Keywords: Ketamine, RSI, TBI (PubMed Search)
Ketamine and RSI for pts p TBI
Keywords: encephalopathy, neurological, mental status abnormality (PubMed Search)
Category: Critical Care
Keywords: mean arterial pressure (PubMed Search)
Mean Arterial Pressure
Keywords: PE, Pulmonary Embolism (PubMed Search)
Optimal pulmonary artery opacification for detecting pulmonary embolism-how good was the CT you ordered?
The PE literature is pretty clear about one thing: a CT with well-timed opacification of the pulmonary arteries is very sensitive for detecting pulmonary embolism. This means that there needs to be enough contrast in the central pulmonary arteries to be able to detect clot. So how can you be really sure the PE Protocol CT you ordered is adequate? Have you really ruled out PE?
What does this mean for the emergency physician?
Some predict that in the future WE (the emergency physician) may in fact be held accountable for knowing whether or not a CTPA (CT Pulmonary Angiography) is optimal or not.
(1) Kline-Carolinas Medical Center (2) Journal of Thrombosis and Hemostasis 2007 (3) AJR 2006,2007
Keywords: atrial fibrillation, ST-segment depression (PubMed Search)
Transient ST-segment depression during rapid atrial fibrillation is of uncertain clinical significance (much as is true for ST segment depression in SVTs). A recent study indicates that ST-segment depression in rapid AFib is not consistently associated with positive stress testing or occlusions on cardiac catheterization.
On the other hand, if the ST-segment depression persists after the rate is controlled, then there should be greater concern.
[Androoulakis A. J Am Coll Cardiol 2007;50:1909-1911.]
Category: Infectious Disease
Keywords: Ludwig, Angina (PubMed Search)
Ludwig’s angina is most commonly a polymicrobial disease of mixed aerobic / anaerobic bacterial origin. Dental disease is the most common cause of Ludwig’s angina.
Diagnosis is usually made after obtaining a CT scan of the Neck and upper chest.
Once the diagnosis is made, treatment should consist of broad spectrum antibiotics and surgical evaluation by ENT or Oral Surgery for possible I&D. Aggressive management of the patient’s airway is a must, and the patient should be intubated early in the course of the illness if there is any sign of airway compromise. Nasal intubation may be preferred by ENT/Oral Surgery.
Typical Antibiotics include a Penicillin with clindamycin or metronidazole.
Ludwig’s Angina Trivia:
Keywords: ITP, Leukemia, Steroids, IVIG, Anti-Rh(d), Bone Marrow Aspiration (PubMed Search)
Pediatric ITP – Bone Marrow Aspiration
Keywords: stroke, tia, prevention, recurrent (PubMed Search)
--> 11.5% at 1 week
--> 6-15% at 1 month
--> 18.5% at 3 months
--> 8% at 1 week
--> 11.5% at 1 month
--> 17.3% at 3 months
Thom, et al. AHA Statistics Committee and StrokeStatistics Subcommittee. Heart Disease and Stroke Statistics-2006 Update. Circulation 2006; 113:e85-151.
Sacco, et al. Predictors of Mortality and Recurrence after Hospitalized Cerebral Infarction in an Urban Community: the Northern Manhattan Stroke Study. Neurology 1994;44:626-34.
Coull, et al. Population Based Study of Early Risk of Stroke after Transient Ischaemic Attack or Minor Stroke: Implications for Public Education and Organisation of Services. BMJ 2004;328:326.
Keywords: bisphosphonates (PubMed Search)
With the aging population, bisphosphonate use will continue to increase. They promote bone growth by inhibiting osteoclast action and resorption of bone. Unfortunately, they have their side effects and the FDA has sent out a recent warning that affects us all:
If a patient presents with severe bone/joint pain, check the med list to see if they are on a bisphosphonate - they may not be faking the pain. This can occur days, weeks or even years after initiation of dose
Category: Critical Care
Keywords: pulmonary hypertension, hypotension, calcium channel blockers (PubMed Search)
Pulmonary Hypertension Pearls
We are beginning to see more and more patients with pulmonary hypertension (PAH), many of whom are on continuous IV infusions of new medications. With that in mind, here are a few pearls:
Keywords: Pulmonary Embolism (PubMed Search)
Risk Factors for Pulmonary Embolism
Can you imagine one of our patients saying"Dr. Abaraham, I have what is known in the hematology community as a Factor 5 Leiden mutation"?
Keywords: aVR, electrocardiography, prehospital, pulmonary edema, CPAP, noninvasive ventilation (PubMed Search)
Keywords: aspirin, acute coronary syndromes (PubMed Search)
In the setting of an ACS, the minimum dose of ASA that should be given is 162 mg. Chewing provides antiplatelet effects slightly faster than simply swallowing, though the difference is probably not clinically significant. Enteric coated aspirin, however, clearly takes longer to work and should therefore be avoided in patients with ACS.
A dose of 325 mg does not appear to provide any further benefit beyond the 162 mg dose, though there might be a slightly higher bleeding rate. Despite that the 2005 PCI guidelines recommend a dose of 325 mg as the initial dose for patients with ACS if they are not chronically taking ASA. Otherwise, 162 mg is sufficient.
Keywords: Knee Injury, ACL, dislocation (PubMed Search)
Some quick facts about Knee Injuries:
Keywords: RSV, Apnea, Congenital Heart Disease, Chronic Lung Disease, Prematurity, Rapid testing (PubMed Search)
Bronchiolitis: Use of RSV rapid testing
Purcell K, Fergie J. Concominant serious bacterial infections in 2396 infans and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch pediatr adolesce med. 2002; 156: 322-324.
Keywords: anticonvulsant, status epilepticus, keppra (PubMed Search)
Knake et al. Intravenous levetriacetam in thetreatment of benzodiazepine-refractory status epilepticus. J Neurol Neurosurg Psychiatry 2007 Sept 26; Epub
Keywords: carotid artery dissection, stroke (PubMed Search)
Selim M, Caplan LR. Carotid Artery Dissection. Current Treatment Options Cardiovascular Medicine. 2004; 6: 249-253.
Stapf C, Elkind MS, Mohr JP. Carotid Artery Dissection. Annual Review Medicine. 2000; 51: 329-47.
Schievink W. Spontatneous Dissection of the Carotid and Vertebral arteries. NEJM. 2001; 344: 898-906.
Category: Critical Care
Keywords: adrenal insufficiency, hypotension, glucocorticoids, hydrocortisone (PubMed Search)
Adrenal Insufficiency in the Critically Ill
Keywords: catheter, lytics (PubMed Search)
Thrombolytic infusion for occluded central venous catheters
For patients with long-term indwelling central venous catheters (dialysis catheters, Hickmans, etc) who develop catheter occlusion, consider infusion of thrombolytic therapy for catheter salvage.
How do you do it, you ask?
This treatment is very safe and is well tolerated.
Journal of Vascular Access, 2006
Keywords: adenosine, ventricular tachycardia (PubMed Search)
Adenosine should be used with great caution in patients with wide complex tachycardia for two major reasons:
1. Adenosine should never be used as diagnostic maneuver to decide whether someone has ventricular tachycardia vs. SVT. Adenosine is well-reported to convert certain types of VT.
2. If the WCT is irregular, this may be atrial fibrillation with WPW, in which case adenosine is well-known to produce ventricular fibrillation.