BACKGROUND:
For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.
CRITERION LINKED TO SEVERE INJURY (Consider transport to nearest TRAUMA CENTER)
From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility."
EXTRAS:
The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm
Octreotide
Teaching in the Emergency Department
Effective ways to teach in the ED:
Clinical Manifestations of Anaphylaxis
The use of a glycoprotein 2b/3a receptor antagonist (often inaccurately referred to as a "G2b3a inhibitor") is considered a Class I intervention for patients with unstable angina/non-STE-MI that are going for percutaneous coronary intervention, according to the ACC/AHA 2007 Guidelines.
The exact timing of the initiation of the G2b3aRA is the subject of some debate, but it is certainly worth discussing with your cardiologist consultant/receiving physician whether they want one of these medications initiated in the ED before taking the patient to the cath. lab, and if so which one of these meds they prefer.
Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion. Some tips that can help differentiate iritis from other causes of painful red are:
Finally, ensure you document:
Six indications that would lead you to suspect SVT in children:
Remember in the stable child treat withe Adenosine 0.1mg/kg rapid IV push followed by rapid flush.
In the unstable child treat with synchronized cardioversion 0.5 -1 Joules/kg.
Tetrodotoxin - Sodium Channel blocker - Extremely toxic causes paresthesias, dysrhythmias and paralysis - Found in the sushi called Fugu (From the Pufferfish) - Eating the sushi is considered a delicacy and goal is to get just enough of the toxin to get perioral paresthesias after eating. - Also found in the blue-ringed octopus, angelfish and parrot fish. Enjoy your seafood and take a look at the attached pic of actual fugu.
Sepsis and Mechanical Ventilation
Thrombolytic Therapy for Pulmonary Embolism
Indications for administration of fibrinolytic therapy for acute PE:
Conjunctivitis:
Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.
A few previous pearls have touched on identifying drugs that cause QT prolongation. In our patient population, methadone is one of the more common causes of drug-induced prolonged QT syndrome. Of 692 physicians surveyed (35% family practitioners, 25% internests, 22% psychiatrists, and 8% self-identified addiction specialists) only 41% were aware of methadone's QT-prolonging properties and just 24% were aware of methadone's association with torsade de pointes.
Now that you know, what do you do when a patient on methadone presents with a QTC of 580 msec and intermittent runs of vtach and torsade de pointes?
The answer is... the exact same thing you would do with any other patient who presents this way, regardless of the cause.
Buprenorphine, an alternative to methadone, is not associated with prolonged QT syndrome.
Intracerebral hemorrhage and fluid management
Neurologic Manifestations of Acute Aortic Dissection
A myriad of neurologic presentations of acute aortic dissection have been reported in the literature. Although classic CVA symptoms may occur, nonspecific neurologic symptoms are much more common
These include:
Take Home Point:
Otitis Externa:
Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...). Most patients should not require PO or IV antibiotics.
However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%. Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk. Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal. Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.
If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.
Next time you have to do a full septic work up on a 2 month old with a fever of 104 F consider giving Ketamine 3mg/kg IM before even starting. Then you can obtain your cath urine, IV, and LP with a calm pain free patient!!
Ketamine induces a catatonic state that provides sedation, analgesia, and amnesia. It does not affect pharyngeal-laryngeal reflexes and the patient maintains a patent airway. This makes it very useful when fasting is not assured.
Route Onset Duration Dose
IM 3-5 min 20-30min 3-5 mg/kg
IV 1 min 5-10 min 1-2 mg/kg
