Keywords: epilepsy, seizure, driving (PubMed Search)
Category: Critical Care
The Rapid Ultrasound in Shock (RUSH) Exam
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill. Emerg Med Clin N Am 2010; 28:29-56.
Keywords: Pulmonary Embolism (PubMed Search)
Pulmonary Embolism-Myths and Misconceptions
Just wanted to mention a few myths/misconceptions about acute PE that I have recently heard discussed in the ED.
1. Emergency physicians have to "get help" to give thrombolytic therapy. Sure it makes sense that we consult critical care and perhaps interventional radiology in some cases. But we do not need permission to use this drug by ourselves if indicated. Consider using lytics ESPECIALLY if the patient is unstable or if there is evidence of RV dysfunction (elevated troponin, echo criteria for dysfunction, or CT with large RV and bowing of the septum). What about the patient with RV dysfunction and a normal BP? Evidence is mounting that lytics are indicated to reduce the severity of pulmonary hypertension.
2. "Just get a d-dimer." Be very careful. Lots of false positives. D-dimer often clouds the picture more often than not.
3. "The mortality rate of missed PE is high." Often quoted as a 30%+ mortality rate if missed. Recent data suggests that it is < 5%.
Keywords: acute coronary syndromes, misdiagnosis, risk management, lawsuit (PubMed Search)
Missed cases of ACS account for 10% of all malpractice cases in emergency medicine, yet account for 30% of all the money emergency physicians pay out in malpractice cases. This misdiagnosis is the biggest cause of monetary payout in the specialty.
Three main themes account for the majority of missed cases of ACS:
1. Failure to recognize atypical presentations (e.g. dyspnea)
2. Failure to recognize high-risk groups (e.g. women, diabetics)
3. Over-reliance on negative tests (e.g. negative troponin or recent stress test)
Keywords: Temporal Arteritis (PubMed Search)
Temporal Arteritis (TA) is commonly associated with the sudden onset of a unilateral headache centered around the temporal region. The most devastating consequence of TA is blindness though this is only reported in up to 50% of cases though can be bilateral in up to 33% of patients.
According to the American College of Rheumatology criteria for classification of temporal arteritis this diagnosis can be made in the ED without a biopsy. You just need at least 3 of the following 5 items to be present (sensitivity 93.5%, specificity 91.2%) to make the diagnosis :
Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. Aug 1990;33(8):1122-8
The umbilical site normally heals by 1 month of age.
Any fluid draining after this period suggests an abnormal connection between the surface of the abdomen and the underlying structures, and requires further investigation. Clear yellow fluid could represent a persistent connection of the bladder with the umbilicus called a patent urachus. The fluid that leaks is actually urine. The treatment is surgical closure of the connection.
Pus oozing from the umbilical stump would imply infection, especially if there is concomitant redness of the skin around the umbilicus. An omphalitis can be life-threatening, and requires admission for invtravenous antibiotics.
Umbilical hernias are common in infants, and are usually noted with diastasis of the rectus muscles. Most umbilical hernias resovle by school age, and do not require surgical intervention.
An umbilical granuloma is a small piece of bright red, moist flesh that remains in the umbilicus after cord separation. It is scar tissue, usually on a stalk, that did not become normally covered with skin cells. It contains no nerves and has no feeling. Most can be simply cauterised with silver nitrate.
Keywords: saline, sodium bicarbonate, acetylcystein (PubMed Search)
Keywords: RCIN, renal failure (PubMed Search)
Radiocontrast Induced Nephropathy (RCIN)
Baker CS, Wragg A, Kumar S, De Palma R, Baker LR, Knight CJ.
J Am Coll Cardiol. 2003 Jun 18;41(12):2114-8.
Keywords: stem cell, stem cell therapy, stroke (PubMed Search)
Category: Critical Care
Patients in the Critical Care setting may develop HIT as a result of chronic pre-existing risk factors (malignancy, obesity, hypertension, diabetes or medications) or acquired factors secondary to their ICU stay (post-operative state, trauma, central lines or medications such as heparin).
Diagnosis of HIT:
Treatment of HIT:
Critical Care Med 2010 Vol. 38, No. 2 (Suppl.)
Keywords: D-Dimer, Aortic Dissection (PubMed Search)
Can you use a serum d-dimer to rule out aortic dissection?
The answer to the question, in 2010, is no.
There has been a flurry of recent literature about the use of serum d-dimer to rule out aortic dissection. Some studies have shown a sensitivity of nearly 100%, but other studies have shown sensitivities of only 60-70%....pretty abysmal sensitivities. And despite some of the authorities on the subject touting how good the test is, there is not firm literature to support it. Better yet, there are some active medical malpractice cases I am aware of in which the diagnosis of aortic dissection was missed based on a "negative d-dimer."
My suggestion, and the vascular pearl for the day, is to avoid using d-dimer as a aortic dissection rule out strategy until good evidence (if it ever becomes available) exists. I know that people are using this test to rule out the disease, just realize that EVERY time I have ever given a talk on acute aortic disasters, 2-3 people from the audience always share that they had a case of a "d-dimer negative dissection."
Keywords: acute coronary syndromes, gender, misdiagnosis (PubMed Search)
Women are more likely to be misdiagnosed than men when they present with acute coronary syndromes. There are several possible reasons for this:
1. Women are more often older and more often have diabetes, both of which are factors involved in atypical presentations.
2. Women present with chest pain less often than men. On the other hand, women are more likely to present with nausea, vomiting, indigestion, malaise, loss of appetitie, or syncope than men.
3. When women do have chest pain, they are more likely to report pain that has atypical features, such as radation to the right arm or shoulder, front neck, or back; and the pain is more often described as sharp, stabbing, or tansient.
The bottom line is something that I've believed since high school: women are confusing...!
[the references for this ACS information comes from many different sources, but if anyone needs a good review on this topic, just email me: email@example.com]
Category: Airway Management
Keywords: Uveitis, Treatment (PubMed Search)
Uveitis and Iritis Treatment:
Keywords: levofloxacin (PubMed Search)
Quinolone Induced Deliurim
Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:
Keywords: alcohol, seizure, alcohol withdrawal seizure (PubMed Search)
-- While we typically associate seizures within the context of alcoholism with physiologic withdrawal, studies have shown that there is a dose-dependent relationship between the consumed amount of alcohol and the onset of seizure activity, independent of alcohol withdrawal.
-- Specifically, Ng and colleagues found a 3-fold increase in seizure occurance with 50 to 100 grams of ethanol per day, compared to an 8-fold increase with 101 to 200 grams of ethanol per day.
-- This study further found that ex-drinkers (abstention for >= 1 yr.) were not at any increased risk of seizure and that drinkers who had seizures did so well outside of the conventional window of withdrawal.
Category: Critical Care
Defining Acute Kidney Injury (AKI)
Dennen P, Douglas IS, Anderson R. Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Crit Care Med 2010; 38:261-27
Keywords: ischemia (PubMed Search)
Evaluation of the acutely ischemic limb
Some considerations when evaluating/treating patients with acute limb ischemia:
Keywords: electrocardiography, acute coronary syndromes, ECG, EKG (PubMed Search)
Most people know that the ECG is only diagnostic of ACS approximately in 50% of cases, and in fact patients presenting with ACS can have an initially completely normal ECG in up to 10% of cases. However, traditional teaching is that if the patient is actively having chest pain or other concerning symptoms, the patient with ACS will nearly always have ECG abnormalities. NOT SO, according to a recent study. Researchers from Davis medical center evaluated patients with presumed ACS and normal ECGs, comparing the prevalence of ACS in patients with active symptoms (e.g. chest pain) during the normal ECG vs. patients that were asymptomatic at the time of the ECG. Cutting to the chase, they found no difference in ther rule-in rate between the two groups. In other words, don't be reassured at all if a patients has a normal ECG during symptoms.
This study supports other studies which continually show that an abnormal ECG is excellent at ruling-in disease, but a normal ECG is poor at ruling-out disease. In the absence of a diagnostic ECG, it's all about the HPI, the HPI, and the HPI. And also...the HPI.
[Turnipsee SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009;16:495-499.]
Keywords: Uveitis, Iritis (PubMed Search)
Iritis is a common diagnosis in the ED, but did you know it was actually a subset of Uveitis.
Uveitis is an inflammation of one or all parts of the uveal tract which consists of the iris, the ciliary body, and the choroid.
The subsets of uveitis are:
Treatment of iritis and uveitis next week.
Emedicine Iritis and Uveitis http://emedicine.medscape.com/article/798323-overview
Keywords: Pediatric Constipation (PubMed Search)
Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume
Defined as less than 2 stools per week for two weeks with hard, large pellet like stools
Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida. Always inspect the spine and perform rectal
Success of treatment is based on the aggressive nature of treatment and timing of treatment. Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.