Red blood cell transfusion in the critically ill patient has been and continues to be surrounded by controversy and lack of hard data. Up to 90 percent of transfusions in the ICU are given for anemia, an indication which is least supported by the data. The joint taskforce of EAST, ACCM and SCCM has published a clinical practice guideline which outlines recommendations and rationale. These recommendations are summarized as follows:
The Emergency Department is often the first line in detecting the sexual abuse of a child. Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.
1. Know your region's dedicated sexual abuse center, if one exists. These centers have personnel trained in interviewing and forensic evidence collection. There may be different centers for children of different ages.
2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse. GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.
3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence. Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.
4. Any sexually transmitted disease in a child warrants further workup and investigation. Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.
5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly. Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.
Yet another publication demonstrates that chest pain radiating to the right arm has the highest predictive value for ruling in ACS. In this study, radiation of the pain to the right arm had a higher predictive value than age, gender, comorbidites or traditional risk factors, specific descriptors of pain (e.g. "pressure" or "crushing"), or associated symptoms (e.g. diaphoresis, nausea, dyspnea). The bottom line....beware chest pain that radiates to the right arm!
[Goodacre S, Pett P, Arnold J, et al. Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram. Emerg Med J 2009;26:866-870.]
Patella fractures are typically due to direct trauma as in a fall or direct blow to the knee.
Fractures may be missed on the AP view or misdiagnosed as a bipartate fracture. To avoid these pitfalls look closely at the lateral view and consider getting a sunrise view of the knee (better visualizes the patella). Finally, unilateral bipartate patella are very rare so consider an x-ray of the contralateral knee if you are considering this as your diagnosis.
Surgery should be considered for:
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The following is a differential diagnosis for unilateral headaches with typical associated features:
Early Recognition of Shock
Effort Thrombosis
Effort thrombosis, also called Paget von Schrotter disease, occurs when either the axillary and or subclavian veins thrombose. The condition is more common in young, healthy (>males) patients and presents with the usual DVT symptoms of arm pain, swelling, and pain.
The disease was originally described in patients performing vigorous activities, like weight lifting or repetitive over-the-head lifting. This type of activity has been reported to kink the subclavian vein and lead to clot formation.
Diagnosis and therapy is the same for any other type of DVT.
Some of the causes of acute vision loss are:
Ductal-Dependent Cardiac Lesions in the Neonate
NEW TREATMENT in diabetes
It was discovered that glucose given ORALLY caused more insulin release than glucose administered INTRAVENOUSLY. This led to the discovery of the incretin hormones, which are secreted by the gut (INtestinal SECRETion of INsulin), GIP and GLP-1.
The incretin-based therapies increase levels of GLP-1, either by providing an incretin mimetic (exenatide and liraglutide), or by inhibiting their breakdown by DPP-4 (sitagliptin, saxagliptin, vilagliptin)
Their administration results in:
Causing:
STAY TUNED FOR DOSING AND ADVERSE EVENTS!
Optimal brain imaging for diagnosing and managing acute ischemic stroke should address the presence of 4 essential issues:
Optimal brain imaging for diagnosing and managing acute ischemic stroke should address the presence of 4 essential issues:
Calciphylaxis is a rare disorder caused by systemic arteriolar calcification which leads to ischemia and necrosis. It is characterized by painful ischemic necrotic lesions on adipose tissue areas such as abdomen, buttock and thighs. This commonly occurs in patients with ESRD on hemodialysis or after transplant, but can also occur with other patients, such as those with hyperparathyroidism.
Diagnosis is made clinically, with the help of a skin biopsy as needed. Differential diagnosis includes cholesterol embolization, warfarin necrosis, cryoglobulinemia, cellulitis and vasculitis. There are no specific laboratory findings, although patients may manifest elevated PTH, phosphorous, calcium or calcium x phosphorous product.
Infection is usually the cause of the high mortality rate of this condition, which has a reported mortality of 46%, or 80% if ulceration is present.
Treatment includes local wound care, trauma avoidance, electrolyte correction, increased frequency of dialysis or parathyroidectomy as needed. Surgical debridement is controversial; as the risk of infection may outweigh the benefit in terms of outcome.
The Art of Pimping-And How to Protect Against
This monday's pearl (ok, I know, it's tuesday now) comes from Michelle Lin's blog: academic life in emergency medicine. It is more gem than pearl, and it discusses what medical students and residents do to avoid being pimped. It is a must read!
Here is the link to the discussion on Michelle Lin's blog:
http://academiclifeinem.blogspot.com/2009/11/trick-of-trade-essential-skills-for.html
Just a few note worthy "pimping protection procedures":
Happy pimping!
Up to 10% of elderly patients in the ED meet criteria for acute delirium, though misdiagnosis rates are very common.
The most common cause of delirium in the elderly, overall, is medication effects. Other common causes are infections (UTIs most common), CNS abnormalities, cardiovascular abnormalities, electrolyte/metabolic abnormalities, and temperature abnormalities (fever or hypothermia).
Vision loss whether acute or chronic is a common presenting complaint to the ED. This will be the first in a series of pearls on the subject. This pearl will address the nomenclature used by ophthalmology based on the length of vision loss.
• Transient visual obscuration - Episodes lasting seconds. Usually associated with papilledema and increased intracranial pressure.
• Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes
• Transient monocular visual loss or transient monocular blindness - A more persistent vision loss that lasts minutes or longer
• Transient bilateral visual loss - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss
• Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss
F - Fever (anything over 100.4 F counts)
E - Encephalopathy
V - Vital signs instability
E - Enzymes elevation (i.e. CPK)
R - Rigidity of muscles
