ࡱ> xzw5@ VYbjbj22 ;tXX&  *++++4+*Ap,,,,,,,,@@@@@@@$*CR|E@-,,- -@,,tAr5r5r5-,,@r5-@r5"r55::,:,, +n3p: =4A0A:.F3HF:**F:,-r5- -,,,@@**d$&5L**IVF for blood products: always NS PRBC for acute blood loss or symptomatic anemia. Never give if hgb M>10, F>7 Adults: 1 U PRBC (peds 3 cc/kg)! ! H/H by 1 / 3 Usually 1 U over 60-90 min, but w/in 4 hrs. Can give 50-100 cc NS to ! rate Plts Give for < 20,000 or < 50,000 and oozing or going for procedure 1 U plts ! ! plts by 5 x 103 No ABO match but match Rh. Usually give adults 6-10 U, peds 1 U/10 kg FFP 1 ml of FFP is H" 1 unit of activity for any clotting factor. For warfarin reversal give 5-8 ml/kg. Otherwise, for 30% of nl plasma factor concentration, give 10-15 ml/kg. Each unit contains 150-250cc FFP. Viral Transmission Risk Hep A 1:1,000,000 Hep B 1:30,000 to1:250,000 Hep C 1:30,000 to1:150,000 HIV 1:200,000 to1:2,000,000 HTLV I & II 1:250,000 to 1:2,000,000 Overall 1 in 30k to 2M, depending on which infection All other systems reviewed and negative, except as noted may be used when > 10 systems reviewed. PMH & FHx may ea ct as one system in ROS. Unable to fully assess d.t. AMS or pts condition Physical exam incomplete due to critical condition Medicare: # of dx or tx opts: 1) dx all probs or conds, 2) Exac worth more, 3) doc addtl w/u, 4) use cc as dx Medicare: Amt &/or complex of data revd: 1) decision to obtain and summ of old recs, labs, rad, 2) d/w family or PMD, 3) labs and rad Medicare: Risk of complics &/or M&M: 1) Meds given: IV > IM > PO Pvt ins: cc, final dx, and ED crs det lvl of visit. Points for rsrc consump. 1) 1 point = pelvic and rectal, consult, rec review, IVF, EKG, montior, O2, bcx, trop; 2) ea x-ray is a sep point Crit care: must doc total time spent. Incls time spent and procs, sep bill procs (cpr, intub, transvenous PM, LP, lac repairs, chest tube). Does not have to be beside or continuous. Swelling of tongue or lip => concern for airwayNorepinephrine alpha > beta1 >> beta2 Epinephrine alpha and beta Dopamine DA, alpha and beta1 Dobutamine beta1 > beta2=alpha ? vasodilation Phenylephrine phenylephrine (alpha) no beta Isoproterenol only beta vasodilation Amrinone PDE inhib vasodilationIV Drip rate: Desired cc/min drop factor = gtt/min e" D20 reqs central line Peds: Bolus 20cc/kg NS, x2 if necessary, then t/c colloids, blood, plasma Maintenance: < 20-25 kg ! D5NS + 20 mEq/L KCl >25 kg ! D5NS + 20 mEq/L KCl  100/50/20 Rule: 100 cc/kg for up to the 1st 10 kg of body weight* 50 cc/kg for up to the 2nd 10 kg of body weight 20 cc/kg for up to the 3rd 10 kg of body weight Max total fluid/day usually 2-2.5L cc  4/2/1 Rule: 010 kg: 4 mL/kg/hr 1020 kg: 40 mL/hr + 2 mL/kg/hr (wt-10 kg) >20 kg: 60 mL/hr + 1 mL/kg/hr (wt-20 kg)DDx: at least 4, justifies ancillary tests Order Observation Status. Order and time, admission note, reassess note, d/c note By Me Reduction/fx: days to f/u with ortho, I think want > 3-4, or may have been 5 Conscious sed: drug used and monitored Splits: doc pre- and post-exam of splinted area LP- CSF interp. Debridement EKG: rath, rhythm, and interp. Rhythm EKG rept: NSR @ 68 bpm no ectopy Doc all interprs and procs Sit whenever possible. Demo high lvl certainty in dx & tx. Town done voice. Let them vent. Blameless apology. Have I done something to upset you? Greeting & ID. Remark on pt cond, waiting time, RN assessment, offer symptom relief. Try to estimate wait times. When can return to nl activ. Can you tell me what your medical problem is? What are you going to do (incl for f/u)? Why is it important that you do this?Otherwise healthy, 1st-onset sz pts w/ no comorbs & have returned to their baseline Level A- none Level B- serum glu, Na, preg test. If immunocompromised ! LP. Should receive CTH in ED, deferred outpt neuroimaging may be used if has reliable f/u Level C- if nl neuro exam, can d/c. If nl neuro exam, no comorbs, and no structural brain dis ! no need start anti-epileptics in ED Sz w/ known sz d/o and subther on phenytoin: Level C- IV or PO phenytoin or IM fosphenytoin and restart qd PO maintenance dose. Status epilepticus: Level C- IV  high-dose phenytoin, phenobarb, valproic acid, midazolam infusion, pentobarb infusion, or propofol infusion T/c EEG in pts if suspect nonconvulsive status epilepticus or in subtle convulsive status epilepticus, pts given long-acting paralytic, or pts in drug-induced coma Level A- high certainty Level B- mod certainty Level C- based on prelim, inconclusive, or conflicting evidence. Or based on consensus of ACEPs Clinical Policies Committee Levels 1-3 Level 4 Level 5 Crit Care Straight Fwd Detailed Comprehensive *crit car must be doc approp with at least 30 min of cumulative time spent & chk the box excluding time spent on separately billed procs Brief HPI Extended HPI Extended HPI HPI 1-3 HPI els d" 4 HPI els d" 4 HPI els ROS 1+ rel to HPI 2-9 sys orFN : @ B  N Q  012vxz0ʷʞ}rfrVGhO6h}CJaJmH sH hO6h}5CJaJmH sH hL3h}5CJaJh}h}CJaJh(-hls:CJaJh(-h(-CJaJh}hMGCJaJh:CJaJnHo(tHh\h:CJH*aJh\h:CJaJhCJaJh:CJaJhgh5CJaJh}h ECJaJh Eh5CJaJh}hCJaJFF l : - r $If]gdlK$$If]^gdl ' XUY $If]gdlK$gkd$IfK$L$ld t044 la ll$If]gdlK$zkdN$IfK$L$l0d t044 la ll$If]gdlK$zkd$IfK$L$l0d t044 la ll$If]gdlLK$zkd$IfK$L$l0d t044 la  ll$If]gdlK$zkdz$IfK$L$l0d t044 la  N l$If]gdlK$zkd$IfK$L$l0d t044 laN O P Q |?$$If]^gd:l <kd$$If4  4 af4$If]^gdl 'gkdB$IfK$L$ld t044 la FBH12Yurrrr$If]^gd(-l T<kd$$If4  4 af4 & F$If]gd:l $If]^gd:l  2xzTD!Q$If]^gd}l '<kdT$$If4  4 af4$If]^gd(-l TTVv ~/Ejk};<Z\ºzrg[M[h~shYe>*CJH*aJh~shYe>*CJaJh}hH^CJaJh<CJaJhACJaJhzCJaJhoCCJaJhPCJaJhb'CJaJhk8CJaJhCJaJh*CJaJh"hT_CJaJh"hTpCJaJhDh"CJaJhDhTpCJaJhS;>*CJaJhDhS;>*CJaJh}hCJaJhYeCJaJnHtHhYeCJaJh~shYe5CJaJjhYe0J<U %<$$If]a$gdYelK$<kdz$$If4  4 af4$If]^gdYel T K3$If]gd%hElK$kd$IfK$L$lr xTT t044 la $!$If]gdy]LlK$$$If]a$gdYelK$$!&!(!J2$If]gd%hElLK$kd}$IfK$L$l4r xTT` t044 la(!*CJaJhDh CJaJUhDh"CJaJhTp>*CJaJhn9hTpCJaJhDhTpCJaJ hDhTpCJPJaJnHtH#hDhTpCJPJaJnHo(tH"!!!J2$If]gd%hElLK$kd$IfK$L$l4r xTT  t044 la!! T"T#T$T/kdx$IfK$L$l4r xTT  t044 la$$If]a$gdYelK$ ROS caveat 10+ sys or ROS caveat PFSH Not reqd 1 area (past hx) 2 areas (past hx & soc hx) Exam Constitutional & rel body areas/org syss 5-7 els reqd (body area/org sys) 8 org sys redq Trich vaginalis Malodor, itchy, profuse white or white tinged d/c (can be gray, green, or frothy). Cvx stippled or punctuate strawberry, pH > 5.5. Motile trichomonads, pear-sh w/ 3-5 flagella at one end, sl lger than leukocyte. Flagyl 2g PO x1 & tx partner BV Malodor homog gray or white d/c, +amine sniff test, clue cells. Fr overgrowth of G vaginalis, mycoplasma hominis, & mobiluncus spp, anaerobes, & other bact. Rel defic of lactobacillus. Flagyl 500 mg po bid x7d or 0.75% gel intravag bid x5d or Clinda 300 mg bid x7d Candida Risk abx, preg, OCs, steroids, DM, restrict clothg. Itch enough to prevent sleep. Non-odorous, sticky d/c cottage cheese texture. Vag, vulva, & perineum hyperpig, scalded. Tx Fluconazole150 mg po x1 if not preg or many OTC antifung creams, suppositories, & tablets Chancroid H ducrei, azithro 1g pox1 [ceftriaxone 250 mg IMx1, erythro 500 mg po x7d] L venereum C trachomatis, doxy 100 mg po bid x21d [erythro 500 mg po qid x21d or SMX 500 mg po qid x21d]  ACEP News, Jan 2005, Jagoda, Andy. 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