Category: Critical Care
Keywords: esophageal varices, upper gastrointestinal bleeding, antibiotics (PubMed Search)
A few days ago Dr. Jump and I had a case of an acute variceal hemorrhage. Dr. Bond already sent out a great pearl earlier in the year highlighting the importance of octreotide in acute variceal bleeding. In fact, octreotide alone can result in cessation of hemorrhage in up to 80% of patients. To add onto Dr. Bond's pearl:
Keywords: Aortic Dissection (PubMed Search)
Patients with aortic dissection (Type A or B) who develop intestinal/renal, etc. ischemia should be considered for aortic fenestration-a procedure in which holes are literally created in the aortic lumen to connect the true and false lumen-this allows perfusion of the involved vessel to occur from true lumen into the false lumen into the involved vessel.
Patients with large vessel malperfusion have a VERY HIGH mortality rate, AND most CT surgeons will not operate even on a Type A unless the involved vessels have been opened up.
This procedure is useful when major vessels (SMA as an example) branch from the aortic false lumen.
So, when to consider this procedure:
Who do you call?
Keywords: bradycardia, pacemaker (PubMed Search)
A few pearls regarding pacing a patient with an unstable bradycardia:
If the patient has an implanted pacemaker (which isn't working properly), the transcutaneous pacing pads should be placed at least 10 cm away from the implanted PM pulse generator.
Placement of a transvenous pacemaker is absolutely contraindicated if the patient has a prosthetic tricuspid valve.
Neither transcutaneous or transvenos pacing is likely to work in the setting of severe acidosis or severe hypothermia. Severely hypothermic patients, in fact, have very irritible myocardial tissue and therefore attempts at pacing may produce ventricular dysrhythmias.
Keywords: Volvulus, Cause, (PubMed Search)
Volvulus Quick Facts
Keywords: Stroke, Embolus, Retinal artery occlusion (PubMed Search)
Majeed Al-Mateen, et al. Cerebral Embolism From Atrial Myxoma in Pediatric Patients. Pediatrics, Aug 2003; 112: e162 - e167.
Keywords: stroke, fever, hypothermia, neuroprotective (PubMed Search)
Adams, et al. Guidelines for the Early Management of Adults with Ischemic Stroke. AHA/ASA Guidelines. 2007.
Keywords: Pulmonary Embolism, Pneumonia (PubMed Search)
Category: Critical Care
Keywords: acute chest syndrome, blood transfusion, respiratory failure (PubMed Search)
Keywords: elderly, geriatric, chest pain, acute coronary syndrome (PubMed Search)
Atypical presentations of ACS in the elderly are common.
Only 40% of patients > 85yo present with chest pain. Dyspnea is the most common presenting complaint in these patients. Other atypical presentations include isolated nausea, vomiting, diaphoresis, or syncope.
The presence of an atypical presentation is not reassuring in terms of prognosis. Patients presenting atypically have a 3-fold higher in-hospital mortality (13% vs. 4%). This doesn't even include the patients that are inadvertently discharged home because of failure to diagnose ACS.
Keywords: Malpractice, Insurance (PubMed Search)
Malpractice insurance may not cover the following activities:
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.
Thanks to Larry Weiss, MD, JD
Keywords: Rheumatic Fever, Jones Criteria, Heart Disease, Salicylates, Chorea (PubMed Search)
Keywords: apraxia, agnosia, stroke symptoms (PubMed Search)
Keywords: sulfonylureas, octreotide, hypoglycemia (PubMed Search)
Fasono et al. Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced Hypoglycemia. Ann Emerg Med 2007 Aug 29.
Category: Critical Care
Keywords: non-invasive arterial monitoring, radial artery (PubMed Search)
Keywords: Aneurysm (PubMed Search)
Splenic Artery Aneurysm
Who cares, you ask?
Keywords: congestive heart failure, high output failure (PubMed Search)
Although CHF is usually associated with low cardiac output, "high output failure" can occur as well. In this condition, cardiac output is normal or even high but not high enough to meet markedly elevated metabolic demands of the heart in certain conditions. Those conditions include: severe anemia, thyrotoxicosis, lartge arteriovenous sunts, Beriberi, and Paget disease of the bone.
What should I do about this finding on the MRI I ordered
Now tha ta lot of EDs are getting MRIs on a more urgent basis, we will need to know what to do with the resutls. However, the natural history of findings on MRI has not been well studied, so what should we do with that small meningioma you find. Well some researchers in the Netherlands have attempted to address your question. In a population-based study [Rotterdam Study] , 2000 adults aged 45 or older underwent a brain MRI.
Some of the common findngs were:
Most of the study patients were white and middle class so these results may not be generalized to the general public. I am sure more studies are in the works, but for now don't be two suprised if you find an asympomatic infarct or meningioma.
Keywords: Heart Transplantation, Rejection, Syncope, Chest Pain (PubMed Search)
Children s/p Heart Transplantation – Rejection
Woods, WA. Care of the Acutely Ill Pediatric Heart Transplant Recipient. Pediatric Emergency Care. 23(10):721-724, October 2007.
Keywords: anticonvulsant, carbamazepine, seizure (PubMed Search)
Keywords: xanthochromia, intracranial bleed, cerebrospinal fluid, CSF (PubMed Search)