ADVANCES IN MEDICINE
From the Annual Review Course for the Family Physician, sponsored by the University of Tennessee College of Medicine, Memphis
| TIPS AND TRICKS IN EMERGENCY AND URGENT CARE —Loren A. Crown, MD, Clinical Professor of Family Medicine, University of Tennessee, College of Medicine, Covington |
| Musculoskeletal problems: medication “pack”—3 drugs (acetaminophen, ibuprofen, and methocarbamol) given 4 times daily for 5 days; no narcotics |
| Kidney stones: increasing intake of fluids does not flush out stones; nonoccluded kidney compensates by increasing rate of filtration; overhydrating patient may result in hyponatremia; medications—opioids; nonsteroidal anti-inflammatory drugs (NSAIDs); desmopressin; infected stones—culture specimens from kidney stones from patients with diabetes or urinary tract infections (UTIs) because of risk for septic shock |
| Hemorrhoids: Preparation H has no active ingredients; anesthetic agent preferred; NSAIDs have some benefit; suppositories—blunt end inserted first; correct orientation decreases likelihood of expulsion |
| Vaginal bleeding: important to check status of Rh factor (commonly forgotten during work-up) |
| Nasal inhalers: improper insertion commonly causes nosebleeds; having patient look at floor while inserting inhaler helps achieve proper angle, directing spray into posterior nasopharynx |
| Sickle cell crisis: rehydration—intravenous (IV) fluids not necessary when patient can take fluids orally; forcing fluid into vascular tree does not resolve “logjam” caused by sickle cells; O2—giving O2 to patient with normal lung function does not increase delivery to hypoxic tissues; analgesia—patients have high index of pain, often requiring narcotics; transdermal delivery systems or injections acceptable; fentanyl lollipops good for self-dosing; large doses often required to relieve pain |
| Refractory urticaria: treatment options include H1 blockers (eg, diphenhydramine [Benadryl] or hydroxyzine [Vistaril]), H2 blockers (eg, cimetidine), steroids, doxepin, and montelukast (Singulair) |
| Pediatric dosing: 4-2-1 rule for IV fluids—give 4 mL/kg hourly for first 10 kg; add 2 mL/kg hourly for second 10 kg; add 1 mL/kg hourly for each kilogram \>20 kg; oral intake—most infants take formula 6 times daily; 1 oz formula for each kilogram body weight at each feeding sufficient |
| Sore throats: 1 to 2 spoonfuls of Benadryl plus laxative or antacid, mixed 50/50 (mixture typically filled by pharmacy), taken every few hours; viscous lidocaine plus antacid (mixed 50/50) to “swish, swirl, spit” (liver detoxifies lidocaine) |
| Anal fissures: nitroglycerine ointment improves healing |
| Toxicology: syrup of Ipecac, charcoal, cathartics, and gastric lavage no longer recommended |
| Hemoccult cards: to improve sensitivity of test, wait 3 to 5 min after smearing card with stool sample before adding 1 to 2 drops developer to other side of paper |
| Deep vein thrombosis (DVT): Lowenberg test—wrap blood pressure (BP) cuff around unaffected calf; increase pressure until patient has pain response (normally occurs at 180-200 mm Hg); repeat on affected side; positive sign—pressure required to elicit pain response decreases by ≥25% compared to unaffected leg (suggests DVT) |
| Foreign-body inspections: anesthetizing both eyes prevents hypersensitivity from developing in unaffected eye; having patient look in 1 direction helps keep eyes still while extracting particle |
| Abdominal examination: ask children to point to area of “tickle” or “where to put Band-Aid”; also ask about hunger and about their ride to hospital; adults—look for peritoneal sign by bumping into stretcher and watching for pain response (eg, wincing) |
| Tapping knees: angiocath causes less pain than needle; injecting 5 mL air into knee may help determine whether angiocath positioned within joint |
| Placement of leads for electrocardiography (ECG): mnemonic—“white is right” (white lead on right side); “smoke rises over fire” (black lead placed above red lead); “green means go” (green lead placed on right side [gas pedal side]) |
| Measuring blood gas: pH of venous blood approximates that of arterial blood (generally within 0.01 pH point); drawing venous blood less painful and can be performed by nurse; O2 saturation provides information about O2 and CO2 |
| Imaging before lumbar puncture (LP): in past, concern about increased intracranial pressure and potential for herniation of brain; currently, CT recommended only in patients with altered mental status, papilledema, or other clinical indication that warrants CT |
| Foreign objects on radiographs: glass—visible, unless overlaying bone (may require \>1 view); fish bones—bones of saltwater fish often visible (high mineral content), but those of freshwater fish often invisible; aluminum—not visible |
| Facial injuries: regional nerve blocks anesthetize large areas of face and reduce exposure to lidocaine (Xylocaine) and epinephrine; fractures—treat fracture only when deformities present (radiographs not necessary if no “step-off” found); palpate around foramina (90% of facial fractures); check for hypoesthesia (clinical indication of fracture) |
| Bacterial cultures: \>99% of positive cultures grow within 24 hr (ie, often not necessary to keep patients in hospital for 3 days) |
| Lung examinations: pediatric—pinch nose to get children to breathe through mouth when listening to lungs; adult—ask about history of smoking immediately after listening to lungs |
| Urine samples from infants: collecting urine sample by wringing out wet (disposable) diaper acceptable according to current guidelines; urine absorbed immediately by fibers (does not stay on skin) |
| Imaging: CT—not useful in most cases of low back pain; plain abdominal radiograph—primarily used for patients with distended abdomen, and sometimes when looking for foreign bodies (not generally useful for kidney stones); associated with high level of radiation exposure and rarely alters patient outcome |
| Chest pain: sublingual nitroglycerine no longer recommended to test for acute coronary syndrome; results unreliable; potential to ameliorate epigastric pain associated with gallstones may lead to incorrect diagnosis |
| DEEP VEIN THROMBOSIS —Gregg E. Mitchell, MD, Instructor of Family Medicine, and Interim Program Director, Residency Program in Family Practice, University of Tennessee, College of Medicine, Jackson |
| Morbidity and mortality: pulmonary embolism (PE) may occur without clinical signs (ie, silent); patients with deep vein thrombosis (DVT) may develop postphlebitic syndrome; patients with PE may develop pulmonary hypertension; fatality—≈50% of fatal PEs potentially curable (top cause of preventable death in hospitals); patients with venous thromboembolism (VTE) have case fatality rate of ≈12% in hospital; long-term fatality rate increases each year after VTE; rates increase in elderly patients; 10% of all hospital deaths caused by PE (11% of patients die within 1 hr; 38% die within 2 hr) |
| Risk factors: age \>40 yr; ischemic (nonhemorrhagic) stroke; congestive heart failure (CHF); history of VTE; inherited thrombophilia; obesity; malignancy; admission to intensive care unit (ICU); chronic lung disease; respiratory failure; pneumonia; infection; active collagen vascular disorder; inflammatory disorder; central venous line or catheter; varicose veins; nephrotic syndrome; oral contraceptives (OCTs) or estrogen replacement therapy; tamoxifen or raloxifene (Evista); pregnancy and immediate postpartum period; smoking; inherited thrombophilia—condition usually presents in patients <50 yr of age; 10% of general population and 25% of patients with DVT have disorder; malignancy— patients diagnosed with VTE may have underlying malignancy; common sites include lungs, pancreas, colon, rectum, kidney, and prostate; VTE second leading cause of death in patients with cancer |
| Diagnosis of DVT: clinical features include pain, tenderness, warmth, congested or turgid tissue, and edema (but none has high specificity for diagnosis); Homan’s sign unreliable; differential diagnosis—muscle strain; inflammation in paralyzed limb; lymphangitis; venous insufficiency; popliteal (Baker’s) cyst; cellulitis; knee problems; unknown etiology (≈25% of patients) |
| Testing: complete blood count (CBC); prothrombin time (PT) and partial thromboplastin time (PTT); complete metabolic panel (CMP); urinalysis; prostate-specific antigen (PSA), chest radiograph, or pregnancy test in appropriate patients; hemoccult test, looking for acute gastrointestinal (GI) bleeding and signs of colon cancer; additional testing—factor V Leiden mutation; prothrombin gene 20210a mutation; homocysteine level; lupus screen; protein C, protein S, and antithrombin III; factor VIII; timing—levels of antithrombin III and proteins C and S reduced by presence of clot and treatment with heparin or warfarin (wait ≥2 wk after completing treatment with anticoagulant to measure levels); testing for mutations in prothrombin gene or factor V Leiden (most common forms of inherited thrombophilia) unaffected by presence of clot or treatment; candidates for screening for inherited thrombophilia—family history of blood clots; age <50 yr when presenting with DVT; recurrent DVTs; blood clot occuring with OCT use or pregnancy; DVT occurring in portal, mesenteric, hepatic, or cerebral veins |
| Diagnostic imaging: DVT—ultrasonography (US) test of choice (but difficulty distinguishing clot from scar tissue in patients with recent history of DVT); contrast venography gold standard; magnetic resonance imaging (MRI) sensitive and specific; PE—spiral computed tomography (CT) often preferred over ventilation-perfusion (V/Q) scan; US good for symptomatic patients but not for asymptomatic patients; MRI good for symptomatic patients; compression US— noninvasive, portable imaging technique, appropriate for clots in femoral and popliteal veins; lower accuracy in diagnosing clots in calf or iliac veins and in asymptomatic patients; unknown accuracy for diagnosing recurrent VTE |
| Diagnostic decision tree: perform US in patients with suspected DVT; treat patients with positive findings; perform additional testing in patients with negative findings; low-risk patients—perform D-dimer test (clinical follow-up, if negative); moderate-risk patients—repeat US in 5 to 7 days; high-risk patients—consider venography or MRI; note— clinical information alone insufficient to confirm or exclude diagnosis of DVT or PE |
| Medical patients: study found 6 to 14 days of daily treatment with 40 mg enoxaparin reduced risk for VTE by 63% and risk for proximal DVT (compared to placebo and daily treatment with 20 mg enoxaparin); reduced risk maintained through day 110 and associated with improved rate of survival; no significant increase in risk for hemorrhage; recommendations—treatment options for prophylaxis in general medical patients with clinical risk factors for VTE include low molecular weight heparin (LMWH) or low-dose unfractionated heparin (UFH); exclusion criteria include bleeding, hypersensitivity to UFH or LMWH, BP \>180/110 mm Hg, significant renal insufficiency (withhold or adjust dose), coagulopathy, recent history of heparin-induced thrombocytopenia (HIT), recent intraocular or intracranial surgery, and spinal tap or epidural anesthesia within 24 hr |
| Surgical patients: low-risk patients—age <40 yr; minor surgery; absence of other risk factors; aggressive mobilization recommended; moderate-risk patients—minor surgery in patients with additional risk factors or in patients 40 to 60 yr of age with no additional risk factors; major surgery in patients <40 yr of age with no additional risk factors; high-risk patients— minor surgery in patients \>60 yr of age or with additional risk factors; major surgery in patients \>40 yr of age or with additional risk factors; highest-risk patients—major surgery in patients \>40 yr of age, with previous VTE, cancer, or hypercoagulable state; knee arthroplasty or surgery for hip fracture; major trauma; injury to spinal cord; recommendations— regimens include heparin therapy (UFH or LMWH), oral anticoagulants, elastic stockings, and intermittent pneumatic compression devices |
| Prophylaxis after surgery: enoxaparin and fondaparinux, but only fondaparinux approved for use in patients with hip fractures (otherwise, efficacies similar); fondaparinux more expensive, contraindicated in patients with low body weight and those with renal disease, and has no reversal agent; protamine sulfate can reverse ≈60% of anticoagulation after treatment with enoxaparin; adverse effects—most effects occur at surgical site; fondaparinux associated with slightly higher rate of hemorrhage, but no reports of thrombocytopenia (as may occur with enoxaparin); local reactions at site of injection |
| Treatment regimens in medical patients: standard therapy—give IV bolus of UFH; monitor PTT; begin warfarin within 24 hr; adjust daily dose according to international normalized ratio (INR); continue combined therapy for ≥4 days; stop UFH when INR \>2.0 for 2 consecutive days; check platelet count daily; anticoagulate for ≥90 days; outpatient treatment— LMWH has less nonspecific binding and more predictable response; reduced binding to macrophages results in longer half- life; LMWH associated with less risk for HIT and osteopenia and has favorable benefit-to-risk ratio; study found 1 mg/kg enoxaparin given subcutaneously q12 hr (or 1.5 mg/kg enoxaparin given subcutaneously q24 hr) at least as effective as standard heparin therapy in treating patients with acute proximal DVT without PE; safety profiles similar; LMWH preferred for patients at risk for bleeding; LMWH associated with lower mortality rate; contraindications for LMWH—symptomatic pulmonary embolism; active bleeding or familial bleeding disorder; marked renal insufficiency; severe liver disease; weight \>120 kg (may have to alter dose); severe inflammation or pain in leg; concurrent use of NSAIDs; pregnancy; prolonged stay in hospital anticipated; treatment duration—treatment with enoxaparin (Lovenox) for up to 17 days well tolerated in trials; average duration of treatment 7 days; loading patients with warfarin (Coumadin) may decrease requirements for Lovenox |
| Coumadin therapy: clinical trials—6-mo treatment with low-dose Coumadin (target INR of 1.5-2.0) improved outcomes (VTE, major hemorrhage, and death) over heparin therapy alone; conventional-intensity therapy further reduces risk for VTE; conventional-intensity therapy with warfarin recommended for lifetime treatment |
Educational Objectives
| The goal of this activity is to provide the clinician with information about treating a wide range of common medical complaints, with emphasis on diagnosing and treating venous thromboembolism (VTE). After hearing and assimilating this program, the clinician will be better able to: |
 | 1. Provide adequate relief of pain to patients with various medical conditions. |
| 2. Discuss appropriate uses of diagnostic imaging in the urgent care setting. |
| 3. Diagnose patients with inherited thrombocytopenia. |
| 4. Identify patients at risk for venous thromboembolism (VTE) and develop plan for prophylaxis. |
| 5. Diagnose and treat patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) |
Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several trade names] Cimetidine [Tagamet, Tagamet HB, Cimetidine Oral Solution] Desmopressin acetate (1-deamino-8-D-arginine vasopressin) [DDAVP, Stimate] Diphenhydramine HCl [Benadryl, others] Doxepin HCl [Adapin, Sinequan, Sinequan Concentrate, Zonalon] Enoxaparin sodium [Lovenox] Fentanyl transmucosal system [Actiq, Fentanyl Oralet] Fentanyl transdermal system [Duragesic-25, Duragesic-50, Duragesic-75, Duragesic-100, E-TRANS Fentanyl (investigational)]] Fondaparinux sodium [Arixtra] Hydroxyzine [Atarax, Atarax 100, Vistaril, Vistazine 50] Hydrocodone bitartrate and acetaminophen (several trade names) Ibuprofen (several trade names) Ketorolac tromethamine [Acular, Acular LS, Toradol] Lidocaine HCl [Xylocaine, others] Methocarbamol [Robaxin] Montelukast sodium [Singulair] Raloxifene [Evista] Tamoxifen citrate [Nolvadex] Warfarin sodium [ Coumadin]
Suggested Reading
Aujesky D, et al: Oral anticoagulation strategies after a first idiopathic venous thromboembolic event. Am J Med 118:625, 2005; Chong BH, et al: Once-daily enoxaparin in the outpatient setting versus unfractionated heparin in hospital for the treatment of symptomatic deep-vein thrombosis. J Thromb Thrombolysis 19:173, 2005; Hayes R: Abdominal pain: General imaging strategies. Eur Radiol 14 Suppl 4:L123, 2004; Heit JA: Venous thromboembolism: Disease burden, outcomes and risk factors. J Thromb Haemost 3: 1611, 2005; Imperiale TF, et al: Fecal DNA versus fecal occult blood for colorectal cancer screening in an average-risk population. N Engl J Med 351:2704, 2004; Kahn SR, et al: Predictors of the post- thrombotic syndrome during long-term treatment of proximal deep vein thrombosis. J Thromb Haemost 3:718, 2005; Perlman KM, et al: A shift from Demerol (meperidine) to Dilaudid (hydromorphone) improves pain control and decreases admission for patients in sickle cell crisis. J Emerg Nurs 30:439, 2004; Ramzi DW, Leeper KV: Deep venous thrombosis and pulmonary embolism: Part II. Treatment and prevention. Am Fam Physician 69:2841, 2004; Rosencher N, et al: Venous thromboembolism and mortality after hip fracture surgery: The ESCORTE study. J Thromb Haemost 3:2006, 2005; Scutellari PN, et al: The value of computed tomography in the diagnosis of low back pain: A review of 2012 cases. Minerva Med 96:41, 2005; Spyropoulos AC: Emerging strategies in the prevention of venous thromboembolism in hospitalized medical patients. Chest 128:958, 2005; Taylor EN, et al: Diabetes mellitus and the risk for nephrolithiasis. Kidney Int 68:1230, 2005; Weitz JI, Bates SM: New anticoagulants. J Thromb Haemost 3:1843, 2005; Wiener SW, Hoffman RS: Trends in clinical toxicology: Advances that may change your practice. Basic Clin Pharmacol Toxicol 97:1, 2005.
Faculty Disclosure
In adherence with ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported nothing to disclose.
Drs. Crown and Mitchell were recorded in Memphis at 38th Annual Review Course for the Family Physician, sponsored by University of Tennessee Health Science Center, College of Medicine, Department of Family Medicine, and held March 14-18, 2005. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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