Keywords: Hemolytic-uremic syndrome (HUS) (PubMed Search)
Hemolytic-uremic syndrome (HUS)
Keywords: overdose, precription drugs, pediatric, substance abuse (PubMed Search)
Classical illicit recreational drugs like cocaine, ecstacy, and marajuana are sometimes difficult for teens to acquire. As a result, many are turning to their parents medicine cabinets as a source for recreational drugs.
[From the website drugabuse.gov] In 2008, 15.4 percent of 12th-graders reported using a prescription drug nonmedically within the past year. This category includes:
When adolescent patient presents to the ED, consider the possibility of a poly-pharmacy overdose. Always query parents about the presence of OTC and Rx medications in their home, and what is within reach of their kids.
While sedatives and analgesics are concerning, be alert for overdoses of more mundane medications like beta blockers and calcium-channel blockers which often pose a much more lethal threat. Consider overdose in adolescent patients with:
Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th-Graders, 10th-Graders, and 12th-Graders
2005-2008 (in percent)*
Any Illicit Drug Use
Full chart available by clicking link in references.
Keywords: nihss, level of consciousness, stroke, nih stroke scale (PubMed Search)
1. "Close your eyes and now open them."
2. "Make a fist and now open it."
0 = performs both tasks correctly.
1 = performs one task corectly.
2 = performs neither task correctly.
Category: Critical Care
Mechanical Ventilation of the Obstetric Patient
Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilator strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206.
Keywords: Nitroprusside (PubMed Search)
Nitroprusside-Friend or Foe?
Nitroprusside is a direct venous and arteriolar vasodilator and is very effective at lowering blood pressure. It has been used for the treatment of hypertensive emergencies for many years and most of are comfortable with using it.
The problems with the drug:
Marik PE, etc. Hypertensive crises: challenges and management. Chest 2007;131:1949-62
Keywords: jugular venous distension, hypotension (PubMed Search)
Patients with catastrophic cardiovascular conditions often manifest with JVD + hypotension. The DDx for this combination is therefore critical to know:
You can make a diagnosis clinically among these 7 entities by:
Of course if you have bedside U/S, it becomes even easier. ECG is almost always diagnostic with either the large LV MI or RV MI. Wet lungs found in large LV MI, acute MR, and acute AR. Murmur found in MR (systolic) and AR (diastolic).
Keywords: Hamate, Fracture, (PubMed Search)
Walsh JJ 4th. Bishop AT. Diagnosis and management of hamate hook fractures. Hand Clinics. 16(3):397-403, viii, 2000 Aug.
Keywords: serotonin (PubMed Search)
Serotonin is a neurotransmitter that has central and peripheral effects. It regulates the secretion of ADH from the hypothalamus and also controls the chemoreceptive trigger zone (CTZ) which induces emesis. Here are a list of medications categorized by the way they affect serotonin. Remember, any combination of these agonists could precipitate serotonin syndrome:
Enhance 5-HT synthesis: L-tryptophan
Direct HT agonists: Ergots, metoclopramide, sumatriptan, buspirone
Increase 5-HT release: amphetamines, cocaine, dextromethorphan, MDMA, L-dopa
Inhibit 5-HT breakdown: MAOIs, Linezolid
Inhibit 5-HT re-uptake: SSRIs (paxil), amphetamines, carbamazapine, tramadol, TCAs, citalopram, trazodone, lamotrigine, meperidine
Keywords: nihss, level of consciousness, stroke (PubMed Search)
-- Answers both questions correctly = 0
-- Answers one of the two questions correctly = 1
-- Answers neither question correctly = 2
Keywords: Acute Laryngotracheobronchitis, Croup (PubMed Search)
Parainfluenza viruses (types 1, 2, 3) account for more than 65% of all cases. The different serotypes have seasonal patterns, with type 1 and 2 occuring in the autumn and being the most common pathogens associated with croup while type 3 is more frequent in the spring and summer and is associated with pneumonia and bronchiolitis.
Infections are rarely associated with high fever and usually last 4 to 5 days. There are no distinctive laboratory abnormalities, and diagnosis is generally made clinically. Chest and neck xray may demonstrate a “steeple sign” from narrowing of the subglottic region. Viral cultures and immunofluorescent rapid antigen identification can be obtained from respiratory secretions. Specific antiviral therapy is not available. Aerosolized epinephrine can be given to severely affected, hospitalized patients to decrease airway obstruction. Parental (>0.3mg/kg) and oral ((0.15mg/kg) dexamethasone have been demonstrated to lessen the severity and duration of symptoms and hospitalization in patients with moderate to severe croup.
American Academy of Pediatrics. Parainfluenza viral infections. In: Pickering LK, ed Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Peditrics; 2006
Category: Critical Care
Critical Illness-Related Corticosteroid Insufficiency (CIRCI)
So, which critically ill patients do you treat with steroids? Current literature suggests the indications for steroid treatment include vasopressor dependent septic shock and persistent ARDS despite supportive therapy and lung protective ventilation. A patient who requires only an hour or two of a vasopressor while being fluid resuscitated is unlikely to benefit. An accepted dosing schedule is hydrocortisone 50 mg IV every 6 hours.
Marik PE. Critical illness-related corticosteroid insufficiency. Chest 2009;135:181-93.
Keywords: Documentation, Chest Pain (PubMed Search)
Documentation of the Chest Pain Patient
Chest pain is a high risk entity in emergency medicine. And since many patients we see with chest pain are eventually discharged, we should consider what our charts should look like should we discharge a patient who has a missed life-threatening diagnosis. In other words, what would an attorney look for?
Considerations for the chart:
Keywords: dopamine, dobutamine, cardiogenic shock (PubMed Search)
Traditional teaching for patients with hypotension in the setting of MI and heart failure (i.e. not just RV MI) is to give dobutamine as a first-line agent when the SBP is 80-100, and to use dopamine when the SBP is 70-80s [note that this recommendation is NOT based on good evidence, but primarily on consensus opinion]. The problem with using these medications, especially at higher doses (e.g >10-15 mcg/kg/min) is that they result in excessive alpha-1 adrenergic stimulation that can produce end-organ ischemia.
However, there is some evidence that rather than using high dosages of dobutamine or dopamine, "the deliberate combination of dopamine and dobutamine at a dose of 7.5 mcg/kg/min each was shown to improve hemodynamics and limit important side effects compared with [high dosages of] either agent [alone]."
[Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008;118:1047-1056.]
Keywords: Lunate, Dislocation, Perilunate (PubMed Search)
Lunate Dislocation and perilunate dislocation are broken down into 4 stages that relates to the progressive disruption of the carpal ligaments due to hyperextension and ulnar deviation of the wrist:
For a good indepth review of lunate and perilunate injuries please read the article by Andy Perron with this attached link.... doi:10.1053/ajem.2001.21306
If you are interested in seeing some xray examples please visit LearningRadiology.com
Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic Pitfalls in the ED: Lunate and Perilunate Injuries Am J Emerg Med 2001;19:157-162
Keywords: acetone, cyanide, odor (PubMed Search)
Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.
The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):
1) Bitter Almond
2) Rotten Eggs
5) Sweet, Fruity (acetone)
1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate
Keywords: blood pressure control, stroke, tPA, thrombolytics (PubMed Search)
Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat x 1
Nitropaste 1 to 2 inches
Nicardipine infusion at 5 mg per hour, titrate by 0.25 mg/hr at 5 to 10 minute intervals up to a maximum
dose of of 15 mg/hr. Once desired blood pressure is achieved, titrate down in increments of 3 mg/hr.
Category: Critical Care
Early Critical Care Management of Aneurysmal SAH
Diringer MN. Managment of aneurysmal subarachnoid hemorrhage. Crit Care Med 2009;37:432-40.
Category: Airway Management
Keywords: Airway (PubMed Search)
Keys to a Successful Intubation
The famous Ken Butler
Keywords: Child Abuse, Fracture (PubMed Search)
A lot of what is taught about fracture patterns in abused children has been extrapolated from post-mortem studies which is a different population then what you will see in the Emergency Department. The study referenced did a metanalysis of all the literature in an attempt to determine what fractures suggest abuse and looked at all comers that had fractures. Some of the patterns they were able to extrapolate are:
Patterns of Skeletal Fractures in Child Abuse: Systemic Review. BMJ, Alison M Kemp et al. 2008;337:a1518
Keywords: Appendicitis, Pediatrics (PubMed Search)
Acute Appendicitis in Childhood: Diagnosis and Treatment in the new Millennium. PEM Practice. December 2008