The incidence and prevalence of thrombocytopenia in the ICU is poorly defined however, it has been found to be an independent predictor of death in the critically-ill. Increased mortality does not appear to be related to bleeding complications. On the other hand, survivors of critical illness tend to recover platelet faster as compared to non-survivors.
Thrombocytopenia in the critically-ill is a marker for systemic inflammation/infection although the exact mechanisms are unknown. Common risk factors associated with thrombocytopenia in the ICU population are:
Sepsis
Renal failure
High-illness severity
Organ dysfunction
Bottom line: Thrombocytopenia in the critically-ill is associated with increased mortality.
The September 5 2006 issue of Circulation contained a guideline, based on collaboration between the American Heart Assn, the American College of Cardiology, and the European Society of Cardiology, indicating that procainamide was preferable to amiodarone for the treatment of stable monomorphic ventricular tachycardia.
The 2010 AHA Guidelines have now also listed procainamide as the preferred drug for stable monomorphic ventricular tachycardia, giving it a Class IIa ("probably helpful") rating vs. amiodarone which has a Class IIb ("possibly helpful") rating. [thanks to Dr. Mike Abraham for pointing this out]
Procainamide is also the safest drug for use in tachydysrhythmias when an accessory pathway (e.g. Wolff-Parkinson-White syndrome) is present.
The caveat is that neither procainamide nor amiodarone should be used in the presence of a prolonged QTc.
Acute care physicians should (re-)familiarize themselves with the use of procainamide, and emergency departments should maintain quick access to this drug to stay up-to-date with current national and international guidelines.
Septic Arthritis
It is generally taught that if the synovial fluid white blood count (WBC) is less than 50,000 it is not septic, however, there is growing evidence that a clear delineation in the WBC between septic arthritis and inflammatory arthritis is not possible. In fact, inflammatory arthritis (rheumatoid and gout) actually increases your risk for septic arthritis and the two can coexist. Gram stains of the fluid only show organisms in 50% of those with septic arthritis so you also can not rely on them either. Inflammatory markers (CRP, ESR) can be elevated with inflammatory or septic arthritis so they too can not differentiate between the two.
In the end, because of the risk of permanent joint dysfunction, it is important to make the diagnosis on clinical grounds and treat empirically if you are unsure. Err on the sound of treatment. Serial joint aspirations to drain synovial fluid have the same outcomes as operative washout.
A recent article that discusses the concerns with making the diagnosis of septic arthritis is:
Mathews et al. Bacterial septic arthritis in adults. Lancet (2010) vol. 375 (9717) pp. 846-55
The answer was fomepizole would be the treatment for life-threatening disulfiram reaction. Blocks Alcohol Dehydrogenase and ironically prevent metabolism of ethanol and prolong intoxication.
I forgot how many see the pearls and the response was overwhelming. That was great and cost a me a little more. There were two winners:
Katie Baugher, PGY-1
Ari Keslter
Please email me how to best send you the gift certificate.
There are medications, if taken with ethanol, will cause a disulfiram reaction. This reaction results from inhibition of aldehyde dehydrogenase, the enzyme in ethanol metabolism that breaks acetaldehyde to acetic acid. The increase in acetaldehyde results in nausea, vomiting, diarrhea, flushing, palpitations and orthostatic hypotension. So if you prescribe a patient with any of these medications you must make certain to tell them NOT to drink any ethanol - that includes cough/cold preparations that have ethanol:
Antibiotics: Metronidazole(Flagyl), Trimethoprim-sulfamethoxazole (Bactrim)
Sulfonylureas: Chlorpropamide and tolbutamide
These have possible reactions: griseofulvin, quinacrine, procarbazine, phentolamine, nitrofurantoin
Bonus Question: $10 Starbuck's Gift Card for first person that emails me with the answer to this question
What treatment could you give to someone suffering from a life threatening disulfiram reaction that biochemically should cure him?
The Importance of Antibiotic Timing for Sepsis and Septic Shock
Diagnosing Subarachnoid Hemorrhage-6 Pitfalls
1. Subarachnoid hemorrhage (SAH) doesn't always present as the "worst ever" headache. Don't most of our patients say their headache is the worst headache anyway? Be suspicious of the diagnosis if your patient has acute onset of an unusual or atypical headache. Diagnoses starts with the history.
2. The neuro exam may be completely normal in some cases, especially early on.
3. The headache due to SAH may get better with analgesics. This is a huge pitfall. Don't rule this diagnosis out if analgesics help.
4. The CT scan may be negative. Enough said.
5. Be careful with interpretation of the CSF. We all want the number of red cells in tube 4 to be zero. Be careful with this. Although the rbcs may have dropped by 50% from tubes 1 to 4, the diagnosis hasn't been excluded unless the cells clear completely. Although there have been some case reports of SAH with rbcs < 100, this is pretty uncommon.
6. CT Angiography and/or MRI with FLAIR is not a substitute for the lumbar puncture.
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Cervical Radiculopathy
The most commonly affected level is C7 (31-81%), followed by C6 (19-25%), C8 (4-12%) and C5 (2-14%)
Anterior compression can selectively affect motor fibers
Posterior compression can selectively affect sensory fibers
-More common due to posterior lateral disc herniation or facet degeneration
Signs and symptoms: Sensory complaints (findings are in a root distribution) and possible weakness and reflex changes.
In the past several years it has become common practice to use cuffed tubes for pediatric intubations. However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!
So:
Check your cuff pressures in all patients, particularly prior to transport
Cuff pressures must be <30cm H2O
Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...
If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.
Most cases of normal anion gap metabolic acidosis result from either urinary (RTA) or gastrointestinal HCO3- losses (diarrhea). A number of xenobiotics can also cause this disorder:
Linezolid is used for gram-positive infections resistant to conventional therapy (e.g., Vancomycin-resistant enterococcus and Methicillin Resistant Staph Aureus). Linezolid is an oxazolidinone, but more importantly it is a weak monoamine oxidase inhibitor (MAOI) and serotonin syndrome (e.g., altered mental status, neuromuscular abnormalities, autonomic instability) may occur when combined with selective serotonin re-uptake inhibitors (SSRIs) or with recent discontinuation of SSRI.
Be aware that the following drugs can precipitate serotonin syndrome when combined with Linezolid:
Mirtazpine Buproprion Fentanyl
Trazodone Buspirone Bromocryptine
Levodopa Lithium Amphetamines
Cocaine Codeine Reserpine
Ergots MAOI's
Got Symptomatic Hypertension? Why not try Fenoldopam?
Fenoldopam is a rapid-acting vasodilator.
Dosing (Adult): After a starting dose of 0.1 to 0.3 mcg/kg/minute, the dose is titrated at 15 minute intervals, depending on the BP response. May be increased in increments of 0.05 to 0.1 mcg/kg/minute every 15 minutes until target blood pressure is reached. Maximal infusion rate reported in clinical studies: 1.6 mcg/kg/minute.
Onset/duration: 5-10 minutes/~ 1 hour.
In order to minimize interruptions in compressions due to pulse checks, continuous end tidal CO2 (ETCO2) monitoring during compressions is recommended. Before spontaneous circulation returns, the ETCO2 is likely to be on the order of < 10 mmg Hg. At the moment spontaneous circulation returns, the ETCO2 is expected to abruptly increase to at least 35-40 mm Hg. Be wary, though, that the administration of sodium bicarbonate may transiently increase the ETCO2 even in the absence of return of spontaneous circulation (ROSC).
Use of ETCO2 in this manner allows one to assess the patient for ROSC without ever having to stop compressions for pulse checks.
Dr. Corwell covered Spondyloysis in July 2010 https://umem.org/res_pearls_referenced.php?p=1134 but if you are like me you might have trouble remembering the differences between the following terms:
We've all been there. It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door. You grab the LP kit and your "best holder." This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.
Toxic Holiday Plants
Of the three plants listed, which is NOT poisonous?
1. Holly plant
2. Poinsettia
3. Mistletoe
Poinsettia plants were once thought to be very poisonous. Contrary to popular belief, poinsettias are safe to have in the home during the holidays.
Although there are reported cases of death with ingestion of Holly plants in older literature, recent experience shows gastrointestinal effects in small doses, and serious toxicity such as CNS depression in large ingestions.
Mistletoe ingestion of few of the berries would, at most, produce mild gastroenteritis; however, ingesting concentrated extracts of the plant, including the berries, may produce serious effects such as seizures, mental confusion, drowsiness, and hallucinations.
Happy holidays!
