ACOFP 54th Annual Convention & Scientific Seminars

Urgency vs. Emergency: Pearls for the Urgent Care Physician

Lindsay Saleski, DO, MBA, FACOEP

3/9/2017

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Urgency vs. Emergency

Pearls for the Urgent Care

PhysicianLINDSAY TJIATTAS-SALESKI DO, MBA, FACOEP

FAMILY PRACTICE/EMERGENCY MEDICINE

MIDLANDS EMERGENCY PHYSICIANS

PALMETTO HEALTH TUOMEY

Objectives

To provide the urgent care physician with evidence based

information regarding common outpatient presentations, initial

treatment strategies and potential need for more emergent care.

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Outline

Head trauma evaluation – PECARN and Canadian Head CT Rules

Human Bite

Evaluation of Hypertension

Supracondylar Fracture

Pharyngitis

Headache

Scaphoid Fracture

Allergy versus Anaphylaxis

Cervical spine trauma

Pulmonary Embolism Clinical Prediction Rules

Doc… my kid fell off the bed and

hit their head!

Pediatric Emergency Care Applied Research Network – PECARN

Federally-funded multi-institutional network for research in pediatric

emergency medicine in the United States

Pediatric Head Injury Prediction provides factors to identify those

at very low risk of clinically important traumatic brain injuries for

whom CT might be unnecessary

Prospective cohort study of 42,412 children

Children (<18 years) presenting within 24 hours of head trauma, with

Glasgow Coma Scale scores of 14 to 15

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Pediatric Head Injury/Trauma

Algorithm

Children younger than 2 years

Normal mental status

No scalp hematoma except frontal

No loss of consciousness or loss of

consciousness for <5 seconds

Non–severe injury mechanism

No palpable skull fracture

Acting normally according to the parents

Children ages 2 years and older

Normal mental status

No loss of consciousness

No vomiting

Non–severe injury mechanism

No signs of basilar skull fracture

No severe headache

Doc…I fell and hit my head!

Traumatic brain injury (TBI) = brain function impairment that results from external force

Mild: GCS 14-15 (Most Common)

Moderate: GCS 9-13

Severe: GCS 3-8

History and Physical Exam

Pupillary response

Altered motor function

Age of patient

Comorbidities (anticoagulant use?)

Decision rules attempt to limit unnecessary CT imaging & identify surgical emergencies

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Canadian CT Head Injury/Trauma

Rule

Can clear a head injury without imaging

Apply to patients with:

GCS 13-15 and LOC

Amnesia to the event

Confusion

Excludes:

Age <16

Seizure after injury

Blood thinner use

Canadian Head CT Rule

High Risk Criteria: Rules out need for neurosurgical intervention

GCS <15 at 2 hours post-injury

Suspected open or depressed skull fracture

Any sign of basilar skull fracture?

Hemotympanum, raccoon eyes, Battle’s Sign, CSF oto-/rhinorrhea

≥ 2 episodes of vomiting

Age ≥ 65

Medium Risk Criteria: In addition to above, rules out “clinically important” brain injury (positive CT's that normally require admission)

Retrograde amnesia to the event ≥ 30 minutes

“Dangerous” mechanism?

Pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from > 3 feet or > 5 stairs.

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Doc…I punched a door and now

my hand hurts!

Human bite: the "Fight Bite”

Clenched-fist injury: 3rd – 5th metacarpophalangeal joints of the

dominant hand

Complications: cellulitis, septic arthritis, osteomyelitis

Injury possible to the extensor tendon/bursa, the superficial/deep fascia,

joint capsule

Polymicrobial infection with normal human oral flora:

S. aureus (20-40%)

Eikenella corrodens (25%)

Streptococcus species

Anaerobic: Prevotella species, Fusobacterium nucleatum, Pepto-

streptococcus

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Treatment

Neurovascular evaluation of the hand & plain radiographs to rule out fracture

Copious irrigation and debridement

DO NOT close the wound (exceptions cosmetic)

Wound culture

Antibiotics ISDA and Tintinalli

Amoxicillin/clavulanic acid 875/125 mg PO BID

Ampicillin-sulbactam 1.5-3 gm Q 6 hours or cefoxitin 2gm Q 8 hours or piperacillin-tazobactam 3.375 grams Q6 hours

PCN allergy – clindamycin plus moxifloxacin or TMP-SMX and metronidazole

Clindamycin 300 mg tid or 600 mg every 6–8 h plus Cipro 500–750 mg bid 400 mg every 12 h

Doc….My blood pressure is

210/115!

First thing…Recheck it!

HTN defined as SBP>140 mm Hg and DBP > 90 mm Hg

Primary (essential) vs. Secondary

ED Classification:

Asymptomatic elevated BP without hx HTN

Uncontrolled HTN

Hypertensive emergency

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Hypertensive Emergency

Hypertensive emergency = HTN with evidence of ACUTE end organ

dysfunction

Heart: Chest pain, Acute MI, Pulmonary edema

Brain: Hypertensive encephalopathy/CVA/Hemorrhage

Cerebral autoregulation

Kidney: Ischemia and Renal impairment

Vascular: Aortic Dissection

Other: Eclampsia, Retinal Hemorrhage, drug abuse (cocaine,

amphetamine)

Sx: SOB, CP, HA, MS change, vision changes

Hypertensive Emergency

Management

Immediate treatment

Reduce MAP 10-20% in 30-60 minutes

Addition reduction 5-15% over next 23 hours

Reduction beyond this risks end organ ischemia due to relative

hypotension

Exception: Aortic dissection acute goal = 100-120mm Hg

Drugs of choice:

IV Meds Nicardipine, Labetalol, Esmolol

Disposition admission

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Asymptomatic Hypertension

2013 ACEP Clinical Policy on Asymptomatic Hypertension

Asymptomatic HTN PCP f/u, no acute tx, labs may be helpful in select patients

Should I screen for target-organ injury?

Routine lab screening not required

If patients have poor follow-up, screening may identify acute kidney injury

Should I treat the blood pressure?

Medical intervention not required

If poor follow-up can treat in the ED and rx meds

Patel KK, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016 Jul 1;176(7):981-8

“Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.”

Asymptomatic Hypertension

Management - Outpatient

JNC 8 BP tx threshold of 150/90 mm Hg in the >60 age group and 140/90 mm Hg in <60 age group, DM and CKD

JNC7: chemistry, EKG, chest xray, UA, prior to therapy initiation

Medical treatment:

Non-black: thiazide type diuretics, ACEIs, ARBs, CCBs

Black: thiazide type diuretics, CCB

Chronic kidney disease: ACE or ARB (do they have a PCP)

AHA/ACA/CDC 2014 Science Advisory:

Stage 1: lifestyle modifications and HCTZ

Stage 2: lifestyle modifications plus thiazide in combo with ACEI, ARB, CCB

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Hypertension Conclusions…

No evidence to suggest that patients with asymptomatic

hypertension should be acutely treated

Controversy as to whether or not to prescribe antihypertensive

ED or Urgent care visit may be one of their few contacts with a

health care professional

Counsel

Outpatient f/u within a month

DC instructions: Return if severe headache, focal weakness or

paresthesias, SOB

Supracondylar Fracture

Posterior

Fat Pad

Anterior humeral line

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Supracondylar Fracture

Distal Humerus Fracture proximal to condyles

Mostly in children due to strong collateral ligaments that prevent dislocation (Peak age 5-10 years)

Mechanism FOOSH, elbow hyperextension

X-ray Posterior fat pad sign, anterior displacement humerus

Treatment:

Gartland I: non-displaced, immobilized in posterior splint and 48 hour ortho f/u

Gartland II: Some displaced, intact posterior cortex

Gartland III: Completely displaced, no cortical contact

Surgical: Closed Reduction with pin fixation

Complications loss of carrying angle, nerve injury, compartment syndrome, Volkmann Ischemic contracture

Lateral Elbow: Normal Anterior

Humeral Line

Middle 3rd of

Capitellum

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Abnormal Joint Effusion

Doc…My Throat Hurts!

Rule out emergencies…

Is the patient in respiratory distress?

Drooling, trismus, Increased RR rate, hypoxia?

Differential Diagnosis:

Peri-tonsillar abscess unilateral, trismus, deviation of the uvula

Epiglottitis sick appearing, leaning forward, drooling

Ludwigs Angina recent dental procedures

Malignancy smoking ,weight loss

Angioedema swelling of tongue, lips, oral mucosa

Thyroiditis neck swelling

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Bacterial Vs. Viral Pharyngitis

Viral vesicular or petechial pattern on the soft palate and tonsils and is associated with rhinorrhea

16% have tonsillar exudate

55% have cervical adenopathy

64% lack cough

Diagnostic testing not necessary except: influenza, mononucleosis, & acute retroviral syndrome

Bacterial Group A β-hemolytic Streptococcus: adults (15%), children (30%)

Incubation period of 2 to 5 days

Sudden onset of sore throat, painful swallowing, chills, and fever

Signs and symptoms:

Erythema of the tonsils (62%)

Exudate (32%)

Enlarged, tender cervical lymph nodes (76%)

Diagnostic Testing

Centor and Modified Centor Criteria

Original article in 1981: exudates, anterior cervical adenopathy, no cough, fever

Modified in 1998: Age qualifier added

Age 3-14 years (+1)

Age 15-44 years (+0)

Age >45 years (-1)

Rapid Antigen Detection Testing (RADT) or Throat culture (gold standard)

Guidelines:

ISDA 2012 2+, perform RADT

AHA/AAP 2009 2+, perform RADT

CDC/AAFP/ACP 2, perform RADT, 3+ RADT or treat empirically

If viral sx (coryza, cough, diarrhea, ulcerative stomatitis) and score 0-1 no testing/no treating

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Treatment

Decrease: symptom duration, infectivity

Complications:

Suppurative peritonsillar abscess, OM, sinusitis

Non-suppurative complications acute rheumatic fever, PSGM

Antibiotics

First Line (CDC recommendations):

Penicillin VK: Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily x 10 days

Amoxicillin: 50 mg/kg once daily (max = 1000 mg); alternate:25 mg/kg (max = 500 mg) twice daily x 10 days

Penicillin G benzathine: <27 kg: 600,000 U; ≥27 kg: 1,200,000 U IM x 1

PCN Allergy (not severe): Cephalexin PO, Cefadroxil PO

Severe PCN Allergy: Clindamycin PO, Azithromycin PO, Clarithromycin PO

Pain Relief

NSAIDS, Acetaminophen, throat lozenges

https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Steroids?

Cochrane Review from 2012 of 8 trials involving 743 patients

showed:

“Oral or intramuscular corticosteroids, in addition to antibiotics, increase

the likelihood of both resolution and improvement of pain in participants

with sore throat. Further trials assessing corticosteroids in the absence of

antibiotics and in children are warranted.”

ISDA 2012 Guidelines recommends against use for symptoms

Dosing:

Dexamethasone 0.6mg/kg, maximum 10mg

Prednisone 60mg PO for 1-2 days

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Doc…my head hurts!

Typical of previous headaches?

Worst headache of your life?

How did it onset? (sudden versus gradual)

Fevers and chills?

Meningeal signs?

Characterize the headache?

Associated symptoms?

Surrounding events? (trauma, pregnancy, recent infection)

Hypercoagulable or on anticoagulants?

Age?

Differential Diagnosis

Differential Diagnosis

Migraine

Meningitis

Cluster headache

Hypertension, hypertensive encephalopathy

Temporal (giant cell) arteritis

Tumor

Caffeine, alcohol or drug withdrawal

Carbon monoxide poisoning

Venous sinus thrombosis

Pseudotumor cerebri

Post-Lumbar Puncture

• Tension Headache

• Sinusitis

• Cervical arthritis

• Acute angle closure glaucoma

• Dental Abscess

• Otitis Media

• TMJ

• Trigeminal neuralgia

• Depression• Cerebral ischemia

• Post LP Headache

• Subarachnoid hemorrhage

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Subarachnoid Hemorrhage

Acute bleed into the subarachnoid space

Non-traumatic Ruptured berry aneurysm 85%

Symptoms

Sudden onset severe headache

Activities that increase ICP

intercourse, coughing, weight lifting, defecation

Nausea and vomiting

Seizures, neck stiffness, photophobia

“Sentinel bleed”

Subarachnoid Hemorrhage

Diagnosis

CT without contrast the longer since onset headache, less sensitive the CT

CT within 6 hours…

Lumbar puncture If clinical suspicion and negative CT

Persistent RBC in tubes 1-4 (usually in thousands) indicates SAH

Zero RBCs in the 4th tube = traumatic tap

CTA/MRI – has not replaced current diagnostic approach

Treatment

Neurosurgery evaluation

BP control

Antiemetics

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Meningitis

1.38 out of 100,000 people with fatality rate 14.3%

Inflammation of membranes covering spinal cord or brain due to

bacterial, viral or fungal infection

Causes

Recent otitis, sinusitis, pneumonia or immunocompromised, trauma,

neurosurgery, indwelling medical devices

Bacterial S. pneumoniae (MC), N. meningitides, L. monocytogenes

Viral Enteroviruses (MC, summer), Herpes simplex

Fungal Cryptococcus, Toxoplasma

Non-infectious Lupus, Vasculitis, Sarcoidosis etc.

Meningitis Diagnosis

Symptoms & Exam

Fever, headache, neck stiffness, altered MS, photophobia, vomiting, seizures, petechial/purpuric rash, Kernig/Brudzinski

CT head without contrast

Before LP IDSA recommends for patients who meet any criteria:

Immunocompromised state

History of CNS disease (mass lesion, stroke, or focal infection)

New-onset seizure within 1 week of presentation

Papilledema

Abnormal level of consciousness

Focal neurologic deficit

LP

Contraindications coagulopathy

Disposition Admission and monitoring

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Chemoprophylaxis

Exposure increases risk by 500-800x normal population

Close contacts:

Housemates

Secretion exposure (kissing, shared utensils or toothbrush, person who

intubated without a facemask)

Can decrease transmission by 89% in N. menengitidis

Initiate within 24 hours, but no later than 2 weeks

Rifampin 10 mg/kg (max 600mg) Q 12 hours x 4 doses

Cipro 500mg PO once

Ceftriaxone 250mg IM once

Scaphoid Fracture

image

Mid-distal scaphoid fracture without displacement

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Scaphoid Fracture

Most common carpal fracture

Must suspect with “snuff box” tenderness

Imaging – wrist and scaphoid x-rays

Sometimes negative with acute injury “occult”

Can CT or MRI

Treatment of Identified fractures and suspected..

Thumb spica splint and ortho follow-up

Complications Avascular necrosis (AVN)

Distal scaphoid supplied by radial artery

AVN of proximal fragment

Picture Thumb Spica

• Fracture of the proximal portion of the scaphoid bone with

displacement of the fracture fragments

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Doc, I’m itchy and my tongue is

swollen…

What is “just” an Allergic Reaction vs. Anaphylaxis?

Vital signs?

Causes: medications, foods, insect stings, environmental allergens,

latex, exercise, and other unknown factors

Differential Diagnosis:

MI, arrhythmia, PE, Asthma, COPD

Vasovagal response, anxiety, septic shock

Scromboid poisoning, monosodium glutamate syndrome

Ace inhibitor or hereditary induced angioedema

Definition of Anaphylaxis from

NIAID/FAAN

1. “Acute onset of an illness (minutes to several hours) with

involvement of the skin, mucosal tissue, or both” AND one of the

following:

Respiratory compromise or reduced BP

2. Two or more of the following that occur rapidly after exposure to a

likely allergen for that patient

Involvement of skin-mucosal tissue, respiratory compromise,

hypotension, GI symptoms

3. Reduced BP after exposure to known allergen for that patient

30% decrease in systolic BP in children or adults

Campbell, Ronna L. et al.Evaluation of National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department

patients. Journal of Allergy and Clinical Immunology , Volume 129 , Issue 3 , 748 - 752

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Treatment of Anaphylaxis

Prehospital

Evaluate VS and ABCs/monitor

Supplemental O2

Large bore IV access

IV fluids, supine position with elevation of legs

Remove hymoneptera stinger

B-agonists – 2.5mg via nebulizer

Steroids

Medications to Initiate

Epinephrine 0.3 to 0.5mL (0.01mg/kg in children max 0.3 dosage) of

epinephrine in a 1:1000 dilution

IM, lateral aspect of the thigh

Every 5-10 minutes as necessary

Antihistamines:

Diphenhydramine 25-50mg

H1 and H2: Ranitidine 50mg (adult) 1mg/kg (children)

Corticosteroids

Prednisone 1mg/kg PO

Methylprednisolone 125mg IV

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Disposition

Admission

Limited access to phone or emergency services

Prior history of anaphylaxis

Underlying asthma, renal disease, CHF, B-blocker usage

Discharge after Observation

AAAI and AI Joint Task force – observation time based on individual

patients

NIAID &FARE – observation time of 4-6 hours

Biphasic reaction in 5-20%

Doc…my neck hurts after an MVA

Low risk trauma patients: Alert, stable, adult trauma patient w/o neurologic deficits

National Emergency X-Radiography Utilization Study (NEXUS) - 1998

Plain cervical spine injury unnecessary if patients lack 5 criteria

99.6% sensitive, 12.9% specific, negative predictive value 99.9%

Limitations: Age >60

Canadian Cervical Spine Rule for Radiography (CCR)

3 assessments asked in sequential order

If any answer is positive imaging

100% sensitive, 42.5% specific

Limitations: Complexity compared to NEXUS

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NEXUS Criteria

1. Absence of midline cervical tenderness

2. Normal level of alertness

3. No evidence of intoxication

4. Absence of focal neurologic deficit

5. Absence of painful distracting injury

If any of the above criteria are present, the C-Spine cannot be

cleared clinically by these criteria, consider imaging

Canadian C-Spine Rule

Assessments

1. There are no high risk factors that

mandate radiography

2. There are low risk factors that

allow for a safe assessment of

range of motion

3. The patient is able to actively

rotate the neck

Definitions

Age 65 or older

A dangerous mechanism of injury

Paresthesias in extremities

Simple rear-end MVA

Patient able to sit up

Ambulatory

Delayed onset of pain

Absence of midline TTP

Can rotate neck 45 degrees bilaterally

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Cervical Spine Imaging

Plain radiography

3 views: Lateral, anterior-posterior, odontoid

Clinically acceptable study: all 7 vertebrae and superior border first

thoracic

Benefits: Cost- effective, bedside, small amount of radiation

Disadvantages: C1 & C2, Visualizing spine due to body habitus

Cervical Spine CT

More sensitive and specific than plain X-rays

Consider for moderate & high risk patients

Thoracic and Lumbar Spine Imaging

Doc…it hurts when I take a deep

breath!

History

Duration?

Location?

Associated symptoms?

Constant or intermittent?

Aggravating or alleviating factors?

Differential:

Pneumonia

Bronchitis

Pulmonary embolism

Pneumothorax

Pericarditis

Rib fracture

Esophageal spasm/rupture

Atypical CP/MI

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Pulmonary Embolism

650,000 - 900,000 PEs each year in the US 200,000 deaths

Pulmonary Embolism:

Thrombus forms in the venous system (MC LE DVT) and embolizes to the lung

Causes acute obstruction of the pulmonary arterial system and pulmonary ischemia/infarction

Large emboli obstruction of right ventricular outflow and circulatory collapse

Risk Factors: THROMBOSIS

Trauma, travel

Hypercoagulable, hormone replacement

Relatives, recreational drugs

Old (age >60)

Malignancy

Birth control

Obesity, obstetrics

Surgery, smoking

Immobilization

Sickness

Pulmonary Embolism

Symptoms

Hemoptysis

Shortness of breath

Pleuritic chest pain

Exam: SOB, tachy, clear lungs, hypoxia, unilateral leg swelling, +/-unstable VS

Diagnosis

EKG ST, S1Q3T3, new RBBB

CXR Hampton Hump, Westermark sign

D-dimer

CTA/VQ Scan

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PERC Rule for Pulmonary Embolism

Rules out PE if no criteria are present and pre-test probability is ≤15%

If all are negative, no need for further workup, <2% chance of PE

ACEP 2011 Clinical Policy: “Level B recommendations. In patients

with a low pretest probability for suspected pulmonary embolism,

consider using the PERC to exclude the diagnosis based on historical

and physical examination data alone.”

D-dimer:

D-dimer if low-risk, but not PERC negative

D-dimer negative and pre-test probability is <15% then no further

testing

D-dimer positive then CT-angiography or V/Q

Criteria for PERC Rule

Clinical low probability (<15% probability of PE based on gestalt

assessment)

Age < 50

HR < 100

O2 sat on room air > 94% at near sea level

No prior hx DVT or PE

Recent trauma or surgery

No Hemoptysis

No estrogen use

No unilateral leg swelling (asymmetrical calves on visual inspection)

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Wells Clinical Prediction Rule for PE

Risk stratifies patients for PE & provides an estimated pre-test

probability

Based on risk, physician chooses next diagnostic study

D-dimer

CTA

3 tiers: low, moderate, high

2 tiers: unlikely, likely (supported by ACEP’s 2011 clinical policy on

PE)

Main criticism: has a “subjective” criterion in it “PE #1 diagnosis or

equally likely”

Wells Clinical Prediction Rule for PE

Point Score

Suspected DVT 3

Alt dx less likely than PE 3 points

Heart rate > 100 bpm 1.5

Prior venous thrombus 1.5

Immobilization w/in 4 wks 1.5

Active malignancy 1

Hemoptysis 1

Risk Score Interpretation

3- Tier model

Low risk (<2 points): 1.3%

Mod risk (2-6 points): 16.2%

High risk (>6 points): 37.5%

2-Tier model

PE unlikely (0-4 points): 12.1%

PE likely (>4 points): 37.1%

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D-dimer

Clots contain fibrin, degraded by plasmin yields D-dimer

Half-life of approximately 8 hours, can be elevated for at least 3 days

Sensitivity: 94-98%, Specificity: 50-60%

Factors known to give false positive D-dimer level

Age > 70

Pregnancy

Malignancy

Recent surgical procedure

Liver disease

RA

Trauma

Potential false negatives: Lipemia, symptoms > 5 days, warfarin, small pulmonary infarction, isolated calf vein thrombosis

Closing Points…

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References Pediatric Head Trauma

Kupperman N, Holmes J, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. Volume 374, Issue 9696, 3–9 October 2009, Pages 1160–1170

Goldman R. Decision rules can identify children at very low risk of clinically important traumatic brain injury. Journal of Pediatrics, The, 2010-03-01, Volume 156, Issue 3, Pages 509-510, Copyright © 2010 Mosby, Inc.

Schonfeld D1, Bressan S, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15.

Easter JS, Bakes K et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014 Aug;64(2):145-52, 152.e1-5. doi: 10.1016/j.annemergmed.2014.01.030. Epub 2014 Mar 11.

PECARN Pediatric Head Injury/Trauma Algorithmhttps://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm

Kupperman N, Holmes J, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. Volume 374, Issue 9696, 3–9 October 2009, Pages 1160–1170

Goldman R. Decision rules can identify children at very low risk of clinically important traumatic brain injury. Journal of Pediatrics, The, 2010-03-01, Volume 156, Issue 3, Pages 509-510, Copyright © 2010 Mosby, Inc.

Schonfeld D1, Bressan S, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15.

Easter JS, Bakes K et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann EmergMed. 2014 Aug;64(2):145-52, 152.e1-5. doi: 10.1016/j.annemergmed.2014.01.030. Epub 2014 Mar 11.

PECARN Pediatric Head Injury/Trauma. Algorithmhttps://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm

Canadian Head CT References

Stiell IG, Wells GA, et al. The Canadian CT Head Rule for patients

with minor head injury. Lancet. 2001 May 5;357(9266):1391-6.

Stiell IG, Clement CM, et al. Comparison of the Canadian CT Head

Rule and the New Orleans Criteria in patients with minor head injury.

JAMA. 2005 Sep 28;294(12):1511-8.

Easter JS, Hakoos JS, et al. Traumatic intracranial injury in intoxicated

patients with minor head trauma. Acad Emerg Med. 2013

Aug;20(8):753-60. doi: 10.1111/acem.12184.

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References Fight Bite

Goldstein E, Abrahamian F. Human Bites. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition. 320, 3510-3515.e1. Eighth Edition. Copyright © 2015 by Saunders, an imprint of Elsevier Inc.

Stevens D, Bisno A, Chambers H, et. al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. CID 2014:59 (15 July).

Germann CA. Germann C.A. Germann, Carl A.Nontraumatic Disorders of the Hand. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109447692. Accessed February 13, 2017.

Hypertension References

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure – The JNC 7 Report. JAMA. 2003; 289 (19):2560-2572.

James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eigth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.

Goldberg E. An Evidence-Based Approach to Managing Asymptomatic Elevated Blood Pressure in the Emergency Department. Emergency Medicine Practice. February 2015. Volume 17, Number 2.

Patel KK, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016 Jul 1;176(7):981-8.

Wolf et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. Ann Emergency Medicine;62:59-68

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Supracondylar Fracture References

Blok B, Cheung D, Platts-Mills T. Elbow Injuries: Supracondylar Fracture. First Aid for the Emergency Medicine Boards. Copyright 2016 by McGraw-Hill Education. P215-16

The Treatment of Pediatric Supracondylar Humerus Fractures: Evidence Based Guideline and Evidence Report. American Academy of Orthopedic Surgeons. Published in 2011. http://www.aaos.org/research/guidelines/SupracondylarFracture/SupConFullGuideline.pdf

Chow YC. Chow Y.C. Chow, Yvonne C.Elbow and Forearm Injuries. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109446609. Accessed March 08, 2017.

References for PERC/PE

Kline JA, Mitchell AM et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004 Aug;2(8):1247-55.

Kline JA, Courtney DM et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.1538-7836.2008.02944.x. Epub2008 Mar 3.

Dachs R, Endres J, Garber M. Pulmonary Embolism Rule-Out Criteria: A Clinical Decision Rule That Works. Am Fam Physician. 2013 Jul 15;88(2):98-100.

Fesmire, Francis MD. ACEP News Contributing Writer. June 1, 2011. ACEP Clinical Policy Review: Suspected Pulmonary Embolism. http://www.acepnow.com/article/acep-clinical-policy-review-suspected-pulmonary-embolism/2/?singlepage=1

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED with suspected PE. ACEP Clinical Policy. Ann Emerg Med 2011;57:628-652

Kline JA. Kline J.A. Kline, Jeffrey A.Venous Thromboembolism. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109429015. Accessed March 08, 2017.

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Pharyngitis References

Hildreth A, Takhar S. Evidence Based Evlauation and Mangement of Patients with Pharyngitis in the Emergency Department. Emergency Medicine Practice. September 2015. Volume 17, Number 9.

Hayward G, Thompson MJ, Perera R, Et al. Corticosteroids as a standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268.

Schams SC, Goldman RD. Steroids as adjuvant treatment of sore throat in acute bacterial pharyngitis. Can Fam Physician. 2012;58(1):52-54

Hartman ND. Hartman N.D. Hartman, Nicholas D.Neck and Upper Airway. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109387281. Accessed February 13, 2017.

Evaluation of Pharyngitis. Urgent Care RAP. April 2015: Volume 1, Issue 2. Accessed 3/7/17.

Group A Streptococcal Disease, For Clinicians. CDC. https://www.cdc.gov/groupastrep/diseases-hcp/index.html. Accessed 3/7/17.

Shulman et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. CID. https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Strep%20Guideline.pdf

Headache References

Blok B, Cheung D, Platts-Mills T. Subarachnoid Hemorrhage. First Aid for the Emergency Medicine Boards. 3rd Edition. p846-848.

Blok B, Cheung D, Platts-Mills T. CNS Infections: Meningitis. First Aid for the Emergency Medicine Boards. 3rd Edition. p840-843.

Based Approach to Diagnosis and Management of Subarachnoid Hemorrhage in the ED. Emergency Medicine Practice: October 2014, Vol. 16, Number 10

Blok KM, Rinkel GJ et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology. 2015 May 12;84(19):1927-32. doi: 10.1212/WNL.0000000000001562. Epub 2015 Apr 10.

Carpenter C, Hussain A et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Academic Emergency Medicine. Volume 23, Issue 9, pages 963–1003, September 2016

Perry J et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011;343:d4277

Nicole M. Dubosh, M. Fernanda Bellolio, Alejandro A. Rabinstein and Jonathan A. Edlow. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage. Stroke. 2016;STROKEAHA.115.011386, originally published January 21, 2016

Bamberger D. Diagnosis, Initial Management, and Prevention of Meningitis. Am Fam Physician. 2010 Dec 15;82(12):1491-1498.

Erin N. Quattromani, MD, and Amer Z. Aldeen, MD. Focus On: Emergent Evaluation and Management of Bacterial Meningitis. ACEP News May 2008. https://www.acep.org/clinical---practice-management/focus-on--emergent-evaluation-and-management-of-bacterial-meningitis.

Tiffee A, Zosky M. Meningitis: Clinical Pearls an Pitfalls. Feb 4, 2015. http://www.emdocs.net/meningitis-clinical-pearls-pitfalls/

Hackman JL, Nelson AM, Ma O. Hackman J.L., Nelson A.M., Ma O Hackman, Jeffrey L., et al.Spontaneous Subarachnoid and Intracerebral Hemorrhage. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’sEmergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109436521. Accessed March 08, 2017.

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Scaphoid References

Boyd A, Benjamin H, Apslund C, Splints and Casts: Indications and

Methods. Am Fam Physician. 2009 Sep 1;80(5):491-499.

Jones B, MD, Rozental T. Ortho Info: Scaphoid Fracture of the Wrist.

American Academy of Orthopedics. Last reviewed March of 2016.

http://orthoinfo.aaos.org/topic.cfm?topic=A00012

Phillips G, Reibach A, Slomiany P. Diagnosis and Management of

Scaphoid Fractures. Am Family Physician. 2004 Sep 1;70(5):879-884.

Allergic Reaction References

Singer E, Zodda D. Allergy and Anaphylaxis: Principles of Acute Emergency Management. Emergency Medicine Practice. August 2015. Volume 17. Number 8.

Campbell, Ronna L. et al.Evaluation of National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients. Journal of Allergy and Clinical Immunology , Volume 129 , Issue 3 , 748 - 752

Sampson HA, Munoz-Furlong A, Bock SA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clinical Immunology. 2005;115(3):584-591

Liebman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clinical Immunology. 2010;126 (3)477-480.

Liebman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunology. 2005;95 (3):217-226

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Neck Pain References

Go S. Go S Go, Steven.Spine Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=1658&sectionid=109387434. Accessed March 02, 2017.

Pullen, Lara. Imaging Not a Necessity for Spine Evaluation in Trauma Patients. http://www.acepnow.com/article/imaging-necessity-spine-evaluation-trauma-patients/

Brunk, Doug. ACEP News June 2008. Studies Challenge Spine Injury Criteria for Children. https://www.acep.org/Clinical---Practice-Management/Studies-Challenge-Spine-Injury-Criteria-for-Children/

Updated Guidelines For Management Of Acute Cervical Spine And Spinal Cord Injury In Pediatric Patients. September 2014. EB Medicine.

Current Guidelines For Assessment Of Cervical Spine And Vertebral Artery Injuries In Adults Following Blunt Trauma. July 2014. EB Medicine.

Cervical Spine Injury: An Evidence-Based Evaluation Of The Patient With Blunt Cervical Trauma. April 2009. EB Medicine.