WikEM - User contributions [en]

User:Modanq

2026-03-01T22:16:16Z

Modanq: Link

'''Omar Usman, MD, MBA

Stanford University
* Informatics Fellowship
University of Chicago
* Emergency Medicine Residency
Ohio State University
* Medical School
Northwestern University
* MBA
University of Michigan
* BBA

[https://modanq.com Personal/Professional Page]

Pneumonia (peds)

2025-07-19T18:45:26Z

Modanq: /* Diagnosis */ Added finding of "round pneumonia"

{{Peds top}} [[pneumonia]]
==Background==
[[File:Number of deaths from pneumonia in children under 5, OWID.svg|thumb|Death rates from pneumonia in children under 5 (2017).]]
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]
*Most common site of infection in neonates

===Bugs by Age Group===
*Newborn
**[[Group B streptococci]]
**[[Gram-negative bacilli]]
**[[Listeria monocytogenes]]
*1-3 months
**[[Streptococcus pneumoniae]]
**[[Chlamydia trachomatis]]
**[[Haemophilus influenzae]]
**[[Bordetella pertussis]]
**[[Staphylococcus aureus]]
*3 months-5 years
**[[S. pneumoniae]]
**[[S. aureus]]
**[[H. influenzae]] type b
**Nontypeable H. influenzae
**[[C. trachomatis]]
**[[Mycoplasma pneumoniae]]
*5–18 years
**[[M. pneumoniae]]
**[[S. pneumoniae]]
**[[C. pneumoniae]]
**[[H. influenzae]] type b
**[[S. aureus]]

==Clinical Features==
''Fever and tachypnea are sensitive but not specific''
*[[Fever]]
*[[Cough]]
**Productive cough is rarely seen before late childhood

==Differential Diagnosis==
{{Pediatric fever DDX}}
{{Pediatric SOB DDX}}

==Evaluation==
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]]
[[File:PNA_US.gif|thumb|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]
===Workup===
====Likely Outpatient====
*Imaging
**[[CXR]], consider for:
***Age 0-3mo (as part of sepsis workup)
***<5yr with temperature >102.2, WBC >20K and no clear source of infection
***Ambiguous clinical findings
***Pneumonia that is prolonged or not responsive to antibiotics
*Consider rapid assays:
**[[Covid-19]]
**[[RSV]]
**[[Influenza]]

====Sick/Likely Inpatient====
''Above plus:''
*CBC
*Chemistry
*Blood/nasal culture are low yield
**In prospective study, 91 blood cultures needed for one positive result for CAP; but in ICU one child had bacteremia for every 24 cultures obtained, one for every 12 with parapneumonic effusion <ref> Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics. 2019 Jun 19. </ref>
**consider for sicker ones, those with effusions
*IDSA does ''not'' support using initial serum [[procalcitonin]] levels to determine whether empiric antibiotics should be initiated.
**Clinical judgement ''plus'' radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)

===Diagnosis===
*Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
*[[CXR]]
**Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
**May have negative CXR early in disease or in cases of dehydration; infiltrate may "blossom" after providing rehydration and repeat imaging<ref>Feldman C. Pneumonia in the elderly. Clin Chest Med. 1999;20(3):563-573. doi:10.1016/s0272-5231(05)70236-7</ref>
**Well-circumscribed round/oval opacity (“round pneumonia”), usually in a posterior lower-lobe segment of children < 8 y; mimics a mass but clears with antibiotics
**Absence of CXR findings does not preclude diagnosis; high clinical suspicion with adventitious breath sounds can be consistent with pneumonia despite negative imaging
**Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
**Clinical and radiographic findings do not necessarily correspond: the patient may be improving clinically despite having a worsening appearance on the CXR
*[[Ultrasound]]
**Can be considered as an alternative to CXR
**Sensitivity 82% and specificity 94% (adults)<ref>Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. J Emerg Med. 2019;56(1):53-69. doi:10.1016/j.jemermed.2018.09.009</ref>

==Management==
{{Pediatric pneumonia treatment}}

==Disposition==
''All Children less than 2 months should be hospitalized<ref>AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011</ref>''
===Consider Admission For===
*Age: <2-3 months old
*History of severe or relevant congenital disorders
*Immune suppression (HIV, SCD, malignancy)
*Toxic appearance/respiratory distress
*SpO2 <90-93%
*Vomiting/dehydration
*Unstable social environment

==See Also==
*[[Pneumonia (Main)]]
*[[Pediatric fever]]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:ID]]
[[Category:Pulmonary]]

User:Modanq

2023-10-13T03:15:25Z

Modanq:

Template:Streptococcal Pharyngitis Antibiotics

2023-10-13T03:14:32Z

Modanq: Added Cefixime as per drug label

''Treatment can be delayed for up to 9 days and still prevent major sequelae''

'''[[Penicillin]] Options:<ref name=Shulman12>Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82</ref>'''
*[[Penicillin V]] 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
*[[Bicillin L-A]] <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
*[[Amoxicillin]] 500-875 mg PO q12h or 250-500 PO q8h for 10d<ref>Shah, U. K., MD. (2020, October 14). Tonsillitis and Pharyngitis Organism-Specific Therapy: Specific Organisms and Therapeutic Regimens. Emedicine. https://emedicine.medscape.com/article/2011872-overview</ref>

'''[[Penicillin]] allergic (mild):<ref name=Shulman12>Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82</ref>'''
*[[Cefuroxime]] 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d
*[[Cefixime]] 400mg/day PO in single daily dose x10d or divided q12hr x10d

'''[[Penicillin]] allergic (anaphylaxis):<ref name=Shulman12>Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82</ref>'''
*[[Clindamycin]] 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d OR
*[[Azithromycin]] 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5

Atrial fibrillation with RVR

2019-03-06T08:37:55Z

Modanq: /* Medication Choices */

==Background==
{{Afib background}}

==Clinical Features==
*[[Palpitations]]
*[[Shortness of breath]]
*Dyspnea on exersion
*[[Chest pain]]
*Consider [[WPW]] if:
**Wide QRS
**Rate approaching 300 bpm

==Differential Diagnosis==
{{Palpitations DDX}}

==Evaluation==
*[[ECG]]
*CBC
*Chem 10
*Mag and phos
*Consider coags, especially if on anticoagulation
*Consider LFTs
*Consider BNP if heart failure unclear
*Consider TFTs
*[[Troponin]] if patient has chest pain
*[[Ultrasound:_Cardiac|Cardiac Echo]] - if signs of new/worsening heart failure
*Chest XR

==Management==
===Unstable===
*Synchronized cardioversion (100-200J)
**Atrial fibrillation - start at 200 J
**Atrial flutter - start at 50 J
*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status
*Consider cardiostable sedation such as 5mg etomidate
**+/- subdissociative pain dosage ketamine at 15mg
*If shock does not work:
**Verify not preexcitation
**Increase diastolic BP to perfuse the heart
***Push-dose [[phenylephrine]]
****Will maintain BP when give rate-control meds
****50-200mcg q2-5min with goal DBP >60
**[[Amiodarone]] 150mg over 10min (preferably through central venous access) OR [[diltiazem]] 2.5mg/min until HR <100 or max 50mg
**Magnesium 2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref>
***Significantly less effective than amio or calcium-channel blockers
***Ensure baseline magnesium level
***Check magnesium q2hrs if infusing

===Stable and Asymptomatic===
If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds

===Stable and Symptomatic===
*'''Goal <110bpm'''
**Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
**RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref>

===[[Cardioversion]]===
*Consider for:<ref>[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol|Ottowa Aggressive Protocol]]</ref>
**Symptoms <48hr
**New diagnosis
**No history of similar episodes
**No LV dysfunction
**No mitral valve disease
**No prior thromboembolic event
**Already Anticoagulated
*If cardioversion is considered, pretreatment with rate or rhythm control medications can reduce effectiveness<ref>Blecher GE, et al. Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates. CJEM. 2012;14(3):169-177.</ref>
**90% effective, 60% effective with pretreatment

====Anticoagulation Prior to Cardioversion====
{{Anticoagulation prior to cardioversion}}

===Medication Choices===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''Dose'''
| align="center" style="background:#f0f0f0;"|'''Comments'''
| align="center" style="background:#f0f0f0;"|'''Contraindications'''
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''[[Calcium-Channel Blockers]]'''
|-
| [[Diltiazem]]||
*Bolus 0.25mg/kg (average adult dose 20mg) over 2 min
*If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35mg/kg
*If patient responds start infusion at 5-15mg/hr or give PO [[diltiazem]] 60mg QID
||
*Preferred in patients with chronic lung such as [[Asthma]] and [[COPD]]<ref>Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of β-blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549</ref>
||
*Decompensated heart failure
*Preexcitation (especially in pediatrics)
*Significant hypotension
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''[[Beta-Blockers]]'''
|-
| [[Metoprolol]]||
*Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
*If patient responds orally load with 25-50mg
||
*Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]]
*Long-term β-blocker improves patient survival (CCB may worsen outcomes), thus starting a β-blocker upon discharge, strongly consider using the agent for rate control also.<ref>Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85</ref>
||
*[[COPD]]
*[[Asthma]]
*[[Decompensated heart failure]]
*[[Hypotension]]
|-
| [[Esmolol]]||
*Bolus 0.5mg/kg over one minute, followed by 50 µg/kg/min
*If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min
*If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min
*If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes
||
*Use if unsure whether patient will tolerate a β-blocker since the duration of action is only 10 minutes
||
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''Other'''
|-
| [[Digoxin]]||
*0.25mg IV q2hr up to 1.5mg, then 0.125-0.25mg PO or IV QD
*Adjust dose in presence of renal failure, amiodarone, etc
||
*Consider as initial therapy for patients with LV dysfunction who:
**Do not achieve rate control targets on β-blockers alone
**Cannot tolerate addition of or increased doses of β-blocker due to decompensated [[CHF]]
**Would have [[digoxin]] added anyway to improve [[CHF]] symptoms independent of A-fib
*Consider as initial therapy in patients with severe hypotension
*Consider as 2nd agent in patients in whom IV BB or IV CCB has failed to control their rate
*May take up to 6-8 hours to work
||
|-
| [[Amiodarone]]||
*Load 3-7mg/kg IV over 30 min
*then, 1200mg over 24hr via continuous infusion or in divided oral doses<ref>Khan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Jun;89(2-3):239-48.</ref>
||
*Consider for patients with decompensated heart failure or those with accessory pathways
*2nd-line agent for chronic rate control when [[beta-blockers]] and [[calcium-channel blockers]], alone, combined, or when used with [[digoxin]], are ineffective
||
|-
| [[Magnesium Sulfate]]||
*4.5 IV over 30 min<ref>Bouida W et al. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med 2018 Feb;26(2):183-191.</ref>
||
*IV MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control.
*Given in conjunction with [[beta-blockers]] and [[calcium-channel blockers]].
||
|}

===Evidence of preexcitation===
*Avoid AV nodal agents
*Unstable:
**Unsynchronized cardioversion (200J)
**[[Procainamide]] (if cardioversion unsuccessful)<ref>GlobalRPH. Procainamide. Page was last updated: 08/05/2016. http://www.globalrph.com/procainamide_dilution.htm.</ref>
***20 - 50 mg/min
***Until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17 mg/kg is given
***Followed by continuous infusion of 2 - 6 mg/min
*Stable:
**Try to avoid [[cardioversion]] without adequate anticoagulation

==See Also==
*[[Atrial Fibrillation (Main)]]
*[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol|Ottawa Aggressive Cardioversion Protocol]]

==External Links==
*[http://www.aliem.com/beta-blockers-vs-calcium-channel-blockers-atrial-fibrillation-rate-control-thinking-beyond-ed/ ALiEM - BB vs CCB]
*[http://emcrit.org/podcasts/crashing-a-fib/ Crashing Afib - EMCrit]
*Diltiazem load: [[:File:dilt-load.pdf]]<ref>http://ehced.org/wp-content/site/Drips/dilt-load.pdf</ref>

==References==
<references/>

[[Category:Cardiology]]

Template:Hypertension DDX

2019-01-05T07:52:41Z

Modanq: /* Hypertension */ added Renal Artery Stenosis

===[[Hypertension]]===
*[[Asymptomatic hypertension]]
*[[Hypertensive urgency]]
*[[Hypertensive emergency]]
**[[ACS]]
**[[Hypertensive encephalopathy]]
**[[Acute renal failure]]
**[[Nontraumatic thoracic aortic dissection]]
**[[Posterior Reversible Encephalopathy Syndrome (PRES)|PRES]]
*[[Stroke]]
*[[Preeclampsia]]/[[Eclampsia]]
*[[Autonomic dysreflexia]]
*Drug use or overdose (e.g stimulants or [[Synthroid]])
*Renal Artery Stenosis
*[[Tyramine reaction]]
*[[Pheochromocytoma]]
*[[Hyperthyroidism]]
*[[Anxiety]]
*Pain

Template:Hypertension DDX

2019-01-05T07:50:01Z

Modanq: /* Hypertension */ added stroke

===[[Hypertension]]===
*[[Asymptomatic hypertension]]
*[[Hypertensive urgency]]
*[[Hypertensive emergency]]
**[[ACS]]
**[[Hypertensive encephalopathy]]
**[[Acute renal failure]]
**[[Nontraumatic thoracic aortic dissection]]
**[[Posterior Reversible Encephalopathy Syndrome (PRES)|PRES]]
*[[Stroke]]
*[[Preeclampsia]]/[[Eclampsia]]
*[[Autonomic dysreflexia]]
*Drug use or overdose (e.g stimulants or [[Synthroid]])
*[[Tyramine reaction]]
*[[Pheochromocytoma]]
*[[Hyperthyroidism]]
*[[Anxiety]]
*Pain

Template:Hypertension DDX

2019-01-05T07:48:25Z

Modanq: /* Hypertension */

===[[Hypertension]]===
*[[Asymptomatic hypertension]]
*[[Hypertensive urgency]]
*[[Hypertensive emergency]]
**[[ACS]]
**[[Hypertensive encephalopathy]]
**[[Acute renal failure]]
**[[Nontraumatic thoracic aortic dissection]]
**[[Posterior Reversible Encephalopathy Syndrome (PRES)|PRES]]
*[[Preeclampsia]]/[[Eclampsia]]
*[[Autonomic dysreflexia]]
*Drug use or overdose (e.g stimulants or [[Synthroid]])
*[[Tyramine reaction]]
*[[Pheochromocytoma]]
*[[Hyperthyroidism]]
*[[Anxiety]]
*Pain

Billing

2018-12-30T06:03:10Z

Modanq: Added Physical Exam and ROS

==CMS Requirements for Billing==
{| {{table}}
| align="center" style="background:#f0f0f0;"|''' '''
| align="center" style="background:#f0f0f0;"|'''99281'''
| align="center" style="background:#f0f0f0;"|'''99282'''
| align="center" style="background:#f0f0f0;"|'''99283'''
| align="center" style="background:#f0f0f0;"|'''99284'''
| align="center" style="background:#f0f0f0;"|'''99285'''
|-
| ||Level1||Level 2||Level 3||Level 4||Level 5
|-
| HPI||1 of 8||1 of 8||1 of 8||4 of 8||4 of 8
|-
| ROS||0||1||1||2||10
|-
| PMHx, FamHx, Social Hx||0||0||0||1||2
|-
| PE||1||2||2||5||8
|-
| MDM||Straight‐forward||Low Complexity||Moderate Complexity||Moderate Complexity||High Complexity
|-
|}

===History of Present Present Illness Illness (HPI)===
*Location
*Severity
*Timing
*Modifying Factors
*Associated Associated Signs and Symptoms Symptoms
*Onset
*Quality
*Duration

===Past Medical, Family, Family, Social History===
*Past Medical
**Past Illnesses
**Major Injuries
**Surgical History
**Hospitalizations
**Immunizations
**Feeding/Dietary
*Family History
**Health Status
**Deaths
**Hereditary Diseases
*Social History
**Drug, etoh , tobacco
**Employment
**Marital Status
**Sexual History

===Review of Systems===
There are 14 organ systems recognized by CMS:<ref>https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/</ref>
*Constitutional
*Eyes
*Ears, Nose, Mouth and Throat
*Cardiovascular
*Respiratory
*Gastrointestinal
*Musculoskeletal
*Integumentary (skin and/or breast)
*Neurologic
*Psychiatric
*Endocrine
*Hematologic/Lymphatic
*Allergic/Immunologic

===Physical Exam===
CMS recognizes the following 14 systems as part of the physical exam:<ref>https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/</ref>
*Constitutional
*Eyes
*Ears, Nose, Mouth and Throat
*Neck
*Respiratory
*Cardiovascular
*Chest (Breasts)
*Gastrointestinal
*Genitourinary
*Lymphatic
*Musculoskeletal
*Skin
*Neurologic
*Psychiatric

==RVU For Level of Service<ref>http://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/</ref>==
*99281 (Level 1) = 0.60 RVUs
*99282 (Level 2) = 1.17 RVUs
*99283 (Level 3) = 1.75 RVUs
*99284 (Level 4) = 3.32 RVUs
*99285 (Level 5) = 4.90 RVUs
*[[Critical care documentation|99291 (Critical Care)]] = 6.31 RVUs 1st hr
**Critical Critical care can be coded when the total duration duration of time spent by a provider in providing critical care services to a critically ill or critically injured patient is at least 30 minutes, even if the time spent is not continuous.

==See Also==
*[[Documentation for emergency physicians]]

==References==
<references/>

[[Category:Misc/General]]
[[Category:Documentation]]

Abdominal aortic aneurysm

2018-12-24T07:03:07Z

Modanq: /* Risk Factors */

==Background==
*Infrarenal diameter >3cm or >50% increase in size of diameter
**85% of cases are infrarenal <ref name="NJM"></ref>
*M to F ratio is 4:1
*Rupture Risk
**<4cm: low risk for rupture
**4-5cm: 5 year risk 3-12%
**>5cm: 25-41%
**Rupture possible at any size, most commonly >5cm
**Mortality with rupture: 85-90% <ref name="NJM">Kent, K. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014; 371:2101-8. DOI: 10.1056/NEJMcp1401430 </ref>

===Risk Factors===
*Smoking
**Risk factor most strongly associated with AAA
**Also promotes the rate of aneurysm growth
*Age (prevalence is negligible in age <50yrs)
*Family history
*Hypertension
*Hyperlipidemia
*Fluoroquinolone use

==Clinical Features==
*Classic triad is pain + hypotension + pulsatile mass
**Pain often described as sudden, severe, radiating to back
*Syncope (10%)
*Signs of [[Retroperitoneal hemorrhage]]
*Massive GI bleed from erosion into intestines
*Pain + AAA = rupture until proven otherwise
*Acute abdomen + hypotension = possible rupture
*Gross [[Hematuria]] can be caused by an aortocaval fistula (very rare)

==Differential Diagnosis==
{{Abdominal Pain DDX Diffuse}}

{{Lower back pain DDX}}

==Evaluation==
[[File:AAA.png|thumb|AAA]]
[[File:AAA_with_Thrombus.gif|thumbnail|AAA with Thrombus<ref>http://www.thepocusatlas.com/aorta-1/</ref>]]

*[[Aortic ultrasound|Ultrasound]]
**~100% sensitive for increased diameter
**Cannot reliably visualize rupture

*CT
**~100% sensitive for increased diameter and rupture
**IV contrast is preferred but not essential

==Management==
===Rupture===
*Do not waste time in ED trying to "stabilize" patient
*Immediate surgery consultation/ go to OR
*Crossmatch 6 units of pRBC
*Pain control (avoid hypotension)
*Antihypertensives (use with caution, goal SBP 110-120 mmHg or MAP 70-80)<ref>Reed, K. Aortic Emergencies, EB Medicine. 2006.</ref>
**[[Labetalol]]: 20mg IV, then 40-80mg IV q10 min (max 300mg)
**[[Esmolol]]: Bolus 500 mcg/kg, then 50-200 mcg/kg/min
**[[Nitroprusside]]: 0.3 - 0.5 mcg/kg/min, titrate to max 10 mcg/kg/min
*Controversial
**Too little (ischemia), too much (increased bleeding)
***Consider allowing for permissive hypotension (SBP 80-100) in conscious patient
**[[Pressors]]
***[[Norepinephrine]] 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
***[[Phenylephrine]] 100-180mcg/min; titrate by 25mcg/min q10min
***[[Dopamine]] 5mcg/kg/min; titrate by 5mcg/kg/min q10min

===Asymptomatic===
*Prompt vascular surgery outpatient follow-up appt
**Endovascular (75%) vs open repair
*Screening frequency:
**3-4 cm diameter: 12 months
**4-5 cm diameter: 6 months
**5-6 cm diameter: 1 month
*Elective Surgery indicated if:
**AAA > 5.5 cm in men <ref name="NJM"></ref>
**AAA > 5 cm in women <ref name="NJM"></ref>
**increase in size > 1 cm/year
**increase in size > 5 mm/6 months

==Complications==
*[[Aortoenteric fistula]]
*[[Aortocaval fistula]]
*[[Inflammatory abdominal aortic aneurysm]]
*[[Acute limb ischemia]] - embolism to lower extremities

==Disposition==
*Admit to OR in cases of ruptured OR
*Vasc surgery follow up in asymptomatic cases

==References==
<references/>

[[Category:Cardiology]]
[[Category:Vascular]]

Guillain-Barre syndrome

2018-05-06T14:39:28Z

Modanq: /* Intubation indications */

==Background==
*Acute polyneuropathy due to immune-mediated peripheral nerve myelin sheath destruction. Although there is often a motor component, patients can also present with sensory deficits.
*Associated with viral or febrile illness, campylobacter infection, or vaccination
*Symptoms at worst 2-4wk after onset, then plateau for 2-4wk, then remit from wks-months
*Associated with [[Campylobacter jejuni]], [[cytomegalovirus]], [[Epstein-Barr virus]], and [[Mycoplasma pneumoniae]]

==Clinical Features==
*Viral illness → ASCENDING, symmetric weakness or paralysis and loss of DTRs
*Little or no sensory involvement
*May progress to diaphragm resulting in need for mechanical ventilation (33% of patients)
*Autonomic dysfunction occurs in 50% of patients
===Variants and Subtypes===
There are multiple Guillain Barre variants with differing presentaions<ref>Ho TW et al.
Guillain-Barrésyndrome in northern China. Relationship to Campylobacter jejuni infection and anti-glycolipid antibodies. Brain. 1995;118 ( Pt 3):597. </ref><ref>Sumner AJ et al. The physiological basis for symptoms in Guillain-Barrésyndrome. Ann Neurol. 1981;9 Suppl:28. </ref>
#Acute inflammatory demyelinating polyneuropathy - most common type with progressive symmetric muscle weakness often with decreased deep tendon reflexes due to peripheral nerve involvment
#Acute motor axonal neuropathy - often associated with [[campylobacter]] infections with only motor involvement
#Acute motor and sensory axonal neuropathy - presence both motor and sensory involement
#Miller-Fisher Syndrome - presence of ophthalmoplegia with ataxia and areflexia
===Miller-Fisher Syndrome===
*Associated with [[campylobacter]] infection
*More likely to be preceded by diarrhea than viral prodrome
*Consists of ophthalmoplegia and ataxia
*Weakness is less severe but DESCENDING; disease course milder than classic GBS
*May present similarly to [[botulism]], which is also descending paralysis

==Differential Diagnosis==
{{Weakness DDX}}

==Evaluation==
===Required===
*Progressive [[weakness]] of more than one limb
*Areflexia

===Suggestive===
*Progression over days to weeks
*Recovery beginning 2–4 wk after cessation of progression
*Relative symmetry of symptoms
*Mild sensory signs and symptoms
*CN involvement ([[Bell's Palsy]], [[dysphagia]], [[dysarthria]], [[ophthalmoplegia]])
*Autonomic dysfunction
**[[Tachycardia]], [[bradycardia]], [[dysrhythmias]], wide variations in BP, postural [[hypotension]]
**[[Urinary Retention]]
**[[Constipation]]
**Facial flushing
*Absence of [[fever]] at onset
*'''Albumin-cytological dissociation of [[CSF]] (high protein (>45) and low WBC count (<10)) is most common. However patients with HIV can have a pleocytosis<ref name="Rosen">Bunney EB, Gallagher EJ: Peripheral Nerve Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 105:p 1400-1401.</ref><ref>Brannagan TH et al. HIV-associated Guillain-Barré syndrome. J Neurol Sci. 2003;208(1-2):39. </ref>'''
*Typical findings on electromyogram and nerve conduction studies
*MRI: Selective enhancement of the anterior spinal nerve roots is suggestive<ref name="Rosen" />

==Management==
===[[IVIG]]===
*Treat nonambulatory patients within 2 weeks of symptom onset

===[[IVIG]] vs [[Plasmapheresis]]===
*IVIG associated with [[thromboembolism]] and aseptic [[meningitis]]
*Plasmapheresis associated with greater hemodynamic instability, lower rate of relapse
*Combined IVIG and plasmapheresis no better than single therapy (IVIG or plasmapheresis)
*IVIG preferred due to convenience and availability

===Intubation indications===
*Vital capacity <15mL/kg
*Negative Inspiratory Force < 30 cm H2O
*PaO2 <70 mm Hg on room air
*Bulbar dysfunction (difficulty with breathing, swallowing, or speech)
*Aspiration

* Avoid succinylcholine during intubation, as this may cause severe hyperkalemia

==Disposition==
===Indications for admission to ICU===
*Autonomic dysfunction
*Bulbar dysfunction
*Initial vital capacity <20 mL/kg
*Initial negative inspiratory force <–30 cm of water
*Decrease of >30% of vital capacity or negative inspiratory force
*Inability to ambulate
*Treatment with plasmapheresis
*Anticipated clinical course requiring mechanical [[ventilation]]

==See Also==
*[[Weakness]]

==References==
<references/>

[[Category:Neurology]]

Abdominal aortic aneurysm

2018-05-06T11:42:01Z

Modanq: /* Risk Factors */ DM is protective https://www.ncbi.nlm.nih.gov/pubmed/26022380

==Background==
*Infrarenal diameter >3cm or >50% increase in size of diameter
**85% of cases are infrarenal <ref name="NJM"></ref>
*M to F ratio is 4:1
*Rupture Risk
**<4cm: low risk for rupture
**4-5cm: 5 year risk 3-12%
**>5cm: 25-41%
**Rupture possible at any size, most commonly >5cm
**Mortality with rupture: 85-90% <ref name="NJM">Kent, K. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014; 371:2101-8. DOI: 10.1056/NEJMcp1401430 </ref>

===Risk Factors===
*Smoking
**Risk factor most strongly associated with AAA
**Also promotes the rate of aneurysm growth
*Age (prevalence is negligible in age <50yrs)
*Family history
*Hypertension
*Hyperlipidemia

==Clinical Features==
*Classic triad is pain + hypotension + pulsatile mass
**Pain often described as sudden, severe, radiating to back
*Syncope (10%)
*Signs of [[Retroperitoneal hemorrhage]]
*Massive GI bleed from erosion into intestines
*Pain + AAA = rupture until proven otherwise
*Acute abdomen + hypotension = possible rupture
*Gross [[Hematuria]] can be caused by an aortocaval fistula (very rare)

==Differential Diagnosis==
{{Abdominal Pain DDX Diffuse}}

{{Lower back pain DDX}}

==Evaluation==
[[File:AAA.png|thumb|AAA]]
[[File:AAA_with_Thrombus.gif|thumbnail|AAA with Thrombus<ref>http://www.thepocusatlas.com/aorta-1/</ref>]]

*[[Aortic ultrasound|Ultrasound]]
**~100% sensitive for increased diameter
**Cannot reliably visualize rupture

*CT
**~100% sensitive for increased diameter and rupture
**IV contrast is preferred but not essential

==Management==
===Rupture===
*Do not waste time in ED trying to "stabilize" patient
*Immediate surgery consultation/ go to OR
*Crossmatch 6 units of pRBC
*Pain control (avoid hypotension)
*Antihypertensives (use with caution, goal SBP 110-120 mmHg or MAP 70-80)<ref>Reed, K. Aortic Emergencies, EB Medicine. 2006.</ref>
**[[Labetalol]]: 20mg IV, then 40-80mg IV q10 min (max 300mg)
**[[Esmolol]]: Bolus 500 mcg/kg, then 50-200 mcg/kg/min
**[[Nitroprusside]]: 0.3 - 0.5 mcg/kg/min, titrate to max 10 mcg/kg/min
*Controversial
**Too little (ischemia), too much (increased bleeding)
***Consider allowing for permissive hypotension (SBP 80-100) in conscious patient
**[[Pressors]]
***[[Norepinephrine]] 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
***[[Phenylephrine]] 100-180mcg/min; titrate by 25mcg/min q10min
***[[Dopamine]] 5mcg/kg/min; titrate by 5mcg/kg/min q10min

===Asymptomatic===
*Prompt vascular surgery outpatient follow-up appt
**Endovascular (75%) vs open repair
*Screening frequency:
**3-4 cm diameter: 12 months
**4-5 cm diameter: 6 months
**5-6 cm diameter: 1 month
*Elective Surgery indicated if:
**AAA > 5.5 cm in men <ref name="NJM"></ref>
**AAA > 5 cm in women <ref name="NJM"></ref>
**increase in size > 1 cm/year
**increase in size > 5 mm/6 months

==Complications==
*[[Aortoenteric fistula]]
*[[Aortocaval fistula]]
*[[Inflammatory abdominal aortic aneurysm]]
*[[Acute limb ischemia]] - embolism to lower extremities

==Disposition==
*Admit to OR in cases of ruptured OR
*Vasc surgery follow up in asymptomatic cases

==References==
<references/>

[[Category:Cardiology]]
[[Category:Vascular]]

User:Modanq

2018-04-20T08:17:52Z

Modanq:

'''Omar Usman, MD, MBA

Stanford University
* Informatics Fellowship
* [https://healthpolicy.fsi.stanford.edu/people/omar-usman-0 Department Profile]
* [https://profiles.stanford.edu/omar-usman Stanford Profile]
* [http://web.stanford.edu/~ousman Personal Website]
University of Chicago
* Emergency Medicine Residency
Ohio State University
* Medical School
Northwestern University
* MBA
University of Michigan
* BBA

User:Modanq

2018-04-20T08:17:19Z

Modanq:

'''Omar Usman, MD, MBA

Stanford University
* Informatics Fellowship
* [https://healthpolicy.fsi.stanford.edu/people/omar-usman-0 Department Profile]
* [https://profiles.stanford.edu/omar-usman Stanford Profile]
* [http://web.stanford.edu/~ousman Stanford Personal Website]
University of Chicago
* Emergency Medicine Residency
Ohio State University
* Medical School
Northwestern University
* MBA
University of Michigan
* BBA

Atrial fibrillation with RVR

2018-04-06T07:24:08Z

Modanq: /* Evaluation */

==Background==
{{Afib background}}

==Clinical Features==
*[[Palpitations]]
*[[Shortness of breath]]
*Dyspnea on exersion
*[[Chest pain]]
*Consider [[WPW]] if:
**Wide QRS
**Rate approaching 300 bpm

==Differential Diagnosis==
{{Palpitations DDX}}

==Evaluation==
*[[ECG]]
*CBC
*Chem 10
*Mag and phos
*Consider coags, especially if on anticoagulation
*Consider LFTs
*Consider BNP if heart failure unclear
*Consider TFTs
*[[Troponin]] if patient has chest pain
*[[Ultrasound:_Cardiac|Cardiac Echo]] - if signs of new/worsening heart failure
*Chest XR

==Management==
===Unstable===
*Synchronized cardioversion (100-200J)
**Atrial fibrillation - start at 200 J
**Atrial flutter - start at 50 J
*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status
*Consider cardiostable sedation such as 5mg etomidate
**+/- subdissociative pain dosage ketamine at 15mg
*If shock does not work:
**Verify not preexcitation
**Increase diastolic BP to perfuse the heart
***Push-dose [[phenylephrine]]
****Will maintain BP when give rate-control meds
****50-200mcg q2-5min with goal DBP >60
**[[Amiodarone]] 150mg over 10min (preferably through central venous access) OR [[diltiazem]] 2.5mg/min until HR <100 or max 50mg
**Magnesium 2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref>
***Significantly less effective than amio or calcium-channel blockers
***Ensure baseline magnesium level
***Check magnesium q2hrs if infusing

===Stable and Asymptomatic===
If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds

===Stable and Symptomatic===
*'''Goal <110bpm'''
**Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
**RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref>

===[[Cardioversion]]===
*Consider for:<ref>[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol|Ottowa Aggressive Protocol]]</ref>
**Symptoms <48hr
**New diagnosis
**No history of similar episodes
**No LV dysfunction
**No mitral valve disease
**No prior thromboembolic event
**Already Anticoagulated
*If cardioversion is considered, pretreatment with rate or rhythm control medications can reduce effectiveness<ref>Blecher GE, et al. Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates. CJEM. 2012;14(3):169-177.</ref>
**90% effective, 60% effective with pretreatment

====Anticoagulation Prior to Cardioversion====
{{Anticoagulation prior to cardioversion}}

===Medication Choices===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''Dose'''
| align="center" style="background:#f0f0f0;"|'''Comments'''
| align="center" style="background:#f0f0f0;"|'''Contraindications'''
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''[[Calcium-Channel Blockers]]'''
|-
| [[Diltiazem]]||
*Bolus 0.25mg/kg (average adult dose 20mg) over 2 min
*If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35mg/kg
*If patient responds start infusion at 5-15mg/hr or give PO [[diltiazem]] 60mg QID
||
*Preferred in patients with chronic lung such as [[Asthma]] and [[COPD]]<ref>Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of β-blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549</ref>
||
*Decompensated heart failure
*Preexcitation (especially in pediatrics)
*Significant hypotension
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''[[Beta-Blockers]]'''
|-
| [[Metoprolol]]||
*Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
*If patient responds orally load with 25-50mg
||
*Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]]
*Long-term β-blocker improves patient survival (CCB may worsen outcomes), thus starting a β-blocker upon discharge, strongly consider using the agent for rate control also.<ref>Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85</ref>
||
*[[COPD]]
*[[Asthma]]
*[[Decompensated heart failure]]
*[[Hypotension]]
|-
| [[Esmolol]]||
*Bolus 0.5mg/kg over one minute, followed by 50 µg/kg/min
*If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min
*If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min
*If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes
||
*Use if unsure whether patient will tolerate a β-blocker since the duration of action is only 10 minutes
||
|-
!colspan="6" style="background-color: #f0f0f0;font-size:110%"|'''Other'''
|-
| [[Digoxin]]||
*0.25mg IV q2hr up to 1.5mg, then 0.125-0.25mg PO or IV QD
*Adjust dose in presence of renal failure, amiodarone, etc
||
*Consider as initial therapy for patients with LV dysfunction who:
**Do not achieve rate control targets on β-blockers alone
**Cannot tolerate addition of or increased doses of β-blocker due to decompensated [[CHF]]
**Would have [[digoxin]] added anyway to improve [[CHF]] symptoms independent of A-fib
*Consider as initial therapy in patients with severe hypotension
*Consider as 2nd agent in patients in whom IV BB or IV CCB has failed to control their rate
*May take up to 6-8 hours to work
||
|-
| [[Amiodarone]]||
*Load 3-7mg/kg IV over 30 min
*then, 1200mg over 24hr via continuous infusion or in divided oral doses<ref>Khan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Jun;89(2-3):239-48.</ref>
||
*Consider for patients with decompensated heart failure or those with accessory pathways
*2nd-line agent for chronic rate control when [[beta-blockers]] and [[calcium-channel blockers]], alone, combined, or when used with [[digoxin]], are ineffective
||
|}

===Evidence of preexcitation===
*Avoid AV nodal agents
*Unstable:
**Unsynchronized cardioversion (200J)
**[[Procainamide]] (if cardioversion unsuccessful)<ref>GlobalRPH. Procainamide. Page was last updated: 08/05/2016. http://www.globalrph.com/procainamide_dilution.htm.</ref>
***20 - 50 mg/min
***Until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17 mg/kg is given
***Followed by continuous infusion of 2 - 6 mg/min
*Stable:
**Try to avoid [[cardioversion]] without adequate anticoagulation

==See Also==
*[[Atrial Fibrillation (Main)]]
*[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol|Ottawa Aggressive Cardioversion Protocol]]

==External Links==
*[http://www.aliem.com/beta-blockers-vs-calcium-channel-blockers-atrial-fibrillation-rate-control-thinking-beyond-ed/ ALiEM - BB vs CCB]
*[http://emcrit.org/podcasts/crashing-a-fib/ Crashing Afib - EMCrit]
*Diltiazem load: [[:File:dilt-load.pdf]]<ref>http://ehced.org/wp-content/site/Drips/dilt-load.pdf</ref>

==References==
<references/>

[[Category:Cardiology]]

Intubation

2018-04-06T05:31:20Z

Modanq: /* Active GI Bleed */ if pt vomits

==Indications==
*Failure to ventilate
*Failure to oxygenate
*Inability to protect airway
**Gag reflex is absent at baseline in ~1/3 of people<ref>Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.</ref>, so lack of gag reflex is inadequate in determination of ability to protect airway.
*Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
*Combative patient who needs imaging (suspicion of intracranial process, etc)
==Considerations==
*2015 AHA ACLS guidelines deemphasize placement of '''advanced airway''' placement in '''''initial resuscitation'''''
*Out-of-hospital arrest data suggests lower survival of those intubated in field<ref>Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.</ref>
*108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation<ref>Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.</ref>
**Patients intubated were significantly less likely to survive to discharge, 16% vs. 19%
**Also less likely to be discharged with good functional status, 11% vs. 14%

==Absolute Contraindications==
*No absolute contraindications when performed as an emergent procedure
**Exception: cannot ventilate and anticipate near impossible orotracheal intubation, strongly consider surgical airway

==Relative Contraindications (Mnemonics)==
{{Difficult BVM}}

===Difficult Intubation (LEMON)===
*'''L'''ook externally (gestalt)
*'''E'''valuate 3-3-2 rule
*'''M'''allampati
*'''O'''bstruction
*'''N'''eck mobility

==Equipment Needed==
*Medications
**Induction agent
**Paralytic agent
*Laryngoscope (type based on clinical indication and provider preference)
**Direct laryngoscope with blade of provider's choice '''or'''
**Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Optical stylet (Shikani, Levitan, etc.) '''or'''
**Fiberoptic device
*Endotracheal tube
*End-tidal CO2 device (colorimetric or quantitative)
*Ventilator
*Suction
*Intubation adjuncts (bougie, lighted stylet, etc)
*BVM
*[[OPA]]/NPA
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Nasal cannula for [[apneic oxygenation]]

==SOAP-ME Checklist Mnemonic==
*'''S'''uction
*'''O'''xygen
**Nasal cannula
**Non-rebreather
**Bag-valve mask
*'''A'''irways
**Endotracheal tube
**Rescue devices
**Adjuncts
*'''P'''ositioning
*'''M'''edications
*'''E'''quipment
**Laryngoscope
**EtCO2
**Bougie

==Procedure==

{{Initial ventilation settings table}}

==Complications==
[[Difficult airway algorithm]]

==Special Situations==
===Severe [[Metabolic Acidosis]]===
''Further drop in pH during intubation can be catastrophic''
*NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
**SIMV on ventilator, not NIV machine
**"Pseudo-SIMV" mode
*Attach end-tidal CO2 and observe value
*Push [[Rapid Sequence Intubation (RSI)|RSI]] medications
*Turn the respiratory rate to 12
*Perform jaw thrust
*Wait 45sec
*[[Intubate]]
*Re-attach the ventilator
*Immediately increase rate to 30
*Change Vt to 8cc/kg
*Change flow rate to 60 LPM (normal setting)
*Make sure end-tidal CO2 is at least as low as before

===Active [[GI Bleed]]===
#Empty the stomach
#*Place an NG and suction out blood
#**Varices are not a contraindication
#*Metoclopramide 10mg IV
#**Increases LES tone
#Intubate with HOB at 45°
#Preoxygenate!
#*Want to avoid bagging if possible
#Intubation meds
#*Use sedative that is BP stable (etomidate, ketamine)
#*Use paralytics (actually increases LES tone)
#If need to bag:
#*Bag gently and slowly (10BPM)
#*Consider placing LMA
#If patient vomits
#*Place in Trendelenberg
#*Place LMA
#*Use meconium aspirator
#If patient aspirates anticipate a sepsis-like syndrome
#*May need pressors, additional fluid (not antibiotic!)

==Video==
{{#widget:YouTube|id=99X2-a4mdxc}}

==See Also==
*[[Difficult Airway Algorithm]]
*[[Rapid Sequence Intubation (RSI)]]
*[[Supraglottic airway]]
*[[Cricothyrotomy]]
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival|DL vs VL]]
*[[Nasal intubation]]
*[[Apneic oxygenation]]
*[[Awake intubation]]
{{Mechanical ventilation pages}}

==External Links==
*[http://emcrit.org/podcasts/tube-severe-acidosis/ EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis]

==References==
<References/>

[[Category:Critical Care]]
[[Category:Procedures]]

Intubation

2018-04-06T04:59:48Z

Modanq: Added EM in 5 video

==Indications==
*Failure to ventilate
*Failure to oxygenate
*Inability to protect airway
**Gag reflex is absent at baseline in ~1/3 of people<ref>Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.</ref>, so lack of gag reflex is inadequate in determination of ability to protect airway.
*Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
*Combative patient who needs imaging (suspicion of intracranial process, etc)
==Considerations==
*2015 AHA ACLS guidelines deemphasize placement of '''advanced airway''' placement in '''''initial resuscitation'''''
*Out-of-hospital arrest data suggests lower survival of those intubated in field<ref>Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.</ref>
*108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation<ref>Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.</ref>
**Patients intubated were significantly less likely to survive to discharge, 16% vs. 19%
**Also less likely to be discharged with good functional status, 11% vs. 14%

==Absolute Contraindications==
*No absolute contraindications when performed as an emergent procedure
**Exception: cannot ventilate and anticipate near impossible orotracheal intubation, strongly consider surgical airway

==Relative Contraindications (Mnemonics)==
{{Difficult BVM}}

===Difficult Intubation (LEMON)===
*'''L'''ook externally (gestalt)
*'''E'''valuate 3-3-2 rule
*'''M'''allampati
*'''O'''bstruction
*'''N'''eck mobility

==Equipment Needed==
*Medications
**Induction agent
**Paralytic agent
*Laryngoscope (type based on clinical indication and provider preference)
**Direct laryngoscope with blade of provider's choice '''or'''
**Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Optical stylet (Shikani, Levitan, etc.) '''or'''
**Fiberoptic device
*Endotracheal tube
*End-tidal CO2 device (colorimetric or quantitative)
*Ventilator
*Suction
*Intubation adjuncts (bougie, lighted stylet, etc)
*BVM
*[[OPA]]/NPA
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Nasal cannula for [[apneic oxygenation]]

==SOAP-ME Checklist Mnemonic==
*'''S'''uction
*'''O'''xygen
**Nasal cannula
**Non-rebreather
**Bag-valve mask
*'''A'''irways
**Endotracheal tube
**Rescue devices
**Adjuncts
*'''P'''ositioning
*'''M'''edications
*'''E'''quipment
**Laryngoscope
**EtCO2
**Bougie

==Procedure==

{{Initial ventilation settings table}}

==Complications==
[[Difficult airway algorithm]]

==Special Situations==
===Severe [[Metabolic Acidosis]]===
''Further drop in pH during intubation can be catastrophic''
*NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
**SIMV on ventilator, not NIV machine
**"Pseudo-SIMV" mode
*Attach end-tidal CO2 and observe value
*Push [[Rapid Sequence Intubation (RSI)|RSI]] medications
*Turn the respiratory rate to 12
*Perform jaw thrust
*Wait 45sec
*[[Intubate]]
*Re-attach the ventilator
*Immediately increase rate to 30
*Change Vt to 8cc/kg
*Change flow rate to 60 LPM (normal setting)
*Make sure end-tidal CO2 is at least as low as before

===Active [[GI Bleed]]===
#Empty the stomach
#*Place an NG and suction out blood
#**Varices are not a contraindication
#*Metoclopramide 10mg IV
#**Increases LES tone
#Intubate with HOB at 45°
#Preoxygenate!
#*Want to avoid bagging if possible
#Intubation meds
#*Use sedative that is BP stable (etomidate, ketamine)
#*Use paralytics (actually increases LES tone)
#If need to bag:
#*Bag gently and slowly (10BPM)
#*Consider placing LMA
#If patient vomits place in Trendelenberg
#If patient aspirates anticipate a sepsis-like syndrome
#*May need pressors, additional fluid (not antibiotic!)

==Video==
{{#widget:YouTube|id=99X2-a4mdxc}}

==See Also==
*[[Difficult Airway Algorithm]]
*[[Rapid Sequence Intubation (RSI)]]
*[[Supraglottic airway]]
*[[Cricothyrotomy]]
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival|DL vs VL]]
*[[Nasal intubation]]
*[[Apneic oxygenation]]
*[[Awake intubation]]
{{Mechanical ventilation pages}}

==External Links==
*[http://emcrit.org/podcasts/tube-severe-acidosis/ EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis]

==References==
<References/>

[[Category:Critical Care]]
[[Category:Procedures]]

Intubation

2018-04-06T04:50:15Z

Modanq: SOAP-ME

==Indications==
*Failure to ventilate
*Failure to oxygenate
*Inability to protect airway
**Gag reflex is absent at baseline in ~1/3 of people<ref>Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.</ref>, so lack of gag reflex is inadequate in determination of ability to protect airway.
*Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
*Combative patient who needs imaging (suspicion of intracranial process, etc)
==Considerations==
*2015 AHA ACLS guidelines deemphasize placement of '''advanced airway''' placement in '''''initial resuscitation'''''
*Out-of-hospital arrest data suggests lower survival of those intubated in field<ref>Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.</ref>
*108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation<ref>Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.</ref>
**Patients intubated were significantly less likely to survive to discharge, 16% vs. 19%
**Also less likely to be discharged with good functional status, 11% vs. 14%

==Absolute Contraindications==
*No absolute contraindications when performed as an emergent procedure
**Exception: cannot ventilate and anticipate near impossible orotracheal intubation, strongly consider surgical airway

==Relative Contraindications (Mnemonics)==
{{Difficult BVM}}

===Difficult Intubation (LEMON)===
*'''L'''ook externally (gestalt)
*'''E'''valuate 3-3-2 rule
*'''M'''allampati
*'''O'''bstruction
*'''N'''eck mobility

==Equipment Needed==
*Medications
**Induction agent
**Paralytic agent
*Laryngoscope (type based on clinical indication and provider preference)
**Direct laryngoscope with blade of provider's choice '''or'''
**Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Optical stylet (Shikani, Levitan, etc.) '''or'''
**Fiberoptic device
*Endotracheal tube
*End-tidal CO2 device (colorimetric or quantitative)
*Ventilator
*Suction
*Intubation adjuncts (bougie, lighted stylet, etc)
*BVM
*[[OPA]]/NPA
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Nasal cannula for [[apneic oxygenation]]

==SOAP-ME Checklist Mnemonic==
*'''S'''uction
*'''O'''xygen
**Nasal cannula
**Non-rebreather
**Bag-valve mask
*'''A'''irways
**Endotracheal tube
**Rescue devices
**Adjuncts
*'''P'''ositioning
*'''M'''edications
*'''E'''quipment
**Laryngoscope
**EtCO2
**Bougie

==Procedure==

{{Initial ventilation settings table}}

==Complications==
[[Difficult airway algorithm]]

==Special Situations==
===Severe [[Metabolic Acidosis]]===
''Further drop in pH during intubation can be catastrophic''
*NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
**SIMV on ventilator, not NIV machine
**"Pseudo-SIMV" mode
*Attach end-tidal CO2 and observe value
*Push [[Rapid Sequence Intubation (RSI)|RSI]] medications
*Turn the respiratory rate to 12
*Perform jaw thrust
*Wait 45sec
*[[Intubate]]
*Re-attach the ventilator
*Immediately increase rate to 30
*Change Vt to 8cc/kg
*Change flow rate to 60 LPM (normal setting)
*Make sure end-tidal CO2 is at least as low as before

===Active [[GI Bleed]]===
#Empty the stomach
#*Place an NG and suction out blood
#**Varices are not a contraindication
#*Metoclopramide 10mg IV
#**Increases LES tone
#Intubate with HOB at 45°
#Preoxygenate!
#*Want to avoid bagging if possible
#Intubation meds
#*Use sedative that is BP stable (etomidate, ketamine)
#*Use paralytics (actually increases LES tone)
#If need to bag:
#*Bag gently and slowly (10BPM)
#*Consider placing LMA
#If patient vomits place in Trendelenberg
#If patient aspirates anticipate a sepsis-like syndrome
#*May need pressors, additional fluid (not antibiotic!)

==See Also==
*[[Difficult Airway Algorithm]]
*[[Rapid Sequence Intubation (RSI)]]
*[[Supraglottic airway]]
*[[Cricothyrotomy]]
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival|DL vs VL]]
*[[Nasal intubation]]
*[[Apneic oxygenation]]
*[[Awake intubation]]
{{Mechanical ventilation pages}}

==External Links==
*[http://emcrit.org/podcasts/tube-severe-acidosis/ EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis]

==References==
<References/>

[[Category:Critical Care]]
[[Category:Procedures]]

Template:Knee DDX

2018-04-06T03:46:33Z

Modanq: /* Nontraumatic/Subacute */

===[[Knee diagnoses]]===
====[[Acute knee injury]]====
*[[Knee dislocation]]
*[[Knee fractures]]
**[[Patella fracture]]
**[[Segond fracture]]
**[[Tibial plateau fracture]]
*[[Meniscus and ligament knee injuries]]
*[[Patella dislocation]]
*[[Patellar tendonitis]]
*[[Patellar tendon rupture]]
*[[Quadriceps tendon rupture]]

====Nontraumatic/Subacute====
*[[Arthritis]]
*[[Gout and Pseudogout]]
*[[Osgood-Schlatter disease]]
*[[Patellofemoral syndrome]] (Runner's Knee)
*[[Patellar tendonitis]] (Jumper's knee)
*[[Pes anserine bursitis]]
*[[Popliteal cyst]] (Bakers cyst)
*[[Prepatellar bursitis (nonseptic)]]
*[[Septic bursitis]]
*[[Septic arthritis (general)|Septic joint]]
*[[DVT]]

Emergency medicine journals

2018-04-06T01:50:36Z

Modanq: /* List */ added more

==Background==
This is a list of academic emergency medicine journals.

==List==
''Impact factor in parentheses''

*Annals of Emergency Medicine http://www.annemergmed.com/
**Official Journal of ACEP (3.755)
*Academic Emergency Medicine http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291553-2712
**Official Journal of SAEM (2.46)
*Journal of Emergency Medicine http://www.elsevier.com/wps/find/journaldescription.cws_home/525473/description*description
**Official Journal of AAEM (0.778)
*Prehospital Emergency Care http://informahealthcare.com/journal/pec
**Official Journal of NAEMSP (1.843)

*Emergency Medicine Journal: EMJ
**(1.776)
*The American Journal of Emergency Medicine
**(1.704)
*The Western Journal of Emergency Medicine
**(1.136)

==External Links==
*http://www.scimagojr.com/journalrank.php?category=2711

==See Also==
[[Emergency Medicine Resources (Main)]]

[[Category:Resources]]

Tillaux fracture

2018-04-06T01:32:45Z

Modanq: split categories

==Background==
*Salter-Harris type III fracture of the anterolateral portion of the distal tibia
**caused by an avulsion of anterior inferior tibiofibular ligament
*Occurs typically in adolescents, age 12-14
**occurs in children nearing skeletal maturity, as anterolateral portion most vulnerable at this age

==Clinical Features==
*Typically due to external rotation force
**forced lateral rotation of foot '''OR''' medial rotation of leg on a fixed foot
*Often associated with external rotation deformity of the ankle/foot

==Differential Diagnosis==
{{Distal leg fractures DDX}}

==Evaluation==
*XR
**Salter-Harris III fracture of anterolateral distal tibia epiphysis
*CT scan
**further delineates fracture pattern and degree of displacement

==Management==
*Ortho consult
*Nonoperative
**closed reduction, long leg cast x 4wks, short leg cast x 2-3wks
**indicated only if <2mm of displacement after closed reduction (rare)
*Operative
**Open reduction and internal fixation ('''OR'''IF)
**indicated if >2mm of displacement after reduction attempt

==Disposition==
*Most will require surgical reduction
*Admit

==See Also==
*[[Salter-Harris fractures]]

==External Links==

==References==
*Tintinalli 7th Edition, pg 905
*http://radiopaedia.org/articles/tillaux-fracture
*http://orthobullets.com/pediatrics/4028/tillaux-fractures
<references/>

[[Category: Orthopedics]]
[[Category: Pediatrics]]

Depleted uranium toxicity

2018-04-06T01:29:33Z

Modanq: changed catagory

==Background==
* Uranium is an alpha-emitting, radioactive heavy metal that occurs naturally in nearly all rocks and soil. Natural uranium is made up of the three naturally occurring isotopes of uranium namely 234U, 235U, and 238U. Naturally occurring uranium deposits are over 99% 238U. You eat, drink, and breather natural uranium on a daily basis.
* Health hazards of natural uranium have been studied extensively since 1940s. Health impact of Depleted Uranium (DU) has been studied since the early 1970s.
* Enrichment is the industrial process by which natural uranium is separated into enriched uranium which has an increased percentage of 235U and depleted uranium which has a decreased percentage of 235U.
** DU is a byproduct of the enrichment process.
** DU has 40% less radioactivity than natural uranium. It has a specific activity of 0.33 microCi/g.
** DU has the same chemical properties as naturally occurring uranium, it simply has different ratio of isotopes of 234U, 235U, and 238U.
** DU health effects will be the same as for natural uranium because the toxicity is primarily due to the chemical toxicity rather than radiotoxicity.
* United States Armed Forces have used depleted uranium in the manufacture of ammunition, armor, and aircraft.
** DU's high density, self-sharpening quality and pyrophoricity make it a good choice for projectile munitions.
** DU's density makes it a good armor choice.
** DU's density also makes it a good choice for counterbalance weights used in aircraft and on helicopter rotors.
{| {{table}}
| align="center" style="background:#f0f0f0;"|''''''
| align="center" style="background:#f0f0f0;"|'''Natural Uranium'''
| align="center" style="background:#f0f0f0;"|'''Depleted Uranium'''
|-
| Isotope||Concentration of isotope||Concentration of isotope
|-
| 234U||0.0058%||0.0010%
|-
| 235U||0.72%||0.20%
|-
| 238U||99.28%||99.80%
|-
| Relative Radioactivity||1.0||0.6
|-
|
|}

===Routes of exposure===
* Inhalation - minor route of exposure for general population. Major route for occupational population. On average in US individual daily intake of uranium is 0.007 micrograms by inhalation.
* Oral - predominant route of exposure for general population through ingestion of food and drinking water. Average daily intake of uranium in US is 1.9 micrograms by ingestion.
* Dermal - unlikely route of exposure for general population. Potential route of exposure for military service members.

===Toxicokinetics===
* DU is poorly absorbed following inhalation, oral, or dermal exposure route.
** Amount absorbed heavily dependent on the solubility of the compound.
** <0.1-6% of uranium is absorbed following oral exposure.
* 67% of uranium in blood is filtered in the kidneys and leaves body in urine within 24 hours. Remainder is distributed to tissues primarily bone, liver, and kidney.
* Retention half-time for uranium in bone is 70-200 days.
* Retention in body skeleton (66%), liver (16%), kidneys (8%), other tissues (10%)

====Radiation Toxicity====
* Alpha emitter thus not serious external radiation hazard. Alpha radiation has poor penetrating ability. Direct contact with bare DU for 250 hours is necessary to exceed annual occupational exposure limits.
* Internal exposure via inhalation, ingestion, wound contamination or retained fragments warrants some concern.
* Chronic exposure by inhalation is potential radiologic hazard to the lung and thoracic lymph nodes.
* Genotoxicity, mutagenicity and reproductive effects are being studied.

====Chemical Toxicity====
* Kidney dysfunction main chemically-induced effect of uranium
* Can develop tubulopathy or renal tubular acidosis

==Clinical Features==
* DU is a heavy metal like lead, tungsten or nickel which can damage the kidneys when present in large amounts.
* DU exposure normally does not result in any symptoms as small amounts are quickly passed
* DU make cause impairment of the kidneys if exposure is significant in short term

==Differential Diagnosis==
*Alpha radiation exposure
*[[Heavy metal toxicity]]

==Evaluation==
* Patients who feel they have been exposed to high levels of DU should be evaluated
* Assess the following in patient:
** Circumstances : date, time, route of exposure, amount
** Evidence of wound or embedded fragments?
** Has patient had any prolong skin contact i.e. through keeping of a souvenir?
* Provide medical examination:
**Physical
**Determine kidney function (blood urea and creatinine)
** Conduct urine analysis
** Complete blood count
** Chest x-ray if history suggestive of significant inhalation exposure
* Test for uranium exposure if history suggest proximity to source or large exposure or any abnormalities on about routine examination
** Check beta-2 microglobulin in 24 hour urine to check for tubulopathy
** Check urine uranium level if elevated than 24 hour excreted DU level should be accessed including isotope-specific methods to identify ratios of isotope of uranium

==Management==
* Acute exposure manage as would for any heavy metal exposure
* Remove patient from exposure
* Externally decontaminate if residue present on patient
* Base further treatment on symptoms observed
* Renal tubulopathy treatment which needs to be applied early prior to fixation of uranium in the skeleton to be truly effective
** Sodium bicarbonate perfusion to alkalinize urine
** Consider heavy metal chelation therapy
** Monitor renal function

==Disposition==
* Most cases of exposure have no permanent effect
* Likelihood to develop any health effects is low
* If exposure is via inhalation and significant amounts of insoluble uranium compounds deposited in lungs than patient will need long-term surveillance/follow-up

==See Also==

==References==
<references/>
# Agency for Toxic Substances and Disease Registry (ATSDR), Toxicological Profile for Uranium (Update), February 2013.
# McDiarmid, M.A. (2001). ''Depleted uranium and public health''. BMJ, 322(7279), 123-124.
# U.S. Army Environmental Policy Institute (AEPI). (June 1995). Health and Environmental Consequences of Depleted Uranium Use in the U.S. Army: Technical Report.
# Department of Defense. (August 4, 1998). Health Effects of Depleted Uranium - Fact Sheet.
# U.S. Army Environmental Policy Institute, (AEPI). (June 1994). Health and Environmental Consequences of Depleted Uranium Use by the U.S. Army, Summary Report to Congress.
# World Health Organization (WHO), Guidance On Exposure to DU- For Medical Officers and Programme Administrators, 2001.
# World Health Organization (WHO), Depleted Uranium: Sources, Exposure and Health Effects, 2001.
# World Health Organization (WHO), Depleted Uranium Fact Sheet, revised January 2003.

[[Category:Military]]
[[Category:Toxicology]]

User:Modanq

2018-04-06T01:26:13Z

Modanq:

'''Omar Usman, MD, MBA

Stanford University
* Informatics Fellowship
* [https://healthpolicy.fsi.stanford.edu/people/omar-usman-0 Stanford Profile]
University of Chicago
* Emergency Medicine Residency
Ohio State University
* Medical School
Northwestern University
* MBA
University of Michigan
* BBA

University of Chicago

2018-04-06T01:20:40Z

Modanq: /* Primary Hospital */

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is the third oldest training program in the country. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger, MD
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn, MD
*'''Associate/Assistant Program Director:''' Navneet Cheema, MD
*'''Associate/Assistant Program Director:''' Cliff Rice, MD

==Training Locations==
===Primary Hospital===
University of Chicago

Comer Children's Hospital

===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]

University of Chicago

2018-04-06T01:20:19Z

Modanq: /* Primary Hospital */

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is the third oldest training program in the country. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger, MD
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn, MD
*'''Associate/Assistant Program Director:''' Navneet Cheema, MD
*'''Associate/Assistant Program Director:''' Cliff Rice, MD

==Training Locations==
===Primary Hospital===
University of Chicago
Comer Children's Hospital

===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]

University of Chicago

2018-04-06T01:19:51Z

Modanq: /* History */ third oldest

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is the third oldest training program in the country. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger, MD
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn, MD
*'''Associate/Assistant Program Director:''' Navneet Cheema, MD
*'''Associate/Assistant Program Director:''' Cliff Rice, MD

==Training Locations==
===Primary Hospital===
University of Chicago
===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]

Emergency medicine conferences and events

2018-01-07T09:12:43Z

Modanq: /* 2018 */ added SAEM

{{#widget:Google Calendar
|id=k0m4c9g29fa2919bdjoihauh2c@group.calendar.google.com
|color=B1440E
|title=Emergency Medicine Conferences & Events
}}

==Background==
*This calendar is open to the public; please feel free to insert upcoming conferences and events of interest to emergency medical practitioners.
*Click the bottom right link on the calendar to add it to your own Google Calendar.

==National==
===2014===
*ACEP Scientific Assembly: October 27-30, Chicago

===2015===
*National Association of EMS Physicians: January 22-24, New Orleans
*AAEM Scientific Assembly Feb 28- March 4 Austin, TX http://www.aaem.org/education/scientific-assembly
*ACEP Leadership and Advocacy Conference: May 3-6; Washington, DC
*SAEM Annual Meeting: May 12-15, San Diego
*SMACC: June 23-26, McCormick Place Chicago http://www.smacc.net.au/
*ACEP Scientific Assembly: October 26-29, Boston, MA

===2016===
*National Association of EMS Physicians: January 14-16; San Diego
*AAEM Scientific Assembly: February 17–21, 2016; Las Vegas
*SAEM Annual Meeting: May 10-14; New Orleans
*ACEP Scientific Assembly: October 15 - October 18, Las Vegas

===2017===
*National Association of EMS Physicians: January 26-28; New Orleans
*AAEM Scientific Assembly March 16-20, 2017; Orlando
*SAEM Annual Meeting: May 16-20, Orlando, FL
*ACEP Scientific Assembly: October 30 - November 2; Washington, DC

===2018===
*National Association of EMS Physicians: January 11-13; San Diego
*AAEM Scientific Assembly April 7-11, 2018; San Diego
*SAEM Annual Meeting: May 15-18, Indianapolis, IA
*ACEP Scientific Assembly: October 1 - October 4; San Diego, CA

===2019===
*AAEM Scientific Assembly March 2-6, 2019; Las Vegas
*ACEP Scientific Assembly: October 28 - October 31; Denver, CO

===2020===
*ACEP Scientific Assembly: October 26 - October 29; Dallas, TX

===2021===
*ACEP Scientific Assembly: October 25 - October 28; Boston, MA

==Regional==
'''2015'''
*Ohio ACEP EM Leadership Forum: April 21; Columbus, OH http://www.ohacep.org/aws/OACEP/pt/sp/conferences_em_leadership
*PACEP15 Scientific Assembly: April 22-24; Lancaster, PA http://www.paacep.org/CMECourseOfferings/tabid/82/anid/584/Default.aspx
*Ohio ACEP Residents Assembly: August 13; Columbus, OH http://www.ohacep.org/aws/OACEP/pt/sp/conferences

==See Also==
[[Emergency Medicine Resources (Main)]]

[[Category:Resources]]

User:Modanq

2017-11-08T02:41:35Z

Modanq:

'''Omar Usman, MD, MBA.

Stanford University
* Informatics Fellowship
* [https://healthpolicy.fsi.stanford.edu/people/omar-usman-0 Stanford Profile]
University of Chicago
* Emergency Medicine Residency
Ohio State University
* Medical School
Northwestern University
* MBA
University of Michigan
* BBA

Superior vena cava syndrome

2017-11-05T03:22:29Z

Modanq: Added HA

==Background==
*External compression by extrinsic malignant mass causes majority of cases
*Thrombus in SVC from indwelling catheter/pacemaker is increasingly more common as cause
*Infection
*Rarely constitutes an emergency
**Gradual process; collaterals dilate to compensate for the impaired flow
**Exception is neurologic abnormalities due to increased ICP, laryngeal edema causing stridor, decreased cardiac output

===Risk Factors===
*Lung Cancer
*Lymphoma
*Indwelling vascular catheters (increasing incidence)
*Thrombotic coagulopathy
*Goiter
*TB
*Radiation
*Pericardial constriction

==Clinical Features==
*[[Facial swelling]]
**Worse in morning, gets better as day progresses
*[[Headache]]
*[[Cyanosis]]
*[[Dyspnea]]
*[[Cough]]
*[[Arm swelling]]
*Distended neck/chest wall veins
*Telangiectasia
*Neurologic abnormalities (rare)
**Visual changes
**[[Dizziness]]
**Confusion
**[[Seizure]]
**[[Syncope]]
**[[Papilledema]] and [[elevated ICP]]

==Differential Diagnosis==
{{Facial swelling DDX}}

{{Oncologic emergencies DDX}}

==Evaluation==
[[File:SVC_syndrome.jpg|thumb|CT chest showing right lung tumor compressing SVC]]
*CT with IV contrast
**Recommended imaging modality (assesses patency of the SVC, evaluate etiology mass vs. thrombus)
*[[CXR]]
**Shows mediastinal mass or paranchymal lung mass (10% of patients)

==Management==
*Elevate head of bed
*Assess for and treat [[elevated intracranial pressure]]
*Use IVs placed in lower extremities to avoid further SVC venous congestion<ref>Chaudhary K, Gupta A, Wadhawan S, Jain D, Bhadoria P. Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2016 Jul 19];28:242-6. Available from: http://www.joacp.org/text.asp?2012/28/2/242/94910.</ref>
*Corticosteroids and loop diuretics have questionable efficacy and should be held until ordered by admitting team<ref>McCurdy M et al. Oncologic emergencies, part I: spinal cord compression, superior vena cava syndrome, and pericardial effusion. Emergency Medicine Practice. 2010; 12(2):7-10.</ref>
*Intravascular stent
*If malignancy
**Mediastinal radiation
*If thrombus
**Anticoagulation, catheter removal, consider thrombolytics

==References==
<references/>

[[Category:Heme/Onc]]

Dacryocystitis

2017-11-02T06:36:42Z

Modanq: Added adjunct tx

==Background==
*Acute or chronic inflammation and bacterial infection of the lacrimal sac
**Most common pathogens: Strep. pneumoniae, staph. aureus, staph. epidermidis, h. influenzae
*Most common in children
*Often after viral URI
*Complications: [[Periorbital Cellulitis]], [[Orbital Cellulitis]], [[Meningitis]]

==Clinical Features==
*Mucopurulent material expressed from nasolacrimal sac
*Erythema and edema between medial canthus and nasal bridge

==Evaluation==
*Physical exam
*May culture purulent material

==Differential Diagnosis==
{{Periorbital swelling DDX}}

{{Neonatal eye problems DDX}}

==Management==
*Oral [[clindamycin]] for 7-10 days
*If ill appearing: IV [[cephalosporin]] ([[cefuroxime]] 50mg/kg IV Q8h or [[cefazolin]] 33mg/kg IV Q6H) or [[clindamycin]] (10mg/kg IV Q8H)
**If [[MRSA]] suspected: [[Vancomycin]] 10-13mg/kg IV Q6-8 h
*Chronic dacryocystitis: topical antibiotic ([[fluoroquinolone]] or [[erythromycin]])
*Consult ophthalmology (outpatient referral follow-up)

*Decongestants
*Warm compress

==References==
*Tintinalli 7th ed, p. 764

[[Category:ENT]]
[[Category:ID]]
[[Category:Ophthalmology]]

Template:Hematuria DDX

2017-01-01T10:51:05Z

Modanq: /* Hematuria */ added causes

===[[Hematuria]]===
*Urologic (lower tract)
**Any location
***Iatrogenic/postprocedure
***[[GU trauma]]
***Infection
***[[Kidney stone]]
***Erosion or mechanical obstruction by tumor
**Ureter(s)
***Dilatation of stricture
**Bladder
***Transitional cell carcinoma
***Vascular lesions or malformations
***Chemical or radiation cystitis
**Prostate
***Benign prostatic hypertrophy
***[[Prostatitis]]
**Urethra
***Stricture
***Diverticulosis
***Foreign body
***Endometriosis (cyclic hematuria with menstrual pain)
*Renal (upper tract)
**Glomerular
***[[Glomerulonephritis]]
***Immunoglobulin A nephropathy (Berger disease)
***[[Lupus nephritis]]
***Hereditary nephritis (Alport syndrome)
***Toxemia of pregnancy
***Serum sickness
***[[Erythema multiforme]]
**Nonglomerular
***Interstitial nephritis
***[[Pyelonephritis]]
***Papillary necrosis: sickle cell disease, diabetes, NSAID use
***Vascular: arteriovenous malformations, emboli, aortocaval fistula
***Malignancy
***Polycystic kidney disease
***Medullary sponge disease
***[[Tuberculosis]]
***[[Renal trauma]]
*Hematologic
**Primary [[coagulopathy]] (e.g., hemophilia)
**Pharmacologic anticoagulation
**[[Sickle cell disease]]
*Myoglobinuria - positive blood, no RBCs: [[rhabdomyolysis]]
*Hemoglobinuria - positive blood, no RBCs
**[[TTP]] / [[HUS]]
**[[DIC]]
**Mechanical valve emergency
**[[Hemolytic anemia]]
**[[Paroxysmal Nocturnal Hemoglobinuria]]
*Miscellaneous
**Eroding abdominal aortic aneurysm
**Malignant hypertension
**Loin pain–hematuria syndrome
**Renal vein thrombosis
**Exercise-induced hematuria
**Cantharidin (Spanish fly) poisoning
**Stings/bites by insects/reptiles having venom with anticoagulant properties
**Schistosomiasis
**Sickle Cell Trait

University of Chicago

2016-12-03T07:11:25Z

Modanq: Minor edits

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is one of the country’s oldest training programs in emergency medicine. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger, MD
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn, MD
*'''Associate/Assistant Program Director:''' Navneet Cheema, MD
*'''Associate/Assistant Program Director:''' Cliff Rice, MD

==Training Locations==
===Primary Hospital===
University of Chicago
===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]

University of Chicago

2016-12-03T07:09:02Z

Modanq: Update

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is one of the country’s oldest training programs in emergency medicine. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger, MD
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn, MD
*'''Associate/Assistant Program Director:''' Navneet Cheema, MD
*'''Associate/Assistant Program Director:''' Cliff Rice, MD

==Training Locations==
===Primary Hospital===
University of Chicago
===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]

University of Chicago

2016-12-03T07:07:12Z

Modanq: Update new info

==History==
Founded in 1972, the University of Chicago Emergency Medicine Residency is one of the country’s oldest training programs in emergency medicine. Program alumni have distinguished themselves by achieving leadership roles in the academic, teaching, political, and practice arenas of emergency medicine.

Its university-based program is unique in that it is comprised of three level one trauma centers located in distinctly different socio-demographic settings. The patient population ranges from the newborn to the aged and reflects a mix of private and referral patients as well as the emergent care of the medically under served. The emergency medicine program has a proud tradition at the University and has played a leadership role in developing the prehospital care system in Chicago, initiating the only hospital-based aeromedical transport system in the city, and contributing to the care of level I trauma patients. This insures its residents an incredibly diverse, comprehensive clinical training experience in a three year training format.

==Leadership==
*'''Department Chair:''' Linda Druelinger
*'''Program Director:''' Christine A. Babcock, MD
*'''Associate/Assistant Program Director:''' James Ahn
*'''Associate/Assistant Program Director:''' Noah DeGarmo MD
*'''Associate/Assistant Program Director:''' Eric Beck
*'''Research Director:'''
==Training Locations==
===Primary Hospital===
University of Chicago
===Secondary Hospital===
NUH-Evanston
===Tertiary Hospital===
Mt. Sinai Hospital
==Curriculum==
===PGY1===
*EM-UCH- 3
*EM-NUH- 1
*PED EM-UCH- 1
*PED EM-MTS- 1
*Trauma Surgical ICU-MTS- 1
*Trauma Service-MTS- 1
*CCU-UCH- 1
*MICU-UCH-1
*ICU/CCU-NUH- 2 weeks
*ANEST/NICU call (NUH or UCH) -1
*Adult CCU/PED ICU-UCH-1.5
*Vacation- 4 weeks
===PGY2===
*EM- Flight Physician UCH- 5
*EM- NUH- 2
*EM MTS- 2
*PEDS EM UCH- 1
*CCU -UCH -1
*Toxicology Selective -1
*Selective -1
*Vacation- 4 weeks
===PGY3===
*EM- Flight Physician UCH -5
*EM- NUH- 1.5
*Ped ED- UCH- 1
*Trauma ED- MTS- 1.5
*Administrative/Teaching Resident -1.5
*International Health/Elective -1.5
*Vacation- 4 weeksips==

==Contact Information==
Residency Program Administrator: Lynne Harnish
Email: lkharnis@uchicago.edu
Phone: +1 773 702 9109
Fax: +1 773 702 3135
==External Links==
http://em.uchicago.edu/
==See Also==
*[[Council_of_Emergency_Medicine_Residency_Directors|Council of Emergency Medicine Residency Directors (CORD)]]
*[[Emergency medicine residency programs]]

[[Category:Resources]]