Category: Critical Care
Keywords: vasopressors, acidosis, bicarbonate (PubMed Search)
Blue Toe Syndrome
This syndrome refers to acute digital ischemia caused by athero-microembolism and is associated with cool, painful, cyanotic toes in the presence of palpable distal pulses.
Presence of this syndrome should prompt the Emergency Physician to search for the proximal source. Failure to identify the source and aggressively treat may lead to limb loss.
Common etiologies include:
Keywords: creatinine clearance, medication adverse effects (PubMed Search)
Recent studies have identified that a significant cause of morbidity and mortality in women, elderly, and patients with renal failure is the failure to consider renal insufficiency in dosing certain anticoagulants and anti-platelet medications, resulting in bleeding complications. Medications should be based on creatinine clearance, NOT SERUM CREATININE. When the creatinine clearance is < 30 mL/min, the dose of any renally-excreted medications should be decreased.
For example, an 85 yo woman that is 110 lbs and has a serum creatinine of 1.2 (sounds normal!) actually has a creatinine clearance < 30, which means that she has relative renal insufficiency. Her dosages of medications (e.g. enoxaparin) should be adjusted for this.
Creatinine clearance can easily be calculated via computer programs that you can "google" (e.g. just google "creatinine clearance calculation"). If you enter the patient's gender, age, weight, and serum creatinine, the programs will calculate the value for you.
Category: Obstetrics & Gynecology
Keywords: Placenta, Abruption, Vaginal Bleed, Third Trimester (PubMed Search)
Keywords: Sepsis, Shock, Tachycardia, Hypotension (PubMed Search)
Pediatric Septic Shock
Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8.
Keywords: Gamma-Hydroxybutyrate, GHB, Liquid X, date rape, overdose (PubMed Search)
Category: Airway Management
Keywords: TBI, Traumatic Brain Injury, Head CT (PubMed Search)
According to ACEP's clinical policy, a non-contrast head CT is only indicated in mild traumatic brain injury under the following circumstances:
3) age over 60
4) drug or alcohol intoxication
5) short-term memory deficits
6) physical evidence of injury above the clavicle
Category: Infectious Disease
Keywords: MRSA, resistant bacteria, sepsis, antiobiotics, baltimore (PubMed Search)
A recent study came out which confirms what we already knew... that MRSA infections are no longer confined to ICUs but are spreading to the community. What the new study does show, is that it affects particular populations disproportionately and Baltimore City, more than any other study population. The full article is attached below, or can be obtained for free from the JAMA website.
"Unadjusted incidence rates of all types of invasive MRSA ranged between approximately 20 to 50 per 100 000 in most ABCs sites but were noticeably higher in 1 site (site 7, Baltimore City) (TABLE 2)."
"... we calculated interval estimates excluding site 7 (Baltimore City) to allow the reader to interpret a range of estimates reflecting different metropolitan areas. Regarding the high observed incidence rates reported by site 7, we conducted an evaluation to determine whether these results were valid, including a review of casefinding methods, elimination of cases to include only those with zip codes represented in the denominator, contamination in any laboratory, and other potential causes for increased rates; however, none were in error."
Category: Critical Care
Keywords: hyperammonemia, hepatic failure, cerebral edema (PubMed Search)
Hyperammonemia in the Critically Ill
Clay AS, Hainline BE. Hyperammonemia in the ICU. Chest 2007;132:1368-1378.
Keywords: Hypertension (PubMed Search)
There is no good evidence for what type of workup an asymptomatic hypertensive patient should get in the ED. An ECG is likely to show LVH, a cxr will be normal in most cases, and many patients will have some degree of proteinuria.
So, what is a safe and reasonable strategy to workup these patients?
American College of Emergency Physicians 2006 Guidelines on the evaluation of asymptomatic HTN.
Keywords: atrial fibrillation, myocardial infarction (PubMed Search)
New onset atrial fibrillation is rarely the sole manifestation of myocardial infarction. In other words, in the absence of accompanying chest pressure, dyspnea, diaphoresis, or other anginal equivalents, a rule-out ACS workup in not supported by the literature and is not cost-effective.
The two exceptions to the statement above are elderly and diabetic patients, in whom subtle presentations of ACS are common with or without atrial fibrillation.
Keywords: Salter Harris, Fracture, Strain, pediatric (PubMed Search)
Pediatric Strain versus Fracture
Review of Salter Harris Fractures
Keywords: Foreign Body, Button Battery, Heliox, Respiratory Distress (PubMed Search)
• No object should be left in the esophagus for >24 hrs
• Unusual FB’s:
==> Very Sharp or pointed objects may perforate the GI tract and should be removed endoscopically.
==> Long objects (>6cm) or wide (>2cm) objects may not pass and should be remove endoscopically.
• Button Batteries
==> 9% of cases involve more than one battery (x-ray mouth to anus)
(1) Heavy metal leakage (Mercury) – low risk but real
(2) Electrical Discharge (Local tissue injury)
(3) Pressure Necrosis
(4) Leakage of Corrosives
==> 85% Pass without symptoms
(1) No intervention if pass the esophagus and pt is without symptoms
• Consider Heliox as a temporizing measure in children with respiratory distress, while awaiting endoscopy/bronchoscopy.
Keywords: valproic acid, poisoning, carnitine (PubMed Search)
Valproic Acid (Depakote) - Increased use for both seizure disorder, migraine prophylaxis and bipolar disorder - Causes hyperammonemia with or without hepatic insufficiency (Liver enzymes could be normal!) - Hyperammonemia can occur at therapeutic concentrations and overdose - If the patient is sedated and has hyperammonemia, consider carnitine therapy antidotal - Carnitine IV or PO: 50-100 mg/kg bolus or divided bid, safe to give
Keywords: SAH, subarachnoid hemorrhage, aneurysm (PubMed Search)
Category: Critical Care
Keywords: abdominal compartment syndrome, decompressive laparotomy, bladder pressure (PubMed Search)
[RESENT - STILL FIXING CODE - THESE TEST EMAILS SHOULD CEASE SHORTLY... SORRY FOR THE INCONVENIENCE]
Keywords: Aorta, Enteric, Fistula (PubMed Search)
Suspect an aortoenteric fistula in patients who present with an upper GI bleed if they have ever had a AAA repair. This occurs when a fistula forms between the abdominal aorta and the GI tract (most commonly the duodenum). Patients may present stable or may present critically-ill. Unstable patients with an upper GI bleed and a history of AAA repair should proceed to the OR for laparotomy.
Stable patient may undergo CT scanning and/or endoscopy. Bottom line: If a patient with a history of AAA repair presents with an upper GI bleed, rally your troops (GI, Surgery, etc) ASAP and don't mess around. If you are wrong, and the patient doesn't have a fistula, no big deal. If you are wrong, and the patient does have a fistula, the patient may very well die on you as you struggle to get a regular ICU bed.
Keywords: acute myocardial infarction, reperfusion, ami (PubMed Search)
In the treatment of an acute ST-elevation MI, there are three major signs of successful reperfusion:
Persistent pain/symptoms OR absence of STE resolution by 90 minutes warrants strong consideration of rescue angioplasty.
Keywords: Back Pain, Guideline, Treatment (PubMed Search)
Low Back is one of the most common complaints that we see in the Emergency Department. Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…). However, most of the back pain that we will see is musculoskeletal in origin.
The American College of Physicians (ACP) and the American Pain Society (APS) recently released some joint recommendations on the evaluation of treatment of individuals with back pain.
In summary their key recommendations are:
Links to the Clinical Guidelines are listed below:
Keywords: Concussion, Second Impact Syndrome, Sports Medicine (PubMed Search)
Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med 1990;87:4.