Amiodarone-induced hypothyroidism is well-reported and should be considered anytime a patient that chronically takes amiodarone presents with hypothyroid symptoms, including decompensated CHF, decreased mental status, or myxedema coma (e.g. bradycardia, hypotension, hypothermia).
Other drugs that have been implicated in producing hypothyroidism include lithium, iodine, iodinated contrast, and sulfonamides.
Keywords: bisphenol A, diabetes (PubMed Search)
Bisphenol A (BPA) is found in epoxy resins that line common food and beverage materials. There has been concern that this compound, like phthalates, may be causing harm through chronic low exposure. An epidemiologic study was performed and published in JAMA that has raised this question. Amazingly, the study did find that:
Lange et al. JAMA 2008; 300(11): 1303-1310.
Keywords: Tourette Syndrome, vocal tics, motor tics (PubMed Search)
-- Tourette Syndrome (TS) is an inherited neurological disorder characterized by repetitive involuntary movements and uncontrollable vocal sounds called tics.
-- Underlying defect is unknown; however, research suggests that it could be caused by abnormalities in serotonin and dopamine activity within the basal ganglia.
-- Associated behavioral problems include OCD, ADHD, anxiety, and depression.
Category: Infectious Disease
Keywords: spontaneous bacterial peritonitis, ascites, paracentesis (PubMed Search)
Can You Rely on Your Clinical Impression to Exclude SBP?
Chinnock B, Afarian H, Minnigan H, Butler J, Hendey GW. Ann Emerg Med 2008;52:268-73.
Keywords: Thrombosis, Cerebral (PubMed Search)
Cerebral Venous Sinus Thrombosis (CVST)
An uncommon but very serious entity that leads to three distinct types of presentations:
Caused by thrombosis of one of the intracerebral venous sinuses (most commonly the transverse sinus) The major risk factor is hypercoagulable disease. May be the underlying cause of a majority of cases of idiopathic intracranial hypertension.
When to suspect:
Keywords: coronary spasm,acute coronary syndrome (PubMed Search)
An estimated 20-30% of patients with ACS end up having no identifiable culprit lesion on angiography. Almost half of these patients have inducible coronary spasm. Although these patients have a good outcome, they also have a tendency to return to the hospital for frequent re-evaluations. Evaluation for and treatment of spasm can improve the quality of life for these patients and also to decrease re-visits.
When patients with reports of "clean" coronaries return to the ED with a concerning presentation for ACS, one of the considerations should be coronary spasm. Consider prompting the primary care physician or admitting team to look into this possibility, as it may result in a reduction in recurrent ED visits.
Keywords: Hypothyroidism, Myxedema, Treatment (PubMed Search)
Severe Hypothyroidism or Myxedema Coma
Keywords: Pediatric Discitis, epidural absces (PubMed Search)
Pediatric Discitis is an intervertebral disc infection due to hematogenous spread to vascular channels in cartilage that disappear later in life. In 1/3 of patients it is caused by S. aureus.
Management is to exclude more severe disease (osteomylelitis,abscess, tumor) and antibiotic use is debatable. Remember children this age rarely complain of back pain.
Pediatrics 2000; 105: 1299
Keywords: lead (PubMed Search)
Clinical Manifestations in relation to lead level in children:
Category: Critical Care
Keywords: gastrothorax, pneumothorax (PubMed Search)
Patton J, Gonzales J, Dillard TA, Szerlip HM. Chest 2008;134:872-5.
Keywords: Hypertension, Headache (PubMed Search)
Does Hypertension (elevated BP) Cause Headache?
This is an age old question that many of us have struggled with in the ED for many years...
Other questions include: Does elevated BP cause headaches? Do we need to scan hypertensive patients with headache just because they have a headache? At what level of BP does the BP actually cause headache?
A few quick pearls:
Keywords: cardiomyopathy, stress (PubMed Search)
Severe emotional stress is well-reported to produce an unusual transient cardiomyopathy that mimics cardiac ischemia or infarction on ECG as well as biomarker testing. On angiography, the coronaries are often clean. The ventriculogram takes on an apical or mid-ventricular ballooning appearance due to akinesis. In the ED, these patients will look just like a real thrombosis-related case of ACS and they often develop cardiogenic shock. Unlike true AMI-related cardiogenic shock, these patients have an excellent prognosis...if treated aggressively early-on with supportive therapy (e.g. pressors).
Intracranial catastrophes, such as hemorrhage, ischemic stroke, and head trauma; and severe medical illnesses, such as sepsis, pheochromocytoma, and catecholamine-excess states, are also reported to produce a similar syndrome of LV dysfunction.
The takeaway points: (1) severe emotional stress can be deadly...be wary of diagnosing "anxiety" or "panic attack" without checking an ECG; (2) check an ECG early in the course of any patients with the above conditions that look sick; (3) if the ECG shows signs of severe ischemia, aggressive treatment can be life-saving.
[ref: Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118;397-409.]
Keywords: Mallet Finger, Extensor Tendon Injury (PubMed Search)
A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into the base of the distal phalanx. Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports. Most can be treated non-surgically.
The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.
Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0. These patients should not be doing ROM exercises and must wear the splint full time.
Keywords: popsicle panniculitis, cold panniculitis, child abuse (PubMed Search)
Popsicle or cold panniculitis is an inflammation of the subcutaneous fat after prolonged exposure to cold. It is thought to occur more often in infants and young children because they have a higher percentage of saturated fatty acids than older children and adults. Pediatric patients may present to you to be evaluated/ruled out for abuse by social workers, schools, or police and if you have the correct history it is easy to dispo quickly.
Clinical Features of Popsicle Panniculitis
Shah B. Lucchesi M. Atlas of Pediatric Emergency Medicine. McGraw-Hill Companies. 2006.
Keywords: ICP, intracranial pressure, antihypertensive, nitroprusside, nitroglycerin, hydralazine (PubMed Search)
Several antihypertensive agents raise intracranial pressure. Normal cerebral blood flow (CBF) is constant within normal cerebral perfusion pressure (CPP) ranges, recalling that CPP=MAP-ICP.
If CPP is outside the range in which autoregulation occurs, e.g. due to a structural lesion, ischemic stroke, or head trauma, CBF decreases and can adversely affect the patient.
In patients with ischemic stroke or intracerebral pathology, labetalol or esmolol may be used to lower blood pressure without raising ICP. Nicardipine is recommended for use in patients with ischemic stroke or SAH but not in patients with brain injury
If the patient has NO structural abnormalities, but has hypertensive encephalopathy, nitroglycerin, nitroprusside, labetalol, esmolol, or nicardipine may be used.
Keywords: encephalomalacia, brain CT, stroke, brain injury, cerebral edema (PubMed Search)
--- well defined, circular vacuoles
--- presence of good gray-white matter differentiation in surrounding areas
--- a lack of significant effacement or lost of sulcus definition
--- a history of prior stroke or head injury
Category: Critical Care
Keywords: insulin, hyperglycemia, critically ill (PubMed Search)
Subcutaneous Insulin in the Critically Ill
Shipman K, Frankel HL. Do not use subcutaneous insulin in the intensive care unit population. In: Marcucci L, et al. Avoiding Common ICU Errors. Lippincott Williams & Wilkins; Phildelphia, PA, 2007
Keywords: Hypertension (PubMed Search)
Avoidable Pitfalls in Managing the Hypertensive Patient
We all see very hypertensive patients on almost every shift. Dr. Winters has an earlier pearl related to pitfalls in treating patients with hypertensive encephalopathy, but I thought it was time to reiterate just a few points.
Keywords: EKG, ECG, electrocardiography, acute myocardial infarction, prognosis (PubMed Search)
A normal ECG should not be a huge source of relief when evaluating patients with possible or confirmed myocardial infarction. 8% of acute myocardial infarctions have a completely normal ECG at the time of presentation, and these patients have a 5.7% in-hospital mortality. Serial electrocardiography can certainly improve the yield of electrocardiography but does not rule out AMI with 100% accuracy.
Like most tests in medicine, the ECG is very useful at ruling in disease, but it is limited at ruling out disease.
[The Prognostic Value of a Normal or Non-specific Initial ECG in AMI. JAMA 2001.]
Keywords: paracentesis, ascites, analysis (PubMed Search)
Paracentesis Part II- Ascites Fluid Analysis:
See last weeks procedure pearl for some hints on doing a paracentesis..
Now that you have the fluid what should you send it for:
Now for the analysis:
** Corrected definition of SAAG as it was initially reversed. Thanks to Dr. McCurdy on his proof reading.