Educational Objective:

Calculate an absolute neutrophil count.

Key Point:

The formula is: ANC = WBC × % (neutrophils + bands)

Explanation:

The formula for calculating this is:

• ANC = WBC × % (neutrophils + bands)

Normal neutropenia counts vary by ethnicity/race and age. Neutropenia is described as mild for an ANC between 1,001 and 1,500/µL; moderate for an ANC between 500 and 1,000/µL; and severe for an ANC below 500/µL.

The more severe the neutropenia, the more the patient is at risk for serious infection. Neutropenia is classified by cause. The types of causes include factors extrinsic to marrow myeloid cells, such as infections, drug use, or cancer; acquired disorders of myeloid cells, such as aplastic anemia, vitamin B12 or folate deficiency, or leukemia; and disorders intrinsic to the myeloid precursor cells such as cyclic neutropenia, Shwachman-Diamond syndrome, disorders of metabolism, and immunodeficiencies.

Reference:

Walkovich KJ, Newburger PE. Leukopenia. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:1047-1053.

Educational Objective:

Treat bacterial meningitis.

Key Point:

Current best practice for suspected bacterial meningitis is initial treatment with vancomycin, ceftriaxone, and dexamethasone.

Explanation:

The incidence of bacterial meningitis has dropped dramatically in recent years, the result of effective vaccines for pneumococcal, Haemophilus influenza, and Neisseria meningitis infections.

Most patients with bacterial meningitis have had an antecedent upper respiratory tract infection or nonspecific febrile illness. Initial empiric treatment for bacterial meningitis in a patient younger than 50 years of age is vancomycin and ceftriaxone (to cover for N. meningitidis, H. influenzae, and S. pneumonia--the most common responsible bacteria). Dexamethasone should be administered before or at the time of antibiotic infusion.

If an organism is isolated, then antibiotics should be adjusted to provide more specific coverage. The antibiotic of choice for S. pneumonia depends on the susceptibilities of the isolate. For isolates with an MIC of 0.1 µg/mL, penicillin or ampicillin is indicated. For isolates with an MIC between 0.1 and 1.0 µg/mL, a third-generation cephalosporin is indicated. For isolates with an MIC of 2 µg/mL, vancomycin and a third-generation cephalosporin are indicated.

Dexamethasone has been shown to reduce neurologic sequelae and mortality from bacterial meningitis--most commonly in patients with pneumococcal meningitis. It is suggested for all cases of suspected bacterial meningitis in adults in the United States and continued only if the meningitis is caused by S. pneumoniae. In those circumstances, it should be continued for 2 to 4 days.

References:

Nath A. Meningitis: bacterial, viral and other (chapter 412). In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2015:2480-2495.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284.

Weinstein MP, Klugman KP, Jones RN. Rationale for revised penicillin susceptibility breakpoints versus Streptococcus pneumoniae: coping with antimicrobial susceptibility in an era of resistance. Clin Infect Dis. 2009;48(11):1596-1600.

Primary amenorrhea describes a failure of the start of menstruation, whereas secondary amenorrhea describes the cessation of menstruation some time following menarche. When a healthy teenage girl follows a normal pubertal progression but does not achieve menarche, the most likely cause is a Müllerian duct system structural anomaly such as an imperforate hymen.

Primary amenorrhea can also be caused by chronic illness, chromosomal abnormalities, complete androgen insensitivity syndrome, and, occasionally, pregnancy or polycystic ovary syndrome.

Treatment depends on the cause of the amenorrhea and may include progestin therapy or oral contraceptives.

Reference:

Cromer B. Menstrual problems. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 19th ed., 2011:685-691.

Educational Objective:

Define the recommended management of blood pressure for support of the brain after ROSC.

Key Point:

The 2015 AHA guidelines (accessed on April 9, 2020; recommendation unchanged since 2015) add a new recommendation for blood pressure management after ROSC, which states the following: “Avoiding or immediately correcting hypotension (systolic blood pressure < 90 mm Hg, mean arterial pressure < 65 mm Hg) during postresuscitation care may be reasonable (class IIb).”

Explanation:

Beyond the avoidance of hypotension, the AHA writing group makes no recommendation for a specific blood pressure target other than suggesting to aim at goals that “would be used for other critically ill patients”. The problem with recommending a specific target is that after cardiac arrest, different patients and different organs have different optimal pressures. For example, organs may not require increased blood pressure; however, the closed, high-pressure space of the cerebral circulation may require increased blood pressure in order to counteract the pressure of ischemic brain swelling.  

By contrast, in patients who have had an ischemic stroke (vs cardiac arrest), the risk of hemorrhagic conversion increases with diastolic blood pressures greater than 105 mm Hg. For this reason, more specific target blood pressures are recommended for patients following an ischemic stroke than cardiac arrest with survival and transient post-cardiac arrest brain ischemia.

References:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: Post Cardiac Arrest Care (this site blends the 2019 Focused Updates with the 2015 AHA Guidelines for CPR and emergency cardiovascular care). (Accessed on April 9, 2020) 

Callaway CW, Donnino MW, Fink EL, et al. Part 8: post–cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132 (suppl 2): S465-S482. (Accessed on April 9, 2020)

Williamson CA. Brain Resuscitation. (Chapter 7) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 77-84.e1

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; Oct 30. (Accessed on April 9, 2020)

Wijdicks EF, Sheth KN, Carter BS, et al; American Heart Association Stroke Council. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45(4):1222-1238. (Accessed on April 9, 2020)

Educational Objective:

Describe clinical presentation of supralevator abscess.

Key Point:

Patients with a supralevator abscess present with complaints of perirectal and gluteal pain, as well as systemic signs of infection, but seldom have findings on physical examination.

Explanation:

Supralevator abscesses arise deep in the pelvis, and are most common among patients who are immunocompromised or have diabetes. Patients typically complain of perirectal and buttocks pain, and may have fever and leukocytosis, but physical examination, including digital rectal examination, are unremarkable. In such cases, suspicion for supralevator abscess should be high. Diagnosis is confirmed with a CT scan, and drainage typically is achieved percutaneously with imaging guidance.

Patients with a postanal abscess often have localized tenderness posterior to the anal verge on physical examination, although fluctuance may be absent. Intersphincteric abscesses often lack external findings, but produce exquisite tenderness on digital rectal examination. Ischiorectal abscesses typically have gluteal findings of induration, tenderness, and fluctuance, without tenderness on digital rectal examination.

Reference:

Christante DH, Thorsen AJ. “The Management of Anorectal Abscess and Fistula.” Current Surgical Therapy, 12^th Ed. Elsevier, 2017.

Coates WC. “Disorders of the Anorectum.” (Chapter 86) Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9^th Ed. Elsevier, 2017: 1166-1177.

Guns should be stored unloaded, locked away, separated from ammunition, and the ammunition should be locked away in any household (regardless of the presence or absence of children, and regardless of the presence or absence of psychiatric illness). Having guns in the household is associated with substantial risk of accidents and suicide, as well as assault-related injuries. Parents may not be aware of the risks to their children posed by guns. The strategies listed substantially decrease the risk of gun injuries to youth (and all others).

References:

Carter PM, Walton MA, Newton MF, et al. Firearm possession among adolescents presenting to an urban emergency department for assault. Pediatrics. 2013;132(2):213-221. 

Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293(6):707-714. 

The nurse practice act in the state where they practice

The nurse practice act is a statute enacted by the legislature of each state. The act delineates the legal scope of the practice of nursing within the geographic boundaries of the jurisdiction. The purpose of the act is to protect the public. The state board of nursing is the agency that enforces the nurse practice act. The Medicare statute provides the funds for paying for health services at the age of 65 years and older.

The health insurance companies, health plans, Medicare, and Medicaid

Third-party payers are the entities that actually pay the bills: health insurance companies, health plans (health maintenance or preferred provider organizations [HMOs or PPOs]), Medicare and Medicaid. The first party is the patient. The second party is the health care provider.

Mood disorders

Benzodiazepines are a class of drugs that work on the central nervous system, acting selectively on gamma-aminobutyric acid-A (GABA-A). Benzodiazepines are similar in pharmacologic action but have different potencies, and some benzodiazepines work better in treatment of particular conditions. Benzodiazepines are used as sedatives, hypnotics, anxiolytics, anticonvulsants, and muscle relaxants. They are not prescribed for mood disorders.

Educational Objective

Identify ophthalmic medicines appropriate for a retinal exam.

Key Point

Short-acting mydriatic agents, such as phenylephrine or atropine drops, are ideal pupillary dilators for examination purposes.

Explanation

The most appropriate medication of those listed is phenylephrine, which is a short-acting mydriatic agent. Homatropine is a long-acting dilator, and pilocarpine is a miotic agent. Proparacaine is a topical optic analgesic.

Dilated examination of the eye is typically performed by ophthalmologists, due to the possibility of adverse effects and the need for an indirect ophthalmoscope.

Reference:

Nelson textbook of pediatrics, 18th ed, p. 2570.

Educational Objective:

Describe the clinical presentation and management of colic.

Explanation:

Colic is defined as an otherwise healthy infant who cries for more than 3 hours per day, more than 3 days per week, and for more than 3 weeks in duration. Colic begins during the second week of life, peaks at 6 weeks, and resolves between 12 and 16 weeks. It is equally common in both breast- and bottle-fed infants.

A diagnosis of colic is made by history and is a diagnosis of exclusion. Colicky infants present with episodic periods of inconsolable crying, most often in the late afternoon and evening. Laboratory tests and imaging are unnecessary to make the diagnosis. An organic cause can be found in fewer than 5% and may include constipation, gastroesophageal reflux disease, infections, feeding disorders, and, less commonly, acute abdominal pain, occult fracture, and maternal drug effects.

First-line therapy includes parental reassurance and behavioral interventions. These interventions can take many forms, including effective swaddling, gentle rocking, and decreased stimulation of the infant. White noise, vibration, and motion can soothe some infants.

Cautioning overtired and frustrated parents never to shake their infant and giving them permission to allow the infant to cry are essential components of any treatment plan and can decrease the risk of child abuse. Encouraging parents to access additional caretakers for their child when they are overly tired or stressed is another important part of a treatment plan.

Simethicone, traditionally considered by many as a mainstay of colic treatment, is no longer recommended, after two systematic reviews revealed no effectiveness. Additionally, simethicone may interact with levothyroxine among infants being treated for congenital hypothyroidism, and should be avoided.  

References:

Biagioli E, et al. “Pain-relieving agents for infantile colic.” Cochrane Database Syst Rev 2016, Sep; 9:CD009999.

Harb T. et al. “Infant colic – What works: a systematic review of interventions for breast-fed infants.” J Pediatr Gastroenterol Nutr. 2016, 62(5):668-686.

Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012;33(7):332-333.

Monitoring of peak vancomycin concentrations is not recommended. The most accurate and practical measurement to guide dosing is a serum trough obtained once vancomycin has reached steady state concentrations, prior to the fourth dose.

Optimal trough concentrations in pediatric patients have not been established. In adults with serious methicillin-resistant Staphylococcus aureus (MRSA) infections, vancomycin trough concentrations of 15-20 micrograms/mL are recommended. The ratio of the area under the curve (AUC) to the minimum inhibitory concentration (MIC) is the best predictor of vancomycin efficacy. One study showed that an AUC/MIC ratio of >400 was associated with better outcomes than were AUC/MIC ratios <400. A serum trough of 15-20 micrograms/mL is needed to achieve an AUC/MIC ratio >400 if the MIC of the organism is <1 in adult studies.

Vancomycin doses of 40 mg/kg/day in children do not consistently reach the target AUC/MIC ratio of 400. Doses of 60 mg/kg/day (or 15 mg/kg every 6 hours) were shown to increase the likelihood of reaching this target, and are recommended for empiric dosing in serious MRSA infections in children. In addition, a loading dose of 20-25 mg/kg was shown to be safe in adults and may be considered in children with serious infections.

References:

Liu et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Infectious Diseases 2011. 52(3): 285.

2009 Report of the Committee on Infectious Diseases, American Academy of Pediatrics Red Book 27th edition, 2009.

Frymoyer, A et al. Prediction of Vancomycin Pharmacodynamics in Children With Invasive Methicillin-Resistant Staphylococcus aureus Infections: A Monte Carlo Simulation. Clinical Therapeutics 2010; 32(3): 534-541.

Jimenez-Truque, Natalia; Thomsen, Isaac; Saye, Elizabeth; and Creech, Buddy. Should Higher Vancomycin Trough Levels Be Targeted for Invasive Community-Acquired Methicillin-Resistant Staphylococcus Aureus Infections in Children? The Ped Infect Dis Journal April 2010: 29(4); 368-370.