Category: Critical Care
Posted: 6/23/2009 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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The Maintenance Phase of Therapeutic Hypothermia
Therapeutic hypothermia (TH) has become standard in the care of patients with return of spontaneous circulation from cardiac arrest. Although the optimal duration of TH is unknown, current literature supports 12-24 hours of cooling to 32-34oC. As many of our critically ill patients remain in the ED for seemingly endless lengths of stay, it is likely that most emergency physicians will be managing patients with TH during the maintenance phase of cooling. Some pearls regarding the maintenance phase:
Seder DB, Van der Kloot TE. Methods of cooling: Practical aspects of therapeutic temperature management. Crit Care Med 2009;37:S211-22.
Category: Cardiology
Keywords: ACS, acute coronary syndrome, acute myocardial infarction (PubMed Search)
Posted: 6/21/2009 by Amal Mattu, MD
(Updated: 2/15/2025)
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Elderly are more likely to have non-diagnostic ECGs. The proportion of patients > 85 years of age with NSTEACS who had non-diagnostic ECGs was 43% vs. 23% for patients < 65 years of age. [Elderly are also more likely to have LBBB as well as prior evidence of MI, either one of which can cause some problems with interpretation of acute cardiac ischemia.] The lack of CP combined with non-diagnostic ECGs probably leads to delays and under-treatment of many of these patients.
[Alexander KP, et al. Acute coronary care in the elderly, part I: Non-ST-segment elevation acute coronary syndromes. Circulation 2007;115:2549-2569.]
Category: Pediatrics
Posted: 6/21/2009 by Rose Chasm, MD
(Updated: 2/15/2025)
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Category: Orthopedics
Keywords: High Pressure, Injection, Injury (PubMed Search)
Posted: 6/20/2009 by Michael Bond, MD
(Updated: 2/15/2025)
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High Pressure Injection Injuries:
Hogan CJ, Ruland RT: High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma 20:503, 2006
Category: Toxicology
Keywords: lithium, heparin (PubMed Search)
Posted: 6/19/2009 by Fermin Barrueto
(Updated: 2/15/2025)
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You have a patient that is on lithium and a serum concentration is checked: 4.3 mmol/l
Therapeutic range is between 0.5 and 1.5 mmol/l
The patient shows no symptoms - is that possible? what do you do?
Answer: highly unlikely that the patient would asymptomatic, at least nystagmus would be present. Remember the symptoms are cerebellar in nature. What may have happened is the blood was drawn in an inappropriate tube. There are green "Lithium Heparinized" tubes in our Emergency Department. They are typically used for cardiac enzymes. This has been a well reported source of error (1)
.
Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. Lee DC, Klachko MN. J Toxicol Clin Toxicol. 1996;34(4):467-9.
Category: Neurology
Keywords: tia, stroke, abcd rule, clinical prediction rule (PubMed Search)
Posted: 6/17/2009 by Aisha Liferidge, MD
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Risk Factor Score
-- Unilateral weakness 2
-- Speech impairment w/o weakness 1
-- Other 0
-- > 60 2
-- 10 to 59 1
-- < 10 0
Total 0-6
Seven-day risk of stroke (stroke/no. of patients; %) | ||
Point total | Possible TIA* | Probable or definite TIA |
0 or 1 | 0/28 (0) | 0/2 (0) |
2 | 0/74 (0) | 0/28 (0) |
3 | 0/82 (0) | 0/32 (0) |
4 | 1/90 (1; 95% CI, 0 to 3) | 1/46 (2; 95% CI, 0 to 6) |
5 | 8/66 (12; 95% CI, 4 to 20) | 8/49 (16; 95% CI, 6 to 27) |
6 | 11/35 (31; 95% CI, 16 to 47) | 11/31 (35; 95% CI, 19 to 52) |
Total | 20/375 (5.3; 95% CI, 3 to 7.5) | 20/188 (10.6; 95% CI, 6 to 15) |
1. Lovett JK, Dennis MS, Sandercock PA, Bamford J, Warlow CP, Rothwell PM. Very early risk of stroke after a first transient ischemic attack. Stroke 2003;34:e138-40.
2. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901-6.
3. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005;366:29-36.
Category: Critical Care
Posted: 6/17/2009 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Acute Hyponatremia and the Critically Ill
Schrier RW, Bansal S. Diagnosis and management of hyponatremia in acute illness. Curr Opin Crit Care 2008;14:627-34.
Category: Toxicology
Keywords: Alcohol (PubMed Search)
Posted: 6/16/2009 by Rob Rogers, MD
(Updated: 2/15/2025)
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The Alcoholic Patient in the ED
Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.
Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:
Category: Cardiology
Keywords: T-wave inversions (PubMed Search)
Posted: 6/14/2009 by Amal Mattu, MD
(Updated: 2/15/2025)
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T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.
T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.
A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!
[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]
Category: ENT
Keywords: Mandible, Dislocation, Unified, Hand (PubMed Search)
Posted: 6/13/2009 by Michael Bond, MD
(Updated: 2/15/2025)
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Manibular Dislocations:
Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.
Cheng D. Unified hands technique for mandibular dislocation. J Emerg Med. Mar 19 2009.
Category: Toxicology
Keywords: vitamin K, phytonadione, warfarin, INR (PubMed Search)
Posted: 6/9/2009 by Bryan Hayes, PharmD
(Updated: 6/11/2009)
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Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed. Simply holding a dose is all that is usually necessary for patients with an INR < 9. Fortunately, guidelines published in CHEST are available to help guide management.
Reference:
Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.
Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.
Category: Neurology
Keywords: cerebral aneurysm, coiling, minimally invasive endovascular coiling, clipping, stroke, intracranial hemorrhage (PubMed Search)
Posted: 6/10/2009 by Aisha Liferidge, MD
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Category: Critical Care
Posted: 6/9/2009 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
Click here to contact Mike Winters, MBA, MD
Transient Hypotension and Mortality in Sepsis
Marchick MR, Kline JA, Jones AE. The significance of non-sustained hypotension in emergency department patients with sepsis. Intensive Care Med 2009 (published online 2/24/09).
Category: Medical Education
Keywords: Teaching (PubMed Search)
Posted: 6/8/2009 by Rob Rogers, MD
(Updated: 2/15/2025)
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Some Pearls on ED Teaching:
Only reference really is the great teaching faculty at the University of Maryland....
Category: Pediatrics
Posted: 6/8/2009 by Rose Chasm, MD
(Updated: 6/9/2009)
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DeNicola LK, Falk JL, Swanson ME, Gayle MO, Kissoon N. Submersion injuries in children and adults. Crit Care Clin. 1997;13:477-502.
Fisher DH. Near-drowning. Pediatr Rev. 1993;14:148-151.
Shaw KN, Briede CA. Submersion injuries: drowning and near-drowning. Emerg Med Clin North Am. 1989;7:355-370.
Category: Geriatrics
Posted: 6/7/2009 by Amal Mattu, MD
(Updated: 2/15/2025)
Click here to contact Amal Mattu, MD
Whereas only 6% of young patients with PE present with syncope, 15-20% of elderly patients with PE present with syncope. The simple takeaway point is that whenever an elderly patient presents with syncope, always strongly consider the possibility of PE, even though they may lack classic pleuritic chest pain.
Count that respiratory rate for an inexpensive clue!
Category: Orthopedics
Keywords: shoulder, dislocation, treatment (PubMed Search)
Posted: 6/7/2009 by Michael Bond, MD
(Updated: 2/15/2025)
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Shoulder Dislocations -- Treatment
McNeil NJ. Postreduction management of first-time traumatic anterior shoulder dislocations. Ann Emerg Med. Jun 2009;53(6):811-813.
Category: Toxicology
Keywords: Oseltamivir,tamiflu,h1n1,influenza (PubMed Search)
Posted: 6/4/2009 by Ellen Lemkin, MD, PharmD
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Oseltamivir (Tamiflu)
For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm
www.cdc.gov/h1n1flu/recommendations.htm
www.cdc.gov/flu/professionals/antivirals/side-effects.htm
Category: Neurology
Keywords: syncope, loss of consciousness, disposition, san francisco syncope rule (PubMed Search)
Posted: 6/3/2009 by Aisha Liferidge, MD
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Category: Critical Care
Posted: 6/3/2009 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
Click here to contact Mike Winters, MBA, MD
Heparin for Maintaining Arteral Catheter Patency ?
Del Cotillo M, Grane N, Llavore M, et al. Heparinized solution vs. saline solution in the maintenance of arterial catheters: a double blind randomized clinical trial. Intensive Care Med 2008;34:339-43.