Thank you to Maggie Krebs, MD for making these conference reviews!
EtOH and Nutrition
Review pathophysiology, diagnosis and treatment alcohol-related nutrition deficiencies.
- Alcoholics are at risk for many nutritional deficiencies due to decreased nutrient intake via diet, decreased absorption and decreased hepatic storage.
- Classically at risk for B12, folate, thiamine deficiency
- B12 deficiency à megaloblastic anemia
- Thiamine deficiency à Wernicke encephalopathy
- Alcoholics also have decreased absorption of vitamins K, A, D, E and are also at risk for hypoK, hypomag, hypoCa
- Diagnosis – obtain serum B12, folate, thiamine
- May obtain serum levels but probably low yield especially in acutely drunk binge-drinkers
- Classically, treatment in the ED is a banana bag but again, probably low yield in binge-drinkers who are otherwise healthy
- Thiamine deficiency treatment 100 mg daily
Review pathophysiology, diagnosis and treatment of Wernicke Encephalopathy and Korsakoff Syndrome.
- Wernicke Encephalopathy thiamine deficiency causing AMS, ocular dysfunction, ataxia
- Korsakoff syndrome – memory impairment and confabulation
- Thiamine is a cofactor in the Krebs cycle, deficiency leads to decrease in enzyme activity à lactate accumulation in the brain and serum à biochemical lesions can be seen in many different parts of the brain. Petechial hemorrhage can be seen in mammillary bodies
- Treatment 500 mg IV TID x3 days, then 250 mg IV/IM daily
- For one time dose of dextrose/glucose, do not need to worry about administering thiamine first
Review pathophysiology, diagnosis and treatment of ethanol withdrawal.
- Pathophsyiology: Chornic EtOH use causes down-regulation of GABA receptors (inhibitory) and upregulation of NDMA receptors (excitatory). Withdrawal à inadequate activity of inhibitory receptors and excessive activity of excitatory receptors à hallucinations, seizures, hyperadrenergic state
- Diagnosis: hypertension, tachycardia, tremors, diaphoresis, vomiting, headache, hallucinations, seizures (utilized in CIWA; downfall is scores can be intentionally manipulated via subjective complaints to get benzos)
- Treatment benzos (Ativan, Valium, longer acting Librium), phenobarbital
- Can consider precedex
- Refractory seizures à intubation, propofol
Review the basics of EM documentation focusing on how to document a level 5 note.
- History of present illness – need 4 elements from the following: location, quality, duration, severity, timing, context modifying factors, associated signs and symptoms (use CODIERS or OPQRST)
- Need 2/3: past medical, family and social history
Focus on the scoring components of the MDM section and understand what elements to focus documentation time on
- 2/3 categories (problems, data, risk) need to be high or extensive to bill as a level 5
Understand how an observation stay is billed and the importance of switching a patient to observation status as soon as possible
- Requires a stay of at least 8 hours to bill as obs(expected less than 48h)
- Decreased door to dispo times
- If admission to obs order placed before mignight, can be difference between a same day or 2 days obs charge (2 day obs charge more than 1 day)
Learn to document clinical impression per ICD-10 guidelines and review general EM code reimbursement levels.
- precise anatomic location is important (including R vs L)
- Where: geographic location important
- Why: Circumstances/activity surrounding
- How: injury related to work, military, altercation etc.