTP/DIC ................................................. 88

14

88 ITP/TTP/DIC

ITP

/TT

P/D

IC

ITP

T

TP

D

IC

Dec

. pla

tele

ts

Yes

Y

es

Yes

Inc.

PT

/IN

R

No

No

Yes

MA

HA

N

o Y

es

No

Nor

mal

fi br

in-

fi bri

noge

n Y

es

Yes

N

o

“Sic

k”

No

Yes

Y

es

Ok

to g

ive

plat

elet

s Y

es if

cr

itic

al

No

deat

h Y

es

Thr

ombo

cyto

peni

a? r

/o T

TP

bef

ore

• gi

ving

pla

tele

ts

MA

HA

(sc

hist

ocyt

es o

n pe

riph

eral

•

smea

r)?

Thi

nk T

TP

! T

TP

ne

eds

plas

ma

exch

ange

•

Tran

sfus

ion

Mne

mon

ic: “

FAT

RN

” F

ever

A

nem

ia

T hr

ombo

cyto

peni

a R

enal

(ki

dney

inju

ry)

N eu

rolo

gic

com

plai

nts


Toxicology

Toxidromes .......................................................... 90

Ingestions ............................................................. 91

Acetaminophen Nomogram .............................. 92

Toxicology ............................................................ 93

Serotonin Syndrome ........................................... 96

Coma “AEIOU TIPS” ....................................... 97

15

90 Toxidromes

Toxi

drom

es

Ant

icho

liner

gic

Cho

liner

gic

Myd

rias

is

Saliv

atio

n

Hyp

erte

nsio

n L

acri

`mat

ion

Dec

reas

ed b

owel

sou

nds

Uri

nati

on

Tach

ycar

dia

Dia

rrhe

a/de

feca

tion

Skin

fl us

hing

, dry

ski

n E

mes

is

AM

S/co

nfus

ion,

agi

tati

on/

hallu

cina

tion

s B

rady

card

ia

Uri

nary

ret

enti

on

Bro

ncho

rrhe

a/br

onch

ospa

sm

Tx:

con

side

r ph

ysos

tigm

ine

Tx:

dec

onta

min

atio

n—at

ropi

ne a

nd

pral

idox

ime

(2-P

AM

)

91Ingestions

Inge

stio

ns

ASA

OD

To

xic

leve

ls e

vide

nt a

t 6

h•

Win

terg

reen

and

bis

mut

h

−co

ntai

n A

SA

Init

ial i

ncre

ased

RR

(re

sp

• al

kalo

sis)

P

rim

ary

AG

met

aci

dosi

s •

N/V

/tin

nitu

s/sw

eati

ng

• A

cute

pul

mon

ary

edem

a •

Toxi

c do

se =

150

–200

mg/

kg

• D

ialy

sis

is t

he d

e fi ni

tive

•

ther

apy

Cal

l poi

son

cont

rol

•

Ace

tam

inop

hen

OD

A

lway

s us

e 4–

20 h

APA

P le

vel

• to

det

erm

ine

risk

Con

side

r 8

h le

vel i

f

−ex

tend

ed r

elea

se A

PAP

Clin

ical

fi nd

ings

•

N/V

, pal

lor,

mal

aise

− H

epat

otox

icit

y af

ter

24 h

− D

epre

ssio

n/su

icid

e

−(a

lway

s as

k)

NA

C is

mai

nsta

y of

the

rapy

•

Cal

l poi

son

cont

rol

•

92 Acetaminophen Nomogram

Ace

tam

inop

hen

Nom

ogra

m

Use

d w

ith p

erm

issi

on fr

om F

irst

Aid

for

the

Em

erge

ncy

Med

icin

e C

lerk

ship

3rd

Ed.

, by

Stea

d et

al.,

McG

raw

Hill

, 201

1.

1,00

0

500

200

100 50 20 10 5 2

48

1216

Tim

e af

ter

inge

stio

n (h

)2024

25 %

1,00

0

500

200

100

50 20 10 5 2

Pro

babl

e he

patic

toxi

city

No

hepa

tic to

xici

ty

Pos

sibl

e he

patic

toxi

city

Plasma concentration of acetaminophen (µg/mL)

Rum

ack

Mat

thew

nom

ogra

m

93Toxicology

Toxi

colo

gy

Com

a C

ockt

ail

•

DO

N’T

−D

extr

ose

(1 a

mp

D50

)

−

O xy

gen

(sup

plem

enta

l)

−N

arca

n (t

itra

te s

low

ly)

−T

hiam

ine

(to

prev

ent

Wer

nick

e’s)

Inge

stio

n A

ntid

ote

APA

P

NA

C

Ant

icho

liner

gic

Phy

sost

igm

ine

Ben

zodi

azep

ines

F

lum

azen

il (c

ontr

over

sial

)

Bet

a-bl

ocke

rs

Glu

cago

n

Ca

chan

nel b

lock

ers

Glu

cago

n, C

a, in

sulin

Cho

liner

gic

Atr

opin

e

Dig

oxin

D

igib

ind

Eth

ylen

e gl

ycol

Fo

mep

izol

e, d

ialy

sis

Iron

D

efer

oxam

ine

INH

B

6 (p

yrid

oxin

e)

Met

hano

l Fo

mep

izol

e, d

ialy

sis

Met

hem

oglo

bine

mia

M

ethy

lene

blu

e

Org

anop

hosp

hate

s P

ralid

oxim

e, a

trop

ine

Salic

ylat

es a

nd T

CA

So

dium

bic

arbo

nate

, dia

lysi

s

94 Toxicology

Toxi

colo

gy

Non

-ani

on G

ap M

etab

olic

Aci

dosi

s

•

USE

D C

AR

−U

rem

ia

−S a

line

−E

nter

ic fi

stul

a

−

D ia

rrhe

a

−

C ar

boni

c an

hydr

ase

inhi

bito

rs

−A

cids

(ex

ogen

ous)

−

R en

al t

ubul

ar a

cido

sis

Ani

on G

ap M

etab

olic

Aci

dosi

s

•

CA

T M

UD

PIL

ES

−C

arbo

n m

onox

ide/

cyan

ide

−A

lcoh

olic

ket

oaci

dosi

s

−

T ol

uene

−

M et

hano

l

−

U re

mia

−

D K

A

−P

heno

thia

zine

s (H

aldo

l)

−I N

H

−L

acta

te

−E

TO

H, e

thyl

ene

glyc

ol

−S a

licyl

ates

95Toxicology

Toxi

colo

gy

Rad

iopa

que

Subs

tanc

es

•

CH

IPS

−C

hlor

inat

ed s

ubst

ance

s (p

esti

cide

s)

−H

eavy

met

als

(lea

d, m

ercu

ry,

arse

nic)

−

I odi

ne/ I

ron

−P

heno

thia

zine

s

−

S ust

aine

d-re

leas

e ta

bs/s

alic

ylat

es

(ent

eric

coa

ted)

Dia

lyza

ble

Toxi

ns

•

I ST

UM

BL

E

−I s

opro

pyl

−S a

licyl

ates

−

T he

ophy

lline

−

U re

mia

−

M et

hano

l

−

B ar

bitu

rate

s

−

L it

hium

−

E th

ylen

e gl

ycol

/ E T

OH

96 Serotonin Syndrome

Sero

toni

n Sy

ndro

me

Hun

ter

Sero

toni

n To

xici

ty C

rite

ria

(if

sero

tone

rgic

age

nt is

pre

sent

)

Dia

gnos

is o

f se

roto

nin

synd

rom

e ca

n be

mad

e if

at

leas

t on

e of

the

cri

teri

a is

pre

sent

1. S

pont

aneo

us c

lonu

s

2. I

nduc

ible

clo

nus

and

agit

atio

n or

dia

phor

esis

3. O

cula

r cl

onus

and

agi

tati

on o

r di

apho

resi

s

4. T

rem

or a

nd h

yper

re fl e

xia

5. H

yper

toni

city

and

feve

r (>

38 C

) an

d oc

ular

clo

nus

or in

duci

ble

clon

us

If n

one

of t

he a

bove

cri

teri

a pr

esen

t, no

t se

roto

nin

synd

rom

e/to

xici

ty

Ada

pted

fro

m:

Dun

kley

EJ,

Isbi

ster

GK

, Si

bbri

tt D

, D

awso

n A

H, W

hyte

IM

(Se

ptem

ber

2003

). “T

he H

unte

r Se

roto

nin

Toxi

city

Cri

teri

a: s

impl

e an

d ac

cura

te d

iagn

osti

c de

cisi

on r

ules

for

ser

oton

in t

oxic

ity”

. QJM

96

(9):

635–

42

97Coma “AEIOU TIPS”

Com

a “A

EIO

U T

IPS”

A :

Alc

ohol

E

: E

ncep

halo

path

y,

endo

crin

e (t

hyro

id, e

tc.)

, el

ectr

olyt

e ab

norm

alit

y I :

ID

DM

O

: Opi

ates

, oxy

gen

depr

ivat

ion

U : U

rem

ia

T :

Trau

ma,

tem

pera

ture

I :

Inf

ecti

on

P :

Psy

chos

is, p

orph

yria

S :

Spa

ce-o

ccup

ying

lesi

on,

stro

ke, S

AH

, sho

ck


Ultrasound and Pregnancy

Ultrasound .......................................................... 100

Ectopic Pregnancy ............................................. 101

16

100 Ultrasound

Use

d w

ith

perm

issi

on f

rom

Fir

st A

id f

or t

he E

mer

genc

y M

edic

ine

Cle

rksh

ip 3

rd E

d., b

y St

ead

et a

l., M

cGra

w H

ill, 2

011

Ult

raso

und

Tran

svag

inal

US

IUP

Fin

ding

s

Ges

tati

onal

sac

(ar

row

head

):•

HC

G >

1,0

00 (

5 w

eeks

)

− Yol

k sa

c (a

rrow

):•

HC

G >

2,5

00

− H

eart

ton

es:

•

HC

G >

10,

500–

17,0

00

−

101Ectopic Pregnancy

Suspected ectopic pregnancy

Yes

No

Not pregnantPregnant

Consideralternativediagnosis

Performendovaginal

US

IUPEctopicpregnancy

Non-diagnosticIUP (NDIUP)

Abnormal IUP

Assistedreproductivetechnology?

Consult OB,type and screen,

2 large PIV’s

Obtain quantHCG

>1,500<1,500

Consult OBRisk stratify

Lowsuspicion

Highsuspicion

D/C with ectopicprecautions and

f/u quant in 48–72 h

Consult OB

Consider alternative

diagnosis andstandard

prenatal care

Consult OB

Consult OB

Reproduced with permission of F. E. Flach, M.D. University of Florida Pregnancy Algorithm

Ectopic Pregnancy


The Red Eye

The Red Eye ........................................................ 104

17

104 The Red Eye

The Red Eye

Red eye

Pain/photophobia?

Purulent?

NoYes

Watery?

Bacterialconjunctivitis

Allergic or viral

conjunctivitis

Fever/rash?

Evaluate for iritis/uveitis,glaucoma, or keratitis

Eye discharge

NoYes

Yes No

Think Kawasaki’s(Peds), SJS

Eyeitching?

Yes No

Allergic conjunctivitis,Blrepharitis,

dry eye

Dry eye or topical

toxicity


Pediatrics

Pediatric Vital Signs .......................................... 106

Kocher Criteria .................................................. 107

Pediatrics ............................................................ 108

Salter-Harris Fractures (SALTR) .................... 109

Pediatric Ossification Centers .......................... 110

Pediatric GCS..................................................... 111

Bilirubin Nomogram ......................................... 112

Pediatric Head CT Criteria .............................. 113

Sick Neonate “THE MISFITS” ....................... 114

Pediatric Fever Neonate ................................... 115

Pediatric Fever (1–2 Month Old Infant) ......... 116

Pediatric Fever (2–3 Month Old Infant) ......... 117

Pediatric Abdominal Pain ................................. 118

18

106 Pediatric Vital Signs

Ped

iatr

ic V

ital

Sig

ns

Age

R

R

HR

SB

P

DB

P

Neo

nate

(30

da

ys)

40–6

0 10

0–18

0 (1

95)

60–9

0 20

–60

1–12

mon

ths

30–6

0 10

0–16

0 (1

95)

70–1

10

50–7

0

13–2

4 m

onth

s 24

–40

80–1

10 (

132)

74

–110

55

–75

2–5

year

s 22

–34

70–1

10 (

132)

80

–112

55

–75

6–7

year

s 18

–30

65–1

10 (

132)

85

–115

57

–75

8 (a

dole

scen

t)

16–2

0 65

–90

(108

) 95

–125

65

–80

HR

in p

aren

thes

es r

epre

sent

s po

ssib

le H

R in

feb

rile

oth

erw

ise

heal

thy

child

107Kocher Criteria

Koc

her

Cri

teri

a

Cri

teri

a

Ery

thro

cyte

sed

imen

tati

on

• R

ate

>40

W

BC

>12

•

Non

-wei

ght-

bear

ing

of t

he

• lo

wer

ext

rem

ity

Feve

r •

Scor

ing

If o

nly

one

sign

is p

rese

nt, t

here

•

is a

3 %

cha

nce

the

child

has

a

sept

ic h

ip

2/4

crit

eria

= 4

0 %

•

3/4

crit

eria

= 9

3 %

•

4/4

crit

eria

= 9

9 %

•

Ada

pted

from

Koc

her

et a

l. V

alid

atio

n of

a C

linic

al P

redi

ctio

n R

ule

for

the

Diff

eren

tiatio

n B

etw

een

Sept

ic A

rthr

itis

and

Tran

sien

t Sy

novi

tis o

f the

Hip

in C

hild

ren.

The

Jou

rnal

of B

one

and

Join

t Sur

gery

(A

mer

ican

) 86

:162

9–16

35 (

2004

).

108 Pediatrics

Ped

iatr

ics

AP

GA

R

App

eara

nce

• 2:

Ent

ire

body

pin

k

− 1:

Bod

y pi

nk, e

xtre

mit

ies

blue

− 0:

Ent

ire

body

blu

e

− Pul

se•

2: >

100

−

1: <

100

−

0: A

bsen

t

− Gri

mac

e•

2: V

igor

ous

cry,

cou

gh, s

neez

e

− 1:

Gri

mac

e, w

eak

cry

−

0: N

o re

spon

se

− A

ctiv

ity

• 2:

Act

ive

−

1: S

ome

−

0: N

one

− R

espi

rati

ons

• 2:

Str

ong

−

1: W

eak,

irre

gula

r

− 0:

Non

e

−

ET

T S

ize/

Dep

th

Use

Bro

selo

w t

ape!

•

Form

ula

uncu

ffed

= (A

ge/4

) + 4

•

109Salter-Harris Fractures (SALTR)

Salt

er-H

arri

s Fr

actu

res

(SA

LTR

)

SS

lippe

dA

Abo

veL

Low

er

TT

hrou

ghR

Rui

ned

III

III

IVV

110 Pediatric Ossification Centers

Ped

iatr

ic O

ssi fi

cati

on C

ente

rs

C –

cap

itellu

m

(1–2

yea

rs)

R –

rad

ial h

ead

(2–4

yea

rs)

I –

inte

rnal

mal

leou

s (4

–6 y

ears

)

T –

troc

hlea

r (6

–8 y

ears

)O

– o

lecr

onon

(8

–10

year

s)E

– e

xter

nal m

alle

olus

(1

0–12

yea

rs)

E

R

I

TC

O

IC

R

O

111Pediatric GCS

Ped

iatr

ic G

CS

Eye

ope

ning

V

erba

l M

otor

4—Sp

onta

neou

s 5—

Age

-app

ropr

iate

spe

ech

6—O

beys

com

man

ds

or s

pont

aneo

us

mov

emen

t

3—To

voi

ce

4—L

ess

than

usu

al;

irri

tabl

e cr

y 5—

Loc

aliz

es p

ain

2—To

pai

n 3—

Cri

es t

o pa

in

4—W

ithd

raw

s pa

in

1—N

one

2—M

oans

to

pain

3—

Fle

xion

to

pain

1—N

one

2—E

xten

sion

to

pain

1—

Non

e

112 Bilirubin Nomogram B

iliru

bin

Nom

ogra

m

25 20 15 10 5

Ris

k fa

cto

rs•

Jaun

dice

in th

e fir

st 2

4 h

• V

isib

le ja

undi

ce b

efor

e di

scha

rge

• P

revi

ous

jaun

dice

d si

blin

g•

Ges

tatio

n ≤

38 w

eeks

• E

xclu

sive

bre

astfe

edin

g

012

3660

8410

824

4872

9612

0

Hig

h r

isk

zon

e

NS

B >

25:

Neo

nato

logy

pho

ne c

onsu

lt: c

onsi

der

exch

ange

tran

sfus

ion

in th

e he

alth

y te

rm in

fant

NS

B >

20:

Con

side

r ex

chan

ge tr

ansf

usio

n in

the

Hem

olyt

ic te

rm in

fant

or

heal

thy

near

-ter

m in

fant

Pho

toth

erap

y an

dN

SB

in 6

–12

h†

NS

B in

24

h†

NS

B in

48

h†

Age

, h

0

Neonatal serum bilirubin, mg/dL

Lo

w r

isk

zon

e

† A T

cB m

ay b

e su

bstit

uted

for

NS

B. N

ear

exch

ange

leve

ls, a

ND

B is

pre

ferr

edN

SB

= N

eona

tal s

erum

bili

rubi

n; T

cB =

Tra

nscu

tane

ous

bilir

ubin

Low

inte

rmed

iate

risk

zon

eH

igh

inte

rmed

iate

risk

zon

e

• E

ast A

sian

rac

e•

Bru

isin

g ce

phal

ophe

mat

oma

• M

ater

nal a

ge >

25

year

s•

Mal

e ge

nder

113Pediatric Head CT Criteria

Ped

iatr

ic H

ead

CT

Cri

teri

a

Age

>2

year

s

CT

O

bser

ve

or C

T

AM

S or

GC

S <

14

Yes

Skul

l FX

Y

es

h/o

LO

C

Yes

h/o

Vom

itin

g Y

es

Hea

dach

e Y

es

Age

<2

year

s (<

3 m

onth

s = C

T)

CT

O

bser

ve o

r C

T

AM

S or

GC

S <

14

Yes

Skul

l FX

Y

es

Scal

p he

mat

oma

Yes

LO

C >

5 s

Yes

N

ot n

orm

al p

er

pare

nt

Yes

A

dapt

ed fr

om: K

uppe

rman

n N

et a

l. Id

enti

fi cat

ion

of c

hil-

dren

at

very

low

ris

k of

clin

ical

ly-i

mpo

rtan

t br

ain

inju

ries

af

ter

head

tra

uma:

A p

rosp

ecti

ve c

ohor

t st

udy.

Lan

cet

2009

Sep

15

114 Sick Neonate “THE MISFITS”

Sick

Neo

nate

“T

HE

MIS

FIT

S”

•

T ra

uma

•

H ea

rt d

isea

se/c

onge

nita

l

• E

ndoc

rine

/ele

ctro

lyte

• M

etab

olic

• I n

born

err

ors

of

met

abol

ism

• S e

psis

•

F or

mul

a (t

oo d

ilute

/co

ncen

trat

ed)

•

I nte

stin

al c

atas

trop

he

•

T ox

ins

•

S eiz

ures

115Pediatric Fever Neonate

Ped

iatr

ic F

ever

Neo

nate

Neo

nate

(0–2

8 da

ys)

Afe

brile

,w

ell a

ppea

ring

Afe

brile

,A

OM

Cor

e te

mp

>38

C (

100.

4 F

)

Afe

brile

, ill-

appe

arin

g, o

rhy

poth

erm

ic

Rea

ssur

ance

an

d an

ticip

ator

ygu

idan

ce

Obs

erve

rech

eck

in

24 h

Abx

if fu

ll se

psis

w/u

per

form

ed

or fe

brile

Ful

l sep

sis

eval

uatio

nC

BC

, blo

od c

x, U

A,

urin

e cx

, CS

F, C

XR

Adm

it an

d be

gin

Abx

Ada

pted

from

Ped

iatr

ic E

mer

genc

y M

edic

ine

Rep

orts

, Her

nand

ez a

nd N

guye

n “F

ever

in I

nfan

ts <

3 M

onth

s O

ld: W

hat i

s th

e C

urre

nt S

tand

ard?

”

116 Pediatric Fever (1–2 Month Old Infant)

Pediatric Fever (1–2 Month Old Infant)

2–3 months old

If normal:Discharge home

with 24 hf/u and no abx

UA, UC, CXR

Full sepsisw/u and

admit with abx

+ RSV or+ Flu?

Modified sepsisw/u withoutLP or abx

Full sepsisw/u and

admit with abx

Full sepsisw/u and

admit with abx

>38.5 C and/or on abx

>38 C

Afebrileand ill

Feverand ill

Fever,well-appearing

Treat asneonates

6–8 weeks4–6 weeks

Admit with abx

Abnormal UAor CXR

If normal:Discharge home

with 24 hf/u and no abx

Adapted from Pediatric Emergency Medicine Reports, Hernandez and Nguyen “Fever in Infants <3 Months Old: What is the Current Standard?”

117Pediatric Fever (2–3 Month Old Infant)

Ped

iatr

ic F

ever

(2–

3 M

onth

Old

Inf

ant)

2–3

mon

ths

old

Wel

l, bu

t cor

ete

mp

> 3

8.5

CU

nwel

l and

ill

appe

arin

g

Low

ris

k fo

r S

BI:

Dis

char

ge w

ith

24 h

f/u

(no

LP =

no

abx)

Hig

h ris

k fo

r S

BI:

LP, a

dmit

and

abx

CB

C, b

lood

cx,

U

A, U

C, C

XR

, co

nsid

er L

P

+ R

SV

, B

ronc

hiol

itis,

+ fl

u, o

r +

vira

lill

ness

Ful

l Sep

sis

w/u

and

adm

it w

ith a

bx

UA

, UC

, CX

R(t

reat

with

abx

ifpo

sitiv

e w

ithlik

ely

disc

harg

e)

Ada

pted

from

Ped

iatr

ic E

mer

genc

y M

edic

ine

Rep

orts

, Her

nand

ez a

nd N

guye

n “F

ever

in I

nfan

ts <

3 M

onth

s O

ld: W

hat i

s th

e C

urre

nt S

tand

ard?

”

118 Pediatric Abdominal Pain

Ped

iatr

ic A

bdom

inal

Pai

n

Neo

nate

2

mon

ths

to

2 ye

ars

2–5

year

s O

ver

5 ye

ars

Mal

rota

tion

wit

h m

idgu

t vo

lvul

us

Non

-acc

iden

tal t

raum

a N

on-a

ccid

enta

l tra

uma

Non

-acc

iden

tal

trau

ma

Pyl

oric

ste

nosi

s In

carc

erat

ed h

erni

a A

ppen

dici

tis

App

endi

citi

s

Nec

roti

zing

ent

eroc

olit

is

Intu

ssus

cept

ion

Intu

ssus

cept

ion

Dia

beti

c ke

toac

idos

is

Test

icul

ar t

orsi

on

Hir

schs

prun

g di

seas

e O

vari

an t

orsi

on

Sick

le c

ell s

yndr

ome

Vas

o-oc

clus

ive

cris

is

Mec

kel’s

div

erti

culu

m

Hem

olyt

ic u

rem

ic

synd

rom

e O

vari

an t

orsi

on

Hep

atit

is

Mec

kel’s

div

erti

culu

m

Cho

lecy

stit

is

Pan

crea

titi

s

Hem

olyt

ic u

rem

ic

synd

rom

e


Head and Neck

Modified Centor (McIsaac) Criteria for Evaluation of Pharyngitis ........................ 120

Retropharyngeal Abscess ................................. 121

Epiglottitis .......................................................... 122

19

120 Modified Centor (McIsaac) Criteria

Mod

i fi ed

Cen

tor

(McI

saac

) C

rite

ria

for

Eva

luat

ion

of P

hary

ngit

is

Poi

nts

Tota

l sco

re a

nd r

isk

1 −

1 or

0 (

1 %

)

1 1

(10

%)

1 2

(17

%)

1 3

(35

%)

1 4

(>50

%)

−1

5 (>

50 %

)

If s

core

1–3

, get

rap

id t

est

If s

core

>4,

tre

at e

mpi

rica

lly

Ada

pted

fro

m M

cIsa

ac, W

J et

al.

Em

piri

cal

Val

idat

ion

of G

uide

lines

for

the

Man

agem

ent

of P

hary

ngit

is i

n C

hild

ren

and

Adu

lts .

JAM

A. 2

004

Apr

il 7;

291

: 158

7–15

95

121Retropharyngeal Abscess

Retropharyngeal Abscess

*Solid arrow represents large amount of prevertebral edema *Dashed arrow represents air Used with permission from fi rst aid for the emergency medicine clerk-ship, 3rd Ed., by Stead et al., McGraw Hill

122 Epiglottitis

From fi rst aid for the emergency medicine clerkship, 3rd Ed., by Stead et al., McGraw Hill

Epiglottitis


Statistics

Statistics ......................................................... 124

20

124 Statistics

Stat

isti

cs

Sen

s =

a/a

+c

PP

V =

a/a

+b

Sp

ec =

d/b

+d

NP

V =

d/c

+d

RR

= (

a/a+

b)/(

c/c+

d)O

R =

ad/

bcA

RR

= (

a/a+

b)/(

c/c+

d)N

NT

= 1

/AR

R

Dis

ease

No

dise

ase

Pos

itive

Neg

ativ

e

a c

b d

Sens

sen

siti

vity

, Sp

ec s

peci

fi cit

y, R

R r

elat

ive

risk

, A

RR

adj

uste

d re

lati

ve r

isk,

PP

V p

osit

ive

pred

icti

ve v

alue

, N

PV

ne

gati

ve p

redi

ctiv

e va

lue,

OR

odd

s ra

tio,

NN

T n

umbe

r ne

eded

to

trea

t


Infusions, Pressors, and RSI

Medications and Infusions ................................ 126

21

126 Medications and Infusions

Med

icat

ions

and

Inf

usio

ns

Am

ioda

rone

1

mg/

min

× 6

h

Pus

h D

ose

Pre

ssor

s

0.5

mg/

min

× 1

8h

Epi

neph

rine

(1:

10,0

00 =

1 m

g/10

ml)

Dec

adro

n 0.

6 m

g/kg

(10

mg

max

) 1

cc e

pi a

nd 9

cc

NS =

1:10

0,00

0= 10

mcg

/ml

Dop

amin

e 5–

20 m

cg/k

g/m

in

Adm

inis

ter

0.5–

2 cc

IV

q2–

5 m

in

Dob

utam

ine

5–20

mcg

/kg/

min

Epi

neph

rine

0.

05–1

mcg

/kg/

min

Epi

neph

rine

SC

0.

1–0.

5 m

g SQ

Esm

olol

50

0 m

cg/k

g fo

r 1

min

50–1

00 m

cg/k

g/m

in

Fent

anyl

1

mcg

/kg/

min

Lab

etal

ol

0.5–

2 m

g/m

in

Las

ix

0.25

–0.7

5 m

g/kg

/h

Lev

ophe

d 1

mcg

/min

Man

nito

l 1–

2 g/

kg

Nit

rogl

ycer

ine

5–20

mcg

/min

127Medications and Infusions

Nit

ropr

ussi

de

0.5–

4 m

cg/k

g/m

in

Pen

toba

rb

1 m

g/kg

/h (

1–5

mg/

kg lo

ad)

Phe

nyle

phri

ne

0.1–

10 m

cg/k

g/m

in

Phe

nyle

phri

ne (

10 m

g/m

l)

Pro

cain

amid

e 3–

6 m

g/kg

ove

r 5

min

1

cc =

10

mg

20–8

0 m

cg/k

g/m

in

Inje

ctio

n in

to 1

00 c

c N

S =

100

mcg

/ml

Pro

pofo

l 10

mcg

/kg/

min

tit

rate

A

dmin

iste

r 0.

5–2

cc I

V q

2–5

min

Vas

opre

ssin

0.

01–0

.04

unit

s/m

in

Ver

sed

0.02

–0.1

mg/

kg/h

RSI

Eto

mid

ate

0.3

mg/

kg

Ket

amin

e 2

mg/

kg

Lid

ocai

ne

1–1.

5 m

g/kg

Roc

uron

ium

0.

5–1

mg/

kg

Succ

inyl

chol

ine

1–1.

5 m

g/kg

Vec

uron

ium

0.

1 m

g/kg

(0.

01 d

efas

c)

Ver

sed

0.1

mg/

kg

129129B. Allen et al., Quick Hits in Emergency Medicine, DOI 10.1007/978-1-4614-7037-3, © Springer Science+Business Media New York 2013

A Abdominal pain, pediatric , 118 Acetaminophen , 91, 92 Acidosis , 24, 40, 94 ACLS . See Advanced Cardiovascular

Life Support (ACLS) Acute coronary syndrome , 73 Advanced Cardiovascular Life

Support (ACLS) bradycardia , 3 description , 2 electromechanical dissociation , 5 PEA and asystole , 4 v- fi b , 5 v-tach , 5

Advanced Trauma Life Support (ATLS)

AMPLE history , 39 checklist , 42 primary survey , 38 shock , 43

Airway Cormack-Lehane airway

grades , 10 and intubation ( see Intubation)

Amiodarone , 126 AMPLE history , 39 Anion gap metabolic acidosis , 94 Antidotes , 93 Aortic dissection , 35 APGAR , 108 Aspirin (ASA) , 91

ATLS . See Advanced Trauma Life Support (ATLS)

B Bilirubin nomogram , 112 BPPV, Broselow tape , 108 Brugada criteria, V-Tach , 81 Brugada syndrome , 80 Burn classi fi cations , 45

C Canadian C-spine , 60 Cardiac arrest , 5 Cardiology

acute coronary syndrome , 73 Brugada criteria, V-Tach , 81 Brugada syndrome , 80 differential diagnosis, chest pain , 72 LAH , 77 LVH , 75 Sgarbossa’s criteria , 78–79 STEMI vs. benign early repol , 74 Wellens’ sign/syndrome , 82

Centor , 120 Cerebrospinal fl uid (CSF)

analysis , 32 Cervical spine alignment and

distances , 58 Chest pain, differential diagnosis , 72

Index

130 Index

Chest x ray (CXR) , 62–63 Chronic obstructive pulmonary

disease (COPD) hospital admission criteria , 21 ICU admission criteria , 21 mechanical ventilation , 11

Coma , 93, 97 Compartment syndrome , 68 Conjunctivitis , 104 COPD . See Chronic obstructive

pulmonary disease (COPD) Cormack-Lehane airway grades , 10 CURB-65 , 18 CXR . See Chest x ray (CXR)

D Dehydration , 28, 30 Dens fracture, Dialyzable toxins , 95 DIC . See Disseminated intravascular

coagulation (DIC) Disseminated intravascular

coagulation (DIC) , 88

E Early goal-directed therapy , 15 Ectopic pregnancy , 101 Electrolyte equations , 30 Emphysema, Epidural hematoma , 53 Epiglottitis , 122 Epinephrine , 126

F Flexor tenosynovitis , 68 Fractional excretion of sodium

(FeNa) , 30

G Gastrointestinal (GI)

bleeding/hemorrhage , 84 Glasgow-Blatchford Score , 85

GCS . See Glasgow Coma Scale (GCS) Gestational sac , 100 GI . See Gastrointestinal (GI) Glasgow-Blatchford score , 85 Glasgow Coma Scale (GCS) , 41,

111 Glaucoma , 104

H Headache , 35 Head and neck , 119–122 Head CT criteria , 113 Head CT Decision Rules

blood , 52 brain and bone , 52 Canadian , 50 cisterns , 52 mild head injury/TBI , 48 Nexus-II , 49 Orleans Criteria , 51

Heart tones , 100 Hematology , 87–88 Hemodynamics , 16 Hemorrhage

classi fi cations , 44 shock , 43

Hypercalcemia , 29 Hyperkalemia (Hyper-K) , 24 Hypernatremia , 27 Hypokalemia (Hypo-K) , 25 Hyponatremia , 26 Hypothermia , 40 Hypovolemic shock , 43

I ICH . See Intracranial hemorrhage

(ICH) Idiopathic thrombocytopenic

purpura (ITP) , 88 Infusions , 126–127 Intracranial hemorrhage (ICH)

epidural hematoma , 53 subarachnoid hemorrhage , 55 subdural hematoma , 54

131Index

Intubation description , 8 dif fi cult tracheal , 10 Mallampati , 9, 10

Intussusception , 118 Iritis , 104 ITP . See Idiopathic

thrombocytopenic purpura (ITP)

IUP , 100

K Kanavel’s signs , 68 Keratitis , 104 Ketamine , 127 Kocher criteria , 107

L LAH . See Left atrial hypertrophy

(LAH) LBBB . See Left bundle branch

block (LBBB) Left atrial hypertrophy (LAH) , 77 Left bundle branch block (LBBB) ,

78, 79 Left ventricular hypertrophy

(LVH) , 75 LVH . See Left ventricular

hypertrophy (LVH)

M Mechanical ventilation , 11 Meckel’s diverticulum , 118 Mediastinum , 62 MI . See Myocardial

infarction (MI) Migraine , 35 Myocardial infarction (MI) , 73, 78

N Neck fracture , 60 Necrotizing enterocolitis , 118

Negative predictive value (NPV) , 124

Neurogenic shock , 43 Neurology

CSF analysis , 32 San Francisco Syncope Rule , 33 stroke and headache , 35 TPA, stroke , 34 vertigo , 36

Nexus C-Spine , 59 Head CT Decision Rule,

Nexus-II , 49 NNT . See Number needed to

treat (NNT) Non-anion gap metabolic

acidosis , 94 NPV . See Negative predictive value

(NPV) Number needed to treat

(NNT) , 124

O Obstructive shock

cardiac tamponade , 43 tension pneumothorax , 43

OD . See Overdose (OD) Odds ratio (OR) , 124 OR . See Odds ratio (OR) Orthopedics

compartment syndrome , 68 disposition , 69 fl exor tenosynovitis , 68 Ottawa ankle and foot , 66 Ottawa knee , 67

Osmolarity , 30 Ottawa ankle and foot , 66 Ottawa knee , 67 Overdose (OD) , 91

P Pediatric fever

neonate , 115 old infants , 116, 117

132 Index

Pediatrics abdominal pain , 118 APGAR , 108 bilirubin nomogram , 112 fever neonate , 115 GCS , 111 head CT criteria , 113 Kocher criteria , 107 old infants , 116, 117 Ossi fi cation Centers , 110 SALTR , 109 sick neonate “THE

MISFITS,” 114 vital signs , 106

PERC . See Pulmonary embolism rule-out criteria (PERC)

Pharyngitis , 120 Pneumonia , 18, 62 Pneumothorax , 62, 72 Positive predictive value

(PPV) , 124 PPV . See Positive predictive

value (PPV) Pressors and RSI , 125–127 Primary survey , 38 Propofol , 127 Pulmonary embolism

PERC , 19 Wells score , 20

Pulmonary embolism rule-out criteria (PERC) , 19

Push-dose pressors , 125–127

R Radiopaque substances , 95 Rapid sequence

intubation , 127 Red eye , 104 Relative risk , 124 Resuscitation , 14 Retropharyngeal abscess , 121

S Salter–Harris Fractures

(SALTR) , 109 SALTR . See Salter–Harris

Fractures (SALTR) San Francisco Syncope

Rule , 33 Sensitivity , 124 Sepsis

septic shock , 14, 15 severe , 14 SIRS , 14

Septic shock , 14, 15 Serotonin syndrome , 96 Severe sepsis , 14, 15 Sgarbossa criteria , 78–79 SIRS . See Systemic In fl ammatory

Response Syndrome (SIRS) Speci fi city , 124 Statistics , 124 STEMI . See ST segment elevation

myocardial infarction (STEMI) Stroke

and headache , 35 TPA , 34

ST segment elevation myocardial infarction (STEMI)

vs. benign early repol , 74 and sepsis , 14

Subarachnoid hemorrhage , 55 Subdural hematoma , 54 Systemic In fl ammatory Response

Syndrome (SIRS) , 14

T TBI . See Traumatic Brain Injury

(TBI) Thrombotic thrombocytopenic

purpura (TTP) , 88 Tissue plasminogen activator

(TPA) , 34 Toxicology

acetaminophen nomogram , 92 anion gap metabolic acidosis , 94

133Index

coma “AEIOU TIPS,” 97 coma cocktail , 93 dialyzable toxins , 95 ingestions , 91 non-anion gap metabolic

acidosis , 94 radiopaque substances , 95 serotonin syndrome , 96

Toxidromes , 90 Transfusion , 112 Transvaginal ultrasound , 100 Traumatic Brain

Injury (TBI) and mild head injury , 48 shock , 43

TTP . See Thrombotic thrombocytopenic purpura (TTP)

U Ultrasound and pregnancy , 99–101

V Ventilator settings , 11 Ventricular fi brillation (v- fi b) , 2, 5 Ventricular tachycardia (v-tach) , 2, 5 Vertigo , 36

W Wellens sign/syndrome , 82 Wells score , 20

Y Yolk sac , 100

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Transcript of 123 - BUKU SUDIRMAN(SIRS) and Sepsis SIRS diagnosis requires two or more to be present Body...