Adult Emergency Medicine Guide

Procedures

• Lumbar Puncture
• Arthrocentesis

HEENT

• Adult Dental Chart

Musculoskeletal

• Code Cord Compression

Sepsis

• Sepsis Cheat Sheet

Tubes 1 & 4: Cell Count and Differential
Tube 2: Glucose and Protein
Tube 3: Gram Stain and Culture

Epidural abscess: fever, immunocompromised, IVDA, history of bacteremia
Epidural tumer: history of cancer or weight loss
Epidural hematoma: anticoagulation, recent spinal anesthesia
General: new frequent falls or ataxia, greater than 3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms

Motor: weakness in legs (or arms)
Sensory: sensory level or saddle anesthesia
Reflexes: diminished or abnormal reflexes, including positive (upward) Babinski reflex
Sphincter tone: lax rectal tone (rectal should be performed on intermediate or high risk patients), post-void residual greater than 100mL

Low Risk

No red flags and normal neurologic exam (or isolated single root finding consistent with sciatica)

1. No routine lab testing, imaging, or consults.
2. Treat symptoms:
   • Use non-steroidal anti-inflammatory drug; opioids for severe pain.
   • Consider a muscle relaxant.
3. Bedrest for 2-3 days for severe pain.
4. Rapid return to normal activities.
5. Explain problem and treatment to patient.
6. Follow-up with PCP.
7. Provide written instructions about symptoms requiring return visit (including red flags)

Intermediate Risk

Presence of one or more red flags and normal neurologic exam (or isolated single root finding consistent with sciatica)

Options based on clinical judgement:

1. Further risk stratification: CRP or ESR for possible cancer or spinal abscess.
2. Consult neurology or spine surgery.
3. Consider imaging:
   • Emergent MRI in the ED?
   • Urgent MRI as outpatient in 48 hours?
4. Disposition
   • Discharge with urgent MRI and PCP follow-up?
   • Admission or observation in hospital?

CAUTION!

1. Communicate clearly with patient:
   • About plans, concerns, and need for PCP follow-up.
   • Symptoms requiring return to the ED.
2. Coordinate with PCP or admitting provider.
3. Treat symptoms in analgesics.

High Risk

Any new abnormality on neurologic exam (except for isolated single root finding consistent with sciatica)

Emergency MRI
Initiate rapid imaging of the correct portion of the spine.

Positive MRI

1. Start ED-based treatments and/or consultations based on the diagnosis.
2. Consult spine surgeon for definitive care.

FOR HIGH RISK (AND APPROPRIATE INTERMEDIATE-RISK) CASES:

• Determine imaging level based on exam findings and possible diagnosis:
  • If spinal epidural abscess or metastatic cancer is a concern, the entire spine should be imaged because skip areas with abscess or multiple metastasis are common.Discuss case with radiologist, including need for emergent MRI.
• Use Primordial Communicator or call x7-7076.
• After-hours, call teleradiologist at (877)595-1271.
• Order MRI and notify imaging about STAT order at x7-7007.
• Ensure pain and anxiety are well controlled, using weight-based analgesic doses.
• Consider empiric antibiotics (after cultures) and IV dexamethasone.
• Consider notifying neurosurgeon at (410)391-6904.

All three of the following must be met within 6 hours of each other.

1. Documentation of a suspected source of clinical infection.
2. Two or more manifestations of systemic infection according to
   the SIRS criteria, which are:

• Temperature > 38.3 or  < 36.0 C
• Heart rate  > 90
• WBC > 12K or < 4K or > 10% bands
• Respiratory rate> 20

3. Organ dysfunction, evidenced by any one of the following:

• SBP < 90, or MAP < 65, or a SBP decrease of more than 40 pts
• Cr > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours
• Bilirubin > 2 mg/dL (34.2 mmol/L)
• Platelet count < 100,000
• INR > 1.5 or a PTT > 60 sec
• Lactate > 2 mmol/L (18.0 mg/dL)

The criteria for Septic Shock are:

1. Severe Sepsis

AND

2. Tissue hypoperfusion persists in the hour after
   crystalloid fluid  administration, evidenced by either
   ▪ Continued hypotension

   OR

   ▪ Lactate level is >= 4 mmol/L

• Obtain lactate
• Obtain blood cultures before initiation of antibiotics
• Broad spectrum antibiotics administered (see bottom of page for suggested antibiotic coverage)
• Administer 30ml/kg IVF bolus

• Persistent hypotension or lactate >4, assess volume status and tissue perfusion (see box below for documentation)
• Repeat lactate level to be drawn after IVF bolus of 30 ml/kg
• Initiate vasopressors to maintain MAP >65 after 30 ml/kg IVF bolus

▪ Vital signs review ,
▪ Cardiopulmonary exam,
▪ Capillary refill evaluation,
▪ Peripheral pulse evaluation,
▪ Skin examination

▪ Bedside Cardiovascular Ultrasound (echo, trans-thoracic echo, TTE, TEE, IVC ultrasound, 2D echo, Doppler echo,  Echocardiogram with Doppler, Doppler US of the heart)

▪ Passive Leg Raise Exam by physician/APN/PA or Fluid Challenge given

▪ Central venous pressure measurement (CVP or RAP/right atrial pressure)

▪ Central venous oxygen measurement (SVO2,  ScvO2 or oxygen saturation via central catheter)

[table]
Infection,Primary Therapy, Alternate for Beta-Lactam Allergy
Pneumonia (CAP),Ceftriaxone 1g IV Q24 + Azithromycin 500 IV Q24, Levofloxacin 750 IV Q24
Pneumonia (HCAP), Cefepime 1g IV Q8 + Azithromycin 500 IV Q24+ Vancomycin IVPB** 2nd antibiotic given**, Aztreonam 2g IV Q8+ Levofloxacin 750 IV Q24+ Vancomycin IVPB**2nd antibiotic given**
Urinary,Cefepime 1g IV Q8H, Aztreonam 2g IV Q8
CNS,Ceftriaxone 2g IV Q12+ Vancomycin IV+
Ampicillin 2g IV Q4 (age>50), Meropenem 2g IV Q8+
TMP/SMX 5mg/kg IV Q6+
Vancomycin IVPB **2nd antibiotic given**

Intra-abdominal, Piperacillin/Tazobactam 4.5g IVq8h, Levofloxacin 750mg IV q24 + Metronidazole 500mg IV q8 + (Vancomycin IVPB) **2nd given**
[/table]