Methods of Engineering Control 

(Standard Precautions)

Meant to reduce employee exposure by either removing the hazard or isolating the worker

sharps disposal container

self-sheathing needles

safer medical devices

Work Practice Controls

(Standard Precautions)

Meant to reduce the likelihood of exposure by altering how a task is performed

Wash hands after removing gloves

Do not bend or break sharps

No food or smoking in work areas

Do not recap needles

Average Risks with needle sticks and general procedure...

HIV

HBV
HCV

HIV: 0.3% - prophylaxis within 24 hours

HBV: 1-6% (with vaccination) - give passive and active immunization upon exposure

HCV: 1.8% - hope and pray

On Campus:

Between 8 - 4p M-F: Report to GW Employee Health Services

Off hours: Report to GW ER

Off Campus:

Follow site's reporting procedures

Notify preceptor, GW PA Program

MCV: size of RBC
MCH: color of RBC

MCHC: concentration of RBC

Red Cell Distribution Width

"Anisocytosis"

Indicates ongoing anemia, such that new RBCs are being actively introduced into the blood stream

Immature RBCs that are larger and bluer than mature RBCs

They contain nuclear remnants

"Polychromasia"

SHOULD be high in anemia 

Polys/PMN/Neutrophils: contain segmented nuclei, indicate bacterial infection

Lymphs: contain very large nuclei, indicate viral infection, lymphocytic anemia
Monocytes/Macrophages: infection

Eosinophils: contain red granules, indicate allergy, parasite

Basophils: contain purple granules, indicate histamine rxn (IgE)

Bands: immature polys with horseshoe nucleus, indicates severe infection

Intrinsic Pathway

Factors

Diseases

Labs

Factors: 12, 11, 9, 8

Hemophilia

Monitor PTT when on Heparin

Extrinsic Pathway

Factors

Diseases 

Labs

Factors: TF, 7 (Vitamin K dependent)

Vitamin K deficiencies and chronic liver disease

Monitor PT and INR when on Coumadin

Presentation:

Psychosis is a disturbance of reality, evidenced by hallucinations, delusions, or thought disorganization

Evaluation:

Ensure that everyone is safe!

Assess for hallucinations, delusions, ADLs, cognitive loss, and diminished verbal communication

Management:

Immediate hospitalization

Calm the pt with verbal reassurance

Haloperidol

Lorezepam

Presentation:
Variable 

Evaluation:
You must ask pt if they have a suicide plan

Assess means, availability, lethality, and likelihood of rescue

Management:

72 hour hold with constant guard

Intensive therapy

Anti-depressants

Assess for co-morbidities

Remember to plan for discharge the minute you admit them

Presentation:

Smell of EtOH, slurred speech, ataxia, confusion

Inappropriate behavior, loss of consciousness

Evaluation:

Level of consciousness, injuries, evidence of chronic abuse, BAC

Management:

Banana Bag (Thiamine, Mg, MVI, Folate, NS)

Tx injuries

Prevent withdrawal with oral benzo 
Always offer detox

Presentation:

Pinpoint pupils (miosis), slurred speech, ataxia, confusion, somnolence, respiratory depression, loss of consciousness

Evaluation:

level of consciousness, respiratory rate and depth

Pupillary size and reactivity, injuries

Urine toxicology

Management:

No respiratory distress: ride the high
Respiratory distress: Naloxone IM, IV, SC, NG

Repeat over 20 hours

Always offer detox

Presentation:

Usually present with complications - chest pain, stroke, spontaneous abortion, asthma sx

Evaluation:

Urine toxicology

EKG, cardiac enzymes, CXR, CT

Management:

Do not give Beta Blockers!

Can use nitro or ASA for chest pain/vasospasm

Benzo if HTN or tachycardia

Presentation:

apathy, agitation, HA, altered mental status

Seizures, coma, weakness, N/V

Signs of cerebral edema

Evaluation:

Serum Na < 136 (< 125)

Electrolytes, BUN, Cr, Glucose

Urine Na, OSM

EKG, CXR

Management:

Hospitalize if clinically significant

Restrict water intake to 1/2 - 1/3 

Increase Na 1 mEq/hr for 4 hours using 3% NaCl

Presentation:

confusion, weakness, tremulousness, seizures, coma, hypotension, tachycardia, thirst, fatigue, lightheadedness

Evaluation:

Serum Na > 145

ALWAYS ASSESS VOLUME STATUS

CBC, electrolytes, glucose, BUN, Cr

Urine Na and OSM, EKG

Management:

Give NS

Presentation: progressively worse symptoms 

Generalized weakness, fatigue, lassitude, constipation, leg cramps, muscle breakdown, paralytic ileus, bowel obstruction, ascending paralysis, impaired respiration, arrhythmias

Evaluation:
Serum K < 3.0 

Electrolytes, BUN, Cr, CPK (muscles), P, Mg, Glucose

EKG: prominent P waves, flat T waves, U waves

Wide QRS, Torsades, Arrhythmias, PEA, asystole

Management:

Give 20 mEq of K, oral preferred

Rapid correction only for highly unstable pts

Limit replacement 10-20 mEq/hr

Presentation:

weakness, hypotension, paresthesia, ascending paralysis, confusion, areflexia, ileus, respiratory insufficiency, cardiac arrest

Evaluation:

Serum > 5.5 

Electrolytes, BUN, Cr, Glucose, Mg

EKG: Peaked T waves, PEA, VF, VT, asystole

Management (in order of severity):

Furosemide, Kayexalate

NaHCO3, glucose/insulin, albuterol

Dialysis

Presentation:

Paresthesias of face, extremities, fatigue, muscle cramps, carpopedal spasms, stridor, tetany, seizures, confusion, impaired memory

Hyperreflexia, Chvostek's sign (CN VII twitch), Trousseau's sign (carpal spasm), decreased contractility, hypotension, heart failure

Evaluation:

Serum Ca < 8.5

Albumin, Ca, Mg, P, BUN, Cr, Liver studies

Amylase, Lipase, Electrolytes, CBC, ABG

EKG: QT prolongation, Terminal T wave inversion, Bradycardia, Heart block, VT or Torsades

Management:

Oral supplementation for asymptomatic

Ca gluconate, Ca chloride IV

Always correct hyperphosphatemia before the hypocalcemia

Presentation:

Depression, weakness, fatigue, confusion, lethargic, hallucinations, disorientation, hypotonicity, comatose, cardiac depression, arrhythmias

Constipation, Peptic ulcers, pancreatitis, polyuria, renal lithiasis, abdominal pain (moans and groans)

EKG: short QT interval, flat T wave, AV block

Management:

Tx if clinically significant

Restore volume rapid NaCl

Furosemide

Zolendronate 

Calcitonin

Glucocorticoids

Presentation:

muscular tremors, fasciculations, vertigo, ataxia, altered mental status, Chvostek's sign, Trousseau's sign, paresthesia, ocular nystagmus, tetany, dysphagia, seizures

Evaluation:

Serum Mg < 1.0 

Mg, Ca, BUN, Cr, Glucose, Electrolytes

EKG: prolonged QT, T wave inversion, Torsades, VFib

Management:

Mild: Oral replacement Mg oxide, sulfate

Moderate/Severe: IV Mg sulfate

Primary abnormality: inc PCO2

Compensation: inc HCO3

pH < 7.4

Presentation:

muscle weakness, paralysis, ataxia, drowsiness, confusion, N/V, hypoventilation, cardiac arrest, respiratory arrest

Evaluation:
Serum Mg > 2.5

Ca, BUN, Cr, Electrolytes

EKG: prolonged PR, QT intervals, complete AV block, asystole

Management:

IV fluids

Ca gluconate or Ca chloride (antagonize Mg)

NS and Furosemide

Dialysis

Presentation:

HA, blurred vision, restlessness, tremor, delirium, sleepiness, arrhythmias, peripheral vasodilation, hypotension

Evaluation:

ABG - pCO > 45, pH < 7.40

Management:

relieve airway obstruction

bronchodilators and abx for COPD

bronchodilators for asthma

diuretics, inotropes for pulmonary edema

chest tube for pneumothorax

NGT for abdominal distension

Presentation:
Tetany, lightheadedness, seizures, arrhythmias, vasoconstriction

Evaluation:

pCO < 35 

pH > 7.40

Management:

Correct hypoxemia, supportive care

Remove stimulating agents

Decrease minute ventilation

Presentation:

hyperventilation, tachycardia, arrhythmias, altered mental status

Evaluation:

HCO3 < 24

pH < 7.40

Management:

Exogenous HCO3- 

Presentation:

Confusion, lethargy, coma, seizure, hypokalemia, arrhythmias, hypoventilation

Evaluation:

HCO3- > 26

pH > 7.40

Management:

Replace gastric losses

H2 blockers

NS

Presentation: 

Thirst weakness, anorexia, apathy, syncope, tachycardia, weight loss, dry mucous membranes, ileus, weakness, decreased turgor, decreased IOP, orthostatic changes, tachycardia

Evaluation:

Increase urine osm, increased urine SG

BUN out of proportion to Cr (> 20:1)

Increased Hct, increased serum protein

Management:

Bolus NS

Maintain urine at 0.5 - 1.0 ml/kg/hr

Replace blood loss with crystalloid 3:1

Presentation:

Weight gain, edema, dyspnea, tachycardia, JVD, pulmonary congestion, ascites

Management:

fluid resuscitation, diuresis, monitor urine output and daily weights

MI, COPD, CHF, pulmonary edema

PE, Pneumonia, Cor pulmonale

Pneumothorax, renal failure, sepsis

Epiglottitis, anaphylaxis, ARDS

Anemia, Bleed, Upper airway obstruction

Asthma, Toxin exposure

Metabolic electrolytes, neurologic

Quick Assessment:
ABCs - do they look well? vitals

Begin forming differential

Get a Hx and Physical Exam

ED Interventions: O2, cardiac monitor, IV access

Labs: ABG, CBC, Chemistries, Cardiac enzymes, Mg, D-dimer (PE), BNP (CHF), EKG, CXR

Presentation:

dyspnea, tachypnea, tachycardia, hypoxemia

History/Risk:

Sepsis, drugs, aspiration, trauma, pancreatitis

Diagnosis:

CXR shows bilateral diffuse infiltrates

ABGs show PCO2 < 60

PCWP helps distinguish from pulm edema (< 18)

Bronchoscopy with lavage

Management:

Hypoxemia will not improve with 100% O2

Mechanical ventilation

Fluid management (prevent overload)

Tx underlying cause

Presentation:
stridor, wheezing

History/Risk:
witness

Diagnosis:

Decubitus expiratory CXR - one lung will expand and the other won't

X-ray for AP and lateral soft tissue

Fiberoptic scope

Management:

Assess spontaneous breathing

If none, do Heimlich and prep for surgical airway

If foreign body inferior to vocal cords, it can be pushed into mainstem bronchus with Ambo bag or ET tube to allow one lung to ventilate until surgery

Presentation:

tachypnea, tachycardia, hypoxia, rales

wheezes, fever (though not common), LE erythema, swelling, redness (signs of DVT)

Variable BP

History/Risk:
DVT, prolonged immobilization, malignancy, hypercoaguable, OCP, smoking, recent surgery, IVDU, nursing home

Evaluation:

Triad: hemoptysis, dyspnea, chest pain

Most common symptoms: SOB, chest pain, anxiety

Most common sign: tachypnea, rales, fever

D-dimer - negative predictive value (helps r/o)

PT/PTT, bHCG

EKG - RBBB, AFib

CVR: Westermark, elevated hemidiaphragm

CT with IV contrast is the standard of care

Management:

Manage airway

Tx shock with IV fluids if no pulmonary edema

Pressors

Anticoagulation (Heparin)

Thrombolysis 

Embolectomy

Presentation:
LE erythma, swelling, redness

History/Risk:
Virchow's Triad: endothelial injury, venous stasis, hypercoaguability

Evaluation:

LE doppler ultrasound

80% PE on autopsy have concurrent DVT

CT of bilateral thighs

Management: see PE

Generalized Seizures

Definitions

Tonic Clonic: convulsions that are bilaterally symmetric and without focal onset

Consciousness is imparied

Absence: brief, sudden, impaired consciousness without motor abnormalities and no post-ictal period

Partial Seizures

Definitions

Simple Partial:

consciousness remains intact, and the seizure is localized. May evolve into complex partial

Complex Partial:
consciousness is impaired, with automatisms, olfactory, and gustatory hallucinations

Status Epileptics

Definition

Ongoing seizure for 10 minutes or more

OR

2 or more sequential seizures within < 30 min

Presentation:
often post-ictal state, are at risk for seizing again

Evaluation:

Get detailed hx from witnesses

Is there a known cause?

Focus PE on acute injuries - make sure to check for increased ICP

D-stick for glucose, CMP, CBC, alcohol, drug screen, phenytoin/carbamazepine levels

CT if suspect stroke, tumor, or trauma

Management:
Tx the cause if known

Give D50

If pt known to be on Dilantin (Phenytoin) or Tegretol (Carbamazepine), give IV meds

IV Lorazepam for subsequent seizures

Neuro consult

Presentation:
unresponsive or tonic clonic seizures

Small jerking movements

Possible non-convulsive status epilepticus

Evaluation:

Continually assess as treatment occurs with hx, PE, labs

Management:

Secure airway, give high flow O2

Give glucose if blood sugar is low

Consider thiamine and Mg if known alcoholic or malnutrition

Lorazepam 

Phenytoin

Phenobarbital/General anesthesia

Admit to hospital with neuro care

EEG and consults

Consider CT/MRI

Presentation:
progressive weakness in arms/legs

areflexia

history of cold/infection in previous weeks

Assessment:
Can they breathe? Can they walk?

CBC, CMP, coags, serial pulm function tests

LP would show elevated proteins but few cells

EMG/NCV

Tests to r/o other ddx

Management:

Admit to hospital with neuro care

IVIG or plasmapheresis

Cardiac monitorings

Pain control (gabapentin, opioids)

PT to avoid contractures

Psych support for family

Presentations of Specific Ischemic Stroke Syndromes

Anterior Cerebral Artery

Light touch and pinprick sensation markedly decreased

Visual cortex defects

If in dominant hemisphere (usually left), may have aphasia

Homonymous hemianopsia

Arm weakness > Leg weakness

Hx of head/neck trauma

CN deficits on one side of face

Contralateral motor weakness

Presentation:

dependent on specific locations

Assessment:

When exactly did the symptoms start?

Thrombotic: DM, cholesterol, PVD

Embolic: AFib, valve replacemetn, carotid stenosis, MI

Hypoperfusion: heart failure, decreasing BP too fast (iatrogenic)

Assess level of consciousness, facial drop, flat nasolabial fold, motor abilities, speech, sensation, visual fields, neglect

CT to look for blood - if you don't see blood, you can r/o ICH

Most acute ischemic strokes will not show on

Coags, CBC, CMP, D-stick, EKG

Management:

Within 3 hours onset of sx: tPA

If > 3 hours, supportive care with O2, NS, intensive monitoring

Tx identifiable causes of stroke

Consider ASA, Plavix

Intracranial Hemorrhage

(Hemorrhagic Strokes)

Presentation:
Often indistinguishable from ischemic stroke in same vascular region (refer to specific stroke syndromes)

Evaluation:

Hx of HTN

CT - will see bood

Shows up as bright white in known vascular distribution

Management:
Neurolosurgery consult

Mannitol if increased ICP

Gradually lower BP if it is elevated

Supportive care and rehab

Subarachnoid Hemorrhage 

(Hemorrhagic Strokes)

Presentation:

Abrupt onset WHOL (back of head and upper neck)

Photophobia, N/V, altered MS

Nuchal rigidity

Hx of sentinel bleed

Evaluation:

Neurosurgery consult

Surgical decompression if large

Avoid increased ICP with anti-emetics, anti-tussives, anti-convulsants

Manage HTN

Nimodipine to decrease vasospasm

Patient should be on CT scanner within 25 min of arrival to hospital

Should be read by radiologist within 45 min

Contraindications to tPA:

bleed anywhere in body

onset of sx > 3 hours ago

time of onset of sx is unknown

pt on anticoagulant therapy

suspected SAH

abnormal coags, platelets

hx of hemorrhagic stroke

acute HTN

Subdural Hemorrhage 

(Intracranial Hemorrhage)

Presentation:

Loss of consciousness, laceration, bruise on head

N/V, confusion, smell of EtOH

Difficulty ambulating

Assessment:

Accerelation-deceleration injury

alcoholism, elderly

CT shows crescent shaped feathered fluid over surface of brain

Mass effect and midline shift

Management:
Neurosurgery consult for potential evacuation

Intubate if low Glasgow Coma Scale

Consider admission to neuro critical care

Address underly medical issues

Epidural Hemorrhage

(Intracranial Hemorrhage)

Presentation:
obvious site of trauma to head, loss of consciousness

Signs of ICP (blown pupil, BP changes)

Focal neuro deficits, hemotympanum, CSF otorrhea and rhinorrhea (Halo sign)

Assessment:

Blunt force trauma to temporal or parietal regions (MMA rupture) 

Skull fracture, Lucid interval of 20-30 min

CT shows lens or balloon shaped mass over surface of brain. Mass effect and midline shift.

May see skull fracture

Management:

Evacuation of blood by neurosurgery

Early surgery is key to recovery

Burr holes

Most fatal ICH due to high pressure arterial bleed and brain herniation

Presentation:
Unilateral, throbbing pain behind an eye

Slow onset +/- aura

N/V, photophobia, phonophobia

No other focal neuro signs

Patient does not want to move

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

Treatment

Abortive therapies - Triptans

Symptomatic Tx - anti-emetics, IV fluids, steroids, opiates (beware of rebound HA)

Presentation:

Bilateral or whole head non-throbbing HA

Slow onset and no assoc N/V, photophobia

No other focal neuro signs

Patient wants to rest

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

Treatment:

NSAIDs (Toradol) IV or IM

Acetaminophen

Combination products

Identify triggers

Anti-emetics or opiates in severe cases

Presentation:

Quick onset severe pain lasting < 3 hours

Periorbital, temporal, supraorbital pain

Associated lacrimation, rhinorrhea, conjunctival injections, miosis, and ptosis

Patient is restless

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

Treatment:

High flow O2 - works every time

Abortive therapies - Triptans

Opiates (beware rebound HA)

Presentation:

Sudden painless monocular vision loss

Pallor of retina

Cherry spot of fovea

Boxcar retinal veins

Generally embolic in origin

Evaluation:

Ophthalmoscope exam

Treatment:

Immediate sight-saving procedure

Digital massage of globe

Inhalation 95% O2 and 5% CO2 

Hyperventilate into bag

Medications to lower IOP (Timolol)
EKG and immediate referal

Presentation:
Red eye, blurred/double vision, HA, fever, edema

Erythema, increased warmth

Restricted and painful EOMs

Evaluation:

EOMs, culture of blood and fluids, CT

Treatment:

Oral abx immediately

Refer immediately with IV abx (?)

Presentation:

Acute onset severe pain, blurred vision

Decreased visual acuity

Red eye, mydriasis non-reactive to light

Steamy cornea, eye feels firm

Halos around lights

Nausea and abdominal pain
IOP > 50 mmHg

Evaluation:

Measure IOP with Tonometer

Treatment:

Ophthalmology consult

IV acetazolamide

Laser therapy

Pilocarpine

Laser peripheral iridotomy

Presentation:

Systemic vasculitis of medium and large arteries that can lead to bilateral blindness

Focal tenderness, thickening, nodularity, decreased pulsation

Evaluation:

ESR > 50

Biopsy specimens

Treatment:

Prednisone

Ophthalmology consult

Presentation:

Floaters/bugs/spots, flashing lights

Decreased visual acuity, visual field defects

Watery vision, veil or curtain

Evaluation:

Slit lamp

Management:

Limit activity

NPO

Refer and immediate surgery

Viral Conjunctivitis

Usually adenovirus 3

Presentation:

Hyperemia of conjunctiva

Itching, tearing

May be assoc with pharyngitis, fever, malaise, preauricular lymphadenopathy

Clear discharge

Common in children

Treatment:

Cool compress

Antihistamine

+/- abx

Lasts 7-10 days

Do not patch

Bacterial Conjunctivitis

Usually Staph, Strep, Haemophilus, Pseudomonas

Moraxella, GC/C

Presentation:

Hyperemia of conjunctiva

Irritation, Tearing

Purulent discharge

Management:

Antibiotic solution

If GC/C (teens and adults) - oral/IM abx

Evacuate if sx persist

Do not patch

Very contagious

Dry eye in older women, hereditary, systemic disease, hormone replacement, environmental

Presentation:

Burning +/- decreased visual acuity

Bilateral and worse later in day

Pain out of proportion to PE

Conjunctival injection

Management:

Artificial tears

Lubricating gel

Preservative-free preparations

Chemical Conjunctivits

Presentation:
Hyperemia of the conjunctiva

Irritation, Tearing

Management:

Irrigation with 2 L water

If alkaline, use at least 3 L or 30 min

Abx solution drops

Cool compress

Do not patch

Presentation:

Intense pain that is improved with topical anesthetic

Evaluation:

Fluorescein stain exam

Slit lamp

Management:

Remove foreign body

Limit anesthetic use

Topical abx, maybe patch

Do not patch if caused by contact lens

Presentation:

Hazy cornea, central ulcer, hypopyon

Evaluation:

Gram stain discharge

Management:

High concentration of topical abx

Levofloxacin, Ofloxacin, Cipro

Presentation:

Red eye, decreased vision, pain, photophobia

Foreign body sensation

Evaluation:

Fluorescein stain exam shows small punctate lesions, single vesicle, or branching pattern

Management:

Topical antiviral

+/- oral antiviral (no steroids)

Must evacuate

Presentation:

Trauma from plant material 

Abscesses are common

Management:

Topical amphotericin

Corneal grafting

Presentation:
Pain, irritation, tearing, redness

Feeling of foreign body

Evaluation:
Upper eyelid eversion

Slit lamp

Management:

Irrigation, cool compress

Evacuate if refractory

Presentation:

decreased vision, pain

Layering of blood in dependent areas of anterior chamber

Management:

Keep patient upright, avoid activity

Shield eye

If large, refer for immediate tx

Do not give ASA or NSAIDs

Do not patch

Presentation:

Bilateral gritty sensation
Photophobia, tearing, extreme conjunctival erythema, edema of lid

Evaluation:

Radiation injury due to UV exposure

Fluorescein stain shows "snowstorm"

Management:

remove contacts, single dose anesthetic

Abx solution, NSAIDs, cool compress

Wear sunglasses

12 hour patch and re-check

Presentation:
Unilateral deep pain with photophobia

Blurred vision, decreased visual acuity

+/- trauma, perilimbal injection

Miotic and decreased reactivity of pupil

Consenual photophobia

Management:

Mydriatic agents

Immediate evaluation

Excess parasympathatic stimulation (ACh)

Caused by sarin, organophosphates, TCAs, mushrooms

Symptoms: salivation, lacrimation, urination, defecation, diaphoresis, GI upset, emesis, bradycardia, miosis, muscle fasciculations

Excess inhibition of parasympathetic sitmulation

Causes: Benadryl

Symptoms: can't see, can't spit, can't pee, can't shit

Very dry, red, hot

Excess sympathetic stimulation

Causes: Albuterol, Amphetamines, Cocaine, Epinephrine

Symptoms: mydriasis, diaphoresis, agitation, hypertension, tachycardia

Excess mu receptor stimulation

Causes: opioids

Symptoms: miosis, respiratory depression, CNS depression, response to naloxone

Weakly corrosive acid that causes local and systemic absorption of Ca++

Causes: used for glass etching, computer chips, air conditioning, rust removers

Symptoms: delayed pain at exposure site

Treat: humidified, dermal, SQ, IM, IV Ca++

Binds competitively to Hgb and inhibits cellular respiration

Symptoms: cherry red/pink skin, flu-like illness with no fever

Treatment: oxygen

Anti-depressant

Causes: Nortriptyline, Amitriptyline, Desipramine, Imipramine

Symptoms: cardiovascular, neurologic, anticholinergic

Excess Ca++ channel blockade

Symptoms: bradycardia, hypotension, mental status changes

Cholinergic Toxindrome

Antidote: Atropine

Nitrates Toxicity and Antidote

Symptoms: blue color to skin, HA, fatigue, SOB

Antidote: Methylene blue

Anticholinergic Toxicity and Antidote

Anticholinergic Symptoms

Antidote: Physostigmine

Cyanide Toxicity and Antidote

Symptoms: weakness, HA, giddiness, vertigo, confusion, coma

Antidote: Cyanide kit, hydroxycobalamine

Alcohol Toxicity and Antidote

Symptoms of hypoglycemia

Antidote: Octreotide

Opiates Toxicity and Antidote

Respiratory depression, Hypotension, Tachycardia, Miosis, Severe drowsiness

Antidote: Naloxone

Isoniazid Toxicity and Antidote

Slurred speech, acidosis, hallucination, hyperglycemia, respiratory distress

Antidote: Pyridoxine (B6)

Digoxin Toxicity and Antidote

New arrhythmias, changes in color vision, tired, weak, confused, N/V, anorexia

Antidote: Digitalis-Fab

Snake Venom (Copperhead, Water Moccasin, Rattlesnake) Toxicity and Antidote

Tylenol Toxicity and Antidote

N/V, poor appetite, ab pain

Antidote: N-acetylcysteine

TCAs/Na Channel Blockage Toxicity and Antidote

Anticholinergic symptoms

CNS effets, cardiac effects

Long QT

Antidote: NaHCO3

Used in favor of Ipecac

Burned wood with divets can absorb drug

Optimum dose: 10:1 or 1 gram/kg

Indications: Phenobarbital, Theophylline, Phenytoin, Carbamazepine

Contraindications: acid or alkali ingestion, pure petroleum distillates

Ineffective for: elemental metals, electrolytes, pesticides, cyanide, alcohols, hydrocarbons

Poison Treatment:

Cathartics

No proven efficacy, but safe, so why not?

Can use Sorbitol, Mg citrate, Mg sulfate

Contraindications: bowel obstruction, active diarrhea, pt < 1 yo

Only give with first dose of charcoal

Facilitates charcoal administration

Most effective within 2 hours post ingestion

Protect airways with cuffed ETT

Place tube orally

Contraindications: alkali ingestion, bleeding diathesis, use in acid ingestion is controversial

Poison Treatment:

Whole Bowel Irrigation

Large volume of isotonic polyethylene glycol (PEG)

Administer po or NG tube to empty bowel

Indications: iron, lithium, drug packets, sustained-release products

Contraindications: gastrointestinal pathology, bowel obstruction

Poison Treatment:

Enhanced Elimination

Urinary alkalinization to increased excretion of acidic drugs

Add bicarb 

Used for increased excretion of salicylates, phenobarbital, chlorpropamide, herbicides

Poison Treatment:

Hemodialysis

Tests: ALT/AST, Alk Phos, GGT, Albumin, PT, Bilirubin

Why:

Test for bilirubin level (bilirubin)

Test for synthetic function of liver (albumin, PT)

If PT corrects with Vit K, it indicates Vit K deficiency

Hepatocyte damage (ALT/AST)

ALT more specific than AST

EtOH hepatitis AST > ALT

Viral hepatitis ALT > AST

Obstruction (Alk Phos, GGT)

Pancreatic enzymes

Tests for pancreatic function

Indicates pancreatitis

Na, K, Ca, Mg

Glucose

Hyponatremia: determine serum osm

Hypernatremia: determine volume status

Hypokalemia: inadequate intake, GI, renal losses

Hyperkalemia: inadequate excretion due to to renal failure or K sparing diuretics

Presentation: 

Dyspnea, fatigue, fluid retenion

Nocturia, orthopnea, non-productive cough, 

wheeze, moderate edema, anorexia

Weight loss, supine chest pain, dizziness

fainting, palpitations, tachycardia, rales

S3/S4, cool skin, hepatojugular reflux, JVD

Diagnosis:

CBC, BMP, LFT, cardiac enzymes, BNP

CXR shows Kerly B lines, upper zone redistribution, cardiomegaly, effusions, Bat wing infiltrates

EKG, Echo, Coronary angiogram with angina

Management:

First line therapy - ACE/ARB, B blocker, diuretic

Control risk factors and lifestyle

Treat etiologic cause and aggravating factors

Cardiac synchronization, implantable defib

Reduce Preload - diuretics, ACE, nitro

Reduce afterload - hydralazine, morphine, nitrates, CCBs, B blockers

Inotropic agents - digitalis, dopamine, dobutamine, BNP

Presentation:

Distressed and obtunded

Confusion, cyanosis, pink sputum

Pulsus alterans, hypotension

narrow pulse pressure, gallop

ascites, Cheyne-Stokes respiration

Diagnosis:

CBC, BMP, LFT, cardiac enzymes, BNP

CXR shows Kerly B lines, upper zone redistribution, cardiomegaly, effusions, Bat wing infiltrates

EKG, Echo, Coronary angiogram with angina

Management:

First line therapy - ACE/ARB, B blocker, diuretic

Control risk factors and lifestyle

Treat etiologic cause and aggravating factors

Cardiac synchronization, implantable defib

Reduce Preload - diuretics, ACE, nitro

Reduce afterload - hydralazine, morphine, nitrates, CCBs, B blockers

Inotropic agents - digitalis, dopamine, dobutamine, BNP

Presentation:

Mostly asymptomatic, unless secondary cause is present

Diagnosis:

BP measurements, thorough PE

Urinalysis, CBC, glucose, K, Ca, Cr, estimated GFR, fasting lipid, TSH

EKG, Echo

Management:

Goals < 140/90 (lower for DM, renal disease)

Lifestyle modification

Stage 1: thiazides, unless high risk condition indicates otherwise

Stage 2: 2 drug combo including thiazide

Presentation:
asymptomatic unless end organ damage

Headache, polyuria, dyspnea

impotence, claudication, angina

Diagnosis:

BP measurements, thorough PE

Urinalysis, CBC, glucose, K, Ca, Cr, estimated GFR, fasting lipid, TSH

EKG, Echo

Management:

Goals < 140/90 (lower for DM, renal disease)

Lifestyle modification

Stage 1: thiazides, unless high risk condition indicates otherwise

Stage 2: 2 drug combo including thiazide

Presentation:
Defined as > 180-220 SBP with severe symptoms and acute/rapidly evolving end-organ damage

Ability of brain, heart, and kidneys to regulated BP becomes impaired

End organ damage: blurred vision, papilledema, hemorrhages, venous tapering, exudates, chest pain, palpitations, dyspnea, displaced PMI, S3/S4, JVD, HA, stroke sx, HTN encephalopathy, renal artery bruits, oliguria, N/V

Diagnosis: BMP - look for elevated BUN/Cr

UA for protein

CXR for cardiomegaly, pulm edema

EKG: LVH, T wave inversion, AMI

Head CT: small vessel ischemic changes, hemorrhages

Chest CT: aortic dissection

Management:

Guided by end organ damage

Admit to ICU, arterial line for BP monitor

Acute MI/Ischemia: Labetelol + nitro

Acute LVF/Pulm Edema: Nitro + ACEI

Acute Renal insufficiency: Fenoldapam to increase renal perfusion

ICH: Esmolol, Labetalol 

SAH: Nimodipine

Aortic Dissection: Labetalol + nitro

Stroke: Labetalol or Nicardipine

Presentation:

Stone in kidney or ureter

Extreme flank pain, very restless

Fever + elevated WBC + elevated CR = hydronephrosis

Evaluation:
CBC shows slightly elevated WBC
UA shows hematuria in most

BUN/Cr for kidney function

Helical CT, renal sonogram for hydronephrosis

Management:

Most can go home

Admit those with one kidney, uncontrolled pain, vomiting, fever, obstruction, infection, bilateral stones

Percocet, Flomax to relax ureter, strainer

Reduce CHD mortality and good for isolated systolic HTN, reverses LVH

Do not use with NSAIDs

Can increase glucose, cholesterol, TG

Can increase Ca and uric acid

Good for HTN with previous MI or current CAD, migraines, angina, tremor, AFib

Can alter lipids, insulin resistance, and cause bronchospasm

Not first line monotherapy unless special indication

Good for systolic CHF, post-MI, DM, stroke, and reversal of LVH

No adverse lipid effects, but cannot use in pregnancy or bilateral renal artery stenosis

Good for angina, systolic HTN, LVH, Raynauds and African Americans

Use with caution in CHF

Good for lipids and insulin sensitivity, BPH, and LVH

Remember first dose effect (syncope)

Do not use as monotherapy

Presentation:

Lower UTI has progressed to upper UTI

More likely to have fever, rigor, chills

Malaise, N/V, flank pain

Diagnosis:

UA shows hematuria, pyruia, CBC, BMP, UA, UC

Can do CT with IV contrast 

Management:

Fluids, pain control, nausea control

Abx: Rocephin, Fluroquinolone, Unasyn

Rule of 2's: 2 L IV fluids, 2g Rocephin, 2 Vicodin, 2 glasses of water, 2 weeks tx

Presentation:

> 3-5 RBCs per HPF - the concern is about obstruction

Causes:

UTI - pyuria, dysuria

Kidney stones - flank pain

Recent vigorous exercise

Painless < 40 - GU infection, nephrolithiasis, trauma, exercise

Painless > 40 - cancer, prostate, renal disease, non-urinary source

Painful - nephrolithiasis, renal vein thrombosis, renal artery occlusion, renal CA, UTI, prostatitis

Rhabdomyolysis if blood with RBC in urine

Diagnosis: UA cultures and sensitivities

CBC, CMP, PT/PTT/INR

CT +/- contrast

Management:
Tx what you find

Reassure and followup

Presentation:
True surgical emergency!

6 hours until testicular necrosis

Inadequate fixation of testis to tunica vaginalis

Diagnosis:

Sonogram shows no flow

UA, Pre-op labs

Management:

Pain control

Manual detorsion (opening a book)

Therapeutic cooling

Presentation:

Abnormal persistent erection of corpora cavernosa > 4 hours - involuntary and unrelated to sexual stimulation

Disturbance of detumescence mechanisms

Can be ischemic (bad) or non-ischemic

Diagnosis:

Hx and cavernosal blood gas will show acidosis, low O2, and high CO2

Management:

Ice bag to perineum, penis

Terbutamine po 

Pain control

Aspirate with 18ga needle 

Massage, repeat

Surgery

Inability to retract the distal prepuce over the glans penis that is congenital or acquired

Management:

Rarely an emergency, refer

Inability to put back the foreskin because it has become a constricting ring that impairs blood and lymphatic drainage

Leads to ischemia, gangrene, autoamputation

Management:

Ice water soaks, compressive elastic dressings

Penile lidocaine block, wrap in topical lidocaine

18ga needle puncture, manual retraction

Dorsal slit, glans penis aspiration

Presentation:

Infection of coiled tubular structure posterior to testis

Positive Phren's Sign

Congestion, edema, abscess, necrosis

Urinary sx, urethral discharge, N/V, abdominal pain, flank pain, fever

Diagnosis:

UA, DNA probe, CBC, CMP

Sonogram shows increased flow

Management:
Tx suspected pathogens

Young: Rocephin, Doxy 10-14 days

Older: Ofloxacin, Levofloxacin

Pain medications

Presentation:

Collection of serous fluid from defect or irritation of the tunica vaginalis

Diagnosis: 

Transillumintion is not reliable

Doppler sonogram

Management:

Urology consultation

Presentation:

Enlarged twisted vein in scrotum

Diagnosis:

Bag of worms

Management:
Surgery

Prescription:

Walnut sized gland becomes enlarged and may obstruct flow of urine

Urinary frequency, urgency, hesitancy, straining, incomplete emptying, decreasing force, dribbling, retention

Diagnosis:

UA culture and screens

DRE, Foley Cath/Coude Cath

Management:

Treat if UTI is present

Leg Bag

Urology followup 

Testicular Torsion:

Hx - post vigorous activity, sex

Sx - tender, swollen 

Sudden onset with diffuse pain

Negative cremasteric reflex

Negative Phren's sign

Bell clapper deformity

Appendiceal Torsion:

Subacute onset

Leading cause of scrotal pain in childhood

Positive cremasteric reflex

Blue Dot Sign

Epididymitis:

Sx - congestion, edema, abscess, necrosis, N/V, ab pain, fever

Subacute onset 

Positive cremasteric reflex

Positive Phren's sign

Presentation:

Polyuria, polydipsia, polyphagia, weight loss

Kussmaul breathing, fruity breath odor, dehydration, blurred vision, N/V, ab pain

Altered mental status, hyperglycemia, metabolic acidosis - mostly Type 1 diabetics

Etiologies: 

Absolute or relative insulin deficiency, stress hormones, infection

Evaluation: 

CBC shows leukocytosis

BMP shows metabolic acidosis and inc BUN/Cr

possible hyperkalemia with pseudohyponatremia

UA shows ketonuria, glucosuria

VBGs show low pH and low bicarb

Other tests to find cause

Management:

Goals - intravascular volume expansion, correction of fluids, electrolytes, and acid-base

IV fluids and add KCl one urine output confirmed

Insulin bolus IV (10 units)

Insulin drip IV (0.1 U/kg/hr)

Add HCO3- if pH < 6.9

Give glucose with insulin to maintain blood glucose at 150-300

Hyperglycemia

Hyperosmolar

Non-Ketotic Syndrome

(HHNS)

Presentation:

Fatigue, weakness, anorexia, cough, abdominal pain, elderly, altered mental statust, dyspnea, CVA, MI, pancreatitis, seizures, sever hyperglycemia

Hyperosmolarity, No ketonemia

Type 2 diabetics

Etiologies: 

Impaired access to water

Evaluation:

CBC, CMP, UA, Lactate, CXR, Mg, P

Glucose > 600 

Plasma osm > 315

VBG pH > 7.3

Negative to mild ketones

Other tests to find cause

Management:

Goals - intravascular volume expansion, correction of fluids, electrolytes, and acid-base

IV fluids and add KCl one urine output confirmed

Insulin bolus IV (10 units)

Insulin drip IV (0.1 U/kg/hr)

Add HCO3- if pH < 6.9

Give glucose with insulin to maintain blood glucose at 150-300

Presentation:
Polydipsia, polyuria, polyphagia

Weakness, fatigue, HA, blurred vision

Dehydration, lightheadedness, dizziness

Signs of infection are common

Etiologies:

known or undiagnosed DM

Complication of untreated DM

Insulin resistance

HTN, PCOS, gestational DM

Evaluation:

Random glucose > 200

Fasting glucose > 126

May have sx of DKA or HHNS

Search for underlying cause with necessary labs

Management:

admit is you supsect Type 1 diabetes

No tx necessary - Mild hyperglycemia with no signs of decompensation

If glucose > 300 - 1 L NS over 1 hr with 

IV insulin 0.1 - 0.5 U/kg

Follow up

Presentation:
Extreme presentation of thyrotoxicosis - fatal if untreated!

Fever, tachycardia, AFib, tremor, weight loss

Heat intolerance, diaphoresis, proximal weakness

Palpitations, N/V, diarrhea, altered mental status, menstrual irregularities, Hx of thyroid manipulation, changes in medications, physiologic stressors

Etiologies:
Post-operative, radioactive iodine therapy, pregnancy, acute iodine load, uncontrolled DM, trauma, acute infection, drug rxn, MI, CVA

Evaluation:
CBC, CMP, UA, bHCG, EKG, BNP, cardiac enzymes

Lactate, cortisol, CXR, Head CT, LP

TSH and Free T4 - not affected during acute phase of thyroid storm, will reflect chronic state

Normal TSH can exclude hyperthyroidism 

Management:
Propanolol or Dexamethasone - block peripheral effects of T4/T3

PTU or MMI - stop production of T4

K iodide, Lugol, Lithium - inhibit hormone release

Presentation:

Severe life-threatening manifestations of hypothyroidism

Altered mental status, bradycardia, hypothermia

Hypoventilation, periorbital edema, hyporeflexia, hypoglycemia, hyponatremia, non-pitting puff appearance of skin and soft tissues

Etiologies: 

Hypothyroidism, medication changes, physiologic or psychologic stressors - infection, cold, trauma, major life changes

Evaluation:
CBC, CMP, UA, ABG, EKG, cortisol, CXR, TSH, Free T4

Management:
Ventilatory support

Thyroid replacement - Levothyroxine

Glucocorticoid

Reverse hypothermia, hypoglycemia, hyponatremia

Presentation:
Inability of adrenal gland to respond to stress by increasing cortisol production

Hypotension is primary symptom

N/V, diarrhea, flank pain, ab pain

Weakness, fatigue, fever, altered mental status, dizziness

Etiologies:
abrupt cessation of steroids, severe trauma, burn, sepsis, surgery, hypoglycemia, MI

Anticoagulant use, pregnancy, AIDS, TB

Anesthesia

Evaluation:
Corticotropin Stimulation Test - 

Measure plasma cortisol

Inject Cosyntropin IV/IM

Draw serum cortisol at 30 and 60 min

Normal response is double basal serum cortisol

Management:

Goals - high dose replacement of circulating glucocorticoids

Repletion of Na and H2O

Hydrocortisone, Dexamethasone

IV fluids - D5NS or NS

Consider pressors (NE, Dopamine)

Presentation:

Intermittent episodes of HA, palpitations, flushing

Diaphoresis, Hypertension

N/V, ab pain, sense of impending doom

Later findings:
Aortic dissection, encephalopathy, cariomyopathy, pulmonary edema, anion gap metabolic acidosis

Etiologies: 

Pheo (intermittent)

MAOI crisis

Cocaine intoxication/sympathomimetics

Evaluation:

24 hour urine collection for metanephrins

CT, MRI, isotope scan for tumor

Management:

Replace volume deficits, correct electrolytes

Phentolamine (alpha blocker)

Nitroprusside or Fenoldopam

Ca channnel blockers

Beta blocker - Esmolol

Benzos to stunt sympathetic response 

Do not Beta block until you Alpha block

Presentation:
usually younger individual, thin, sudden onset

Precipitated by illness, stress

Polys, weight loss, blurred vision, dehydration

Diagnosis Criteria (need one):

1. Symptoms of DM + random glc > 199

2. Fasting glc > 125

3. 2 h OGTT > 199

4. Hgb A1c > 6.5

Impaired fasting glucose > 140

Management:

Target levels - 

Avg fasting and pre-prandial: 70 - 120

Avg 2 hr post-prandial: < 140-160

Should test 3+ times daily

Insulin therapy

Presentation:

usually older age, obese, gradual onset

symptomatic hyperglycemia, recurrent infections

Diagnosis Criteria (need one):
1. Symptoms of diabetes + random glc > 199

2. Fasting glucose > 125

3. 2 hr OGTT > 199

4. Hgb A1c > 6.5

Management:
Target levels -

Avg fasting, pre-prandial: 70 - 120

Avg 2 hr post-prandial: < 140 - 160

First line therapy: Metformin + lifestyle

Later add Sulfonylurea or basal insulin

Less common therapies: pioglotazone, GLP-1 agonist

Human Insulin:

regular - 30-60 min

NPH - basal insulin - 2-4 hours

Insulin Analogues:

Aspart (Novolog) - 15 min

Glulisine (Apidra) - 15 min

Lispro (Humalog) - 15 min

Glargine (Lantus) - 3-4 hours

Premixed Insulins:

Human 70/30, 50/50

Humalog 75/25

Novolog 70/30

(mixed basal/bolus 2x per day, higher risk for hypoglycemia)

Initiating Insulin Therapy

and 

Adjusting Insulin Therapy

Begin with bedtime intermediate acting NPH

OR

Begin with bedtime/morning long-acting (Lantis)

Long acting is easier to initiate

Check fasting glucose and titrate insulin:

Increase 2-4 Units every 3 days until fasting glucose is at goal

If hypoglycemia occurs, or fasting glucose < 70, reduce bedtime glucose

After 2-3 months, check HgbA1c

If < 7% - continue regimen and re-check in 3 mo

If > 7%....intensify insulin:

Intensifying Insulin
If fasting glucose is in target range, but HgbA1c is too high, check glucose before lunch, dinner, and bedtime and add a second injection

Prelunch glc out of range: add rapid acting insulin at breakfast

Predinner glc out of range: add NPH at breakfast OR rapid acting insulin at lunch

Prebed glc out of range: add rapid acting insulin at dinner

Adjust 2 Units every 3 days until glc is in range

Do this until glc range and HgbA1c is in range after 3 months

Presentation:

Subacromial bursitis + rotator cuff tendonitis + bicipital tendonitis

Inflammation of bursa, rotator cuff tendons, and long head of biceps

Asynchronous shoulder motion

Diagnosis:

Impingement signs - 

Neer Impingement sign

Hawkin's Test

Bicipital Signs - 

Speed's Test

Yergason's Test

Glenohumeral Instability - 

Apprehension sign

Treatment:
decrease inflammation with NSAIDs

Restore ROM with PT

Subacrominal injections prn

Surgical decompression, stabilization

Presentation:

decreased ROM, pain

point tenderness over greater tuberosity

Diagnosis:

Impingement signs

full passive ROM but limited active ROM

Positive drop arm test

External rotation weakness is most sensitive sign

X-ray can r/o occult fracture

Treatment:

Tx like impingement initially

If function is impaired, do MRI

If tear is confirmed, do surgery

Presentation:

Mostly anterior dislocations

Posterior dislocations are common in seizures, alcoholics, and electrocution

Pt holds arm in adduction, elbow flexed

Pain with  minor movements

Palpable glenoid fossa

Diagnosis:
complete neurovascular exam

document radial and brachial pulses

Should Series X-ray

Treatment:

Sedation and reduction

Post-reduction X-rays

Sling and swath

Length of immobilization varies with age

Presentation:

Direct blow to lateral shoulder

Tender or deformed AC joit

Swelling, tenderness, crepitus

Can be confused with clavicle injury

Diagnosis and Treatment:

Prominent distal clavicle and depression of shoulder

Classified according to degree of ligamentous inury

I: strain of AC ligaments, normal X-ray

Ice and sling for comfort

ROM as tolerated, resume activities when ROM is established for 2 weeks

II: rupture of AC ligaments, clavicle sublux

Ice, sling for 2 weeks, pendulum exercises, heavy lifting, sports at 6 weeks

III: complete rupture of AC and CC ligaments, complete dislocation of clavicle

Similar tx to Type II, anatomic reductino is not always necessary

PT to restore strength and ROM

Presentation:
proximal or distal rupture - bulging appearance

Due to forceful flexion of arm, older athletes

Ecchymoses depends on location

Predictive of rotator cuff tear

Diagnosis: clinical

Treatment:

Proximal - surgery if < 40 yo

Distal - surgery for most to preserve supination

Presentation:
tendonosis from repetitive pronation/supination 

Pain over lateral epicondyle and into extensor mass

Numbness or tingling - entrapment of sensory branch of radial nerve

Diagnosis:

Point tenderness over lateral epicondyle

Pain worsened with forced wrist and finger extension

Some X-rays will show spur off lateral epicondyle

Treatment:
activity modification, ice massage

Counter force brace

PT for stretching and strength

Presentation:

2nd most common dislocated joint

Radius and ulnar are displaced together

Pt holds elbow at 45 degree flexion

Visible olecranon deformity

Diagnosis:

Assess neurovascular status 

X-rays

Treatment:

Reduce asap if NV compromise is present

Reassess for NV injury and then splint and sling

Nursemaid's Elbow

(Radial Head Subluxation)

Presentation:
25% of elbow injuries in children

Longitudinal traction on arm while elbow is extended and pronated

No deformity visible but tenderness is present over radial head

Children refuse to use arm

Diagnosis:

Clinical, X-rays

Treatment:

Reduce by stabilizing elbow and applying gentle pressure on radial head, supinating forearm and flexing elbow until click or snap is heard

Trigger Finger

(Flexor Tenosynovitis)

Presentation:
Thickening of flexor tendon that catches as it passes through A1 pulley

Inflammation of flexor tendon sheath

Common in diabetics

Diagnosis:

Trigger at PIP

Tenderness over volar MCP

Palpable nodule, PIP is rarely locked

X-rays are negative

Treatment:

Cortisone injections into sheath may give transient improvement

Surgical release to divide A1 pulley

Presentation:
dorsal finger and hand wound

90% lacerated tendon can retain function

Diminished strength and pain against resistance 

Diagnosis:

Provide resistance against extension

Treatment:

< 50% tear requires protective splint

Irrigation, inspection, debridement in ER

Tendon suture repair by hand surgeon

Mallet Finger

(Swan Neck Deformity)

Presentation:

Laceration or avulsion of extensor tendon at insertion of dorsum distal phalanx

Distal finger is forcibly flexed

Pain with resistance

Diagnosis: X-ray may be normal

Treatment:

Stack splint with DIP in full extension (closed)

Surgery for open 

Presentation:

hyper-extended PIP joint as a result of laceration or blunt trauma to dorsum

Painful swollen PIP

Diagnosis: X-rays normal unless dislocation is present

Treatment:

4 weeks of PIP splint (closed)

Surgery (open)

Presentation:

PIP is most common (dorsal dislocation caused by hyperextension and axial compression)

MCP - due to hyperextension

DIP dislocation is rare - axial force to distal phalanx

Diagnosis: gross deformity

Treatment:

Digital nerve block for PIP and DIP

Ulnar, median, or radial nerve block for MCP

Reduce with splint

PIP volar entrapments are not reducible

Post-reduction X-ray

Gamekeeper's Thumb

(Skier's Thumb)

Presentation:

Tear of UCL of MCP joint as a result of adbuction force to thumb's MCP 

Pain, swelling, ecchymoses over MCP

Pain is worse on ulnar side

Diagnosis:
Assess degree of instability

Stress joint in full extension and 30 deg of flexion

X-rays: stressful views may be helpful

Stener's Lesion: displaced avulsion fracture

Treatment:
1% lidocaine block for comfort during stress

Thumb Spica cast

Surgery for avulsion

Presetation:
Zone 1 - distal amputation

pad loss of < 1 cm, heal by secondary intention

Zone 2 - involve nail bed, partial bone disruption

Zone 3 - extreme nail involvement

Zone 4 - amputation at level of distal phalanx near DIP

Zones 2-4 require hand surgeon

Presentation:

Tibiofemoral joint dislocation is an emergency

Seen in high energy trauma or falls

Tenderness, joint effusion, visual deformity

Diagnosis:

Careful neurovascular status exam

X-ray confirms diagnosis

Arteriography helps ID arterial injuries

Serial ABI can exclude arterial injury

Treatment:

Emergent redution by in-line longitudinal traction

Neurovascular monitoring

Presentation:

Deceleration, rotational force, hyperextension, valgus force, effusion, ROM

Diagnosis:

Aspirate joint

Re-examine in 7 days if too painful

Anterior Drawer Test, Lachman Test

Pivot Shift

X-rays are typically normal

Segon's sign: postero-lateral corner avulsion

Treatment:

Depends on age and level of activity

Rehab, bracing, reconstruction

Presentation:

MCL > LCL, graded according to severity

Direct force to medial/lateral knee

Leg wrenched into varus/valgus force

Pain over ligament, swelling, ecchymoses

Diagnosis:

I: tenderness, no laxity

II: opening of joint, firm endpoint

III: opening of joint w/o endpoint

Assess degree of laxity (if laxity in full extension, ACL is torn)

Treatment:

RICE, knee immobilizer, weight bearing as tolerated

I: immediate ROM and strengthening

II, III: immobilizer for 3 weeks, ROM when comfortable, PT at 3 weeks

Return to activity in 6 weeks

Presentation:

Acute tears due to twisting injury

Chronic tears are degenerative in nature

Pain, locking, catching, giving way, +/- swelling

Diagnosis:

+/- effusion, ROM, r/o ligament injury

Meniscal signs: Steinman's sign, Apley's Sign

McMurray Test

Presentation:

RICE, activity as tolerated if full ROM

Consider athroscopy if sx > 6 wks

Locked knee: ice and elevated, ROM

Patellar Tendonitis

(Jumper's Knee)

Presentation:
Tendonosis at insertion into inferior pole of patella

Pain worse with resisted knee extension

Diagnosis: X-ray shows spur off inferior pole

Treatment:

Activity modification, PT for hamstring and quad stretches

Surgery 

NO CORTISONE!

Presentation:

Due to fractures, crush injuries, and burns

Results in ischemia to muscle and nerves

Pain out of proportion to injury

Pain with passive ROM of muscles

Paresthesia, pulselessness

Diagnosis:

Must have high index of suspicion

Absolute compartment  pressure > 30

Treatment:

Early treatment is key

Adequate surgical decompression of compartment

Presentation:

Inversion and eversion injuries

ATFL and deltoid ligament tears

Diagnosis:
Assess foot and ankle

Jones Fracture: 5th MT

Palpate medial and lateral ankle

Maissoneuve fx: tear of deltoid, tear of IO membrane, and fx of fibula

Treatment:

RICE, posterior spint, modified WB for comfort

SLC with WBAT, aircast 

Formal PT for recurrent sprains

Presentation:

displacement of talus and foot from tibia - open or closed

Gross deformity of ankle joint

Diagnosis:

Assess neurovascular status

X-rays not necessary

Treatment:

Reduce and reasses NV

Splint ankle, obtain radiographs and orthopedic consultation

Presentation:

Swelling, ecchymoses

Palpable defect, unable to PF ankle/foot

Diagnosis:

+/- Thompson-Dougherty Test

X-rays show occasional bony spur

Treatment:
Cast immobilization for 6 wks

Surgical repair

Presentation:
Inflammation at insertion into calcaneus

Pain in plantar heel worse in am

Recent weight gain, lack of exercise

Diagnosis: 

Pain over plantar-medial calcaneous

Exacerbated with dorsiflexion of great tose

Gastroc tightness

X-rays may show spur off anterior calcaneous

Treatment:

NSAIDs, heel cups, shoes with good arch support

Calf stretches, surgical release

Presentation:
Acute monoarthritis, usually in 1st MTP

Overnight, intense pain on awakening

Difficulty walking, inflammed skin

Hx of EtOH, high uric acid meal

Diagnosis:

Elevated serum uric acid 

Elevated WBC and ESR

Arthrocentesis

Treatment:

Short course NSAIDs (indomethacin)

Colchicine, steroids

Probenecid, Allopurinol for chronic attacks

Presentation:

Chronic aching pain, stiffness

Prominent around neck, shoulder, low back, hips

Fatigue, sleep disorders, numbness

Chronic HA, IBS are also common

Diagnosis: exclusion

Trigger points produce pain by palpation (Trapezius, medial fat pad of knee, and lateral epicondyle)

Treatment:

Amitriptyline, Fluoxetine, Chloropromazine

Gabapentin

Exercise

Presentation:

Myalgia, muscle weakness, dark urine

Tenderness, decreased strength, swelling

Bruising, soft extremities, depressed reflex

Normal sensory examination

Diagnosis:

Red-tinged urine, turns dark brown, myoglobinuria on dipstick, elevated CK

Treatment:

Hydration to ensure high urine volume

NS at 1.5 L/h

Maintain urine at 300 ml/h

Mannitol or NaHCO3- to alkalinize urine

Presentation:
Fever, painful joint, effusions, erythema

Limited ROM, will appear ill

Diagnosis:

Arthrocentesis, cultures 

Synovial lactic acid can exclude dx

Blood cultures - r/o GC

Treatment: 

Aspirate

High dose IV abx empiric, then focus with cultures

Presentation:

Pain, fever, swelling, focal tenderness

Diagnosis:

High ESR, X-rays show soft tissue swelling and lytic lesions (late finding)

MRI, bone scan, culture, histology

Treatment:

Systemic abx and surgery to drain abscess or debridement

Uncomplicated, child: cover Staph

Presentation:

Muscle strain is most common cause

May present with pain, paresthesia

Diagnosis:

PE shows ROM, areas of tenderness, neuro exam

Radicular signs: indicates nerve root entrapment

Contralateral straight leg raise

Treatment:

Activity modification
NSAIDs

PT if the sx persist

fracture associated with overlying soft tissue injury, creating a communication between the fracture site and external surface of the body

Includes bone poking through skin or puncture wound that extends on surface of a broken bone

Complication: osteomyelitis

fracture in which fragments are offset from one another

(no longer aligned)

the angles of the respective bone fragments, expressed in terms of direction and amount

Direction: 

Varus - apex away from midline

Valgus - apex toward midline

Recurvatum - apex posterior

Procurvatum - apex anterior

Amount: amount of unbending, expressed in degrees, that would be required to make the fragments parallel

Frank disruption of cortex on side of the bone, but no discernable cleavage plane on the opposite side

Fractures are angulated, but not displaced because the bones are not actually separated

Reduce and cast, 7-10 followup

Salter Harris Fracture

Presentation:

Injuries to ligaments and may be associated with fx

Grade 1: swelling, ecchymoses

Grade 2: + laxity

Grade 3: + completely unstable joint

Diagnosis and Treatment: 

Grade 1: incomplete tear

immobilization, conservative care

Grade 2: significant incomplete tear

immobilization, ortho followup

Grade 3: complete disruption

orthopedic followup for surgical repair

Presentation:
injury to muscle-musculotendonous unit

Diagnosis:
Also graded according to severity

Management:

immobilization, conservative mgmt

Ortho referal and surgical repair maybe

Presentation:
complete disruptions in normal relationship or articular surfaces of bones making up the joint

Diagnosis:

Must assess NV status

Management:

reduce

The longer the joint is displaced, the more difficult it is to reduce

Presentation:

break of a tendon 

Can be caused by steroid injections, gout, RA, and hyperparathyroidism

Signs and sx dependent on location

Often hear pop, snap, sharp pain

Swelling, ecchymoses, palpable defect

Diagnosis:

Drop Arm test for biceps

Thompson test for achilles

X-rays may show bony avulsion

Management:

often controversial

cast immobilization 

surgical repair

Fracture through the growth plate

The epiphysis is separated from the metaphysis without radiographic evidence of metaphyseal or epiphyseal fracture

[image]

Fracture through the metaphysis and growth plate (Most common type)

Fracture line travels through the physis and is associated with the oblique fracture of metaphysis on the opposite side from the applied force

(Thurston-Holland sign: metaphyseal fragment)

Fracture through the growth plate and epiphysis into the joint

Vertical fracture of epiphysis perpendicular to physis, extending into the growth plate

Uncommon, occurs mostly in distal tibia

Fracture through the metaphysis, growth plate, and epiphysis into joint

Result of compressive (rather than rotational or shearing forces) - requires surgical repair

Crush of growth plate, may not be seen on X-ray

Rare, and results from severe crushing force applied to epiphysis in area of physis

Most often distal tibia and knee

Often missed on radiograph and diagnosed during followup visits after shortening deformities

Non-traumatic causes are osteomyelitis and epiphyseal aseptic necrosis

Gram + 

Anaerobes

Methcillin, Oxacillin, Nafcillin coverage

Gram + 

Staph/MSSA

Gram - Anaerobes

Augmentin, Unasyn (IV) coverage

Gram + 

Staph/MSSA

Gram - 

Anaerobes

Gram +

Staph/MSSA 

Gram - 

Pseudomonas

Anaerobes

Meropenem, Imipenem (IV only) coverage

Gram + 

Staph/MSSA

Gram - 

Pseudomonas

Anaerobes

Generally used only as last resort for in-pt

Cefazolin, Keflex (1st gen) coverage

Gram + 

Staph/MSSA

Cefuroxime, Cefoxitin (2nd gen) coverage

Gram + (some)

Staph/MSSA

Mostly Gram - 

Rocephin (3rd gen) coverage

Gram + 

Staph/MSSA

Gram - 

Ceftazidime (3rd gen + pseudo) coverage

Gram +

Staph/MSSA

Gram - 
Pseudomonas

Erythromycin, Azithromycin, Clarithromycin 

(Macrolides) coverage

Gram + 

Staph/MSSA

Gram - 

Atypicals

Ciprofloxacin (Quinolone) coverage

Gram + 

Staph/MSSA

Gram - 

Very good at Pseudomonas

Atypicals

Levofloxacin (Quinolone) coverage

Very good at Gram +

Very good at Staph/MSSA

Gram -

Pseudomonas

Atypicals

Gentamicin, Tobramycin, Amikacin (Aminoglycosides) coverage

Gram - 

Pseudomonas

Gram - 

Atypicals - PCP

Gram + 

Staph/MSSA

Gram - 

Best for UTI

Penicillin G, V

Methcillin, Oxacillin, Nafcillin

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentin

Meropenem, Imipenem

Cefazolin, Keflex

Cefuroxime, Cefoxitin

Rocephin

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Nitrofurantoin for UTI

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentin

Cefuroxime, Cefoxitin

Rocephin

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Gentamicin, Tobramycin, Amikacin

Bactrim

Nitrofurantoin for UTI

Vancomycin

Linezolid

Pipercillin, Zosyn, Timentin

Meropenem, Imipenem

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Gentamicin, Tobramycin, Amikacin

Penicillin V, G

Methicillin, Oxacillin, Nafcillin

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentim

Gentamicin, Tobramycin, Amikacin

Metronidazole in gut (C. diff)

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Bactrim for PCP

Staph, Strep, Enterococcus

Listeria, Clostridium

Gonorrhea, Moraxella

Haemophilus

E. coli, Pseudomonas, Klebsiella

Pseudomonas!!!!!!

Imipenem/Meropenem

Zosyn + Aminoglycoside

Zosyn + Quinolone

General approach to trauma patient

Primary Survey

Primary Survey:

A - airway 

Intubate if GCS < 8

Continually reassess need for surgical airway

Check placement of ET tube with portable CXR

B - breathing

Ventilate with 100% O2

Contralateral tracheal deviation = tension pneumo

Palpate for subcutaneous emphysema

Flail segment = 2 or more ribs broken in 3 or more places (paradoxical respiration)

C - circulation

apply pressure to sites of bleeding

Establish 2 large bore IVs

Place central line if peripheral not accessible

Assess pulses and capillary refill

Pulses present at 

a) carotid --> SBP = 60

b) femoral --> SBP = 70

c) radial --> SBP = 80

Beck's Triad for cardiac tamponade: 

JVD, hypotension, muffled heart sounds

D - disability

Brief neuro exam 

Pupil size and reactivity, motor assessment, and sensation

Glasgow coma scale: eyes, verbal response, and motor (max of 16 points)

E - expose

Completely disrobe pt and log-roll for back injuries

General Approach to Trauma Patient

Secondary Survey

Trauma Series X-ray includes:
lateral C-spine, chest, AP pelvis

Head to Toe exam:

TMs, facial stability, teeth, jaw, neck ROM

Ab exam for distension, tenderness, stable pelvis

Blood at urethral meatus = pelvic fracture, bladder rupture

Rectal tone and blood guiac test 

deformities and open fractures

Miscellaneous

Consult with surgery or transfer

FAST U/S exam for ab/chest trauma

Enhanced CT for chest or ab with IV contrast

IV Mannitol for neurological decompensation

IV steroids for spinal cord injury

IV abx for ruptured ab viscus

State of severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization as well as decreased removal or waste byproducts of metabolism

Generally final preterminal event in many diseases

Determinants of BP are

systemic vascular resistance, HR, preload, and contractiltiy

Initial derangements and compensations include 

a) vasodilation causing decrease systemic resistance from sepsis, anaphylaxis, drugs, or cervical cord lesion

The body compensates with tachycardia, thirst

The skin remains perfused and warm

b) extremes of HR

c) loss of preload volume  causes decreased EDV from blood or volume loss

The body compensates with an increase in systemic resistance, an increase in DBP, narrowed pulse pressures, cholinergic sweating, pale, cool, thirsty, hypotension, tachycardia

d) loss of contractility causes an increased ESV from heart failure

The body compensates with an increase in systemic resistance

Primary derangement in EDV caused by blood or volume loss (see initial derangement c)

Presentation:
Pale, cool, moist skin, narrowed pulse pressure

Anxiety, tachycardia, dec urine volume

Treatment:
stop bleeding or fluid loss and replace it

20 ml/kg crystalloid NS or LR

replace blood (type and cross)

May require surgery

Primary derangement in ESV caused by arrhythmias, MI, cardiomyopathies, or mechanical anomalies (see initial derangement d)

Presentation:

pale, cool, moist skin, narrowed pulse pressure

anxiety, tachycardia, dec urine output 

same as hypovolemic shock

Right sided heart failure --> pulm edema

Left sided heart failure --> peripheral edema + JVD

Treatment:

Cardioversion is tachyarrhythmia

Transcutanfous pacing if bradyarrhythmia

Atropine for sinus brady, Wenkebach

Supportive O2, ASA, Heparin, fluids

Pressors

Primary derangement in SVR (relaxed tubes)

Subtypes: anaphylactic, septic, neurogenic, drug induced (beta blockers, Ca channel blockers), endocrine (adrenal insufficiency)

Presentation:

Loss of vascular tone presents with erythematous warm skin, depsite hypotension

Tachycardia, hyperdynamic heart

Treatment:

Anaphylactic: epinephrine, Beta agonist, H1/H2 antagonist, steroids

Septic: targeted abx, pressors

Neurogenic (disruption of sympathetic chain): fluids, vasopressors

Drug induced: IV glucagon, Ca gluconate, general decontamination

Problem with SV due to mechanical obstruction to preload - causes are often classified as hypovolemic or cardiogenic

Causes: tension pneumo, pericardial disease, massive PE

Presentation:

pale, cool, moist skin, narrowed pulse pressure

Anxiety, tachycardia, decrease urine output

same as hypovolemic

Treatment:
Tension Pneumo: decompression and chest tube thoracostomy

Pericardial tamponade: U/S guided pericardiocentesis

PE: NE, surgical embolectomy

Presentation:

Paradoxical chest wall motion 

inward movement with inspiration

outward movement with expiration

Respiratory distress + signs of hypoxia

Diagnosis:

careful inspection and palpation that reveals paradoxical motion of flail segment

Treatment:

intubation!

maintain ventilation and fluids

supplemental oxygen

Presentation:

pneumothorax that interferes with venous return to heart

Respiratory distress, distended neck veins, and unilateral diminished breath sounds

Contralateral tracheal deviation

Percussion typmany

+/- external signs of trauma

Diagnosis:

Clinical diagnosis confirmed by CXR

Treatment:

emergency thoracostomy 

insert large bore (14ga) needle into 2nd ICS, MCL

Definitive tx is tube thoracostomy in 5th ICS MAL

Presentation:
penetrating or blunt injuries can interfere with intra-pericardial pressure and interrupts diastolic filling, leading to inadequate CO and end organ perfusion

Beck's Triad: hypotension, JVD, muffled heart sounds

Diagnosis:
EKG shows alternating positive and negative QRS complexes with each beat (pathognomonic)

FAST exam can confirm

Emergency echo TEE

Treatment:

Pericardiocentesis

Open thoracotomy

Presentation:

Altered MS +/- focal deficits

Cranial lacerations, hematomas

Basilar skull fracture shows hemotympanum, CSF leak, Battle's sign, Raccoon eyes, CN 7 palsy

Diagnosis:

Examine head, nose, ears

Rapid neuro exam - GCS, AVPU, pupils, EOMs, posturing, motor function, response to pain, DTR, Babinski

CT without contrast

Treatment:

Achieve euvolemia

Maintain PCO2 35 - 40

Hyperventilation indicated if uncal herniation

Mannitol for osmotic diuresis if ICP

Decompressive craniotomy, burr hole if rapid deterioration

Presentation:

Trachea - hoarseness, aphonia, apnea, respiratory distress, stridor, subcutaneous emphysema, bubbling of blood

Esophagus - dysphagia, neck pain

Vascular - Zones 1 - 3

Diagnosis:

Examine neck for trauma, hematoma, crepitus, SQ air, external hemorrhage, tracheal deviation, cervical spine tenderness, or deformity

Esophagus - requires CXR and esophagoscopy or barium swallow

Vascular - surgical exploration if in Zone 2, esophagoscopy

Presentation:

High velocity blunt trauma to chest (MVA)

that causes hypotension, wall motion abns that lead to a decrease in CO

Diagnosis:

EKG shows unexplained sinus tach

EKG may also show other arrhythmias, ST and T wave changes, and heart blocks

Echo, cardiac enzymes

Treatment: 

Treat arrthymias

Serial EKGs to assess for changes

Will heal completely

Can d/c if hemodynamically stable, < 55 yo

Presentation:
Trauma to chest causing respiratory distress, hypoxia that worsens over time, and diffuse pulmonary opacities on CXR

One of the most lethal injuries to the chest

Diagnosis: 

CXR - beware radiographic findings may be delayed > 24 hours

CT scan can confirm diagnosis before CXR

Treatment:

Monitoring and oxygen, ventiltion

Intubation if pulse ox < 90

Presentation:

requires high index of suspicion based on mechanism of injury

Deceleration, ped struck by vehicle, falls > 30 ft

Pseudocoarctation, diminished femoral pulses

New harsh systolic murmur

50% of pts have no external signs

Diagnosis:

CXR may show widened mediastinum > 8 cm 

Tracheal or NG tube deviation to right

Widening of paratracheal stripe > 5 cm

Depression of left main-stem bronchus

Indistinct aortic knob, Left apical capping

Helical CT, TEE

Aortography is gold standard

Treatment:

Surgial consult, immediate surgery

BP support with IV fluids, blood

Maintain Hct at 30%, Maintain BP 100-120

Beta blockers, afterload reduction to control HTN

Presentation:

Logroll pt to examine entire spine

Rectal exa for tone, perineal sensation

+/- neuro deficits early

Diagnosis: 

detailed motor and sensory exam to determine all extremities 

Radiography

Treatment:

Neuro/ortho consult for deficits/fractures

Presentation:
Injuries may be blunt or penetrating, resulting in intra-abdominal bleed

Blunt trauma - spleen

Penetrating trauma - liver, small bowel

Diagnosis:

Mechanism of injury, muscle guarding

CBC, electrolytes, lactate, EtOH, drug screen, HCG

Serial FAST exams, CT of ab with IV/oral/rectal contrast

Treatment: 
Hemodynamically stable - may be sent to radiology for CT and DPL, FAST

Hemodynamically unstable - FAST exam, followed by CT if they become stable

If positive FAST, immediate laparotomy

Presentation:

Pelvic fractures associated with GU injury

Blood in urinary meatus

Scrotal or perineal hematoma

High riding prostate on rectal exam

Diagnosis:

retrograde urethrogram prior to Foley insertion

Cystogram

CT scan with IV contrast

Treatment:

Treat shock as indicated

Presentation:
pregnancy outside of uterus

Abdominal pain, vaginal bleeding, Nausea, lightheadedness

Diagnosis:

Ultrasound is most sensitive and serum HCG

Will need Rh factor

Treatment:

If still intact - manage medically

Ruptured - surgery and stabilization

RhoGAM if indicated

Presentation:
Bleeding

Diagnosis:
Vitals, compression of uterus, pelvic U/S

Treatment:

Treat for trauma

Obtain consult

Presentation:

Placenta attaches to lower part of uterine wall, possibly covering cervix

Presents with bleeding

Treatment:

bed rest, transfusions

C-section, possible RhoGAM

Presentation:

Separation of placenta from uterine wall prior to delivery

Ab pain, back pain, vaginal bleeding

Diagnosis:

U/S and labwork

Treatment:

Observation, IV fluids, maybe blood

Routine C-section or emergent delivery

RhoGAM

Presentation:
Full thickness separation of uterine wall and overlying serosa

Uterine bleeding, fetal distress

Expulsion of fetus, placenta into cavity

Diminished uterine pressure, ab paon

Hemorrhage, shock 

Presentation:
Stabilize mother and fetus (C-section)

Mother may need repair or hysterectomy

Obtain Rh factor and treat accordingly

Presentation:

Fetal death < 20 wks gestation

Vaginal bleeding, cramping

Diagnosis:
U/S, serial serum HCG

Treatment:

Obtain Rh factor and tx accordingly

Misoprostol to help evacute contents

Consider D&C if retained POC persists

Presentation:
sudden onset lower abdominal pain

Usually due to mass, tumor > 5 cm

Pregnancy increases risk

Treatment:
surgical repair

Presentation:

Follicle does not open, creating fluid filled cyst that ruptures and causes mild peritoneal signs

Diagnosis:
Pelvic exam and U/S

Presentation:

Caused by GC/C

Ab pain, vaginal discharge, vaginal bleeding

Dyspareunia, fever, nausea

Vomiting, signs of peritonitis

PID shuffle

Diagnosis:
Clinical, labs

Treatment:
Inpt may require IV abx

Outpt: Cefriaxone 250 mg IM one dose + Doxycycline for 14 days

Presentation:
candida, anaerobes, GC

Discharge and pruritis

Diagnosis:

Pelvic exam, UA

Wet Prep: bacterial shows clue cells

Wet Prep: candida shows yeast

Treatment:

Candida: Diflucan, topical cream

BV: metronidazole

GC: Cefriaxone

Presentation:
Infection of Bartholin gland, usually GC

Diagnosis:

Physical exam - abscess appears erythematous and tender to palpation in posterior labia major or vestibule

Treatment:

Drainage with word cath

Marsupialization

Broad spectrum abx

Presentation:
N/V, diffuse ab pain, watery diarrhea, low grade fever, HA, myalgias

Pt usually has sick contacts

Usually viral, blood may mean bacterial

Diagnosis:
check electrolytes, pregnancy test

Treatment:

Rehydration with IV fluids

Correction of any electrolyte abn

Anti-pyretics for fever or body aches

Anti-emetics if pt cant stop vomiting

Low dose immodium will help with viral

Presentation:
Inflammation of stomach specifically, usually cause by EtOH, NSAIDs

Possible bleeding

Anorexia, Nausea, dyspepsia, pain

Post-prandial emesis

Diagnosis: endoscopy

Treatment:

Antacids with lidocaine for non-bleeding

Consider PPI or H2 antagonist

Avoid ASA, NSAIDs, caffeine, EtOH

Hospitalize if bleeding

Presentation:

H. pyloria, NSAIDs

Gnawing, burning, epigastric pain

Typically 2-4 hours after meals relieved by food

Nocturnal pain, early morning wakening

Symptomatic periods appear in clusters and are followed by sx-free periods

Hematemesis

Diagnosis:

H. pylori serum testing

H. pylori breath testing (expensive)

Endoscopy - view mucosa, biopsy ulcerations, sample of stomach for H. pylori and r/o cancer

Confirm there is no GI bleed

Treatment:

Stop NSAIDs

Treat H. pylori with PPI

clarithromycin + amoxicillin +/- bismuth

Presentation:
Significant epigastric pain or RUQ pain that radiates through the body to the back

N/V, fever, decreased pain leaning forward, and restlessness

Mild jaundice, tachycardia, guarding

Diagnosis:

CBC with differential 
CMP, lipase, amylase (more sensitive), ABG

Must r/o aortic dissection/AAA

CT

Treatment:

Aggressive fluid, IV pain control

Abx if pt appear septic

Anti-emetics

NPO, NG tube if vomiting a lot

Treat the precipitant

Presentation:
< 3 defecations per week, straining

Incomplete evacuation, no ab pain

Causes: low fiber, medications, DM, dehydration, thyroid disease

Diagnosis:

Hx is most important

Unintentional weight loss? melena? BRBPR?

Do ab and rectal exam, hemorroids, fissures, prolapse

May need CT, hemoccult, colonoscopy

Treatment:
Chronic: fiber supplements bid, stool softeners, increased hydrations, exercise, more fiber

Acute: enemas, Mg citrate po, Miralax, manual disimpaction, hydration

Presentation:
weakening of supportive tissues cause hemorrhoids to bleed - BRBPR

Perianal itching, irritation

Mucofecal staining of underwear

Frank prolapse

Hx of constipation or constipating meds

Treatment:

High fiber fiet

1% hydrocortisone cream briefly

Careful anal hygeine

Referal to colorectal surgeon for rectal prolapse or chronic anal problems

Presentation:

Superior aspect of intragluteal cleft

Acute or chronic presentation

Due to hairs that puncture the skin

Erythematous, edematous, warm, tender skin superior to gluteal cleft

Low grade fever

Diagnosis:

CBC may show elevated WBC if surrounding cellulitis

Treatment:

Incision and drainage with packing

Abx if cellulitis or immunocompromised

Recurrent cyst may need wider incision

Presentation:
Collection of pus in anus or rectum

May be due to blocked crypts or infection

Can cause fistula, systemic sepsis

Diagnosis:

CBC will show elevated WBC

Do CT if abscess is deep or if you are concerned for fistulae

U/S if abscess is more superficial

Treatment:

Incision and drainage by surgeon

Complications can include transection of anal musculature leading to incontinence

IV abx if sepsis or cellulitis

Presentation:

Diffuse periumbilical pain that localizes to RLQ

Anorexia is the most sensitive sign

N/V, diarrhea, low grade fever

Diagnosis:
Mostly clinical diagnosis

McBurney's point tenderness

Rovsing's sign (deep LLQ palpation)

Psoas sign (hip flexion against resistance)

Obturator sign (internal rotation)

CBC, CMP, wet prep in women, UA, HCG

CT scan with oral, IV contrast

RLQ U/S for pts who can't have CT

Treatment:

Surgical removal

IV abx if surgery is delayed or rupture

Presentation:

Gallbladder inflammation - usually due to gallstones

5 F's 

RUQ pain, radiation to back or shoulder

Constant and severe, assoc with fever

Worse post-prandial, N/V, anorexia

+ Murphy's sign, pt is very still

Diagnosis: 

CBC, CMP, Lipase to r/o pancreatits

U/S most sensitive test - may show gallstones, thickened wall, sonographic Murphy's, pericholecystic fluid

Can do HIDA scan 

Treatment:

GI tract rest - NPO

IV pain meds and hydration

Possible surgery

Abx if pt has fever, elevated WBC, or any other reason to suspect actual or threatened ascending infection

Presentation:

Perforation of any abdominal organ caused by trauma, infection, instrumentation, or obstruction

Abrupt onset pain or relief from pre-existing pain at time of perforation

Fever, hypotension, rigid abdomen

Diagnosis:

Plain films (supine, upright)

Possible CT

CBC for WBC

Treatment: 

Call surgery now

Supportive care until surgery takes them to OR

Presentation:
Abrupt onset dysphagia w/ inability to swallow saliva

Neck tenderness, sense of fullness

Attempts to induce vomiting

Diagnosis:

Hx of recent ingestion of meat, achalasia, esophageal strictures, previous impactions

Plain films of neck, chest, abdomen may show radiopaque foreign body, signs of esophageal perforation, or nothing

Check for SQ air on X-ray

Treatment:
IV Glucagon to relax esophagus

Endoscope can be used to push food down

May need esophageal dilation

Disc batteries must come out

Some things can be allowed to pass

Sharp or long > 5 cm can be removed by GI doc or general surgery

Presentation:

Aorta 2x width of normal diameter

Abrupt onset ab, chest, or flank pain, hypotension

Pulsatile mass in abdomen

May be unconscious

Diagnosis:

Bedside U/S

CBC, PT/PTT/INR, chemistries

More stable pts - CT w/ IV contrast

Treatment:

Call vascular surgery!

At least 2 large bore IVs

Type and cross 10 U of blood

Aggressive rehydration IV fluids

O2 via nasal cannula

Serial Hgb/Hct

Patient to OR asap

Presentation:
Arterial emboli and venous thrombosis causing severe acute or chronic pain presenting in diffuse pattern. May also be sub-acute.

Usually older pts with hx of MI, CHF, PVD, AFib, AAA, dissections, hypercoaguable states, hypercholesterolemia, PVD, pancreatitis, diverticulitis, appendicitis, trauma, DM

Diagnosis:
Pain out of proportion to exam

Heme-positive stool

Elevated serum lactate (hypoperfusion)

CT, Angiography is gold standard

Treatment:
IV fluids immediately to improve flow 

Immediate surgery consult

IV abx to protect pt in case of perforation

Aggressive pain control

Heparin if known thrombus

Presentation:

Hx of adhesions (surgery), hernias, tumors, strictures, Crohn's disease

Crampy ab pain, inability to pass flatus or stool

Vomiting, vomiting stool, ab distension

Crampy developing into constant pain may be a sign of strangulation

Diagnosis:

Signs of peritonitis, ab distenstion, high pitched bowel sounds, diffuse ab tenderness to light palpation, surgical scar

X-rays - supine and upright shows air/fluid levels or free air under diaphragm

CT if X-ray is non-specific

CBC, coags, chemistries, gastroccult

Treatment:

NG tube, NPO

IV hydration