Keywords: stroke, tia, prevention, recurrent (PubMed Search)
--> 11.5% at 1 week
--> 6-15% at 1 month
--> 18.5% at 3 months
--> 8% at 1 week
--> 11.5% at 1 month
--> 17.3% at 3 months
Thom, et al. AHA Statistics Committee and StrokeStatistics Subcommittee. Heart Disease and Stroke Statistics-2006 Update. Circulation 2006; 113:e85-151.
Sacco, et al. Predictors of Mortality and Recurrence after Hospitalized Cerebral Infarction in an Urban Community: the Northern Manhattan Stroke Study. Neurology 1994;44:626-34.
Coull, et al. Population Based Study of Early Risk of Stroke after Transient Ischaemic Attack or Minor Stroke: Implications for Public Education and Organisation of Services. BMJ 2004;328:326.
Keywords: bisphosphonates (PubMed Search)
With the aging population, bisphosphonate use will continue to increase. They promote bone growth by inhibiting osteoclast action and resorption of bone. Unfortunately, they have their side effects and the FDA has sent out a recent warning that affects us all:
If a patient presents with severe bone/joint pain, check the med list to see if they are on a bisphosphonate - they may not be faking the pain. This can occur days, weeks or even years after initiation of dose
Category: Critical Care
Keywords: pulmonary hypertension, hypotension, calcium channel blockers (PubMed Search)
Pulmonary Hypertension Pearls
We are beginning to see more and more patients with pulmonary hypertension (PAH), many of whom are on continuous IV infusions of new medications. With that in mind, here are a few pearls:
Keywords: Pulmonary Embolism (PubMed Search)
Risk Factors for Pulmonary Embolism
Can you imagine one of our patients saying"Dr. Abaraham, I have what is known in the hematology community as a Factor 5 Leiden mutation"?
Keywords: aVR, electrocardiography, prehospital, pulmonary edema, CPAP, noninvasive ventilation (PubMed Search)
Keywords: aspirin, acute coronary syndromes (PubMed Search)
In the setting of an ACS, the minimum dose of ASA that should be given is 162 mg. Chewing provides antiplatelet effects slightly faster than simply swallowing, though the difference is probably not clinically significant. Enteric coated aspirin, however, clearly takes longer to work and should therefore be avoided in patients with ACS.
A dose of 325 mg does not appear to provide any further benefit beyond the 162 mg dose, though there might be a slightly higher bleeding rate. Despite that the 2005 PCI guidelines recommend a dose of 325 mg as the initial dose for patients with ACS if they are not chronically taking ASA. Otherwise, 162 mg is sufficient.
Keywords: Knee Injury, ACL, dislocation (PubMed Search)
Some quick facts about Knee Injuries:
Keywords: RSV, Apnea, Congenital Heart Disease, Chronic Lung Disease, Prematurity, Rapid testing (PubMed Search)
Bronchiolitis: Use of RSV rapid testing
Purcell K, Fergie J. Concominant serious bacterial infections in 2396 infans and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch pediatr adolesce med. 2002; 156: 322-324.
Keywords: anticonvulsant, status epilepticus, keppra (PubMed Search)
Knake et al. Intravenous levetriacetam in thetreatment of benzodiazepine-refractory status epilepticus. J Neurol Neurosurg Psychiatry 2007 Sept 26; Epub
Keywords: carotid artery dissection, stroke (PubMed Search)
Selim M, Caplan LR. Carotid Artery Dissection. Current Treatment Options Cardiovascular Medicine. 2004; 6: 249-253.
Stapf C, Elkind MS, Mohr JP. Carotid Artery Dissection. Annual Review Medicine. 2000; 51: 329-47.
Schievink W. Spontatneous Dissection of the Carotid and Vertebral arteries. NEJM. 2001; 344: 898-906.
Category: Critical Care
Keywords: adrenal insufficiency, hypotension, glucocorticoids, hydrocortisone (PubMed Search)
Adrenal Insufficiency in the Critically Ill
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.