AGE occurs when gas bubbles enter arteries or veins; AGE may cause clinical symptoms even with very small volumes of air.
Air enters the circulatory system via:
· Barotrauma – Alveolar injury allows air to enter systemic bloodstream; occurs in divers following rapid ascent after breath holding, during mechanical ventilation, chest tube placement, or bronchoscopy
· Decompression sickness – Dissolved gas precipitates out of bloodstream as bubbles; typically following scuba diving without appropriate time to ascend or prolonged flying in unpressurized aircrafts
· Direct injection of air into arterial or venous circulation – Examples include accidental IV injection of air, needle biopsy of lung, or aspiration of air during central line placement
Serious clinical manifestations include:
· Neurologic changes - loss of consciousness, confusion, or focal neurological deficits
· Hemodynamic changes – hypotension, arrhythmias, cardiac ischemia, or cardiac arrest.
· Respiratory changes – obstruction of pulmonary circulation, pulmonary edema, or hypoxemia
Treatment:
· Strict attention to ABC’s using high-flow O2.
· Keep head of bed elevated to minimize/reduce cerebral edema.
· Hyperbaric Oxygen (HBO) therapy is recommended for neurological manifestations or cardiovascular instability. Good outcomes associated with shorter intervals from air embolism to HBO. Typically only 1 to 2 treatments are needed; occasionally additional treatments are necessary.
Many physicians have the opportunity to invest in a variety of retirement funds. The most common commercial vehicle is a 401k. Academic and non-profits have access to an analogous 403b. Many physicians also have access to a 457b.
It is important to understand what it is, and most importantly how it differs from a conventional 401k or 403b. Like its' peers, it permit pre-tax contributions of a finite amount. They are offered through your employer and are bound to a specific vendor(s). These vendors provide a select number of investment choices specific to the employer contract. The maximum contribution for 2012 is $17,000.
The 457b is different from the other investment vehicles because of who and where your funds are held:
Non-governmental 457 plans have a number of restrictions that governmental ones do not. Money deferred into non-governmental 457 plans may not be rolled into any other type of tax-deferred retirement plan. It may be rolled only into another non-governmental 457 plan. Also, money deferred into non-governmental plans is not set aside in a trust for the exclusive benefit of the employee making the deferral. The Internal Revenue Code requires that money in a non-governmental 457 plan remains the property of the employer and is thus available to general creditors of the employer in legal or bankruptcy
If you work for a private entity, or a non-profit and they offer a non-governmental 457b, your personal funds are pooled with corporate resources. Your retirement contributions are at risk, should the company default and declare bankruptcy. This risk is apparently not born by GSRA 457b (Governmental agency 457b plans). A decade ago, this risk would seem insignificant. With the number of large companies and municipalities defaulting in this economic climate, prudence is warranted when considering this investment vehicle. DISCLAIMER - This pearl is not intended to provide financial advice. Please consult your HR department and / or financial advisor for additional information and advice.
Our old friend Captain Morgan (the rum pirate) may now be able to assist us during a shift, not just afterwards.
http://www.inquisitr.com/wp-content/2011/08/captain-morgans-pirate-ship-satisfaction-panama.jpg
In a small case series in last months Annals of Emergency Medicine, a new reduction maneuver was described as an alternative to the traditional Aliis's maneuver.
The maneuver is named after the pirate spokesperson for the similarities in body positioning.
The patient is placed supine on a stretcher. The pelvis is fixed to a backboard with a strap. The patient's hip and knee are flexed to 90 degrees. The physician places one foot on the back board with the same knee behind the patient's knee. By holding the patient's ankle down, the patient's knee is kept in flexion. The physician then lifts his/her calf, thereby applying an upward force to the hip while gently rotating the lower leg from side to side.
http://www.youtube.com/watch?v=l07K-mO2X84
with a slight variation
http://www.youtube.com/watch?v=sGQZaqB48rw
The success rate was 12 of 13 cases. The single failure occurred in a patient with an acetabular fracture with an intra-articular fragment requiring open reduction. There were no described neurovascular complications or injuries to the knee. The technique limits the physician's risk of back strain and of falling from the stretcher.
Potential Causes of Neonatal Apnea and Bradycardia
• Central nervous system
Intraventricular hemorrhage, drugs maternal/fetal, seizures, hypoxic injury, herniation, neuromuscular disorders, brainstem infarction or anomalies (e.g., olivopontocerebellar atrophy), general anesthesia.
• Respiratory
Pneumonia, obstructive airway lesions, upper airway collapse, atelectasis, extreme prematurity (<1,000 g), phrenic nerve paralysis, severe hyaline membrane disease, pneumothorax, hypoxia, malformations of the chest.
• Infectious
Sepsis, meningitis (bacterial, fungal, viral), RSV
• Metabolic
Hypoglycemia, hyper/hyponatrmia, hyperammonemia, decreased organic acids, hypothermia.
• Cardiovascular
Hypotension/hypovolemia, heart failure, PDA, anemia, vagal tone.
As we go through the problems of national drug shortages it is important to remember the old drugs but to also remember why they became old and seldom used drugs. Prime example is many hospitals are beginning to develop shortages of rocuronium - the nondepolarizing paralytic that has a fast onset. This shortage has caused many to switch back to succinylcholine. The following case report should serve as reminder of how succinylcholine - due to its depolarizing nature and fasciculations - can cause a transient but significant hyperkalemia.
Levine M et al. – This case report describes a 38–year–old woman with multiple sclerosis who developed life–threatening hyperkalemia after the administration of succinylcholine during rapid sequence intubation. This case highlights the potential for iatrogenic hyperkalemia after succinylcholine in patients with neurologic diseases, including multiple sclerosis.
SAH and Pulmonary Edema - Think Twice About Diuresis!
20 year old female complains of “itchy” rash to her foot x 1 week and recently the rash has spread to her other other foot and both hands (shown below). No past medical history, no fever or chills, no mucus membranes involvement, no new medications, no tick bites, no travel. She is also 16 weeks pregnant. What’s the diagnosis?
The WBC count is normal in up to 45% of elderly patients with bacteremia. The most predictive factors for bacteremia in the elderly are delirium, vomiting, bandemia, and tachypnea.
Flexor Tenosynovitis
You can follow this link, http://www.youtube.com/watch?v=qf9SW0ChsCU , to see the physical exam findings of flexor tenosynovitis
Never be the first or last person to use a drug
Vioxx was once touted to be the drug that would be the new standard for anti-inflammatories until it was found to increase your chance of MI by 33% and cause hypertension.
Dabigatran was recently pulled from Japan markets and now is dealing with an impressive meta-analysis by Uchino et al. It showed that dabigatran was significantly associated with higher risk of MI or ACS than other agents.
Control arms (included warfarin, enoxaparin or placebo): MI rate 83 per 10,514
Dabigatran arms: MI rate 237 per 20,000
OR 1.33; 95% CI, 1.03-1.71; p=0.03
The rush for what is perceived as a panaceae for all that is wrong with coumadin could actually cause an MI while it tries to prevent a stroke in nonvalvular a-fib.
Look at the study and decide for yourself and remember Vioxx:
http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.1666v1
Fungal endopthalmitis is an intraocular infection of the aqueous and/or vitreous humor secondary to fungal pathogens; Candida and Aspergillus species are the most common pathogens.
Risk factors: intravenous drug abuse (#1 risk factor), critical illness, systemic fungal infection, immunosuppression (from cancer or medications), diabetes, and alcoholism.
Have a high-index of suspicion for endopthalmitis when patients with systemic fungal disease have visual symptoms; endopthalmitis is present in up to 33% of patients with systemic fungal disease.
Symptoms include:
Inspection of both the anterior and posterior chamber is essential to during evaluation; several small yellow-white circular or “fluffy” lesions with surrounding hemorrhage are demonstrated.
Definitive diagnosis made by vitreous biopsy, culture, or PCR; presumptive treatment is acceptable if systemic fungal disease has been demonstrated.
Treatment with Amphotericin B or Voriconazole may be used for broad-spectrum fungal coverage until specific culture and sensitivities return.
As many as 1/3 of patients with proven ACS have no chest pain at presentation. Among the more common alternative presentations (anginal equivalents) are dyspnea, diaphoresis, nausea/vomiting, and syncope/near-syncope.
Note also that the absence of pain does not confer a better prognosis. The overall in-hospital mortality rate for patients with painless presentations is 13% vs. 4.3% for patients with chest pain.
Approximately 48% of shoulder dislocations occur during sports and recreation.
These are usually first managed in the clinic and sideline setting.
In 6 reviewed studies, 5 used 20mL of 1% lidocaine and 1 used 4 mg/kg of 1% lidocaine.
Patients incurred significantly reduced cost compared to IV sedation
There were no infections, neurovascular damage or systemic effects of the lidocaine.
No significant differences were noted in pain control, success rate or ease of reduction between intra-articular lidocaine and systemic sedation.
The risk of chondrolysis increases with higher concentration and longer duration of exposure to local anesthetics.
There is scant research about the effects of a single exposure of cartilage to lidocaine.
Suboxone = buprenorphine and naloxone in a 4:1 ratio, respectively. Formulated in 2 mg or 8mg tablets and film.
Buprenorphine acts as a partial agonist on the mu receptor and an antagonist at the kappa receptor.
If > 2 mg are ingested or age < 2 years old, these patients should be evaluated in an ED as ALL children with > 4 mg ingestion had symptoms.
There is a ceiling effect with respiratory depression however no ceiling with analgesia. This gives buprenorphine a better safety profile compared to methadone.
Onset of symptoms is about an hour and onset of respiratory depression is about 2-3 hours.
Increased doses of naloxone starting at 0.1 mg/kg may be needed to overcome high receptor affinity of buprenorphine. Remember, most children are opioid-naive and will not experience withdrawal symptoms. Repeat doses of naloxone and even infusions may be needed.
In the ED, a minimum of 6 hours observation is necessary. If no clinical effects are noted at 6 hours the patient can safely be discharged, although one small case series recommended 24 hours observation.
Unintentional overdose is common in toddlers, so advise family to keep prescriptions including family pet prescriptions locked (buprenorphine in the IV form is used for veterinary pain control).
Hypertonic Saline for Intracranial Hypertension
23 year-old male fell off porch while intoxicated. The head CT is shown below. Diagnosis?
We've noted studies in recent years indicating that cardiac risk factors are ineffective at predicting the likelihood of ACS in patients with acute chest pain (in other words, it's all about the HPI and EKG!). Now there's evidence also that cardiac risk factors are ineffective at predicting in-hospital mortality in patients that rule in for acute MI. [1] In fact, this study actually demonstrated that in-hospital mortality is inversely related to the number of cardiac risk factors!
The bottom line is simple: cardiac risk factors are useful at predicting long-term risk for development of coronary artery disease, but they are NOT useful at in the acute setting.
In 2011, updated treatment guidelines were published for acute uncomplicated cystitis and pyelonephritis in women. The recommendations differ from the previous iteration due to increased E. Coli resistance. The good news is we have been ahead of the curve in changing our prescribing habits.
Cystitis (recommendations in order of preference)
Take home points:
There are limited direct comparisons of (intravenous (IV) vs. intramuscular (IM) ketamine for pediatric procedural sedation in the emergency department. The only RCT comparing IV and IM ketamine was by Roback et al. and compared an IV dose of 1mg/kg vs. IM 4mg/kg. The study authors reported less procedural pain with IM administration compared with IV. However, vomiting occurred more frequently in the IM group, 26.3% compared to 11.9% in the IV group and recovery time was 49 minutes shorter with IV vs IM use.
Route Onset Duration Dose
IM 3-5 min 20-30min 3-5 mg/kg
IV 1 min 5-10 min 1-2 mg/kg
