Keywords: serevent, foradil (PubMed Search)
Keywords: migraine, demerol, meperidine, headache (PubMed Search)
Category: Critical Care
Keywords: central venous catheter (PubMed Search)
Keywords: Chest Pain (PubMed Search)
There is clearly no way you can document everything on a chest pain chart. However, there are some pretty important things that should be on the chart.
Some key things to consider documenting:
1. Daniel Sullivan, M.D.
2. The great Amal Mattu, M.D.
3. Larry Weiss, M.D.
Keywords: hyperkalemia, treatment, management, kayexalate (PubMed Search)
Category: Obstetrics & Gynecology
Keywords: metronidazole, pregnancy, safety (PubMed Search)
It seems to come up about once or twice a month about the safety of metronidazole in pregnancy. This has been very controversial over the years, but the current stance is that it is safe in pregnancy. In fact, untreated vaginal infections, bacterial vaginosis and trichomonas, have been associated with miscarriages and preterm labor, so the benefits outweigh the risks.
Below are two good references to add to your file in case you get into a debate with somebody quoting old data.
Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. J Antimicrob Chemother 1999; 44: 854-855 http://jac.oxfordjournals.org/cgi/content/full/44/6/854
Category: Critical Care
Keywords: central venous catheter, tissue plasminogen activator (PubMed Search)
Central Venous Catheter Occlusion
Keywords: naloxone, clonidine, valproic acid, captopril (PubMed Search)
A search of the toxicology literature will reveal that naloxone has been tried in many different overdose situations. It is thought that the endogenous opioid system mediates several physiologic and pharmacologic pathways.
Bottom line: In none of these instances was improvement as dramatic or consistent as in the reversal of the toxic effects of an opioid. Naloxone can certainly be tried in non-opioid overdoses but should not be considered a first-line antidote. The most benefit appears to be with clonidine.
Keywords: stroke, tpa, ischemic stroke, acute stroke (PubMed Search)
Important things to document in acute ischemic stroke cases from a medicolegal aspect:
-- time of onset
-- time of diagnosis
-- why tPA given or not given (the longer note for NOT giving it; 90% of related litigation cases based on NOT giving tPA.)
-- date and time on each side of note of every page
-- make it legible
Keywords: Hypertension, Epistaxis (PubMed Search)
Hypertension and Epistaxis
We commonly encounter patients with epistaxis who are found to be hypertensive. Some have taught over the years that hypertension causes nosebleeds and that some nose bleeds won't stop until the BP is lowered...
Some pearls about HTN/Epistaxis:
Keywords: hyperkalemia, treatment, management, beta agonists (PubMed Search)
Keywords: Thrombotic thrombocytopenia Purpura, TTP (PubMed Search)
Just a quick remainder that Thrombotic thrombocytopenia Purpura, TTP, is typically described as a pentad of symptoms:
Not all symptoms need to be present and it would be rare for you to see the full pentad. Consider the diagnosis and request that the lab due a manual differentiation or blood smear. It is there that they will notice schistocytes, fragmented RBCs, that will help clinch the diagnosis.
Most cases of TTP are idiopathic (~60%) but secondary TTP is known to occur with cancer, pregnancy, HIV, bone marrow transplantation, immunospressive drugs like cyclosporin and tacrolimus, and platelet aggregation inhibitors such as cloperidol.
Treatment consists of plasmapheresis, plasma exchange, immunospression with steroids, Rituximab, and other chemotherapies.
Keywords: carbon monoxide, CO, hyperbarics, HBO (PubMed Search)
CO is formed from the incomplete combustion of carbon materials, eg. fires, stoves, portable heaters CO reversibly binds hemoglobin, producing carboxyhemoglobin (HbCO). This causes oxygen to bind more tightly to hemoglobin, releasing less in the tissues. Because of this, it affects the organs with the highest oxygen requirements most profoundly (eg. brain and heart).
Symptoms are mainly neurological and cardiovascular, but may include a wide variety of non-specific symptoms. The initial symptoms of CO poisoning may include headache and flu-like illness progressing to confusion, agitation, lethargy, seizures and coma.
Place patients on 100% oxygen to decrease the half-life of HbCO. Though controversial, HBO therapy is thought to decrease the incidence of neurologic sequelae. HBO therapy should be considered for patients with a HbCO level above 20%, severely symptomatic patients with lower levels, and pregnant patients. Remember that pulse oximetry will not be accurate.
Keywords: fosphenytoin, phenytoin, dilantin, seizure (PubMed Search)
** Fosphenytoin (Cerebyx) is a pro-drug of Phenytoin (Dilantin).
** Differences between fosphenytoin and phenytoin are primarily due to fosphenytoin being more water soluble.
Fosphenytoin versus Phenytoin:
• Fosphenytoin > less risk for cardiac-related adverse effects (propylene glycol not required for solubilization)
• Fosphenytoin > lower risk of local skin and subcutaneous irritation during infusion
• Fosphenytoin > can be given intramuscularly
• Fosphenytoin > can be infused at a faster rate (20 mg/kg phenytoin equivalents (PE’s) load at a rate of 100 to 150 mg of PE’s/minute) due to its safer side/adverse effects profile.
Category: Critical Care
Keywords: hemodialysis catheters (PubMed Search)
Two weeks ago, we had a PEA arrest of a patient receiving HD. A significant delay occurred in administering fluids and medications as a result of "no iv access". Don't forget that in these situations you can use the hemodialysis catheter.
Keywords: Warfarin, Skin Necrosis (PubMed Search)
Warfarin-Induced Skin Necrosis (WISN)
Some pearls about a rare, but serious side effect of Warfarin...
55 yo female presented to the ED on the day of hospital discharge for evaluation of this rash.
The rash began 4 days after starting Warfarin. Was being treated for a DVT.
Keywords: hyperkalemia, treatment, management (PubMed Search)
Keywords: SIDS (PubMed Search)
Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the scene of death, and review of the clinical history.
SIDS is the single most common cause of death in infants aged 1 mo to 1 yr
Education is key for prevention of these tragic events:
Following the "Back to Sleep" campaign, federal SIDS researchers have conducted annual surveys to examine how infant sleep practices and SIDS rates have changed. The rate of prone sleeping for infants decreased from approximately 75% in 1992 to a low of 11.3% in 2002
Since 1992, SIDS rates have fallen approximately 58%. In 2002, the National Center for Health Statistics reported a total of 2295 SIDS deaths nationwide for a SIDS rate in the United States of 0.51 per 1000 live births.
Bed-sharing may lead to compromise of the infants' airway because the infant may be suffocated by soft, loose bedding or a sleeping adult.
Cosleeping on a couch or sofa is associated with an unusually high risk for SIDS and should be avoided.
Keywords: tryptophan (PubMed Search)
Tryptophan - a precursor to melatonin, it is often blamed for the post prandial coma that many go into after a big turkey dinner. Never mind the 5000 kcals that was consumed during the meal. The supplement really doesn't help with sleeping. Interestingly, turkey isn't even in the top 10 or 20 of foods that contain tryptophan. The top five are:
1) Game meat (Elk): 746 mg of tryptophan
2) Seaweed (Spirulina): 736 mg of tryptophan
3) Spinach: 690 mg of tryptophan
4) Egg White: 673 mg of tryptophan
5) Soy protein: 630 mg of tryptophan
Supplements of L-tryptophan have been contaminated with a compound that has been associated with eosinophilia myalgia syndrome.
Category: Critical Care
Keywords: stress related mucosal injury, histamine antagonists, proton pump inhibitors, sucralfate (PubMed Search)
Stress Related Mucosal Injury (SRMI)