Basics of Emergency Medicine PDF
Preview Basics of Emergency Medicine
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
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