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
Category: Critical Care
Keywords: central venous catheter, guidewire (PubMed Search)
Guidewire length for central venous catheterization
Keywords: Sternoclavicular, Dislocation, Posterior (PubMed Search)
Sorry this is being delivered to you late.
Keywords: electrocardiography, EKG, cardiogenic shock, acute myocardial infarction (PubMed Search)
Here's a nice, simple pearl for cardiogenic shock:
"A normal ECG virtually rules out shock due to myocardial infarction."
Essentially, even though MI may be associated with a normal ECG in approximately 5-8% of cases, if a patient has cardiogenic shock due to MI, the ECG will ALWAYS be abnormal.
Gowda RM, Fox JT, Khan IA. Cardiogenic shock: basics and clinical considerations. Int J Cardiol 2008;123:221-228.
Diarrhea and the Petting Zoo
Now that it is Spring Time, trips to the Zoo and to Pools will become more frequent… consider them as potential environmental exposure sites.
Petting Zoos, Farmers Markets and Fairs, and Swimming Pools (especially kiddie swimming pools) are known sources of enteropathogens that can cause diarrhea (sometimes bloody).
Consider these on your DDx of vomiting/diarrhea.
Ask about these possible exposure sites along with Travel History and Nontraditional Pets.
Keywords: heparin, chondroitin, toxicity (PubMed Search)
Heparin FDA Alert
In case you had not heard, there was a major recall of Baxter's Heparin. It was responsible for dozens of deaths in the USA and an investigation was launched. It has been found that the contaminant comes from manufacturing plants in China. The most concerning part is that it looks like it was chemically synthesized sulfated chondroitin. This brings the suspicion of intentional adulteration. First lead in toys now cartilage in our heparin - what's next?
Some fascinomas of Heparin:
News link for FDA Heparin Alert:
Keywords: tPA, stroke, intracerebral hemorrhage (PubMed Search)
Category: Critical Care
Keywords: phosphate, hypotension, hypomagnesemia (PubMed Search)
Potassium Phosphate ("K-phos")
Over the weekend, I had a patient with Dr. Scott that had a phosphate of 0.8 mmol/L. Phosphate < 1.0 mmol/L is an indication for IV repletion. IV repletion involves giving potassium phosphate. An important clinical question, therefore, is how much potassium does the patient actually get?
Keywords: cardiogenic shock, hypertrophic cardiomyopathy (PubMed Search)
Cardiogenic shock associated with LV outflow obstruction is managed best without the use of vasoconstrictive agents and vasopressors. Ideally, patients should be treated with IVF and beta blockade. Alpha agonists (e.g. ISO) can also be added.
Typical vasopressors may actually worsen LV outflow obstruction in these patients.
Keywords: Avulsed Tooth, hanks solution, dental emergencies (PubMed Search)
Dental Emergency -- Avulsed Tooth
Keywords: Gonorrhea, Chlamydia, Syphilis, Sexual Abuse, Trichomonas (PubMed Search)
Keywords: sumatriptan, myocardial infarction, migraine (PubMed Search)
Keywords: benign paroxsymal positional vertigo, vertigo, bppv, dix hallpike maneuver, dizziness (PubMed Search)
Keywords: Variceal Bleed (PubMed Search)
Medical Regimen for Suspected Variceal Bleed
To review what Dr. Bond and Dr. Winters have already posted:
Three medical therapies have been shown to be effective in patients with severe upper GI bleed thought to be due to esophageal varices:
Most of our gastroenterologists recommend this regimen (all three therapies)
Other things to consider:
Category: Critical Care
Keywords: fresh frozen plasma, coagulopathy, PRBC (PubMed Search)
Coagulopathy and Trauma
Keywords: MI, Cardiogenic Sock (PubMed Search)
Post-MI cardiogenic shock, while traditionally thought to carry a mortality > 80%, actually has perhaps half that mortality when patients are treated aggressively with prompt invasive therapy (PCI, possibly CABG). Fibrinolytics have traditionally been discouraged, but authors now indicate that they should be given if all of the following three conditions are present:
Sent on behalf of Dr. Amal Mattu
[adapted from: Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686-697.]
Keywords: Trigeminal Neuralgia, Microvascular decompression, treatment (PubMed Search)