Category: Toxicology
Keywords: glargine, insulin, lantus (PubMed Search)
Posted: 4/9/2009 by Bryan Hayes, PharmD
(Updated: 10/9/2024)
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Overdoses of insulin glargine (Lantus) are rarely reported in the literature. In fact, there are only 6 case reports. We recently had a patient in our ED who was hypoglycemic from insulin glargine. The hypoglycemic episode was quite prolonged (> 24 hours) in the ED before being the patient was transferred to the MICU. Here are a few points to remember:
Category: Neurology
Keywords: ataxia, nih stroke scale, weakness, cerebellar function, stroke (PubMed Search)
Posted: 4/8/2009 by Aisha Liferidge, MD
(Updated: 10/9/2024)
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Category: Critical Care
Posted: 4/7/2009 by Mike Winters, MBA, MD
(Updated: 10/9/2024)
Click here to contact Mike Winters, MBA, MD
Ventilation in the Brain-injured Patient
Lapinsky SE, Posadas-Calleja JG, Mcullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206-13.
Category: Medical Education
Keywords: Teaching (PubMed Search)
Posted: 4/6/2009 by Rob Rogers, MD
(Updated: 10/9/2024)
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The One Minute Preceptor-Microskills in Teaching
Most clinical teaching takes place in the context of busy clinical practice where time is at a premium. Microskills enable teachers to effectively assess, instruct, and give feedback more efficiently. This model is used when the teacher knows something about the case that the learner needs or wants to know.
Most of already do this on a daily basis when a learner (student or resident) presents a case to us.
One of the biggest pitfalls in teaching, particularly to medical students, is the first skill, getting a commitment. Let (i.e. make) the student commit to a diagnosis and treatment plan and avoid spoonfeeding them.
1. Irby, D.M., How Attending Physicians Make Instructional Decisions when Conducting Teaching Rounds. Academic Medicine, 1992. 67: p. 630-638.
2. Irby, D.M., Three Exemplary Models of Case-based Teaching. Academic Medicine, 1994. 69(12): p. 947-953.
3. Irby, D.M. What Clinical Teachers in Medicine Need to Know. Academic Medicine, 1994. 69(5): p. 333-342.
4. Neher, JO, Gordon, KC, Meyer, B, and Stevens, N. A Five-step "Microskills" Model of Clinical Teaching. Journal of the American Board of Family Practice. 5:419-424, 1992.
Category: Cardiology
Keywords: adenosine, medication side effects (PubMed Search)
Posted: 4/5/2009 by Amal Mattu, MD
(Updated: 10/9/2024)
Click here to contact Amal Mattu, MD
Adenosine is everyone's favorite drug for SVTs, and it is often even used as a diagnostic maneuver in some tachydysrhythmias of uncertain origin. BUT there are some definite cautions of which we must all be wary:
1. Adenosine CAN convert some types of ventricular tachycardia to sinus rhythm. This "adenosine sensitive VT" is very well reported in the cardiology literature. Don't use adenosine as a diagnostic method of distinguishing VT from SVT (with aberrant conduction).
2. Atrial fibrillation with WPW can sometimes mimic SVT if one doesn't look closely and notice the irregularity. If you misdiagnose these patients as having SVT and give adenosine, you will likely induce VFib. Not good, Mav, not good!
3. Adenosine causes some histamine release (thus the flushing and hot sensation that patients report). That's bad for patients that have reactive airway disease (RAD). Adenosine should be avoided in patients with severe RAD by history (asthma, COPD) or if patients have active wheezing.
4. Concurrent use of adenosine in patients on digoxin or patients that have received digoxin or verapamil has been reported to cause VFib in rare cases.
5. The effects of adenosine appear to be potentiated by dipyridamole and carbamazepine. Lower the dose of adenosine in patients that take these medications.
6. The effects of adenosine are antagonized by methylxanthines such as caffeine or theophylline. You will probably need higher doses of adenosine in these patients.
7. There are rare cases of adenosine inducing atrial fibrillation. I'm not sure what to say about this, except don't be surprised if your patients goes from SVT into atrial fibrillation. Rare, fortunately.
8. And finally...always remember to push adenosine very quickly and follow immediately with saline BOLUS flush (don't just open up the IVF...you must PUSH 10-20cc of NS); and warn your patient that for ~10 seconds they are going to feel like they are about to die while the adenosine takes effect. If you don't warn them, they will never trust you or the drug again.
9. And finally finally...always have your code cart ready to go when you are using potent cardiac drugs such as adenosine. Don't let yourself be unprepared for a side effect.
Bad luck only happens when you are unprepared!
AM
Category: Orthopedics
Keywords: Radial, Head, Fracture (PubMed Search)
Posted: 4/3/2009 by Michael Bond, MD
(Emailed: 4/4/2009)
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
Radial Head Fractures:
Radial head fractures are more common in adults, where radial neck fractures are more common in children. Remember to look for fat pads to help make the diagnosis if it is not obvious on plain films. On plain films, a line drawn down the middle of the radial head should always line up with the capitellum of the humerus. If this does not occur the radial head is dislocated and/or fracture.
Orthopaedics use the Mason classification to help guide treatment, and break down fractures into 3 different types.
Category: Pediatrics
Keywords: Hemolytic-uremic syndrome (HUS) (PubMed Search)
Posted: 4/3/2009 by Rose Chasm, MD
(Updated: 10/9/2024)
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Hemolytic-uremic syndrome (HUS)
Category: Toxicology
Keywords: overdose, precription drugs, pediatric, substance abuse (PubMed Search)
Posted: 4/1/2009 by Dan Lemkin, MS, MD
(Emailed: 4/2/2009)
(Updated: 5/24/2009)
Click here to contact Dan Lemkin, MS, MD
Classical illicit recreational drugs like cocaine, ecstacy, and marajuana are sometimes difficult for teens to acquire. As a result, many are turning to their parents medicine cabinets as a source for recreational drugs.
[From the website drugabuse.gov] In 2008, 15.4 percent of 12th-graders reported using a prescription drug nonmedically within the past year. This category includes:
When adolescent patient presents to the ED, consider the possibility of a poly-pharmacy overdose. Always query parents about the presence of OTC and Rx medications in their home, and what is within reach of their kids.
While sedatives and analgesics are concerning, be alert for overdoses of more mundane medications like beta blockers and calcium-channel blockers which often pose a much more lethal threat. Consider overdose in adolescent patients with:
Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th-Graders, 10th-Graders, and 12th-Graders
2005-2008 (in percent)*
8th-Graders | 10th-Graders | 12th-Graders | ||||||||||
2005 | 2006 | 2007 | 2008 | 2005 | 2006 | 2007 | 2008 | 2005 | 2006 | 2007 | 2008 | |
Any Illicit Drug Use | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Lifetime | 21.4 | 20.9 | [19.0] | 19.6 | 38.2 | 36.1 | 35.6 | 34.1 | 50.4 | 48.2 | 46.8 | 47.4 |
Full chart available by clicking link in references.
Category: Neurology
Keywords: nihss, level of consciousness, stroke, nih stroke scale (PubMed Search)
Posted: 4/2/2009 by Aisha Liferidge, MD
(Updated: 10/9/2024)
Click here to contact Aisha Liferidge, MD
1. "Close your eyes and now open them."
2. "Make a fist and now open it."
0 = performs both tasks correctly.
1 = performs one task corectly.
2 = performs neither task correctly.
Category: Critical Care
Posted: 3/31/2009 by Mike Winters, MBA, MD
(Updated: 10/9/2024)
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Mechanical Ventilation of the Obstetric Patient
Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilator strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206.
Category: Vascular
Keywords: Nitroprusside (PubMed Search)
Posted: 3/30/2009 by Rob Rogers, MD
(Updated: 10/9/2024)
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Nitroprusside-Friend or Foe?
Nitroprusside is a direct venous and arteriolar vasodilator and is very effective at lowering blood pressure. It has been used for the treatment of hypertensive emergencies for many years and most of are comfortable with using it.
The problems with the drug:
Marik PE, etc. Hypertensive crises: challenges and management. Chest 2007;131:1949-62
Category: Cardiology
Keywords: jugular venous distension, hypotension (PubMed Search)
Posted: 3/29/2009 by Amal Mattu, MD
(Updated: 10/9/2024)
Click here to contact Amal Mattu, MD
Patients with catastrophic cardiovascular conditions often manifest with JVD + hypotension. The DDx for this combination is therefore critical to know:
You can make a diagnosis clinically among these 7 entities by:
Of course if you have bedside U/S, it becomes even easier. ECG is almost always diagnostic with either the large LV MI or RV MI. Wet lungs found in large LV MI, acute MR, and acute AR. Murmur found in MR (systolic) and AR (diastolic).
Category: Orthopedics
Keywords: Hamate, Fracture, (PubMed Search)
Posted: 3/28/2009 by Michael Bond, MD
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
Hamate Fractures:
Walsh JJ 4th. Bishop AT. Diagnosis and management of hamate hook fractures. Hand Clinics. 16(3):397-403, viii, 2000 Aug.
Category: Toxicology
Keywords: serotonin (PubMed Search)
Posted: 3/26/2009 by Fermin Barrueto
(Updated: 10/9/2024)
Click here to contact Fermin Barrueto
Serotonin is a neurotransmitter that has central and peripheral effects. It regulates the secretion of ADH from the hypothalamus and also controls the chemoreceptive trigger zone (CTZ) which induces emesis. Here are a list of medications categorized by the way they affect serotonin. Remember, any combination of these agonists could precipitate serotonin syndrome:
Enhance 5-HT synthesis: L-tryptophan
Direct HT agonists: Ergots, metoclopramide, sumatriptan, buspirone
Increase 5-HT release: amphetamines, cocaine, dextromethorphan, MDMA, L-dopa
Inhibit 5-HT breakdown: MAOIs, Linezolid
Inhibit 5-HT re-uptake: SSRIs (paxil), amphetamines, carbamazapine, tramadol, TCAs, citalopram, trazodone, lamotrigine, meperidine
Category: Neurology
Keywords: nihss, level of consciousness, stroke (PubMed Search)
Posted: 3/26/2009 by Aisha Liferidge, MD
(Updated: 10/9/2024)
Click here to contact Aisha Liferidge, MD
-- Answers both questions correctly = 0
-- Answers one of the two questions correctly = 1
-- Answers neither question correctly = 2
Category: Pediatrics
Keywords: Acute Laryngotracheobronchitis, Croup (PubMed Search)
Posted: 3/25/2009 by Rose Chasm, MD
(Updated: 10/9/2024)
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Parainfluenza viruses (types 1, 2, 3) account for more than 65% of all cases. The different serotypes have seasonal patterns, with type 1 and 2 occuring in the autumn and being the most common pathogens associated with croup while type 3 is more frequent in the spring and summer and is associated with pneumonia and bronchiolitis.
Infections are rarely associated with high fever and usually last 4 to 5 days. There are no distinctive laboratory abnormalities, and diagnosis is generally made clinically. Chest and neck xray may demonstrate a “steeple sign” from narrowing of the subglottic region. Viral cultures and immunofluorescent rapid antigen identification can be obtained from respiratory secretions. Specific antiviral therapy is not available. Aerosolized epinephrine can be given to severely affected, hospitalized patients to decrease airway obstruction. Parental (>0.3mg/kg) and oral ((0.15mg/kg) dexamethasone have been demonstrated to lessen the severity and duration of symptoms and hospitalization in patients with moderate to severe croup.
American Academy of Pediatrics. Parainfluenza viral infections. In: Pickering LK, ed Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Peditrics; 2006
Category: Critical Care
Posted: 3/24/2009 by Mike Winters, MBA, MD
(Updated: 10/9/2024)
Click here to contact Mike Winters, MBA, MD
Critical Illness-Related Corticosteroid Insufficiency (CIRCI)
So, which critically ill patients do you treat with steroids? Current literature suggests the indications for steroid treatment include vasopressor dependent septic shock and persistent ARDS despite supportive therapy and lung protective ventilation. A patient who requires only an hour or two of a vasopressor while being fluid resuscitated is unlikely to benefit. An accepted dosing schedule is hydrocortisone 50 mg IV every 6 hours.
Marik PE. Critical illness-related corticosteroid insufficiency. Chest 2009;135:181-93.
Category: Med-Legal
Keywords: Documentation, Chest Pain (PubMed Search)
Posted: 3/23/2009 by Rob Rogers, MD
(Updated: 10/9/2024)
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Documentation of the Chest Pain Patient
Chest pain is a high risk entity in emergency medicine. And since many patients we see with chest pain are eventually discharged, we should consider what our charts should look like should we discharge a patient who has a missed life-threatening diagnosis. In other words, what would an attorney look for?
Considerations for the chart:
Category: Cardiology
Keywords: dopamine, dobutamine, cardiogenic shock (PubMed Search)
Posted: 3/22/2009 by Amal Mattu, MD
(Updated: 10/9/2024)
Click here to contact Amal Mattu, MD
Traditional teaching for patients with hypotension in the setting of MI and heart failure (i.e. not just RV MI) is to give dobutamine as a first-line agent when the SBP is 80-100, and to use dopamine when the SBP is 70-80s [note that this recommendation is NOT based on good evidence, but primarily on consensus opinion]. The problem with using these medications, especially at higher doses (e.g >10-15 mcg/kg/min) is that they result in excessive alpha-1 adrenergic stimulation that can produce end-organ ischemia.
However, there is some evidence that rather than using high dosages of dobutamine or dopamine, "the deliberate combination of dopamine and dobutamine at a dose of 7.5 mcg/kg/min each was shown to improve hemodynamics and limit important side effects compared with [high dosages of] either agent [alone]."
[Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008;118:1047-1056.]
Category: Orthopedics
Keywords: Lunate, Dislocation, Perilunate (PubMed Search)
Posted: 3/20/2009 by Michael Bond, MD
(Emailed: 3/21/2009)
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
Lunate Dislocation and perilunate dislocation are broken down into 4 stages that relates to the progressive disruption of the carpal ligaments due to hyperextension and ulnar deviation of the wrist:
For a good indepth review of lunate and perilunate injuries please read the article by Andy Perron with this attached link.... doi:10.1053/ajem.2001.21306
If you are interested in seeing some xray examples please visit LearningRadiology.com
Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic Pitfalls in the ED: Lunate and Perilunate Injuries Am J Emerg Med 2001;19:157-162