Category: Critical Care
Posted: 3/24/2009 by Mike Winters, MBA, MD
(Updated: 5/28/2025)
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: 5/28/2025)
Click here to contact Rob Rogers, MD
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: 5/28/2025)
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
(Updated: 5/28/2025)
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
Category: Toxicology
Keywords: acetone, cyanide, odor (PubMed Search)
Posted: 3/19/2009 by Fermin Barrueto
(Updated: 5/28/2025)
Click here to contact Fermin Barrueto
Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.
The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):
1) Bitter Almond
2) Rotten Eggs
3) Wintergreen
4) Garlic
5) Sweet, Fruity (acetone)
Answers:
1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate
Category: Neurology
Keywords: blood pressure control, stroke, tPA, thrombolytics (PubMed Search)
Posted: 3/19/2009 by Aisha Liferidge, MD
(Updated: 5/28/2025)
Click here to contact Aisha Liferidge, MD
Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat x 1
OR
Nitropaste 1 to 2 inches
OR
Nicardipine infusion at 5 mg per hour, titrate by 0.25 mg/hr at 5 to 10 minute intervals up to a maximum
dose of of 15 mg/hr. Once desired blood pressure is achieved, titrate down in increments of 3 mg/hr.
Category: Critical Care
Posted: 3/17/2009 by Mike Winters, MBA, MD
(Updated: 5/28/2025)
Click here to contact Mike Winters, MBA, MD
Early Critical Care Management of Aneurysmal SAH
Diringer MN. Managment of aneurysmal subarachnoid hemorrhage. Crit Care Med 2009;37:432-40.
Category: Airway Management
Keywords: Airway (PubMed Search)
Posted: 3/16/2009 by Rob Rogers, MD
(Updated: 5/28/2025)
Click here to contact Rob Rogers, MD
Keys to a Successful Intubation
The famous Ken Butler
Category: Orthopedics
Keywords: Child Abuse, Fracture (PubMed Search)
Posted: 3/15/2009 by Michael Bond, MD
(Updated: 5/28/2025)
Click here to contact Michael Bond, MD
A lot of what is taught about fracture patterns in abused children has been extrapolated from post-mortem studies which is a different population then what you will see in the Emergency Department. The study referenced did a metanalysis of all the literature in an attempt to determine what fractures suggest abuse and looked at all comers that had fractures. Some of the patterns they were able to extrapolate are:
Patterns of Skeletal Fractures in Child Abuse: Systemic Review. BMJ, Alison M Kemp et al. 2008;337:a1518
Category: Pediatrics
Keywords: Appendicitis, Pediatrics (PubMed Search)
Posted: 3/13/2009 by Don Van Wie, DO
(Updated: 5/28/2025)
Click here to contact Don Van Wie, DO
Acute Appendicitis in Childhood: Diagnosis and Treatment in the new Millennium. PEM Practice. December 2008
Category: Toxicology
Keywords: metoclopramide, black box warning, tardive dyskinesia (PubMed Search)
Posted: 3/12/2009 by Bryan Hayes, PharmD
(Updated: 5/28/2025)
Click here to contact Bryan Hayes, PharmD
Add metoclopramide (Reglan) to the laundry list of medications with black box warnings from the FDA. Why was a black box warning added?
Category: Neurology
Keywords: nihss, stroke scale (PubMed Search)
Posted: 3/11/2009 by Aisha Liferidge, MD
(Updated: 5/28/2025)
Click here to contact Aisha Liferidge, MD
Category: Vascular
Keywords: Hypertensive (PubMed Search)
Posted: 3/10/2009 by Rob Rogers, MD
(Updated: 5/28/2025)
Click here to contact Rob Rogers, MD
Follow-up for the Hypertensive Patient
We see hypertensive patients every day, every shift. And, we discharge many of them. So, when do you get them follow-up?
The JNC-7 recommends that patients with BPs > 180/110 mm Hg have follow-up within 7 days. Like most of the HTN recommendations in the primary care setting, this recommendation is based on a "smart person" concensus....and no data.
This is a tremendous issue for us in the ED, because we don't want to see a bad outcome in our discharged hypertensive patients.
Some pearls regarding discharging the very hypertensive (but asymtomatic) patient:
Category: Cardiology
Keywords: tamponade, pericardial tamponade, intubation, positive pressure ventilation, complications (PubMed Search)
Posted: 3/8/2009 by Amal Mattu, MD
(Updated: 5/28/2025)
Click here to contact Amal Mattu, MD
Category: Orthopedics
Keywords: Galeazzi, Fracture (PubMed Search)
Posted: 3/7/2009 by Michael Bond, MD
(Updated: 5/28/2025)
Click here to contact Michael Bond, MD
The Galeazzi Fracture:
To see a photo of a Galeazzi fracture please visit the Learning Radiology Website by clicking on the following link:
http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg
Category: Pediatrics
Posted: 3/6/2009 by Rose Chasm, MD
(Updated: 5/28/2025)
Click here to contact Rose Chasm, MD
Rocky Mountain spotted fever (RMSF)
Systemic small vessel vasculitis caused by R rickettsii which is transmitted by a tick bite.
Clinical features: fever, headache, myalgia, nausea, vomiting, and characteristic rash. Rash usually appears before the sixth day of the illness initially on the wrists and ankles, and spreads to the trunk within hours. Initially. It is erythematous and macular, later becoming petechial.
Laboratory findings: thrombocytopenia, anemia, and hyponatremia.
Complications: meningitis, multiorgan involvement, DIC, shock, and death.
Treatment: doxcycycline (even despite the risk of dental staining in children younger than 8 years old)
American Academy of Pediatrics. Rickettsial diseases, Rickettsialpox, Rocky Mountain spotted fever. In: Pickering LK, ed. Red Book: 2006 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:529-534.
Category: Toxicology
Keywords: Clevidipine, calcium channel antagonist, calcium channel blocker, antihypertensive (PubMed Search)
Posted: 3/5/2009 by Ellen Lemkin, MD, PharmD
(Updated: 5/28/2025)
Click here to contact Ellen Lemkin, MD, PharmD
Clevidipine
1. Anon. The Medical Letter. Sept 22 2008;50(1295)73-4.
Category: Neurology
Keywords: cavernous sinus thrombosis, extraocular palsies (PubMed Search)
Posted: 3/5/2009 by Aisha Liferidge, MD
(Updated: 5/28/2025)
Click here to contact Aisha Liferidge, MD
Category: Vascular
Keywords: Hypertension, End-Organ Damage (PubMed Search)
Posted: 3/3/2009 by Rob Rogers, MD
(Updated: 5/28/2025)
Click here to contact Rob Rogers, MD
Evaluation of End Organ Damage in Hypertensive Patients
No evidence to date supports the ED workup for end-organ damage in asymptomatic hypertensive patients.
End-Organ Damage Pearls:
Category: Critical Care
Posted: 3/3/2009 by Mike Winters, MBA, MD
(Updated: 5/28/2025)
Click here to contact Mike Winters, MBA, MD
Neuromuscular Blocking Agent (NMBA)