Goldfarb Guide 2018 Podiatric Surgery Review PDF

The Foundation Board Certification Review Study Guide Editor-in-Chief Assistant Editors John Marty, MS, DPM Thomas J. Ortenzio, DPM FASPS Diplomate, American Board of Podiatric Surgery Diplomate, American Board of Podiatric Surge...

The Foundation Board Certification Review Study Guide Editor-in-Chief Assistant Editors John Marty, MS, DPM Thomas J. Ortenzio, DPM FASPS Diplomate, American Board of Podiatric Surgery Diplomate, American Board of Podiatric Surgery Fellow, American College of Foot and Ankle Fellow, American Society of Podiatric Surgeons Surgeons Chairman, William L. Goldfarb Foundation Certified in Laser Foot and Ankle Arthroscopic Vice President/Treasurer, Podiatric Medical Surgery Assurance of Pennsylvania Board Certified Wound Care Specialist, Past President, Pennsylvania Podiatric Medical American Academy of Wound Management Association President, William L. Goldfarb Foundation Private Practice, Ankle & Foot Care, Inc. Jeffrey Dunkerley, DPM xxxx Chapter Editors Previous Editorial Contributors Larry R. Goss, DPM Christopher E. Attinger, MD Steven J. Berlin, DPM Paul C. LaFata, DPM Libby Cone, MD Jason R. Miller, DPM Douglas Glod, DPM Kevin Naugle, DPM Edwin Hart III, DPM Arthur E. Helfand, DPM Mark Pinker, DPM Edwin J. Juda, DPM Tracey Vlahovic, DPM Peter F. Kelly, DPM Steven Kravitz, DPM Guido LaPorta, DPM, MS James Lawton, DPM Gene K. Potter, DPM, PhD William H. Simon, DPM John Walter, DPM, MS Terry Wills, DPM Fredrick E. Youngblood, MD  Prepared and distributed by the William L. Goldfarb Foundation for Education & Research of the Lower Extremity, Inc. John Marty, MS, DPM, President & Scientific Chairman and Thomas Ortenzio, DPM, General Chairman Original Concept by William L. Goldfarb, DPM Original Material compiled by Jonathan M. Singer, DPM All rights reserved. © 2016 William L. Goldfarb Foundation 757 Poplar Church Road Camp Hill, PA 17011 717-763-7665 ISBN: 0-9639030-04 Printer: GANCOM, Camp Hill, PA, USA This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage or retrieval system without written permission from the copyright owner. Violators will be prosecuted. Accurate indications, adverse reactions, and dose schedules for drugs are provided in this book, but it is possible that they may change. The reader is urged to review the package information data of the manufacturers of the medications mentioned. The author has made every effort to ensure the accuracy of the information herein. However, appropriate information sources should be consulted, especially for new or unfamiliar procedures. It is the responsibility of every practitioner to evaluate the appropriateness of a particular opinion in the context of actual clinical situations and with consideration to new developments. The author, editors, and publisher cannot be held responsible for any typographical or other errors found in this book.  Table of Contents CHAPTER 1 Emergency Medicine The Patient with Clotting Abnormalities...... Cardiopulmonary Resuscitation........... 1 The Rheumatoid Patient.................. Current Protocol........................ The Sickle Cell Patient................... Advanced Life Support................... The Cardiac Patient..................... Office Emergencies...................... The Pulmonary Disease Patient............. Medical Emergencies Perioperative Management of the Infant (Cardiac Dysrhythmias)................. and Child............................ Other Medical Emergencies................ The Mitral Valve Prolapse Patient........... Shock................................ The Gouty Arthritic Patient................ Blood and Blood Components for Emergency Use..................... CHAPTER 4 Preoperative Evaluation Screening the Preoperative Patient.......... CHAPTER 2 Anesthesia Summary of Perioperative Laboratory Anesthesia Classifications................. Testing.............................. General Anesthesia...................... Local Anesthetics....................... CHAPTER 5Postoperative Care Special Cases for Lowering the Maximum and Complications Allowable Dose........................ Fever................................ Complications Due to Local Anesthetics Altered Mental States.................... Pediatric Anesthesia..................... Water and Electrolyte Imbalance............ Lumbar Epidural and Caudal Anesthesia..... Oliguria: Urine Output Less Than 400 ml/day in Adults................... Regional Nerve Blocks.................... Chest Pain............................ General Complications of Anesthesia........ Postoperative Hypertension................ Complications of Endotracheal Intubation.... Postoperative Infection................... Nerve Injuries During Anesthesia........... Anxiety and Pain Management............. Other Medical Complications.............. Nausea............................... from Anesthesia........................ Constipation........................... CHAPTER 3 Perioperative Management Shivering............................. The Healthy Patient..................... DVT................................. The Diabetic Patient..................... Compartment Syndrome.................. The Hypertensive Patient................. Hemorrhage........................... The Patient on Steroid Therapy............. Septic Syndrome........................ The Asthmatic Patient.................... Thyroid Storm Hemorrhage................ The Alcoholic Patient.................... Septic Syndrome........................ The Patient on Anticoagulant Therapy........ Thyroid Storm......................... Table of Contents i  CHAPTER 6 Infectious Diseases Radiation Burns........................ Specific Diseases....................... Chemical Burns........................ Principles of Anti-Infective Therapy.......... Frostbite.............................. Antibiotics............................ Chilblains............................. Drug Fever............................ Specific Antimicrobial Therapy............. CHAPTER 11Fluid Management and Surgical Considerations.................. Replacement in the Surgical Patient Fluid Management...................... Necrotizing Infections.................... Intravenous Fluids and Therapy............ Osteomyelitis.......................... Calculations........................... Septic Arthritis......................... Complications of Total Parenteral Nutrition.... Mycology.............................. Replacement Therapy.................... Viral Diseases.......................... Estimating Blood Loss................... Rickettsial Diseases..................... Blood Products and Indications............ Protozoan and Metazoan Infections CHAPTER 12 Osseous Tumors CHAPTER 7 Wound Healing Overview of Osseous Tumors.............. Repair of Skin.......................... Statistics on Bone Tumors................ Factors That Interfere with Wound Healing.... Staging Techniques...................... Growth Factors in Wound Repair........... Enneking Surgical Staging System (SSS)...... Wound Dressings....................... Radiology of Bone Tumors................. Suture Materials and Needles.............. Biologic Behavior of Tumors............... Surgical Approaches to Reduce Wound Dehiscence.......................... Tumor Mimicking Disorders (Pseudotumors)....................... Tourniquets........................... Benign Versus Malignant Characteristics..... CHAPTER 8 Plastic Surgery Classification of Osseous Tumors........... Skin Grafting.......................... Benign Osseous Tumors.................. Local Cutaneous Flaps................... Tumors of Cartilaginous Origin............. Local Muscle and Myocutaneous Flaps....... Tumors of Fibrous Origin................. Fasciocutaneous Flaps................... Tumors of Unknown Origin................ Microsurgery and Free Flaps............... Soft-Tissue Tumors...................... Diagrams of Skin Flaps................... Cystic Lesions of Bone................... Other Bone Tumors..................... CHAPTER 9 Bone Healing Malignant Tumors...................... Primary Bone Healing.................... Bone Tumors: Quick Reference Chart........ Complications of Bone Healing............. Phases of Cancer Development............. Treatment of Non-Unions................. Summary of Benign Versus Fusion............................... Malignant Tumors..................... Bone Grafting.......................... Aseptic Necrosis of the First Metatarsal CHAPTER 13 Dermatology Head Following Osteotomy............... The Skin.............................. Current Bone Growth Stimulator Dermatological Lesions................... Technology.......................... Cartilage Healing....................... CHAPTER 14 Rheumatology Etiology of Joint Pain.................... CHAPTER 10 Burns and Frostbite Patterns of Joint Involvement.............. Assessment and Treatment of Burns........ Classification of Arthritis................. Nutrition.............................. Specific Types of Arthritis................. Infection.............................. Laboratory Testing for the Arthritic Burn Wound Closure.................... Conditions........................... Electrical Burns........................ Articular Disorders Affecting the Heel........ Charcot Neuroarthropathy................ ii The Foundation Board Certification Review Study Guide, 13th Edition CHAPTER 15 Peripheral Vascular Disease In-Toe Gait............................ Arterial Disease........................ The Limp in Childhood................... Peripheral Artery Disease (PAD)............ The Toe-Walking Child................... Venous Disease......................... Congenital Deformities................... Venous Thromboembolism................ Juvenile Hallux Valgus................... Pediatric Radiology..................... Pediatric Fractures...................... CHAPTER 16 Internal and External Corrective Casting Techniques in Infants..... Fixation Osteochondroses....................... Arbeitgemeinshaft für Osteosynthesisfragen Brachymetatarsia....................... (AO)................................ Polydactyly............................ Requirements of Implant Materials.......... Syndactyly............................ Principles Affecting Internal Fixation......... Ectrodactyly........................... Factors Affecting Fixation Type............. Tarsal Coalition........................ Internal Fixation Devices................. Calcaneovalgus......................... Fragmentary Compression Vertical Talus.......................... (Dynamic or Static).................... Metatarsus Adductus.................... Techniques of Stable Fixation.............. Clubfoot.............................. AO Technique.......................... Jumping Screws........................ CHAPTER 20 Pharmacology Plate Fixation.......................... Diabetic Medications..................... Plating Procedures...................... Select Drug Interactions.................. External Fixation....................... Large Bone Fixation..................... CHAPTER 21 Surgery of the Small Bone External Fixation of the Foot..... Congenital Foot Other Fixation Available.................. Flexible Flatfoot Surgery.................. Other Techniques....................... Subtalar Joint Blocking Procedures......... (Arthroereisis and Arthrodesis) for Flatfoot.... CHAPTER 17 Nail Disorders and Surgery Rigid Flatfoot Surgery: Nail Anatomy.......................... Convex Pes Planovalgus................ Nail Descriptions....................... Metatarsus Adductus.................... Disease Processes that Affect the Nail........ Cavus Foot Type........................ Treatment for Onychomycosis.............. Talipes Equinovarus (Clubfoot)............. Surgical Nail Procedures: Chemical Indications for TEV Surgery............... and Surgical Matrixectomies............. CHAPTER 22 Generalized Disease CHAPTER 18 Neurology Conditions of Bone Neurological Pathways................... Soft-Tissue and Osseous Overgrowth........ Presenting Features..................... Connective Tissue Disorders............... Assessment of Clinical Problems............ General Appearance of Increased Innervation of the Lower Extremity.......... Bone Density......................... Tarsal Tunnel Syndrome.................. Osteopenic Conditions................... Classification of Nerve Injuries............. Marrow Abnormalities.................... Neuromuscular Causes of the Cavus Foot..... The Dysplasias......................... Types of Nerve Surgery................... CHAPTER 23 Radiology CHAPTER 19 Pediatrics Standard Radiographic Techniques.......... Evaluation of the Pediatric Patient.......... of the Foot and Ankle.................... Pediatric Biomechanics— Specific Radiographic Studies.............. Normal Values: Newborn to Adult.......... Anatomic Angles........................ Biomechanical Evaluation of the Child....... Common Structural Measurements......... Pediatric Gait Patterns................... Pediatric Radiology...................... Table of Contents iii  The Osteochondritities................... Calcaneal Fractures..................... The Accessory Bones of the Foot............ Ankle Instability........................ Ultrasonography (Primary) Indications....... Ankle Fractures........................ Ultrasonography (Secondary) Indications..... Pilon Fracture.......................... Ultrasonography Advantages............... Compartment Syndrome.................. Tendon Injuries........................ CHAPTER 24 Hallux Valgus Principles of Bone Healing................ and Related Disorders Breaks in the Integument System........... Goals of Hallux Valgus Surgery............. Treatment of Open and Closed Fractures..... Anatomical Facts of the Nerve and Vascular Injury................. 1st Metatarsophalangeal Joint............ Pediatric Injuries....................... Predisposing Factors of Hallux Valgus........ Biomechanics.......................... CHAPTER 26 Digital Deformities Etiology of Hallux Abducto Valgus........... and Surgery Deformity Types........................ Hammertoe Syndrome................... Radiological Measurements for HAV......... Mallet Toe Syndrome.................... Physical Examination.................... Clawtoe Deformity...................... Preoperative Considerations (Planning)....... Adductovarus 5th Toe Deformity Arthroplasty Procedures.................. (Overlapping 5th Toe)................... Capsule-Tendon Balance Procedures........ Hallux Hammertoe Deformity.............. Arthrodesis Fusion...................... Hallux Interphalangeal Arthrodesis.......... Proximal Phalangeal Osteotomies........... Lesser Digital Arthrodesis................. Distal Metatarsal Osteotomies.............. Overlapping 2nd Toe..................... Shaft Procedures....................... Syndactylization........................ Combination Procedures.................. Digital Implants........................ Other Procedures....................... Absorbable Implants..................... Proximal Metatarsal Osteotomies........... Floating Toe Syndrome................... Hallux Rigidus and Hallux Limitus.......... Blue Toe Syndrome...................... Implant Arthroplasties................... Polydactylism.......................... Hallux Varus........................... Addendum............................ Hallux Hammertoe (Etiology)............... Differential Diagnosis of Pain CHAPTER 27 Muscle and Tendon in the Sesamoid Area................... Pathology Complications of HAV Surgery (General)...... Muscle Physiology....................... Chart of Procedures and Their Indications.... Principles of Tendon Repair............... Tendon Lengthening and Tenotomy......... CHAPTER 25 Trauma of the Foot Tendon Transfers....................... and Ankle Tendon Grafts.......................... Initial Assessment and Management Posterior Tibial Tendon Rupture............ of the Trauma Patient.................. Posterior Tibial Tendon Dysfunction......... Forefoot Trauma........................ (Adult Acquired Flatfoot Deformity).......... Turf Toe Injury......................... Peroneal Tendon Pathology— Sesamoid Fractures..................... Frequently Missed Even on MRI Studies..... First Metatarsophalangeal Dislocation....... Achilles Tendon Rupture.................. Fifth Metatarsal Base Fractures............ Lateral Ankle Stabilization Procedures Stress Fractures........................ (Tendon Transfers)..................... Rearfoot Trauma (Lisfranc’s) Fracture/ Postoperative Care and Training Following Dislocation........................... Tendon Transfer...................... Navicular Fractures..................... Tenosynovitis.......................... Talar Fractures......................... iv The Foundation Board Certification Review Study Guide, 13th Edition CHAPTER 28 Lesser Metatarsal Surgery Prosthetic Considerations at Different Anatomy (Metatarsals 2-3-4)............... Amputation Levels..................... Differential Diagnosis of Metatarsalgia....... Transmetatarsal Amputations.............. Surgical Treatment of the IPK.............. Tarsometatarsal Amputations (Lisfranc’s)..... Summary of Metatarsal................... Midfoot Amputation (Chopart’s)............ Surgical Procedures..................... Amputation at the Ankle (Syme’s, Boyd, Complications of Metatarsal Osteotomies..... Pirogoff)............................. Lesser Metatarsal Fractures............... Below Knee Amputations................. Lesser Metatarsal Joint Replacement........ CHAPTER 32 Biomechanics Panmetatarsal Head Resection............. Normal Values......................... Metatarsus Adductus.................... Criteria of Normalcy in the Lower Extremity.... Freiberg’s Disease....................... Adult Biomechanical Examination.......... Tailor’s Bunion......................... Common Structural Variations: Splayfoot............................. Signs and Symptoms................... Brachymetatarsia (Brachymetapody)......... Planes of Motion........................ Skewfoot.............................. Axes of Joint Motion..................... Angular and Axial Deformities CHAPTER 29 Ankle Conditions of the Lower Extremity in Children......... Differential Diagnosis of Chronic Ankle Pain.... Anatomy of Gait: Phasic Activity of Muscles.... Tarsal Tunnel Syndrome.................. Observation of Gait...................... Sinus Tarsi Syndrome................... Subtalar Joint Measurements.............. Peroneal Subluxation Arthrodesis/ Subtalar Joint Function.................. Arthroplasty/Replacement of the Ankle..... Midtarsal Joint Function................. Osteochondral Defects: Talar Dome......... Lateral Ankle Instability.................. CHAPTER 33 Anatomy Chronic Lateral Ankle Instability............ Neuroanatomy......................... Chronic Medial Ankle Instability............ Angiology............................. Ankle Equinus......................... Myology.............................. Malunion and Non-Union of the Malleoli...... Arthrology............................. CHAPTER 30 Heel Pain CHAPTER 34 Soft-Tissue Tumors Anatomy of the Heel..................... Soft-Tissue Tumors Overview.............. Radiological Evaluation of the Calcaneus..... Soft-Tissue Tumor Terminology............ The Heel in Systemic Disease.............. Systematic Approach to Soft-Tissue Seronegative Arthritis and Heel Pain......... Tumors............................. Calcaneal Spurs/Plantar Fasciitis/ Diagnostic Modalities.................... Fasciosis............................ Biopsy of Soft-Tissue Tumors Tumors of the Heel...................... (Non-Epithelial Lesions)................. Tarsal Coalitions........................ Staging of Benign Soft-Tissue Lesions Sever’s Disease......................... and Non-Epithelial Neoplasms............ Haglund’s Deformity..................... Staging of Malignant Sarcomas............. Causes of Heel Pain (A Summary)........... Additional Staging...................... Classifications of Sarcomas................ CHAPTER 31 Amputations Classification of Soft-Tissue Tumors......... General Surgical Technique............... Part I: Benign Soft-Tissue Tumors.......... Other Considerations.................... Pseudotumors.......................... Digital Amputations..................... Part II: Malignant Sarcomas............... MPJ Amputations....................... Part III: Metastatic Tumors................ Ray Amputations....................... Part IV: Systemic Carcinoma............... Metatarsal Disarticulations................ Vascular Changes Associated with Cancer.... Table of Contents v  CHAPTER 35 Physical Medicine and Rehabilitation for the Management of Foot Conditions Physical Modalities and Diseases/ Therapeutic Modalities and Procedures..... Physical Modalities and Diseases........... Therapeutic Modalities and Procedures....... Foot and Ankle Physical Therapy........... CHAPTER 36 Arthroscopy Ankle Joint Arthroscopy.................. CHAPTER 37 Laser Applications in Podiatric Surgery Lasers and Laser Physics History........... Theory of Laser Operation................. Tissue Interaction....................... Laser Safety........................... Clinical Laser Applications in Podiatric Surgery............................. Laser Nail Matrixectomy.................. The Nd:YAG Laser....................... The Argon Laser........................ The KTP Laser......................... Other Surgical Lasers.................... Lasers in Podiatry (Addendum)............. Summary............................. CHAPTER 38 Radiological Pathology (Specific Radiological Studies) Magnetic Resonance Imaging (MRI).......... Computerized Tomography (CT Scan)........ CT Image Reconstruction................. vi The Foundation Board Certification Review Study Guide, 13th Edition Chapter 1 1 Emergency Medicine Cardiopulmonary Resuscitation Current Protocol Advanced Life Support Office Emergencies Medical Emergencies (Cardiac Dysrhythmias) Other Medical Emergencies Shock Blood and Blood Components for Emergency Use 1  G. Reassessment: Check pulse and Cardiopulmonary Resuscitation breathing, if breathing then stop CPR. If no breathing but pulse present, then just There have been significant changes in continue ventilations. If no breathing the CPR protocol. According to 2010 AHA and no pulse, then begin CPR. Guidelines, there is no longer the A–B–Cs H. Start chest compressions over sternum (Airway–Breathing–Circulation) but now it using heel of hand with fingertips off is C–A–B (Compressions–Airway–Breathing). sternum and with elbows straight; “Look, Listen, and Feel” have been replaced by compress 1.5–2 inches at 80–100/ “Compressions First, Then Airway.” minute 1. Compression rate at least 100/minute. I. Provide proper ventilations: Give The depth should be as follows. 2 breaths after 15 compressions if A. Adults 2 inches (5 cm) working alone or 1 breath to every 5 compressions when two rescuers are B. Children 2 inches (5 cm) present C. Infants 1.5 inches (4 cm) 2. Rescue breathing: Infant victim 2. Compression to ventilation ratio 30:2 A. Check responsiveness single rescuer, 15:2 two rescuers B. Open airway: If obstructed then clear 3. Rescue breathing: 1 breath every 6–8 D. Check for breathing: If no breathing seconds; roughly 10 breaths/minute then cover victim’s mouth and nose with A. AHA ECC Adult Chain of Survival rescuer’s mouth and give 4 puffs of air i. Immediate recognition of cardiac (Observe chest rise) arrest and activation of EMS E. Check for pulse (brachial): If pulse ii. Early CPR with emphasis on chest present but no breathing, start rescue compressions breathing iii. Rapid defibrillation (AED) F. Rescue breathing: Inflate at 1 breath iv. Effective Advanced Life Support every 3 seconds, continue for 1 minute v. Integrated post-cardiac arrest care G. Reassessment i. Check pulse and breathing ii. If victim is breathing then stop CPR Current Protocol iii. If victim is not breathing and pulse present, then continue ventilations For the most up-to-date protocol, go to the iv. If victim is not breathing and has no American Heart Association’s website at pulse, then start chest compressions www.heart.org. H. Infant chest compressions should incorporate 2–3 fingers on the sternum 1. Rescue breathing: Adult victim centered on an imaginary line between A. Check responsiveness: Shake or tap the nipples, compressing vertically 0.5–1 gently and ask “Are You OK?” inch at a rate of 100/minute ventilations B. If unresponsive, yell for help occurring after every 5 compressions C. Open the airway: Head tilt/chin lift to open airway, and check for obstruction. 3. Rescue breathing: Child victim Remove if present A. All of the above holds true except that D. Check for breathing: If no breathing then the rescuer feels for the carotid pulse; give 4 quick breaths (observe chest rise) compressions occurring one finger width above the substernal notch using the E. Check for pulse (carotid) for 5–10 heel of the hand at a compression rate seconds: If pulse is present but there is of 80–100/minute; maintain cycles of no breathing then start rescue breathing 5 compressions to every 1 ventilation F. Rescue breathing: Inflate at 1 breath every 5 seconds. Continue for 1 minute 2 The Foundation Board Certification Review Study Guide, 13th Edition  Used to suppress ventricular Advanced Life Support ectopics when lidocaine fails Dosage: 100 mg IV with a rate of 1. Advanced cardiac life support includes 20 mg/minute until dysrhythmia the use of drugs, defibrillation, and disappears or hypotension ensues, intubation. The basic protocol is as QRS complex is widened by 50%, follows. or total of 1 g of drug is injected A. Begin basic CPR (Compressions–Airway– Can’t use in patients with a Breathing) history of Long QT Syndrome B. Determine circumstances (past history, vi. Propranolol (Inderal) current medications) Beta blocker (to be used with C. Begin IV and intubate caution in patients with COPD, D. Determine cardiac rhythms diabetes, and heart failure) E. Determine blood gases Used to control recurrent ventricular F. Begin appropriate drug therapy. These and atrial tachydysrhythmia drugs include: Dosage: 1 mg IV every 5 minutes i. Epinephrine to 5 mg total (total dose not to exceed 0.1 mg/kg) Alpha and beta agonist increases heart rate and contractility Must administer slowly Adrenergic agent of choice for vii. Vasopressin cardiac arrest Anti-diuretic hormone Used in asystole, V-fibrillation, Dispensed in a single dose every and cardiac arrest 3–4 hours Dosage: 0.5–1 mg (5–10 ml of Does not have the negative side 1–10,000) IV every 5 minutes effect like epinephrine (ischemia) ii. Atropine viii. Amiodarone Decreases vagal tone to increase Has alpha and beta adrenergic heart rate effect Used in sinus bradycardia/high Dose 100 mg IV push for 1st dose degree AV block ix. Magnesium Sulfate Dosage: 0.5 mg IV every 15 Used to prevent Torsades de minutes up to 2 mg Pointes associated with Long QT iii. Furosemide (Lasix) Syndrome Loop diuretic and vasodilator 1–2 g IV diluted in 10 ml of Used for pulmonary edema and dextrose 5% in water (D5W) over congestive heart failure 5–20 minutes Dosage: Starting dose is 0.5 mg/ x. Sodium Bicarbonate kg IV and total dose not to exceed Used to counteract metabolic 2 mg/kg IV acidosis iv. Lidocaine (Xylocaine) Dosage is based on blood pH or Decreases automaticity and raises empirically, 2–5 mEq/kg IV infuse v-fib threshold over 4–8 hours Used to suppress PVCs, v-tach G. Cardioversion as necessary and v-fib (defibrillation) for ventricular fibrillation. The procedure is: 1.5 mg/kg IV for 1st dose, then 0.75 mg/kg IV for max of 3 doses i. Use paste or pads on skin v. Procainamide (Pronestyl) ii. Charge defibrillator with synchronization switch off Decreases cardiac excitability, decreases automaticity of ectopic iii. Place paddles as directed on the pacemakers, and slows conduction handles: One on the right upper sternum and the other on the left anterior axillary line Chapter 1 Emergency Medicine 3  iv. Apply paddles with firm pressure F. Treatment: Position patient in a position (turn off oxygen) with legs elevated, check vitals, provide v. Shout “Clear” and make sure no one O2, Ephedrine 20 mg IM convulsions/ is touching the victim Valium 5 mg IV, and CPR if necessary vi. Press both paddle switches simultaneously to fire the unit NOTE—Ephedrine raises blood pressure vii. Repeat as necessary: Start at and causes tachycardia while Vasoxyl raises 200–300 joules, maximum output blood pressure without tachycardia (due to 400 joules the alpha effect). Office Emergencies 3. Anaphylactic reactions A. These are toxic reactions that occur in 1. Syncope–vasovagal reflex persons who are allergic by heredity or (primary shock; fainting) who have become sensitized to a given A. Defined as transient loss of drug or therapeutic agent after previous consciousness due to sudden release administration. Respiratory obstruction of the arterial vasomotor tone and is the cause of death. temporary insufficiency of cerebral B. Reactions: Anaphylactic shock, circulation angioneurotic edema (swelling of soft B. Causes are sudden extreme fear or pain tissues of throat), asthma with acute or the effect of severe injury bronchospasm, urticaria, and pruritus C. Differential diagnosis: Epilepsy, C. Signs and symptoms of anaphylactic hyperventilation, hysteria, carotid sinus shock: Skin wheals, itching, angioedema, syndrome, cardiac arrhythmia, drugs, laryngeal edema, bronchospasm and orthostatic hypotension (wheezing) dyspnea, cyanosis, apnea, D. Signs and symptoms: Pallor, sweating, vomiting, hypotension, cardiorespiratory slow pulse, yawning, and marked collapse, and death transient hypotension D. Treatment of anaphylactic shock must E. Treatment is supportive: Recumbent be immediate: 0.5 cc epinephrine IV or or Trendelenburg position, take blood IM (children 0.01 mg/kg); tourniquet and pressure, pulse, spirits of ammonia, O2, 0.25 cc epinephrine at injection site; O2 and drugs (Atropine/Ephedrine) only if and airway; Solu-Cortef 200 mg IV; and previous treatment fails CPR if necessary 2. Local anesthetic toxicity 4. Allergic reactions (see Table 1.1) A. Esters: Metabolized in the bloodstream A. End organ response of the skin by pseudo-cholinesterases B. Symptoms are hives (urticaria), bronchial B. Amides: Processed by microsomal asthma, and gastrointestinal upset enzymes in the liver C. Treatment: 25–50 mg IM Benadryl; C. Causes are too much volume or too if severe then treat as if anaphylactic concentrated solution; extreme rapid reaction; if tongue swelling use absorption epinephrine D. Reactions: Rapid and delayed; with 5. Acute asthmatic attack cerebral stimulation and/or depression; A. This is an intermittent airway respiratory stimulation; cardiac obstruction, which is reversible, but depression; hypotension; shock can be acute and severe leading to E. Signs and symptoms: Apprehension, respiratory failure nausea, blood pressure elevation, B. Causes: Allergies, irritants, infections, convulsions, perioral tingling, or extreme cold, drugs, and emotion most seriously—dizziness, respiratory C. Signs and symptoms: Classic triad— depression, hypotension respiratory, and dyspnea, cough, and wheezing cardiac arrest 4 The Foundation Board Certification Review Study Guide, 13th Edition TABLE 1.1. Classification of Allergic Reactions C. Signs and symptoms in grand mal (major Based on Their Time of Onset epilepsy): Aura, severe generalized clonic, convulsive body movements followed by Reaction Onset a period of flaccid coma, then a period of type (hour) Clinical reactions sleep (postictal depression) Immediate 0–1 Anaphylaxis i. Including status epilepticus: Hypotension Recurrent and severe seizures Laryngeal edema with short or no intervals between Urticaria/angioedema seizures Wheezing D. Treatment: Except in status epilepticus, Accelerated 1–72 Urticaria/angioedema no specific treatment is necessary Laryngeal edema except to protect patients from hurting Wheezing themselves (in status epilepticus start Late > 72 Morbilliform rash with Valium, 5–10 mg IV) Interstitial nephritis Hemolytic anemia 7. Hypertension Neutropenia A. Defined as persistent elevated blood Thrombocytopenia pressure above normal for the patient Serum sickness (borderline hypertension blood pressure Drug fever > 140/90) Stevens-Johnson B. Signs and symptoms: Headache, syndrome convulsions, visual changes, with acute Exfoliative dermatitis rise in blood pressure Levine BB, Immunologic Mechanisms of Penicillin Allergy: C. Initial treatment: Start supportive A Haptenic Model System for the Study of Allergic Diseases therapy and reduce blood pressure with of Man, N Engl J Med, 275:1115–1125, 1966 sublingual nifedipine 10 mg (Procardia) then send for medical evaluation D. Other treatment includes Clonidine 0.1 mg, Labetalol 20 mg IV or 100 mg PO D. Treatment: Reassurance, rest, O2 (3–6 L/ minute), drug therapy (Epinephrine 8. Insulin shock (hypoglycemia) 0.3 cc 1:1000 SC every 20 minutes up to A. Defined as low blood sugar that occurs 3 doses. If no relief, then aminophylline when a diabetic who has taken insulin, 5–6 mg/kg over 20 minutes, fails to ingest food, or engages in too hydrocortisone 100 mg.) strenuous exercise E. If the patient has inhaler with them B. Treatment: If conscious and able to encourage immediate use swallow then give orange juice. If F. Every office should have an albuterol unconscious give IV glucose inhaler on hand in case of emergency 20–50 ml of 50% solution C. Hypoglycemia in the alcoholic patient: 6. Seizures (major convulsions) Administer 100 mg of thiamine IV or IM A. Defined as convulsive disorders before dextrose to decrease the likelihood characterized by abrupt transient of developing Wernicke’s encephalopathy symptoms of motor sensory, psychic, or autonomic nature, frequently associated with change in consciousness. Changes NOTE—If the diabetic patient is seen when thought to be secondary to sudden unconscious, and if the diagnosis of coma transient alterations in brain function or insulin reaction is in doubt, give 50% associated with excessive rapid electrical glucose IV. This will overcome insulin discharge in the gray matter. reaction but will not generally harm patient B. Causes: Idiopathic (65%), pathological in diabetic acidosis. states (brain tumor, CVA, head trauma), local anesthetic toxicity, and intoxications Chapter 1 Emergency Medicine 5  9. Myocardial infarction D. Use Amiodarione or lidocaine A. Chest pain most common symptom E. If no response use procainamide B. Pain is described as crushing or squeezing F. After successful conversion use lidocaine C. Contact EMS immediately, administer drip nasal cannula 5–6 L/minute at 100% O2 D. Nitroglycerin (0.4 mg pill) can be given every 5 minutes for 3 doses. Aspirin can also be given. Ventricular fibrillation 10. Stroke/CVA A. Early recognition is paramount 4. Ventricular tachycardia B. Main risk factors are diabetes and A. Begin lidocaine hypertension B. Use CPR if no pulse/O2/IVs (and C. 80% are caused by thrombus or unconscious) embolus, 20% hemorrhagic C. Consider cardioversion and D. Call EMS stat, and give supplemental O2 procainamide or bretylium if lidocaine ineffective Medical Emergencies (Cardiac Dysrhythmias) 1. Myocardial infarct (uncomplicated): Characterized on EKG by big ST elevation or new onset left bundle branch block (LBBB) Ventricular tachycardia A. Monitor EKG B. 100% O2 with nasal cannula C. Start IV lines with dextrose 5% in water 5. Third degree AV heart block (D5W) A. Use atropine 0.5 mg IV D. Sublingual nitroglycerin can help B. Pacemaker placement E. Relieve pain with morphine sulfate 6. Premature ventricular contractions (PVCs) F. Do blood gases/pH/electrolytes (frequent): May lead to v-fib (if untreated) G. Consider use of prophylactic lidocaine A. Lidocaine 100 mg IV bolus followed by lidocaine IV drip 2. Asystole: Characterized by a flat line on the EKG A. Use basic CPR, begin IV, intubate B. Give epinephrine and vasopressin C. If ineffective give atropine D. If ineffective repeat steps B–D and Sinus rhythm with 3 unifocal PVCs as a last resort can give epinephrine intracardially or using a transvenous or external pacemaker 7. Wolff-Parkinson-White syndrome 3. Ventricular fibrillation: The gravest of all A. Characterized by a short P–R interval arrhythmias characterized by irregular and prolonged QRS time. There is a 40% and uncoordinated movements of the incidence of episodes of paroxysmal ventricles tachycardia, atrial fibrillation and A. Use basic CPR, begin IVs, intubate atrial flutter, as well as the possibility if unconscious of sudden death. Can occur in healthy individuals. B. If no response give epinephrine and bicarbonate B. Treatment: Digitalis, quinidine, Propranolol, atrial pacing C. Defibrillate at 360 joules 6 The Foundation Board Certification Review Study Guide, 13th Edition Other Medical Emergencies NOTE—It is better to call hotline first for specific directions in the treatment of 1. Narcotics overdose specific ingested agents. A. Give Naloxone: 0.2–0.4 mg IV or IM/ in children 0.01 mg/kg; repeat every 5 minutes 5. Deep vein thrombosis 2. Acetaminophen overdose (APAP) A. This disease commonly occurs in the A. The major toxic effect is centrilobular lower extremity, but it may also occur in necrosis of the liver, with toxicity likely other areas including the cerebral sinus, to occur after a minimum acute ingestion arms, retina, and mesentery of about 10 g or 30 acetaminophen B. The sequella of venous thrombosis tablets can vary from complete resolution B. Perform plasma APAP levels; treatment of the clot to including post-embolic based accordingly symptoms. These may include venous hypertension causing pain, swelling, C. Emesis with ipecac or gastric lavage hyperpigmentation, dermatitis, D. Administer Acetylcysteine (Mucomyst) if ulcers, venous gangrene, and elevated APAP plasma level lipodermatosclerosis. 3. Salicylate overdose: The most common C. Possible causes of pain and swelling in cause of fatal drug ingestion in the the lower limbs pediatric age group (Reyes syndrome) i. Venous insufficiency A. There is a relationship of signs and ii. Deep vein thrombosis symptoms to the amount of ASA ingested iii. Superficial vein thrombosis i. Mild: > 100 mg/kg: hyperventilation, iv. Post thrombotic syndrome lethargy, tinnitus v. Venous obstruction ii. Moderate: 200–300 mg/kg: D. Other conditions that may be included in hyperventilation, vomiting, sweating, the differential diagnosis vertigo, and hallucinations i. Baker’s cyst iii. Severe: 300–400 mg/kg: hyperventilation, seizures, coma, ii. Tear of the gastrocnemius muscle shock iii. Fracture B. Treatment begins with fluids and iv. Hematoma activated charcoal. Laxatives are also v. Acute arterial ischemia used. vi. Lymphedema C. Alkalinize the plasma, helps promote vii. Hypoproteinemia secretion of salicylates, with push doses E. Screening for DVT includes the of bicarbonate D-dimer test, ultrasound, impedance, D. If shock present start IV with Ringer’s plethysmography lactate F. More definitive testing includes testing E. Start dialysis if renal failure that can actually visualize the thrombus. These tests include ultrasonography, 4. Poisoning computed tomography, and magnetic A. Each type of poisoning is treated resonance imaging. differently. Begin basic CPR if necessary. G. Ultrasonography is considered to be the B. Determine ingested substance and give best of the noninvasive test and is found antidote if available to be 97% accurate. However, when it C. If unconscious, protect airway with ET comes to diagnosing cancer-induced tube; lavage with 28 French NG tube; DVT, the test is reported to be only 75% use 300 ml normal saline for adults accurate. (activated charcoal can be added) D. If conscious, use syrup of ipecac to induce vomiting, ambulate patient, and give large quantities of water Chapter 1 Emergency Medicine 7  i. Three types of ultrasonography i. It significantly reduces the Compression ultrasound occurrence of major hemorrhaging Duplex ultrasound during initial treatment Color flow duplex imaging ii. This is important overall as it does decrease the mortality at the end of H. The gold standard for establishing the follow-up treatment diagnosis of deep vein thrombophlebitis is contrast venography. This procedure iii. Long-term treatment with low is invasive and not always technically molecular weight heparin is sometimes possible. There is also a small risk of an indicated rather than treatment with allergic reaction as well as further DVT oral anti-coagulant therapy formation. iv. Contraindications for this include I. Spiral computed tomography and their use in pregnant women magnetic resonance imaging do show Immediate anti-coagulation promise in the diagnosis of DVT IV unfractionated heparin initial J. D-dimer test is a screening test that dose 80 mg/kg IV bolus and then involves getting a blood sample 18 mg/kg/hour i. It shows a specific cross-link fiber, PTT should be checked q6 until it which is produced fibrin graded stabilizes at 1.5–2.5x normal by plasma, so the concentrations Goal is to get PTT in this range are raised in patients with venous M. Low molecular weight heparin may also embolism be used ii. Even if sensitivity for venous i. Enoxaparin (Lovenox) 1 mg/kg SC thromboembolism is indicated, high every 12 hours concentrations of d-dimers are not ii. Follow the same PTT parameters significant enough for making a N. For continued anti-coagulation therapy: positive diagnosis, as they may occur in other conditions i. Warfarin (Coumadin): Load at 10 mg or 7.5 mg PO QD for 2 days iii. These may include pregnancy, malignancy, or after any surgical ii. Decrease dose to a target of 2.5 INR procedures iii. Do not stop infusion of heparin until iv. It can be a good test when used reaching 2.5 INR target in conjunction with other imaging iv. This INR of 2.5 should be maintained or ultrasound procedures for for 3–12 months determining predictive values O. There is weak evidence that use K. Treatment for DVT: Heparin and low of thrombolytic agents such as molecular weight heparin Streptokinase or Urokinase may produce i. The basic differences between a more rapid resolution of symptoms and the low molecular weight heparin preserve venous integrity. The problem includes polysaccharide chains. is that there is 3x the chance of bleeding Low molecular weight heparin is a complications. fragment of unfractionated heparin P. The use of Coumadin is one of the most and created by polymerization. widely used oral thrombolytic agents. ii. The advantages of low molecular It does require close monitoring of dose weight heparin are that it offers a regulation. This is done by monitoring more predictable anti-coagulant the partial thromboplastin levels on a response and has a longer half-life regular basis. iii. This permits a once-a-day 6. Hypertensive emergencies subcutaneous administration A. Hypertensive encephalopathy without the need to monitor the B. Malignant hypertension activated partial thromboplastin time C. Accelerated hypertension L. Low molecular weight heparin is at least as effective as unfractionated heparin D. Hypertensive crisis and improves recurrent DVT and venous i. Diagnosis of hypertensive thrombosis encephalopathy or accelerated 8 The Foundation Board Certification Review Study Guide, 13th Edition  malignant hypertension is clinical E. If suspicious of malignant hyperthermia and demands immediate aggressive preoperatively, do CPK level. This level therapy to lower blood pressure is elevated in 79% of the patients with ii. Treatment initially should be Diazoxide malignant hyperthermia. (Hyperstat) 300 mg by rapid IV bolus; F. Early signs or can give hydralazine with i. Tachycardia Furosemide simultaneously, as it ii. Tachypnea prevents fluid retention iii. Unstable blood pressure 7. Pulmonary embolism: Complete or iv. Arrhythmias partial blockage of the pulmonary vessels v. Dark blood in the surgical field from an intravascular clot originating vi. Cyanotic mottling of the skin elsewhere in the body, usually the deep veins of the lower extremity vii. Profuse sweating A. Signs and symptoms can include chest viii. Fever pain, dyspnea, cough, sweats, syncope, ix. Fasciculations respirations > 16/minute, pulse > G. Suggested treatment regimen 100/minute, temp > 37.8 °C, phlebitis, i. Stop anesthesia and edema ii. Hyperventilate with 100% oxygen B. EKG can show ST-T wave changes (8–10 L/minute) C. Presumptive diagnosis made by lung iii. Start Dantrolene sodium IV as soon scan; definitive diagnosis made by as possible (starting dose 1 mg/kg pulmonary angiogram up to a maximum cumulative dose of D. Treat with bed rest and Streptokinase, 10 mg/kg by rapid infusion) then Heparin 5,000 units as loading dose iv. Start Procainamide IV if required for followed by continuous infusion (25,000 arrhythmias units added to 500 ml dextrose 5% in v. Initiate cooling water, D5W, administered via IVAC) IV iced saline (not Ringer’s) E. Prior to Heparinization do PTT; during treatment adjust to keep PTT 2x normal Surface cooling with ice and hypothermia blanket F. If thrombophlebitis present treat with elevation and moist heat; may need Lavage of stomach, bladder and antibiotics rectum vi. Correct acidosis and hyperkalemia 8. Malignant hyperthermia (see also with sodium bicarbonate Chapter 2: Anesthesia—Other Medical vii. Monitor EKG, temp, urinary output, Complications from Anesthesia) electrolytes, arterial pressure and blood gases, pH, and electrolytes NOTE—Defined as a catastrophic reaction viii. Maintain urine output of at least to general anesthesia. An inherited trait 2 ml/kg/hour; administer Mannitol incidence of 1 in 20,000. and Furosemide if necessary ix. If necessary administer insulin to provide energy to the cells and A. With exposure to inhaled anesthetic normalize the pH agent, the patient exhibits fasciculation x. Administer oral Dantrolene for and increased muscle tone; jaw 1–3 days after the crisis clenching during the induction of anesthesia, a typical early sign; and body muscles becoming rigid and excessive NOTE 1—Avoid amide local anesthetics body heat produced if a patient has a history of malignant B. Anesthesia must be discontinued hyperthermia reaction. C. Patient must be cooled NOTE 2—Malignant hyperthermia is D. Intravenous Dantrolene sodium has a most frequently seen when halothane and therapeutic effect succinylcholine are used together. Chapter 1 Emergency Medicine 9  3. Treatment of shock Shock A. Assess the physical status of the patient The mechanism of shock is poorly understood. B. Lie the patient down and keep him/her However, this phenomenon results in warm inadequate tissue perfusion with accompanying C. Maintain airway by administering oxygen cellular injury and metabolic disturbances. at 8–10 L/minute. If patient unable to Shock cannot be defined, but it can be classified breath on their own use Ambu bag or by etiologic means. CPR if necessary. D. IV fluid replacement to avoid 1. General clinical presentation dehydration; do not use lactate solutions A. Tachycardia B. Hypotension NOTE—Expanding the intravascular volume C. Low tension pulse (thready pulse) is the primary goal in the initial treatment of D. Collapsed superficial peripheral veins hypovolemic shock. E. Oliguria F. Hypothermia G. Metabolic acidosis E. Vasopressor drugs can be used providing there is sufficient blood volume to be 2. Etiology effective A. Hypovolemic: Caused by a reduction in i. The mechanism and etiology of shock circulating blood as a result of traumatic dictates the specific drug injury, gastrointestinal bleed, crush F. Lab studies should be instituted such as injuries, burns, massive diarrhea, and pH, pO2, pCO2, serum electrolytes, BUN, peritonitis lactic and pyruvic acids, and hematocrit B. Septic: Caused by infections that G. Measure the urine volume produce an endotoxic or exotoxic i. Normally it should be above 30 ml/ reaction. Most common grams (–) are hour E. coli, Proteus group, Pseudomonas, ii. Persistent oliguria below 25 ml/hour Klebsiella, and meningococci. Less for more than 2 hours may cause often involved are grams (+) such renal cell necrosis as staphylococci, streptococci, and clostridia. H. If infection is suspected, cultures should be performed and appropriate antibiotics C. Neurogenic: Severe injury to the spinal initiated cord or brain can cause a loss in vasomotor tone, resulting in vasodilation I. For allergic/anaphylactic reactions, and hypotension from the loss of treatment as mentioned above should be peripheral vascular resistance. Also instituted psychogenic factors such as the sight of blood or surgery can produce shock. NOTE—Patients with a history or suspicion D. Cardiogenic: Produced by hypotension of penicillin allergy may be tested as follows. arising from inadequate cardiac output Dilute penicillin G to a concentration of 1,000 as a result of serious arrhythmias, units per ml and place 1 drop on a skin tamponade, myocardial infarction, scratch on the forearm. If the test is positive congestive heart failure, and pulmonary a wheal will be seen within 15–20 minutes. embolism If the test is negative, inject a small amount E. Metabolic: Caused by alterations in of this solution intradermal to double check. the fluid electrolyte balance as a result This indicates the decreased probability of of systemic diseases such as diabetic anaphylactic response but does not totally acidosis, renal failure, or chronic rule out an allergic state. Keep a “shock kit” respiratory diseases immediately available because even a test F. Anaphylactic: Occurs following the can initiate anaphylactic shock. Also the risk injection of heterologous sera, penicillin, of testing is that patients may become and other medications iatrogenically sensitized to future doses. 10 The Foundation Board Certification Review Study Guide, 13th Edition  D. Indications for RBCs Blood and Blood Components i. Hypovolemia due to acute blood loss for Emergency Use and associated with one or more of (See also Chapter 11: Fluid Management and the following: Replacement in the Surgical Patient) Acute bleeding with an actual or anticipated blood loss of 750 ml or 1. Red blood cells (RBCs) more A. Description Systolic blood pressure < 90 mm i. Available as Packed RBCs of 250 cc, Tachycardia (pulse > 100) split units of 125 cc, or quad packs Hct < 30% and documentation of a for newborns fall of 5% or more within 24 hours ii. Anticoagulants are used to prevent or 10% or more within one week clotting and when a small residual Central venous pressure < 3 cm/ amount of plasma is present H2O iii. Units can be prepared and combined ii. Chronic anemia with special filters to prevent febrile Uncomplicated: Hct < 24% or Hgb reactions, leukocyte poor < 8 mg/dL, and not due to acute iv. Units can be washed to prevent blood loss with anemia syndrome allergic reactions, washed RBCs Complicated: Hct < 30% or Hgb v. One unit can raise the hematocrit by < 10 mg/dL with complications 3% or Hb by 1 g affecting oxygenation (cardiac or B. Compatibility respiratory insufficiency) i. The unit must be ABO compatible, Anesthesia preoperatively: but Rh compatibility not required, Hct < 30% or Hgb < 10 mg/dL only preferred iii. Hemodialysis ii. Rh positive blood can be given to patients especially those age > 50 years, who are expected to use NOTE—RBCs must be used within 4 hours multiple units after removal from the refrigerator and must return within 20 minutes to the blood 10% will develop Rh antibodies bank if not used. Warming can result in 3–4 months later, and by this time bacterial proliferation if allowed to warm the transfused Rh+ cells have to room temperature before returning to been cleared refrigeration. iii. When Rh-units are in short supply, they should be saved for women of childbearing age E. Adverse reactions C. Alternatives i. Infectious reactions i. Autologous transfusions: Patients AIDS: Risk is 1:20,000 to 1:40,000 can donate up to 3 units of blood for each unit transfused prior to surgery and have these units Hepatitis B, C available if subsequent bleeding ii. Noninfectious reactions occurs during the procedure (the safest) Febrile: Fever reaction most common. This reaction involves ii. Directed transfusions: Patients can antibodies circulating in the elect to have friends and relatives recipient that react to HLA donate blood for upcoming surgery antigens in infused granulocytes. iii. Perioperative cell salvage: Patients Allergic: Associated with may elect in certain operative serum antibodies circulating procedures to have blood lost during in the recipient to infused surgery, recollected, filtered, and immunoglobulins within the transfused small amount of residual plasma Sterile orthopedic procedures and of the red cell unit (hives, serum abdominal aortic aneurysms sickness, anaphylaxis) Chapter 1 Emergency Medicine 11  Hemolytic: A result of naturally at least 150 mg of fibrinogen in < 15 ml occurring antibodies circulating of plasma. Transfused 4–6 unit pool. in the recipient to antigens on the B. Compatibility: ABO compatibility is RBCs causing cell lysis preferred but not required in emergency Graft vs. host disease: situations Engraftment and multiplication C. Alternatives: Fresh frozen plasma can be of donor blood cells in an used if there are associated deficiencies immunosuppressed recipient of individual coagulation factors, are possible; and here massive blood transfusion, or when immunocompetent lymphocytes cryoprecipitate is in short supply become engrafted and cannot be D. Indications rejected i. Von Willebrand disease (dDAVP is the 2. Platelets first line treatment) A. Description: A concentrate separated ii. Hypofibrinogenemia associated with from a single donor by plasmapheresis bleeding or surgery (perioperative) from whole blood containing 5.5 x 1011 iii. Dysfibrinogenemia associated with platelets in 200–300 cc of plasma and bleeding or surgery anticoagulant, and can be expected iv. Uremia associated with bleeding to raise the adult platelets count by v. Factor XIII deficiency 60,000–80,000 unless platelet antibodies are present vi. Hemophilia B. Compatibility: ABO compatibility is vii. Disseminated intravascular preferred, but in emergencies or short coagulation (DIC) supply any ABO group can be used. E. Adverse reactions: Same as with RBCs Rh is not a factor. 4. Fresh frozen plasma (FFP) C. Alternatives: Random donor platelets A. Description: The anticoagulated clear are obtained from a single unit of whole liquid portion of blood that is separated blood and contain 1/10 the number of and frozen within a few hours of whole platelets in 30–50 cc, 6–10 units are blood collection. A unit of FFP contains standard suggested therapy about 200 units of factor VIII as well D. Indications as other coagulation factors. Volume is i. Prophylaxis 250 cc. Platelet count < 20,000/mm3 or B. Compatibility: ABO compatibility anticipated drop below 20,000 in required the next 24 hours C. Alternatives Platelet count < 80,000 with i. Specific coagulation factors; surgery anticipated or in the acute cryoprecipitate for low fibrinogen or postoperative period von Willebrand disease A platelet function defect with ii. Crystalloid or albumin is the surgery anticipated or in the acute preferred product for volume postoperative period expansion ii. Bleeding D. Indications Platelet count < 20,000/mm3 i. Replacement of isolated deficiencies, Platelet function defect (known or factor II, V, VII, IX, XI suspected) ii. Reversal of Warfarin effect E. Adverse reactions: Same risks as RBCs iii. Massive blood transfusion; greater 3. Cryoprecipitate (cryoprecipitated than 1 blood volume within several antihemophilic factor) hours A. Description: Prepared by thawing fresh iv. Antithrombin III deficiency frozen plasma at 4 °C and recovering v. Thrombotic thrombocytopenia the cold precipitate. Each bag of ‘Cryo’ purpura contains 90 or more factor VIII units and E. Adverse reactions: Same as with RBCs 12 The Foundation Board Certification Review Study Guide, 13th Edition  NOTE—Allergic reaction, dermal and anaphylaxis, can be severe. Treatment includes Benadryl 50 mg IM STAT, repeated every 10–20 minutes as needed. Steroids and fluids may be necessary in severe reactions. 5. Albumin A. Description: A solution containing the albumin component of human blood, which can affect immediate and prolonged restoration of circulating blood volume by causing a shift of fluid from the interstitial spaces into the circulation, and slightly increasing the concentration of plasma proteins B. Action: 25% albumin will draw approximately 3.5x its volume of additional fluid into the circulation within 15 minutes, and provides a means of replacing human plasma proteins C. Indications i. Plasma or blood volume deficit secondary to surgery, hemorrhage, burns, or trauma to support blood pressure by expanding the plasma volume ii. Hemolytic disease in the newborn iii. Hypovolemic shock: To restore blood volume, increase CO iv. Hemodialysis for the treatment of shock or hypotension when the patient is fluid overloaded D. Contraindications: History of hypersensitivity or severe anemia or congestive heart failure, renal insufficiency, chronic cirrhosis E. Precautions: Solutions containing 5% albumin are usually indicated for hypovolemic patients; 25% solutions should be used when fluid and Na+ intake must be minimized (cerebral edema and pediatric patients) F. Adverse reactions: Rare Chapter 1 Emergency Medicine 13 14 The Foundation Board Certification Review Study Guide, 13th Edition Chapter 2 2 Anesthesia Anesthesia Classifications General Anesthesia Local Anesthetics Special Cases for Lowering the Maximum Allowable Dose Complications Due to Local Anesthetics Pediatric Anesthesia Lumbar Epidural and Caudal Anesthesia Regional Nerve Blocks General Complications of Anesthesia Complications of Endotracheal Intubation Nerve Injuries During Anesthesia Other Medical Complications from Anesthesia 15  Anesthesia Classifications TABLE 2.1. American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System* ASA PS Category Preoperative Health Status Comments, Examples ASA PS 1 Normal healthy patient No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerance ASA PS 2 Patients with mild systemic disease No functional limitations; has a well- controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy ASA PS 3 Patients with severe systemic disease Some functional limitation; has a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms ASA PS 4 Patients with severe systemic disease Has at least one severe disease that is poorly that is a constant threat to life controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure ASA PS 5 Moribund patients who are not Not expected to survive > 24 hours without expected to survive without the surgery; imminent risk of death; multiorgan operation failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy ASA PS 6 A declared brain-dead patient whose organs are being removed for donor purposes * ASA PS classifications from the American Society of Anesthesiologists © Copyright 1995–2010 The Cleveland Clinic Foundation. All rights reserved. 1. Stages of anesthesia General Anesthesia A. There are four stages of general anesthesia that help providers to better A reversible state of unconsciousness predict the course of events, from (unconscious anesthesia) produced by either anesthesia induction to emergence intravenous or inhaled anesthetic agents, with loss of sensation of pain over the whole i. Stage I begins with the induction body. The patient is endotracheally intubated. of anesthesia and ends with the The order of descending depression of the patient’s loss of consciousness. central nervous system during anesthesia is: The patient still feels pain in Stage I. cortical and psychic centers, basal ganglia and ii. Stage II, or REM stage, includes cerebellum, medullary centers, and spinal cord. uninhibited and sometimes dangerous responses to stimuli, including vomiting and uncontrolled movement 16 The Foundation Board Certification Review Study Guide, 13th Edition  iii. Stage III, or surgical anesthesia, is the ii. Morphine: the standard analgesic stage in which the patient’s pupillary narcotic drug for relief of severe gaze is central and the pupils are pain. Depresses the central nervous constricted. This is the target depth system, reduces gastrointestinal of surgical anesthesia. During this motility, constricts the bronchi (due stage, the skeletal muscles relax, the to histamine release), and lowers the patient’s breathing becomes regular, metabolic rate. Has strong sedative and eye movements stop. and analgesic properties. iv. Stage IV, or overdose, is marked by iii. Meperedine (Demerol®): has analgesic, hypotension or circulatory failure. sedative, and spasmolytic properties; Death may result if the patient induces amnesia in conjunction with cannot be revived quickly. barbiturates. Can cause tachycardia and is used with caution in patients 2. Preanesthetic or supplementary agents with atrial flutter and anything A. Sedative/hypnotics that causes increased intracranial i. Diazepam (Valium®): Produces a pressure, just as with any other satisfactory sedative and amnesic narcotic. A strong emetic is usually effect. Indicated to prevent and treat paired with an antiemetic (Vistaril). convulsions. Can be given orally C. IV intraoperative pain management 1–2 hours before surgery. i. IV acetaminophen (Ofirmev®): ii. Lorazepam (Ativan®): Can be given decreased incidence of nausea, safe orally 1–2 hours before surgery for pediatric patients, decreased iii. Midazolam (Versed®): Used as bleeding risks preoperative medication and ii. IV ketorolac (Toradol®): increased induction agent; rapid onset and risk of bleeding event (NSAIDs), short duration of action contraindicated in the cardiac patient iv. Hydroxyzine (Vistaril®) has sedative D. Anticholinergics (belladonna compounds) antihistaminic, antiemetic, and i. Atropine: Decreases respiratory bronchodilating properties, but used secretions and is the drug of choice primarily for its sedative properties; to reduce bronchial and cardiac excellent premedication in patients effects of parasympathetic origin. with a history of bronchial asthma Increases the heart rate by blocking v. Promethazine (Phenergan®): the vagus nerve, stimulates the antiemetic and sedative cerebral cortex. Superior to vi. Propofol (Diprivan®): used with scopolamine as a vagolytic agent; Versed and Fentanyl for balanced therefore, can prevent severe anesthesia. May be used as induction bradycardia and asystole in the agent or as continuous drip for presence of vagotonic agents intravenous anesthetic. Contains (halothane). Atropine and scopolamine egg lecithin, a phospholipid in egg are potent bronchodilators. Patients yolk, which had one reported case of allergic to atropine can be given adverse allergic reaction. However, scopolamine + benadryl. most people who are allergic to eggs ii. Scopolamine: Effective drug for are allergic to the protein, not the psychic sedation and amnesia. The phospholipid. Propofol is not an drying effect is better than atropine. analgesic. B. Narcotic analgesics (opioids) i. Fentanyl (Sublimaze®): produces depression of ventilation that is short in duration. Reversed by narcotic antagonist (Naloxone®). Can also produce muscle rigidity in large doses. Chapter 2 Anesthesia 17  3. Inhalation agents B. Gaseous anesthetic agents A. Volatile liquids i. Nitrous oxide: Least potent of the i. Halothane (Fluothane®): Rarely anesthetic gases and most frequent