emergency and urgent care review

emergency and urgent care review
“…Bites, Stings and other emergency things…” Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

introduction “Family physicians are an essential part of the emergency medicine safety net, and without this contribution, large areas of the country would be without adequate emergency medical care.” Critical Challenges for Family Medicine: Delivering Emergency Medical Care - “Equipping Family Physicians for the 21st Century” (Position Paper) – The Future of Family Medicine Project “40% of family physicians provide emergency medical services, and many family physicians have made lifelong careers in emergency medicine.” Bullock, K. Turf Wars: Emergency Medicine and Family Physicians; AFP 54:4 pgs (Sept. 15, 1996) “Most primary care physicians report at least one emergency presenting to their office per year. ” Toback, SL. Medical Emergency Preparedness in Office Practice. Am Fam Physician. 2007 Jun 1;75(11): Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Learning objectives Recognize and manage acute allergic reactions
Recognize and determine which toxicology emergencies require specific antidotes Evaluate and manage environmental injuries Appropriately manage a variety of animal bites Assess and manage pit viper bites Recognize spider and other insect bites and determine treatment Review current ACLS guidelines Except for the highlighted item – this list is a “clone” of the original presentation by Dr. Robert Dachs Many of you know more about this topic than I do – so feel free to chime in with a patient encounter or relevant message to help reinforce the message. Again...this is only a review and many minute details may not be presented here. And one last thing, stand up comedy is not one of my strong points but I will do the best I can to keep the discussion lively and keep us all engaged Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Acute Allergic reactions
Anaphylaxis Anaphylactoid reactions Angioedema Bee stings Scombroid Poisoning Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Acute Allergic reactions
Gell and Coomb’s Classification Type of reaction Mechanism Representative Examples Type 1 – Anaphylactic IgE- & IgG4 –mediated immediate hypersensitivity Anaphylaxis Urticaria Angioedema Type 2 – Cytotoxic IgG- or IgM Abs against cell antigens with complement activation Blood transfusion reaction AIHA ITP Type 3 – Immune Complex Ag-Ab (immune) complex deposition & complement activation Serum sickness Post-strep GN Vasculitis Type 4 – Cell-mediated Activated T-cells against cell surface-bound antigens Contact dermatitis – Poison Ivy PPD Photosensitivity dermatitis Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis Systemic reaction Develops rapidly over seconds to minutes
Life-threatening Early recognition and treatment may avert death by airway obstruction or vascular collapse U. S. incidence rate: 49.8 cases per 100,000 person-years Lifetime prevalence ≈ 2 percent, with a mortality rate of 1 percent The risk of anaphylaxis is doubled and tripled in patients with mild and severe asthma respectively! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis - Classification
Immunologic Allergic IgE-mediated Immune-complex-complement-mediated Cytotoxic-mediated Non-immunologic Nonallergic anaphylaxis (anaphylactoid) Idiopathic Preformed immunoglobulins Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis - triggers
Immunologic Non-immunologic Foods - egg, fish, food additives, milk, peanuts, sesame, shellfish, tree nuts Hymenoptera stings Medications – Abx (beta-lactams) Latex rubber Blood products Radiocontrast media Medications – vancomycin, NSAIDs, ACEIs Hemodialysis Physical factors – cold, heat, exercise Idiopathic Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis - manifestations
Dermatologic/mucosal Respiratory Cardiovascular Gastrointestinal Neurologic General Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis - manifestations
Mild dermatologic Moderate Dermatologic + cardiorespiratory compromise Severe Neurologic compromise Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis – differential diagnosis
Vasovagal syncope Myocardial ischemia Pulmonary embolism Foreign body aspiration Acute poisoning Hypoglycemia Seizure Red man syndrome Shock states Mastocytosis Scombroidosis Flushing syndromes Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Clinical criteria for anaphylaxis – 1
Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g., generalized hives; pruritus or flushing; swollen lips, tongue, or uvula), and at least one of the following: Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence) Summarise – clinical criteria: consistent clinical manifestations – derm± rs, cvs; +ve h/o exposure + 2 ftrs of clinical manifestation; hemodynamic drop after exposure Source: Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Ann Emerg Med. 2006;47(4):374. Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Two or more of the following that occur rapidly (minutes to several hours) after exposure to a likely allergen for that patient: Involvement of the skin, mucosal tissue, or both (e.g., generalized hives; pruritus or flushing; swollen lips, tongue, or uvula) Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) Reduced blood pressure or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence) Persistent gastrointestinal symptoms (e.g., abdominal cramps, vomiting) Source: Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Ann Emerg Med. 2006;47(4):374. Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Reduced blood pressure that occurs rapidly (minutes to several hours) after exposure to a known allergen for that patient Infants and children: low systolic blood pressure (age-specific)* or a more than 30 percent decrease in systolic blood pressure Adults: systolic blood pressure of less than 90 mm Hg or a more than 30 percent decrease from that person's baseline Source: Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Ann Emerg Med. 2006;47(4):374. Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis – Lab testing
Anaphylaxis is a clinical diagnosis! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylaxis-management
Continuous noninvasive hemodynamic monitoring pulse oximetry monitoring urine output monitoring epinephrine! epinephrine!! epinephrine!!! 0.3 to 0.5 mg IM (mid-outer thigh)may repeat every 5 to 15 minutes PRN. (NO ABSOLUTE CONTRAINDICATIONS) SECURE THE AIRWAY PLACE PATIENT IN RECUMBENT POSITION GIVE 100% 8 – 10L/MIN ISOTONIC FLUID BOLUS FOR HYPOTENSION Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Adjuncts to care Albuterol H1 antihistamine H2 antihistamine Glucocorticoid Biphasic/rebound reaction may occur up to 72hrs after 1o episode in 1 – 20% of patients Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

In refractory cases Start epinephrine infusion 2 to 10 micrograms per Add other vasopressors as needed Glucagon 1 to 5 mg IV over five minutes, followed by infusion of 5 to 15 micrograms per minute Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Anaphylactoid reaction
Non-IgE-mediated Classically caused by radiocontrast media Management is the same! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Urticaria and angioedema
Localized reactions to allergens IgE and non-IgE mediated: Medications – ACEIs, NSAIDs Other non-immunologic mechanisms Infections Autoimmune disease Insect bites Rx: eliminate triggers supportive H1 & H2 receptor blockers If concomitant anaphylaxis – we know what to do! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Bee stings Allergic reactions — Anaphylaxis!
Hymenoptera species bees, wasps, yellow jackets, hornets, and imported fire ants Uncomplicated local reaction cold compresses Large local reaction short-course of systemic steroids Allergic reactions — Anaphylaxis! Prevention: EpiAutoInjector/Allergy referral & testing/Consider LT Venom Immunotherapy (VIT) Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Scombroidosis (Scombroid poisoning)
Ingestant-related reaction Spoiled fish (tuna/mackerels/skip- jack/bonito) – presence of sulfites or histidines Kept above 4oC for upto 3hrs Sweese cheese Signs and symptoms of scombroid toxicity usually begin within an hour of eating contaminated fish Rapid response to antihistamines! flushing of the face and neck urticarial rash - face and upper torso Diarrhea Headache Perioral burning or itching Dizziness palpitations, tachycardia Rarely, severe cardiorespiratory compromise may occur, especially in patients with underlying cardiorespiratory heart disease Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Scombroidosis – differential diagnosis
Allergic reactions to seafood can mimic scombroid poisoning Myocardial ischemia or infarction Staphylococcal enterotoxin-induced food poisoning Other types of marine foodborne poisoning ciguatera poisoning shellfish poisoning pufferfish poisoning Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Scombroidosis - management
Primarily, antihistamines – PO versus IV Notify local health department officials Education on rapid chilling of fish below 4°C (40°F), immediately after being caught! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Environmental injuries
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018 Environmental injuries

Heat-induced injury Heat-related illness affects a diverse group of individuals At risk populations include older persons, children, and persons who perform strenuous outdoor activities. Persons with cardiopulmonary disease, chronic mental disorders, and individuals taking medications that interfere with salt and water balance are also at increased risk Mortality increases as the heat index increases ( > 95°F (35°C) Severity correlates with elevation of temperature and duration of the heat Early recognition and rapid cooling are crucial, because heat stroke is a medical emergency! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

*Core temp: < 104oF (40oC)
Heat-induced injury Heat Exhaustion *Core temp: < 104oF (40oC) Heat Syncope Presents with HA, N/V, dizziness, weakness, irritability ± cramps Diaphoresis, Postural hypotension Core temp – normal-to-increased Rx Cool environment Rest Fan evaporation Isotonic fluid replacement Variant of postural hypotension Commonly seen with exercise in a hot environment Peripheral vasodilatation Venous pooling Transient LOC Rapid recovery once supine! Rx: rest, cool envt. & fluid repletion Water or sodium depletion Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

*Core temp: > 104oF (40oC)
Heat stroke *Core temp: > 104oF (40oC) Cardinal features Hyperthermia Altered mental status CNS involvement tends to be early Cerebellar symptoms/signs: ataxia. Seizures Differential Diagnosis Malignant hyperthermia NMS Anticholinergic toxicity Sympathomimetic toxicity Severe hyperthyroidism Sepsis Meningitis/Encephalitis Hypothalamic dysfunction Brain abscess Cerebral malaria Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Heat stroke Diagnostic testing Treatment Labs Imaging Consider LP
Immediate cooling ice-water cooling versus tepid spraying Ice water sheets Ice water submersion Cold fan Ice packs to major points of heat transfer Antipyretics/Dantrolene sodium Continuous core temp monitoring Goal to drop temp to 102.2oF (<39oC) within 30mins. Physiologic cooling thereafter. Monitor and treat complications – hypotension, rhabdomyolysis/AKI, ARDS Labs CBCD, CMP, PT/PTT, FDPs, Serum CPK ABGs UA EKG Imaging Head CT Consider LP Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Cold-induced injury Most commonly described among homeless populations
Major determinants of Injury Absolute temperature Duration of exposure Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Cold-induced injury-Predisposing factors
Substance abuse Peripheral vascular disease Poor nutrition Peripheral neuropathy Dehydration Hypothyroidism Diabetes Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Cold-induced injury 4 Major forms Hypothermia*** Chilblains
Immersion Injury (Trench Foot) Frostnip (Superficial frostbite) Deep Frostbite Hypothermia*** ***cold-related emergency Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Frostsnip Superficial Frostbite Involves skin and subcutaneous tissues
Level of skin involvement First-degree Second-degree Rx of Choice Rapid rewarming Immerse body in part in water for 15 – 30 minutes Heals within 3 – 4 weeks Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Deep Frostbite Involves deeper skin layers
Exposure at < 44oF for 7 – 10 hours Third-degree (Skin, Subcut + muscle) Fourth-degree (+ deep tendons, bones) Clinically, tissues appear frozen, hard with capillary filling on rewarming Hemorrhagic blisters Eschars Autoamputation Rx Rapid rewarming Analgesics Elevate extremity Prevent weight-bearing Separate affected digits wit hcotton wool Update tetanus immunization Early surgical intervention is not indicated Role of Abx is unclear Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Toxicology emergencies
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018 Toxicology emergencies

Overdoses – principles of management
Overdoses are common in the ED but are rarely fatal AAPCC indicates 2 million exposures and 1,146 fatalities in 2010 Clin Toxicol 49 (10):910) Early recognition and management guided by sound physiologic principles is key to good outcomes! 5 toxidromes are recognized based on clinical presentation sympathomimetic |cholinergic |anticholinergic |opiate |sedative-hypnotic Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

medication od toxidromes
antimuscarinic syndrome SLUDGE Syndrome/CNS symptoms resp depression is not a significant feature of BZD OD (PO) Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Overdoses – diagnostic evaluation
Undifferentiated or mixed exposure is not uncommon. Diagnostic tests RBG BMP ± LFTs VBG/ABG Serum Drug Screen – APAP, salicylate, EtOH ± TCA Urine Drug Screen – high FP+FN rates! cocaine, & THC screens – fairly sensitive Amphetamines –x OTC cold meds PCP – x dextromethorphan, ketamine, diphenhydramine EKG Role of imaging: consider KUB – CHIPES (chloral hydrate, heavy metals, iron, phenothiazines, EC preparations, SR preparations) Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Overdoses – Treatment Prevention of absorption
No “stomach pumping” – IPECAC Activated Charcoal – mainstay Best results - < 1 hr. after ingestion Whole-bowel irrigation PEG at 1 - 2L/hr. till clear rectal effluents SR preps, body packing, heavy metals Cathartics “GI Rx” – contraindicated in patients with airway compromise, persistent vomiting , ileus, bowel obstruction or perforation Enhanced Elimination Forced diuresis Urinary alkalinization Urinary acidification Hemodialysis and hemoperfusion Antidotes Disposition psychiatric evaluation outpatient obs versus inpatient versus ICU care A-B-Cs of resuscitation! CBG Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Acetaminophen toxicity
Leading cause of toxicologic fataities in the US. APAP-induced hepatotoxicity - most frequent cause of ALF Leading indication for liver transplantation. Risk factors Decreased glutathione stores – fasting state, malnutrition, anorexia nervosa, chronic alcoholism, febrile illness, chronic disease states CYP450 enzyme inducers – EtOH, INH, phenytoin, barbiturates, cigarette smoking Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

4 clinical stages Asymptomatic (stage 1 – 1st 24hrs.) Hepatotoxic (stage 2 – 24 – 48 hrs.) Fulminant hepatic failure (stage 3 – 2 – 4 days) Recovery (stage 4 – 4 – 14 days) History : reliable time of ingestion is crucial to management! In addition – amount, what form, and over what period of time. Any co-ingestants Physical: ABCs, mental status evaluation Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Diagnostic Criteria Obtain APAP level at 4hrs post-ingestion and plot Rumack-Mathew nomogram Assess risk for progressive hepatic failure King’s College Hospital(KCH) Criteria pH < 7.3 (at 48hrs) PT > 100 Cr > 3.3mmol/L Grade 3 -4 hepatic encephalopathy Other labs: CMP (AST vs. ALT), PT/INR, VBG, serum lactate, serum phosphate Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Acetaminophen toxicity - treatment
Prevent absorption Activated charcoal Replenish glutathione N-acetylcysteine (NAC) PO vs. IV administration AC – NAC co-administration not recommended – give 2 hours apart. Indications for NAC acute poisoning with toxic APAP levels Delayed presentation > 8hrs with pending APAP levels Delayed presentation > 24hrs with detectable APAP levels + ↑AST Chronic APAP OD exposure with associated transaminitis Fulminant hepatic failure Monitor & treat complications - hypoglycemia, electrolyte & metabolic disturbances, GI bleeding, cerebral edema, Infections, AKI GI/Hepatology consult – notify transplant center – arrange early transfer! Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Animal bites Principles of Management of Bite Wounds
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018 Animal bites Principles of Management of Bite Wounds

Bite wounds - management
Copious irrigation Culture when visibly infected Consider imaging To exclude fracture, foreign body and/or joint space involvement Avoid primary closure Exception: lesions on the face Elevate extremity Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Bite wounds - management
Antibiotic Rx For overt infection Prophylaxis for high-risk bite wounds Location: hands, genitalia, close proximity to joints Type of Injury: puncture, crush injury Severity: moderate-to-severe Bite Source: cat bites Immune status: DM, asplenia, immunosuppression Choice: Amoxicillin-clavulanate 875/125 PO BID x 3 – 5 days Most effective when wound > 8 hrs Tetanus and Rabies prophylaxis as indicated Arrange surgical consultation and out-patient f/u as appropriate Patient xtics, Wound xtics, Source xtics Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Bite wounds – specific considerations
Dog Bites Most common bite wounds (80%), not commonly infected (5%) P. multocida, Strep, Staph, C.canimorsus Amoxicillin-clavulanate or Ciprofloxacin + clindamycin Cat Bites High infection rates – 80% P.multocida, S. aureus Amoxicillin-clavulanate always – Cephalosporins Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Bite wounds – human bites
Pediatric wounds Generally trivial Intercanine distance > 3cm suggests adult bite – red flag for child abuse Clenched fist injury High infection risk – raises concern for significant deep soft tissue/bone/joint infections Late presentation – very common! Virus transmission risk Hepatitis B – consider PEP HIV, HCV transmission rates are low (blood in saliva?!) Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Bite wounds – human bites
Common organisms Viridans strep Bacteroides spp Fusobacterium spp Peptostreptococci Eikinella corrodens Prophylaxis is recommended in most cases Amoxicillin-clavulanate 875/125 PO BID x 5 days Infected wounds: IV Rx recommended Ampicillin-sulbactam, Ticarcillin-clavulanate, Cefoxitin x weeks Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Insect bites Tick-Borne Infections
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018 Insect bites Tick-Borne Infections

Tick-borne infections
Common in summer months Prevalence is a function of Vector tick population Animal reservoirs Co-infection with multiple TBIs can occur Outdoor activity rather than report of tick bite correlates better with presentation Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Lyme borreliosis Most common vector-borne disease in the US
Endemic regions include Northeastern coastal regions Upper Midwest Northern California Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Lyme borreliosis Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

Current ACLS guidelines - review
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018 Current ACLS guidelines - review

Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
10/13/2018 Q & a section

q1 Which one of the following accurately describes the classic rash of erythema migrans? A) Scattered individual purple macules on the ankles and wrists B) An annular rash with a bright red outer border and partial central clearing C) A dry, scaling, dark red rash in the groin, with an active border and central clearing D) A diffuse eruption with clear vesicles surrounded by reddish macules E) A migratory pruritic, erythematous, papular eruption Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

q2 72-year-old male is brought to your office by a friend because of increasing confusion, irritability, and difficulty walking. This began shortly after the patient’s car broke down in a rural area and he had to walk a mile to get to a phone and call the friend. The temperature outdoors has been near 100°F. On examination the patient has a rectal temperature of 39.5°C (103.1°F), a pulse rate of 110beats/min, and a blood pressure of 100/60 mm Hg. His shirt is still damp with sweat. Which one of this patient’s findings indicates that he has heatstroke rather than heat exhaustion? A) Confusion B) Sweating C) His temperature D) His heart rate E) His blood pressure Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

q3 A 42-year-old female has a 3-day history of an intensely pruritic rash on her arm, shown below. Which one of the following is most likely to have caused these skin lesions? A) Balsam of Peru B) Bedbugs C) Neomycin D) Nickel E) Poison ivy Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

q4 A 45-year-old obtunded male is brought to the emergency department by ambulance. Slow, shallow respirations are noted. His wife tells you that he is being treated by a local painspecialist for chronic back pain stemming from a severe workplace injury 2 years ago. A urine immunoassay drug screen is negative for opioids. Which one of the following opioid medications would NOT be detected by this drug screen? A) Codeine B) Fentanyl C) Hydrocodone D) Hydromorphone (Dilaudid) E) Morphine Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

q5 What is the specific antidote used to treat methanol poisoning?
A) Ethanol B) Haloperidol C) Lorazepam (Ativan) D) Naloxone E) Thiamine Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

q6 A 3-year-old male is brought to your office the day after he was stung by a honeybee. He developed a significant local reaction, with redness and swelling around the site of the sting on his forearm. He also had some swelling of his lips which lasted 2–3 hours. He was treated with oral diphenhydramine (Benadryl) at home and now his symptoms have completely resolved. Which one of the following should be recommended for this patient? A) An epinephrine autoinjector (EpiPen) B) Corticosteroids as needed for stings C) Immunotherapy for 1–2 years D) Reassurance only Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

references Jang JL. Cheng S. Fluid and Electrolyte Management. The Washington Manual of Medical Therapeutics. Godara et al. Eds. 34th Edition. Multiple Uptodate Resources American Family Physician Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport 10/13/2018

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