Basics of Emergency Medicine

28 Pages·2017·9.498 MB·English

by  Joseph Habboushe, MD, MBA, Eric M. Steinberg, DO, FACEP

TABLE OF CONTENTS
Headache ~8
Head Injury ~9
EyeComplaints ~ 10
Altered Mental Status (AMS)~ 11
Intoxication ~ 12
Dizzy/Lightheaded ~ 13
Shortness of Breath (SOB)~ 16
Asthma ~ 17
Chest Pain(CP)~ 18
Vomiting ~ 19
Abdominal Pain(AP)~20
AP Upper ~21
AP Diffuse +Flank ~22
AP Lower~23
Vaginal Bleeding
(VB)~24
Back Pain~25
Fever~29
Syncope/Pre-Syncope~30
Foot) Weakness~31
Rash~32
Ankle and
Injuries ~28 Important PhoneNumbers _7
Glossary
AM Abdominal Aortic Aneurysm ICP Intracranial Pressure
ABx Antibiotics IIH Idiopathic Intracranial
APAP Tylenol Hypertension
APD Afferent Pupillary Defect lOP Intraocular Pressure
ASA Aspirin JVD Jugular Venous Distention
BIL Bilateral LOC Loss ofConsciousness
BMP Basic Metabolic Panel MAP Mean Arterial Pressure
BCX Blood Cultures MES-I Mesenteric Ischemia
Bx Biopsy MRA MR-Angiography
Coags PT/PTIlINR NN Nausea
CP Chest Pain NPO Nothing byMouth
CT-A CTangiography OBS Observation
CVA Stroke orCostoVertebral OCP Oral Contraceptive Pills
Angle OMFS Oral &Maxillofacial
CXR Chest x-ray Surgery
D/C Discharge (2meanings) PMP Primary Medical Provider
DM Diabetes Mellitus PNA Pneumonia
DTR Deep tendon reflex PTA Peritonsillar Abscess
EHL Extensor Hallucis Longus PTX Pneumothorax
EtOH Alcohol PUD Peptic Ulcer Disease
FND Focal Neuro Deficit RIO Rule Out
FOBT Fecal Occult Blood Testing RPA Retropharyngeal Abscess
FlU D/C Home with SAH Subarachnoid Hemorrhage
Follow-up Appt SBP Spontaneous Bacterial
Full ROM Full Range of Motion Peritonitis
FSBG Finger Stick Blood Glucose sa Subcutaneous
Gluc Glucose Sx Symptoms
hlo History of TIA Transient Ischemic Attack
HOB Head of Bed TIP Tenderness toPalpation
HA Headache VBG Venous Blood Gas
HR Heart Rate VSS Vital Signs Stable
ICH Intracranial Hemorrage WPW Wolff-Parkinson-White
Headache
• First HA•Different from previous HA•Sudden onset
Worst HA•Syncope· Neck stiffness· Significant trauma
III-appearing •Meningeal siqns sNeuro deficit
I I' I' , ,
Acuteglaucoma Unilateral, blurry,fixed pupil SeeEyeComplaints, p.10
Carotidartery dissect Unilateral, neckpain,trauma? CTAIMRA,US Anticoagulation, csnrsrg
COPoisooing Weakness, nIv,exposure? Co-oximetry, VBG 100% 0,
Encephalitis Fever,AMS,seizures? CTILP IVABx!antitlraVisolation
Encephalopathy (HTN) dBP>120,AMS,?11vision vend organs MAP! $25%
Meningitis Fever,stiffneck,photophobia, CT/LP SteroidsbeforeABx,beforeLP,
- rash isolation
- Preeclampsia >20 weeks upto6weeks LFTS/CBC/UA Mag,BPcontrol, CsOBiGYN
- poastpartum, iBP,HA
Pseudotumor (IIH) Overweight, young,visual Sx CT,LP LP,acetazolamide?
SAH Sudden,worst, syncope? CTIlP BPcontroVcs nrsrg
Temporal arteritis! Unilateral, >55 y/o,tender ESR Steroids, FlUwith
giantcellarteritis temporal artery,jaw pain ophthalmology/rfleumatology
Traumatic ICH Trauma, EtOH,elderly CT Csneurosurgery
Cluster Unilateral, sudden, orbital, tears, male,tobacco, 40s 0,
*l!l Migraine Unilateral, NN,photophobia Clinical NSAIDs,metoclopramide,lVF
.§.Sinusitis URI,sinustendemess! Clinical, CT? Nasalspray/pseudoephedrine,
s
opacified ABx'>
""
Tension BIL,tight Exdusion Paincontrol
Documentation
Pearls+Pitfalls
Onset,unilateralvs.BIL,similartoprevious
•AcuteHA+syncope=SAH Fever,suppleneck,photophobia
•HTNrarelycausesHA Pupils
•>50y/oandNEWHA~ conceming Fullneurological exam
I8aydoun S,Lanolx R. Updated byGupta N,Cophn M,Gutterodge D,JIang L,Robak M.
Headache
Head Injury
• LOC • Blood thinners •Vomiting •Seizure
Significant mechanism· Severe HA• Elderly
•Alcoholic • Intoxicated •Neuro deficit
Skull Fx(Battle's sign, raccoon eyes, nasal CSFleak, hemotympanum)
• Pupils asymmetrical· Distracting injury
Brain C-Spine
BEST RULE: Canadian BESTRULE: Canadian C
Head CTRule Spine Rule (CCR)
• Using only major criteria will • More sensitive andspecific
capture -100% ofpatients requiring than Nexus
intervention
SAH,subduralhematoma, epidura~ICH,skullFx FacialFracture
:Consu~neurosurgery :Nasal~ FlUwith PMDIENT
:Closelyobserveneurological stalus :Orbital~ Ophtho/OMFScensult
LCon~ider,Antiseizure meds,jICp,ICU :,Dth,er-:c.c,onsiderconsult O,MFS"
GCS I 1 I 2 I 3 I 4 I 5 I 6
Eyes Closed Withpain Withvoice Spontaneous
Verbal Nosounds Now()(ds Inappropriate Confused Normal
Motor None Posture Posture Withdraws Localize Obeys
(extension) (flexion) frompain pain
Pea~s+Pitfalls Documentation
• Bder1yoralcoholics:Bewaresubdural General:LOC,NN,Sz,elderly,alcoholic,distractinginjury,
• Lucenlperiod:Epidural bloodthinneruse
• CCHR:Q()('tforgettolookinears Head:Deformrties,TMs,nasalseplum,pupils,lacs/abrasions
• Anticoagulants(notantiplatelets) Neuro:Fullexam
considerdelayedbleed MVC:Mechanism,betted,alrbag,totaled
Geracimos D,Habboushe J,l.anoix R. Updaled byGupta N,Bennett J,Sperling J,Pendery L,Neshelwall. I
Headlniury
•
Eye Complaints
TRAUMATIC
X&PE REATMENT
·Blowout Ix EOM'eno hthalmos Cs0 htho/ENT
·Chemical conunct Exosure:alkali» acid Coiousirri ation ABx
Corneal abrasion FBsensation' flrsnutake RemoveFB'ABx tt
*Eelidlaceration Tarsus/canthus involved? Reairb 0 htho
·Globe ru lure irre ular u il+Seidel Protectivecu
*Retrobulb hematoma Protosis:APD'!EOM' lOP Lateralcanthotom A is
Subcon hemmorna e Bloodcollection insclera AvoidASA/NSAID
ATRAUMATIC
0'
Clinical ABxdro s Faifcontacts
'Corneal ulelll' Clini I ABxdni s/oint·nocontacts
£'" Eiscleritis Clinical NSAIDself-limited
'Herpes Zoster Clinical Systemic+topicalantiviral
E
0hthalmicus
~ ·Keratitis Clinical TopicalCYCloplegic
'Scleritis Clinical NSAID,topicalsteroid
Clinical To steroid+ cia Ieic
Cardiacw/u Occularmassage?
ESRlCRP !lOP
Clinical Mana eHTNDM
Clinical IntravitrealABx
Clinical Top+systemiclOPmeds
CBC'coa s Situ avoidASAINSAID
OcularUS Cs0htho
Clinical Wanmcom ress ABxoint
MRI Considersteroids.Csneuro
CTface' csc IVABx
Clinical Wanmcom ress POABx
Documentation RED (FBMllrlle) PAIN
PMH: Fever,Neurosymptoms, Episcleritis
Systemic symptoms, Painful!
painless vision change?
Skin: Rash(vesicles, _--
erythema, etc.),laceration
Eyes: Pupils, EOM,visual
acuity, visual field, lOP, •.•....
•..•.•
fluorescein uptake/staining,
fundoscopy, slitlamp BokI_Opblhoconsult
InEDortIosefollow-up VISION CHANGE/LOSS
Lee H,Steinberg E,Nagori S,LoC.
EyeComplaints
Immediate Actions
Check FS_ 050 • Opioid with resp depression _ naloxone • Uncooperative - sedate +restrain
AEIOU TIPS
" "
Alcohol (See +Alcohol onbreath Clinical, EtOHlevel? Observe
A Intoxication, p.12)
Alcohol withdrawal Confusion, anxiety, Clinical, EtOHlevel Anxiolytic, IVF,consider admit
diaphoresis, BP.tremors ifCIWA>10
8ectrolytes BMP,EKG
Encephalopathy (Hep) Jaundice, cirrhotic LFTs,ammonia Lactulose, neomycin
Encephalopathy (HTN) HA,diastolic BP>120 -JEndorgans MAPj';25%
I Insulin OM FSBG 050
0 Opiates Pupils, RR Naloxone Observe, naloxone?
U Uremia Renalfailure, AVfistula BUN/Cr Dialysis (csrenal)
Trauma Pupils,bloodloss? CThead CsneurosurgeryllVFs
Toxins Pupils,skin,reflexes ASA,APAP,UTox Cstox/poison control
Tumor Insidious, focaldeficit CThead Csneurosurgery
Thyrotoxicosis Tremors, )HRIT,NN TSH IVFs,propanolol
lntecflon Fever,source?, elde~y, UNCXR,+/-other IVFs,ABx,source?
SIRS sources
Polypharmacy Neworchange inmeds ToxWIU Otc,change meds
Psychiatric HIDpsychiatric illness Exclusion Cspsychiatry
Seizure Seizure hx,tongue,biting, Lactate, CThead CsorFlUneurology
S post-ictal (if1sttime)
Stroke FocalSx,timeofonset CThead Csneurology, tPA?,ASA?
Documentation
Difficultl Searchforfamily,PMD,EMSsheetprevioushospitalrecord.Documentthepatienfs contact
informatior. Tellthestoryofwhathappeneddulingresuscitation.Comparewithbaselinementalstatus.
General:LOC,NN,Sz,HA?,eldeny?+alcoholonbreath?
Head:Signsoftrauma
Neuro:Documentasbestyoucan(SeeHeadInjury,p.9).
Habboushe J,Shah K, Updated byNguyen V,Coplin M,Gutteridge D,Jian L,Nesheiwat L
#1:Fingerstick
#2:Undress/examine completely
#3:Signs oftrauma? ~ Lowthreshold forCThead
#4:Epigastric tendemess? ~ Lowthreshold forpancreatitis workup
Confident It's only alcohol?
Alcohol onbreath?Admits toEtOH?
Frequent visitsforEtOH?
Yes No
/
ConsiderIMIIVthiamineifolate ConsiderwiderAMSdifferential
Observetosobnety(A&Ox3,steadygatt) Failure to (SeeAltered Mental Status, p,tt)
Notwaking~ ConsiderCThead sober wltime? • ConsiderEtOHIASNAPAPlevels,UTox
Severelyintox~ PulseOx,capnography,
nasaltrumpet,and/ormonitor
ReassessQl-2hrs
Oncesober,assessforSIIHI
Pearts+Pitfalls
•Beware!Intoxicationmimics:
- ICH
- Hypoglycemia
- Hypothermia(incoldenvironment)
•Watchoutfordevelopingwithdrawal!
•EtOHlevelnotpredictiveofsobriety;don'troutinelycheck
Documentation
General/Neuro: GCS(SeeHeadInjury,p,9),Neurologicalexamgrosslyconsistentwith
EtOHintoxication,Frequentlyreassess,
HEENT:Signsoftrauma,PERRL
Abdominal: Epigastlictenderness
Skin:Celiulitisilacerations/abra~OI1S
Reassessment beforeD/C:1\&0x3,steadygait,nofocaldeficits,nonewcomplaints
Khan F,Habboushe J,Shah K. Updated byNguyen, Bennett J,Pendery l,Choe B,Mordel A,
DizzyILightheaded
Sees nco e 30
• Fever· Headache •Focalweakness' AMS
CP/SOB/Palps •Darkstools' Diaphoresis
Abnormal HiNTS(Headimpulse-Nystagmus-Test ofSkew)
Sensation?
Lightheaded orpre-syncope Vertigo
¥ "
BAD:Cardiac,anemia,Iglucose Central: BADUnsidious,mild,constant)
COMMON:Dehydration,nonspec Periph:COMMON(sudden,intense,intenmittent)
UseHiNTSexamtodistinguish between thetwo
VERTIGO I' I' ••• , ,
'" Isppv Positional, fatigable Dix-Hallpike Meclizine, Epleymnvr
.~ ILabyrinthitis RecentURI,~hearing Meclizine, steroids
"-
.Meniere's ~Hearing, tinnitus Meclizine, HCTZ
CVAIICH Nystagmus, ipsilateral facenumb CTIMRI Csneurology
. MS NeuroSx,20-308 MRI FlUneurology
,I:
HAcoustic neuroma Unilateral hearing loss MRI Csneurology
Carotidartery Unilateral, neckpain,trauma? CTA/MRA, Anticoagulation,
dissect US csnrsrg
LlGHTHEADED HISTORY&PHYSICALEXAM IWORKUP ITREATMENT
Cardiac (valve! CAD/CHF,SOB/CP/palps, EKG,tropanins, monitor ASA,admrttelemetry
arrhythmia) munmurs
Anemia GIbleed/melena, CSC,coags,T&S Source?Transfuse?
conjuctiva pallor,FOST
I Glucose DM,AMS FSSG D501food,(POmeds?)
Infection Elderly,source? UA/CXR,lactate Source
Orthostatic Dehydrated? Newmed? Orthostatic VSs Fluids
Nonspecific Infection? Vasovagal? Exclusion
Documentation
HEENT:Nystagmus,TMs,WNL,hearingexam,carotidbruits,noconjuncpalk<,MMM
Neuro:Complete(dysmetria;Romberg;gait;allCNs,sensation,motor),Dix-Hallpike
Heart Munmurs,arrhythmia
Seccurro S,Lanoix R, Updated byPaulis J,Arena E,Levin J,Choe 8,Mordel A.
I
Dizzy/Lightheaded
Sore Throat
• Fever· Drooling •Abdominal complaints
Uvula NOTmidline· Voice change· FBsensation
Muffled voice?Drooling? I---~ Epiglottitis
PTA
Slrep
Likelyviral
I I I
DISEASE HISTORY&PHYSICALEXAM WORKUP TREATMENT
Epiglottitis Fever,drool,~voice, Neckx-ray Airway,CsENT
FB FBsensation/stridor Clinical,CTneck ENT,scope
GC/Chl' Oralsex,discharge GClChlCx Ceftriaxone +(azithldoxy)
Ludwig's Dentaldz,neckswelling CTneck AirwaY,ABx, ENTcs
Mono Lymphadenopathy, Monospot? Supportive, nocontact sports
splenomegaly, rashafterPCN
PTA Fever,deviated uvula Clinical(US?) Aspirate,ABx,steroids
Slrep Centorcriteria" (Seecnen below) PCN(1MorPO),steroids?
Viral Fever,cough,congestion Exclusion Symptomatic treatment
'GClChl=GonorrhealChlamydia
-CENTOR CRITERIA
Fever +1 Score Slrep? Nextsteps Note:Thetreatment01strepis
Exudates +1 Oor1 <10% Nothing atopic01ongoingdebate.Many
Tenderlymphnodes +1 2or3 17-35% Test attendingphysicianswilldepart
Nocough +1 4 >50% Treat lromtheseoldguidelines.
Documentation
General:Phonationnormal
HEENT:Midlineuvula,noexudates,tonsilsnotenlarged,non-erythematous,nodrooling
Neck:Supple,nocervicallymphadenopathy
Matern J,Lanoix R. Updated byArena E,Downing J,Levin J,Bandzar S,Kleist S.
Sore Throat