Keywords: myasthenia graves, muscle weakness, weakness, edrophonium (PubMed Search)
Category: Critical Care
Keywords: dialysis disequilibrium syndrome, mannitol, cerebral edema (PubMed Search)
Dialysis Disequilibrium Syndrome (DDS)
Keywords: Fever (PubMed Search)
A few pearls about neutropenic fever:
IDSA Guidelines on Neutropenic Fever, 2002. New Guidelines coming Summer 2008!
Keywords: cardiac tamponade, pulsus paradoxus (PubMed Search)
Pulsus paradoxus (exaggerated decrease in BP during inspiration) > 10 mm Hg is a physical exam finding that is often considered diagnostic of cardiac tamponade. The sensitivity of the finding, based on pooled studies, is actually only 82% and specificities are reported as low as 70%. In other words, the presence of the PP does not guarantee the presence of tamponade, and (more importantly) the absence of PP does not rule it out.
Conditions that can mask the presence of PP include hypotension, pericardial adhesions, aortic regurgitation, atrial septal defects, and RVH.
Conditions that can produce a PP in the absence of tamponade include severe COPD, CHF, mitral stenosis, massive PE, severe hypovolemic shock, obesity, and tense ascites.
The bottom line...when you are considering the diagnosis of tamponade, get the bedside ECHO. Don't hang your hat (and the patient's life!) on a pulsus paradoxus.
Keywords: DeQuervain, Intersection, Tenosynovitis (PubMed Search)
DeQuervain and Intersection Syndromes:
Keywords: Hypertension, HUS, Coarctation, renal disease (PubMed Search)
Belsha, CW. Pediatric hypertension in the emergency department. Ann Emerg Med. 2008 Mar;51(3 Suppl):S21-3. Epub 2008 Jan 11.
There is actually very little data that actually supports the administration of activated charcoal (AC) to the poisoned patient. AC works by binding the toxin and preventing its absorption from the GI tract. Here are some of the practical points:
Once you have assessed your risk:benefit ratio, then administer AC. Of note, it definitely works in the right situation as noted in a landmark article that showed a decrease in mortality following poisoning by oleander - a plant that contains a digoxin like substance.(1)
1 - de Silva HA, et al. Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial. Lancet 2003: 361(9373):1935-8.
Keywords: neuroprotective agents, NXY-059, stroke, ischemic stroke, SAINT trial (PubMed Search)
Keywords: Pulmonary Embolism (PubMed Search)
Treatment of Pulmonary Embolism
Treatment of acute PE:
If administering thrombolytic therapy (currently tPA is the only FDA approved drug) for massive PE, most authorities recommend UFH (Unfractionated Heparin) because the infusion needs to be turned off while the tPA hangs for 2 hours.
Although other agents are being promoted for the treatment of acute PE, like direct thrombin inhibitors, many institutions do not have these drugs available yet. Plus, they are expensive and have not been shown to be superior to standard therapy (at least yet)
References: Kline, Journal of Thrombosis and Hemostasis, 2005, 2006, 2007
Category: Critical Care
Keywords: central venous catheter, guidewire (PubMed Search)
Guidewire length for central venous catheterization
Keywords: Sternoclavicular, Dislocation, Posterior (PubMed Search)
Sorry this is being delivered to you late.
Keywords: electrocardiography, EKG, cardiogenic shock, acute myocardial infarction (PubMed Search)
Here's a nice, simple pearl for cardiogenic shock:
"A normal ECG virtually rules out shock due to myocardial infarction."
Essentially, even though MI may be associated with a normal ECG in approximately 5-8% of cases, if a patient has cardiogenic shock due to MI, the ECG will ALWAYS be abnormal.
Gowda RM, Fox JT, Khan IA. Cardiogenic shock: basics and clinical considerations. Int J Cardiol 2008;123:221-228.
Diarrhea and the Petting Zoo
Now that it is Spring Time, trips to the Zoo and to Pools will become more frequent… consider them as potential environmental exposure sites.
Petting Zoos, Farmers Markets and Fairs, and Swimming Pools (especially kiddie swimming pools) are known sources of enteropathogens that can cause diarrhea (sometimes bloody).
Consider these on your DDx of vomiting/diarrhea.
Ask about these possible exposure sites along with Travel History and Nontraditional Pets.
Keywords: heparin, chondroitin, toxicity (PubMed Search)
Heparin FDA Alert
In case you had not heard, there was a major recall of Baxter's Heparin. It was responsible for dozens of deaths in the USA and an investigation was launched. It has been found that the contaminant comes from manufacturing plants in China. The most concerning part is that it looks like it was chemically synthesized sulfated chondroitin. This brings the suspicion of intentional adulteration. First lead in toys now cartilage in our heparin - what's next?
Some fascinomas of Heparin:
News link for FDA Heparin Alert:
Keywords: tPA, stroke, intracerebral hemorrhage (PubMed Search)
Category: Critical Care
Keywords: phosphate, hypotension, hypomagnesemia (PubMed Search)
Potassium Phosphate ("K-phos")
Over the weekend, I had a patient with Dr. Scott that had a phosphate of 0.8 mmol/L. Phosphate < 1.0 mmol/L is an indication for IV repletion. IV repletion involves giving potassium phosphate. An important clinical question, therefore, is how much potassium does the patient actually get?
Keywords: cardiogenic shock, hypertrophic cardiomyopathy (PubMed Search)
Cardiogenic shock associated with LV outflow obstruction is managed best without the use of vasoconstrictive agents and vasopressors. Ideally, patients should be treated with IVF and beta blockade. Alpha agonists (e.g. ISO) can also be added.
Typical vasopressors may actually worsen LV outflow obstruction in these patients.
Keywords: Avulsed Tooth, hanks solution, dental emergencies (PubMed Search)
Dental Emergency -- Avulsed Tooth
Keywords: Gonorrhea, Chlamydia, Syphilis, Sexual Abuse, Trichomonas (PubMed Search)
Keywords: sumatriptan, myocardial infarction, migraine (PubMed Search)