Keywords: geriatric, elderly, laboratory (PubMed Search)
A handful of lab abnormalities occur as a normal part of aging. Elderly patients will often demonstrate the following lab abnormalities without these indicating pathology:
1. ESR increases...use the following correction factor: top normal ESR < (age + 10)/2
2. creatinine falls
3. alkaline phosphatase may be elevated 2-3 fold
4. urinalysis may show asymptomatic pyuria or bacteriuria
5. ABGs demonstrate lower PaO2s and elevated A-a gradients
6. the top normal D-dimer level elevates slightly
7. the top normal BNP level elevates slightly
8. the ECG may show a first degree AV block, poor R-wave progression, leftward axis, and PVCs
Keywords: winged scapula, trapezius, serratus anterior, long thoracic nerve (PubMed Search)
Winged scapula is caused by muscular injury or damage to corresponding muscular innervation. Mechanism can be due to blunt or penetating thoracic trauma.
Clinical findings include
Forbes D, Withers G. Prophylactic therapy in cyclic vomiting. J Pediatr Gastroenterol Nutr. 1995;21:S57-S59
Symon DN, Russell G. The relationship between cyclic vomiting syndrome and abdominal migraine. J pediatr Gastroenterol Nutr. 1995:21:S42-S43
Keywords: Relenza, zanamivir, influenza, H1N1 (PubMed Search)
Zanamivir (Relenza) is another neuraminidase inhibitor effective against influenza strains A and B. We are currently reserving its use for patients with H1N1 that may develop resistance to oseltamivir (Tamiflu) since it has been effective in these situations with past influenza strains.
Keywords: guillain-barre' syndrome, guillain-barre, gbs, polyneuropathy, peripheral neuropathy (PubMed Search)
Category: Critical Care
Extracorporeal Membrane Oxygenation
Schuerer DJE, Kolovos NS, Boyd KV, Coopersmith CM. Extracorporeal membrane oxygenation: Current clinical practice, coding, and reimbursement. Chest 2008;134:`79-84.
Got some interesting info today on the costs of some commonly used antihypertensive medications. Keep in mind that in patients with severe hypertension, your options of IV drips are limited.
Here is some info from our hospital:
Fenoldopam - $113.28
Nicardipine - $94.67
Esmolol - $82.15
Nitroprusside - $20.86
Labetalol - $14.40
Nitroglycerin - $2.90
Although Fenoldopam (Corlopam), which has been around for years, is more expensive than Nitroprusside, it is just as effective and without the side effects.
A new drug on the market that we don't have yet, Clevidipine, is just as effective as the big guns Nipride and Fenoldopam. Costs at this point are unknown.
More on antihypertensive medications next week....
Keywords: adverse drug effects (PubMed Search)
It's no secret that the elderly are at high risk for adverse drug effects. The average elderly patient takes 5 prescribed medications plus two over-the-counter medications. As many as 5% of admissions in the elderly are attributable to adverse drug effects.
Anytime you prescribe a new medication to an elderly patient, ALWAYS check for the possibility of drug interactions.
Keywords: Scaphoid Fracture, CT (PubMed Search)
Snuff Box Tenderness:
It has become the standard of care that individuals with snuff box tenderness, or pain with axial loading of the thumb, be placed in a thumb spica splint for 1-2 weeks until follow up x-rays can be done. This is done to rule out an occult scaphoid fracture. However, this practice can be hugely inconvenient to the patient and result in some atrophy of their forearm.
An alternative approach is to obtain a CT scan through the wrist to look specifically at the scaphoid bone. If the CT scan is negative you can send them home with some pain control, RICE (Rest, Ice, Compression, Elevation) treatment and let them use thier thumb. No splint is needed. If it is positive then you can splint them and have them follow up with orthopedics or hand surgery.
Keywords: partial agonist, buprenorphine (PubMed Search)
This is a semi-synthetic opiate with partial agonist activity at the mu receptor. For an example of what a partial agonist is - see attached illustration. It is used in opioid addiction but is not as regulated as methadone clinics. Take a small course and you are licensed to prescribed it. Primary caregivers are now able to administer buprenorphine to assist addicts though it is not recommended if the patient is requiring more than 40mg of methadone (rules out everyone in Baltimore).
The tablets (Suboxone) also contain naloxone to prevent intravenous injection which would induce withdrawal. Naloxone is not orally bioavailable and thus can be mixed into the pill.
Overdose is treated like any other opioid and naloxone should work.
Buprenorphine can illicit an opioid withdrawal response if the patient is currently on an opioid and then takes buprenorphine.
Suppose to be safer than methadone - no QT prolongation and less respiratory depression
Keywords: pregnancy, seizure, epilepsy, first time seizure (PubMed Search)
Category: Critical Care
Critically Ill Patients with H1N1
Dominguez-Cherit G, Lapinsky SE, Macias AE, et al. Critically ill patients with 2009 influenza A (H1N1) in Mexico. JAMA (published online October 12, 2009) doi:10.1001/jama.2009. 1536.
Kumar A, Zarychanski R, Pinto R, et al. Canadian Critical Care Trials Group H1N1 Collaborative. Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA (published online October 12, 2009) doi:10.1001/jama.2009. 1496.
The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) influenza Investigators. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA (published online October 12, 2009) doi.10.1001/jama.2009. 1535.
Keywords: Thrombocytopenia (PubMed Search)
Management of Heparin-Induced Thrombocytopenia (HIT)
HIT occurs when antibodies form to a Heparin-Platelet Factor 4 (PF4) complex in patients who have been exposed to Heparin.
The main clinical manifestation is thrombosis (arterial/venous). Treatment is unique in that only certain medications can be used.
Medical Management options in HIT:
So, when a patient with a history of HIT shows up in the ED with a DVT/PE or other thrombotic problem, these are your mainstay drugs.
Keywords: troponin, non-cardiac (PubMed Search)
The recent Baltimore City Marathon served as a nice reminder in a few cases that long-distance running and other ultra-endurance events can produce elevations in troponin levels. To review the non-cardiac-disease causes of troponin elevations:
sepsis, PE, COPD, carbon monoxide, intracranial abnormalities (including SAH, stroke, IC hemorrhage, seizures), ESRD, rhabdomyolysis, eclampsia and preeclampsia, extreme endurance exercises, UGI bleeding, LVH, catecholamine toxicity
Keywords: Reimburshment, Coding (PubMed Search)
Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.
For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex. In order to prevent this document:
I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.
More to come...
Adapted from Michael A. Granovsky's ACEP lecture entitled :"RVU Killers: The Most Common Reimburshment Documentation Errors"
Keywords: nasal foreign bodies, button battery, batteries, ENT (PubMed Search)
While it is often ok to defer removal of pesky nasal foreign bodies until ENT follow up, if the foreign body may be a button battery, emergent identification and removal is indicated.
Damage can occur in 3 hours, and by 24 hours, near complete necrosis of turbinates and ala has been described.
Dane S, Smally AJ, Peredy TR. A Truly Emergent Problem: Button Battery in the Nose. Academic Emergency Medicine. 2000; 7:204-206
Glynn F, Amin M, Kinsella J. Nasal Foreign Bodies in Children: Should They Have a Plain Radiograph in the Accident and Emergency? Pediatric Emergency Care. 2004;24:217-218.
Keywords: haloperidol, cocaine, amphetamine, sympathomimetic (PubMed Search)
A 34 y/o m presents to the ED agitated and combative with the following vitals signs: T 104.6, P 136, BP 198/124. His urine toxicology screen is positive for amphetamines.
Keywords: stroke, mca stroke (PubMed Search)
Category: Critical Care
Damage Control Resuscitation
Beekley, AC. Damage control resuscitation: A sensible approach to the exsanguinating surgical patient. Crit Care Med 2008;36:S267-74.
Keywords: erythrocyte sedimentation rate, sed rate, ESR (PubMed Search)