WikEM - User contributions [en]

Benign paroxysmal positional vertigo

2011-08-15T06:18:34Z

Fsanchezmd:

==Diagnosis==

-first decide which ear affected- do Dix Hallpike test w head rotated to R and neck hyperextended and head hanging off bed- if get R sided nystagmus then R ear affected

- once decide which ear affected- do bedside manuever on that ear

==Treatment ==

L Ear Affected

- place pt recumbant w head turned to left, head hanging off of bed and chin pointing up and wait for sxs to stop

- then rotate head and body until R ear down

- then rotate further until face down

- vertex of head kept down throughout rotation

- keep face down for 15 sec

- bring pt back to seated position with head turned to R

- now keep chin down

[[File:Epley Maneuver.png]]

[[Category:Neuro]]

Benign paroxysmal positional vertigo

2011-08-15T06:16:39Z

Fsanchezmd:

Benign Positional Vertigo (BPV)

2011-08-15T06:06:31Z

Fsanchezmd: moved Benign Positional Vertigo (BPV) to Benign Paroxysmal Positional Vertigo (BPPV)

#REDIRECT [[Benign Paroxysmal Positional Vertigo (BPPV)]]

Benign paroxysmal positional vertigo

2011-08-15T06:06:31Z

Fsanchezmd: moved Benign Positional Vertigo (BPV) to Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo

2011-08-15T06:05:25Z

Fsanchezmd:

Pelvic pain

2011-08-11T06:27:55Z

Fsanchezmd:

== Acute Pelvic Pain DDx ==
==== Gynecologic/Obstetric ====
#Pregnancy-related
##[[Ectopic Pregnancy]]
##Abortion, threatened or incomplete
##Septic Abortion
#Acute Infections
##Endometritis
##[[Pelvic Inflammatory Disease (PID)]]
##TOA
#Adnexal Disorders
##Hemorrhage/rupture of ovarian cyst
##Torsion of Adnexa
##Twisted paraovarian cyst
#Recurrent
##Mittelschmerz (midcycle pain)
##Primary/Secondary Dysmenorrhea
##Endometriosis
==== Genitourinary ====
#Cystitis
#Pyelonephritis
#Ureteral lithiasis
==== Gastrointestinal ====
#Gastroenteritis
#[[Appendicitis]]
#Bowel obstruction
#Perirectal abscess
#[[Diverticulitis]]
#Inflammatory bowel disease
#[[Irritable Bowel Syndrome (IBS)]]
==== Musculoskeletal ====
#Abdominal wall hematoma
#Psoas hematoma
#Hernia
==== Vascular ====
#Pelvic thrombophlebitis
#[[Abdominal Aortic Aneurysm (AAA)]]
#Ischemic bowel ([[Mesenteric Ischemia]])

== Postmenopausal Pelvic Pain DDX ==
==== Gynecologic ====
#Vaginitis
##Atrophic
##Infectious
##Allergic
#Uterine prolapse
#Cervical polyps
#Uterine fibroids
#Endometrial hyperplasia
#Neoplasm
##Uterine
##Ovarian
==== Gastrointestinal ====
#Rectocele
#[[Diverticulitis]]
#Neoplasm
#[[Appendicitis]]
#Ischemic Bowel ([[Mesenteric Ischemia]])
==== Urologic ====
#Infection ([[UTI]])
##Cystitis
##Urethritis
##Pyelonephritis
#Cystourethrocele

== Source ==
Hardwood-Nuss

== See Also ==
[[Pelvic Pain Prepubertal]]

[[Category:OB/GYN]]

Pelvic pain

2011-08-10T23:40:15Z

Fsanchezmd:

Pelvic pain

2011-08-10T23:39:32Z

Fsanchezmd:

Prepubertal pelvic pain

2011-08-10T23:38:27Z

Fsanchezmd:

== Pelvic Pain Prepubertal DDX ==
==== Gynecologic ====
#Trauma
##Laceration
##Hematoma
##Sexual Abuse
#Vaginal foreign body
#Vaginal infection
#Vulvar dermatitis
##Chemicals (bubble baths)
##Poor hygiene
##Allergic dermatitis
##Parasitic infestation (pinworms)
#Outflow-tract obstruction
##Imperforate hymen
##Labial adhesions
##Congenital abnormalities
==== Gastrointestinal ====
#Appendicitis
#Gastroenteritis
#Obstruction
#Constipation
#Volvulus
==== Musculoskeletal ====
#Muscle tendon injury
#Growth-plate injury
#Ligamentous injury
#Avulsion fracture
#Inguinal hernia
#Intervertebral disc herniation
==== Urologic ====
#Nephrolithiasis
#Cystitis
#Pyelonephritis
#Urethritis

==== Other ====
#Diabetic ketoacidosis
#Sickle cell crisis
#Neoplasms

== Source ==
Hardwood-Nuss

== See Also ==
[[Pelvic Pain]]

[[Category:Peds]]

Prepubertal pelvic pain

2011-08-10T23:38:06Z

Fsanchezmd: Created page with "== Pelvic Pain Prepubertal DDX == ==== Gynecologic ==== #Trauma ##Laceration ##Hematoma ##Sexual Abuse #Vaginal foreign body #Vaginal infection #Vulvar dermatitis ##Chemicals (bu..."

== Pelvic Pain Prepubertal DDX ==
==== Gynecologic ====
#Trauma
##Laceration
##Hematoma
##Sexual Abuse
#Vaginal foreign body
#Vaginal infection
#Vulvar dermatitis
##Chemicals (bubble baths)
##Poor hygiene
##Allergic dermatitis
##Parasitic infestation (pinworms)
#Outflow-tract obstruction
##Imperforate hymen
##Labial adhesions
##Congenital abnormalities
==== Gastrointestinal ====
#Appendicitis
#Gastroenteritis
#Obstruction
#Constipation
#Volvulus
==== Musculoskeletal ====
#Muscle tendon injury
#Growth-plate injury
#Ligamentous injury
#Avulsion fracture
#Inguinal hernia
#Intervertebral disc herniation
==== Urologic ====
#Nephrolithiasis
#Cystitis
#Pyelonephritis
#Urethritis

==== Other ====
#Diabetic ketoacidosis
#Sickel cell crisis
#Neoplasms

== Source ==
Hardwood-Nuss

== See Also ==
[[Pelvic Pain]]

[[Category:Peds]]

Pelvic pain

2011-08-10T23:24:41Z

Fsanchezmd:

Pelvic pain

2011-08-10T23:22:36Z

Fsanchezmd:

Pelvic pain

2011-08-10T23:17:59Z

Fsanchezmd: Created page with "== Acute Pelvic Pain DDx == ==== Gynecologic/Obstetric ==== #Pregnancy-related ##Ectopic Pregnancy ##Abortion, threatened or incomplete ##Septic Abortion #Acute Infections ##..."

Pelvic Inflmatory Disease (PID)

2011-08-10T23:10:22Z

Fsanchezmd: moved Pelvic Inflmatory Disease (PID) to Pelvic Inflammatory Disease (PID)

#REDIRECT [[Pelvic Inflammatory Disease (PID)]]

Pelvic inflammatory disease

2011-08-10T23:10:22Z

Fsanchezmd: moved Pelvic Inflmatory Disease (PID) to Pelvic Inflammatory Disease (PID)

==Background==
*Commonly begins as cervical infection (cervicitis) with gonorrhea or chlamydia

==Diagnosis==
#Pelvic pain (90%)
#Constitutional sx-Vaginal discharge (75%)
#Abnl pelvic exam (60%)
#Vaginal bleeding (40%)

===CDC Treatment Criteria===
#Cervical motion tenderness (CMT) OR
#Uterine tenderness OR
#Adnexal tenderness
#Additional criteria that make the dx more likely:
##Fever
##WBC >10k
##Mucopurulent cervical or vaginal discharge
##WBCs on wet mount
##Proven infection w/ GC or chlamydia

^CDC Criteria are Sn, but not Sp (i.e. many intra-abominal processes have CMT)

==Work-Up==
#Upreg (negative)
#Pelvic exam (send GC/Chlamy, wet mount)
#Pelvic US if toxic (r/o TOA)
#R/O other intra-abd pathology (consider CT, UA, labs)

== Treatment ==
*Tx all partners that had sex w/ pt during previous 60d prior to onset of symptoms
=== Outpatient ===
#CTX 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d
##Metronidazole based upon assessment of risk for anaerobes; consider in:
###Pelvic abscess
###Proven or suspected infection w/ trichomonas or bacterial vaginosis
###History of gynecological instrumentation in the preceding 2-3wks

=== Inpatient ===
#(Cefotetan 2gm IV q12h OR cefoxitin 2mg IV q6h) + doxycycline 100mg IV/PO q12h OR
#Clindamycin 900mg IV q8h + genamicin 2mg/kg QD OR
#Ampicillin/sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr

==Disposition==
Admit for:
# TOA, Fitz-Hugh-Curtis
# Sepsis/peritonitis
# Unable to tol POs
# Failed outpt Rx

==Complications==
#TOA/sepsis
#Infertility
#[[Ectopic Pregnancy]]
#Chronic pelvic pain

==See Also==
[[Sexually Transmitted Diseases (STD)]]
[[Ectopic Pregnancy]]
[[Pelvic Pain]]

== Source ==
CDC 2010, KajiQuestions

[[Category:ID]] [[Category:OB/GYN]]

Pelvic inflammatory disease

2011-08-10T20:47:02Z

Fsanchezmd:

Pelvic inflammatory disease

2011-08-10T20:44:39Z

Fsanchezmd:

==Background==
*Commonly begins as cervical infection (cervicitis) with gonorrhea or chlamydia

==Diagnosis==
#Pelvic pain (90%)
#Constitutional sx-Vaginal discharge (75%)
#Abnl pelvic exam (60%)
#Vaginal bleeding (40%)

===CDC Treatment Criteria===
#Cervical motion tenderness (CMT) OR
#Uterine tenderness OR
#Adnexal tenderness
#Additional criteria that make the dx more likely:
##Fever
##WBC >10k
##Mucopurulent cervical or vaginal discharge
##WBCs on wet mount
##Proven infection w/ GC or chlamydia

^CDC Criteria are Sn, but not Sp (i.e. many intra-abominal processes have CMT)

==Work-Up==
#Upreg (negative)
#Pelvic exam (send GC/Chlamy, wet mount)
#Pelvic US if toxic (r/o TOA)
#R/O other intra-abd pathology (consider CT, UA, labs)

== Treatment ==
*Tx all partners that had sex w/ pt during previous 60d prior to onset of symptoms
=== Outpatient ===
#CTX 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d
##Metronidazole based upon assessment of risk for anaerobes; consider in:
###Pelvic abscess
###Proven or suspected infection w/ trichomonas or bacterial vaginosis
###History of gynecological instrumentation in the preceding 2-3wks

=== Inpatient ===
#(Cefotetan 2gm IV q12h OR cefoxitin 2mg IV q6h) + doxycycline 100mg IV/PO q12h OR
#Clindamycin 900mg IV q8h + genamicin 2mg/kg QD OR
#Ampicillin/sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr

==Disposition==
Admit for:
# TOA, Fitz-Hugh-Curtis
# Sepsis/peritonitis
# Unable to tol POs
# Failed outpt Rx

==Complications==
#TOA/sepsis
#Infertility
#{[Ectopic Pregnancy]]
#Chronic pelvic pain

==See Also==
[[Sexually Transmitted Diseases (STD)]]
[[Ectopic Pregnancy]]
[[Pelvic Pain]]

== Source ==
CDC 2010, KajiQuestions

[[Category:ID]] [[Category:OB/GYN]]

Resident editors

2011-08-10T05:57:22Z

Fsanchezmd:

==General==
We are currently recruiting Resident Editors from accredited Emergency Medicine residency programs. Contact Dr. Jordan Swartz <jordanlswartz@gmail.com>, if you would like to be the Resident Editor for your program.

==Resident Editors==
===Harbor-UCLA Medical Center===
Jordan Swartz, MD (2011-Present)

===University of Pittsburgh Medical Center===
Neal Madhani, MD (2011-Present)

===Christiana Care Health System===
Edgar Ordonez, MD (2011-Present)

===Akron General===
Paul M. Been, MD (2011-Present)

[[Category:WikEM]]

New onset diabetes mellitus

2011-08-10T05:30:25Z

Fsanchezmd:

==Treatment==
*If HbA1c > 6.5, titrate fasting blood sugar to 80 to 120
*ADA diet control until HbA1c is >7
*1st line Metformin 500mg BID --> 1000mg BID, do not give in people with abnormal LFT's, CHF Stage 3/4 and ARI, CKD
*2nd Agent Glipizide start 2.5mg BID -->5mg BID, need to monitor for hypoglycemia
*3rd Agent Pioglitazone
*After 3 agents need to start insulin if not controlled, ie NPH BID or Lantus Qday (0.5mg/kg) and titrate to Fasting Blood Sugar
*all DM need HbA1c q 3mo, Ma-cr to check for microalbuminuria q year

==See Also==
*[[DKA]]
*[[Diabetes (Meds)]]
*[[HONC]]
*[[Hypoglycemia]]

[[Category:Endo]]

Asymptomatic Hypertension (HTN)

2011-08-10T03:39:00Z

Fsanchezmd: moved Asymptomatic Hypertension (HTN) to Hypertension Asymptomatic (HTN)

#REDIRECT [[Hypertension Asymptomatic (HTN)]]

Asymptomatic hypertension

2011-08-10T03:39:00Z

Fsanchezmd: moved Asymptomatic Hypertension (HTN) to Hypertension Asymptomatic (HTN)

== JNC-7 Classification ==
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
| '''Class'''
| ''' Systolic'''
| 
| '''Diasolic'''
|-
| Normal
| <120
| and
| <80
|-
| Pre-hypertension
| 120-130
| or
| 80-89
|-
| Stage 1
| 140-150
| or
| 90-99
|-
| Stage 2
| ≥160
| or
| ≥100
|}

== Work-Up ==
#Upreg
#<120 diastolic --> home, outpt rx
#>210 systolic or >120-130 diastolic --> search end organ
##Chem 7 (creatinine)
##UA (protein)?
##ECG?

Note:

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends an average of 2 or more properly measured, seated blood pressure readings on each of 2 or more office visits to establish the diagnosis

== Treatment ==
#First line for people without comorbidities: HCTZ 12.5mg, max 25mg (need labs before starting, does not work in people with CKD)
#First line for people with DM and/or Proteinuria: ACEi/ARB: Lisinopril either Qday or BID but need Chem 10 before and after starting to check for hyperK and Cr.
#Anyone with CAD, CHF: Beta-Blocker (don't need labs)
#Amlodipine for anyone, except for people with LE edema (don't need labs)
#Diltiazem for proteinuria in people unable to tolerate ACEi (don't need labs)
#Lasix for CHF and/or lower ext edema 2/2 proteinuria

[[Category:Cards]]

Asymptomatic hypertension

2011-08-10T03:35:45Z

Fsanchezmd: /* Treatment */

Acute leukemia

2011-08-09T02:14:21Z

Fsanchezmd:

== Acute Myeloid Leukemia ==

=== Background ===

*aka Acute myelogenous leukemia or non-lymphocytic leukemia
*Most common acute leukemia in adults (around 80% of cases)
*65yo median age of diagnosis, Male:Female 5:3
*characterized by clonal proliferation of myeloid precursors(blast cells >20% in the periphery)

=== Diagnosis ===

*Presents with anemia, neutropenia, thrombocytopenia,
*weakness, easy fatigability, infections, gingival bleeding/enlargement, ecchymoses, epistaxis, menorrhagia

 

=== Work-Up ===

*CXR
*CBC with peripheral smear
*Chem7, ca, mg, phos, Uric Acid, UA, LDH (to check for Tumor Lysis)
*LFTs, Coags, FDP, D-Dimer, Haptoglobin, Fibrinogen (to check for DIC)
*Get extra purple top for flow cytometry, especially before transfusion

 

=== Treatment ===

*Aggressive IV hydration
*If febrile, complete cultures and broad spectrum antibiotics
*Manage Complications
**see [[DIC]]
**see [[Leukostasis]]
**see [[Tumor Lysis Syndrome]]

 

== Acute Lymphocytic Leukemia ==

=== Background ===

*Characterized by proliferation of immature lymphoblast( >20% in periphery)
*Less than 20% of acute leukemias in adults,
*Most common form in children (see also [[Leukemia (Peds)]])
*Highest incidence in 7th decade of life

=== Diagnosis ===

*Lymphocytosis, neutropenia, anemia, thrombocytopenia,
*Lymphadenopathy, hepatosplenomegaly
*CNS and testes involvement common

=== DDX ===

*Hodgkin and non-Hodgkin lymphomas

=== Work-Up ===

*CXR
*CBC with peripheral smear
*Chem7, ca, mg, phos, Uric Acid, UA, LDH (to check for Tumor Lysis)
*LFTs, Coags, FDP, D-Dimer, Haptoglobin, Fibrinogen (to check for DIC)
*Get extra purple top for flow cytometry, especially before transfusion

=== Treatment ===

*Aggressive IV hydration
*If febrile, complete cultures and broad spectrum antibiotics
*Manage Complications
**see [[DIC]]
**see [[Leukostasis]]
**see [[Tumor Lysis Syndrome]]

 

== Source ==

Uptodate & MKSAP15

== See Also ==

[[Lymphoma]]

[[Category:Heme/Onc]]

Acute leukemia

2011-08-09T02:12:29Z

Fsanchezmd:

== Acute Myeloid Leukemia ==

=== Background ===

*aka Acute myelogenous leukemia or non-lymphocytic leukemia
*Most common acute leukemia in adults (around 80% of cases)
*65yo median age of diagnosis, Male:Female 5:3
*characterized by clonal proliferation of myeloid precursors(blast cells >20% in the periphery)

=== Diagnosis ===

*Presents with anemia, neutropenia, thrombocytopenia,
*weakness, easy fatigability, infections, gingival bleeding/enlargement, ecchymoses, epistaxis, menorrhagia

 

=== Work-Up ===

*CXR
*CBC with peripheral smear
*Chem7, ca, mg, phos, Uric Acid, UA, LDH (to check for Tumor Lysis)
*LFTs, Coags, FDP, D-Dimer, Haptoglobin, Fibrinogen (to check for DIC)
*Get extra purple top for flow cytometry, especially before transfusion

 

=== Treatment ===

*Aggressive IV hydration
*If febrile, complete cultures and broad spectrum antibiotics
*Manage Complications
**see [[DIC]]
**see [[Leukostasis]]
**see [[Tumor Lysis Syndrome]]

== Acute Lymphocytic Leukemia ==

=== Background ===

*Characterized by proliferation of immature lymphoblast( >20% in periphery)
*Less than 20% of acute leukemias in adults,
*Most common form in children (see also [[Leukemia (Peds)]])
*Highest incidence in 7th decade of life

=== Diagnosis ===

*Lymphocytosis, neutropenia, anemia, thrombocytopenia,
*Lymphadenopathy, hepatosplenomegaly
*CNS and testes involvement common

=== DDX ===

*Hodgkin and non-Hodgkin lymphomas

=== Work-Up ===

*Aggressive IV hydration
*If febrile, complete cultures and broad spectrum antibiotics
*Manage Complications
**see [[DIC]]
**see [[Leukostasis]]
**see [[Tumor Lysis Syndrome]]

 

== Source ==

Uptodate & MKSAP15

== See Also ==

[[Lymphoma]]

[[Category:Heme/Onc]]

Arthrocentesis

2011-08-09T02:10:14Z

Fsanchezmd:

== Indications ==

Diagnosis

*suspicion of septic arthritis, crystal induced arthritis
*evaluation of therapeutic response for septic arthritis
*unexplained arthritis with synovial effusion

=== Relative Indications ===

Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)

== Contraindications ==

#No absolute contraindications for diagnostic arthrocentesis
#do not inject steroids into a joint that you suspect or know to be infected
#Relative Contraindications:
##coagulopathy
##local or systemic infection

== Equipment Needed ==

#Betadine or Chlorhexadine
#Sterile Gloves/drape
#sterile gauze
#Lidocaine
#Syringes
##small syringe (6-12cc) for injection of local anesthetic
##Large (one 60cc or 2 30cc) syringe for aspiration
#Needles
##18 gauges
##27 gauge
#Collection tubes (red tops)
#Culture bottles
#adhesive bandage

== Procedure ==

#Position the patient in a way so that they are comfortable and so you have easy access to the joint that you are going to tap (see below for positioning pearls)
#Prep the area with betadine or chlorhexadine using circular motion moving away from the joint x 3. Drape the joint in a sterile fashion
#Inject lidocaine superficially and then into the deeper tissues
#Confirm landmarks and then insert the needle into the joint space while you are simultaneously pulling back on the plunger of the syringe. Stop once you aspirate fluid and aspirate as much fluid as possible (you may need to replace the syringe multiple times to get larger volumes)
#Once fluid is removed, remove the needle and apply adhesive bandage

== Approach ==

=== Shoulder ===

#anterior approach: have patient sitting with should in external rotation. Insert needle anteriorly below the tip of the coracoid medial to the humeral head directing it posterolaterally
#posterior approach: same as anterior approach except needle is inserted on the posterior side of the shoulder

=== Elbow ===

#Have patient sitting with elbow in 90 degrees of flexion, forearm pronated, palm facing downward
#insert needle within triangle bounded by radial head, lateral humeral epicondyle, and olecranon directing it toward the medial epichondyle

=== Wrist ===

#3-4 portal approach: have wrist in slight flexion and ulnar deviation. Insert needle dorsally just distal to Lister's tubercle (bony prominence over the dorsum of the distal radius) and ulnar to the extensor pollicus longus

=== Metacarpophalangeal ===

#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally just medial or lateral to midline and proximal to the base of the proximal phalanx

=== Interphalangeal ===

#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally medial or lateral to midline and proximal to base of middle or distal phalanx

=== Knee ===

#Inferior-medial approach: knee flexed at 90 degrees and needle inserted between patella tendon, medial femoral condyle, and medial tibial plateau
#Medial approach: knee extended and needle inserted 1-2cm medial to patella just distal to proximal edge of the patella directing it posteriorly beneath the patella

=== Ankle ===

#plantarflex the ankle and locate the medial malleolus and anterior tibialis tendon
#Insert needle 1/2 inch above medial malleolus, 1/2 inch lateral to anterior edge of medial malleolus, and medial to the anterior tibialis tendon advancing it posteriorly

=== Metatarsophalangeal ===

#patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction
#insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx

=== Interphalangeal ===

#patient supine with joint flexed 15-20 degrees with gentle traction
#insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx

== Complications ==

#pain
#infection
#reaccumulation of effusion
#damage to tendons, nerves, or blood vessels

== See Also ==

[[Septic Arthritis (General)]]

[[Monoarticular Arthritis]]

[[Septic Arthritis (Hip)]]

[[Septic Arthritis (Peds)]]

== Source ==

http://emprocedures.com/arthrocentesis/introduction.htm

[[Category:Procedures]] [[Category:Ortho]]

Arthrocentesis

2011-08-09T02:06:54Z

Fsanchezmd:

== Indications ==

Diagnosis

*suspicion of septic arthritis, crystal induced arthritis
*evaluation of therapeutic response for septic arthritis
*unexplained arthritis with synovial effusion

=== Relative Indications ===

Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)

== Contraindications ==

#No absolute contraindications for diagnostic arthrocentesis
#do not inject steroids into a joint that you suspect or know to be infected
#Relative Contraindications:
##coagulopathy
##local or systemic infection

== Equipment Needed ==

#Betadine or Chlorhexadine
#Sterile Gloves/drape
#sterile gauze
#Lidocaine
#Syringes
##small syringe (6-12cc) for injection of local anesthetic
##Large (one 60cc or 2 30cc) syringe for aspiration
#Needles
##18 gauges
##27 gauge
#Collection tubes (red tops)
#Culture bottles
#adhesive bandage

== Procedure ==

#Position the patient in a way so that they are comfortable and so you have easy access to the joint that you are going to tap (see below for positioning pearls)
#Prep the area with betadine or chlorhexadine using circular motion moving away from the joint x 3. Drape the joint in a sterile fashion
#Inject lidocaine superficially and then into the deeper tissues
#Confirm landmarks and then insert the needle into the joint space while you are simultaneously pulling back on the plunger of the syringe. Stop once you aspirate fluid and aspirate as much fluid as possible (you may need to replace the syringe multiple times to get larger volumes)
#Once fluid is removed, remove the needle and apply adhesive bandage

== Approach ==

=== Shoulder ===

#anterior approach: have patient sitting with should in external rotation. Insert needle anteriorly below the tip of the coracoid medial to the humeral head directing it posterolaterally
#posterior approach: same as anterior approach except needle is inserted on the posterior side of the shoulder

=== Elbow ===

#Have patient sitting with elbow in 90 degrees of flexion, forearm pronated, palm facing downward
#insert needle within triangle bounded by radial head, lateral humeral epicondyle, and olecranon directing it toward the medial epichondyle

=== Wrist ===

#3-4 portal approach: have wrist in slight flexion and ulnar deviation. Insert needle dorsally just distal to Lister's tubercle (bony prominence over the dorsum of the distal radius) and ulnar to the extensor pollicus longus

=== Metacarpophalangeal ===

#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally just medial or lateral to midline and proximal to the base of the proximal phalanx

=== Interphalangeal ===

#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally medial or lateral to midline and proximal to base of middle or distal phalanx

=== Knee ===

#Inferior-medial approach: knee flexed at 90 degrees and needle inserted between patella tendon, medial femoral condyle, and medial tibial plateau
#Medial approach: knee extended and needle inserted 1-2cm medial to patella just distal to proximal edge of the patella directing it posteriorly beneath the patella

=== Ankle ===

#plantarflex the ankle and locate the medial malleolus and anterior tibialis tendon
#Insert needle 1/2 inch above medial malleolus, 1/2 inch lateral to anterior edge of medial malleolus, and medial to the anterior tibialis tendon advancing it posteriorly

=== Metatarsophalangeal ===

#patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction
#insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx

=== Interphalangeal ===

#patient supine with joint flexed 15-20 degrees with gentle traction
#insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx

== Complications ==

#pain
#infection
#reaccumulation of effusion
#damage to tendons, nerves, or blood vessels

== Source ==

http://emprocedures.com/arthrocentesis/introduction.htm

== See Also ==

[[Septic Arthritis (General)]]

[[Monoarticular Arthritis]]

[[Septic Arthritis (Hip)]]

[[Septic Arthritis (Peds)]]

[[Category:Procedures]] [[Category:Ortho]]

Drug levels

2011-08-09T01:01:53Z

Fsanchezmd: Created page with "== Serum Drug Levels == {| width="600" border="1" cellpadding="1" cellspacing="1" |- | '''DRUG    '''         | '''THERAPEUTIC''' | '''TOXIC''' ..."

== Serum Drug Levels ==

{| width="600" border="1" cellpadding="1" cellspacing="1"
|-
| '''DRUG    '''        
| '''THERAPEUTIC'''
| '''TOXIC'''
|-
| Carbamazepine (Tegretol)
| 4-12 ug/mL
| >12 ug/mL
|-
| Digoxin 
| 0.8-2.0 ng/mL
| >2 ng/mL
|-
| Ethosuximide 
| 40-100 ug/mL
| >150 ug/mL
|-
| Lidocaine (Xylocaine)
| 1.5-6 ug/mL 
| >6 ug/mL
|-
| Lithium (Eskalith)
| 0.6-1.2 mEq/L
| >1.5mEq/L
|-
| NAPA (N-acetyl procainamide)
| 5-30 ug/mL
| >40 ug/mL
|-
| Phenobarbital
| 15-40 ug/mL
| >35 ugmL
|-
| Phenytoin (Dilantin)
| 10-20 ug/mL 
| >20 ug/mL
|-
| Procainamide (Procan)
| 3-10 ug/mL 
| >10 ug/mL
|-
| Quinidine (Quinaglute)
| 1.5-5 ug/mL 
| >5 ug/mL
|-
| Theophylline (Theo-Dur) 
| 10-20 ug/mL 
| >20 ug/mL
|-
| Valproic Acid (Depakene)
| 50-100 ug/mL 
| >100 ug/mL
|}

 

== Source ==

Maxwell Quick Medical Reference

Heart murmurs

2011-08-09T00:41:58Z

Fsanchezmd:

== Diagnosis ==

=== Lesions ===

#[[Aortic Stenosis]]
##Systolic murmur heard best in the aortic area; rarely at apex. Crescendo-decrescendo, radiates to carotids. A2 decreased. Paradoxical splitting of S2; narrow pulse pressure. Pulsus parvus et tardus.
#[[Aortic Insufficiency]]
##Diastolic blowing murmur heard at left sternal border in 3rd and 4th interspace. Wide pulse pressure. Quincke's sign (capillary pulsations at fingertips), DeMusset's sign (bobbing head), Muller's sign (pulsing uvula), Corrigan's pulse (water hammer). Pistol shot sounds.
#Pulmonic stenosis
##systolic murmur heard in pulmonic area, transmitted to back and neck. A2 is decreased, P2 is delayed, RVH with parasternal lift.
#Pulmonic insufficiency
##High pitched diastolic murmur; heard in pulmonic area; decrescendo; RVH
#[[Mitral Stenosis]]
##low rumbling diastolic murmur heard best at apex c bell. Opening snap sometimes present worse c closer to S2. Loud S1. (associad c L atrium dilation)
##Can hear presystolic sound confused c systolic murmur.
#[[Mitral Insufficiency]]
##loud, holosystolic, high-pitched, heard best at apex and transmitted to axilla. Soft S1. Severity gauged by s3, rumble.
##paradoxical splitting:

=== Sounds ===

#Gallavardin Effect
##AS sounds like MR--high frequency vibrations to the apex through a calcific AV
#Austin-Flint
##MS sounds like AR--Soft, rumbling murmur, likely due to functional mitral valve stenosis as the backflow of blood from the aorta presses on anterior leaflet of MV.
#Parodoxical S2
##Splittin during expiration and goes away during inspiration. 2/2 inc L sided volume; AS, HOCM
#Wide S2
##2/2 Inc R sided volume; PE, ASD, VSD, Pulmonic stenosis
#S3
##AKA ventricular gallop produced during passive LV filling when blood strikes a compliant LV; CHF, Inc Vol, CAD, benign in youth, train athletes
#S4
##AKA atrial gallop produced when blood is force into a stiff/hypertrophic ventricle ;MI, HTN, restrictive cardiomyopathy

 

== Maneuvers ==

*Valsalva
**Increases thoracic pressure and lowers preload; then then decreased CO and afterload
**Increases murmur in MP & HOCM
**With release: R heart murmurs return first
*Hand grip
**Increases HR + CO
**Increases murmur in MR, MS, AR
**Decreases murmur in AS and HOCM
*Squatting
**Increased venous return
**Delays MP click
*Standing
**Dec in both R & L venous return & SV
**Decreases murmur of PS, AS, AR, TR, VSD
**Increases murmur of HOCM
*Inspiration
**Increases R sided venous return while decreasing L sided return
**Increases S2 splitting with P2 further from A2
**Increases in R sided S3 & S4
**Increases TS opening snap & murmur, PR, TR
**Decreases MS opening snap, MVP murmur

== See Also ==

*[[Valvular Emergencies (Valve)]]
*[[Innocent Murmurs (Peds)]]

== Source ==

7/2/09 PANI

[[Category:Cards]]

Heart murmurs

2011-08-09T00:14:42Z

Fsanchezmd:

== Diagnosis ==

=== Lesions ===

#[[Aortic Stenosis]]
##Systolic murmur heard best in the aortic area; rarely at apex. Crescendo-decrescendo, radiates to carotids. A2 decreased. Paradoxical splitting of S2; narrow pulse pressure. Pulsus parvus et tardus.
#[[Aortic Insufficiency]]
##Diastolic blowing murmur heard at left sternal border in 3rd and 4th interspace. Wide pulse pressure. Quincke's sign (capillary pulsations at fingertips), DeMusset's sign (bobbing head), Muller's sign (pulsing uvula), Corrigan's pulse (water hammer). Pistol shot sounds.
#Pulmonic stenosis
##systolic murmur heard in pulmonic area, transmitted to back and neck. A2 is decreased, P2 is delayed, RVH with parasternal lift.
#Pulmonic insufficiency
##High pitched diastolic murmur; heard in pulmonic area; decrescendo; RVH
#[[Mitral Stenosis]]
##low rumbling diastolic murmur heard best at apex c bell. Opening snap sometimes present worse c closer to S2. Loud S1. (associad c L atrium dilation)
##Can hear presystolic sound confused c systolic murmur.
#[[Mitral Insufficiency]]
##loud, holosystolic, high-pitched, heard best at apex and transmitted to axilla. Soft S1. Severity gauged by s3, rumble.
##paradoxical splitting:

=== Sounds ===

#Gallavardin Effect
##AS sounds like MR--high frequency vibrations to the apex through a calcific AV
#Austin-Flint
##MS sounds like AR--Soft, rumbling murmur, likely due to functional mitral valve stenosis as the backflow of blood from the aorta presses on anterior leaflet of MV.

== Maneuvers ==

*Valsalva
**Increases thoracic pressure and lowers preload; then then decreased CO and afterload
**Increases murmur in MP & HOCM
**With release: R heart murmurs return first
*Hand grip
**Increases HR + CO
**Increases murmur in MR, MS, AR
**Decreases murmur in AS and HOCM
*Squatting
**Increased venous return
**Delays MP click
*Standing
**Dec in both R & L venous return & SV
**Decreases murmur of PS, AS, AR, TR, VSD
**Increases murmur of HOCM
*Inspiration
**Increases R sided venous return while decreasing L sided return
**Increases S2 splitting with P2 further from A2
**Increases in R sided S3 & S4
**Increases TS opening snap & murmur, PR, TR
**Decreases MS opening snap, MVP murmur

== See Also ==

*[[Valvular Emergencies (Valve)]]
*[[Innocent Murmurs (Peds)]]

== Source ==

7/2/09 PANI

[[Category:Cards]]

Eponyms

2011-08-08T20:48:56Z

Fsanchezmd:

== Eponym: Exam Finding; Disease ==

*'''Adson's:'''  Decreased radial pulse c neck turn & breathhold; Thoracic Outlet Syndrom
*'''Brudzinski's:''' Forced neck flexion produces hip+knee flexion; Meningitis
*'''Cheyne-Stokes:''' Breathing alternates between fast & slow; CNS disease
*'''Chvostek's: ''' Facial spasm elicited by tapping facial nerve; Hypocalcemia
*'''Dance's: '''Emptiness to palpation in RLQ; Intussusception
*'''de Musset's: '''Head bobbing with each systole; Aortic Insufficiency
*'''Ewart's: '''Dull to percussion at L scapula; Pericardia Effussion
*'''Fathergill's: '''Abdomen more tender with sit up; Muscle strain
*'''Grey Turner's: '''Flank ecchymossis; Retroperitoneal bleed
*'''Hamman's: '''Crunching sound with each heartbeat; Pneumomediastinum
*'''Hoffman's: '''Flicking tip of 3rd finger causes thumb flexion; UMN disease
*'''Horner's: '''Ptosis, anhydrosis, miosis; Sympathetic lesion
*'''Ishihara's: '''Color blindness cards; Color blindness
*'''Janeway's: '''Painless red embolic hand lesions; Endocarditis
*'''Kussmaul's: ''' JVD increases with inspiration; Pericardial Tamponade
*'''Levine's: '''Clenched fist over chest; MI
*'''Murphy's: '''Inspiratory splint with c RUQ pressure; Cholecystitis
*'''Nikolsky's: '''Lateral pressure on blister causes extension; Pemphigus, TEN, SSSS..
*'''Osler's Nodes: ''' Tender Nodules on palms; Endocarditis
*'''Phalen's: '''Prolonged wrist flexion causes median nerve paresthesias; Carpal Tunnel Syndrome
*'''Pregerson's: '''Subpatellar bulge c kness flexed; Knee effusion
*'''Prehn's: '''Testicle pain relieved by support; Epidymitis
*'''Psoas: '''Hip flexion vs resistance increases abdominal pain; Appendicitis
*'''Quincke's: '''Nail bed pulsations c pressure; Aortic Insufficiency
*'''Romberg's: ''' Falls over with eyes closed; Decreased proprioception
*'''Rovsing's: '''LLQ percussion causes RLQ pain; Appendicitis
*'''Rumpel Leede: '''Petechiae from capillary lreak after tourniquet or BP cuff; Dengue, RMSF, Scarlatina
*'''Steinberg: '''Thumb IP joint can project past ulnar edge of pinky; Marfan's
*'''Thompson's: '''Calf squeeze does not cause plantar flexion; Achilles tendon rupture
*'''Tinel's: '''Percussion of median nerve at wrist provokes paresthesias; Carpal Tunnel Syndrome
*'''Traube's: '''Pistol shot sound at femoral artery; Aoric insufficiency
*'''Trousseau's: '''Carpal spasm from BP cuff; Hypocalcemia
*'''Uhthoff's: '''Increased body temp causes worsening neuro sx; Multiple sclerosis''' '''
*'''Vircow's: '''Palpable left supraclavicular lymph node; Pancreatic or GI CA
*'''Von Graefe's: '''Lid lag with visual tracking from hight to low; Grave's disease
*'''Walker: '''1st and 5th digit encircling other wrist overlap proximal to DIP; Marfan's
*'''Weber: '''Tuning fork to mid forehead heard asymmetrically; Hearing deficit
*'''Yerganson's: '''Pain and weakness with resisted supination; Biceps Tendonitis

[[Category:Misc/General]]

Eponyms

2011-08-08T20:47:35Z

Fsanchezmd: Created page with "== Eponym: Exam Finding; Disease == *'''Adson's:'''  Decreased radial pulse c neck turn & breathhold; Thoracic Outlet Syndrom *'''Brudzinski's:''' Forced neck flexion..."

Intubation (peds)

2011-08-08T19:09:55Z

Fsanchezmd:

==Airway Adjuncts==
*OP Airway Size:
**from lip/teeth to angle of jaw
*NP Airway:
**tip of nose to tragus
*BVM in Kids
** 10cc/kg

==ETT==
ETT Size: (Age/4) + 4

===Preemies===
*1kg 2.5mm tube at 7cm depth
*2g 3.0mm tube at 8 cm depth
*3kg 3.5 tube at 9 cm depth

Cuffed 1/2 size smaller than cuffless

Depth of Tube Placement: 3 x ETT

Why uncuffed in kids:

because cricoid ring is narrowest portion of the airway...however cuff is now consider better if available esp in patients that will be difficult to ventilate

==Other Tubes:==
*NG, OG, foley: 2 x ETT
*Chest Tube (max) 4x ETT

==ETT Drug Delivery==
Endotracheal Drug Delivery: 1:1000 solution @ 0.1 mg/kg = 0.1ml/kg

==Source==
Adapted from Pani, DeBonis

[[Category:Peds]]
[[Category:Airway/Resus]]

Undifferentiated shock

2011-08-08T18:53:13Z

Fsanchezmd:

== Definition ==

#SBP <90 in nl pt
#SBP<100 with h/o HTN or age >60
#ABG = lactate > 4 or base def < -4
#MAP = SVR x CO

== Types ==

{| border="1"
|-
| '''Type'''
| '''Skin'''
| '''HR'''
| '''Oth'''
|-
| Hypovolemic
| cold
| inc
| 
|-
| Obstructive
| cold
| inc
| 
|-
| Cardiogenic
| cold
| inc/dec
|  ?dysth
|-
| Distributive
| warm
| inc
| 
|-
| Neurogenic
| warm
| dec
| 
|}

== Undifferentiated Hypotension Algorithm ==

Check:

#HR (age appropriate)
##<40 and >150-180 --> likely HR = Primary etiology
###Tx with cardioversion/defib or pace
##Plasma vs. RBC loss
###Evaluate CVP, IVC, UOP
###Check for GI, intraperitoneal, lung, retroperitoneal loss/sequestration
#Contractility
##Bounding/thready pulse, hyperdynamic precordium
##Dx with ultrasound
###Will have high afterload
####May be due to STEMI, CHF
#Forward flow
##Valvular dysfunction (MR) or obstruction
###Evaluate via auscultation, ultrasound
####Consider PE, HOCM
#Volume Status - LVEDP (approx by CVP, IVC, etc.)
##History of volume loss
##Lung Exam
##Mucous membrane
##Ultrasound IVC (RUQ window or AAA)
##Hemeacuu, Guaic
##Cardiac Ultrasound
#SVR
##Pathologic vasodilation
###Warm extremities, bounding pulse
####Consider sympathetic dysregulation/neurogenic shock
##Cool extremities and "normal" BP
###Consider vasoconstriction and treat as hypotension from the top

== Lack of Response to Normal Tx (DDX) ==

#Cardiogenic
##Acute Valvular Regurg/VSD
##CHF
##Dysrhythmia
##Ischemia/Infarction
##Myocardial Contusion/Myocarditis
#Obstructive
##Air embolism
##Aortic Stenosis
##Cardiac Tamponade
##Massive PE
##Tension Pneumo
#Distributive
##Adrenal Crisis
##Anaphylaxis
##Neurogenic
##Sepsis
##Toxicologic
#Hypovolemic
##Hemorrhage Traumatic and Non-traumatic
##Severe Dehydration

==See Also==
[[Ultrasound in Shock and Hypotension]]

== Source ==
2/06 DONALDSON (Adapted from Tintinalli)

Morchi 2010

[[Category:Airway/Resus]]
[[Category:Cards]]

Acute pain management

2011-08-08T03:07:22Z

Fsanchezmd:

== WHO 3-step Ladder for Pain Control ==

{| width="700" border="1" align="left" cellpadding="1" cellspacing="1"
|-
! scope="col" | Agent
! scope="col" | Oral
! scope="col" | Parenteral
|-
| colspan="2" | '''Step1. Mild Pain, Nonopiod, +/- Adjuvant'''
|
|-
| Acetaminophen
| 650mg q4-q6h prn or 1000mg q6h prn
| -
|-
| Aspirin
| 650mg q4-6h prn or 1000mg q6h prn
| -
|-
| Ibuprofen 
| 400-800mg q6-8h prn
| -
|-
| Gabapentin (neuropathic Pain)
| Start 300mg qhs 
| -
|-
| colspan="2" | '''Step2. Mod Pain, Opiod for mild/mod pain, +/-nonopiod, +/-Adjuvant'''
|
|-
| Hydrocodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4-6h prn
| -
|-
| Oxycodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4h prn
| -
|-
| Oxycodone(Oxycontin)
| 5mg q4-6h
| -
|-
| Tramadol
| 50-100mg q4-6h (max 400mg/day)
| -
|-
| colspan="2" | '''Step3. Severe Pain, Opiod for mod/sev pain, +/- nonopiod, +/-Adjuvant'''
|
|-
| Morphine
| 10-30mg q3-4h
| 0.1-0.2 mg/kg(up to 15mg q4h)
|-
| Morphine(controlled release)
| Start 30mg q8-12h , increase prn to 90-120mg q12h
| -
|-
| Fentanyl
| -
| 0.1mg q1-3h
|-
| Hydromorphone(Dilaudid)
| 2-4mg q4-6h
| 1-4mg q4-6h 
|-
| Levorphanol
| 2mg q6-8h
|
2mg q6-8h

 

 

|}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

^In elders had a bulk laxative & instructions regarding activity, hydration and close f/u

 

== Opioid Analgesics Chart ==

                                                                                                                                                                                                                                                                                                                                                      

 

 

{| align="left" border="1" cellpadding="1" cellspacing="0"
|-
|
'''DRUG'''

|
'''TYPICAL ADULT DOSE'''

|
'''PHARMACOKINETICS'''

|
'''COMMENTS'''

|-
|
Morphine

|
0.1 mg/kg IV

10mg IM

0.3 mg/kg PO

|
Onset: 1-2 min (IV), 10-15 min (IM/SC)

Peak effect: 3-5 min (IV), 15-30 min (IM)

Duration: 1-2 h (IV), 3-4 h (IM/SC)

|
Histamine release may produce transient hypotension or nausea and emesis, neither require routine adjunctive treatment

|-
|
Hydromorphone

(Dilaudid)

|
0.015 mg/kg IV

1-2 mg IM

|
Onset: 3-5 min (IV)

Peak effect: 7-10 min (IV)

Duration: 2-4 h (IV)

| 
|-
|
Fentanyl

|
1.0 mcg/kg IV

|
Onset: <1 min (IV)

Peak effect: 2-5 min (IV)

Duration: 30-60 min (IV)

|
High doses can cause chest wall rigidity (>5 mcg/kg IV)

|-
|
Meperidine

(Demerol)

|
1.0-1.5 mg/kg IV/IM

|
Onset: 5 min (IV)

Peak effect: 5-10 min (IV)

Duraction 2-3 h (IV)

|
Contraindicated when patient taking a MAOI; neurotoxicity occur when multiple doses given in the presence of renal failure

|-
|
Oxycodone

|
5-10 mg PO

30 mg PR

|
Onset: 10-15 min (PO)

Duration 3-6 h (PO)

|
Possible inadvertent acetaminophen overdose with combination agents

|-
|
Hydrocodone

|
5-10 mg PO

|
Onset: 30-60 min (PO)

Duraction 4-6 h (PO)

|
Lower incidence of nausea; possible inadvertent acetaminophen overdose with combination agents

|-
|
Codeine

|
30-60 mg PO

30-100 mg IM

|
Onset: 30-60 min (PO)

Duraction: 4-6 h (PO)

|
High incidence of GI side effects; some patients cannot convert to codeine-6-glucuronide and morphine; possible inadvertent acetaminophen overdose with combination agents

|-
|
Tramadol

(Ultram)

|
50-100 mg PO

|
Onset: 10-15 min (PO)

Duration: 4-6 h (PO)

|
Central nervous system side effects

|}

== Non-Opioid Analgesics Chart ==

{| align="left" border="1" cellpadding="2" cellspacing="0"
|-
| <div>'''DRUG'''</div>
| <div>'''TYPICAL ADULT DOSE'''</div>
| <div>'''COMMENTS'''</div>
|-
| Acetaminophen
|
650-1000 mg PO q4h

1-2 g PO q4h

| Liver dysfunction and necrosis 
|-
| Aspirin
| 650-1000 mg PO q4h 
| Reye syndrome in children, tinnitus, central nervous system toxicity, metabolic acidosis 
|-
| Ibuprofen
| 400-800 mg PO q4-6h 
| GI upset, platelet dysfunction, renal dysfunction, bronchospasm 
|-
| Naproxen
|
250 mg PO q6-8h

500-1000 mg PR q6-8h

| GI upset, platelet dysfunction, renal dysfunction, bronchospasm plus interacts with protein-bound drugs 
|-
| Indomethacin
|
25-50 mg PO q12h

100 mg PR q24h

| GI upset, platelet dysfunction, renal dysfunction, bronchospasm
|-
| Ketorolac
|
15-30 mg IV q6h

30-60 mg IM

| GI upset, platelet dysfunction, renal dysfunction, bronchospasm; much greater risk of GI bleeding than ibuprofen; use limited to 3d IV and 5d PO 
|}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

== Dosing Guidelines for Parenteral Opioids ==

{| align="left" border="1" cellpadding="2" cellspacing="0"
|-
| '''DRUG''' 
| '''ROUTE''' 
| '''DOSAGE''' 
| '''COMMENTS''' 
|-
| Morphine 
| IV or IM
|
Titrate 2-5 mg increments q5-10 min

Peak analgesia in 10-20 min

Average: 10 mg q3-4h

| Preferred first-line agent in most situations 
|-
| Fentanyl
| IV or IM 
|
Titrate 25-50 mcg increments q2-3 min

Peak analgesia in 3-5 min

Duration 30-60 min

|
Ideal for short procedures

No histamine release

Typically not suitable for the ED

|-
|
Meperidine

(Demerol)

| IV
|
Titrate 12.5-50 mg increments

Peak analgesia in 5-10 min

Average: 100 mg q2-3h

|
Risk of unique CNS toxicity with repeated dosing

IM injection is very irritating to tissue

|-
|
Hydromorphone

(Dilaudid)

| IV 
|
Titrate 0.5-1.0 mg increments

Peak analgesia in 5-15 min

Average: 1.5 mg q3-4h

| 
|-
|
Butorphanol

(Stadol)

| IV 
|
Titrate 0.5-2.0 mg increments

Peak analgesia in 4-5 min

Average: 2 mg q3-4h

|
Mixed agonist-antagonist

May be preferred in biliary colic

|}

  

  

  

  

  

  

  

  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

== Oral Opioid Dosing Chart   ==

{| align="left" border="1" cellpadding="2" cellspacing="0"
|-
| '''DRUG''' 
| '''ANALGESIC EQUIVALENCE'''
| '''USUAL STARTING DOSE''' 
| '''USUAL INTERVAL''' 
|-
| Morphine (MSIR, Roxanol, others) 
| 30 mg 
| 15-30 mg 
| 3-4 h 
|-
| Morphine: sustained release (MS Contin, Oramorph-SR) 
| 30 mg 
| 30 mg 
| 8-12 h 
|-
| Meperidine (Demerol) 
| 300 mg 
| 50-100 mg 
| 2-3 h 
|-
| Codeine (in Tylenol #3, others) 
| 200 mg 
| 30-60 mg 
| 3-4 h 
|-
| Oxycodone (Roxicodone, also in Percocet, Percodan, Tylox, others) 
| 20-30 mg 
| 5-10 mg 
| 3-6 h 
|-
| Hydrocodone (in Lorcet, Lortab, Vicodin, others) 
| 30 mg 
| 5-10 mg 
| 3-6 h 
|-
| Hydromorphone (Dilaudid) 
| 7.5 mg 
| 4-8 mg 
| 2-3 h 
|-
| Tramadol (Ultram) 
| N/A 
| 25-50 mg 
| 4-6 h 
|-
| Note: Dose equianalgesic to 10mg morphine IV
|
|
|
|}

 

 

 

 

 

 

 

 

 

 

 

== Sources ==

Adapted from Tintinalli and Harwood & Nuss, World Health Organization 3-Step Analgesia Ladder for Cancer & Washington Manual Intership Survival Guide, 2008

 

[[Category:Misc/General]] [[Category:Drugs]]

Acute pain management

2011-08-08T03:05:37Z

Fsanchezmd:

Pain control

2011-08-08T01:10:46Z

Fsanchezmd:

{| width="700" border="1" align="left" cellpadding="1" cellspacing="1"
|-
! scope="col" | Agent
! scope="col" | Oral
! scope="col" | Parenteral
|-
| colspan="2" | '''Step1. Mild Pain, Nonopiod, +/- Adjuvant'''
|
|-
| Acetaminophen
| 650mg q4-q6h prn or 1000mg q6h prn
| -
|-
| Aspirin
| 650mg q4-6h prn or 1000mg q6h prn
| -
|-
| Ibuprofen 
| 400-800mg q6-8h prn
| -
|-
| Gabapentin (neuropathic Pain)
| Start 300mg qhs 
| -
|-
| colspan="2" | '''Step2. Mod Pain, Opiod for mild/mod pain, +/-nonopiod, +/-Adjuvant'''
|
|-
| Hydrocodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4-6h prn
| -
|-
| Oxycodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4h prn
| -
|-
| Oxycodone(Oxycontin)
| 5mg q4-6h
| -
|-
| Tramadol
| 50-100mg q4-6h (max 400mg/day)
| -
|-
| colspan="2" | '''Step3. Severe Pain, Opiod for mod/sev pain, +/- nonopiod, +/-Adjuvant'''
|
|-
| Morphine
| 10-30mg q3-4h
| 0.1-0.2 mg/kg(up to 15mg q4h)
|-
| Morphine(controlled release)
| Start 30mg q8-12h , increase prn to 90-120mg q12h
| -
|-
| Fentanyl
| -
| 0.1mg q1-3h
|-
| Hydromorphone(Dilaudid)
| 2-4mg q4-6h
| 1-4mg q4-6h 
|-
| Levorphanol
| 2mg q6-8h
|
2mg q6-8h

 

 

|}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

^In elders had a bulk laxative & instructions regarding activity, hydration and close f/u

 

 

 

 

Source from World Health Organization 3-Step Analgesia Ladder for Cancer & Washington Manual Intership Survival Guide, 2008

 

[[Category:Misc/General]]

Pain control

2011-08-08T01:09:40Z

Fsanchezmd:

{| width="700" border="1" align="left" cellpadding="1" cellspacing="1"
|-
! scope="col" | Agent
! scope="col" | Oral
! scope="col" | Parenteral
|-
| colspan="2" | '''Step1. Mild Pain, Nonopiod, +/- Adjuvant'''
|
|-
| Acetaminophen
| 650mg q4-q6h prn or 1000mg q6h prn
| -
|-
| Aspirin
| 650mg q4-6h prn or 1000mg q6h prn
| -
|-
| Ibuprofen 
| 400-800mg q6-8h prn
| -
|-
| Gabapentin (neuropathic Pain)
| Start 300mg qhs 
| -
|-
| colspan="2" | '''Step2. Mod Pain, Opiod for mild/mod pain, +/-nonopiod, +/-Adjuvant'''
|
|-
| Hydrocodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4-6h prn
| -
|-
| Oxycodone (5mg/Acetaminophen 325mg)
| 1-2 tabs PO q4h prn
| -
|-
| Oxycodone(Oxycontin)
| 5mg q4-6h
| -
|-
| Tramadol
| 50-100mg q4-6h (max 400mg/day)
| -
|-
| colspan="2" | '''Step3. Severe Pain, Opiod for mod/sev pain, +/- nonopiod, +/-Adjuvant'''
|
|-
| Morphine
| 10-30mg q3-4h
| 0.1-0.2 mg/kg(up to 15mg q4h)
|-
| Morphine(controlled release)
| Start 30mg q8-12h , increase prn to 90-120mg q12h
| -
|-
| Fentanyl
| -
| 0.1mg q1-3h
|-
| Hydromorphone(Dilaudid)
| 2-4mg q4-6h
| 1-4mg q4-6h 
|-
| Levorphanol
| 2mg q6-8h
|
2mg q6-8h

 

 

|}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*In elders had a bulk laxative & instructions regarding activity, hydration and close f/u

 

 

 

 

Source from World Health Organization 3-Step Analgesia Ladder for Cancer & Washington Manual Intership Survival Guide, 2008

 

[[Category:Misc/General]]

Pediatric Quick Emergency Reference Card

2011-08-07T16:51:52Z

Fsanchezmd:

== Intubation ==

*'''Atropine 0.02 mg/kg''' (min 0.1mg; max 1mg; Always for pts <5yrs or before 2nd dose of Succinylcholine)

*'''Lidocaine 1 mg/kg''' (blunts increase in ICP)

*'''Succinylcholine 1.5-2 mg/kg''' (avoid in incr K, renal failure, h/o neuromuscular disorder or malignant hyperthermia)

*'''Rocuronium 1 mg/kg''' (onset 1min, lasts 30min)

*'''Etomidate 0.3 mg/kg''' (less hypotension than other sedatives)

*'''Versed 0.05-0.1 mg/kg''' (decreases BP,HR,RR)

*'''Fentanyl 2-5 mcg/kg''' (can cause chest wall rigidity if given rapidly)

*'''Ketamine 2 mg/kg''' (preferred in Asthma)

 

== Cards ==

*'''Epinephrine 0.1 cc/kg of 1:10,000''' (ETT dose is 0.1 cc/kg of 1:1000 epi)

*'''Atropine 0.02 mg/kg''' (min 0.1mg; max 1mg; may repeat once after 5min)

*'''Adenosine 0.1-0.2 mg/kg''' (max 1mg; may repeat x2 at 0.2 mg/kg)

*'''Defib 2J/4J/4J per kg'''

 

== AMS/SZ ==

*'''D25W 2 cc/kg''' (repeat as needed)

*'''Ativan 0.05-0.1 mg/kg''' (may repeat 1-2 times)

*'''Fosphenytoin 18-20 mg PE/kg''' (rate 150mg PE/min; PE=Phenytoin equivalent)

*'''Phenytoin 18-20 mg/kg''' (give SLOW, max rate 1mg/kg/min, 2nd choice after Fosphenytoin)

*'''Phenobarb 10-20 mg/kg''' (rate 1mg/kg/min slow)

*'''Valium rectal 0.5 mg/kg'''

*'''Mannitol 1 gm/kg'''

ET = (age-in-years/4) + 4

 

== See Also ==

[[Adult Quick Drug Card]]

== Source ==

2/8/06 DONALDSON (from 'Peds board')

[[Category:Drugs]] [[Category:Airway/Resus]] [[Category:Peds]]

Pediatric Quick Emergency Reference Card

2011-08-07T16:46:12Z

Fsanchezmd:

== Intubation ==

*'''Atropine 0.02 mg/kg''' (Min 0.1mg; max 1mg; Always for pts <5yrs or before 2nd dose of Succinylcholine)

*'''Lidocaine 1 mg/kg''' (Blunts increase in ICP)

*'''Succinylcholine 1.5-2 mg/kg''' (Avoid in incr K, renal failure, h/o neuromuscular disorder or malignant hyperthermia)

*'''Rocuronium 1 mg/kg''' (Onset 1min, lasts 30min)

*'''Etomidate 0.3 mg/kg''' (Less hypotension than other sedatives)

*'''Versed 0.05-0.1 mg/kg''' (Decreases BP,HR,RR)

*'''Fentanyl 2-5 mcg/kg''' (Can cause chest wall rigidity if given rapidly)

*'''Ketamine 2 mg/kg''' (Preferred in Asthma)

 

== Cards ==

*'''Epinephrine 0.1 cc/kg of 1:10,000''' (ETT dose is 0.1 cc/kg of 1:1000 epi)

*'''Atropine 0.02 mg/kg''' (min 0.1mg; max 1mg; may repeat once after 5min)

*'''Adenosine 0.1-0.2 mg/kg''' (max 1mg; may repeat x2 at 0.2 mg/kg)

*'''Defib 2J/4J/4J per kg'''

 

== AMS/SZ ==

*'''D25W 2 cc/kg''' (Repeat)

*'''Ativan 0.05-0.1 mg/kg''' (may repeat 1-2 times)

*'''Fosphenytoin 18-20 mg PE/kg''' (rate 150mg PE/min; PE=Phenytoin equivalent)

*'''Phenytoin 18-20 mg/kg''' (give SLOW, max rate 1mg/kg/min, 2nd choice after Fosphenytoin)

*'''Phenobarb 10-20 mg/kg''' (rate 1mg/kg/min slow)

*'''Valium rectal 0.5 mg/kg'''

*'''Mannitol 1 gm/kg'''

ET = (age-in-years/4) + 4

 

== See Also ==

[[Adult Quick Drug Card]]

== Source ==

2/8/06 DONALDSON (from 'Peds board')

[[Category:Drugs]] [[Category:Airway/Resus]] [[Category:Peds]]

Pediatric Quick Emergency Reference Card

2011-08-07T16:10:26Z

Fsanchezmd:

==Intubation==

Atropine 0.02 mg/kg

Lidocaine 1 mg/kg

Succ 1.5-2 mg/kg

Vec 0.1 mg/kg

Rox 1 mg/kg

Etomidate 0.3 mg/kg

Versed 0.05-0.1 mg/kg

Ketamine 2 mg/kg

==Cards==

Epi 0.1 cc/kg

Atropine 0.02 mg/kg

Adenosine 0.1-0.2 mg/kg

Defib 2J/4J/4J per kg

==AMS/SZ==

D25W 2 cc/kg

Ativan 0.05-0.1 mg/kg

Dilantin 18 mg/kg

Phenobarb 10-20 mg/kg

Valium rectal 0.5 mg/kg

Mannitol 1 gm/kg

ET = (age-in-years/4) + 4

==See Also==
[[Adult Quick Drug Card]]

==Source==
2/8/06 DONALDSON (from 'Peds board')

[[Category:Drugs]]
[[Category:Airway/Resus]]
[[Category:Peds]]

Updating and creating notes on WikEM

2011-08-07T15:59:11Z

Fsanchezmd:

== Website Address ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, you can edit from the downloaded WikEM smartphone software.

== Creating a New Note ==

You must go to www.WikEM.org on a computer or smart phone to create a new note. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to make a new note.

=== On the Web ===

To create a new note:

#'''YOU MUST FIRST LOGIN'''
##See [[Create an Account]]
#Search for the term in the search field in the upper right hand corner of the page
##If you find a note with a similar theme, please edit it with your new content (see below)
##If you don't find a note on your subject, click on the link: "Create the page on this wiki!"
#Please follow formatting guidelines below

=== iPhone ===

The new version allows users to store personal notes within the WikEM iOS application. To create your note:

*Tap the Personal Notes icon
*Tap the + icon in the upper right corner
*Type a note title, this cannot be changed
*Type a note body

Notes can be deleted by swiping over a note title in the list view, or tapping the edit button in the upper left corner.

== Editing Notes ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to edit the note directly.

To edit a note:

#Find the note using the "Categories" tab on the Navigation field on the left side of the page or search for it via the search field in the upper right hand corner
#Click on the "Edit" in the middle of the page above the note
#Edit away
##Please follow formatting guidelines below

== General Comments ==

*Before making new notes, please first use the search function to see if there are already similar or related note! If there are, make your additions to the existing note, unless you're adding distinctly new content.
*Keep entries concise and as simple as possible, so that you can look up information quickly. Preference is for "notes," not "chapters" (i.e. think Pepid, not UpToDate)
*Remember that the user format is the PDA (view it on your PDA to see the final format)
*Focus on practical knowledge (with little to no pathophysiology or non-useful facts)
*Reference other Memos if appropriate (as done above)
*Put your source(s) at the bottom, if appropriate (the date and your name will be included automatically at the bottom in the future, so no need to add it as is currently seen on some notes)
*Put a category at the end of the entry, see example of how to add the category from other notes.
*Feel free to divide notes into several notes, or combine them, if it makes them more useful
*Use one of the templates (see above) if appropriate, you will need to copy the wikitext of the template onto your new entry
*Do not use "*" signs, as the wiki software uses this for other purposes. Please use "^".

== Style Guidelines ==

All major headings should be set to Format: Heading 2. Headings should not be entered in all caps. A maximum of 3 indent levels should be used in all articles. Beyond 3 indent levels text becomes hard to read on mobile devices All tables should be sized to be 300px wide. If content is not readable in this size please consider reformatting to an outline or some another format. Valid text formatting includes: bold, underline, italics, strike through, foreground color, background color. Any other formatting may interfere with mobile display. Please note that text formatting is currently not available on the blackberry, so please use it very limitedly (or not at all) Cite other notes as "Folder: Name-of-Note" (e.g. Peds: Rash)

== Images ==

Embedded images are now supported. To upload an image to WikEM, (must first log-in) click on the link [[Special:Upload]] which appears under 'Toolbox' in the links on the left. The page also includes directions for how to use the images once uploaded. Please be considerate of the Style Guidelines. For formatting of the file (resizing, thumbnails, etc..) please refer here[http://www.mediawiki.org/wiki/Help:Images#Linking_to_an_image_without_displaying_it].

To see a list of uploaded images by WikEM users, see [[Special:ListFiles]]. 

== Standardized Abbreviations ==

CXR Chest X-Ray / Radiograph

DM Diabetes Mellitus

HTN Hypertension

DDx Differential Diagnosis

== See Also ==

*[[Template 1 (General)]]
*[[Template 2 (Drug)]]
*[[Template 3 (List)]]
*[[Template 4 (DDx)]]

[[Category:WikEM]]

Updating and creating notes on WikEM

2011-08-07T15:55:21Z

Fsanchezmd:

== Website Address ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, you can edit from the downloaded WikEM smartphone software.

== Creating a New Note ==

You must go to www.WikEM.org on a computer or smart phone to create a new note. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to make a new note.

=== On the Web ===

To create a new note:

#'''YOU MUST FIRST LOGIN'''
##See [[Create an Account]]
#Search for the term in the search field in the upper right hand corner of the page
##If you find a note with a similar theme, please edit it with your new content (see below)
##If you don't find a note on your subject, click on the link: "Create the page on this wiki!"
#Please follow formatting guidelines below

=== iPhone ===

The new version allows users to store personal notes within the WikEM iOS application. To create your note:

*Tap the Personal Notes icon
*Tap the + icon in the upper right corner
*Type a note title, this cannot be changed
*Type a note body

Notes can be deleted by swiping over a note title in the list view, or tapping the edit button in the upper left corner.

== Editing Notes ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to edit the note directly.

To edit a note:

#Find the note using the "Categories" tab on the Navigation field on the left side of the page or search for it via the search field in the upper right hand corner
#Click on the "Edit" in the middle of the page above the note
#Edit away
##Please follow formatting guidelines below

== General Comments ==

*Before making new notes, please first use the search function to see if there are already similar or related note! If there are, make your additions to the existing note, unless you're adding distinctly new content.
*Keep entries concise and as simple as possible, so that you can look up information quickly. Preference is for "notes," not "chapters" (i.e. think Pepid, not UpToDate)
*Remember that the user format is the PDA (view it on your PDA to see the final format)
*Focus on practical knowledge (with little to no pathophysiology or non-useful facts)
*Reference other Memos if appropriate (as done above)
*Put your source(s) at the bottom, if appropriate (the date and your name will be included automatically at the bottom in the future, so no need to add it as is currently seen on some notes)
*Put a category at the end of the entry, [[Category:Example]]
*Feel free to divide notes into several notes, or combine them, if it makes them more useful
*Use one of the templates (see above) if appropriate, you will need to copy the wikitext of the template onto your new entry
*Do not use "*" signs, as the wiki software uses this for other purposes. Please use "^".

== Style Guidelines ==

All major headings should be set to Format: Heading 2. Headings should not be entered in all caps. A maximum of 3 indent levels should be used in all articles. Beyond 3 indent levels text becomes hard to read on mobile devices All tables should be sized to be 300px wide. If content is not readable in this size please consider reformatting to an outline or some another format. Valid text formatting includes: bold, underline, italics, strike through, foreground color, background color. Any other formatting may interfere with mobile display. Please note that text formatting is currently not available on the blackberry, so please use it very limitedly (or not at all) Cite other notes as "Folder: Name-of-Note" (e.g. Peds: Rash)

== Images ==

Embedded images are now supported. To upload an image to WikEM, (must first log-in) click on the link [[Special:Upload]] which appears under 'Toolbox' in the links on the left. The page also includes directions for how to use the images once uploaded. Please be considerate of the Style Guidelines. For formatting of the file (resizing, thumbnails, etc..) please refer here[http://www.mediawiki.org/wiki/Help:Images#Linking_to_an_image_without_displaying_it].

To see a list of uploaded images by WikEM users, see [[Special:ListFiles]]. 

== Standardized Abbreviations ==

CXR Chest X-Ray / Radiograph

DM Diabetes Mellitus

HTN Hypertension

DDx Differential Diagnosis

== See Also ==

*[[Template 1 (General)]]
*[[Template 2 (Drug)]]
*[[Template 3 (List)]]
*[[Template 4 (DDx)]]

[[Category:WikEM]]

Updating and creating notes on WikEM

2011-08-07T15:52:00Z

Fsanchezmd:

== Website Address ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, you can edit from the downloaded WikEM smartphone software.

== Creating a New Note ==

You must go to www.WikEM.org on a computer or smart phone to create a new note. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to make a new note.

=== On the Web ===

To create a new note:

#'''YOU MUST FIRST LOGIN'''
##See [[Create an Account]]
#Search for the term in the search field in the upper right hand corner of the page
##If you find a note with a similar theme, please edit it with your new content (see below)
##If you don't find a note on your subject, click on the link: "Create the page on this wiki!"
#Please follow formatting guidelines below

=== iPhone ===

The new version allows users to store personal notes within the WikEM iOS application. To create your note:

*Tap the Personal Notes icon
*Tap the + icon in the upper right corner
*Type a note title, this cannot be changed
*Type a note body

Notes can be deleted by swiping over a note title in the list view, or tapping the edit button in the upper left corner.

== Editing Notes ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to edit the note directly.

To edit a note:

#Find the note using the "Categories" tab on the Navigation field on the left side of the page or search for it via the search field in the upper right hand corner
#Click on the "Edit" in the middle of the page above the note
#Edit away
##Please follow formatting guidelines below

== General Comments ==

*Before making new notes, please first use the search function to see if there are already similar or related note! If there are, make your additions to the existing note, unless you're adding distinctly new content.
*Keep entries concise and as simple as possible, so that you can look up information quickly. Preference is for "notes," not "chapters" (i.e. think Pepid, not UpToDate)
*Remember that the user format is the PDA (view it on your PDA to see the final format)
*Focus on practical knowledge (with little to no pathophysiology or non-useful facts)
*Reference other Memos if appropriate (as done above)
*Put your source(s) at the bottom, if appropriate (the date and your name will be included automatically at the bottom in the future, so no need to add it as is currently seen on some notes)
*Put a category at the end of the entry.
*Feel free to divide notes into several notes, or combine them, if it makes them more useful
*Use one of the templates (see above) if appropriate, you will need to copy the wikitext of the template onto your new entry
*Do not use "*" signs, as the wiki software uses this for other purposes. Please use "^".

== Style Guidelines ==

All major headings should be set to Format: Heading 2. Headings should not be entered in all caps. A maximum of 3 indent levels should be used in all articles. Beyond 3 indent levels text becomes hard to read on mobile devices All tables should be sized to be 300px wide. If content is not readable in this size please consider reformatting to an outline or some another format. Valid text formatting includes: bold, underline, italics, strike through, foreground color, background color. Any other formatting may interfere with mobile display. Please note that text formatting is currently not available on the blackberry, so please use it very limitedly (or not at all) Cite other notes as "Folder: Name-of-Note" (e.g. Peds: Rash)

== Images ==

Embedded images are now supported. To upload an image to WikEM, (must first log-in) click on the link [[Special:Upload]] which appears under 'Toolbox' in the links on the left. The page also includes directions for how to use the images once uploaded. Please be considerate of the Style Guidelines. For formatting of the file (resizing, thumbnails, etc..) please refer here[http://www.mediawiki.org/wiki/Help:Images#Linking_to_an_image_without_displaying_it].

To see a list of uploaded images by WikEM users, see [[Special:ListFiles]]. 

== Standardized Abbreviations ==

CXR Chest X-Ray / Radiograph

DM Diabetes Mellitus

HTN Hypertension

DDx Differential Diagnosis

== See Also ==

*[[Template 1 (General)]]
*[[Template 2 (Drug)]]
*[[Template 3 (List)]]
*[[Template 4 (DDx)]]

[[Category:WikEM]]

Updating and creating notes on WikEM

2011-08-07T07:02:31Z

Fsanchezmd:

== Website Address ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, you can edit from the downloaded WikEM smartphone software.

== Creating a New Note ==

You must go to www.WikEM.org on a computer or smart phone to create a new note. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to make a new note.

=== On the Web ===

To create a new note:

#'''YOU MUST FIRST LOGIN'''
##See [[Create an Account]]
#Search for the term in the search field in the upper right hand corner of the page
##If you find a note with a similar theme, please edit it with your new content (see below)
##If you don't find a note on your subject, click on the link: "Create the page on this wiki!"
#Please follow formatting guidelines below

=== iPhone ===

The new version allows users to store personal notes within the WikEM iOS application. To create your note:

*Tap the Personal Notes icon
*Tap the + icon in the upper right corner
*Type a note title, this cannot be changed
*Type a note body

Notes can be deleted by swiping over a note title in the list view, or tapping the edit button in the upper left corner.

== Editing Notes ==

You must go to www.WikEM.org on a computer or smart phone to edit content. If you have a working internet connection, the downloaded WikEM smartphone software will take you to the site to edit the note directly.

To edit a note:

#Find the note using the "Categories" tab on the Navigation field on the left side of the page or search for it via the search field in the upper right hand corner
#Click on the "Edit" in the middle of the page above the note
#Edit away
##Please follow formatting guidelines below

== General Comments ==

*Before making new notes, please first use the search function to see if there are already similar or related note! If there are, make your additions to the existing note, unless you're adding distinctly new content.
*Keep entries concise and as simple as possible, so that you can look up information quickly. Preference is for "notes," not "chapters" (i.e. think Pepid, not UpToDate)
*Remember that the user format is the PDA (view it on your PDA to see the final format)
*Focus on practical knowledge (with little to no pathophysiology or non-useful facts)
*Reference other Memos if appropriate (as done above)
*Put your source(s) at the bottom, if appropriate (the date and your name will be included automatically at the bottom in the future, so no need to add it as is currently seen on some notes)
*Feel free to divide notes into several notes, or combine them, if it makes them more useful
*Use one of the templates (see above) if appropriate, you will need to copy the wikitext of the template onto your new entry
*Do not use "*" signs, as the wiki software uses this for other purposes. Please use "^".

== Style Guidelines ==

All major headings should be set to Format: Heading 2. Headings should not be entered in all caps. A maximum of 3 indent levels should be used in all articles. Beyond 3 indent levels text becomes hard to read on mobile devices All tables should be sized to be 300px wide. If content is not readable in this size please consider reformatting to an outline or some another format. Valid text formatting includes: bold, underline, italics, strike through, foreground color, background color. Any other formatting may interfere with mobile display. Please note that text formatting is currently not available on the blackberry, so please use it very limitedly (or not at all) Cite other notes as "Folder: Name-of-Note" (e.g. Peds: Rash)

== Images ==

Embedded images are now supported. To upload an image to WikEM, (must first log-in) click on the link [[Special:Upload]] which appears under 'Toolbox' in the links on the left. The page also includes directions for how to use the images once uploaded. Please be considerate of the Style Guidelines. For formatting of the file (resizing, thumbnails, etc..) please refer here[http://www.mediawiki.org/wiki/Help:Images#Linking_to_an_image_without_displaying_it].

To see a list of uploaded images by WikEM users, see [[Special:ListFiles]]. 

== Standardized Abbreviations ==

CXR Chest X-Ray / Radiograph

DM Diabetes Mellitus

HTN Hypertension

DDx Differential Diagnosis

== See Also ==

*[[Template 1 (General)]]
*[[Template 2 (Drug)]]
*[[Template 3 (List)]]
*[[Template 4 (DDx)]]

[[Category:WikEM]]

Acute kidney injury

2011-08-07T03:49:58Z

Fsanchezmd:

==Background==
*Majority of cases of community-acquired ARF is secondary to volume depletion
===RIFLE Classification===
#Risk - Serum Cr increased 1.5x baseline
#Injury - Serum Cr increased 2.0x baseline
#Failure - Serum Cr increased 3.0x baseline OR Cr >4 and acute increase >0.5
#Loss - Complete loss of kidney function for >4wk
#ESRD - Need for renal replacement therapy for >3mo
===Chronic Kidney Disease Stages===
*Useful if pt's baseline creatinine is unknown
**Stage 1: Kidney damage (e.g. proteinuria) and normal GFR; GFR >90
**Stage 2: Kidney damage (e.g. proteinuria) and mild decr in GFR; GFR 60-89
**Stage 3: Moderate decrease in GFR; GFR >30-59
**Stage 4: Severe decrease in GFR; GFR 15-29
**Stage 5: Kidney failure (dialysis or kidney transplant needed); GFR <15

==Risk Factors==
#Radiocontrast agents
##Esp if GFR <60, hypovolemic
#Atherosclerosis
#Chronic hypertension
#Chronic kidney disease
#NSAIDs
#ACEI/ARB
#Sepsis
#Hypercalcemia
#Hepatorenal syndrome

==Etiology==
===Prerenal===
#Hypovolemia
##GI: decreased intake, vomiting and diarrhea
##Pharmacologic: diuretics
##Third spacing
###Pancreatitis
##Skin losses: fever, burns
##Miscellaneous
###Hypoaldosteronism
###Salt-losing nephropathy
###Postobstructive diuresis
#Hypotension
##Septic vasodilation
##Hemorrhage
##Decreased cardiac output
###Ischemia/infarction
###Valvulopathy
##Pharmacologic
###B-blockers
###CCBs
###Antihypertensive medications
##High-output failure
###Thyrotoxicosis
###AV fistula
#Renal artery and small-vessel disease
##Embolism: thrombotic, septic, cholesterol
##Thrombosis: atherosclerosis, vasculitis, sickle cell disease
##Dissection
##Pharmacologic
###NSAIDs
###ACEI/ARB
####Observed shortly after initiation of therapy
##Microvascular thrombosis
###Preeclampsia
###HUS
###DIC
###vasculitis
###SCD
##Hypercalcemia

===Intrinsic===
#Tubular diseases
##Ischemic acute tubular necrosis
###Caused by more advanced disease due to the prerenal causes
#Nephrotoxins
##Aminoglycosides, radiocontrast, amphotericin, heme pigments (rhabdo, hemolysis)
##Obstruction
###Uric acid, calcium oxalate, myeloma, amyloid
###Pharmacologic: sulfonamide, triamterene, acyclovir, indinavir
#Interstitial diseases
##Acute interstitial nephritis: typically a drug reaction (NSAIDs, abx, phenytoin)
##Infection: bilateral pyelonephritis, Legionnaire disease, hantavirus
##Infiltrative disease: sarcoidosis, lymphoma
##Autoimmune diseases: SLE
#Glomerular diseases
##Rapidly progressive glomerulonephritis
###Goodpasture, Wegener granulomatosis, HSP, SLE, membranoproliferative GN
##Postinfectious glomerulonephritis
#Small-vessel diseases
##Microvascular thrombosis
###Preeclampsia, HUS, DIC, TTP, vasculitis (PAN, SCD, atheroembolism)
##Malignant hypertension
##Scleroderma
##Renal vein thrombosis

===Postrenal===
#Infants and children
##Urethra and bladder outlet
###Anatomic malformations
####Urethral atresia
####Meatal stenosis
####Anterior and posterior urethral valves
##Ureter
###Anatomic malformations
####Vesicoureteral reflux (female preponderance)
####Ureterovesical junction obstruction
####Ureterocele
####Retroperitoneal tumor
#All ages
##Various locations in GU tract
###Trauma
###Blood clot
##Urethra and bladder outlet
###Phimosis or urethral stricture (male preponderance)
###Neurogenic bladder
####DM, spinal cord disease, multiple sclerosis, Parkinson's
####Pharmacologic: anticholinergics, a-adrenergic antagonists, opiates
#Adults
##Urethra and bladder outlet
###BPH
###Cancer of prostate, bladder, cervix, or colon
###Obstructed catheters
##Ureter
###Calculi, uric acid crystals
###Papillary necrosis
####SCD, DM, pyelonephritis
###Tumor: Ureter, uterus, prostate, bladder, colon, rectum; retroperitoneal lymphoma
###Retroperitoneal fibrosis: idiopathic, tuberculosis, sarcoidosis, propranolol
###Stricture: TB, radiation, schistosomiasis, NSAIDs
###Miscellaneous
####Aortic aneurysm
####Pregnant uterus
####IBD
####Trauma

==Clinical Features==
*Acute renal failure itself has few symptoms until severe uremia develops:
**N/V, drowsiness, fatigue, confusion, coma
*Pts more likely to present w/ symptoms related to underlying cause:
**Prerenal
***Thirst, orthostatic light-headedness, decreasing urine output
**Intrinsic
***Flank pain, hematuria
****Nephrolithiasis
****Papillary necrosis
****Crystal-induced nephropathy
***Myalgias, seizures, recreational intoxication
****Pigment-induced ARF (rhabdo)
***Darkening urine and edema (esp w/ preceding pharyngitis or cutaneous infection)
****Acute glomerulonephritis
***Fever, arthralgia, rash
****Acute interstitial nephritis
***Cough, dyspnea, hemoptysis
****Goodpasture, Wegener granulomatosis
**Postrenal
***Alternating oliguria and polyuria is pathognomonic of obstruction
***Anuria

==Diagnosis==
#Prerenal
##BUN/Cr ratio > 20
##FeNa <1% ((urine sodium/plasma sodium) / (urine creatinine / serum creatinine))
##Urine osm >500
##Microscopic analysis
###Hyaline casts
#Instrinsic
##FeNa >1%
##Urine Osm <350
##Microscopic analysis
###Acute glomerulonephritis: RBCs, casts
###Acute tubular necrosis: protein, tubular epithelial cells
#Postrenal
##FeNa >1%
##Urine Osm <350

==Work-up==
#Urine
##UA, urine sodium, urine creatinine, urine urea
#ECG (hyperkalemia)
#Imaging
##CXR
###Evidence of volume overload, PNA
##US
###Test of choice in setting of acute renal failure
####Bladder size (post-void)
####Hydronephrosis
####IVC collapsibility (prerenal)
##CT
###Indicated if hydronephrois found on US in order to define the location of obstruction

==Treatment==
#Treat underlying cause
#IVF (prerenal)
#Obstruction
##Note: Postobstructive diuresis can result in significant volume loss and death
###Typically occurs when obstruction has been prolonged / has resulted in renal failure
###Admit pts w/ persistent diuresis of >250 mL/h for >2hr
##Foley Catheter, consider [[Coude Catheter]]
##Suprapubic (if Coude fails)
#Dialysis
##Indicated for:
###A: Acidosis (severe)
###E: Electrolyte abnormality (e.g. uncontrolled hyperkalemia)
###I: Intoxicants (Lithium, ASA, methanol, ethylene glycol, theophylline)
###O: Overload (volume) w/ persistent hypoxia
###U: Uremic pericarditis/encephalopathy/bleeding dyscrasia
###Also:
####Na <115 or >165 mEq/L
####BUN >100

==Disposition==
Admit

==See Also==
[[Hyperkalemia]]

==Source==
Tintinalli

[[Category:Nephro]]

Urolithiasis

2011-08-07T03:44:55Z

Fsanchezmd:

==Background==
=== Type ===
#Calcium 75%
##hyperparathyroidism, hypercalcemia of malignancy, sarcoidosis, increased absorption from gut; thiazide diuretics; topiramate, protease inhibitors (indinavir or sulfadiazine)
#Struvite 15%
##Proteus, Klebsiella, Pseudomonas, Staphylococcus
#Uric Acid 6%

=== Pass Rates ===
'''Size'''
*4mm ~75%
*4-6mm ~50%
*>6mm ~10%

'''Location in Ureter'''
#Distal ~70%
#Middle ~50%
#Proximal ~20%

== DDx ==
#[[Cholelithiasis]] (5%)
#Appy (4%)
#Pyelonephitis (3%)
#Ovarian cyst (2%)
#Renal mass (1.4%)
#[[AAA]] w/or w/o rupture (1.4%) 

== Treatment ==
#ED
##Toradol 30mg IV/IM
##Morphine 3-5mg IV
#Outpt
##NSAIDS PO
##Vicodin PO
##Smooth muscle relaxant (alpha-adrenergic blocker)
###Tamsulosin (Flomax) 0.4mg PO QHS x 21 days, OR
###Terazosin (Hytrin) 1mg PO QHS x 21 days

^IVF of no benefit in acute setting

=== Surgical Treatment===
Persistent obstruction, failure of stone progression, or increasing or unremitting colic

Shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy

==Disposition==
Admit for:
#Intractable pain (on orals)
#Solitary or transplanted kidney
#Presence of urinary tract infection (UTI), fever, sepsis, or pyonephrosis

==Prognosis==
=== Recurrence Rates ===

1 yr ~33%

5yr ~50%

#Increasing H2O intake decreases rate
#Protease inhibitors and diuretics increases rate

==See Also==
[[EBQ Medical Treatment for Nephrolithiasis]]

== Source ==
10/07 DONALDSON (adapted from Tintinalli)

[[Category:Nephro]]

Epididymitis

2011-08-07T01:15:46Z

Fsanchezmd:

==Background==
*Often confused with testicular torsion
**Cremasteric reflex intact
*Sexually active men <35yo:
**Consider chlamydia, gonorrhea
*Not sexually active, age >35yo, or anal intercourse:
**Also consider E. Coli, Pseudomonas, Enterobacter, TB, syphilis

==Diagnosis==
*Pain of gradual onset, peaks at 24hr
**Dysuria, frequency, fever
*Pain relieved with elevation of testicle (positive Prehn sign)

==Work-Up==
#UA, urine culture, urine GC/Chlam
##UA may show pyuria but absence does not r/o disease
#Ultrasound for equivocal cases

==DDx==
#Testicular torsion
#Torsion of testicular appendage
#Testicular tumor
#Orchitis
#Scrotal abscess
#Indirect inguinal hernia

==Treatment==
#Scrotal elevation
#Analgesia
#Abx
##Sexually transmitted (<35yo):
###CTX 250mg IM x1 for GC AND:
###Doxycycline 100 mg BID x10d for chlamydia
##Anal intercourse, nonsexually active, and/or >35yo:
###PO: Cipro 500mg BID x 14d OR Ofloxacin 200mg BID x 14d
###IV: Piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
##Treat sexual partner

==Disposition==
#Admit for systemic signs of toxicity (fever, chills, nausea, vomiting)
#D/c w/ f/u in one week with Urology if non toxic

==See Also==
[[Testicular Torsion]]

[[Torsion of Testicular Appendages]]
==Source==
Anatomical Approach to Scrotal Emergencies: A New Paradigm for the Diagnosis and Treatment of the Acute Scrotum. The Internet Journal of Urology 2010 : Volume 6 Number 2. Sardar Ali. KhanRosens

CDC Guidelines

[[Category:GU]]
[[Category:ID]]

Acute urinary retention

2011-08-06T23:54:22Z

Fsanchezmd:

== Background ==

*Urinary retention is the inability to void resulting in bladder distention
*Symptoms include frequency, urgency, hesitancy, dribbling, decrease in voiding stream
*A sense of incomplete emptying
*Most commonly affects adult men 2/2 BPH, however must exclude neurologic disease (ie Cord compression)
**Common causes: BPH, prostatic carcinoma, bladder carcinoma, urethral stricture, spinal cord disease or trauma, and blood clots
**Uncomon causes: phimosis, paraphimosis, urethritis, urethral calculus, foreign body, medications(primarily anticholinergics but also narcotics, phenothiazines, sympathomimetics, cyclic antidepressants, antihistamines, antihypertensives, and muscle relaxants)

== Work-Up ==
*UA, UCX, CBC, Chem Panel
*Complete GU/Rectal exam

== Treatment ==
*Bladder Decompression
**Pass 16F Foley catheter(larger if large blood clots)
**If unable to pass Foley catheter, try a 16F [[Coude Catheter]]
**If still unable, try a smaller size, obtain urologic consult, or perform suprapubic catherization

== Disposition ==
*Consider admission to Urology if uncontrolled pain, obstruction with infection, or inability to clear large clots
*Pt with obstructive uropathy, go home with catheter and leg drainage bag
*Follow up with Urology within 1 week

== See Also ==
[[UTI]]

[[Coude Catheter]]

[[Category:GU]]

Acute urinary retention

2011-08-06T23:50:52Z

Fsanchezmd:

Acute urinary retention

2011-08-06T23:48:46Z

Fsanchezmd: Created page with "== Background == *Urinary retention is the inability to void resulting in bladder distention *Symptoms include frequency, urgency, hesitancy, dribbling, decrease in voiding stre..."

== Background ==

*Urinary retention is the inability to void resulting in bladder distention
*Symptoms include frequency, urgency, hesitancy, dribbling, decrease in voiding stream
*A sense of incomplete emptying
*Most commonly affects adult men 2/2 BPH, however must exclude neurologic disease (ie Cord compression)
**Common causes: BPH, prostatic carcinoma, bladder carcinoma, urethral stricture, spinal cord disease or trauma, and blood clots
**Uncomon causes: phimosis, paraphimosis, urethritis, urethral calculus, foreign body, medications(primarily anticholinergics but also narcotics, phenothiazines, sympathomimetics, cyclic antidepressants, antihistamines, antihypertensives, and muscle relaxants)

== Work-Up ==
*UA, UCX, CBC, Chem Panel
*Complete GU/Rectal exam

== Treatment ==
*Bladder Decompression
**Pass 16F Foley catheter(larger if large blood clots)
**If unable to pass Foley catheter, try a 16F [[Coude catheter]]
**If still unable, try a smaller size, obtain urologic consult, or perform suprapubic catherization

== Disposition ==
*Consider admission to Urology if uncontrolled pain, obstruction with infection, or inability to clear large clots
*Pt with obstructive uropathy, go home with catheter and leg drainage bag
*Follow up with Urology within 1 week

== See Also ==
[[UTI]]

[[Pyelonephritis]]

[[Coude Catheter]]