Category: Vascular
Keywords: AV fistulas, bleeding (PubMed Search)
Posted: 2/21/2009 by Michael Bond, MD
(Updated: 11/26/2024)
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Bleeding AV Fistulas
It is not an uncommon complaint for dialysis patients to present with bleeding from their fistula. They can lose a large amount of blood in a short period of time if not treated promptly, and if treated too agressive their fistula can clot off. Some tips on how to control the bleeding.
Most of the bleeding occurs at the site that the needle puntured the fistula. If it is due to an ulcer eroding into the fistula these tips may not be effective.
I typically check a CBC and coags. Once the bleeding is controlled observe the patient for awhile [typically the hour to hour and half to get the labs back] and then road test them with a walk around the Emergency Department to ensure it does not start bleeding again.
Category: Pediatrics
Posted: 2/19/2009 by Rose Chasm, MD
(Updated: 11/26/2024)
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Krogstad P. Osteomyelitis and septic arthritis. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. Philadelphia, Pa: WB Saunders Co; 2004713-736.
Tan TQ. Osteomyelitis and septic arthritis. In: Perkin RM, Swift JD, Newton DA, eds. Pediatric Hospital Medicine: Textbook of Inpatient Management. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:497-500.
Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Arch Pediatr Adolesc Med. 1995; 149:537-540.
Category: Toxicology
Keywords: rocuronium, succinylcholine (PubMed Search)
Posted: 2/19/2009 by Fermin Barrueto
(Updated: 11/26/2024)
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Rocuronium is fast becoming the agent of choice for RSI in the Emergency Department. Here is a head to head comparison of the two drugs to understand why:
Rocuronium | Succinycholine | |
Dose | 1-1.2mg/kg | 1mg/kg |
Onset | 1-1.5min | 1min |
Duration | 7-12min | 30-40min |
Histamine Release | No | Minimal Yes |
CVS Effect | Tachycardia rare | Severe Brady rare |
Other Adverse Effect | No fasciculations, No ICP effect, No Rhabdo | Fasciculations, increase ICP, rhabdo, movement of displaced Fxs |
Category: Neurology
Keywords: cavernous sinus thrombosis, etraocular palsy, extraocular motions, sinus infections, sinusitis (PubMed Search)
Posted: 2/18/2009 by Aisha Liferidge, MD
(Updated: 11/26/2024)
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Category: Critical Care
Posted: 2/17/2009 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
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Sepsis in Pregnancy
Guinn DA, Abel DE, Tomlinson MW. Early goal directed therapy for sepsis during pregnancy. Obstet Gynecol Clin N Am 2007;34:459-79.
Category: Vascular
Keywords: aortic dissection (PubMed Search)
Posted: 2/16/2009 by Rob Rogers, MD
(Updated: 11/26/2024)
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BEWARE sudden onset thoracic back pain
Just reviewed a case last week of a person who presented with back pain (thoracic) as the sole manifestation of an aortic dissection. No chest pain, belly pain, etc. JUST severe, acute, thoracic back pain.
Keys to staying out of trouble:
Elefteriades, 2008
Category: Cardiology
Posted: 2/15/2009 by Amal Mattu, MD
(Updated: 11/26/2024)
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Category: Orthopedics
Keywords: Ankle Sprain, Treatment (PubMed Search)
Posted: 2/14/2009 by Michael Bond, MD
(Updated: 11/26/2024)
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Ankle sprains are typically treated with a short period of immbolization and then functional exercises are prescribed to rehabilitate the ankle. A study published in the Lancet this week might just change that. Lamb et al looked at 584 people with severe ankle sprains (unable to weight bear 3 days out from injury) that were randomized to be treated with a 10 day below knee cast, Aircast, Bledshoe Shoe or Tubular Compression dressing (similar to Ace Wrap). Those that were treated with the Cast and Aircast had quicker return to function and less disability at 3 months. There was no increased risk of DVTs in the cast group.
A commentary in the same issue points out that severe ankle sprains are associated with:
Based on this article I think it is prudent to treat all patients with severe Ankle Sprains with a prolonged period of forced immobilzation (Posterior Splint, Short Leg Cast or Aircast). I would also recommend the Aircast be used to prevent recurrent sprains especially if the patient is involved in sports that require jumping (Basketball, Volleyball) where the risk of reinjury is higher.
Mechanical supports for acute, severe ankle sprain:a pragmatic, multicentre, randomised controlled trial
S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*. Lancet 2009; 373: 575–81
Immobilisation for acute severe ankle sprain [Commentary] Hertel J. Lancet 2009; 373: 524-526
Category: Toxicology
Keywords: phentolamine, tyramine, pheochromocytoma (PubMed Search)
Posted: 2/12/2009 by Bryan Hayes, PharmD
(Updated: 11/26/2024)
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You have a 44 y/o female patient with an arterial line monitoring her blood pressure which is reading 302/156 mm Hg. Her heart rate is 140 bpm. Her history reveals she is taking a monoamine oxidase inhibitor (MAOI) and has inadvertantly ingested tyramine at her friend's cheese/wine party. What do you do?
Category: Misc
Keywords: Hyphema IOP Ophthalmology (PubMed Search)
Posted: 2/11/2009 by Ben Lawner, MS, DO
(Updated: 11/26/2024)
Click here to contact Ben Lawner, MS, DO
Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam:
General indications for "very urgent" ophthalmologic consultation:
Category: Neurology
Keywords: tPA, angioedema, stroke (PubMed Search)
Posted: 2/11/2009 by Aisha Liferidge, MD
(Updated: 11/26/2024)
Click here to contact Aisha Liferidge, MD
-- Diphenhydramine (Benadryl) 50 mg IV
-- Ranitidine (Zantac) 50 mg IV
-- Methyprednisolone (Solumedrol) 50 - 100 mg IV
-- Racemic Epinephrine
-- Anesthesia consult re: airway management
Category: Misc
Keywords: ED Teaching (PubMed Search)
Posted: 2/10/2009 by Rob Rogers, MD
(Updated: 11/26/2024)
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Pitfalls in ED Teaching
One of the best ways to improve as a teacher is to understand what mistakes expert educators have made in the past.
The following is a short list of pitfalls offered from some of the great teachers in our specialty:
Category: Critical Care
Keywords: ventilator associated pneumonia, head of bed (PubMed Search)
Posted: 2/10/2009 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
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Ventilator Associated Pneumonia (VAP)
Category: Cardiology
Posted: 2/9/2009 by Amal Mattu, MD
(Updated: 11/26/2024)
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Torsades de pointes and polymorphic ventricular tachycardia are two terms that are often used interchangeably. However, they are not the same!
Torsades is a type of PVT that is characterized by an undulating appearance of the QRS complexes which give the rhythm the appearance of QRS complexes twisting around a central axis. The defining feature of torsades, however, is the presence of a prolonged QTc on the ECG before or after the run of torsades.
Although either rhythm is usually amenable to cardioversion/defibrillation, post-cardioversion treatment is very different between the two. Torsades should be treated with magnesium, whereas PVT can be treated with lidocaine, amio, or procainamide. Beware that treatment of torsades with any of these sodium channel blockers can actually prolong the QTc further and induce intractable torsades.
Category: Trauma
Keywords: Epinephrine, Lidocaine, Fingers, (PubMed Search)
Posted: 2/7/2009 by Michael Bond, MD
(Updated: 11/26/2024)
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Lidocaine with Epinephrine and it use on Fingers and Toes
It has been taught for a long time that Lidocaine with Epinephrine should not be used on fingers, toes, ears and nose [There has to be a kid's song in there somewhere] due to the risk of vasoconstricition/vasospasm and possible digitial infarcation.
The short story is that this practice is not supported by the literature, and there are now numerous publications that have shown that lidocaine with epinephrine is safe for use on the finger tips. It turns out the the original case reports were submitted with procaine and epinephrine and not lidocaine with epinephrine. Most of the cases of digital infarction where with straight procaine that is now thought to have been contaiminated or too acidic pH close to 1 when injected.
The effects of epinephrine last approximately 6 hours. This time is well within the accepted limit of ischemia for fingers that has been established in digitial replanation.
So why use Lidocaine with Epinephrine:
Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. Jan 2007;119(1):260-266.
Category: Pediatrics
Keywords: Epstien Barr Virus, Mononucleosis (PubMed Search)
Posted: 2/6/2009 by Rose Chasm, MD
(Updated: 11/26/2024)
Click here to contact Rose Chasm, MD
Epstein-Barr virus (EBV)-associated infectious mononucleosis (IM)
Most commonly presenting clinical findings: fever, fatigue, exudative pharyngitis, lymphadenopathy, and hepatosplenomegaly.
Self-limited illness that lasts an average of 2 - 3 weeks.
Treatment is primarily supportive. Use of ampicillin, amoxicillin, or penicillin during the acute phase not indicated and may result in the development of a morbilliform rash, which studies have suggested may occur in more than 50% of the cases. Antiviral therapy is not recommended. Splenic rupture occurs in about 1 - 2:1000 cases. Therefore, avoidance of activities that increase the risk for injury is recommended until splenomegaly has resolved.
Hickey SM, Strasburger VC. What every pediatrician should know about infectious mononucleosis in adloscents. Pediatr Clin North Am. 1997;44:1541-1556.
Katz BZ. Epstein-Barr virus. In: Long SS, Pickering LK, Prober CG, eds. York, NY: Churchill Livingstone; 2—3:1059-1068
Peter J, Ray CG. Infectious mononucleosis. Pediatr Rev. 1998; 19:276-279.
Category: Toxicology
Keywords: Clopidogrel, DVT, thrombosis, stents (PubMed Search)
Posted: 2/5/2009 by Ellen Lemkin, MD, PharmD
(Updated: 11/26/2024)
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Category: Neurology
Keywords: cea, carotid artery stenosis, stroke (PubMed Search)
Posted: 2/4/2009 by Aisha Liferidge, MD
(Updated: 11/26/2024)
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Category: Critical Care
Keywords: sedation, analgesia, mechanical ventilation (PubMed Search)
Posted: 2/3/2009 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
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Sedation and Analgesia in Mechanical Ventilation
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 2/3/2009 by Rob Rogers, MD
(Updated: 11/26/2024)
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Pulmonary Embolism-Beware Two Important Atypical Presentations
Seems like we have had several atypical PE presentations recently so I thought it timely to quickly highlight some of the well-reported presentations of pulmonary embolism. Remember, although we won't and can't diagnose every case, these types of presentations should at the very least prompt us to consider the diagnosis.
Atypical PE Presentations: