EM Clerkship

Cold. Dark. Quiet. Get exercise. Avoid alcohol. 

C→ Episode Summary

We are considering rabies prophylaxis on all animal bites or scratches that come to the Emergency Department. We don’t have to give it every time, but there is a specific protocol we’re supposed to follow

Introduction * What is rabies?* A very rare and aggressive encephalitis* Global impact with exception of UK/Australia* Animals whose bites/scratches may require prophylaxis* Bats* Dogs, Cats, Ferrits* Other carnivorous animals* Foxes, Coyotes, Skunks, Raccoons* Post exposure prophylaxis* Both Rabies vaccine and immunoglobulin When Do You Give Rabies Prophylaxis? * Step 1: Bitten or scratched by domesticated pet?* Immunization status of pet does not matter* Animal must be monitored* Give prophylaxis if animal develops encephalitis* Step 2: Bitten or scratched by wild animal? * If animal is captured it can be sacrificed and tested* Give prophylaxis the animal is not captured and is a potential carrier* Step 3: Possible bat scratch/bite?* Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”* Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)* Reptiles* Birds* Small rodents* Rabbits/Hares* Livestock* Step 5: How to give prophylaxis* Only contraindication is severe egg allergy* Can be given to babies/pregnant women/etc* Rabies immunoglobulin* Give ONCE in the department* Inject as much as possible around wound* Rabies vaccine* Give first day* Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28) Pearls * It doesn’t matter if the bite/scratch was provoked or unprovoked* It doesn’t matter where on the body the patient received the bite/scratch* It’s a universally fatal disease* No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits* The NNT is >300,000 (but we still do it) Additional Reading * Rabies Guidelines (CDC)

You have to be very knowledgable about occupational exposures because this is the only chief complaint that I guarantee, you will eventually manage in a colleague. LEARN THIS. 

The only chief complaint that you are guaranteed to eventually have to manage in a colleague Respiratory Exposures * Meningococcus​ (meningococcemia, meningitis, etc)* Give prophylaxis (ceftriaxone) if…* Intubated a pt without a mask* Suctioned a pt without a mask* Performed mouth to mouth resuscitation* Tuberculosis​ * CDC recommends testing if exposed* Treat if positive* CDC recommends prophylaxis in..* Little children, HIV positive, immunosuppressed Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick) * Hepatitis B​* Test source patient* If positive, 1-30% risk of transmission with needle stick exposure* (Mucous membrane/broken skin exposures are much lower risk)* Test exposed colleague for anti-HepB surface antibody level* If source patient is positive and coworker is not fully immunized…* Treatment * Hep B Vaccine* Hep B Immunoglobulin* Hepatitis C​* Test source patient* If positive, 2% risk of transmission with needle stick exposure * (Mucous membrane/broken skin exposures are much lower risk)* Get baseline hepatic function labs (LFTs) in coworker* Follow-up on outpatient basis, no prophylaxis available* HIV​* Test source patient with rapid HIV test* If positive, 1/300 risk of transmission with needle stick exposure* Transmission risk increases if: bloody exposure, large needle bore* (Mucous membrane/broken skin exposures are much lower risk)* Generally recommend prophylaxis if source is positive* Prophylaxis is potentially curative if given at exposure* Counsel on safe sex practices* Counsel on common treatment side effects* GI symptoms, headaches, fatigue Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Breast complaints are usually pretty straight forward. Just remember that all breast complaints are cancer until proven otherwise.

All breast complaints are cancer until proven otherwise!!! History * Increased risk of breast cancer* Family history of breast cancer (especially 1st degree)* Delayed childbearing (no children until after 30)* Age >50* Associated with menstrual cycle Exam * Asymmetric appearance of breasts* Palpable mass* Red Flags* Non-mobile* Overlying skin changes* Lymphadenopathy* Located in upper/outer quadrant of breast Differential Diagnoses * Red/inflamed/painful breast* Postpartum engorgement* Treat with warm compresses, continue breastfeeding/pumping, massage* Infection (“Mastitis”)* Treat with antibiotics and continue breastfeeding* Abscess* Treat with needle aspiration* Refer to breast surgeon* Non-inflamed breast pain* Fibrocystic changes* Associated with menses* Treat with supportive bra* Breast mass* Fibroadenoma* Slippery/mobile* Fibrocystic changes* Nipple discharge* Red flags* Unilateral discharge* Bloody discharge Additional Reading * Breast Cancer Screening Guidelines (CDC)

Neonatal conjunctivitis is a quick topic, but has some big LIFE THREATS which you’ll need to know for both real life and your test. 

The 3 Worst Causes of Neonatal Conjunctivitis * Gonorrhea* Causes corneal ulcers and sepsis* Red flags* 1st week of life* Copious purulent drainage* Diagnose with cultures* Treatment* Cefotaxime (3rd generation cephalosporin)* Admit* Chlamydia* Occurs in 1st month of life* Treat with PO erythromycin* HSV* Can disseminate to the brain* Red flags* Mother tested positive (or had active lesions)* Vesicles on baby* Treatment* IV acyclovir* Admit Other Causes of Conjunctivitis * Viral/other bacterial* Treat with erythromycin ointment* Chemical conjunctivitis* Caused by eye drops given after birth* Dacryostenosis (closed eye ducts)* Watery eyes from tears not draining Additional Reading * Neonatal Conjunctivitis (CDC)

This is a concept episode for a series of lectures on Emergency Dermatology (one of my favorite topics). Over the course of several episodes, we will develop an organized, systematic, visual approach to the diagnosis of all life threatening rashes as well as the majority of the other rashes you will see in the ED. 

T→ Episode Summary

Subarachnoid hemorrhage is the king of life-threatening headaches and is on my differential every time. This episode will cover how to take the history, exam, testing and treatment of this devastating diagnosis.

History * Sudden and maximal in onset* Compared to previous headaches* Family history of aneurysm* Associated Symptoms* Photophobia* Visual Changes* Neck Stiffness Exam * Full neuro examination* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Gait Testing Plan * Non-contrast head CT* Excellent sensitivity <6 hours from onset* Lumbar puncture* >100 RBCs in tube 4* Can be difficult to interpret after a traumatic lumbar puncture* Xanthochromia Treatment Plan * Prevent rebleeding* Keep SBP <140* Nicardipine* Reverse any anticoagulants* Vitamin K* Prothrombin complex concentrate* Fresh frozen plasma* Prevent vasospasm* Nimodipine PO* Prevent delayed ischemia* Avoid hyperthermia* Avoid hyper/hypoglycemia* Prevent seizures* Levetiracetam (aka Keppra) Additional Reading * Ottawa Subarachnoid Hemorrhage (MDCalc)

Babies frequently have red stuff in their diapers, and when they do, mom will rush them to the department concerned that they are having a fatal GI bleed. Usually it’s not…