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ACOFP 54th Annual Convention & Scientific Seminars Urgency vs. Emergency: Pearls for the Urgent Care Physician Lindsay Saleski, DO, MBA, FACOEP 3/9/2017 Urgency vs. Emergency Pearls for the Urgent Care Physician LINDSAY TJIATTAS-SALESKI DO, MBA, FACOEP FAMILY PRACTICE/EMERGENCY MEDICINE MIDLANDS EMERGENCY PHYSICIANS PALMETTO HEALTH TUOMEY Objectives To provide the urgent care physician with evidence based information regarding common outpatient presentations, initial treatment strategies and potential need for more emergent care. 1 3/9/2017 Outline Head trauma evaluation – PECARN and Canadian Head CT Rules Human Bite Evaluation of Hypertension Supracondylar Fracture Pharyngitis Headache Scaphoid Fracture Allergy versus Anaphylaxis Cervical spine trauma Pulmonary Embolism Clinical Prediction Rules Doc… my kid fell off the bed and hit their head! Pediatric Emergency Care Applied Research Network – PECARN Federally-funded multi-institutional network for research in pediatric emergency medicine in the United States Pediatric Head Injury Prediction provides factors to identify those at very low risk of clinically important traumatic brain injuries for whom CT might be unnecessary Prospective cohort study of 42,412 children Children (<18 years) presenting within 24 hours of head trauma, with Glasgow Coma Scale scores of 14 to 15 2 3/9/2017 Pediatric Head Injury/Trauma Algorithm Children younger than 2 years Children ages 2 years and older Normal mental status Normal mental status No scalp hematoma except frontal No loss of consciousness No loss of consciousness or loss of consciousness for <5 seconds No vomiting Non–severe injury mechanism No signs of basilar skull fracture No severe headache Non–severe injury mechanism No palpable skull fracture Acting normally according to the parents Doc…I fell and hit my head! Traumatic brain injury (TBI) = brain function impairment that results from external force Mild: GCS 14-15 (Most Common) Moderate: GCS 9-13 Severe: GCS 3-8 History and Physical Exam Pupillary response Altered motor function Age of patient Comorbidities (anticoagulant use?) Decision rules attempt to limit unnecessary CT imaging & identify surgical emergencies 3 3/9/2017 Canadian CT Head Injury/Trauma Rule Can clear a head injury without imaging Apply to patients with: GCS 13-15 and LOC Amnesia to the event Confusion Excludes: Age <16 Seizure after injury Blood thinner use Canadian Head CT Rule High Risk Criteria: Rules out need for neurosurgical intervention GCS <15 at 2 hours post-injury Suspected open or depressed skull fracture Any sign of basilar skull fracture? Hemotympanum, raccoon eyes, Battle’s Sign, CSF oto-/rhinorrhea ≥ 2 episodes of vomiting Age ≥ 65 Medium Risk Criteria: In addition to above, rules out “clinically important” brain injury (positive CT's that normally require admission) Retrograde amnesia to the event ≥ 30 minutes “Dangerous” mechanism? Pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from > 3 feet or > 5 stairs. 4 3/9/2017 Doc…I punched a door and now my hand hurts! Human bite: the "Fight Bite” Clenched-fist injury: 3rd – 5th metacarpophalangeal joints of the dominant hand Complications: cellulitis, septic arthritis, osteomyelitis Injury possible to the extensor tendon/bursa, the superficial/deep fascia, joint capsule Polymicrobial infection with normal human oral flora: S. aureus (20-40%) Eikenella corrodens (25%) Streptococcus species Anaerobic: Prevotella species, Fusobacterium nucleatum, Peptostreptococcus 5 3/9/2017 Treatment Neurovascular evaluation of the hand & plain radiographs to rule out fracture Copious irrigation and debridement DO NOT close the wound (exceptions cosmetic) Wound culture Antibiotics ISDA and Tintinalli Amoxicillin/clavulanic acid 875/125 mg PO BID Ampicillin-sulbactam 1.5-3 gm Q 6 hours or cefoxitin 2gm Q 8 hours or piperacillin-tazobactam 3.375 grams Q6 hours PCN allergy – clindamycin plus moxifloxacin or TMP-SMX and metronidazole Clindamycin 300 mg tid or 600 mg every 6–8 h plus Cipro 500–750 mg bid 400 mg every 12 h Doc….My blood pressure is 210/115! First thing…Recheck it! HTN defined as SBP>140 mm Hg and DBP > 90 mm Hg Primary (essential) vs. Secondary ED Classification: Asymptomatic elevated BP without hx HTN Uncontrolled HTN Hypertensive emergency 6 3/9/2017 Hypertensive Emergency Hypertensive emergency = HTN with evidence of ACUTE end organ dysfunction Heart: Chest pain, Acute MI, Pulmonary edema Brain: Hypertensive encephalopathy/CVA/Hemorrhage Cerebral autoregulation Kidney: Ischemia and Renal impairment Vascular: Aortic Dissection Other: Eclampsia, Retinal Hemorrhage, drug abuse (cocaine, amphetamine) Sx: SOB, CP, HA, MS change, vision changes Hypertensive Emergency Management Immediate treatment Reduce MAP 10-20% in 30-60 minutes Addition reduction 5-15% over next 23 hours Reduction beyond this risks end organ ischemia due to relative hypotension Exception: Aortic dissection acute goal = 100-120mm Hg Drugs of choice: IV Meds Nicardipine, Labetalol, Esmolol Disposition admission 7 3/9/2017 Asymptomatic Hypertension 2013 ACEP Clinical Policy on Asymptomatic Hypertension Should I screen for target-organ injury? Asymptomatic HTN PCP f/u, no acute tx, labs may be helpful in select patients Routine lab screening not required If patients have poor follow-up, screening may identify acute kidney injury Should I treat the blood pressure? Medical intervention not required If poor follow-up can treat in the ED and rx meds Patel KK, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016 Jul 1;176(7):981-8 “Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.” Asymptomatic Hypertension Management - Outpatient JNC 8 BP tx threshold of 150/90 mm Hg in the >60 age group and 140/90 mm Hg in <60 age group, DM and CKD JNC7: chemistry, EKG, chest xray, UA, prior to therapy initiation Medical treatment: Non-black: thiazide type diuretics, ACEIs, ARBs, CCBs Black: thiazide type diuretics, CCB Chronic kidney disease: ACE or ARB (do they have a PCP) AHA/ACA/CDC 2014 Science Advisory: Stage 1: lifestyle modifications and HCTZ Stage 2: lifestyle modifications plus thiazide in combo with ACEI, ARB, CCB 8 3/9/2017 Hypertension Conclusions… No evidence to suggest that patients with asymptomatic hypertension should be acutely treated Controversy as to whether or not to prescribe antihypertensive ED or Urgent care visit may be one of their few contacts with a health care professional Counsel Outpatient f/u within a month DC instructions: Return if severe headache, focal weakness or paresthesias, SOB Supracondylar Fracture Anterior humeral line Posterior Fat Pad 9 3/9/2017 Supracondylar Fracture Distal Humerus Fracture proximal to condyles Mostly in children due to strong collateral ligaments that prevent dislocation (Peak age 5-10 years) Mechanism FOOSH, elbow hyperextension X-ray Posterior fat pad sign, anterior displacement humerus Treatment: Gartland I: non-displaced, immobilized in posterior splint and 48 hour ortho f/u Gartland II: Some displaced, intact posterior cortex Gartland III: Completely displaced, no cortical contact Surgical: Closed Reduction with pin fixation Complications loss of carrying angle, nerve injury, compartment syndrome, Volkmann Ischemic contracture Lateral Elbow: Normal Anterior Humeral Line Middle 3rd of Capitellum 10 3/9/2017 Abnormal Joint Effusion Doc…My Throat Hurts! Rule out emergencies… Is the patient in respiratory distress? Drooling, trismus, Increased RR rate, hypoxia? Differential Diagnosis: Peri-tonsillar abscess unilateral, trismus, deviation of the uvula Epiglottitis sick appearing, leaning forward, drooling Ludwigs Angina recent dental procedures Malignancy smoking ,weight loss Angioedema swelling of tongue, lips, oral mucosa Thyroiditis neck swelling 11 3/9/2017 Bacterial Vs. Viral Pharyngitis Viral vesicular or petechial pattern on the soft palate and tonsils and is associated with rhinorrhea 16% have tonsillar exudate 55% have cervical adenopathy 64% lack cough Diagnostic testing not necessary except: influenza, mononucleosis, & acute retroviral syndrome Bacterial Group A β-hemolytic Streptococcus: adults (15%), children (30%) Incubation period of 2 to 5 days Sudden onset of sore throat, painful swallowing, chills, and fever Signs and symptoms: Erythema of the tonsils (62%) Exudate (32%) Enlarged, tender cervical lymph nodes (76%) Diagnostic Testing Centor and Modified Centor Criteria Original article in 1981: exudates, anterior cervical adenopathy, no cough, fever Modified in 1998: Age qualifier added Age 3-14 years (+1) Age 15-44 years (+0) Age >45 years (-1) Rapid Antigen Detection Testing (RADT) or Throat culture (gold standard) Guidelines: ISDA 2012 2+, perform RADT AHA/AAP 2009 2+, perform RADT CDC/AAFP/ACP 2, perform RADT, 3+ RADT or treat empirically If viral sx (coryza, cough, diarrhea, ulcerative stomatitis) and score 0-1 no testing/no treating 12 3/9/2017 Treatment Decrease: symptom duration, infectivity Complications: Suppurative peritonsillar abscess, OM, sinusitis Non-suppurative complications acute rheumatic fever, PSGM Antibiotics First Line (CDC recommendations): Penicillin VK: Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily x 10 days Amoxicillin: 50 mg/kg once daily (max = 1000 mg); alternate: 25 mg/kg (max = 500 mg) twice daily x 10 days Penicillin G benzathine: <27 kg: 600,000 U; ≥27 kg: 1,200,000 U IM x 1 PCN Allergy (not severe): Cephalexin PO, Cefadroxil PO Severe PCN Allergy: Clindamycin PO, Azithromycin PO, Clarithromycin PO Pain Relief NSAIDS, Acetaminophen, throat lozenges https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html Steroids? Cochrane Review from 2012 of 8 trials involving 743 patients showed: “Oral or intramuscular corticosteroids, in addition to antibiotics, increase the likelihood of both resolution and improvement of pain in participants with sore throat. Further trials assessing corticosteroids in the absence of antibiotics and in children are warranted.” ISDA 2012 Guidelines recommends against use for symptoms Dosing: Dexamethasone 0.6mg/kg, maximum 10mg Prednisone 60mg PO for 1-2 days 13 3/9/2017 Doc…my head hurts! Typical of previous headaches? Worst headache of your life? How did it onset? (sudden versus gradual) Fevers and chills? Meningeal signs? Characterize the headache? Associated symptoms? Surrounding events? (trauma, pregnancy, recent infection) Hypercoagulable or on anticoagulants? Age? Differential Diagnosis Differential Diagnosis Migraine Meningitis Cluster headache Hypertension, hypertensive encephalopathy Temporal (giant cell) arteritis Tumor Caffeine, alcohol or drug withdrawal Carbon monoxide poisoning Venous sinus thrombosis Pseudotumor cerebri Post-Lumbar Puncture • • • • • • • • • Tension Headache Sinusitis Cervical arthritis Acute angle closure glaucoma Dental Abscess Otitis Media TMJ Trigeminal neuralgia Depression • Cerebral ischemia • Post LP Headache • Subarachnoid hemorrhage 14 3/9/2017 Subarachnoid Hemorrhage Acute bleed into the subarachnoid space Non-traumatic Ruptured berry aneurysm 85% Symptoms Sudden onset severe headache Activities that increase ICP intercourse, coughing, weight lifting, defecation Nausea and vomiting Seizures, neck stiffness, photophobia “Sentinel bleed” Subarachnoid Hemorrhage Diagnosis CT without contrast the longer since onset headache, less sensitive the CT CT within 6 hours… Lumbar puncture If clinical suspicion and negative CT Persistent RBC in tubes 1-4 (usually in thousands) indicates SAH Zero RBCs in the 4th tube = traumatic tap CTA/MRI – has not replaced current diagnostic approach Treatment Neurosurgery evaluation BP control Antiemetics 15 3/9/2017 Meningitis 1.38 out of 100,000 people with fatality rate 14.3% Inflammation of membranes covering spinal cord or brain due to bacterial, viral or fungal infection Causes Recent otitis, sinusitis, pneumonia or immunocompromised, trauma, neurosurgery, indwelling medical devices Bacterial S. pneumoniae (MC), N. meningitides, L. monocytogenes Viral Enteroviruses (MC, summer), Herpes simplex Fungal Cryptococcus, Toxoplasma Non-infectious Lupus, Vasculitis, Sarcoidosis etc. Meningitis Diagnosis Symptoms & Exam Fever, headache, neck stiffness, altered MS, photophobia, vomiting, seizures, petechial/purpuric rash, Kernig/Brudzinski CT head without contrast Before LP IDSA recommends for patients who meet any criteria: Immunocompromised state History of CNS disease (mass lesion, stroke, or focal infection) New-onset seizure within 1 week of presentation Papilledema Abnormal level of consciousness Focal neurologic deficit LP Disposition Admission and monitoring Contraindications coagulopathy 16 3/9/2017 Chemoprophylaxis Exposure increases risk by 500-800x normal population Close contacts: Housemates Secretion exposure (kissing, shared utensils or toothbrush, person who intubated without a facemask) Can decrease transmission by 89% in N. menengitidis Initiate within 24 hours, but no later than 2 weeks Rifampin 10 mg/kg (max 600mg) Q 12 hours x 4 doses Cipro 500mg PO once Ceftriaxone 250mg IM once Scaphoid Fracture image Mid-distal scaphoid fracture without displacement 17 3/9/2017 Scaphoid Fracture Most common carpal fracture Must suspect with “snuff box” tenderness Imaging – wrist and scaphoid x-rays Sometimes negative with acute injury “occult” Can CT or MRI Treatment of Identified fractures and suspected.. Thumb spica splint and ortho follow-up Complications Avascular necrosis (AVN) Distal scaphoid supplied by radial artery AVN of proximal fragment Picture Thumb Spica • Fracture of the proximal portion of the scaphoid bone with displacement of the fracture fragments 18 3/9/2017 Doc, I’m itchy and my tongue is swollen… What is “just” an Allergic Reaction vs. Anaphylaxis? Vital signs? Causes: medications, foods, insect stings, environmental allergens, latex, exercise, and other unknown factors Differential Diagnosis: MI, arrhythmia, PE, Asthma, COPD Vasovagal response, anxiety, septic shock Scromboid poisoning, monosodium glutamate syndrome Ace inhibitor or hereditary induced angioedema Definition of Anaphylaxis from NIAID/FAAN 1. “Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both” AND one of the following: 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient 3. Respiratory compromise or reduced BP Involvement of skin-mucosal tissue, respiratory compromise, hypotension, GI symptoms Reduced BP after exposure to known allergen for that patient 30% decrease in systolic BP in children or adults Campbell, Ronna L. et al.Evaluation of National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients. Journal of Allergy and Clinical Immunology , Volume 129 , Issue 3 , 748 - 752 19 3/9/2017 Treatment of Anaphylaxis Prehospital Evaluate VS and ABCs/monitor Supplemental O2 Large bore IV access IV fluids, supine position with elevation of legs Remove hymoneptera stinger B-agonists – 2.5mg via nebulizer Steroids Medications to Initiate Epinephrine 0.3 to 0.5mL (0.01mg/kg in children max 0.3 dosage) of epinephrine in a 1:1000 dilution IM, lateral aspect of the thigh Every 5-10 minutes as necessary Antihistamines: Diphenhydramine 25-50mg H1 and H2: Ranitidine 50mg (adult) 1mg/kg (children) Corticosteroids Prednisone 1mg/kg PO Methylprednisolone 125mg IV 20 3/9/2017 Disposition Admission Limited access to phone or emergency services Prior history of anaphylaxis Underlying asthma, renal disease, CHF, B-blocker usage Discharge after Observation AAAI and AI Joint Task force – observation time based on individual patients NIAID &FARE – observation time of 4-6 hours Biphasic reaction in 5-20% Doc…my neck hurts after an MVA Low risk trauma patients: Alert, stable, adult trauma patient w/o neurologic deficits National Emergency X-Radiography Utilization Study (NEXUS) - 1998 Plain cervical spine injury unnecessary if patients lack 5 criteria 99.6% sensitive, 12.9% specific, negative predictive value 99.9% Limitations: Age >60 Canadian Cervical Spine Rule for Radiography (CCR) 3 assessments asked in sequential order If any answer is positive imaging 100% sensitive, 42.5% specific Limitations: Complexity compared to NEXUS 21 3/9/2017 NEXUS Criteria 1. Absence of midline cervical tenderness 2. Normal level of alertness 3. No evidence of intoxication 4. Absence of focal neurologic deficit 5. Absence of painful distracting injury If any of the above criteria are present, the C-Spine cannot be cleared clinically by these criteria, consider imaging Canadian C-Spine Rule Assessments 1. There are no high risk factors that mandate radiography 2. There are low risk factors that allow for a safe assessment of range of motion 3. The patient is able to actively rotate the neck Definitions Age 65 or older A dangerous mechanism of injury Paresthesias in extremities Simple rear-end MVA Patient able to sit up Ambulatory Delayed onset of pain Absence of midline TTP Can rotate neck 45 degrees bilaterally 22 3/9/2017 Cervical Spine Imaging Plain radiography 3 views: Lateral, anterior-posterior, odontoid Clinically acceptable study: all 7 vertebrae and superior border first thoracic Benefits: Cost- effective, bedside, small amount of radiation Disadvantages: C1 & C2, Visualizing spine due to body habitus Cervical Spine CT More sensitive and specific than plain X-rays Consider for moderate & high risk patients Thoracic and Lumbar Spine Imaging Doc…it hurts when I take a deep breath! History Differential: Duration? Pneumonia Location? Bronchitis Associated symptoms? Pulmonary embolism Constant or intermittent? Pneumothorax Aggravating or alleviating factors? Pericarditis Rib fracture Esophageal spasm/rupture Atypical CP/MI 23 3/9/2017 Pulmonary Embolism 650,000 - 900,000 PEs each year in the US 200,000 deaths Pulmonary Embolism: Thrombus forms in the venous system (MC LE DVT) and embolizes to the lung Causes acute obstruction of the pulmonary arterial system and pulmonary ischemia/infarction Large emboli obstruction of right ventricular outflow and circulatory collapse Risk Factors: THROMBOSIS Trauma, travel Hypercoagulable, hormone replacement Relatives, recreational drugs Old (age >60) Malignancy Birth control Obesity, obstetrics Surgery, smoking Immobilization Sickness Pulmonary Embolism Symptoms Hemoptysis Shortness of breath Pleuritic chest pain Exam: SOB, tachy, clear lungs, hypoxia, unilateral leg swelling, +/unstable VS Diagnosis EKG ST, S1Q3T3, new RBBB CXR Hampton Hump, Westermark sign D-dimer CTA/VQ Scan 24 3/9/2017 PERC Rule for Pulmonary Embolism Rules out PE if no criteria are present and pre-test probability is ≤15% If all are negative, no need for further workup, <2% chance of PE ACEP 2011 Clinical Policy: “Level B recommendations. In patients with a low pretest probability for suspected pulmonary embolism, consider using the PERC to exclude the diagnosis based on historical and physical examination data alone.” D-dimer: D-dimer if low-risk, but not PERC negative D-dimer negative and pre-test probability is <15% then no further testing D-dimer positive then CT-angiography or V/Q Criteria for PERC Rule Clinical low probability (<15% probability of PE based on gestalt assessment) Age < 50 HR < 100 O2 sat on room air > 94% at near sea level No prior hx DVT or PE Recent trauma or surgery No Hemoptysis No estrogen use No unilateral leg swelling (asymmetrical calves on visual inspection) 25 3/9/2017 Wells Clinical Prediction Rule for PE Risk stratifies patients for PE & provides an estimated pre-test probability Based on risk, physician chooses next diagnostic study D-dimer CTA 3 tiers: low, moderate, high 2 tiers: unlikely, likely (supported by ACEP’s 2011 clinical policy on PE) Main criticism: has a “subjective” criterion in it “PE #1 diagnosis or equally likely” Wells Clinical Prediction Rule for PE Point Score Risk Score Interpretation Suspected DVT 3 Alt dx less likely than PE 3 points Low risk (<2 points): 1.3% Heart rate > 100 bpm 1.5 Mod risk (2-6 points): 16.2% Prior venous thrombus 1.5 High risk (>6 points): 37.5% Immobilization w/in 4 wks 1.5 Active malignancy 1 PE unlikely (0-4 points): 12.1% Hemoptysis 1 PE likely (>4 points): 37.1% 3- Tier model 2-Tier model 26 3/9/2017 D-dimer Clots contain fibrin, degraded by plasmin yields D-dimer Half-life of approximately 8 hours, can be elevated for at least 3 days Factors known to give false positive D-dimer level Sensitivity: 94-98%, Specificity: 50-60% Age > 70 Pregnancy Malignancy Recent surgical procedure Liver disease RA Trauma Potential false negatives: Lipemia, symptoms > 5 days, warfarin, small pulmonary infarction, isolated calf vein thrombosis Closing Points… 27 3/9/2017 References Pediatric Head Trauma Kupperman N, Holmes J, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. Volume 374, Issue 9696, 3–9 October 2009, Pages 1160–1170 Goldman R. Decision rules can identify children at very low risk of clinically important traumatic brain injury. Journal of Pediatrics, The, 2010-03-01, Volume 156, Issue 3, Pages 509-510, Copyright © 2010 Mosby, Inc. Schonfeld D1, Bressan S, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15. Easter JS, Bakes K et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014 Aug;64(2):145-52, 152.e1-5. doi: 10.1016/j.annemergmed.2014.01.030. Epub 2014 Mar 11. PECARN Pediatric Head Injury/Trauma. Injury/Trauma Algorithmhttps://www.mdcalc.com/pecarn-pediatric-head-injury-traumaAlgorithmhttps://www.mdcalc.com/pecarn-pediatric-head-injury-traumaalgorithm Canadian Head CT References Stiell IG, Wells GA, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6. Stiell IG, Clement CM, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1511-8. Easter JS, Hakoos JS, et al. Traumatic intracranial injury in intoxicated patients with minor head trauma. Acad Emerg Med. 2013 Aug;20(8):753-60. doi: 10.1111/acem.12184. 28 3/9/2017 References Fight Bite Goldstein E, Abrahamian F. Human Bites. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition. 320, 3510-3515.e1. Eighth Edition. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. Stevens D, Bisno A, Chambers H, et. al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. CID 2014:59 (15 July). Germann CA. Germann C.A. Germann, Carl A.Nontraumatic Disorders of the Hand. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGrawHill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.as px?bookid=1658§ionid=109447692. Accessed February 13, 2017. Hypertension References Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure – The JNC 7 Report. JAMA. 2003; 289 (19):2560-2572. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eigth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. Goldberg E. An Evidence-Based Approach to Managing Asymptomatic Elevated Blood Pressure in the Emergency Department. Emergency Medicine Practice. February 2015. Volume 17, Number 2. Patel KK, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016 Jul 1;176(7):981-8. Wolf et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. Ann Emergency Medicine;62:59-68 29 3/9/2017 Supracondylar Fracture References Blok B, Cheung D, Platts-Mills T. Elbow Injuries: Supracondylar Fracture. First Aid for the Emergency Medicine Boards. Copyright 2016 by McGraw-Hill Education. P215-16 The Treatment of Pediatric Supracondylar Humerus Fractures: Evidence Based Guideline and Evidence Report. American Academy of Orthopedic Surgeons. Published in 2011. http://www.aaos.org/research/guidelines/SupracondylarFracture/SupC onFullGuideline.pdf Chow YC. Chow Y.C. Chow, Yvonne C.Elbow and Forearm Injuries. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.as px?bookid=1658§ionid=109446609. Accessed March 08, 2017. References for PERC/PE Kline JA, Mitchell AM et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004 Aug;2(8):1247-55. Kline JA, Courtney DM et al. Prospective multicenter evaluation of the pulmonary embolism ruleout criteria. J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.1538-7836.2008.02944.x. Epub 2008 Mar 3. Dachs R, Endres J, Garber M. Pulmonary Embolism Rule-Out Criteria: A Clinical Decision Rule That Works. Am Fam Physician. 2013 Jul 15;88(2):98-100. Fesmire, Francis MD. ACEP News Contributing Writer. June 1, 2011. ACEP Clinical Policy Review: Suspected Pulmonary Embolism. http://www.acepnow.com/article/acep-clinical-policy-reviewsuspected-pulmonary-embolism/2/?singlepage=1 Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED with suspected PE. ACEP Clinical Policy. Ann Emerg Med 2011;57:628-652 Kline JA. Kline J.A. Kline, Jeffrey A.Venous Thromboembolism. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658§ioni d=109429015. Accessed March 08, 2017. 30 3/9/2017 Pharyngitis References Hildreth A, Takhar S. Evidence Based Evlauation and Mangement of Patients with Pharyngitis in the Emergency Department. Emergency Medicine Practice. September 2015. Volume 17, Number 9. Hayward G, Thompson MJ, Perera R, Et al. Corticosteroids as a standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268. Schams SC, Goldman RD. Steroids as adjuvant treatment of sore throat in acute bacterial pharyngitis. Can Fam Physician. 2012;58(1):52-54 Hartman ND. Hartman N.D. Hartman, Nicholas D.Neck and Upper Airway. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658§ionid=1093 87281. Accessed February 13, 2017. Evaluation of Pharyngitis. Urgent Care RAP. April 2015: Volume 1, Issue 2. Accessed 3/7/17. Group A Streptococcal Disease, For Clinicians. CDC. https://www.cdc.gov/groupastrep/diseaseshcp/index.html. Accessed 3/7/17. 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. CID. https://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/2012%20Strep%20Guideline.pdf Headache References Blok B, Cheung D, Platts-Mills T. Subarachnoid Hemorrhage. First Aid for the Emergency Medicine Boards. 3 rd Edition. p846-848. Blok B, Cheung D, Platts-Mills T. CNS Infections: Meningitis. First Aid for the Emergency Medicine Boards. 3 rd Edition. p840-843. Based Approach to Diagnosis and Management of Subarachnoid Hemorrhage in the ED. Emergency Medicine Practice: October 2014, Vol. 16, Number 10 Blok KM, Rinkel GJ et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology. 2015 May 12;84(19):1927-32. doi: 10.1212/WNL.0000000000001562. Epub 2015 Apr 10. Carpenter C, Hussain A et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Academic Emergency Medicine. Volume 23, Issue 9, pages 963–1003, September 2016 Perry J et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011;343:d4277 Nicole M. Dubosh, M. Fernanda Bellolio, Alejandro A. Rabinstein and Jonathan A. Edlow. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage. Stroke. 2016;STROKEAHA.115.011386, originally published January 21, 2016 Bamberger D. Diagnosis, Initial Management, and Prevention of Meningitis. Am Fam Physician. 2010 Dec 15;82(12):1491-1498. Erin N. Quattromani, MD, and Amer Z. Aldeen, MD. Focus On: Emergent Evaluation and Management of Bacterial Meningitis. ACEP News May 2008. https://www.acep.org/clinical---practice-management/focus-on--emergent-evaluation-and-management-of-bacterial-meningitis. Tiffee A, Zosky M. Meningitis: Clinical Pearls an Pitfalls. Feb 4, 2015. http://www.emdocs.net/meningitis-clinical-pearls-pitfalls/ Hackman JL, Nelson AM, Ma O. Hackman J.L., Nelson A.M., Ma O Hackman, Jeffrey L., et al.Spontaneous Subarachnoid and Intracerebral Hemorrhage. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658§ionid=109436521. Accessed March 08, 2017. 31 3/9/2017 Scaphoid References Boyd A, Benjamin H, Apslund C, Splints and Casts: Indications and Methods. Am Fam Physician. 2009 Sep 1;80(5):491-499. Jones B, MD, Rozental T. Ortho Info: Scaphoid Fracture of the Wrist. American Academy of Orthopedics. Last reviewed March of 2016. http://orthoinfo.aaos.org/topic.cfm?topic=A00012 Phillips G, Reibach A, Slomiany P. Diagnosis and Management of Scaphoid Fractures. Am Family Physician. 2004 Sep 1;70(5):879-884. Allergic Reaction References Singer E, Zodda D. Allergy and Anaphylaxis: Principles of Acute Emergency Management. Emergency Medicine Practice. August 2015. Volume 17. Number 8. Campbell, Ronna L. et al.Evaluation of National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients. Journal of Allergy and Clinical Immunology , Volume 129 , Issue 3 , 748 - 752 Sampson HA, Munoz-Furlong A, Bock SA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clinical Immunology. 2005;115(3):584-591 Liebman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clinical Immunology. 2010;126 (3)477-480. Liebman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunology. 2005;95 (3):217-226 32 3/9/2017 Neck Pain References Go S. Go S Go, Steven.Spine Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658§ioni d=109387434. Accessed March 02, 2017. Pullen, Lara. Imaging Not a Necessity for Spine Evaluation in Trauma Patients. http://www.acepnow.com/article/imaging-necessity-spine-evaluation-trauma-patients/ Brunk, Doug. ACEP News June 2008. Studies Challenge Spine Injury Criteria for Children. https://www.acep.org/Clinical---Practice-Management/Studies-Challenge-Spine-Injury-Criteriafor-Children/ Updated Guidelines For Management Of Acute Cervical Spine And Spinal Cord Injury In Pediatric Patients. September 2014. EB Medicine. Current Guidelines For Assessment Of Cervical Spine And Vertebral Artery Injuries In Adults Following Blunt Trauma. July 2014. EB Medicine. Cervical Spine Injury: An Evidence-Based Evaluation Of The Patient With Blunt Cervical Trauma. April 2009. EB Medicine. 33
