Keywords: internal cardioverter defibrillator (PubMed Search)
ICD shocks are often associated with ST segment elevation and even positive troponin levels that can simulate acute MI. So how do you know if the patient experienced an acute MI with VF that triggered the ICD shock? Or if there simply was an aberrant ICD shock that triggered STE with positive troponins?
STE that is due purely to the ICD shock generally resolves after only 15-20 minutes. Persistent STE beyond that time should be assumed to be true ischemia.
Troponin elevations that are due purely to an ICD shock are usually mild and normalize within 24 hours. Huge troponin elevations and those that last beyond 24 hours should be assumed to be caused by true infarction.
Keywords: Pancreatitis (PubMed Search)
Some simple facts about Pancreatitis:
Keywords: Neonatal Fever, HSV, Acyclovir (PubMed Search)
Whitley R, Davis EA, Suppapanya N. Incidence of neonatal herpes simplex virus infections in a managed-care population. Sex Transm Dis. 2007 Sep;34(9):704-8.
Benson PC, Swadron SP. Empiric acyclovir is infrequently initiated in the emergency department to patients ultimately diagnosed with encephalitis. Ann Emerg Med. 2006 Jan;47(1):100-5. Epub 2005 Nov 8.
Keywords: naloxone, opioids (PubMed Search)
1) No IV - Try naloxone in a nebulizer - Dose: 2-4 mg and saline in your nebulizer container.
2) When using naloxone IV, use following dose: 0.05 mg IV - you will find it reverses the respiratory depression without inducing withdrawal. Anesthesia doses naloxone in micrograms, we often overdose our patients. The effect is delayed and not as pronounced as the 0.4 mg blast that causes nausea, vomiting, diarrhea, agitation - all not desirable in the ED.
Keywords: flumazenil. seizure, drug overdose (PubMed Search)
Williams, JS. "Flumazenil Revisited."
Category: Critical Care
Keywords: ACTH stimulation test, adrenal insufficency, corticosteroids (PubMed Search)
ACTH Stimulation Test
Keywords: DVT, Pulmonary Embolism (PubMed Search)
DVT and Asymptomatic Pulmonary Embolism
A few important pearls about PE:
Journal of Thrombosis and Hemostasis and Chest-2006, 2007
Keywords: implantable cardioverter defibrillator, AICD, ICD, succinylcholine, intubation (PubMed Search)
NOTE THE CORRECTION TO THIS PEARL BELOW:
If a patient with an implantable cardioverter defibrillator needs to receive a paralytic for rapid sequence intubation, succinylcholine alone is not the best choice. The muscle fasciculations sometimes produced by succ can cause enough electrocardiographic artifact that inappropriate discharges of the ICD can occur.
Therefore, giving defasciculating doses of a paralytic before administering succ is recommended. Alternatively, use a nondepolarizing paralytic. Give 'em the rock!
Yet another reason to go with rocuronium.
Dr. Ron Walls and colleagues emailed me about the pearl above, which was adapted from an article in AJEM [McMullan J, Valento M, Attari M, Venkat A. Care of the pacemaker/implantable cardioverter defibrillator patient in the ED. Am J Emerg Med 2007;25:812-822.]
The authors of the AJEM article reference another article for the statement [Stone KR, McPherson CA. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care med 2004;32(4)Suppl:S155-S165.]. The CCM article actually states that SCH-induced fasciculations may cause artifact which may cause problems with some pacemakers, not ICDs. So it appears that there is no reported problem in using SCH in patients with ICDs. Sorry for the confusion.
Category: Obstetrics & Gynecology
Keywords: Bacterial Vaginosis, Treatment, Pregnancy (PubMed Search)
Keywords: Analgesia, Oral Sucrose, topical lidocaine, Lumbar puncture (PubMed Search)
Tips for Common Painful Procedures:
EMSC Panel (Writing Committee) on Critical Issues in the Sedation of Pediatric Patients in the Emergency Clinical policy: Critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008 Apr;51(4):378-99, 399.e1-57
Keywords: antiepileptics, suicide, carbamezepine, felbamate, gabapentin, lamotrigine, levetiracetam, valproate, pregabalin (PubMed Search)
SUICIDE RISK WITH ANTIEPILEPTICS
Drugs in the analysis included:
Carbamazepine (Carbatrol, Equetro, Tegretol, Tegretol XR)
Valproate (Depakote, Depakote ER, Depakene, Depacon)
Interestingly, other agents including varenicline (a partial nicotinic antagonist, for smoking cessation), levetiracetam (Keppra), zolpidem (Ambien), oseltamivir (Tamiflu), isotretinoin (Accutane), and other agents have been noted to have an increased rate of bizarre and aggressive behavior.
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