Category: Critical Care
Keywords: sedation, analgesia, mechanical ventilation (PubMed Search)
Posted: 2/3/2009 by Mike Winters, MBA, MD
(Updated: 11/1/2024)
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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: 11/1/2024)
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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:
Category: Cardiology
Keywords: troponin,prognosis (PubMed Search)
Posted: 2/2/2009 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Pediatrics
Keywords: Pediatric Bradycardia, heart blocks (PubMed Search)
Posted: 1/30/2009 by Don Van Wie, DO
(Updated: 11/1/2024)
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Bradycardia in children is most often caused by hypoxemia but can also be caused by acidosis, elevated ICP, vagal stimulation, heart blocks or overdoses.
First degree heart block in otherwise healthy children can be caused by infectious diseases, myocarditis, rheumatic fever, Lyme disease and congenital heart disease.
Third degree heart block can be congenital, caused by maternal connective tissue disorders such as Lupus, or may result from cardiac surgery.
Any infant presenting with a third degree heart block should have an investigation for neonatal lupus.
Doniger S. Pediatric Dysrhythmias. Pediatric Emergency Medicine Reports. Sept 2008. Vol 13, No 9 (This was edited by a UMMS Combined EM/PEDS graduated Dr. Jim Colletti who is Associate Residency Director, Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN.)
Category: Toxicology
Keywords: brodifacoum, cholecalciferol, strychnine (PubMed Search)
Posted: 1/29/2009 by Fermin Barrueto
(Updated: 11/1/2024)
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Rodenticides have taken many forms. The following is a list of some of the more interesting ones either due to the mechanism of toxicity or how it is lethal. All of these are also toxic to people.
1) Strychnine - Glycine Antagonist at the post-synaptic spinal cord neurons - patient or rat will have convulsion of the extremeties but will be awake, alert and in extreme pain. Essentially look like generalized seizure except awake. Treatment: Benzodiazepines, Analgesia, Supportive
2) Brodifacoum - Long Acting Coumarin - rat eats, later develops elevated INR then tries to run through thin cracks in the wall or takes a little too high of a jump, then boom - subdural or some other internal hemorrhage. In human, they can stay anticoagulated for weeks after an overdose. Treatment: Vitamin K and large padded room
3) Cholecalciferol - Vitamin D precursor - there are big blocks of this drug in the NY and other subway systems. Rat nibbles, gets hypercalcemic, then gets thirsty because of this. Rat runs out into middle of subway to drink out of puddle then - splatt - the M train to Brooklyn comes along. Treatment: IVF, Loop Diuretics, Bisphosphonates
Category: Neurology
Keywords: gcs, glasgow coma scale, motor function (PubMed Search)
Posted: 1/28/2009 by Aisha Liferidge, MD
(Updated: 11/1/2024)
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Category: Critical Care
Keywords: pneumonia, sepsis, severe sepsis, septic shock, mrsa, vancomycin (PubMed Search)
Posted: 1/28/2009 by Mike Winters, MBA, MD
(Updated: 11/1/2024)
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Pneumonia and Sepsis
Category: Misc
Keywords: Feedback, Teaching (PubMed Search)
Posted: 1/26/2009 by Rob Rogers, MD
(Updated: 11/1/2024)
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Feedback as a Teaching Tool
Why do we, in general, stink at giving feedback?
Consider a few quick pearls that will increase your success at giving valuable feedback:
Category: Cardiology
Keywords: elderly, geriatric, acute coronary syndrome, electrcardiography (PubMed Search)
Posted: 1/25/2009 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Misc
Keywords: Frostbite, treatment (PubMed Search)
Posted: 1/24/2009 by Michael Bond, MD
(Updated: 11/1/2024)
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FrostBite
Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia. Here are some tips for treating frostbite.
Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.
Category: Pediatrics
Keywords: pediatric atrial fibrillation, pediatric arrhythmias (PubMed Search)
Posted: 1/23/2009 by Don Van Wie, DO
(Updated: 11/1/2024)
Click here to contact Don Van Wie, DO
The most common arrhythmias in children presenting to the ED are:
Atrial fibrillation in children is irregularly irregular with disorganized atrial activity with atrial rates ranging from 350-600 BPM.
Children at increased risk of developing atrial fibrillation include those with underlying structural heart defects and hyperthyroidism.
Hemodynamically stable children have several treatment options including digoxin, amiodarone, propranolol, esmolol, or procainamide for ventricular rate control.
Hemodynamically unstable children need immediate synchronized cardioversion with 0.5 - 1 J/kg. (don't forget light sedation.)
References:
Sacchetti A, Moyer V, Baricella R, et al. Primary cardiac arrhythmias in children. Pediatr Emerg Care 1999;15:95-98
Doniger S. Pediatric Dysrhythmias. Pediatric Emergency Medicine Reports. Sept 2008. Vol 13, No 9 (This was edited by a UMMS Combined EM/PEDS graduated Dr. Jim Colletti who is Associate Residency Director, Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN.)
Sacchetti A, Moyer V, Baricella R, et al. Primary cardiac arrhythmias in children. Pediatr Emerg Care 1999;15:95-98
Doniger S. Pediatric Dysrhythmias. Pediatric Emergency Medicine Reports. Sept 2008. Vol 13, No 9 (This was edited by a UMMS Combined EM/PEDS graduated Dr. Jim Colletti who is Associate Residency Director, Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN.)
Category: Neurology
Keywords: gcs, glasgow coma scale, verbal response (PubMed Search)
Posted: 1/23/2009 by Aisha Liferidge, MD
(Updated: 11/1/2024)
Click here to contact Aisha Liferidge, MD
Below is an edited version of this week's neurological clinical pearl. Somehow the scores and their definitions showed up incorrectly matched. See corrections below.
Category: Misc
Keywords: EMS, trauma, injury, ISS, triage (PubMed Search)
Posted: 1/22/2009 by Ben Lawner, MS, DO
(Updated: 11/1/2024)
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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
Category: Toxicology
Keywords: octreotide, sulfonylurea, hypoglycemia (PubMed Search)
Posted: 1/22/2009 by Fermin Barrueto
(Updated: 11/1/2024)
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Octreotide
Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30.
Category: Misc
Keywords: Teaching, Emergency Department (PubMed Search)
Posted: 1/20/2009 by Rob Rogers, MD
(Updated: 11/1/2024)
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Teaching in the Emergency Department
Effective ways to teach in the ED:
Bandiera, Thurgur. 2006-2008
Category: Critical Care
Keywords: anaphylaxis, urticaria, angioedema, shock (PubMed Search)
Posted: 1/20/2009 by Mike Winters, MBA, MD
(Updated: 11/1/2024)
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Clinical Manifestations of Anaphylaxis
Winters ME. Anaphylaxis. In: Field JM (ed) The Textbook of Emergency Cardiovascular Care and CPR. Philadelphia, Lippincott Williams & Wilkins, 2009:530-7.
Category: Cardiology
Keywords: glycoprotein receptor antagonists, unstable angina, ischemic heart disease, percutaneous coronary intervention (PubMed Search)
Posted: 1/18/2009 by Amal Mattu, MD
(Updated: 11/1/2024)
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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.
King S, Smith S, Hirschfeld JW, et al. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008;51:172-209.
Category: ENT
Keywords: Iritis, diagnosis (PubMed Search)
Posted: 1/17/2009 by Michael Bond, MD
(Updated: 11/1/2024)
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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:
Adapted from Pfaff J and Moore G. Eye, Ear, Nose and Throat. Emergency Medicine Clinics of North America. Volume 15, Issue 2 (May 1997)
Category: Pediatrics
Keywords: SVT, pediatric tachycardia (PubMed Search)
Posted: 1/16/2009 by Don Van Wie, DO
(Emailed: 1/17/2009)
(Updated: 11/1/2024)
Click here to contact Don Van Wie, DO
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.
Category: Toxicology
Keywords: tetrodotoxin, sushi (PubMed Search)
Posted: 1/15/2009 by Fermin Barrueto
(Updated: 11/1/2024)
Click here to contact Fermin Barrueto
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.
0901152329_fugu_0111.jpg (145 Kb)