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.
Keywords: anion gap, metabolic acidosis (PubMed Search)
As we are now into the winter months, exposures to ethylene glycol (antifreeze) and methanol (windshield washer fluid) increase. Here is a good mnemonic for sorting through an anion gap metabolic acidosis:
C – cyanide, carbon monoxide
A – alcoholic ketoacidosis, acetaminophen (massive OD)
T – toluene (chronic from glue sniffing)
M – methanol, metformin
U – uremia
D – diabetic ketoacidosis
P – propofol infusion syndrome, propylene glycol, paraldehyde
I – iron, isoniazid, ibuprofen (massive OD)
L – lactic acidosis
E – ethylene glycol
S – salicylates, starvation ketoacidosis
Keywords: stroke, seizure (PubMed Search)
Arboix et al. Predictive Factors of Early Seizures after Acute Cerebovascular Disease. Stroke.
Category: Critical Care
The term Sepsis is frequently and colloquially used to describe "sick" patients; but accuracy requires understanding the specific criteria of Sepsis and its associated syndromes. Following are the defining criteria for SIRS and Sepsis:
at least 2 of the following:
Temp >38C or <36C
Heart rate >90
RR> 20 or pCO2<32mm Hg
WBC>12,000, <4,000 or >10% bands
Systemic response to infection, manifested by 2 or more SIRS criteria with a source of infection confirmed by culture or a clinical syndrome pathognomic for infection.
Sepsis associated with acute organ dysfunction, hypoperfusion or hypotension; including lactic acidosis, oliguria or altered mental status.
Sepsis-induced hypotension not responsive to fluid resuscitation.
Category: Airway Management
Keywords: Altered mental status (PubMed Search)
Altered Mental Status-Three Diagnoses That Can "Bite You On The Buttocks"
When evaluating the patient who is altered, consider the following diagnoses:
1. DTs-seems simple enough, right? Remember that some altered patients will not be able to give a history of alcoholism. And this is definitely a diagnosis that can sneak up on you. Bottom line: consider DTs in ALL patients with a delirium.
2. Wernicke's encephalopathy-can also be very difficult to detect. Consider in ALL alcoholic patients with altered mental status and give Thiamine.
3. Herpes encephalitis-speaking from personal experience, this diagnosis can be extremely tough to diagnose. Consider giving emperic Acyclovir in patients with WBCs in their CSF and a negative gram stain. And don't forget to send off a Herpes PCR. As far as clinical presentations, CNS Herpes can present with a wide spectrum of findings, from isolated headache, to new psychobehavioral changes, to severe depression of consciousness and coma. Be aware that this diagnosis isn't common but failure to initiate Acyclovir may be a fatal mistake.
Keywords: Acute myocardial infarction, acute MI, cardiac arrest, STEMI, hypothermia, therapeutic hypothermia (PubMed Search)
Though most people know that therapeutic hypothermia is indicated in resuscitated victims of cardiac arrest, is it safe if that cardiac arrest victim is also being treated for STEMI? Do you need to worry about increased bleeding complications in these patients that are receiving anticoagulants, lytics, PCI, or other standard "bleeding" medications? Are these patients at increased risk for hemodynamic instability with therapeutic hypothermia?
Recent studies have demonstrated that therapeutic hypothermia in acute MI patients receiving other standard treatments (i.e., anticoagulants, etc.) is SAFE: it is associated with no increase in bleeding complications (1), no increase in time to balloon inflation (2), and no increase in hemodynamic instability or malignant arrhythmias (3).
1. Schefold JC, et al. Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction. Int J Cardiol 2009;132:387-391.
2. Knafelj R, Radsel P, Ploj T, et al. Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction. Resuscitaiton 2007;74:227-234.
3. Wolfrum S, Pierau C, Radke PW, et al. Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 2008;36:1780-1786.
Keywords: Paronychia (PubMed Search)
Keywords: hyperleukocytosis, leukemia, blast crisis (PubMed Search)
Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K. Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.
Keywords: DMSA, succimer, lead, arsenic, mercury (PubMed Search)
Keywords: stroke (PubMed Search)
Cortical versus Subcortical Strokes
Aisha T. Liferidge, MD, FACEP
Assistant Professor, Attending Physician
University of Maryland School of Medicine
Department of Emergency Medicine
Baltimore, MD 21201
MPH Candidate, Columbia University 2011
Category: Critical Care
AKI and the Critically Ill
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: ACLS, ALS, advanced cardiac life support, cardiac arrest (PubMed Search)
Despite the traditional use of intravenous medications such as vasopressors and antiarrhythmics for victims of cardiac arrest, there is actually very little evidence to support these therapies. On the contrary, 2 recent multicenter center studies demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines are ineffective at improving survival to hospital discharge of patients with primary cardiac arrest. In contrast, these medications have been shown to increase hospital admissions, bed and resource utilization, and costs. The only interventions that have been shown to improve meaningful outcomes are rapid defibrillation for shockable rhythms, good compressions, post-resuscitation therapeutic hypothermia, and there's increasing evidence for post-resuscitation cardiac catheterization as well.
In other words, the best thing you can do early for patients with primary cardiac arrrest is to focus on the basics.
Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest. JAMA 2009;302:2222-2229.
Stiell IG, Wells GA, Field B, et al. Ontario Prehospital Advanced Life Support Study Group. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-656.
Keywords: Pityriasis rosea (PubMed Search)
Keywords: meningitis, neisseria meningitidis, streptococcus pneumoniae, haemophilus influenzae, child care, nursery (PubMed Search)
Meningitis Prophylaxis in Children
While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes. Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).
However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis. What do you do?
The causative agent will often dictate your choice of management.
Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset; casual school or work contacts do NOT require prophylaxis
Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)
Haemophilus influenzae - if only one case reported, no intervention; if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)
Pediatrics in Review, July 2009: "Infections in Child-Care Facilities and Schools"
Keywords: stroke, acute ischemic stroke, MCA Sign, middle cerebral artery (PubMed Search)
Category: Critical Care
Keywords: bleeding (PubMed Search)
How to stop dialysis fistula/graft bleeding
The number of patients being placed on hemodialysis seems to be increasing. And the ED is where they will go when there is a any complication from their fistula or graft.
Hemodialysis shunts require cannulation with large bore instruments. This combined with heparinization may lead to prolonged bleeding from puncture sites.
What to do when a patient shows up in the ED with persistent bleeding from a fistula puncture site:
Vorwerk D, et al. A simple trick to facilitate bleeding control after percutaneous hemodialysis fistula and graft interventions. Cardiovasc Intervent Radiol 1997.
Keywords: Nikolsky's sign, Dermatology (PubMed Search)
Nikolsky's sign is positive when slight rubbing of the skin results in exfoliation of the skin's outermost layer. The more technical term is acantholysis which is the loss of the normal adhesion of the epithelial skin cells which allows for this sloughing.
Often helpful to differentiate pemphigus vulgaris from bullous pemphigoid. The sign is usually absent in bullous pemphigoid. Just be careful with how much testing you are doing as this can be very painful to the patient.
After seeing all the electrical and extension cords supplying various seasonal holiday decorations, I thought this would be appropriate.