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.
Keywords: Academics, Billing, Teaching, Residents (PubMed Search)
Fraud (PATH audits) (PATH = physicians at teaching hospitals)
So for the residents, a lot of attendings will want to be present when you do a procedure, not because they think you will need their assistance, but because, procedures are a large revenue stream that can be lost if the attending is not present.
Thanks to Larry Weiss, MD, JD
Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.
Keywords: Childhood Cancers, Leukemia, Lymphoma, pallor, fatigue (PubMed Search)
Pediatric Leukemia/Lymphoma Presentation in the ED
Jaffe D, Fleisher G, Grosflam J. Detection of cancer in the pediatric emergency department. Pediatr Emerg Care. 1985 Mar;1(1):11-5.
Keywords: phenytoin, anticonvulsants, loading dose (PubMed Search)
Phenytoin po Phenytoin IV Fosphenytoin
Time to therapeutic 6.4 hrs 1.7 hrs 1.3 hrs
Adverse Events 0.69/pt 1.86/pt 1.87/pt
Also to take into account is that the adverse events with IV phenytoin include soft-tissue necrosis if there is extravasation of infusion. The cardiotoxicity seen with phenytoin and fosphenytoin is largely due to the propylene glycol diluent and thus not seen with oral loading or even in oral overdosing.
You decide, at least you have the data to properly evaluate the risk:benefit ratio.
Keywords: sarcoidosis, neurosarcoidosis, cranial nerve dysfunction (PubMed Search)
Keywords: Pulmonary Embolism (PubMed Search)
The PERC Rules revisted
How can I rule out PE without ANY testing, you ask? Do I have to get a d-dimer on that low risk patient?
Do these things keep you up at night like they do me?
Consider using the PERC rule (Pulmonary Embolism Rule Out Criteria)
This set of rules was mentioned in an earlier pearl, but there are now 3 large studies (and one on the way) that validate the use of these rules.
So, if you have a patient who is LOW risk for PE but you would like to document something in the chart that proves you thought about the diagnosis and clinically ruled it out:
If the patient is LOW risk for PE by your clinical gestalt and if the answer to ALL of the following questions is YES, then the patient is considered PERC negative:
PERC negative + Low Risk clinical gestalt = PE ruled out
Jeff Kline, PERC rule. Journal of Thrombosis and Hemostasis. 2007/2008
Here's a pearl for everyone that is "enjoying" the holidays with friends...friends named Jack Daniels, Remy Martin, and Louis XIII, among others.
It's fairly well-known that light-moderate alcohol intake is associated with reductions in cardiovascular death and nonfatal MI and also a reduction in the development of heart failure. In case you've ever wondered exactly what a "drink" is and what "moderate" intake are, here are some definitions:
a. In the U.S., a standard alcohol "drink" is 1.5 oz or a "shot" of 80-proof spirits or liquor, 5 oz of wine, or 12 oz of beer.
b. "Moderate" drinking is no more than 1 drink per day for women and 2 per day for men.
c. "Binge" drinking is > 4 drinks on a single occasion for men or > 3 for women within 2 hours.
Although some studies suggest that wine (esp. red) has an advantage over other types of alcohol, other studies (including ones we've reviewed in the cardiology update series) indicate that the type of alcohol doesn't matter. Good news for many of our patients!
Keywords: Limp, Antalgic Gait, Trendelenburg Gait, Septic Arthritis, Legg-Calve-Perthes Disease, SCFE (PubMed Search)
Child with a Limp
Grossman, Emblad, Plantz. Orthopedic Emergencies in Pediatric Emergency Medicine Board Review. 2nd Edition. 2006. p305.
Keywords: NSAID, ketorolac, gastritis, renal failure (PubMed Search)
Ketorolac: an NSAID that gained popularity since it is not an opioid, has excellent anti-inflammatory/analgesic effects and is given IM or IV. Also has been used in renal colic secondary to smooth muscle relaxation (Prostaglandin mediated) in the ureters. You should know:
Corelli et al. Renal Insufficiency and ketorolac. Ann Pharmacother. 1993; 27(9): 1055-7
Keywords: steroids, spinal cord injury, SCI (PubMed Search)
Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of
methylprednisolone or naloxone in the treatment of acute spinal-cord injury.
Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med
1990 May 17; 322(20): 1405-11.
Category: Critical Care
Keywords: end-tidal CO2, capnography, status asthmaticus, increased intracranial pressure (PubMed Search)
Critical Care Monitoring - End-Tidal CO2
Keywords: Hypertension (PubMed Search)
Secondary Causes of Hypertension
Although not that common, consider the following (with accompanying history and/or physical examination findings) in patients with hypertension:
Although most of the time the patient will end up having essential hypertension, these entities should at the very least be considered.
Journal of Hypertension 2007
Keywords: Coding, Billing, Reimburshment (PubMed Search)
The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money. Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .
|Diagnosis ||Consider Diagnosising It this, if the condition fits|
|Flu/Viral Ilness|| |
|Musculoskeletal Pain|| |
|Otitis Media|| |
The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.
Keywords: AICD, shock (PubMed Search)
What do you do if a patient with an AICD presents to the ED with a shock?
If the patient receives a single shock and is otherwise asymptomatic and fine, there is probably no need for intervention (or even an ED visit). For the patient in the ED, monitor them and discuss with their cardiologist. Consider checking some labs, but emergent pacer evaluation is not generally necessary (unless there are other concerning issues--abnormal rhythms on monitor, complaints of lightheadedness and preceding chest pain, etc.). You should manage and treat the patient for other symptoms and signs, but not for the shock itself.
If the patient received multiple shocks, however, device interrogation is generally required. Also search for the underlying cause--ischemia, electrolyte abnormalities, etc. Bear in mind that most of the time, multiple shocks are later deemed to be inappropriate (device error).
Post-shock ECG will likely show ST segment changes but they normalize within 15 minutes.
15-20% of the time there will be some TN-I elevation for up to 24 hours due to a shock.
Keywords: Child Abuse, Fractures (PubMed Search)
Keywords: thyroid, hypothyroid, hyperthyroid (PubMed Search)
Lithium: Hypothyroidism (5-15% of pts) and goiter (37% of pts), mechanism unclear
Amiodarone (37% Iodine by weight): Hyper or Hypothroidism
Beta-Blockers: by blocking peripheral conversion of T4 to T3 cause hypothyroidism
Corticosteroid: same as beta-blockers but can also cause transient thyrotoxicosis (Jod-Basedow effect)
Iodine, Iodinated contrast, radiactive iodine all can cause hypothyroidism but iodinated contrast material can actually induce thyrotoxicosis and thyroid storm from unknown mechanism.
Keywords: Ischemic Stroke, Intra-arterial Thrombolysis, IA tPA, Intra-venous Thrombolysis, IV tPA (PubMed Search)
-- candidates with severe neurological deficits (NIHSS score > 10)
-- candidates with a recent history of major surgical procedures
-- candidates with occlusion of major cervical or intracranial vessels
Zaidat OO, Saurez JL, Santillan C, et al. "Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion." Stroke 2002, 33: 1821-1826.
Bellolio MF, et al. "Stroke Update 2007: Better Early Stroke Treatment (BEST)," Emergency Medicine Practice, Augst 2007, Volume 9, Number 8.
Category: Critical Care
Keywords: pulmonary edema, aortic dissection, heroin (PubMed Search)
Unilateral Pulmonary Edema
Keywords: subarachnoid hemorrhage (PubMed Search)
Subarachnoid hemorrhage: Unilateral or bilateral headache?
Pretty good evidence exists that most patients with subarachnoid hemorrhage will have a bilateral headache.
In fact, unilateral headache is helpful in the history in ruling out SAH in most cases. Presence of an unruptured aneurysm, however can be present with a unilateral headache.
J NeuroSurg 2006