Ventricular assist devices (VAD) pump blood from the left, right or both ventricles for patients in severe ventricular failure.
VADs may be placed temporarily (as a bridge to transplant) or permanently in patients who are not transplant candidates (also known as Destination Therapy)
Certain types of VADs continuously pump blood in a non-pulsatile fashion. In these cases, a patient may be perfusing normally without a palpable pulse.
Familiarity with potential VAD complications is important as a patient with a VAD may be presenting to an ED near you. Complications include:
24 year-old male presents following fall from a scaffolding and complains of wrist pain. Diagnosis?
Quick pearls on cardiogenic shock
Post-MI cardiogenic shock is associated with a mortality of 50-70%. There are only a few interventions that have been demonstrated to improve outcomes: early use of intra-aortic balloon pump, stenting, and G2B3A inhibitors.
It is generally recommended to avoid clopidogrel since so many of these patients will require CABG.
Early use of mechanical ventilation decreases work of breathing and improves oxygenation.
Remember that age alone is not a contraindication to aggressive treatment.
Severs disease
- Perhaps the most common overuse injury
-Pain is due to inflammation of the calcaneal apophysis growth plate
- Caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis.
- Occurs in young athletes ages 7-14
Sx’s bilateral in >50%
Hx – Gradual onset of posterior heel pain, worse with activity, better with rest.
PE – Tenderness at the insertion of the Achilles tendon onto the calcaneous. Swelling is mild.
This is a self limited condition because as the adolescent ages, the physis closes
Tx – Rest (no running or jumping), ice, NSAIDs, heel lifts/arch supports. Outpatient physical therapy for stretching and strengthening exercises.
You have seen the study comparing diazepam to lorazepam IV for the cessation of seizures. Lorazepam one that one. Now, for prehospital status epilepticus midazolam IM went head to head with IV lorazepam to see which would stop seizure more quickly.
This study was more about the practicality of starting an IV than it was of the pharmacokinetics or onset of action of a particular benzodiazepine. It was a large enough study to warrant publication in New Engl J Med last month and is worth noting.
Subjects whose seizures ceased before ED arrival (median):
Time to active treatment: 1.2 min IM Midazolam group; 4.8 min IV Lorazepam group
Median times active treatment to cessation of SZ: 3.3 min IM Midazolam and 1.6 min IV Lorazepam
Safety was equal in both groups. This study validates EMS initiating therapy with IM midazolam for the cessation of seizures while intravenous access is being attempted.
Ice-Cold Crystalloid for Therapeutic Hypothermia
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Morton's Neuroma
Children & Appendicitis
A fluid bolus is often the first-line therapy for patients with pericardial tamponade. A fluid bolus, however, may not always improve hemodynamics.
The cardiac index of forty-nine patients with cardiac tamponade was assessed before and after a 500 cc normal saline bolus:
Bottom-line: A fluid bolus may a reasonable first choice in a hypotensive patient with tamponade, but remember that fluid boluses may not always work. Attempts at fluid resuscitation should never delay definitive treatment with pericardiocentesis.
35 year old male with sudden onset of abdominal pain. Diagnosis?
You might think that patients with painless MIs might have a better prognosis than patients with pain. Unfortunately, this is just not true. A recent study (1) supported prior literature indicating that the lack of pain is not a predictor of a more benign course, and in fact patients with painless MIs have a higher in-hospital and 1-year mortality. There are several other factors that may associate lack of pain with worse outcomes (e.g. painless MIs occur more often in older patients), but regardless it's important to remember that (1) many patients with MI will present without pain, and (2) the lack of "typical" symptoms should not be reassuring.
Common herbs and supplements used to treat pain
1) Turmeric root - used for arthritis pain. Little evidence to support its use. May slow blood clotting/enhance anticoagulant/antiplatelet effects.
2) Boswellia - used for OA and RA pain. Little evidence to support its use.May interfere with anticoagulant drugs and leukotreine inhibitors.
3) St. John's Wort - used for HA, migraine, neuralgia, muscle pain, sciatica, fibromyalgia. Little to no evidence to support its use.May interfere with numerous medications including anticoagulants, digoxin and SZ medications.
4) Glucosamine and Chondroitin - used for OA, knee pain, back pain. The glucosamine/chondroitin arthritis intervention trial found that "the dietary supplements Glucosamine and Chondroitin, taken alone or in combination are generally ineffective for OA pain of the knee." May increase the effect of Warfarin.
5) KavaKava - used for HA, muscle pain. Insufficient evidence demonstrating effectiveness for treatment of painful conditions. May cause severe liver damage and potentiate drowsiness side effects of other medications.
6) Echinacea - used for pain, migraines, arthritis. Little evidence to support its use. May exacerbate symptoms of autoimmune disorders.
7) Valerian root – used for joint and muscle pain. Insufficient evidence to support its use. May potentiate sedative side effects of barbiturates and benzos.
8) Chinese Thunder God Vine – used for arthritis. There is some evidence to suggest that this agent has anti-inflammatory properties. Long term this agent may decrease bone mineral density in women, decrease fertility in men, and may produce GI side effects.
9) Feverfew – used for muscle pain, arthritis. Some evidence to suggest that may reduce frequency of migraine headaches. No evidence for benefit in RA. May enhance effects of anticoagulants and some drugs that undergo hepatic metabolism.
10) Cat’s claw – used for herpes zoster, bone pain, arthritis. Possible benefit for OA and RA in small studies in humans but no large study has shown benefit. May interact with clotting agents, BP meds and cyclosporine.
11) Black Cohosh – used for muscle pain and arthritis. Insufficient evidence demonstrating benefit. May be associated with severe liver side effects.
12) Bromelain – used for muscle pain, arthritis, knee pain. The NIH reports that bromelain may be effective for arthritis when used in combination with trypsin and rutin. May interact with amoxicillin and other antibiotics, anticoagulants and antiplatelet drugs.
13) Devil’s claw – used for muscle pain, back pain, arthritis, migraine. The NIH reports that “taking devil’s claw alone or with NSAIDs seems to help decrease OA related pain.” May increase effects of warfarin.
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, previously named “anticonvulsant hypersensitivity syndrome,” is a severe adverse drug reaction which occurs in approximately 1 of every 1,000–10,000 uses of anticonvulsants.
Characterized by triad of fever, rash, and internal organ involvement.
Usually involves aromatic anticonvulsants such as phenytoin, carbamazepine, phenobarbital, primidone, lamotrigine, and possibly oxcarbazepine.
DRESS occurs most frequently within the first 2 months of therapy and is not related to dose or serum concentration.
Treatment includes prompt discontinuation of the offending agent. Patients should be admitted to the hospital and receive methylprednisolone 0.5–1 mg/kg/d divided in four doses. Other promising therapies include use of IVIG.
ECMO for ARDS and Refractory Hypoxemia
28 y.o. male felt his left knee "pop" after landing from a jump while playing basketball. Knee exam revealed limited knee extension. X-ray is shown. Diagnosis?
In the setting of critical drug shortages of ondansetron, prochlorperazine, and metoclopramide, consider droperidol as a viable option for the treatment of nausea and vomiting.
Although it is similar to haloperidol, it is actually FDA-approved for “prevention and/or treatment of nausea and vomiting from surgical and diagnostic procedures” (unlike haloperidol). Ironically, it is not approved for agitation, although it can be used for that indication.
Dosing for antiemesis is 1.25 to 2.5 mg IV/IM. Additional doses of 0.625 to 1.25 mg can be administered to achieve desired effect. Onset is 3-5 minutes and duration of effect is 2-4 hours. It should be administered via slow IV push over 2 minutes.
Why is it not commonly used? Black Box Warning for QTc prolongation. An ECG is a must prior to administration. Also be cautious in patients who are on other medications that can prolong the QT interval (www.qtdrugs.org).
