Keywords: Warfarin (PubMed Search)
Reversal of Warfarin
Reversal of Warfarin can be accomplished by administering any of the following:
A few pearls:
Keywords: syncope, seizure (PubMed Search)
Syncope patients are often misdiagnosed as having a seizure. Some factors favoring true syncope:
1. Preceding nausea or diaphoreses
2. Oriented (not confused) upon waking (no post-ictal period).
3. Age > 45
4. Prolonged sitting or standing before episode
5. History of CHF or CAD
Factors favoring seizures:
1. History of seizure disorder
2. Tongue biting
3. Confusion upon waking
4. Loss of consciousness > 5 min
5. Age < 45
6. Preceding aura
7. Observed unusual posturing, jerking, or head turning during episode
Keywords: felon, management, incision (PubMed Search)
Management of Felons
For good photos of the incision technique please visit the reference article listed.
Keywords: Erythema Infectiosum,parvovirus B-19 (PubMed Search)
With the cooler weather on us all our favorite viral infections will start to appear. Included in this is the "slapped - cheek disease" Erythema infectiosum.
Keywords: anticholinergic, olanzapineA (PubMed Search)
This is an atypical antipsychotic that gained popularity because it caused less sedation and fewer extrapyramidal effects. However, there are many other adverse effects that need to be emphasized. Some of these may contribute to a patient's condition in the ED:
Keywords: migraine, anitemetic, Reglan, metoclopramide, prochlorperazine, Compazine, diphenhydramine (PubMed Search)
Category: Critical Care
Keywords: influenza, zanamivir, oseltamivir (PubMed Search)
Influenza and the Critically Ill
Beigel JH. Influenza. Crit Care Med 2008;36:2660-6.
Keywords: HeparinPro (PubMed Search)
Anticoagulation with Heparin-How to Reverse?
So you just started Heparin on that ACS patient? Just bolused the patient in room 12 with the large PE with a slug of Heparin? The nurse tells you that one of them just vomited blood and the other just had a large bloody bowel movement. What to do, oh, what to do?
How to reverse Heparin...use Protamine:
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.]