May irrigate with NS.

IC phenylephrine: make 500 mcg/cc solution (1/2 mL of 10 mg in 1 mL solution, in 9.5 cc of NS) give 1 cc every 3-5 minutes as needed, max 10 cc.

I know I keep harping on about this, but these techniques may save you from a catastophe if you’re intubating someone in the ED. The guys over at Emergency Medicine Updates have done a sweet article on the concept of nasal oxygen during RSI, but have …

http://www.sciencedirect.com/science/article/pii/S0735675710002093

We ARE experts.
Who else knows more about…
-toxicology
-environmental medicine (hypothermia/drownings/heat stroke/dysbarisms)
-retrieval medicine
-disaster medicine
Not sure if its the same in the States but in New Zealand/Australia, this is the stuff we are consulted on.

Sylvie
peloqusy@gmail.com

Sylvie

http://resusme.em.extrememember.com/?p=5254

Sylvie

I am french speeking.
In Uptodate aka means above knee amputation.
What does it mean for you?

The tonic pupil, sometimes called Adie’s tonic pupil or simply the Adie pupil, is the term used to denote a pupil with parasympathetic denervation that constricts poorly to light but reacts better to accommodation (near response)

My pedigree:
Infectious diseases and Microbiology specialist until 2005
Emergency medicine until year 2000
Minor emergency medicine until year 2010
General medicine in Africa 2 times a year

My new challenge at the age of 58:
Help out in emergency medicine in distant Canadian regions 1 week a month

After ATLS, ACLS, PALS, supervised emergency shifts (costing me $300 a shift), I found your blog, podcasts and especially your cards an invaluable source of knowledge and concision. I thank you so much for your generosity in sharing your hard work with the medical community and me.

Sylvie Peloquin m.d.

PMID 21143399

http://www.poison.org/battery/guideline.asp

Consider vasopressin 5 mg IV in epinephrine-resistent anaphylaxis, especially if patient on beta blockers.

http://www.rxlist.com/haldol-drug.htm#

doi:10.1016/j.resuscitation.2011.03.030

suggests that we should use pulse oximetry in cardiac arrest to monitor adequacy of compressions. The authors report “In our clinical practice, high quality chest compressions often produce excellent pulse oximetry tracings in patients with a lack of spontaneous circulation.” If that’s true, it’s hard to argue against using it.

To prevent sloughing and necrosis in ischemic areas, the area should be infiltrated as soon as possible with 10 to 15 mL of saline solution containing 5 to 10 mg of Regitine (brand of phentolamine), an adrenergic blocking agent. A syringe with a fine hypodermic needle should be used, and the solution liberally infiltrated throughout the ischemic area. Sympathetic blockade with phentolamine causes immediate and conspicuous local hyperemic changes if the area is infilatrated within 12 hours. Therefore, phentolamine should be given as soon as possible after the extravastation is noted.

Source

http://goo.gl/B4mRY

DDx:

SAH
Meningoencephalitis
ICH / increased ICP (e.g. from tumor)
CO toxicity
Temporal arteritis
Cerebral venous sinus thrombosis
Cerebral artery dissection
Hypertensive encephalopathy
Acute angle closure glaucoma
Idiopathic intracranial hypertension

Rare: pre-eclampsia, pheochromocytoma

Diagnostic options:

CT brain
LP
CT angio neck
MRV
ESR
Fundoscopy
Co-oximetry

Amiodarone: 150 mg given over 10 minutes and repeated if necessary, followed by a 1 mg/min infusion for 6 hours, followed by 0.5 mg/min. Total dose over 24 hours should not exceed 2.2 g.

Procainamide: 20 to 50 mg/min until arrhythmia suppressed, hypotension ensues, or QRS prolonged by 50%, or total cumulative dose of 17 mg/kg; or 100 mg every 5 minutes until arrhythmia is controlled or other conditions described above are met

1 Part viscous lidocaine 2%
1 Part Maalox (do not substitute Kaopectate)
1 Part diphenhydramine 12.5 mg per 5 ml elixir
Quantity: 120 ml

Sig: Swish, gargle, and spit one to two teaspoonfuls every six hours as needed.

[Credit: Sigrid]

http://chestjournal.chestpubs.org/content/133/6_suppl/71S.full

4.1.1. For patients with objectively confirmed pulmonary embolism (PE), we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such acute treatment. Patients with acute PE should also be routinely assessed for treatment with thrombolytic therapy (see Section 4.3 for related discussion and recommendations).

4.1.2. For patients in whom there is a high clinical suspicion of PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).

4.1.3. In patients with acute PE, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is ≥ 2.0 for at least 24 h (Grade 1C).

4.1.4. In patients with acute PE, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A).

4.1.5. In patients with acute PE, if IV UFH is chosen, we recommend that after an initial IV bolus (80 U/kg or 5,000 U), it is administered by continuous infusion (initially at dose of 18 U/kg/h or 1,300 U/h) with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity by the amidolytic assay rather than administration as IV boluses throughout treatment, or administration without coagulation monitoring (Grade 1C).

4.1.6. In patients with acute PE, if monitored SC UFH is chosen, we recommend an initial dose of 17,500 U, or a weight-adjusted dose of about 250 U/kg, bid, with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity when measured 6 h after injection rather than starting with a smaller initial dose (Grade 1C).

4.1.7. In patients with acute PE, if fixed-dose, unmonitored SC UFH is chosen, we recommend an initial dose of 333 U/Kg followed by a twice-daily dose of 250 U/kg rather than non–weight-based dosing (Grade 1C).

4.1.8. In patients with acute nonmassive PE, we recommend initial treatment with LMWH over IV UFH (Grade 1A). In patients with massive PE, in other situations where there is concern about SC absorption, or in patients in whom thrombolytic therapy is being considered or planned, we suggest IV UFH over SC LMWH, SC fondaparinux, or SC UFH (Grade 2C).

4.1.9. In patients with acute PE treated with LMWH, we recommend against routine monitoring with anti-factor Xa level measurements (Grade 1A).

4.1.10. In patients with acute PE and severe renal failure, we suggest UFH over LMWH (Grade 2C).

4.3 Systemically and Locally Administered Thrombolytic Therapy for PE
4.3.1. All PE patients should undergo rapid risk stratification (Grade 1C). For patients with evidence of hemodynamic compromise, we recommend use of thrombolytic therapy unless there are major contraindications owing to bleeding risk (Grade 1B). Thrombolysis in these patients should not be delayed, because irreversible cardiogenic shock may ensue. In selected high-risk patients without hypotension who are judged to have a low risk of bleeding, we suggest administration of thrombolytic therapy (Grade 2B). The decision to use thrombolytic therapy depends on the clinician’s assessment of PE severity, prognosis, and risk of bleeding. For the majority of patients with PE, we recommend against using thrombolytic therapy (Grade 1B).

4.3.2. In patients with acute PE, when a thrombolytic agent is used, we recommend that treatment be administered via a peripheral vein rather than placing a pulmonary artery catheter to administer treatment (Grade 1B).

4.3.3. In patients with acute PE, with administration of thrombolytic therapy, we recommend use of regimens with short infusion times (eg, a 2-h infusion) over those with prolonged infusion times (eg, a 24-h infusion) [Grade 1B].

4.4 Catheter Extraction or Fragmentation for the Initial Treatment of PE
4.4.1. For most patients with PE, we recommend against use of interventional catheterization techniques (Grade 1C). In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest use of interventional catheterization techniques if appropriate expertise is available (Grade 2C).

4.5 Pulmonary Embolectomy for the Initial Treatment of PE
4.5.1. In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest that pulmonary embolectomy may be used if appropriate expertise is available (Grade 2C).

4.6 Vena Caval Filters for the Initial Treatment of PE
4.6.1. For most patients with PE, we recommend against the routine use of a vena caval filter in addition to anticoagulants (Grade 1A).

4.6.2. In patients with acute PE, if anticoagulant therapy is not possible because of risk of bleeding, we recommend placement of an inferior vena caval filter (Grade 1C).

4.6.3. For patients with acute PE who have an inferior vena caval filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

- scott weingart

here’s his extubation algorithm, pulled from

http://blog.emcrit.org/podcasts/extubation/

Inclusion:
- Resolution of clinical issue requiring intubation
- Sp02 > 95% on FiO2 ≤40%, PEEP ≤5 cm H20
- RR < 30, SBP > 100, HR <130
- Patient not known to be a difficult intubation

Preparation:
- Turn off sedatives
- Leave opioids on at a low dose (e.g. fentanyl 50 mcg/hr)
- Allow patient to regain full mental status
- If patient shows signs of discomfort, consider administering more pain medication
- Patient should be able to understand and respond to commands

Testing for readiness:
- Ask patient to raise arm and leave in the air for 15 seconds
- Ask patient to raise their head off the bed
- Ask patient to cough, they should be able to generate a strong cough
- Place patient on pressure support at a setting of 5 cm H20 and sit patient up to at least 45 degrees
- Observe for 15-30 minutes, if SpO2 < 90%, HR > 140, SBP > 200, severe anxiety, or decreased LOC >> discontinue extubation attempt

Procedure:
- Have a nebulizer filled with normal saline attached to a mask
- Sit patient up to at least 45 degrees
- Suction ETT with bronchial suction catheter
- Suction oropharynx with Yankauer suction
- Deflate ET tube cuff
- Have the patient cough, pull the tube during cough [[make sure pt is end-inhalation at the moment you pull tube -- rjs]]
- Suction oropharynx again
- Encourage patient to keep coughing up secretions
- Place nebulizer mask on patient at 4-6 liters per minute

After extubation:
- Patient should receive close monitoring for at least 60 minutes
- If patient develops respiratory distress, NIV will often be sufficient to avoid reintubation

JAMA. 2010;304(19):2161-2169. doi:10.1001/jama.2010.1651

http://academiclifeinem.blogspot.com/2010/11/trick-of-trade-legg-maneuever-for.html

Did you invent the Dangerous Diagnosis wheel or do you have a source for it? Would be really great as an online resource that allows you to select different presenting complaints, like how you did headache in the presentation. Perhaps it would be too good and become a crutch, however.

Fire victims covered in soot with triad of (1) hypotension, (2) metabolic acidosis (with anion-gap) and (3) elevated lactate level (>8-10) -> such patients should be treated empirically for CO and CN toxicity: hydroxycobolamine is the agent of choice, and nitrates should be avoided (the sodium thiosulfate agent also present in the CN-kit may be used as well)

Other situations: fumigators, photographers, jewelers, nail polish use, apricot pits ingestion or iatrogenic nitroprusside overdose

Use: Hydroxycobolamine 5g IV (needs to be diluted) over 15min (both 2.5g vials of the ?Hydroxycobolamine kit? need to be given), repeated up to 15g total if necessary Pediatric dose is 70mg/kg per infusion

Side-effects: chromoturia (red discoloration of urine, and possibly of blood drawn), possible hypertension (due to NO scavenging properties ? do not treat the hypertension with nitrates)

The syndrome is due to infarction of the lateral medulla (lateral medullary syndrome) where there are a bunch of tighly packed structures. Depending on what is infacted the symptoms and signs can vary. The most distressing symptom to the patient and the reason it is important on your diff dx in the ED is vertigo. Some or one of the others may be present:

Symptoms:
1. Hyperacute onset vertigo without sudden head position change.
2. Have you tried to eat or drink? If yes, any dyphagia (usually they haven’t yet tried to eat anytihng because they are too vertiginous)
3. Hiccups
4. Unsteady/gait disturbance (will be hard to identify in the setting of vertigo.
5. The cause is usally verebral dissection (because the PICA comes off the vert) or a.fib. So, neck pain could be another clue.

Signs:
1. Horner’s (miosis, ptosis) — (don’t ever mention the clinically useless anhydosis again)
2. Diminished pain and temperature on the ipsilateral face and contralateral body (test with ice chips/cold soft drink/pin)…look for an asymmetry
3. Gaze evoked sustained nysagmus. (they’ve infarcted there one vestibular nuclei–say the right side–so the left is pushing the eyes to the right unopposed—so when they look to the right you’ll see nystamgus.)
4. Skew deviation — the eyes are verically misaligned. if you do a cover uncover test on their eyes one at a time you’ll see them shift up and down as the eye refixates

[credit: Roy Baskind]

Unvaccinated patients
- Wound cleansing
- HRIG ? 20 IU/kg. Administer as much as possible around the wounds and the rest IM at a site distant from the vaccine administration site. Do not administer more than the recommended dose.
- Rabies vaccine- 1mL IM in the deltoid (or later thigh in small children- not gluteal) at days 0,3,7,14.

If patient is immunocompromised, continue to give the 5th dose at day 28.

If patient is previously vaccinated with a documented history of antibody response to prior vaccination, you don’t give the HRIG; just give 1mL of rabies vaccine on day 0 and 3.

These recommendations are different from what the instructions that are included in the packaging of the vaccine.

Medications That Cause QT Interval Prolongation and/or Torsades de Pointes

Amiodarone
Amitriptyline
Arsenic trioxide
Azithromycin
Bepridil
Chlorpromazine
Clarithromycin
Desipramine
Disopyramide
Domperidone
Doxepin
Droperidol
Enflurane
Erythromycin
Fluconazole
Gatifloxicin
Haloperidol
Halothane
Ibutilide
Imipramine
Indapamide
Isoflurane
Itraconazole
Ketoconazole
Levofloxacin
Levomethadyl
Mesoridazine
Methadone
Moxifloxacin
Nortriptyline
Pentamidine
Pimozide
Procainamide
Quetiapine
Quinidine
Risperidone
Sotalol
Sparfloxacin
Tacrolimus
Tamoxifen
Televancin
Thioridazine
Trimethoprim-sulfamethoxazole
Voricollazole

Substrates of CYP450 3A4

Alprazolam
Amlodipine
Astemizole
Atorvastatin
Buspirone
Cafergot
Chlorpheniramine
Clarithromycin
Cocaine
Cyclosporine
Dapsone
Dextromethorphan
Diazepam
Diltiazem
Erythromycin
Estradiol
Felodipine
Haloperidol
Hydrocortisone
Indinavir
Irinotecan
LAAM
Lidocaine
Lovastatin
Methadone
Midazolam
Nelfinavir
Nifedipine
Nisoldipine
Ondansetron
Paclitaxel
Pimozide
Progesterone
Propranolol
Quinidine
Quinine
Ritonavir
Salmeterol
Saquinavir
Sildenafil
Simvastatin
Sirolimus
Tacrolimus
Tamoxifen
Testosterone
Trazodone
Triazolam
Verapamil
Vincristine
Zaleplon
Zolpidem

Inhibitors of CYP450 3A4

Cimetidine
Ciprofloxacin
Clarithromycin
Delaviridine
DiItiazem
Erythromycin
Fluconazole
Fluvoxamine
Grapefruit juice
lndinavir
Itraconazole
Ketoconazole
Mifepristone
Nefazodone
Nelfinavir
Ritonavir
Saquinavir
Verapamil
Voriconazole

[from keeping up in EM]

Academic Emergency Medicine
Volume 17 Issue 1, Pages 44 – 49

Objectives: Caffeine, an adenosine receptor blocker, should theoretically reduce adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia (SVT). We aimed to determine the effect of recent caffeine ingestion on the likelihood of reversion of SVT with adenosine.

Methods: This was a multicenter, case?control study of adult patients with SVT treated with adenosine between September 2007 and July 2008. The primary endpoint was reversion to sinus rhythm (SR) after a 6-mg adenosine bolus, as a function of recent (within 2, 4, 6, and 8 hours) caffeine ingestion. Caffeine ingestion data were collected using a self-administered questionnaire.

Results: Of 68 patients enrolled, 52 (76.5%, 95% confidence interval [CI] = 64.4% to 85.6%) reverted after a 6-mg adenosine bolus. There were no significant differences in age, sex, or daily caffeine ingestion between patients who did and did not revert (p > 0.05). However, as a group, patients who did not revert had recently ingested significantly more caffeine (p < 0.05). If caffeine had been ingested less than 2 or 4 hours before the adenosine bolus, the odds of reversion to SR were significantly reduced (odds ratio [OR] = 0.18, 95% CI = 0.04 to 0.93; and OR = 0.14, 95% CI = 0.04 to 0.49, respectively). If caffeine had been ingested less than 6 or 8 hours before the adenosine, the odds of reversion were not reduced (OR = 0.31, 95% CI = 0.09 to 1.02; and OR = 0.31, 95% CI = 0.09 to 1.08, respectively).

Conclusions: Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduces its effectiveness in the treatment of SVT. An increased initial adenosine dose may be indicated for these patients.

excellent summary

some points:
depending on the dose choice and how you do your economic analysis, PCC may be cheaper than FFP reversal.

the 3-factor PCCs available in the united states have no activated factors, so there probably isn’t any increased thrombotic risk. Europe has 4-factor PCC and thrombotic risk is a potential problem

If there is a delay in getting the patient’s blood type, AB FFP can be given empirically

liver failure patients should probably receive FFP regardless of whether you have started with PCC b/c they will have a deficiency in all factors, not just the ones included in the PCC.

With regards to the height of the saline, do we use SBP or MAP? Just wanted to clarify.

My reply:

Let’s take a patient with a BP of 70/40 mm Hg resulting in a MAP of 50 mm Hg. We’ll also assign him a CVP of 4 mm Hg.

Note that CVP is variously reported in mm Hg and cm H20 which is confusing. As mercury is 13.6 times as dense as water, the conversion from mm Hg to cm H20 is 1.36. Since 2.54 cm are in one inch, the conversion from mm Hg to inches H20 is .53 or, roughly, half.

I’m going to convert all pressures in this patient to inches water (which is roughly equivalent to inches blood or inches saline) to illustrate. For this patient

CVP = 2 inches water
MAP = 25 inches water
SBP = 35 inches water

So, in this patient, for a venous catheter, if a bag of saline is at a height of

1 inch: no forward flow
3 inches: continuous forward flow

For an arterial catheter, if a bag of saline is at at a height of

20 inches: no forward flow
40 inches: continuous forward flow

The question is what would happen if the bag were at a height of 30 inches, i.e. between MAP and SBP. My guess is that either there would be no forward flow (in which case the recommendation should be to use MAP and not SBP) or there would be intermittent forward flow, as in, forward flow during diastole and no flow during systole.

In any event, the point is that in a hypotensive patient, if the saline bag is a relatively elevated above the bed (which, in a hypotensive patient, it often is, to increase flow), you will see forward flow even if the catheter is in the artery. So, in cases where venous position is not certain, keep the bag initially at a low height, e.g. 15 inches, which will overcome CVP in nearly everyone and be less than MAP in nearly everyone.

Oral/Outpatient Treatment of Mild to Moderately Severe Acute PID

* Ceftriaxone 250 mg IM x 1 PLUS doxycycline 100 mg PO bid x 14d with or without metronidazole 500 mg PO bid x 14d.
* Cefoxitin 2 g IM PLUS probenecid 1 g PO x 1 PLUS doxycycline 100 mg PO BID x 14 d with or without metronidazole 500 mg PO bid x 14d.
* Other parenteral 3rd generation cephalosporin PLUS doxycycline 100 mg PO bid x 14 d with or without metronidazole 500 mg PO bid x 14 d.

Inpatient/Parenteral Regimens for PID

* Cefotetan 2g IV q12h (no longer available in US) or cefoxitin 2g IV q6h PLUS doxycycline 100 mg IV or PO q12h for at least 24h after clinical improvement, then outpatient regimen to complete 14 d.
* Clindamycin 900 mg IV q8h PLUS gentamicin loading dose IV/IM (2 mg/kg), then 1.5 mg/kg q8h or 5 mg/kg once daily for at least 24h after clinical improvement, then change to outpatient regimen to complete 14d.
* Alternative parenteral regimen: ampicillin/sulbactam 3 g IV q6h PLUS doxycycline 100 mg IV or PO q12h for at least 24 hrs after clinical improvement; then change to outpatient regimen to complete 14 d.

Alternative Oral Regimens if Parenteral Therapy Not Feasible

* If community prevalence and risk of gonococcal infection is LOW (<5%): Levofloxacin 500 mg PO once daily or ofloxacin 400 mg PO q12h with or without metronidazole 500 mg IV q8h, for at least 24h after clinical improvement, then change to outpatient regimen to complete 14 d. Tests for gonorrhea must be performed prior to instituting treatment and the patient managed as follows if the test is positive for N. gonorrhoeae: 1) if a non-culture test is used and is positive, a parenteral cephalosporin regimen is recommended; 2) if culture for gonorrhea is positive, treatment should be based upon results of antimicrobial susceptibility. If the the isolate is fluoroquinolone resistant or resistance cannot be assessed, parenteral cephalosporin therapy is recommended.

Penicillin or Cephalosporin Allergic Patients

* Patients with a history of cephalosporin or penicillin allergy should be referred to a specialist for evaluation and possible desensitization prior to treatment with either a penicillin or cephalosporin.
* In areas where <5% of all gonococcal isolates identified by culture and sensitivity testing in the past 6 months have been found to be fluoroquinolone resistant providers may consider use of levofloxacin as outlined above under “Alternative Oral Regimens if Parenteral Therapy Not Feasible”.
* Spectinomycin efficacy in the treatment of pelvic inflammatory disease is too low and should not be used for treatment.

Diagnosis?Warts are generally diagnosed from physical appearance. Examine his genitalia in good light (in women, use a speculum to examine vagina and cervix).

Differential diagnosis includes molluscum contagiosum, epidermoid cysts, hair follicles, sebaceous glands, pearly penile papules, and, rarely, condylomata lata of secondary syphilis and (pre)malignant tumours. In women, remnants of the hymen and vulval papillomatosis (a variant of the normal vulva anatomy) can sometimes be mistaken for warts. If diagnosis is unclear, refer the patient to the genitourinary medicine department.

Management?The patient can be advised to attend the genitourinary medicine clinic for treatment and a sexually transmitted infection screen. Alternatively, he can be offered treatment and further testing by his general practitioner.

Treating warts?Correct treatment will speed clearance of the warts. Most treatments can be applied by the patient, thus avoiding repeated visits to the surgery. Ensure the patient fully understands the treatment, finding warts, and applying the cream or liquid. If there is any doubt, the general practitioner or practice nurse can supervise treatment. About 75% of people are clear of warts a month after starting treatment.

A few warts only?first line treatment is freezing with liquid nitrogen; second line treatment depends on the site (see below).
Many soft warts?for example, at vaginal introitus, underneath foreskin. First line treatment is podophyllotoxin 0.15% cream. Apply twice daily for three days, then have a four day break before resuming if warts persist. Use for a maximum of five weeks before review. Second line treatment is podophyllotoxin 0.5% liquid with same dosing as cream above, or imiquimod cream, applying half or whole sachet on alternate night, washed off after 6-10 hours. Use for maximum of 16 weeks with a review every four to six weeks.
Many keratinised warts and site is accessible to patient?for example, the penile shaft. First line treatment is podophyllotoxin 0.5% liquid. Second line treatment is imiquimod cream.
Perianal warts?first line treatment is imiquimod or liquid nitrogen. Refer to general surgeons if warts persist.
Cervical warts?refer to your local colposcopy department.
Urethral meatus?difficult to treat; refer to either genitourinary medicine or urology.
Warn patients that all treatments can cause discomfort and local skin reactions. If these are severe, they should stop treatment and seek advice. Advise patients to stop treatment once the warts disappear. If they are using podophyllotoxin, normal surrounding skin can be protected by applying some petroleum jelly.

Lesions larger than 4 cm must be treated under direct medical supervision. Giving no treatment is also an option, as warts can regress spontaneously.

If the patient is female, reassure her that cervical screening intervals can stay the same. Avoid imiquimod and podophyllotoxin in pregnancy, or if there is any risk of pregnancy.

Investigations for other sexually transmitted infections?Send off a urethral swab or a urine sample, ensuring the patient has not urinated in the past one to two hours, for chlamydia and gonorrhoea. Offer tests for HIV, syphilis, hepatitis B and C, as indicated by his sexual history. All positive results can be referred to genitourinary medicine or the chlamydia screening office for follow-up. See the RCGP/BASHH primary care guideline (http://www.bashh.org/documents/702/702.pdf) for additional advice.

Follow-up?About 20% of patients have a recurrence in the following three months. If the warts are visible and you are confident that the patient can identify them correctly, then follow-up is usually unnecessary. Review if the warts persist or if the patient has side effects from treatment.

Key points
Most anogenital warts are associated with human papillomavirus types 6 and 11, whereas cervical intraepithelial neoplasia is associated with types 16 and 18
They may go away spontaneously, so one option is no treatment
Most treatment can be applied by patient
Up to 75% of genital warts clear within a month
20-30% patients may have another sexually transmitted infection so screening should be offered

Joints
O = heart / carditis
Nodules
Erythema marginatum
Sydenham’s chorea