Category: Critical Care
Posted: 5/26/2009 by Mike Winters, MBA, MD
(Updated: 10/10/2024)
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NICE-SUGAR and Glucose Control in the Critically Ill
The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. NEJM 2009;360(13):1283-1348.
Category: Vascular
Keywords: Transvenous pacing (PubMed Search)
Posted: 5/26/2009 by Rob Rogers, MD
(Updated: 10/10/2024)
Click here to contact Rob Rogers, MD
Transvenous pacing
We had a very interesting case the other day in the ED. A 60 yo male presented after a syncopal episode. After arriving in the ED he was awake (with a pulse of 50) but then became asystolic, without warning. He then woke up and 10 minutes later became asystolic again. He then woke up again. So, we decided to put in a transvenous pacer.
Some considerations when putting in a transvenous pacer:
Category: Cardiology
Keywords: post-cardiac arrest care, early goal directed therapy (PubMed Search)
Posted: 5/24/2009 by Amal Mattu, MD
(Updated: 10/10/2024)
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Category: Orthopedics
Keywords: Elbow Dislocation (PubMed Search)
Posted: 5/23/2009 by Michael Bond, MD
(Updated: 10/10/2024)
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Elbow Dislocation
Quick clinical clues that the elbow is dislocated:
Category: Neurology
Keywords: bell palsy, weakness, stroke, stroke mimic (PubMed Search)
Posted: 5/20/2009 by Aisha Liferidge, MD
(Updated: 10/10/2024)
Click here to contact Aisha Liferidge, MD
-- acute onset of unilateral upper and lower facial paralysis (over 48 hr. period)
-- posterior auricular pain
-- decreased tearing
-- hyperacusis (due to stapedius muscle weakness)
-- taste disturbances
Category: Critical Care
Posted: 5/18/2009 by Mike Winters, MBA, MD
(Updated: 10/10/2024)
Click here to contact Mike Winters, MBA, MD
Platelet Transfusions and the Critically Ill
Category: Hematology/Oncology
Keywords: multiple myeloma, altered mental status, hyperviscosity syndrome (PubMed Search)
Posted: 5/18/2009 by Rob Rogers, MD
(Updated: 10/10/2024)
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Multiple Myeloma + Altered Mental Status=Hyperviscosity Syndrome
Although the differential diagnosis of altered mental status is quite extensive, a patient with multiple myeloma and altered mental status should prompt consideration of one important, albeit not too common, condition.....hyperviscosity syndrome.
Some important pearls:
Category: Cardiology
Keywords: ST-segment elevation (PubMed Search)
Posted: 5/17/2009 by Amal Mattu, MD
(Updated: 10/10/2024)
Click here to contact Amal Mattu, MD
There are multiple causes of electrocardiographic ST-segment elevation which are well-known to mimic STEMI and often are a cause of misdiagnosis of STEMI. These are:
Whenever there is doubt regarding whether you are dealing with a STEMI or a mimic, look for reciprocal ST-depression. Most of these will not produce ST-depression (LVH, LBBB, Pacers, and hyperkalemia WILL). The other key intervention is to perform serial ECGs and look for evolving changes, which strongly points to the presence of a true STEMI.
Category: Orthopedics
Keywords: Trimallelor Fracture (PubMed Search)
Posted: 5/16/2009 by Michael Bond, MD
(Updated: 10/10/2024)
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Trimallelor Fractures:
Bimallelor fracture involve both the medial mallelous of the tibia and the distal fibula. The third malleloi is the posterior tip of the articular surface of the tibia. Can result in instability in the posterior and lateral directions along with external rotation.
Some indications for Open Reduction Internal Fixation when the posterior mallelous is fractured are:
Category: Pediatrics
Posted: 5/15/2009 by Rose Chasm, MD
(Updated: 10/10/2024)
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Classic presentation: breastfeeding failure with umbilical stump and gastrointestinal bleeding by postnatal day 7. Oozing from circumcision, venipuncture, and heel sticks is also common. Beware bleeding into the scalp or intracranial space.
Due to essential vitamin K deficiency which exists at birth as the fetus receives little vitamin K from the uteroplacental circulation. It is responsible for impaired neonatal clotting function (deficiency of factors II, VII, IX, and X).
Prevented by a single intramuscular dose of 1mg vitamin K in the first few hours following delivery.
American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics. 2003;112:191-192.
American Academy of pediatrics, the American College of Obstetricians and Gynecologists. Care of the neonate. In: Gilstrap LC, Oh W, eds. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, Ill, Wash DC: American Academy of Pediatrics, teh American College of Obstetricians and Gynecologists; 2002:187-236.
Category: Toxicology
Keywords: benzodiazepine, oxazepam, toxicology, urine, blood (PubMed Search)
Posted: 5/14/2009 by Bryan Hayes, PharmD
(Updated: 10/10/2024)
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Your patient presents unresponsive with an empty bottle of alprazolam (Xanax). You order a urine and blood toxicology screen. The blood comes back negative for benzodiazepines but the urine test is positive. How do you interpret this result?
Category: Neurology
Keywords: complications, transplant, cyclosporine, tacrolimus, movement disorder, cranial nerve palsy, visual abnormalities (PubMed Search)
Posted: 5/13/2009 by Aisha Liferidge, MD
(Updated: 10/10/2024)
Click here to contact Aisha Liferidge, MD
Zivkovic S. Neuroimaging and neurologic complications after organ transplantation. J Neuroimaging. Apr 2007;17(2):110-23.
Category: Vascular
Keywords: venous thromboembolism, microalbuminuria (PubMed Search)
Posted: 5/12/2009 by Rob Rogers, MD
(Updated: 10/10/2024)
Click here to contact Rob Rogers, MD
Risk of PE/DVT in patients with microalbuminuria....another risk factor to consider??
Microalbuminuria (protein in the urine) is a known risk factor for arterial thromboembolic disease, and recent studies suggest that arterial thromboembolism and venous thromboembolism (VTE) have common risk factors. In a prospective community-based cohort study in the Netherlands, researchers enrolled 8574 adults (age range, 28-75) who were followed for 9 years. People with insulin-dependent diabetes or pregnancy were excluded.
Of 129 identified episodes of VTE, roughly half were deep venous
thromboses, and half were pulmonary embolisms. The annual VTE incidence
rate was 0.12% in patients with normoalbuminuria (<30 mg/24 hours)
versus 0.40% in those with microalbuminuria. After adjustment for known VTE
risk factors and other factors (including hypertension, known coronary arterydisease, and elevated C-reactive protein level), the hazard ratio for
VTE in people who had microalbuminuria, compared with those who had
normoalbuminuria, was 2.0.
Comment: The importance of this study is not in the clinical value of
usingmicroalbuminuria as a marker for VTE risk, because the absolute risk
conferred by microalbuminuria is very low, and the therapeutic
implicationsare unclear. Rather, this study suggests that microalbuminuria is a
marker for endothelial dysfunction in both arterial and venous systems, and it
suggests a mechanism for how statins interact with the endothelium to
prevent VTE (JW Cardiol Mar 29 2009).
So, does this affect us as emergency physician? Unclear. But it may very well mean that we might be dealing with a new risk factor that needs to be taken into consideration when evaluating patients with chest pain or SOB. Obviously, we might need medical records to find this risk factor...can you imagine asking a patient if they have microalbuminuria?
Mahmoodi BK et al. Microalbuminuria and the risk of venous
thromboembolism. JAMA 2009 May 6; 301:1790
Category: Critical Care
Posted: 5/12/2009 by Mike Winters, MBA, MD
(Updated: 5/24/2009)
Click here to contact Mike Winters, MBA, MD
Ultrasound of the IVC for Volume Assessment
Category: Cardiology
Posted: 5/10/2009 by Amal Mattu, MD
(Updated: 10/10/2024)
Click here to contact Amal Mattu, MD
Cardiocerebral resuscitation is a new approach to CPR which has demonstrated improvements in survival and neurological recovery. The main focus is early defibrillation and good compressions with an early dose of EPI, but with a strong de-emphasis on early intubation or bagging. Most patients with sudden cardiac arrest don't need early oxygenation anyway, and the previous emphasis on ventilations only serves to take time and effort away from the important chest compressions. Intubation is deferred for 6-8 minutes after the cardiac arrest in favor of simple passive oxygenation with a non-rebreather.
The bottom line is that when facing a patient in cardiac arrest, the traditional mantra in emergency medicine of "A-B-C" needs to now be changed to emphasize the "C" coming first, second, and third.
Kellum MJ, et al. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hosptial cardiac arrest. Ann Emerg Med 2008;52:244-252.
Category: Orthopedics
Posted: 5/9/2009 by Michael Bond, MD
(Updated: 10/10/2024)
Click here to contact Michael Bond, MD
Knee Dislocations:
Are relatively rare injuries, but can result in loss of the limb if missed. Patients will sometimes say they dislocated their knee when they actually mean their patella, so a good history where they describe what their knee looked like, and what they were doing at the time will help differentiated the two.
Some signs that you are dealing with a spontanously reduced knee dislocation are:
The loss of limb is due to unrecognized injury to the popiteal artery which as be estimated to occur 7-45% of the time.
If you would like to see some videos of knee injuries in the making follow this link www.csmfoundation.org/Educational_Lower_Extremity.html
Category: Toxicology
Keywords: ethanol,fomepizole,toxic alcohols,ethylene glycol,methanol (PubMed Search)
Posted: 5/7/2009 by Ellen Lemkin, MD, PharmD
(Updated: 10/10/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Category: Neurology
Keywords: akathisia, diphenhydramine, restlessness, neuroleptics, anti-emetics (PubMed Search)
Posted: 5/6/2009 by Aisha Liferidge, MD
(Updated: 10/10/2024)
Click here to contact Aisha Liferidge, MD
Subjective Findings Do you feel restless or the urge to move especially in th legs? 0=No (none) 1=Some times (mild) 2=Most times (mod) 3=All times (severe) Objective Findings Observe patient for 2 full minutes on stopwatch: For how much time were they off their stretcher? 0=None 1=1 to 30 sec. 2=31 to 60 secs. 3=61 to 108 secs. 4=Whole time For how much time do they have purposeless or semi-purposeless leg or foot movement? 0=None 1=1 to 30 sec. 2=31 to 60 secs. 3=61 to 108 secs. 4=Whole time Diagnosis requires an elevation of 1 grade or more in the reported severity of subjective findings between the baseline and follow-up assessment (i.e. from none to mild, mild to mod.), with objective corroboration. |
Category: Critical Care
Posted: 5/5/2009 by Mike Winters, MBA, MD
(Updated: 10/10/2024)
Click here to contact Mike Winters, MBA, MD
New Perspectives on Clostridium difficile
Janka J, O'Grady NP. Clostridium difficile infection: current perspectives. Curr Opin Crit Care 2009;15:149-53.
Category: Medical Education
Keywords: Lecture (PubMed Search)
Posted: 5/5/2009 by Rob Rogers, MD
(Updated: 10/10/2024)
Click here to contact Rob Rogers, MD
Giving a Lecture-Pearls and Pitfalls
Giving a lecture is filled with many potential pearls and pitfalls. Here are just a few important points that are frequently discussed:
For an entertaining discussion of the pearls and pitfalls if giving a presentation check out the May episode of EMRAP: Educators' Edition on iTunes (also on the website www.emrap-ee.com). There is a great discussion by Greg Henry, Mel Herbert, and Amal Mattu. Check it out. It's free!
Amal Mattu, Joe Lex, Greg Henry