Category: Cardiology
Keywords: lupus, systemic lupus erythematosus, atherosclerotic, coronary artery disease (PubMed Search)
Posted: 9/20/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
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Systemic lupus erythematosus produces a significant predisposition towards premature atherosclerosis. Although the exact mechanism for what causes this is uncertain, premature CAD is at least partially (or largely) caused by systemic inflammation, which can produce endothelial damage and initiates the process of atherogenesis.
The literature indicates that there is a 9X increased risk of CAD in patients with lupus, and the risk increases to 50X higher in women 35-44 years of age! In general, patients with lupus develop their first MI 20 years earlier than age-matched non-lupus counterparts.
[Mattu A, Petrini J, Swencki S, et al. Premature atherosclerosis and acute coronary syndrome in systemic lupus erythematosus. Am J Emerg Med 2005;23:696-703.]
Category: Med-Legal
Keywords: legal, malpractice, discovery, privacy, online (PubMed Search)
Posted: 9/12/2009 by Dan Lemkin, MD, MS
(Emailed: 9/19/2009)
(Updated: 9/19/2009)
Click here to contact Dan Lemkin, MD, MS
Beware of your online contributions, they can come back to hurt you in legal settings. You must remember that there is a digital trail of everything you post online. Discovery rules vary state to state. It is best to practice save surfing. What you may perceive as paranoia is really just good practice.
The following guidelines apply to:
General guidelines
Assume that whenever you hit send, your message will be available to a plaintiff attorney who will twist it to suit his/her needs. The only potential exception is direct email communication to your personal legal counsel. Please verify that local laws protect this form of communication before making an assumption of privacy.
[This pearl is a review of published general recommendations on privacy practices and should not be interpreted as, or replace competent legal advice.]
Brenner, Ilene MD. Anything you tweet can, and will, be used against you. Emergency Physician's Monthly. September 2009. Vol 16-9.
Category: Pediatrics
Keywords: Brain Abscess, Pediatrics (PubMed Search)
Posted: 9/19/2009 by Reginald Brown, MD
(Updated: 4/23/2024)
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Category: Pediatrics
Keywords: Sickle Cell Trait, Sudden Death, Pediatrics, Military, Sports Medicine, Law Enforcement, Medical Legal (PubMed Search)
Posted: 9/18/2009 by Adam Friedlander, MD
(Updated: 4/23/2024)
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You've probably long been taught that Sickle Cell Trait is an irrelevant piece of the PMH, unless you are a genetic counselor. Well, thanks to Dr. Rolnick and a literature search, I (and now you) know that that is incorrect.
Though Sickle Cell Trait (SCT) does not cause exactly the same pathologies as Sickle Cell Disease (SCD), there are believed to be a variety of RBC abnormalities associated with HgbS (such as measurably lower RBC deformability, and low levels of sickling under extreme heat and exercise conditions) which contribute to increased exercise-related sudden death. In one NEJM study of all deaths among 2 million (MILLION) military recruits over a 4 year period, the relative risk of otherwise unexplained sudden death for black recruits with HgbAS vs. black recruits without HgbS was 27.6 (p<0.001), and 39.8 (p<0.001) for all recruits (HgbAS vs. no HgbS).
I must say that this topic is not controversy-free, however, I should also note that my search for "Sickle Cell Trait and Sudden Death" turned up quite a few articles directed at plaintiff's attorneys.
The take-home point is that SCT is likely not a benign condition, and you must be cautious in telling patients that it is. Again, this phenomenon is best described in patients undergoing extreme physical exertion, but hopefully this will change how you think about SCT.
Category: Neurology
Keywords: meningitis, bacterial meningitis, headache, Kernig sign, Brudzinski sign (PubMed Search)
Posted: 9/16/2009 by Aisha Liferidge, MD
(Updated: 4/23/2024)
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Category: Infectious Disease
Posted: 9/15/2009 by Mike Winters, MD
(Updated: 4/23/2024)
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Daptomycin and MRSA
Stryjewski ME, Corey GR. New treatments for methicillin-resistant Staphylococcus aureus. Curr Opin Crit Care 2009;15:403-12.
Category: Geriatrics
Keywords: geriatrics, elderly, pulmonary, pneumothorax (PubMed Search)
Posted: 9/13/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
Elderly patients are at higher risk of barotrauma with positive pressure ventilation (e.g. CPAP, BiPAP, and especially after intubation) because of decreased vital capacity and lung compliance. Watch those plateau pressures closely!
If an elderly patient develops hypotension within minutes of endotracheal intubation, always consider tension PTX (and don't forget about hypovolemia, as we've discussed before).
Category: Toxicology
Keywords: hand sanitizer, ethanol, alcohol (PubMed Search)
Posted: 9/10/2009 by Bryan Hayes, PharmD
(Updated: 4/23/2024)
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Most hand sanitizers contain ethanol, while some contain isopropyl alcohol. The concentration of alcohol in these products varies from 45% to 95%, with the most commonly used products containing 62%. How much would a 15 kg child have to ingest to obtain a blood alcohol concentration of 100 mg/dL (or 0.1%)?
Assuming a volume of distribution of 0.6 L/kg and 100% bioavailability, only 15-20 mL is required to produce this toxic level. That is equivalent to 3-4 teaspoons or approximately 8-10 “squirts” of hand sanitizer!
Category: Neurology
Keywords: phenytoin, dilantin, dilantin toxicity, ataxia, nystagmus (PubMed Search)
Posted: 9/9/2009 by Aisha Liferidge, MD
(Updated: 4/23/2024)
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The following symptoms of phenytoin toxicity typically present initially, once plasma concentrations reach the listed levels below:
Other associated symptoms include tremor, hyper-reflexia, nausea, and vomiting.
Category: Critical Care
Posted: 9/8/2009 by Mike Winters, MD
(Updated: 4/23/2024)
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Complications of Resuscitation
Buschmann CT, Tsokos M. Frequent and rare complications of resuscitation attempts. Intensive Care Med 2009;35:397-404.
Category: Misc
Posted: 9/7/2009 by Rob Rogers, MD
(Updated: 4/23/2024)
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This week's monday pearl is from our very own Azher Merchant....who recently gave an excellent talk on the risks of radiation.
Be afraid....be very afraid....
Radiation Risk:
Risk is based on acute exposure and is extrapolated largely from atomic bomb survivors.
Effective radiation dose = Sievert (Sv)
Adults:
Lifetime Attributable Risk of Cancer 1:1000 at 10mSv
Lifetime Attributable Risk of Cancer Mortality 1:2000 at 10mSv
Risk estimates follow a linear rate of change such that:
Lifetime Attributable Risk of Cancer in Adults = Radiation Dose (mSv) x 0.0001
Risk is Cumulative
Pediatrics:
Lifetime Attributable Risk of Cancer is greater than for adults and is age-dependent
Lifetime Attributable Risk of Cancer Mortality 1:1000 at 10mSv
Common Effective Dose Estimates (mSv)
Background radiation 3.5/year (chronic exposure)
CXR 0.1
CT
Head, Face 2
Neck, Cervical Spine 2
Chest, Thoracic Spine 8
Abdomen 7.5
Pelvis 7.5
Abdomen/Pelvis, Lumbar Spine 15
Extremity 0.5
Note that it doesn't take very much radiation to reach the 10 mSv level!
Bottom line: CT if you need to, but carefully consider whether it is worth it or not
One last pearl, carefully consider whether or not you want that d-dimer and don't order one unless you are prepared to order a CT scan.
Category: Geriatrics
Keywords: UTI, infection, delirium (PubMed Search)
Posted: 9/7/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
The most common cause of delirium in the elderly is infection, and the most common type of infection is just a simple UTI. The second most common cause of delirium is medication effects. ALWAYS look carefully for signs of infection and look carefully at medication lists whenever evaluating an elderly patient with a change in mental status.
Category: Endocrine
Keywords: Hypercalcemia, Hyperparathyroidism (PubMed Search)
Posted: 9/5/2009 by Michael Bond, MD
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Medical Treatment of Hyperparathyroidism
Category: Pediatrics
Keywords: infant, neonate, spasm (PubMed Search)
Posted: 9/4/2009 by Heidi-Marie Kellock, MD
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Infantile Spasms (West Syndrome):
Nelson's Essentials of Pediatrics, 5th Edition.
Category: Toxicology
Keywords: Iron; Poisoning; Deferoxamine (PubMed Search)
Posted: 9/3/2009 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Out | In |
Checking TIBC to determine if treatment is necessary | Checking iron levels...If peak is > 500 mcg/dl, or the patient shows signs of systemic toxicity, treat with deferoxamine |
Deferoxamine challenge... no longer recommended! | Using WBI for ingestion of 20 mg/kg iron, if visible iron pills on x-ray, or symptoms of mild toxicity (for treatment of severe toxicity see above) |
Platform shoes | Strappy sandals |
WBI: whole bowel irrigation
Reminder from Poisondex:
OVERDOSE: SEVERE: Stupor, shock, acidosis, GI bleed, coagulopathy, hepatotoxicity, and coma. MILD/MODERATE: Nausea, vomiting, diarrhea, lethargy, leukocytosis, and hyperglycemia. Clinical phases: (1) 0-2 hours: Nausea, vomiting, diarrhea, and abdominal pain. Lethargy, shock, GI bleeding, and acidosis if severe; (2) Apparent recovery; (3) 2-12 hours: Acidosis, hypotension; (4) 2-4 days: Hepatotoxicity; (5) days-weeks: GI strictures.
Balmadrid C, Bono M. Recognizing and Managing Iron Toxicity. Emergency Medicine May 2009;14-21.
Category: Neurology
Keywords: phenytoin, phenbarbital, dilantin (PubMed Search)
Posted: 9/2/2009 by Aisha Liferidge, MD
(Updated: 4/23/2024)
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Category: Critical Care
Posted: 9/1/2009 by Mike Winters, MD
(Updated: 4/23/2024)
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The Supraclavicular Subclavian Central Venous Cathetherization
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: The forgotten central line. West J Emerg Med 2009;10(2):110-4.
Category: Vascular
Keywords: aortic dissection, syncope (PubMed Search)
Posted: 8/31/2009 by Rob Rogers, MD
(Updated: 4/23/2024)
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Painless thoracic aortic dissection (TAD) and syncope
Patients with TAD do not always present with chest pain. In the International Registry of Aortic Dissection (IRAD) study, 2.2% of TAD cases were painless and approximately 13% of TAD cases presented with isolated syncope (i.e. NO PAIN). Other studies have shown that as many as 15% of TAD cases are painless.
Patients with TAD may present after a syncopal episode. The underlying pathophysiology of syncope is related to proximal rupture into the pericardium with resultant tamponade.
Add TAD to your differential diagnosis of unexplained syncope, especially in older folks and especially if a patient "looks bad" and you don't have a reason.
Category: Geriatrics
Keywords: resuscitaiton, elderly, geriatric, magnesium, ventricular, dysrhythmia (PubMed Search)
Posted: 8/31/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
When caring for elderly patients that are having dysrhythmias, especially ventricular dysrhythmias, or in cardiac arrest, give strong consideration to empiric use of magnesium. Elderly patients are more likely to be hypomagnesemic because of diuretic use, poor GI absorption, poor daily intake, and diabetes.
[Narang AT, Sikka R. Resuscitation of the elderly. Emerg Med Clin N Am 2006;24:261-272.]
Category: Endocrine
Keywords: hyperparathyroidism, hypercalcemia (PubMed Search)
Posted: 8/29/2009 by Michael Bond, MD
(Updated: 9/5/2009)
Click here to contact Michael Bond, MD
Hyperparathyroidism results in elevated PTH and typically results in elevated calcium levels (hypercalcemia).
Though most cases are asymptomatic, symptomatic patients can present with:
Treatment options to be discussed next week....Stay tuned.