Category: Toxicology
Keywords: Valproic acid (PubMed Search)
Posted: 10/16/2014 by Hong Kim, MD, MPH
(Emailed: 3/24/2023)
Click here to contact Hong Kim, MD, MPH
Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).
VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.
In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.
Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.
Signs and symptoms of acute toxicity include:
Laboratory abnormalities
Treatment: L-carnitine
Goldfrank's Toxicologic Emergencies 9th ed. p 705
Category: Airway Management
Keywords: RSI, Preoxygenation (PubMed Search)
Posted: 9/13/2016 by Rory Spiegel, MD
(Emailed: 3/24/2023)
Click here to contact Rory Spiegel, MD
During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.
A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2).
1. Hayes-bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68(2):174-80.
2. Driver BE, Prekker ME, Kornas RL, Cales EK, Reardon RF. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med. 2016;
Category: Critical Care
Keywords: Alarm Fatigue (PubMed Search)
Posted: 5/20/2019 by Robert Brown, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Robert Brown, MD
In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.
While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Category: Toxicology
Keywords: opioids, toxicology (PubMed Search)
Posted: 11/20/2014 by Fermin Barrueto, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Fermin Barrueto, MD
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
NCHS Data Brief, Number 166, September 2014
Category: Toxicology
Posted: 9/5/2019 by Kathy Prybys, DO
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Kathy Prybys, DO
A 3 year old is bitten by a spider on his right ear which is causing him intense pain, tachycardia, and muscle cramping. Identify the spider. What is the treatment?
Category: Orthopedics
Keywords: Sports Hernia, groin pain (PubMed Search)
Posted: 4/6/2014 by Brian Corwell, MD
(Emailed: 3/24/2023)
Click here to contact Brian Corwell, MD
Sports Hernia/Athletic pubalgia
Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.
Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.
Bilateral symptoms not uncommon.
PE: Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms.
If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.
Fluoroscopic guided injections can be helpful to isolate the site of pain generation.
First line therapy is rest, non-narcotic analgesia and physical therapy.
With surgery, >80% return to pre injury level of play.
http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg
Sports Hernia/Athletic Pubalgia: Evaluation and Management. Christopher Larson. Sports Health.
Category: Visual Diagnosis
Posted: 4/7/2014 by Haney Mallemat, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Haney Mallemat, MD
23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)
Answer: Rectus sheath hematoma
Rectus Sheath Hematoma (RSH)
Rectus muscle tear causing damage to the superior or inferior epigastric arteries with subsequent bleeding into the rectus sheath; uncommon cause of abdominal pain but mimics almost any abdominal condition.
May occur spontaneously, but suspect with the following risk factors:
Typically a self-limiting condition, but hypovolemic shock may result from significant hematoma expansion.
Category: Neurology
Keywords: Stroke, EMS, prehospital care, tPA, emergency medical services, fibrinolysis (PubMed Search)
Posted: 5/15/2014 by Ben Lawner, DO
(Emailed: 3/24/2023)
(Updated: 7/3/2014)
Click here to contact Ben Lawner, DO
The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events.
Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:
1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care?
Stateside study has already started. The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA.
STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/
Ebinger M, Winter B, Wendt, M, et al. Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke. A randomized clinical trial. JAMA. 2014;311(16):1622-1631
Lake, D. "UTHeath introduces nation's first mobile stroke unit." Available at:https://www.uth.edu/media/story.htm?id=b1485cfc-110f-4a4c-91ea-06b573b3ba6d. Accessed on May 15, 2014
Category: Visual Diagnosis
Posted: 5/11/2022 by Michael Bond, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Michael Bond, MD
Pulmonary Embolism
For more information on how to perform these exams and research data take a look at coreultrasound.com, thepocusatlas.com and ultrasoundgel.org.
Category: Critical Care
Posted: 3/11/2009 by Mike Winters, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Mike Winters, MD
Oxygenation goals
Category: Vascular
Keywords: D-Dimer, Pregnancy (PubMed Search)
Posted: 7/9/2008 by Rob Rogers, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Rob Rogers, MD
D-Dimer levels are known to be elevated in pregnancy. But how high is too high and can this test be used in the workup of VTE in pregnant patients?
Recent literature indicates that D-dimer levels in each of the three trimesters are approximately 39% higher: 700, 1000, and 1400 ng/dL for each trimester (normal cutoff 500 ng/dL). So, figure out what trimester your patient is in and use the corresponding D-Dimer level for that trimester.
Hernandez J, Hambleton G, Kline JA. D-dimer concentrations in normal pregnancy. Acad Emerg Med 2004;11:526-527
Category: Visual Diagnosis
Keywords: fever, cough, alcoholic (PubMed Search)
Posted: 5/7/2012 by Rob Rogers, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Rob Rogers, MD
An alcoholic patient presents with a cough, fever, and very foul smelling breath (worse than usual)
What's the diagnosis? And what are the risk factors?
Lung abcess
Risk factors for a lung abscess include:
case compliments of our very own Zac Dezman
Category: Toxicology
Keywords: octreotide, sulfonylurea (PubMed Search)
Posted: 4/12/2013 by Bryan Hayes, PharmD
(Emailed: 3/24/2023)
(Updated: 4/13/2013)
Click here to contact Bryan Hayes, PharmD
Methods: A large retrospective case series evaluated 121 children under 6 years old with hypoglycemia from a sulfonylurea ingestion.
Results:
Authors' Conclusion: Octreotide administration decreases the number of hypoglycemic events and increases blood glucose concentrations in children with sulfonylurea ingestion.
Dougherty PP, et al. Evaluation of the use and safety of octreotide as antidotal therapy for sulfonylurea overdose in children. Pediatr Emerg Care 2013;29(3):292-5.
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Category: Infectious Disease
Posted: 4/12/2013 by Andrea Tenner, MD
(Emailed: 3/24/2023)
(Updated: 3/24/2023)
Click here to contact Andrea Tenner, MD
General Information:
-As of April 5th, 14 confirmed cases of a new influenza A virus (H7N9) have occurred in China. Six of those have died.
-Presumed transmission via infected poultry in bird markets, and thus far no person-to-person transmission has occurred.
-Likely susceptible to oseltamavir or inhaled zanamivir
Area of the world affected:
-China
Relevance to the US physician:
- Suspect in patients with a respiratory illness and appropriate travel history.
- Refer to CDC within 24 hours if test positive for flu A but cannot be subtyped
- If H7N9 is suspected, patients should be under droplet and airborne precautions
Bottom Line:
No human-to-human transmission from H7N9 thus far, but the possibility exists. Any unsubtypeable influenza A patient should be placed on droplet and airborne precautions and oseltamavir or zanamivir started immediately.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
http://www.who.int/csr/don/2013_04_04/en/index.html
http://emergency.cdc.gov/HAN/han00344.asp