Category: Vascular
Keywords: aortic dissection, chest xray (PubMed Search)
Posted: 9/23/2008 by Rob Rogers, MD
(Updated: 11/26/2024)
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So, how good is a screening CXR for aortic dissection?
vonKodolitsch, 2005
Category: Cardiology
Keywords: syncope, arrhythmia, dysrhythmia (PubMed Search)
Posted: 9/22/2008 by Amal Mattu, MD
(Updated: 11/26/2024)
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17-18% of cases of syncope are attributable to dysrhythmias.
The best predictors of dysrhythmias in these patients are:
1. abnormal ECG (odds ratio 8.1)
2. history of CHF (odds ratio 5.3)
3. age > 65 (odds ratio 5.4)
[reference: Sarasin FP, et al. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003.]
Category: Procedures
Keywords: Paracentesis (PubMed Search)
Posted: 9/21/2008 by Michael Bond, MD
(Updated: 11/26/2024)
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Paracentesis:
Since we have covered so many other procedures I though I would include paracentesis for completion.
A diagnostic paracentesis (typically 30-60 ml) is indicated to:
A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:
Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.
Absolute Contraindications to paracentesis include: Acute abdomen requiring surgery
Relative contraindications are:
To view a video on how to do a paracentesis please visit the New England Journal of Medicine http://content.nejm.org/cgi/content/short/355/19/e21
Next I will address how to interpret the paracentesis fluid results.
Category: Pediatrics
Keywords: oxycodone pediatrics, codeine pediatrics, fracture pain management (PubMed Search)
Posted: 9/19/2008 by Don Van Wie, DO
(Updated: 11/26/2024)
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Oxycodone v. Codeine for Fracture Pain Management in Children
Charney RL, Yan Y, Schootman M, Kennedy RM, Luhmann JD. Oxycodone Versus Codeine for Triage Pain in Children With Suspected Forearm Fracture: A Randomized Controlled Trial. Pediatr Emerg Care. 2008 Sep;24(9):595-600.
Category: Toxicology
Keywords: diphenhydramine, heroinI (PubMed Search)
Posted: 9/18/2008 by Fermin Barrueto
(Updated: 11/26/2024)
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Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine
Treatment
Category: Neurology
Keywords: coagulopathic, tPA, stroke, coagulopathy (PubMed Search)
Posted: 9/18/2008 by Aisha Liferidge, MD
(Updated: 11/26/2024)
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Category: Infectious Disease
Keywords: health care associated pneumonia, antibiotics, (PubMed Search)
Posted: 9/16/2008 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
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Health care-associated pneumonia
Abrahamian FM, DeBlieux PM, Emerman CL, et al. Health care-associated pneumonia: identification and initial management in the ED. Am J Emerg Med 2008;26:1-11.
Category: Vascular
Keywords: Cardiovascular, CocaineC (PubMed Search)
Posted: 9/15/2008 by Rob Rogers, MD
(Updated: 11/26/2024)
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Key Cardiovascular complications of cocaine:
Pearls:
Restrepo CS, et al. Cardiovascular complications of cocaine: Imaging findings. Emerg Radiol 2008
Category: Cardiology
Keywords: HIV, human immunodeficiency virus, coronary heart disease (PubMed Search)
Posted: 9/14/2008 by Amal Mattu, MD
(Updated: 11/26/2024)
Click here to contact Amal Mattu, MD
HIV positive patients are at increased risk of premature atherosclerosis for at least a few reasons:
1. HIV disease causes increased activation of platelets.
2. HIV produces arterial endothelial dysfunction [which promotes thrombosis formation].
3. Protease inhibitors produce dyslipidemias and insulin resistance.
HIV-associated CAD is also unusual in that the vessel involvement is frequently diffuse and circumferential along the whole artery.
HIV positive patients are known to have their first MI at an earlier age than non-HIV controls, and the effect is not related to CD4 count (not related to severity of disease).
The takeaway point here is to always strongly consider ACS in the differential diagnosis of patients with HIV that are presenting with cardiopulmonary complaints, even in relatively younger patients.
Amal
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular Manifestations in Human Immunodeficiency Virus-Infected Patients. Am J Cardiol 2008;102:635-642.]
Category: Procedures
Keywords: Dental Blocks (PubMed Search)
Posted: 9/13/2008 by Michael Bond, MD
(Updated: 11/26/2024)
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Dental Pain and Blocks:
I am sure that most of us have felt like we should have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating. For these patients the only way to truly get their paint under control is to perform a dental block. This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.
For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html
So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)
Category: Toxicology
Keywords: latrodectus, black widow, spider (PubMed Search)
Posted: 9/11/2008 by Fermin Barrueto
(Updated: 11/26/2024)
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Latrodectus sp (Black Widow Spider)
Take a look at a picture of the black widow on the following attachment
Category: Neurology
Keywords: avm, arteriovenous malformation, intracranial bleed (PubMed Search)
Posted: 9/10/2008 by Aisha Liferidge, MD
(Updated: 11/26/2024)
Click here to contact Aisha Liferidge, MD
- Ataxia - Paresthesia/dysesthia - Aphasia - Memory deficits - Confusion - Hallucinations - Apraxia - Papilladema
Category: Vascular
Keywords: Ischemia (PubMed Search)
Posted: 9/9/2008 by Rob Rogers, MD
(Updated: 11/26/2024)
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Management of acute limb ischemia
Just a few pearls regarding acute limb ischemia
Vasc Surg Reviews 2007
Category: Critical Care
Keywords: intraabdominal pressure, intraabdominal hypertension, bladder pressure (PubMed Search)
Posted: 9/8/2008 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
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Intraabdominal Hypertension and the Critically Ill
Cheatham ML. Intraabdominal pressure monitoring during fluid resuscitation. Curr Opin Crit Care 2008;14:327-33.
Category: Cardiology
Keywords: troponin, sepsis (PubMed Search)
Posted: 9/7/2008 by Amal Mattu, MD
(Updated: 11/26/2024)
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Troponin levels are often elevated in patients with sepsis. This doesn't necessarily mean that the patient has suffered an acute Mi or ACS, but rather it seems to correlate with myocardial dysfunction that is caused by sepsis. Much like with true MI, troponin elevations predict a greater risk of in-hospital mortality in these patients.
Category: Pediatrics
Keywords: Pediatric Anaphylaxis (PubMed Search)
Posted: 9/5/2008 by Don Van Wie, DO
(Updated: 11/26/2024)
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When the Sting REALLY hurts!!
Remember the dose of Epinephrine is :
0.01 mg/kg or 0.01 mL/kg of 1:1,000 IM or
0.01 mg/kg IV or 0.1 mL/kg/dose 1:10,000 IV
to the adult dose or 0.3 mg
Also
Epipen Jr = 0.15 mg (use for < 30 Kg)
Epipen = 0.3 mg (use for > 30 Kg)
To show patients an instructional video click on the referenced link.
Category: Airway Management
Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)
Posted: 8/27/2008 by Ben Lawner, MS, DO
(Updated: 11/26/2024)
Click here to contact Ben Lawner, MS, DO
To echo Dr. Rogers' fantastic airway tips:
When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:
1. P osition: No intubating on the floor! Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.
2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis.
3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.
4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.
5. P aralysis: This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.
6. P ass the tube: What Dr. Rogers said.
7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.
-Our very own Dr. Ken Butler: "Be prepared!"
Category: Toxicology
Keywords: Lidocaine, pediatrics, anesthesia (PubMed Search)
Posted: 9/4/2008 by Ellen Lemkin, MD, PharmD
(Updated: 11/26/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Topical Lidocaine for local anesthesia
Disclosure: I have no financial or invested interest in the product or the company.
1. Pharmacist's Letter 2008 24(9):240912
2. Cregin R. Improving pain management for pediatric patients undergoing nonurgent painful procedures. ASHSP April 15 2008;Vol 65(8):723-7.
3. Kaweski S. Topical Anesthetic Creams. Plastic and Reconstructive Surgery. June 2008; Vol 121(6):2161-5.
Category: Neurology
Keywords: asterixis, liver failure, elevated ammonia, flapping tremor (PubMed Search)
Posted: 9/3/2008 by Aisha Liferidge, MD
(Updated: 11/26/2024)
Click here to contact Aisha Liferidge, MD
-- azotemia
-- cardon dioxide toxicity
-- metabolic encephalopathies
-- Wilson's Disease
Category: Critical Care
Keywords: sodium bicarbonate, lactic acidosis, hypoperfusion, shock (PubMed Search)
Posted: 9/3/2008 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
Click here to contact Mike Winters, MBA, MD
Bicarbonate for severe lactic acidosis from shock?
Boyd JH, Walley KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Curr Opin Crit Care 2008;14:379-83.