Clinical Pathways for Status Epilepticus – Dr. Kuzel and Dr. McKinney

In First 5 minutes:

-ABCDEFG (ABC’s, Don’t Ever Forget Glucose).

-Airway considerations: lateral decubitus, nasal trumpets, O2, suction

-Obtain IV access and search for reversible causes, can consider initiation of first line tx with benzos prior to waiting 5 minutes; be aggressive early

5-10 minutes:

First Line Agents: IV Lorazepam 4 mg and up to 0.1 mg/kg, may repeat Q5min or Midazolam 10 mg IM once if no IV access, or IV Diazepam 10-20 mg. Go big or go home. Get the seizures to stop sooner rather than later as more likely to have respiratory depression from status than with benzos.

Second Line Agents: Levetiracetam 60 mg/kg IV (max 4500 mg) or Fosphenytoin or Phenytoin 20 mg/kg IV (max 1500 mg) or Valproate 40 mg/kg IV (max 3000 mg)

Consider intubation if needed.

10-30 minutes:

Medications in refractory status epilepticus: Propofol 2-5 mg/kg IV, then infusion of 2-10 mg/kg/hr. Midazolam 0.2 mg/kg IV, then infusion of 0.05-2 mg/kg/hr. Ketamine 0.5-3 mg/kg IV, then infusion of 0.3-4 mg/kg/hr. Phenobarbital 15-20 mg/kg IV at 70-75 mg/min.

Advanced airway management: RSI. Preoxygenation. Induction: Propofol or Ketamine. Paralytics: Succinylcholine or Rocuronium (however consider status not being seen). When to intubate: when predicted course of seizures will necessitate high dose of respiratory depressing drugs.

–Special considerations: Consider nonconvulsive status epilepticus in known epileptic patient without return to baseline (emergent EEG, consider benzos). Always consider tox causes (avoid Phenytoin of Fosphenytoin in undifferentiated tox patient or drug withdrawal. Also avoid if this is a home medication due to concern of cardiotoxicity). Give Thiamine 100 mg if alcoholic. In isoniazid overdose, give pyridoxine 70 mg/kg, Max 5 gm.

–Pediatric considerations: Access usually a problem. Intranasal Midazolam 5 mg/mL solution dosed at 0.2 mg/kg divided into each nostril. Lorazepam 0.1 mg/kg IV, max 4 mg. See CHOP status epilepticus

Oral Boards – Dr. Shoff

-What do I see when I walk in room? If AMS, get POC glucose early on

-IV access, heart monitor, O2 monitor

-If a vital sign is missing, ask for it, likely will be abnormal

-If vitals are abnormal, start addressing immediately. Can always request “if this intervention changes a vital sign, will you let me know?”

-Always ask allergies before giving meds

-Get history from whoever you can: paramedics, family. Don’t forget social, surgery, family hx

-When to order things: right when you walk in, after history, after physical (can whenever but these are the 3 best times)

-If you ask specifics in regards to exam, they will answer yes/no, don’t want to be too broad but don’t forget to ask things either.

Geriatrics Lecture – Mobility

-Find out who lives at home, steps at home, assistive devices?

-Walk the patient in the ED and see how they do

-Could request PT/OT eval; may be hard from ED but could admit for these services.

-If thinking needs rehab/admit and not obs because they need a 3 day stay for insurance purposes

-If discharging, make sure home health eval can occur. If discharging with pain meds, do only half a pill.

-If patient is falling, consider that this is #1 morbidity/mortality for elderly

Meningitis – Dr. Platt

–Important higher level questions to ask: exposure to recent meningitis, current sinusitis/OM, recent antibiotic use, travel such as to Hajj and Umrah, recent IVDA, progressive rash, recent or remote head trauma, HIV infection, immunocompromised, recent drug use including OTC, age, vaccination status

-Screening CT not necessary if none of these apply: immunocompromised state (HIV, immunosuppressive therapy, solid organ or hematopoietic cell transplant), Hx of CNS disease (mass lesion, stroke, or focal infection), New onset seizure within 1 week of presentation, papilledema, abnormal level of consciousness, focal neurological deficit.

-LP: try to get blood cultures first and quickly do LP before antimicrobial therapy. If there will be a delay, blood cultures, abx.

-Drug that cause aseptic meningitis: NSAIDS!, antimicrobials (Bactrim, Amoxicillin, Isoniazid) most common but others include Muromonab-CD3 (Orthoclase OKT3), Azathioprine, IVIG, Intrathecal methotrexate or cystine arabinoside.

-CSF studies: normal glucose is about 2/3 concentration of blood. Glucose may decrease with bacteria, WBCs, or cells shed by tumors. Small amount of protein is normal in CSF but increases commonly seen with meningitis and brain abscess, brain or spinal cord tumors, MS, GB, syphillis. Don’t forget to order specifics for what you want.

-Don’t forget Dexamethasone prior to/same time as antibiotics

-Antibiotics based on age: <1 month (Ampicillin + Cefotaxime or aminoglycoside), 1 month to 50 years (Vanc + ceftriaxone +/- Rifampin if dexamethasone given), >50 years (Vanc + Ampicillin + Ceftriaxone +/- Rifampin if dexamethasone given).

Journal Club – Dr. Mary Jane Schumacher

-Compression therapy for prevention of recurrent cellulitis of the leg – do it

-TXA vs oxymetazoline for hemostasis in epistaxis: need a better study, would still try Affrin first but remember TXA as another option as this review shows it could be clinically beneficial and may prevent need for nasal packing

72 hour returns/Deaths in ED/Deaths within 24 hours – Dr. Mary Jane Schumacher

-Great job on care of patients and documentation

–For documentation: remember to take out the things that are saved in every note but do not apply. For ex. a patient dies in the ED, do not have in your note: discussed plan and all of their questions were answered or follow up with primary care physician upon discharge

-Important patient care points:

Remember to think of social situation and set patients up for success if going to discharge. Are they going to go home and fall and break a hip/get a brain bleed? Do they have a PCP to follow up with?

If vitals or clinical change on a trauma patient – repeat FAST.

Seizure patients – monitor in ED for a period of time, give their seizure meds/keppra load if they have definitely missed doses and discharging but be cautious of restarting Lamotrigine for risk of SJS if they haven’t been taking it. People coming back with recurrent seizures – neuro consult.

Alcohol withdrawal – really pay attention to these people, they can become sick very quickly. Symptoms can range from mild to severe. Recognize the symptoms from tremors/tachycardia to hallucinations/delusions and seizures. If alcoholic and reported seizure at home and don’t look well, consider admission. If they look well, can give phenobarbital 260 IM if discharging as it has a long half life and can prevent decompensation. You can also give phenobarbital IV if admitting for sxs.

Cirrhotics – use ideal body weight, use LR for resuscitation. Don’t forget considerations of Albumin in SBP, HRS, etc.

Morbidity and Mortality Case – Dr. Caleb Webb

-HIV/AIDS: AIDS when CD4 count <200

-AIDS defining illnesses: Several; discussed cryptococcosis, MAC, PCP

-Cryptococcal Meningitis: HA, fever, neck pain, n/v, photophobia. Will see increased ICP on lumbar puncture. Need to specifically order crypto testing on CSF fluids. Treatment is induction therapy with Amphotericin B and Flucytosine.

-MAC: most likely when CD4 count <50. Disseminated MAC: fever, night sweats, abd pain, diarrhea, weight loss. Diagnosis via isolation of MAC from the blood.

-PCP: diffuse, bilateral interstitial infiltrates. Induced sputum sample. Consider ordering LDH as often elevated.

Electrolytes – Capstone Dr. Dan Grace

Hyperkalemia

Causes: #1 cause hemolysis followed by renal failure, acidosis, cell death, drugs (ACE/ARBS)

Sxs: Abd pain, diarrhea, chest pain, muscle weakness/numbness, n/v, palpitations

EKG changes: variable depending on K; peaked T waves then P flattens and PR lengthens, conduction abnormalities and bradycardia – prolonged QRS up to sine wave, then cardiac arrest

Treatment: stabilize cardiac membrane with calcium gluconate, shift K into cells via 5-10 U regular insulin with 1-2 D50 amps, albuterol neb, sodium bicarb (esp if acidotic), Get rid of K via lasix if properly hydrated, dialysis.

Hypokalemia

Causes: chronic ETOH, malnutrition, diuretics, vom/diarrhea, hyperventilating, alkalosis

Sxs: cramping, weakness

EKG changes: U waves, flattening/loss of T waves, tornadoes, AV block, brady, PVCs

Deficit: For every 0.3 meq/L below 3.5, 100 meq deficit, replace with KCl PO if can, or IV; also have Effer-K, K phos at no more than 60 meq at at time

Hypernatremia

Causes: unreplaced water losses, decreased water intake or excessive Na intake

Sxs: HA, n/v, confusion/AMS, seizure, coma

Treatment: Depends on sxs, mild symptomatic (if euvolemic consider 1/2NS), severe with seizure/coma (D5W), Free water deficit on MDCalc [(serum Na – 140)/140] x 0.6body weight in kg. Don’t correct more than 0.5/hr.

Hyponatremia

Causes: vomiting, diarrhea, diuretics, drinking too much water, dehydration, heart/kidney/liver problems, inadequate salt intake – generally classified into hypovolemic, euvolemic, or hypervolemic

Sxs: dizziness, fatigue, HA, confusion, nausea, seizures

Repletion: no more than 0.5 meq/hr and 8meq/day to avoid osmotic demyelination syndrome. Give hypertonic saline 3% for seizure, coma 100 -150 cc over 10 min, can repeat x 1

Other electrolytes important in ED

Hypercalcemia: bones, stones, groans, psychiatric overtones; Tx if 12-14 with sxs or >14; fluid resuscitate, lasix if fluid overload, calcitonin is faster than bisphosphonates

Hypophosphatemia: anemia, bruising, seizure, coma, constipation, muscle weakness; usually caused by DKA, refeeding, malabsorption, ETOH; tx with NaPhos or KPhos PO or IV

Environmental Kahoot – Dr. Dan Grace

-Killerbees more likely to swarm and sting multiple times

-Acute Mountain Sickness – descend; Acetazolamide works by causing primary metabolic acidosis

-Ruptured TM following ascent from scuba diving – antibiotic drops and ear precautions

-Difference b/t heat stroke/exhaustion = neuro sxs

-Iguana bite – cipro

-ARDS after wet drowning due to water washing away surfactant

Toxic Smoothie – Dr. Bosse

-Digoxin toxicity is only time you do not want to use calcium for hyperkalemia

-Cyanide toxicity: lactate level. Tx with hydroxycobalamin. Other tx: nitrite (causes methemoglobinemia which then scavenges cyanide); thiosulfate, cyanokit (amyl nitrite, sodium nitrite, sodium thiosulfate)

-Antihypertensive overdose: hypotension possible but not common with ACE-I OD

-Few toxins cleared by HD: lithium, toxic alcohols, salicylates, theophylline

Geriatrics Lecture – Mentation

-Normal aging: slowed, need more time.

-Confusion, problems with judgement not normal

-Dementia progresses over years vs delirium acute change in things like attention, falling asleep, disorganized thinking or altered level of consciousness

-Delirum causes – several, but think of infection, meds, seizures, intracranial bleed, NPH

-Can use ADEPT Tool to assess change in mental status

-Use smaller doses of medications for elderly

-If need meds for agitation ex: Haldol 0.5 mg (IV,IM,PO), Seroquel 12.5 mg, Olanzapine 2.5-5 mg, Risperidone 0.25-0.5 mg

Decompensated Cirrhosis – Dr. McGee

-Have high index of suspicion for cirrhosis – use clues from exam and labs

-Search for underlying etiology of portosystemic encephalopathy, GIB, etc.

-Diagnose and treat SBP: diagnostic paracentesis with >250 PMNs, Ceftriaxone 2g Q24 hrs, Alubmin 1.5g/kg on day 1 reduces mortality

-GIB: early GI consult; varies 15-30% risk of death. 2 large bore IVs, cultures, ceftriaxone (or broader), keep Hb around 7. correcting INR with FFP not recommended, transfuse if plt <50 K, cryo for fibrinogen <100. Protonix, octreotide. Blakemore tube if needed.

-Hepatorenal Syndrome: High index of suspicion, Cirrhosis and Cr >1.5. If cirrhotic with AKI, use albumin 5% if hypovolemic, 25% if euvolemic/hypervolemic, non ICU midodrine and octreotide; if ICU levo with MAP >85.

-Medications to AVOID: Never NSAIDs, if opiates needed then fentanyl > Hydromorphone > morphine, avoid benzos as much as possible; can give Tylenol up to 2 g/day

MICU Follow Up – Hypothermia

-ECMO (if available) may be best way to rewarm, 7-10 ⁰C /hr

-Thoracic lavage up to 6 ⁰C/hr

-If coding, can attempt defibrillation x 3; rewarm to at least 86 ⁰ F

-Try to avoid stimulating heart, if need central access, fem line is best

-Rewarming complications include several electrolyte/coag abnormalities; check frequently

-Goal rewarm temp is 86-89 ⁰F

Neuro Cases

1. Stroke in Sickle Cell

-Neuro/hem consults early

-Exchange transfusion as treatment

-Can use upper motor neuron/lower motor neuron signs to help delineate where problem is

ex. UMN: +Babinski, spasticity, hyperreflexia ; LMK: Fasciculations, hypotonia, hypo/areflexia

2. Posterior Circulation Strokes

-Several symptoms: vertigo/dizziness, imbalance, unilateral limb weakness, dysarthria, diplopia, nystagmus, n/v, dysphagia

-HINTS exam can be used if symptomatic (Head Impulse, Nystagmus, Test of Skew)

-Subclavian Steal Syndrome: suspect in a patient with vertebrobasilar territory neuro sxs, arm claudication (exercise-induced arm pain or fatigue; coolness or paresthesias in extremity)

3) tPA

-BP goals for tPA administration <180/110 – may use Labetalol/Nicardipine for BP control

-Know some of the absolute contraindications; ex: any hx of intracranial hemorrhage, BP >180/110, known bleeding diathesis (platelet count <100,000; use of warfarin with INR > 1.7, use of DOACs) Can use MDCALC to run absolute/relative contraindications

-tPA symptom onset < 4.5 hours (prefer <3 hours esp in those >80 years)

Geriatrics Lecture

4 M’s for the ED: Medications

-Medications/polypharmacy should be high on differential for acute change in elderly

-1/3 of elderly patients lose independence in at least 1 activity when admitted

-Several meds are problematic; warfarin, ASA, plavix, digoxin, metformin and other diabetic medications, antibiotics

Room 9 Follow Up Case – Massive Hemoptysis

-Massive hemoptysis, no clear consensus definition. 100-1,000 mL/24 hours or >50 mL in a single event – really any bleed that is life threatening due to airway obstruction, hypotension, or blood loss

-Usually arises from bronchial circulation; MCC usually TB, bronchiectasis, lung abscess, bronchogenic carcinomas

-Airway protection: if having difficulty clearing airway or hypoxic/dyspneic, prepare for difficult intubation; intubation of mainstem of the good lung; can do this via going past the cords and turning ET 90 degrees; have patient lay on side of the bad lung

-TXA: nebulized TXA with 1 g TXA in 10 cc saline. Can also do 500 mg TID. Systemic route also an option, 1gm load in 100 mL NS over 10 minutes and 1 gm over 8 hours.

-Bronchoscopy and CT; CTA may help identify source; consults to consider early: Pulm, IR or CT surgery

EMS Lecture- PreHospital Stroke

-Several scoring systems (RACE, Stroke VAN, FAST-ED, CSTAT, LAMS) to help guide pre-arrival notification and transport to comprehensive stroke center

-CSTAT: Cincinnati Stroke Triage Assessment Tool, Screen for Large Occlusion Strokes >/= 2 is positive

Conjugate Gaze Deviation 2 points

Incorrectly Answers Age or Month and Does not follow at least one command (close your eyes, open and close your hand) 1 point

Arm (right, left or both) falls to the bed within 10 seconds 1 point

-Mobile stroke units – can decrease time to stroke tx by 50%, 20 units worldwide, CT scanner in back; tremendous expense without great improvement in outcomes

-tPA goal 60 minutes door to drug.

Hey I was going over some articles with a friend for Board Prep. Check out a few valuable figures from the papers:

• TIA Management. Think about the mimics. High risk for stroke if true TIA.

Edlow JA. Managing patients with transient ischemic attack. Ann Emerg Med 2018 Mar;71(3):409-15.

• Cord Compression Diagnosis and Treatment. Steroids only for malignancy. Keep BP up, ABx when indicated, and call the surgeon!

Ropper AE, Ropper AH. Acute spinal cord compression. N Engl J Med 2017 Apr;376(14):1358-69.

• Algorithm approach for New Onset Seizure. Anticonvulsants recommended even for first time IF epilepsy diagnosed.

Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA 2016 Dec;316(24):2657-68

• Outcomes with Endovascular stroke therapy in hours 6-16. This is why we room 9 strokes outside of the tPA window.

DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018 Feb;378(8):708-18

Trauma Conference – Amanda Corzine

• Domestic violence underreported in Louisville and nationally
• SANE and CWF are important resources to use here
• Have increased concern for women that present intoxicated on alcohol with no prior history of intoxications – be informed about domestic violence; Dr. Coleman has done research looking at the coincidence of domestic violence in this patient population

MICU Case Review – Royalty

• Patient with AMS, seizure-like activity. PMH of COPD on home O2, HFpEF, HTN, T2DM, Afib on AC, intubated prior to ICU
  • Subsequently COVID+ on floor transfer; sent back to MICU
  • Intubated again. Started on Remdesivir, Dexamethasone. Code during intubation.
  • Ultimately complicated course of Afib management and thrombocytopenia
  • +trop in trending labs q48h in COVID patient; cards consulted.

DED/72H Returns – Staben

• Remember to get labs in hypothermic patients who have arrested – it can lead to more appropriate prognostication and cessation of futile codes. K>12 means further resuscitative efforts are futile.
• Reviewed Brain Trauma Foundation guidelines regarding surgical management of acute SDH
• Remember to do indicated procedures like bilateral chest tubes or finger thoracostomy in blunt traumatic arrest even in seemingly futile cardiac arrest as these patients can have occult injury.

2-10-2020 Conference Notes

GME disability discussion – Calvin Rasey

• Endorsed by UofL
• COVID long term effects “long haulers.”

Pediatric Fractures – Elizabeth Lehto

• Torus fracture
• Plastic deformation, kids < 4
  • Generally associated fractures
  • >20 degrees of angulation require reduction
• Greenstick, kids < 10
  • Convex surface fracture
• Complete fractures
• Salter-Harris Fracture – SALTER vs know your MEME
  • I – Straight through the growth plate, may be radiographically absent
  • II – Above, through the growth plate and above into the metaphysis
  • III – Lower, fracture through growth plate and epiphysis
  • IV – Through both epiphysis, growth plate, and metaphysis
  • V – Rammed, growth plate crush injury
• Name that fracture game
• Elbow fractures
  • Capitellum – age 1
  • Radial head – age 3
  • Internal  epicondyle – age 5
  • Trochlea – age 7
  • Olecranon – age 9
  • External epicondyle – age 11
  • Need true 90 degree flexion X-rays – don’t get lazy with them.
    • Anterior fat pad – normal
      • Big sail sign = lipohemearthrosis
    • Posterior fat pad – pathological
    • Radiocapitellar Line
    • Anterior humeral line
  • Supracondylar fractures
    • Volkman’s Contracture if neurovascular injury
    • Anterior interosseous syndrome – normal if a good “okay sign”
  • Nursemaid’s elbow
• Non-accidental trauma
  • Torso, ears, neck, 4 years or younger
  • Watch out for kids that aren’t pulling up or walking – they should not have any bruises.
  • High specificity fractures
    • Metaphyseal fractures
      • Corner fractures – oblique avulsions of the metaphysis
      • Bucket handle fractures – horizontal avulsions of metaphysis
    • Rib fractures
      • Posterior more specific; CPR causes anterior rib fractures
    • Skull fractures
      • Non-parietal, cross suture lines, depressed
    • Scapular fractures
    • Sternal fractures
    • Spinous process fractures
• Leg fractures
  • Tibial fractures
    • High risk for compartment syndrome
      • Tibial shaft fractures requiring reduction tend to be admitted
    • Toddler’s fracture – distal shaft spiral/oblique fracture between 9-3 years
  • Juvenile Tillaux fracture – SH III
    • May require CT to evaluate closed vs open reduction, <2mm can be reduced
  • Triplane fracture, distal SH IV  – requires CT
• Hand fractures
  • Carpal fractures
    • Scaphoid fracture, think FOOSH, snuffbox tenderness
  • Distal phalanx fractures
    • Tuft fractures, splinted in DIP extension
    • Nailbed associated fractures – give abx
    • Seymour fracture – displaced SH II fracture, generally open, and requires reduction.
• Hip fractures
  • SCFE
    • Fat teens presenting with knee pain
    • Surgical pinning and NWB
  • Avascular necrosis – Legg-Calve-Perthes Disease
    • Preteen, insidious onset, antalgic gait

GI Review Game – Dr. Shaw

• NEC – new babies, mostly premature, pre-E, cocaine use in pregnancy
  • Amp/Gent, bowel rest
• Giardia – treat with flagyl
• Boerhaave – L pleural effusion, CXR with pneumomediastinum
• Esophageal foreign bodies
  • Esophageal bodies align in coronal plane
  • Sharp objects, objects > 6cm in length require surgical removal, then 24h trial of passage
  • All EFB require GI f/u to rule-out structural abnormalities
• AAA
  • >5.5cm = OR, include the mural thrombus
• Hernias
  • Indirect vs direct vs femoral hernias
    • Indirect follows inguinal canal

Ventilator Management Lecture – Obrien

• Check out Scott Weingart’s post on EMcrit regarding mastering the vent.
• PRVC or VC is preferred
• Remember ARDSNet

Intern Lightning Lectures – Schutzman, French, Strohmaier

• Positively electrifying.
• Acid-Base Status
  • Bicarb vs respiration vs buffers control pH
  • Delta gap in context of AGMA  – (AG-12) – (24-Bicarb)
    • Normal -6 to +6
    • Can indicate AGMA +NAGMA superimposed or vice versa.
• Unstable C-spine fractures
  • Denis Column Concept
    • Anterior column – always stable
    • Middle column – sometimes stable
    • Posterior column – always unstable
  • Jefferson’s Fracture
    • Consider vertebral artery injury
  • Bilateral Facet Dislocation
    • Consider CTA C-spine, MRI may be warranted as SCI strongly associated
  • Odontoid Fracture
    • Types I, II, III
  • Atlanto-Occipital Dissociation
    • Calculate that Power’s ratio, folks.
  • Atlanto-Axial Dislocation
    • Remember increased likelihood in some populations; Trisomy 21, OI, Marfan, NF1, SLE, AS, psoriasis, RA
  • Hangman’s Fracture
    • C2 fx with anterior displacement
  • Flexion Teardrop
    • Can disrupt posterior longitudinal ligament, high association with anterior cord syndrome
• DRESS vs SJS vs TEN
  • DRESS – drug rash with eosinophilia – morbilliform rash
    • Remember herpes reactivation
  • SJS/TEN
    • Mucosal involvement

Can’t Miss EKG Review – Huecker

• Didn’t miss a beat.
• Read Amal Mattu. If you don’t, you won’t understand EKGs very well
• He’ll send out his presentation

Test Taking Strategies – Shreffler

• 225 multiple choice questions, 4.5 hours to complete
• Feel okay to change answers after you re-read questions; you will likely have more insight later on.
• He will send out his presentation

Headaches in Small Groups – Nichols

• HA1
  • Temporal Arteritis
    • Get ESR, can do US vs MRI, will require temporal artery biopsy
    • Ophtho involvement means a larger burst x3 days of methylprednisolone, likely requires admission
• HA2
  • CO poisoning
    • Need ABG with co-oximetry
    • Consider EKG and troponin
    • Remember fetal Hb binds CO much more preferentially than maternal Hb, so lower threshold to treat with hyperbarics.
• HA3
  • Epidural hematoma
    • Consider BP goals, mannitol/3%, elevate HOB, hyperventilate

Procedural Review – Baker

• Excellent multiple choice questions.
• SBP
  • Remember albumin, get abx early
  • Low thresholds for diagnosis with cell count greater than or equal to 100 in peritoneal dialysis
  • We need to do more paracentesis
• LP
  • Watch that bevel
  • Platelets > 20/25, INR >=1.5
• Pacemakers
  • RIJ
  • Transvenous: 80 BPM, 20mA, 20cm
• Thoracotomy
  • >1500 initial output, >200mL over first 3 hours
  • 5^th intercostal space
• Yolk sac + gestational sac required for confirming IUP earliest.