Category: Cardiology
Keywords: hypokalemia, herbal supplements, hyperkalemia (PubMed Search)
Posted: 4/25/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
Click here to contact Amal Mattu, MD
Three common herbal supplements are reported to be associated with clinically significant hypokalemia: aloe vera, gossypol (used as a male contraceptive), and licorice.
Another popular herbal supplement is reported to be associated with clinically significant hyperkalemia: oleander.
Always ask your cardiac patients (especially those on digoxin) if they are taking any of these herbal supplements!
[Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol 2010;55:515-525.]
Category: Orthopedics
Posted: 4/25/2010 by Michael Bond, MD
(Updated: 7/16/2024)
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Carpal Tunnel Syndrome (CTS):
Category: Pediatrics
Posted: 4/23/2010 by Rose Chasm, MD
(Updated: 7/16/2024)
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Category: Toxicology
Keywords: heparin, cimetidine, thrombocytopenia (PubMed Search)
Posted: 4/22/2010 by Fermin Barrueto, MD
(Updated: 7/16/2024)
Click here to contact Fermin Barrueto, MD
Here are is a list of common drugs that will cause thrombocytopenia as a result of antiplatelet antibodies (its not just heparin!). This list is not complete but are common ones that you will see in the ED, coming from USH or on the floors/units during residency:
Abciximab, Acetaminophen, amiodarone, amphotericin B, ASA
Carbamazepine, cimetidine
Digoxin
Methyldopa
Quinidine, Quinine
Rifampin
Trimethoprin-sulfamethoxazole
Vancomycin
Category: Neurology
Keywords: brachial plexus, brachial plexus injuries, Erb palsy (PubMed Search)
Posted: 4/21/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
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Category: Critical Care
Posted: 4/20/2010 by Evadne Marcolini, MD
(Updated: 7/16/2024)
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It is true, 1/3 of Americans are obese. There is conflicting evidence regarding the mortality risk of obesity (defined as BMI>30 kg/m2) in critically ill patients.
It has been shown that abdominal fat has greater consequences than peripheral obesity, and based on this, a recent study has utilized the sagittal abdominal diameter (SAD) in ICU patients to show that abdominal obesity (as differentiated from BMI) poses an independent risk of death. The SAD detects visceral fat, which has been shown to have metabolic and immune health consequences, including the following:
-incidence and severity of certain infections is higher
-excess adipocytes are associated with elevated levels of proinflammatory factors that favor insulin resistance, diabetes, dyslipidemia and hypertension, all of which lead to microcirculatory dysfunction
-rates of required renal replacement therapy and abdominal compartment syndrome correlate to increased SAD
-there is also a trend toward a longer length of ventilator weaning
See you at the gym.
Paolini JM et al: Predictive value of abdominal obesity vs. body mass index for determining risk of intensive care unit mortality. Crit Care Med 2010; 38:1-7
Category: Vascular
Keywords: Hypertension (PubMed Search)
Posted: 4/19/2010 by Rob Rogers, MD
(Updated: 7/16/2024)
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Secondary Hypertension...say what?
We obviously see tons of patients in the ED with hypertension, and we are very comfortable with both symptomatic and asymptomatic presentations. Most of these patients have essential or primary hypertension. Some patients, however, may have secondary hypertension (i.e. something is causing it). Although we will refer patients to a primary care physician for further management and workup it is worth discussing when to suspect other diagnoses as the cause of the hypertension. Is it out job necessarily to diagnose these conditions in the ED? No.
Causes of secondary hypertension to consider:
Consider the ABCDE mnemonic:
A-Accuracy (is it really htn?), Apnea, Aldosteronism
B-Bruits, Bad Kidneys
C-Catecholamines, Coarctation, Cushing's
D-Drugs, Diet
E-Endocrine
Aren't you glad you didn't do a Medicine residency???
Onusko E. Diagnosing secondary hypertension. Am Fam Physician. 2003 Jan 1;67(1):67-74.
Category: Cardiology
Keywords: myopericarditis, pericarditis, aspirin (PubMed Search)
Posted: 4/18/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
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Patients with pericarditis are generally treated with high-dose aspirin (e.g. 2-4 gms/day) or other NSAIDs in high dose. However, when myocarditis is also present (e.g. elevated TN levels), lower dosages of aspirin (e.g. 500 mg TID) or other NSAIDS should be used. The higher dosages of anti-inflammatory medications in the setting of myocarditis are thought to exacerbate the myocarditic process and increase mortality (animal studies).
Imazio M, Spodick DH, Brucato A, et al. Controversial Issues in the management of pericardial diseases. Circulation 2010;121:916-928.
Category: Ophthamology
Keywords: Conjunctivitis (PubMed Search)
Posted: 4/15/2010 by Michael Bond, MD
(Emailed: 4/17/2010)
(Updated: 8/28/2014)
Click here to contact Michael Bond, MD
All to often we see children that are sent to the ED for "Pink Eye" as the school nurse will not allow them back into class unless they are treated with antibiotics. A recent study out of New York identified 4 factors that are associated with low risk (<8% chance) of bacterial (culture postive) conjunctivitis. They are:
An editorial in journal watch comments that if this study can be replicated in other geographic areas we could change the practice of prescribing antibiotics that are not necessary.
Meltzer JA et al. Identifying children at low risk for bacterial conjunctivitis. Arch Pediatr Adolesc Med 2010 Mar; 164:263.
Category: Pediatrics
Keywords: Adolescent Consent, EMTALA (PubMed Search)
Posted: 4/16/2010 by Reginald Brown, MD
(Updated: 5/7/2010)
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EMTALA stipulates that any patient presenting to the Emergency Department is required to receive a medical screening exam regardless of age, ability to pay, or whether or not a parent accompanies the child.
EMTALA supersedes any state/local provisions or laws.
In performing a medical screening exam if an emergency medical condition exists then diagnostic testing, surgery or even transfer of hospitals may be appropriate without ever obtaining parental consent
MInors have the right to give or refuse informed assent of a procedure
If their is conflict between physician, parent or patient in the rendering of emergent care the physician must weigh the severity of the condition, risks and benefits of the treatment, as well as the patients maturity and cognition. The physician may have to seek ethical committee review, or assistance from either social services or the court system.
If an emergent condition does not exist, EMTALA does not apply after the MSE.
Consent for Emergency Medical Services for Children and Adolescnets: Committee on Pediatric Emergency Medicine, Pediatrics VOL 111 No.3 March 20003, pp703-706 reaffirmed 2007.
Levine, S. Adolescent Consent and Confidentiality. Pediatrics in Review. Vol 30 No. 11 pp 457-8. Nov 2009.
Category: Pediatrics
Keywords: DKA, diabetic ketoacidosis, Pediatric, Children, Mental Status Change (PubMed Search)
Posted: 4/13/2010 by Adam Friedlander, MD
(Emailed: 4/16/2010)
(Updated: 4/16/2010)
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...more to come.
Category: Toxicology
Keywords: iron, metals (PubMed Search)
Posted: 4/15/2010 by Fermin Barrueto, MD
(Updated: 7/16/2024)
Click here to contact Fermin Barrueto, MD
Several drugs and compounds may be radiopaque on an abdominal radiograph. This may be helpful in an overdose to determine ingestion or amount ingested. Attached is a pic a patient that ingested potassium sustained release tables.
The mneumonic CHIPES will help you remember which are:
C - Calcium Carbonate, chloral hydrate
H - Heavy metal - like Mercury, lead
I - Iron and Iodine
P - Phenothiazines (compound that has S(C6H4)2NH in it), drugs that include: antipsychotics like chlorpromazine (thorazine) and antiemetics like prochlorperazine (compazine)
E - Enteric coated pills
S - Solvents [halogenated ones like chloroform] and Sustained Release preparations [Lithobid and K-Dur]
1004150936_KCl_patient_1.JPG (182 Kb)
Category: Neurology
Keywords: bitemporal hemianopsia, pituitary adenoma, tunnel vision, visual field testing, Cushing's Disease, acromegaly (PubMed Search)
Posted: 4/14/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
Click here to contact Aisha Liferidge, MD
www.dwp.gov.uk/
1004140823_Visual_Field_Abnormalities.jpg (44 Kb)
Category: Critical Care
Posted: 4/13/2010 by Mike Winters, MBA, MD
(Updated: 7/16/2024)
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Type B Lactic Acidosis
Vernon C, LeTourneau JL. Lactic acidosis: Recognition, kinetics, and associated prognosis. Crit Care Clin 2010; 26:255-83.
Category: Cardiology
Keywords: pericarditis, immigrants, etiology, cause (PubMed Search)
Posted: 4/11/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
Click here to contact Amal Mattu, MD
Though most causes of acute pericarditis in patients from developed countries are viral or idiopathic, the etiology of pericarditis in patients visiting from developing countries is usually TB, and the TB accounts for > 90% of cases of pericarditis in patients with HIV infection. This group of patients, therefore, should almost always be admitted for a full workup of the cause and for appropriate treatment.
Category: Orthopedics
Keywords: Hip Dislocation, Treatment (PubMed Search)
Posted: 4/11/2010 by Michael Bond, MD
(Updated: 7/16/2024)
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Prosthetic hip dislocations are a common occurance in the Emergency Department. After you have gotten the hip back in place there are several ways to prevent the hip from coming out again. An abductor pillow will work but it confines the patient to bed. A better option to prevent further hip dislocations until the patient can get an appropriate brace made or reparative surgery is to place the patient in a straight leg knee immoblizer. It is nearly impossible to dislocate your hip if your knee is fully extended.
So after reduction of their simple hip dislocation (i.e: no fractures) place the patient in a straight leg knee immobolizer and they can followup with their orthopedist as an outpatient.
Category: Toxicology
Keywords: nystagmus, pcp, phenytoin (PubMed Search)
Posted: 4/8/2010 by Bryan Hayes, PharmD
(Updated: 4/11/2010)
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Many drugs/toxins cause nystagmus, particularly in overdose. Vertical, horizontal, or rotary nystagmus may be noted.
The most common drug/toxin overdoses that cause nystagmus are the following:
Category: Neurology
Keywords: brain atrophy, stroke, Alzheimer's Disease (PubMed Search)
Posted: 4/7/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
Click here to contact Aisha Liferidge, MD
-- Multiple areas of local cortical brain atrophy (wedge-shaped
appearance) suggests multi-infarct dementia.
-- Disproportionate atrophy in the frontal and temporal lobes may be a
sign of Alzheimer's Disease.
Category: Critical Care
Posted: 4/6/2010 by Evadne Marcolini, MD
(Updated: 7/16/2024)
Click here to contact Evadne Marcolini, MD
Magnesium depletion has been described as "the most underdiagnosed electrolyte abnormality in current medical practice"
Important for electrically excitable tissues and smooth muscle cells, Mg is mostly located in bone, muscle and soft tissue. Because only 1% is located in blood, your patient can be Mg depleted with normal serum levels.
65% of ICU patients are magnesium depleted (and may not be hypomagnesemic). Because labs are unreliable, consider predisposing causes, such as diuretics, antibiotics (aminoglycosides, amphotericin), digitalis, diarrhea, chronic alcohol abuse, diabetes and acute MI (80% of AMI patients will have magnesium depletion in the first 48 hours).
Mg depletion is typically accompanied by depletion of other electrolytes (K, Phos, Ca), and can cause arrhythmias (especially torsades) and promote digitalis cardiotoxicity.
Hypermagnesemia is less common, and can be caused by hemolysis, renal insufficiency, DKA, adrenal insufficiency and lithium toxicity. Clinical findings include hyporeflexia, prolonged AV conduction, heart block and cardiac arrest. Treatment includes fluid and furosemide, calcium gluconate and dialysis.
Marino P. The ICU Book. 3rd ed. Lippincott Williams & Wilkins, 2007:625-638.
Category: Vascular
Keywords: aortic dissection (PubMed Search)
Posted: 4/5/2010 by Rob Rogers, MD
(Updated: 7/16/2024)
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Some not too uncommon complications of Type B (distal) aortic dissection: