Category: Neurology
Keywords: aed, antiepileptic medication, post-stroke seizure, stroke, seizure (PubMed Search)
Posted: 6/11/2008 by Aisha Liferidge, MD
(Updated: 10/31/2024)
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Keywords: sepsis, intravenous fluids, chronic kidney disease, end stage renal disease (PubMed Search)
Posted: 6/10/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
Click here to contact Amal Mattu, MD
Submitted on behalf of Dr. Winters:
Sepsis, Fluids, and ESRD
-ESRD patients are at increased risk of sepsis and bacteremia secondary to
indwelling devices
-Many of are hesitant to aggresively fluid resuscitate patients with ESRD
-Several studies have concluded that volume resuscitation should proceed the
same as patients without ESRD, even if that means more patients are eventually
intubated.
Reference:
Otero RM, et al. Chest 2006;130:1579-95.
Category: Vascular
Keywords: AAA (PubMed Search)
Posted: 6/9/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
Click here to contact Rob Rogers, MD
Clinical Presentation of AAA
Everyone is familiar with the "classic," textbook, presentation of AAA:
This presentation, however, is not all that common. Many patients simply present with unexplained abdominal and/or flank pain.
Consider the diagnosis in anyone with risk factors (i.e. older folks, family history, etc) who presents with abdominal and/or flank pain. In most cases, CT scanning of this group of patients is the way to go.
And, one last pearl: put the US probe on early. May make a huge difference in time to diagnosis.
Be afraid, be very afraid.
J Vasc Surg, 2007
Category: Toxicology
Keywords: sedation, propofol, ketamine (PubMed Search)
Posted: 6/5/2008 by Ellen Lemkin, MD, PharmD
(Emailed: 6/9/2008)
(Updated: 10/31/2024)
Click here to contact Ellen Lemkin, MD, PharmD
"Ketofol" (Ketamine plus propofol)
Category: Cardiology
Keywords: renal failure, kidney disease, acute coronary syndrome, myocardial infarction (PubMed Search)
Posted: 6/8/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
Click here to contact Amal Mattu, MD
Chronic kidney disease is a risk factor for accelerated atherogenesis. It is also a poor prognostic factor for patients with ACS or after MI. Elevated serum creatinine has been found to be an independent predictor of death after ACS and also a predictor of recurrent cardiovascular events. Cardiovascular death is 10-30 times higher in dialysis patients with ACS than in the general population.
Category: Neurology
Keywords: Thiamine, Wernicke, Encephalopathy (PubMed Search)
Posted: 6/4/2008 by Michael Bond, MD
(Emailed: 6/7/2008)
(Updated: 10/31/2024)
Click here to contact Michael Bond, MD
Treatment of Wernicke's Encephalopathy
Traditionally the treatment dose of thiamine in those that we suspect to have Wernicke's Encephalopathy is 100mg per day. The problem is that this does was arbiarily picked by two physicians, Victor and Adams, in the 1950's. They thought that 100mg a day would be a large dose. They also made their recommendation without fully understanding the pharmacokinetics of thiamine which has a half life of 96 minutes or less. Compound this with case reports of individuals dying of Wernike's Encephalopathy despite being given 100mg of Thiamine daily.
Several authors are now advocating that patients with Wernicke's Encephalopathy be treated with 500mg of IV thiamine daily, but with the short half life some are advocating that the thiamine be given 2 to 3 times a day. There are no good studies to refute or support the claims that higher doses are needed, but there are well documented cases of treatment failures at the lower dose.
PEARLs:
Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke's encephalopathy: what every emergency physician should know. Ann Emerg Med. Dec 2007;50(6):715-721.
Category: Pediatrics
Keywords: Pediatric Central Lines (PubMed Search)
Posted: 6/7/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
Click here to contact Don Van Wie, DO
Pediatric vascular access can be a challenge especially in a critically ill child. When placing central lines finding information on what size catheter to use and the depth of insertion can be hard to locate so here are some starters :
Age (yrs) IJ SC Femoral
0-0.5 3F 3F 3F
0.5-2 3F 3F 3-4F
3-6 4F 4F 4-5F
7-12 4-5F 4-5F 5-8F
Use a single, double, or triple lumen. (General rule more lumens the better.)
Right IJ and Right SC Depth of insertion:
If Height < 100cm then Initial Catheter Depth (cm) = Ht (cm)/10 -1 cm
If Height > 100 cm then Initial Catheter Depth (cm) = Ht (cm)/10 -2 cm
These formulas will place 98% of catheters above R atrium.
Anesth Analg 2001;93:883.
Category: Neurology
Keywords: seizure, stroke, antiepileptic treatment (PubMed Search)
Posted: 6/4/2008 by Aisha Liferidge, MD
(Updated: 10/31/2024)
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Keywords: acinetobacter, polymixin, ventilator-associated pneumonia, bacteremia (PubMed Search)
Posted: 6/3/2008 by Mike Winters, MBA, MD
(Updated: 10/31/2024)
Click here to contact Mike Winters, MBA, MD
Acinetobacter in the Critically Ill
Munoz-Price LS, Weinstein RA. Acinetobacter infection. NEJM 2008;358:1271-81.
Category: Vascular
Keywords: CT Venogram, Ultrasound, DVT, Deep Venous Thrombosis( (PubMed Search)
Posted: 6/2/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
Click here to contact Rob Rogers, MD
What study should we be getting to evaluate for DVT in patients with suspected VTE (venous thromboembolic disease)?
Ultrasound of the legs seems to be equivalent to CT Venography (CTV).
Drawbacks of CT Venography (CT scanning into the abdomen/pelvis/legs after pulmonary CTPA):
Despite the fact that leg ultrasound obviously doesn't evaluate for deep pelvis clots and intraabdominal clots (IVC, etc), outcome studies and other studies in recent years show ultrasound is just as good as CTV.
Goodman LR, et al. CT Venography and Compression Sonography are Diagnostically Equivalent: Data from PIOPED II. Am J Roent 2007
Category: Orthopedics
Keywords: Lisfranc Fracture (PubMed Search)
Posted: 6/2/2008 by Michael Bond, MD
(Updated: 10/31/2024)
Click here to contact Michael Bond, MD
Lisfranc Fracture:
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism is when a person steps into a hole and twists the foot.Originally described when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficult weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Pearls:
Category: Cardiology
Keywords: cocaine, chest pain, myocardial infarction (PubMed Search)
Posted: 6/1/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
Click here to contact Amal Mattu, MD
Just a few quick pearls about cocaine-chest pain and myocardial infarction:
[McCord J, et al. Management of cocaine-associated chest pain and myocardial infarction. Circulation 2008;117:897-1907.]
Category: Pediatrics
Keywords: Pediatric Laryngoscope blade size, RSI, Airway Management, Intubation (PubMed Search)
Posted: 5/31/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
Click here to contact Don Van Wie, DO
Remember in the heat and pressure of a pediatric intubation (if you don't have your Pediatic Qwic Card handy) you can estimate what size blade to use very quickly and successfully by using facial landmarks!!
And remember to start with a straight blade (Miller, Wisconsin, Guedel, Wis-Hipple etc.) for your patients under 2 years of age because:
Pediatric Emergency Care. 22(4):226-229, April 2006.
Mellick, Larry B. MS, MD, FAAP, FACEP ; Edholm, Thomas MD, FACEP ; Corbett, Stephen W. MD, PhD, FACEP
Category: Critical Care
Keywords: jlactated Ringer's solution, dextrose, cerebral edema (PubMed Search)
Posted: 5/27/2008 by Mike Winters, MBA, MD
(Updated: 10/31/2024)
Click here to contact Mike Winters, MBA, MD
Fluids in Acute Liver Failure
Auzinger G, Wendon J. Intensive care management of acute liver failure. Curr Opin Crit Care 2008;14:179-88.
Category: Cardiology
Keywords: cardioversion, defibrillation (PubMed Search)
Posted: 5/26/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
Click here to contact Amal Mattu, MD
It is well-accepted that good, rapid compressions are one of the best interventions we can employ in managing patients with cardiac arrest. It is imperative that we minimize interruptions. Unfortunately, delivering shocks to a patient is a frequent cause of interruptions in compressions. It now appears that we may not need to discontinue compressions during shocks.
A recent study indicates that if shocks are delivered using the common self-adhesive pregelled pad electrodes and the person performing compressions is wearing gloves, the rescuers do not sense a shock at all. Compressions, therefore, do NOT have to stop during the cardioversion or defibrillation.
Whether this statement is true regarding handheld manual defibrillators also is uncertain.
Lloyd MS, Heeke B, Walter PF. Hands-on defibrillation: An analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008;117:2510-2514.
Kerber RE. "I'm clear, you're clear, everybody's clear:" a tradition no longer necessary for defibrillation? Circulation 2008;117:2435-2436.
Category: Orthopedics
Keywords: Clavicle, fracture, surgery (PubMed Search)
Posted: 5/25/2008 by Michael Bond, MD
(Updated: 10/31/2024)
Click here to contact Michael Bond, MD
I remember being taught as a medical student that clavicle fractures could be treated conservatively. A direct quote was "if both ends of the clavicle are in the same room it will heal".
Though conservative treatment with a sling for 6 weeks with early pendulum ROM exercises for the shoulder is appropriate for the vast majority of clavicle fractures surgery should be considered for those that have:
Category: Pediatrics
Keywords: ALTE, Menningitis, Sepsis (PubMed Search)
Posted: 5/24/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
Click here to contact Don Van Wie, DO
ALTE and Infections - when to do full septic workups?
Given some recent cases of newborns with ALTEs at UMMS and Wash Co I thought I'd offer the following Pearls:
That being said THE RISK OF MISSING A SERIOUS LIFE THREATENING INFECTION is much greater than the risk of doing a complete septic workup, administering antibiotics, and admitting an infant with an ALTE.
McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004;89(11):1043-8.
Category: Toxicology
Keywords: chlorine, pneumonitis (PubMed Search)
Posted: 5/22/2008 by Fermin Barrueto
(Updated: 10/31/2024)
Click here to contact Fermin Barrueto
Pool Cleaner Toxicity - Chlorine Gas Exposure
The "shock" treatment that is utilized in pool cleaner is often contained in a large plastic container and is calcium hypochlorite. Chlorine gas accumulates in the small amount of airspace found in the container. If a future patient opens the container either in an enclosed space or within close proximity of the face that allows for large inhalational exposure.
Category: Neurology
Keywords: traumatic brian injury, TBI, respirations, cheyne-stokes, hyperventilation (PubMed Search)
Posted: 5/22/2008 by Aisha Liferidge, MD
(Updated: 10/31/2024)
Click here to contact Aisha Liferidge, MD
Category: Misc
Keywords: superior vena cava, svc syndrome (PubMed Search)
Posted: 5/20/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
Click here to contact Rob Rogers, MD
Superior Vana Cava Synrome....when to suspect
Two common causes of SVC syndrome include thrombus (secondary to CV catheters) and lung tumors/lymphoma
Consider this diagnosis in patients with a history of cancer and/or who have a central line in place and the complaint of facial swelling. Patients may not look swollen to you.
In addition, make sure to look at their necks and chest wall-presence of asymmetric, prominent veins should prompt consideration for this diagnosis.
A useful clinical tool is to look at the patient's driver's license (assuming they have one) and compare to their appearance on presentation.
Workup in most cases will involve a CT of the chest.
Clinical Oncology, 2007