Keywords: HIV, human immunodeficiency virus, coronary heart disease (PubMed Search)
HIV positive patients are at increased risk of premature atherosclerosis for at least a few reasons:
1. HIV disease causes increased activation of platelets.
2. HIV produces arterial endothelial dysfunction [which promotes thrombosis formation].
3. Protease inhibitors produce dyslipidemias and insulin resistance.
HIV-associated CAD is also unusual in that the vessel involvement is frequently diffuse and circumferential along the whole artery.
HIV positive patients are known to have their first MI at an earlier age than non-HIV controls, and the effect is not related to CD4 count (not related to severity of disease).
The takeaway point here is to always strongly consider ACS in the differential diagnosis of patients with HIV that are presenting with cardiopulmonary complaints, even in relatively younger patients.
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular Manifestations in Human Immunodeficiency Virus-Infected Patients. Am J Cardiol 2008;102:635-642.]
Keywords: Dental Blocks (PubMed Search)
Dental Pain and Blocks:
I am sure that most of us have felt like we should have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating. For these patients the only way to truly get their paint under control is to perform a dental block. This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.
For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html
So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)
Keywords: latrodectus, black widow, spider (PubMed Search)
Latrodectus sp (Black Widow Spider)
Take a look at a picture of the black widow on the following attachment
Keywords: avm, arteriovenous malformation, intracranial bleed (PubMed Search)
- Ataxia - Paresthesia/dysesthia - Aphasia - Memory deficits - Confusion - Hallucinations - Apraxia - Papilladema
- Ataxia - Paresthesia/dysesthia
- Aphasia - Memory deficits
- Confusion - Hallucinations
- Apraxia - Papilladema
Keywords: Ischemia (PubMed Search)
Management of acute limb ischemia
Just a few pearls regarding acute limb ischemia
Vasc Surg Reviews 2007
Category: Critical Care
Keywords: intraabdominal pressure, intraabdominal hypertension, bladder pressure (PubMed Search)
Intraabdominal Hypertension and the Critically Ill
Cheatham ML. Intraabdominal pressure monitoring during fluid resuscitation. Curr Opin Crit Care 2008;14:327-33.
Keywords: troponin, sepsis (PubMed Search)
Troponin levels are often elevated in patients with sepsis. This doesn't necessarily mean that the patient has suffered an acute Mi or ACS, but rather it seems to correlate with myocardial dysfunction that is caused by sepsis. Much like with true MI, troponin elevations predict a greater risk of in-hospital mortality in these patients.
Keywords: Pediatric Anaphylaxis (PubMed Search)
When the Sting REALLY hurts!!
Remember the dose of Epinephrine is :
0.01 mg/kg or 0.01 mL/kg of 1:1,000 IM or
0.01 mg/kg IV or 0.1 mL/kg/dose 1:10,000 IV
to the adult dose or 0.3 mg
Epipen Jr = 0.15 mg (use for < 30 Kg)
Epipen = 0.3 mg (use for > 30 Kg)
To show patients an instructional video click on the referenced link.
Category: Airway Management
Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)
To echo Dr. Rogers' fantastic airway tips:
When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:
1. P osition: No intubating on the floor! Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.
2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis.
3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.
4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.
5. P aralysis: This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.
6. P ass the tube: What Dr. Rogers said.
7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.
-Our very own Dr. Ken Butler: "Be prepared!"
Keywords: Lidocaine, pediatrics, anesthesia (PubMed Search)
Topical Lidocaine for local anesthesia
Disclosure: I have no financial or invested interest in the product or the company.
1. Pharmacist's Letter 2008 24(9):240912
2. Cregin R. Improving pain management for pediatric patients undergoing nonurgent painful procedures. ASHSP April 15 2008;Vol 65(8):723-7.
3. Kaweski S. Topical Anesthetic Creams. Plastic and Reconstructive Surgery. June 2008; Vol 121(6):2161-5.
Keywords: asterixis, liver failure, elevated ammonia, flapping tremor (PubMed Search)
-- cardon dioxide toxicity
-- metabolic encephalopathies
-- Wilson's Disease
Category: Critical Care
Keywords: sodium bicarbonate, lactic acidosis, hypoperfusion, shock (PubMed Search)
Bicarbonate for severe lactic acidosis from shock?
Boyd JH, Walley KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Curr Opin Crit Care 2008;14:379-83.
Keywords: HIV, human immunodeficiency virus, pericardial effusion (PubMed Search)
Patients with HIV are at increased risk for several cardiovascular complications of the disease. The most common cardiac manifestation in HIV disease is reported to be pericardial effusion.
The presence of a pericardial effusion in HIV is a poor prognostic sign, an independent predictor of mortality (62% mortality at 6 mos is reported, compared to 7% in those without effusion).
The pericardial effusion is often associated with TB in endemic areas, but can also be associated with other organisms including Staph, Strep, Chlamydia, and some viruses. HIV itself can cause an effusion as part of a generalized serous effusive process.
Takeaway: In late-stage HIV patients with any cardiopulmonary complaints, it would be prudent to make bedside ED ECHO part of your usual initial evaluation.
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol 2008;102:635-642. Authors are from Michigan State Univ.]
Keywords: HIDA, narcotics, biliary colic (PubMed Search)
Biliary Colic and Narcotics:
It is common to give patients with biliary colic narcotics inorder to relieve their pain. It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi. It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.
So this weeks pearls are:
Many things can be fatal with only one pill or sip for a young child. One teaspoonful of Oil of wintergreen (5ml) contains about 7000 mg of salicylate (the equivalent of about 21 adult aspirin). It would take only one swallow of Oil of wintergreen to be lethal for a young child.
Other Potential single dose killers for your Pediatric patients:
Monoamine oxidase inhibitors
Oil of wintergreen
Pediatric Emergency Medicine Practice. July 2005.
Keywords: methadone, buprenorphine (PubMed Search)
Keywords: anisocoria, pupillary response, pupils (PubMed Search)
Category: Airway Management
Keywords: laryngoscopy (PubMed Search)
Quick Pearls for Intubating:
1. When intubating, make sure to use two hands!
2. Resist the urge to look for cords
3. Stylet shape is crucial
1. Our very own Ken Butler
2. Rich Levitan-Airway Course
Category: Critical Care
Keywords: norepinephrine, epinephrine, epinephrine, dopamine, phentolamine (PubMed Search)
Phentolamine for vasopressor extravasation
I was recently informed of a case from an another institution in which a patient was started on a vasopressor medication via a peripheral IV while attempts at central access where attempted. The patient unfortunately suffered permanent extremity ischemia due to significant extravasation of the vasopressor medication into the soft tissue.
Keywords: bedside ultrasound, bedside echocardiography, fluid status (PubMed Search)
The longitudinal subcostal view on bedside ultrasound can be very helpful at addressing a patient's fluid status.
Take a look at the diameter of the IVC 2 cm proximal to the hepatic vein on this view and ask the patient to quickly sniff. If the patient has normal fluid status, the diameter of the IVC will collapse approximately 50%.
If you notice that the IVC completely collapses during the sniff, the finding is highly accurate at predicting hypovolemia and a low CVP.
If, on the other hand, the IVC doesn't appear to collapse much at all, the finding is highly accurate at predicting a high CVP and elevated right atrial pressure. This may occur in the presence of fluid overload from decompensated CHF, cardiac tamponade, and conditions associated with RV failure (e.g. massive pulmonary embolism).