A recent study highlighted the challenges we face managing ED patients on warfarin therapy. Some key observations about how we're doing:
Literature continues to show warfarin is the most dangerous medication for our patients. Meticulous monitoring and follow up will help us potentially avoid serious interactions and adverse events.
-- occurs during or immediately following urination, often when bladder is full.
-- occurs at night or after standing from the recumbent position of a deep sleep to urinate.
-- risk factors: enlarged prostate, alpha blocker therapy, dehydration, alcohol, fatigue.
Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation.
High-flow nasal cannulas (HFNC) have been adapted from use in neonates to adults to deliver continuous positive airway pressure (CPAP).
HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx. Patients tolerate it well and it is less claustrophobic than tight-fitting masks.
HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula) and non-invasive positive pressure ventilation with tight-fitting masks.
Check with your respiratory department if these devices are locally available.
Minimizing interruptions in chest compressions during CPR is critically important. As an example of the adverse consequences of interruptions, consider the following finding from Edelson (Resuscitation 2010): for every 10 seconds of hands-off time during cardiac arrest, the patient's chances of successful return of spontaneous circulation decreases by 50% due to reductions in cerebral perfusion.
Next time you are involved in a code, keep this in mind, and do EVERYTHING POSSIBLE to minimize those interruptions in chest compressions.
You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg. You suspect child abuse. You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services. While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”
A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years. Approximately 60% of the fractures seen in abused children are younger than 18 months old.
When you are looking at a skeletal survey, carefully look for the following:
1. Multiple, healing fractures of various ages
2. Rib fractures, especially in the posterior ribs
3. Metaphyseal chip and buckle fractures
4. Spiral fractures in long bones (especially in children that can’t walk)
5. Skull fractures which are not simple and linear
6. Scapula fractures
More to come about child abuse….
A recent article estimated 100,000 emergency hospitalizations for adverse drug events in U.S. adults 65 years of age or older each year. Nearly half of these hospitalizations were among adults ≥80 years old and two-thirds were due to unintentional overdoses.
Four medications or medication classes were implicated alone or in combination in 67% of hospitalizations:
Opioids were #5. Digoxin was #7 and resulted in the highest percentage of hospitalizations per ED visit at 80%.
High dose insulin is recommended in treatment of beta-blocker and calcium channel blocker overdose. In a recent observational case series of cardiogenic shock, high dose insulin was evaluated for efficacy and safety.
Hypotension in the PAH Patient
9 year-old boy with sudden onset of unilateral facial swelling. What’s the diagnosis?
Right heart endocarditis is much more common in patients that are injection drug users. Fortunately for them, they have a lower mortality than patients with left heart endocarditis because they have a lower rate of developing heart failure. This is a reminder that the most common cause of death from endocarditis is heart failure.
The Weber classification system
A commonly used, simple, easily remembered system used to describe ankle fractures. The system focuses on the integrity of the syndesmosis.
http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=simo_c017f013t.gif
- TYPE A: fibula fracture below the ankle joint/syndesmosis (which is intact). Deltoid ligament intact. Medial malleolus can be fractured. Usually treated with closed reduction.
http://www.gentili.net/image1.asp?ID=-241442344&imgid=AnkleWeberAAP600.jpg&Fx=Weber+A+Fracture
- TYPE B: is a transsyndesmotic fracture with usually partial rupture of the syndesmosis (though may be intact). No gross widening to the tib/fib articulation.. Deltoid ligament intact. Medial malleolus often fractured. Variable stability. Any clinical or radiographic injury to the medial joint complex make this an unstable fracture
http://www.gentili.net/image.asp?ID=145&imgid=AnkleWeberBmortise600.jpg&Fx=Weber+B+Fracture
- TYPE C: Fibular fracture above the level of the syndesmosis with usually a total rupture of the syndesmosis (seen as widening of the distal tib/fin articulation), resulting in instability of the ankle mortise. Associated with medial malleolus fracture or deltoid ligament injury. Unstable.
http://www.gentili.net/image1.asp?ID=146&imgid=anklewebcapoblx2600.jpg&Fx=Weber+C+Fracture
Classic Kawasaki is diagnosed by fever for greater than 5 days plus 4 out of 5 classic signs.
But what about an 8 month-old with 6 days of fever plus nonexudative conjunctivitis, unilateral cervical adenopathy and a diffuse maculopapular rash? Send some labs!
Incomplete Kawasaki is defined as fever for >5 days with 2 or more of the classic findings plus elevated ESR (>40mm/hr) and CRP (>3.0mg/dL). It is most common in infants under 12 months of age.
Disposition for the 8 month-old?
If the echo is normal, follow up in 24-48 hours and will need a repeat echo if fever persists.
TREAT kids with IVIG and aspirin (which generally means admission) if echo is positive, or with normal echo and the presence of 3 or more supplemental criteria:
Determining the exact etiology of hypotension / shock can sometimes be difficult in the Emergency Department.
The Rapid Ultrasound for Shock / Hypotension (RUSH) exam is a sequential, 5 step-protocol (typically requiring less than 2 minutes) that can be used to determine the cause(s) of hypotension.
The mnemonic for the exam is “HI MAP”, and is easy to remember because a "HI MAP" is our goal with hypotensive patients.
H - Heart (parasternal and four-chamber views)
I - Inferior Vena Cava (for volume responsiveness)
M - Morrison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
A - Aortic Aneurysm (ruptured abdominal aneurysm)
P - Pneumothorax (i.e., Tension PTX)
Refer to the link for a more detailed discussion and podcast from the creators of this exam: emcrit.org/rush-exam
Reasons for acutely elevated troponins
ACS
Acute heart failure
PE
Stroke
Aortic dissection
Tachyarrhythmias
Shock
Sepsis
Perimyocarditis
Endocarditis
Tako-tsubo cardiomyopathy
Cardiac contusion
Strenuous excercise
Sympathomimetic drugs
Chemotherapy
I guess that means that your history, physical, and clinical judgment still supersede the lab test.
Low Back is one of the most common complaints that we see in the Emergency Department. Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…). However, most of the back pain that we will see is musculoskeletal in origin.
The American College of Physicians (ACP) and the American Pain Society (APS) released joint recommendations on the evaluation of treatment of individuals with back pain in 2007.
In summary their key recommendations were:
Links to the Clinical Guidelines are listed below:
Child Passenger Safety.
Perhaps one of the greatest contributions emergency physicians can provide to society comes in the form of anticipatory guidance. It is important to take the opportunity during the ED encounter to provide information to parents to prevent future injuries. Child passenger safety is one clear example. With over 330,000 pediatric visits to EDs across the US annually attributed to motor vehicle collisions, the need to provide clear recommendations to parents on how to restrain their children in their vehicle is paramount. Despite a recent survey of over 1000 EPs in which 85% of respondents indicated child passenger safety should routinely be a part of pediatric MVC discharge instructions, only 36% of EPs knew the latest guidelines on child passenger safety. The American Academy of Pediatrics provides such guidelines. These recommendations were recently adjusted in 2011.
(1) Infants up to 2 years must be in REAR-facing car seats
(2) Children through 4 years in forward-facing car safety seats
(3) Belt-positioning booster seat for children through at least 8 years old
(4) Lap-and-shoulder seat belts for those who have outgrown booster seats. How does one know when the child has outgrown the booster seat?
a. Can the child sit with his/her knees bent at the edge of the seat?
b. Does the shoulder belt lie across the middle of the chest/shoulder?
c. Does the lap belt lie across the upper thighs and not the abdomen?
(5) Children younger than 13 should sit in the rear seats
Special Thanks to JV Nable, MD, EMT-P for writing this pearl.
TEN is a rare, life-threatening dermatologic emergency characterized initially by erythema and tenderness. It is followed by a severe exfoliation that resembles a severe burn patient. Classically occurs within days of the exposure of the drug. Nikolsky's sign may be present - not pathognomonic.
The following is a short list of medications that can cause this lethal reaction:
allopurinol, bactrim, nitrofurantoin, NSAIDs, penicillin, phenytoin, lamotrigine, sulfasalazine
Treatment: transfer to a burn center may be needed, steroids are not generally recommended however immunomodulators are beginning to show promise - IVIG, cyclosporine and cyclophosphamide
See pic that is attached for example of the sloughing
