Neonates (<28 days of age) are a fragile population that can present in life-threatening distress that requires immediate evaluation and treatment. As such, utilizing a systematic approach can help identify and treat the most common causes of neonatal distress. As more hospital nurseries discharge patients earlier, emergency departments must be ready to evaluate, diagnose, and treat neonatal emergencies. For more information; ACEP "The Misfits" The MisfitsThe Misfits is a useful mnemonic for neurologic changes in the neonate, and can be expanded to neonatal distress in general to aid in a systematic approach to all neonates in distress. Keep in mind that neurologic changes in the very young may be subtle and difficult to diagnose.
Intestinal Emergencies
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Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain1/6/2016 According to this new article from JAMA, the addition of Percocet or Flexeril to Naproxen does not improve functional outcomes in acute low back pain. The article compared functional outcomes in lower back pain at 1 and 3 weeks between Naproxen, Flexeril, and Percocet. Via a randomized, double-blind study in NYC, 323 patients were randomized to Naproxen + Placebo, Naproxen + Flexeril, and Naproxen + Percocet. Using an improvement in the Roland-Morris Disability Questionnaire (RMDQ), the study found that adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting.
Adapted from Rosens, chp 16. Little Old Lady Workup (LOL)Testing to consider in an elderly patient with altered mental status ABG: hypoxia, CO2 retention, SOB BMP/CMP: electrolyte abnormalities, hepatic encephalopathy UA: infection, DKA, ingestion PT/INT: hemorrhage, anemia, hypercoagulable Lactate: ketotic state, ingestion, ischemia TSH: thyroid storm, hypothyroid Cardiac Enzymes: MI, ischemia, cardiogenic shock CXR: infection, pneumothorax, CHF CT head: hemorrhage, mass MRI: edema, mass, ischemia CTA: pulmonary emboli, aortic dissection LP/CSF: infection, ICP Confusion
The Himmelfarb librarians have built an extensive reading list for internal medicine sub-specialties, from Cardiology to Infectious Disease. These are a great resource for studying up on both bread and butter as well as zebras.
Teaching Pearl: Bell's Palsy can be easily diagnosed by clinical examination, however the treatment varies depending on severity and the patient's own medical history. You should never prescribe steroids longer than antivirals, due to the possibility of a viral infection progressing while steroids are continued. Additionally, any patient who has a House-Brackmann score of IV or more, must go home with instructions and material to tape their eye shut at night, otherwise, they risk corneal abrasions and ulcers. You should also consider antivirals, and be sure to check their auditory canals for signs of herpetic skin lesions.
Can a CT read within 6 hours of headache onset can rule out SAH without the need for a lumbar puncture? This study found a 99% NPV of staff-read CTs in 11 non-academic centers with a 1/15,200 missed aneurysmal SAH. This study did not discuss the accuracy of resident or emergency medicine interpretations of CT scans.
A multicenter, retrospective study of 11 non-academic centers. Included patients older than 16, with acute-onset headache of known duration without focal deficits or altered mental status. To be included, patients had to undergo a CT in <6 hours from headache onset and a lumbar puncture >12 hours from headache onset. 760 patients were included with 52 positive CSF findings. On review of CT imaging, 51 were considered negative, and only one perimesencephalic nonaneurysmal SAH was found, and no readmissions due to SAH. Adapted from a presentation by Ty Nichols, 12/2/2015 Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2 for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. A mechanism to risk stratify patients presenting with syncope
The SFSR is criticized as being unsafe given a high miss rate (pooled sensitivity of 86%). Notably, there is one patient in the original trial who was SFSR negative and subsequently died (cardiac arrest after inpatient hospital discharge). Exclusion Criteria
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