Category: Pediatrics
Posted: 8/13/2010 by Adam Friedlander, MD
(Updated: 3/28/2024)
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A common debate on the topic of pediatric burns is whether or not blisters should be debrided. ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED. There are two reasons for this:
1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided.
The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement.
The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas. Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia. Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.
Sargent, RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res 2006; 27:66.
Alsbjorn, B, Gilbert, P, Hartmann, B, et al. Guidelines for the management of partial-thickness burns in a general hospital or community setting--recommendations of a European working party. Burns 2007; 33:155.
Category: Toxicology
Keywords: serotonin syndrome, cyproheptadine (PubMed Search)
Posted: 8/12/2010 by Bryan Hayes, PharmD
(Updated: 3/28/2024)
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If benzodiazepines and supportive care fail to improve agitation and correct vital signs, several case reports indicate the successful use of cyproheptadine, an antihistamine with nonspecific antagonist effects at 5-HT1A and 5-HT2A receptors.
Cyproheptadine is available in 4 mg tablets or 2 mg/5 mL syrup. When administered as an antidote for serotonin syndrome, an initial dose of 8-12 mg is recommended, followed by 2 mg every two hours until clinical response is seen. Cyproheptadine is only available in an oral form, but it may be crushed and given through a nasogastric tube.
Cyproheptadine may lead to sedation, but this effect is consistent with the goals of management. It may also produce transient hypotension due to the reversal of serotonin-mediated increases in vascular tone. Such hypotension usually responds to IV fluids. Cyproheptadine is rated category B for safety in pregnancy by the FDA.
Category: Neurology
Keywords: headaches, cervicogeic headache (PubMed Search)
Posted: 8/12/2010 by Aisha Liferidge, MD
(Updated: 3/28/2024)
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Consider the diagnosis of a Cervicogenic Headache when the following findings are present:
A. Pain localized to the neck and occipital region, potentially with projection to forehead, orbits, temples, vertex or ears.
B. Pain is precipitated or aggravated by particular neck movements or sustained postures.
C . At least one of the following:
1. Resistance to or limitation of passive neck movements.
2. Changes in neck muscle contour, texture, tone or response to active and passive stretching and contraction.
3. Abnormal tenderness of neck muscles.
D. Radiological imaging reveals at least one of the following:
1. Movement abnormalities in flexion/extension.
2. Abnormal posture.
3. Fractures, congenital abnormalities, bone tumors, rheumatoid arthritis or other distinct pathology (not spondylosis or osteochondrosis).
1. Headache classification committee of the IHS. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988 8: 1-96.
Category: Critical Care
Posted: 8/10/2010 by Mike Winters, MD
(Updated: 3/28/2024)
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Drug-Induced Hypophosphatemia
Buckley MS, LeBlanc JM, Cawley MJ. Electrolyte disturbances associated with commonly prescribed medications in the intensive care unit. Crit Care Med 2010; 38(S):S253-S264.
Category: Medical Education
Posted: 8/10/2010 by Rob Rogers, MD
(Updated: 3/28/2024)
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Some Tips for Designing an Insanely Great Talk
Here are just a few things you can do to create a fantastic presentation:
Great website for making great, memorable slides:
http://www.brainslides.com/
Amal Mattu, Joe Lex, Mel Herbert
Category: Cardiology
Keywords: ventricular, aneurysm, myocardial infarction, electocardiography, electrocardiogram (PubMed Search)
Posted: 8/8/2010 by Amal Mattu, MD
(Updated: 3/28/2024)
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The ECG distinction between ventricular aneurysm vs. true STEMI is a tough one. Aside from reviewing the patient's history, here are a few pearls that may help.
1. Both entities cause Q-waves and STE that can be concave or convex upwards. However, aneurysms shouldn't cause reciprocal depression, whereas a true STEMI often does.
2. Serial ECGs and old ECGs are helpful. The aneurysm shouldn't change from a recent ECG or with serial testing, but STEMI ECGs often do, even over the course of 1-2 hours. Look for any changes in ST segments, T-wave morphology changes, or development of Q-waves.
3. Aneurysms are almost always associated with STE in the anterior leads (because most aneurysms involve the anterior wall). STEMI can involve anterior, lateral, or inferior wall.
4. Aneurysms are almost always associated with Q-waves, whereas STEMI may not (yet) have Q-waves.
Category: Orthopedics
Posted: 8/7/2010 by Michael Bond, MD
(Updated: 3/28/2024)
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Some common injuries and their board review associated complications
Category: Pediatrics
Keywords: Ethanol, Pediatric, Ingestion (PubMed Search)
Posted: 8/7/2010 by Adam Friedlander, MD
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Pediatric Ethanol Ingestion
A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:
Category: Infectious Disease
Keywords: rabies, vaccination, animal bite, racoon, bat (PubMed Search)
Posted: 8/5/2010 by Ellen Lemkin, MD, PharmD
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The number of rabies vaccines recommended by the ACIP (Advisory Committee on Immunization Practices) has been reduced from 5 to 4 doses for unvaccinated patients.
This was based on evidence from multiple source, including pathogenesis data, animal trials, clinical studies, and epidemiological surveillance. The first dose of the 4-dose regimen should be administered as soon as possible after exposure (day 0). Additional doses are then given on day 3, 7, and 14. The first dose of rabies vaccine should be administered with HRIG, infiltrating as much as possible into the wound, with the remainder given IM at a distant site from the vaccine.
This recommendation is not applicable to immunocompromised patients, who should continue to receive the full five doses.
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-rabies.pdf
Sullivan, DM. Update on Emerging Infections: News from the Centers for Disease Control and Prevention. Infectious disease/CDC Update. Ann Em Med July 2010;56(1):64-6.
Category: Neurology
Keywords: Cluster, headaches (PubMed Search)
Posted: 8/4/2010 by Aisha Liferidge, MD
(Updated: 3/28/2024)
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Cluster headaches are defined as a group of at least five headache attacks causing unilateral orbital, supraorbital and/or temporal pain, with at least one of the following simultaneous associated findings on the affected side:
Cluster headaches can occur at a frequency of one every other day t eight episodes per day.
Category: Critical Care
Posted: 8/3/2010 by Mike Winters, MD
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Hypocapnia and Brain Injury
Curley G, Kavanagh BP, Laffrey JG. Hypocapnia and the injured brain: More harm than benefit. Crit Care Med 2010; 38:1348-59.
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 8/2/2010 by Rob Rogers, MD
(Updated: 3/28/2024)
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Pulmonary Embolism and Blood Pressure
Patients with massive PE will often develop worsening hypotension after a fluid bolus due to increased right ventricular distension and deviation of the interventricular septum towards the left side of the heart. This septal deviation decreases left heart cardiac output.
In addition, patients with massive PE will sometimes develop higher blood pressures after intubation as positive pressure ventilation reduces preload, decreases deviation of the septum, and increases left sided cardiac output.
Category: Endocrine
Keywords: DKA, Management (PubMed Search)
Posted: 7/31/2010 by Michael Bond, MD
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Diabetic Ketoacidosis Treatment:
Charfen MA, Fernadez-Frackelton M. Diabetic Ketoacidosis. EMCNA 2005:609-628.
Category: Procedures
Posted: 7/30/2010 by Rose Chasm, MD
(Updated: 3/28/2024)
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Category: Toxicology
Keywords: caustic (PubMed Search)
Posted: 7/29/2010 by Fermin Barrueto, MD
(Updated: 3/28/2024)
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Ingestion of caustics can lead to immediate burns to mouth, esophagus, stomach as well as possible perforation. Months and years later, further complications are esophageal stenosis and increased incidence of esophageal carcinoma. The main benefit to EGD is to determine extent of injury within the esophagus. The lesions are graded much like a burn:
Grade I: Mild burn, no risk for esophageal stenosis
Grade II: Moderate, if circumferential, patient is at risk for esophageal stenosis
Grade II: Eschar present, high risk of perforation as well as esophagel stenosis
You can make a case that all intentional-suicidal ingestions of caustics should undergo EGD since there should be some injury if ingestion truly occurred or at the least a higher probability. The difficult case is the pediatric unintentional ingestion. Utilizing clinical exam and history will assist with that determination - there is a little research to guide this decision (next pearl)
The attached picture is the post-mortem of a caustic injury showing grade II linear lesions in esophagus with eschar distally and in stomach (Grade III).
Category: Neurology
Keywords: migraine headache with aura, aura, headache (PubMed Search)
Posted: 7/28/2010 by Aisha Liferidge, MD
(Updated: 3/28/2024)
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A. At least two attacks with at least 3 of the following:
1. One or more fully reversible aura symptoms (indicates focal cerebral cortical and/or brain stem functions).
2. At least 1 aura symptom develops gradually over greater than 4 minutes, or 2 or more symptoms occur in succession.
3. No aura symptom lasts greater than 60 minutes.
4. Headache follows aura with free interval of at least 60 minutes.
B. At least 1 of the following aura features establishes a diagnosis of migraine with typical aura:
1. Homonymous visual disturbance.
2. Unilateral paresthesias and/or numbness.
3. Unilateral weakness.
4. Aphasia or speech difficulty.
Category: Critical Care
Posted: 7/27/2010 by Mike Winters, MD
(Updated: 3/28/2024)
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Drug-Induced Thrombocytopenia
Priziola JL, Smythe MA, Dager WE. Drug-induced thrombocytopenia in critically ill patients. Crit Care Med 2010; 38(S):S145-54.
Category: Cardiology
Posted: 7/25/2010 by Amal Mattu, MD
(Updated: 3/28/2024)
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Classic electrocardiographic findings for hypokalemia:
u-waves (produces appearance of long QT), especially in the precordial leads
ventricular ectopy (PVCs typically)
ST segment depression or downward sagging, especially in the precordial leads
note that the sagging ST segments that terminate in large U-waves end up producing biphasic T-waves; these have the mirror image appearance of Wellens waves
Category: Orthopedics
Posted: 7/24/2010 by Brian Corwell, MD
(Updated: 3/28/2024)
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History and Physical Examination Red Flags | |
Historical Red Flags | Physcial Red Flags |
Age under 18 or over 50 Pain lasting more than 6 weeks History of cancer Fever and chills Night sweats, unexplained weight loss Recent bacterial infection Unremitting pain despite rest and analgesics Night pain Intravenous drug users, immunocompromised Major trauma Minor trauma in the elder | Fever Writhing in pain Bowel or bladder incontinence Saddle anesthesia Decreased or absent anal sphincter tone erianal or perineal sensory loss Severe or progressive neurologic defect Major motor weakness |
Category: Toxicology
Keywords: anticholinergic, sympathomimetic, pupil (PubMed Search)
Posted: 7/22/2010 by Michael Bond, MD
(Updated: 7/24/2010)
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A patient arrives via EMS agitated with VS: P 140, BP 155/100, R 18, T 101F. There is an admitted drug exposure and you examine his eyes which are dilated. You shine the light in the eyes - if the pupil reacts, would that be consistent with anticholinergic or sympathomimetic toxidrome?
Answer: Anticholinergic exposure paralyzes pupillary constrictor muscles and causes dilated pupils that do not react to light. Think about when you go to the eye doctor's office. They put homoatropine in your eyes so that when they look with the slit lamp they can see the retina without interference from pupillary constriction. Sympathomimetic exposure like cocaine activates pupillary dilator muscles, the constrictors are still intact and will give a reflexive constriction to light. This patient has reactive pupils and by the mere fact is in Baltimore probability dictates a sympathomimetic exposure like cocaine.