Keywords: AAA, aneurysm (PubMed Search)
AAA...be afraid, be very afraid
Abdominal Aortic Aneurysm (AAA) is known as the great masquerader in the elderly for good reason....
Keywords: acute coronary syndrome, history (PubMed Search)
The 5 most important factors at predicting the presence of ACS in a patient presenting with chest pain (in order of importance):
1. nature of anginal symptoms (i.e. the HPI)
2. prior history of CAD
3. male gender
4. older age
5. increasing number of traditional risk factors
Notice this means that the MOST important factor is the HPI...the OLDCAAAR. If the patient has a concerning HPI, NEVER drop your concerns just because the patient is young or has minimal other risk factors.
Category: Obstetrics & Gynecology
Keywords: Rhogam, Pregnancy (PubMed Search)
Trivial Fact: Rhogam is Pregnancy Class C
Keywords: Neonatal Conjunctivitis, Chlamydia, Gonorrhea, Red Eye (PubMed Search)
Neonate with Red Eye
Keywords: stroke, visual field cuts, peripheral vision (PubMed Search)
Keywords: Inferior Vena Cava, Physical Examination, Thrombosis (PubMed Search)
Physical Examination finding in inferior vena cava thrombosis
Consider IVC thrombosis if you ever see vertically oriented, dilated abdominal wall veins, or dilated veins on the back. As opposed to abdominal wall veins that radiate out from the umbilicus in patients with cirrhosis-known as caput medusae.
Etiologies include hepatic tumors abutting the IVC, renal cell tumors, open abdominal surgery, catheter related, IVC filter-related.
Keywords: clopidogrel, ACS, STEMI, myocardial infarction (PubMed Search)
The ACC/AHA just recently published a "Focused Update" of their guidelines for management of ST-elevation MI. Amongst the changes:
Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI who receive thrombolytics.
Clopidogrel 300-600 mg orally should be added to aspirin in patients that are going for PCI for STEMI. This is listed as a Class I intervention, although the level of evidence is rated "C." In other words, it is judged to be definitely helpful though based on not-so-robust evidence (you figure that one out!).
Glycoprotein receptor antagonists can also be added (Class IIa, level of evidence B).
[I personally believe there is better evidence for the GP2B3A inhibitors than for clopidogrel, but there is a general push for more and more guideline writers to support clopidogrel. The number of writers for these ACC/AHA guidelines who have affiliations with the drug companies, including the ones that manufacture clopidogrel (Plavix), is tremendous; the list of disclosures is listed at the back of the document. Nevertheless, people tend to want to follow guidelines, and the boards will test you on this stuff so it is worth knowing.]
[Also for the record, if I have a STEMI, here's what I want: 162 mg ASA (not 325 mg), unfractionated heparin (not enoxaparin), abciximab/ReoPro (not eptifibitide/Integrilin) in the cath lab (not in the ER), and quick PCI; if I can't get the PCI within 60 minutes (not 90, but 60 minutes!), give me either tenectaplase or retaplase (not tPA) + 162 mg ASA + UFH; if I have a lot of pain that is not responding to NTG, give me dilaudid or fentanyl (not morphine)...and some Bailey's on ice; add oral BBs, ACEIs, and a statin at the 24 hour mark, NOT any earlier (early BBs only if I have Bailey's-resistant hypertension). Thanks.]
Keywords: crotimaton, permethrin, lindane (PubMed Search)
We have seen this lovely bug infect our patients and have to instutitue therapy. But do you know what is the first line drug and which one has now become second line due to its toxicity? Here is the short list:
First Line Therapy: Permethrin (Nix) - least toxic, only causes local irritation
Second Line Therapy: Crotamiton (Eurax) - again local irritation
Third LIne Therapy: Lindane - SEIZURES if you leave it on too long or put on too much. Children were particularly susceptible and relatively contraindicated.
Keywords: Metacarpal, Fracture, Boxer's Fracture (PubMed Search)
Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5th Metacarpal)
Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.
Keywords: Laceration, Dermabond, cyanocrylate (PubMed Search)
Cyanocrylate Tissue Adhesive is an excellent product to use when repairing linear lacerations.
A few things to remember:
The wound needs to be irrigated as you would any other wound prior to closure.
Gravity works. Consider where the product may drip to before you apply it (Eyes, Ears, Nose, etc).
Use Surgi-Lube (or other petroleum product) to create a barrier to limit the flow of the cyanocrylate.
For long lacerations, you may use steri-strips to help approximate edges before applying the tissue adhesive.
What to do if the glue gets out of control and drips onto the eyelids... may also apply to Krazy-Glue:
Use copious irrigation and then Mineral Oil (not acetone or alcohol - which won't go well in the eyes).
Often there will be an associated corneal abrasion... treat it as other corneal abrasion.
Keywords: hyperkalemia, medications (PubMed Search)
Keywords: DHE, dihydroergotamine, migraine headache, headache, cluster headache (PubMed Search)
Category: Critical Care
Keywords: radial arterial line (PubMed Search)
Invasive Arterial Pressure Monitoring - Complications
In critically ill patients with hemodynamic instability we often place arterial catheters to continuously monitor mean arterial pressure. Since we frequently use the radial artery for cannulation, it is important to know the complications associated with these catheters. Scheer et al performed, perhaps, the largest review of complications of peripheral arterial catheters. The results:
Pearl: Although permanent ischemic damage is rare, when placing a radial artery catheter use the non-dominant hand.
Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:198-204.
Keywords: Fenoldopam, Hypertension (PubMed Search)
Intravenous Fenoldopam has been shown in recent years to be a very effective antihypertensive medication. Studies have compared it to Nitroprusside (Nipride), the older generation "gold standard" antihypertensive, and have found to be just as effective.
Journal of Hypertension 2007
Keywords: congestive heart failure, CHF, pulmonary edema (PubMed Search)
Recent literature (Collins, et al, Ann Emerg Med, Jan 2008; and Cotter, et al, Am Heart J, Jan 2008) confirms something that we've been talking about for YEARS....more than 50% of patients presenting with acute cardiogenic pulmonary edema are not fluid overloaded, but rather have fluid mis-distributed into the lungs. Management should focus on fluid re-distribution rather than diuresis. Use of diuretics in these patients is associated with worsening renal function, which is a significant predictor of in-hospital mortality.
The best patients to use diuretics on are patients with slow progression of dyspnea, lower extremity edema, and weight gain over days-weeks. In the absence of a history of this slow progression, don't go crazy with the diuretics!
Category: Obstetrics & Gynecology
Keywords: Migraines, Pregnancy (PubMed Search)
Migraines and Pregnancy
Keywords: Back Pain, Leukemia, Lymphoma, Neuroblastoma (PubMed Search)
Pediatric Back Pain
Keywords: transient neurological attack, transient ischemic attack, TNA, TIA, stroke (PubMed Search)
Bos, et al. "Incidence and Prognosis of Transient Neurologcial Attacks, " JAMA, pgs. 2877-85. Dec. 26, 2007.
Johnston. "Transient Neurological Attack: A Useful Concept?," JAMA, pgs. 2912-13. Dec. 26, 2007
Category: Critical Care
Keywords: pulse oximetry (PubMed Search)
Pitfalls in pulse oximetry in the critically ill
Keywords: Pulmonary, Pulmonary Embolism (PubMed Search)
Pulmonary CTA Sensitivity and PIOPED II
The publication of PIOPED II has led some to doubt the sensitivity of pulmonary CTA for pulmonary embolism. This study reported an overall sensitivity of 83% which could be increased to nearly 90% with the addition of CTV (CT Venography). 83% is a horrible sensitivity. So, why should you care?