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Template:HIV post-exposure prophylaxis regimens

2022-04-02T00:15:26Z

ZKhesbak: /* Preferred HIV PEP RegimenKuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 1...

====Preferred HIV [[PEP]] Regimen<ref>Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271</ref><ref>Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services</ref>====

''PEP should be started as soon as possible after significant exposure and continued for 28 days''<ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>
*[[Raltegravir]] (Isentress; RAL) 400 mg PO twice daily, '''plus'''
*[[Truvada]], 1 PO once daily (Tenofovir DF [Viread; TDF] 300 mg emtricitabine [Emtriva; FTC] 200 mg)

'''Other Considerations'''
*If known source patient with resistant HIV strain, consult HIV service for source-patient-specific PEP
*Consider interactions with current medication interactions and contraindications, such as renal impairment with [[Truvada]]
**For patients with creatinine clearance <60mL/min, consider [[Raltegravir]] 400mg PO twice daily, '''plus''' [[Zidovudine]] and [[Lamivudine]] with doses adjusted to the degree of renal dysfunction.<ref>Dominguez KL et al. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV--United States, 2016. Available at: https://stacks.cdc.gov/view/cdc/38856</ref>
*If the source exposure does report exposure to HIV within the last 6 weeks, HIV RNA PCR (HIV viral load) should be sent along with HIV Ag/Ab screen on the source and nPEP should be initiated for the exposed patient
**If both tests result not detected and nonreactive, respectively, nPEP should be discontinued.
**If the source is willing and able to be tested and is found to be HIV-negative with no recent high-risk exposures to HIV, nPEP is not indicated and should not be initiated, or discontinued if already started.
**The exposed patient still warrants baseline HIV testing and should be offered baseline and follow-up testing for other transmissible infections, e.g. hepatitis A, B, and C, syphilis, chlamydia, and gonorrhea.

Subungual hematoma

2018-09-28T00:59:43Z

ZKhesbak: /* Background */

==Background==
*Collection of blood under the nail
*There is a strong association with distal phalanx fractures.
*In the past, complete nail removal and exploration and closure of possible nail bed lacerations was performed. A prospective study of 52 children supports management with trephination alone for any size hematoma.<ref>Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg. 1999;24(6):2266-1170.</ref>
*Atraumatic subungual hematoma may be caused by melanoma or Kaposi's sarcoma

===Types===
[[File:Subungal hematoma.jpg|thumb|Subungal hematoma]]
#Simple: No nailbed dislocation or evidence of open fracture
#Complex: Aassociated with fracture or nail plate disruption

{{Fingertip anatomy}}

==Clinical Features==
*Blood trapped under nail

==Differential Diagnosis==
{{DDX distal finger}}

{{Hand and finger injury DDX}}

==Evaluation==
*Clinical diagnosis
*Evaluate percentage of nail bed involved, test extensor/flexor tendons and distal cap refill

==Management==
===Simple===
[[File:Post trephonation.jpg|thumb|All blood has been expelled through the trephination hole]]
*Trephination
*#Cleanse with povidone-iodine solution (not flammable alcohol)
*#Handheld cautery works best - no anesthesia is required
*#Alternatively a needle spun in a drilling fashion
*#Sharp object (i.e. safety pin) heated with flame in an austere environment
*If a fracture is present, the digit should be splinted
*Instruct patients to soak affected finger in warm water BID-TID x7d
*Prophylactic antibiotics are not needed after trephination of uncomplicated hematomas <ref name="Incision and Drainage">Holtzman L. Incision and Drainage. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014. </ref>

===Complex===
*Nail removal only recommended if there is associated [[nail avulsion]] or nail fold disruption<ref>Seaberg DC, ANgelos WJ, et al. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991; 9(3):209-210</ref>
*Repair [[nailbed laceration]] using absorbable sutures

===Contraindications===
*Electrocautery
**Presence of acrylic nails secondry to fire risk. Remove acrylic nails before using electrocautery tool.

==Disposition==
*Discharge

==See Also==
*[[Hand and finger diagnoses]]
*[[Nailbed laceration]]

==References==
<references/>

[[Category:Orthopedics]]
[[Category:Trauma]]

Pulmonary embolism in pregnancy

2017-09-19T00:56:54Z

ZKhesbak: /* If clinical features suggestive of PE and lower extremity swelling then: */

==Background==
*Incidence of VTE in pregnancy and postpartum is 1.72 per 1000<ref>James AH, et al. Venous thromboembolism during pregnancy and the postpartum period: Incidence, risk factors, and mortality. 2006; 194(5):1311–1315.</ref>
*The risk is significantly elevated in the 6 wks postpartum
**Risk of [[DVT]] equal in 1st and 2nd trimesters, higher risk in 3rd trimester and 3 weeks postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.</ref>
**[[PE]] most commonly occurs in postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.</ref>
**Common risk factors include: Advanced maternal age, C-Section, Obesity, multiple gestations, thrombophilia, prior VTE
*Risk returns to baseline by 12 wks postpartumm<ref>Kamel H, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014; 370:1307-1315.</ref>
*Consider MI in differential as risk can increase 3-6 times during the postpartum period

{{Venous thromboembolism types}}

{{PE types}}

==Clinical Features==
{{PE clinical presentation}}

==Differential Diagnosis==
{{Chest Pain DDX}}

==Evaluation==
===Clinical Decision Rules===
*Limited utility as no studies (PERC, Wells) have proven effective in pregnancy
**8% (9/114) of PERC Negative patients with CT or V/Q proven [[PE]] were pregnant or post-partum <ref>Kline JA, et al. Clinical Features of Patients With Pulmonary Embolism and a Negative PERC Rule Result. Ann Emerg Med. 2013 January 60(1): 122-124</ref><ref>West, J. “When the PERC Rule Fails”. ALiEM. Feb 2014[http://www.aliem.com/when-perc-rule-fails/]</ref>

===If clinical features suggestive of [[PE]] and lower extremity swelling then:===
*Bilateral LE Ultrasound
**if Positive→treat empirically for PE
**if Negative→CTA
***CTA and V/Q scans yield approximately 0.025 rad and 0.040 rad respectively to the fetus<ref>Astani SA, et al. Detection of pulmonary embolism during pregnancy: comparing radiation doses of CTPA and pulmonary scintigraphy. Nucl Med Commun. 2014; 35(7):704-711.</ref>
***>5 rads is considered teratogenic<ref>Bentur Y, Horlatsch N, and Koren G. Exposure to ionizing radiation during pregnancy: perception of teratogenic risk and outcome. Teratology. 1991; 43(2):109-112.</ref>
***However, 20-100 times more radiation is delivered to maternal breast tissue with CT, increasing the risk of breast cancer<ref>Greer IA. Pregnancy complicated by venous thrombosis. N Engl J Med 2015; 373:540-547</ref>
*Up to 17% of pregnant patients have isolated pelvic [[DVT]](not found with ultrasound)<ref>Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. CMAJ. 2010; 182(7):657- 660.</ref>

;CT (with shield) vs. V/Q is roughly equivalent radiation exposure to fetus, but CT confers increased radiation to maternal breast tissue

{{Guidelines PE Pregnancy}}

===D-Dimer===
*D-Dimer MAY BE used with following limits with '''very poor evidence'''<ref>Kovac M. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2010 Jan;148(1):27-30</ref><ref>http://blog.ercast.org/2013/04/pulmonary-embolism-in-pregnancy/</ref><ref>D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long</ref>
**1st trimester: <750 ng/mL (+50% increase from normal lab threshold)
**2nd trimester: <1000 ng/mL (+100% from normal)
**3rd trimester: <1250 ng/mL (+150% from normal)

==Management==
*[[Heparin]] and [[Enoxaparin]] are safe (coumadin is not)
**Heparin 80 units/kg IV bolus followed by continuous infusion 18 units/kg/hr <ref name="multiple1"> Tintinalli's 7th edition</ref>
**Enoxaparin 1 milligram/kg (100 IU/kg) SC every 12 or 24 h <ref name="multiple1"> Tintinalli's 7th edition</ref>
*[[Perimortem cesarean delivery]] with cardiac arrest with no ROSC in 5 min
*Consider thrombolysis in severely unstable post-partum pulmonary embolism<ref>Stone SE and Morris TA. Pulmonary embolism during and after pregnancy. (Crit Care Med 2005; 33[Suppl.]:S294 –S300.</ref>(see [[Adult pulseless arrest]] for tPA dosing in pulmonary embolism)

==Disposition==
*Admit

==See Also==
*[[Pulmonary Embolism]]

==References==
<references/>

[[Category:Pulmonary]]
[[Category:Cardiology]]
[[Category:OBGYN]]
[[Category:Vascular]]

Septic arthritis

2017-09-19T00:28:37Z

ZKhesbak: /* Work-Up */

==Background==
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Knee most commonly involved in adults; hip most common in pediatric
*Most often seen in patients >65yr
*Most common causative organisms
**<35 y/o ''[[N. gonorrhoeae]]''
**>35 y/o ''[[S. aureus]]''

==Clinical Features==
*Fever
*Warm, red, painful, swollen joint
*Decreased range of motion to active and passive movement
*[[Gonococcal]] arthritis
**[[Urethritis]]/[[vaginitis]] may be absent
**May have prodromal phase:
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
***Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
*Endocarditis should be considered in the presence of 2 or more affected joints

==Differential Diagnosis==
*[[Transient (Toxic) Synovitis]]
*Abscess
*[[Cellulitis]]
*Primary rheumatologic disorder (i.e. vasculitis)
*Iatrogenic
*[[Reactive Arthritis (Poststreptococcal)]]
*Consider if patient has Sickle Cell (fever '''and''' limited joint ROM)
**Osteomyelitis typically has neither

{{Differential Diagnosis Monoarthritis}}

==Evaluation==
===Work-Up===
*Arthrocentesis with synovial fluid analysis
**Synovial fluid culture only (not 100% sensitive)
*CBC
*ESR
**Sn 94% (with 15mm/h cut-off)<ref>Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029</ref>
*CRP
**Sn 92% (with 20mg/L cut-off)
*Blood Culture
*Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
*Imaging
**Helpful for excluding other diagnoses (e.g. trauma, osteo)
*Immunocompromised
**Consider mycobacterial or fungal arthritis
**Leukemia history: predisposed to Aeromonas infections
*Periprosthetic infection
**Non-emergent: acute microbiological diagnosis is more important than rapid antibiotics
**Diagnose with two synovial fluid cultures (avoid collection from a draining sinus)
**CRP >100mg/L during first 6 weeks post-op warrants aspiration and may be used to differentiate from superficial skin infection

{{Arthrocentesis diagnostic chart}}

==Management==
===[[Arthrocentesis]]===
*Treatment based on diagnostic studies
===[[Antibiotics]]===
{{Septic Arthritis Antibiotics}}
===Consultation===
*Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection

==Disposition==
*Admit all to ortho

==See Also==
*[[Arthrocentesis]]
*[[Monoarticular Arthritis]]
*[[Septic Arthritis (Hip)]]
*[[Septic Arthritis (Peds)]]
*[[Knee Diagnoses]]

==External Links==
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]

==References==
<references/>

[[Category:ID]] [[Category:Orthopedics]]

Template:Platelet transfusion indications

2016-07-22T23:31:59Z

ZKhesbak: /* Platelet Transfusion Thresholds */

===[[Platelet Transfusion]] Thresholds===
''most if not all of the following thresholds are based on weak recommendations with low quality evidence<ref>Kaufman, R. et al. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Annals of Internal Medicine. 2015. Vol 162. No. 3 205-214 [http://annals.org/article.aspx?articleid=1930861 Full Text]</ref>
*<50K if planned lumbar puncture or neurosurgical procedure
*<20K if planned for central venous catheter placement (preference toward compressible site), or febrile patient
*<10K in asymptomatic patients (unless due to [[ITP]], [[TTP]], or [[HIT]])
There are no firm recommendations for transfusion thresholds in acute traumatic bleeding but many providers will opt for a goal of 100K, especially if there is evidence of [[ICH]]

Harbor:Teaching Rounds Topics

2016-07-22T23:29:30Z

ZKhesbak: /* Teaching Rounds Topics */

==Teaching Rounds Topics==
*[[Status epilepticus]]
*Right-sided heart failure and complications

Harbor:Teaching Rounds Topics

2016-07-22T23:29:18Z

ZKhesbak: /* Teaching Rounds Topics */

==Teaching Rounds Topics==
*[[Status epilepticus]]
Right-sided heart failure and complications