A critically-ill patient requires fluid resuscitation. Someone hands you a bag of this. What’s the pH of this fluid?
Nonatherosclerotic Coronary Artery Disease
- Nonatherosclerotic coronary artery disease (NACAD) is a term used to describe a category of diseases, which include: spontaneous coronary artery dissection (SCAD), coronary fibromuscular dysplasia (FMD), ectasia, vasculitis, embolism, vasospasm, or congenital anomaly.
- NACAD is an important cause of myocardial infarction (MI) in young women, but is often missed on coronary angiography.
- A small retrospective study of women <50 years of age with ACS found that 54.8% had normal arteries, 30.5% atherosclerotic heart disease (ACAD), 13% nonatherosclerotic coronary artery disease (NACAD), and 1.7% unclear etiology.
- NACAD accounted for 30% of MI’s with SCAD & Takotsubo cardiomyopathy accounting for the majority of cases.
Is there any benefit to the use of prednisone in the treatment of lower back pain? One study showed that about 5% of patients receive prednisone for the treatment of their low back pain, but does it work.
A recent study by Eskin et al published in the Journal of Emergency Medicine looked at this question. They conducted a randomized controlled trial of 18-55 year olds with moderately severe low back. Patients were randomized to receive prednisone 50mg for 5 days or placebo.
The study enrolled a total of 79 patients, and 12 were lost to follow up. At followup there was no difference in their pain, or in them resuming normal activities, returning to work, or days lost from work. To make matters worse more patients in the prednisone group sought additional medical treatment 40% versus 18%.
Conclusion: With the results of this study we should continue the treatment of low back pain with non-steroidials, muscle relaxants and exercise. There does not appear to be any role for steroids in the treatment of these patients.
6-7% of kids presenting with upper respiratory symptoms will meet the definition for ABS.
The American Academy of Pediatrics (AAP) reviewed the literature and developed clinical practice guideline regarding the diagnosis and management of ABS in children and adolescents.
The AAP defines ABS as: persistent nasal discharge or daytime cough > 10 days OR a worsening course after initial improvement OR severe symptom onset with fever > 39C and purulent nasal discharge for 3 consecutive days.
No imaging is necessary with a normal neurological exam.
Treatment includes amoxicillin with or without clauvulinic acid (based on local resistance patterns) or observation for 3 days.
Optimal duration of antibiotics has not been well studied in children but durations of 10-28 days have been reported.
If symptoms are worsening or there is no improvement, change the antibiotic.
There is not enough evidence to make a recommendation on decongestants, antihistamines or nasal irrigation.
Since synthetic cannabinoids arrived on the scene, we have become familiar with their sympathomimetic effects such as emesis, tachycardia, hypertension, agitation, hallucinations, and seizures.
Acute kidney injury is also being linked to synthetic cannabinoid use. Several clusters have been described in a handful of states, the most recent coming from Oregon with 9 patients.
AKI seems to be one more adverse effect to be on the lookout for when evaluating patients after synthetic cannabinoid use.
Should I Give My Patient with Septic Cardiomyopathy Fluids?
The incidence of acute LV dysfunction in septic shock is estimated to occur in 18 - 46% of patients within the first 24 hours of shock. Unlike the "classic" pattern of cardiogenic shock where LV filling pressure is high, in septic shock there are normal or low LV filling pressures.
Three therapeutic options should be strongly considered in the patient with a septic cardiomyopathy [CM]:
30 year-old female with complains of night sweats and painful lesions on her fingertips. What’s the diagnosis and list some things to have in the differential diagnosis?
- Toxic effects of tricyclic antidepressants (TCA) are result of the following 4 pharmacologic properties:
1. Inhibition of norepinephrine & serotonin reuptake --> resultant seizure
2. Anticholinergic activity --> resultant altered mental status, tachycardia, mydriasis, ileus
3. Direct alpha-adrenergic blockade --> resultant hypotension
4. Cardiac myocyte sodium channel blockade --> resultant widened QRS
- A QRS interval greater than 100 milliseconds has ~30% chance of developing seizures and ~15% chance of developing a life-threatening cardiac arrhythmia.
- A QRS interval greater than 160 milliseconds increases the chance of ventricular arrhythmias to greater than 50%.
- Clinical pearl: A very wide complex ventricular rhythm, concomitant hypotension and/or seizure disorder is suspicious for toxic ingestion and standard ACLS algorithm will not suffice, treatment must address the underlying culprit (i.e. TCA --> Tx. fluids, vasopressors, sodium bicarbonate, and intravenous lipid emulsion).
Return to Play After Infectious Mononucleosis (IM)
-Long incubation period make it difficult to determine source or onset
Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.
DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)
Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)
Symptoms then progress into the classic “triad” of IM
Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)
May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)
Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)
Most commonly seen in patients treated with PCN antibiotics
Splenomegaly is an important complication in the athletic population
Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)
- Lymphocytic proliferation enlarges the spleen beyond protection from the ribs
- Physical examination has been shown to be unreliable for determining splenomegaly
- Highest risk is in the first 21 days (rare after 28 days)
Ultrasound is the modality of choice
-Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks
Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.
General Information:
Hypothermia is when the body’s core temperature is less than 35º C. Often thought as a winter disease, it can occur in nearly any climate or weather condition. However, a number of cold related conditions can occur without a drop in core body temperature.
Specific Cold Related Conditions:
Bottom line:
Remember that cold related injuries can occur without core hypothermia. Don’t forget the tetanus and antibiotics, as indicated.
There are many ventilator modes to choose from, but almost every mode can be distilled down to its basic principles by understanding the “Three T's of Mechanical Ventilation”
Trigger: You must determine whether the vent or patient will trigger a mechanical breath. For example, machine-triggered breaths (a.k.a. control mode of ventilation) are used for paralyzed patients and will deliver a breath after a period of time has elapsed (e.g., if RR is 10/min, then a breath is given every 6 seconds). On the other hand, if a patient’s respiratory drive is intact (a.k.a. assist-mode) than the patient triggers the breath when the vent detects a patient induced change in airflow or airway pressure. These two modes can also be mixed together.
Target: Mechanical breaths must have a specific target, either a target airway pressure or a tidal volume. Because pressure and volume are directly related, pick the variable you want to target and the other parameter will vary depending on the patient’s intrinsic physiology. For example, if you choose to target a specific tidal volume, we may get one plateau pressure in a patient with normal lungs, but a higher plateau pressure in another patient with stiffer lungs.
Terminate: You must decide when the mechanical breath (i.e., inspiration) terminates and expiration begins. Termination occurs: 1) after a set inspiratory time has elapsed in certain pressure-targeted modes, 2) when a predefined target volume has been achieved (i.e., volume-cycled modes), or 3) when airflow has been reduced by a certain percentage (as in pressure-support ventilation; to be discussed separately)
Let’s put this all together by looking at an example: pressure control ventilation (rate = 12/min and target pressure 20cm H20). Trigger: Because this is a “control”, not assist mode, the machine will trigger a breath 12 times per minute or every 5 seconds. Target: Here we chose to have pressure be the target, so when the ventilator triggers a breath it will deliver a constant airway pressure of 20 cmH2O until we tell the vent terminate that breath. Terminate: the constant airway pressure will be turned off after a fixed period of time has elapsed; for this example we will set the inspiratory time as 1 second, then expiration begins. Now, after a few vent breaths we will observe the results of our settings and reassess; if the resulting tidal volume is lower than what we wanted, we will increase the target pressure to increase the tidal volume. If the tidal volume is higher than what we wanted, we will reduce the target pressure to reduce the tidal volume. We can also tweak the inspiratory time to manipulate the tidal volume, but this does so to a lesser degree.
Try to break down your favorite modes of ventilation using the Three T’s and see if this helps you understand vent modes better.
40 year-old female presents with painful lesions and ulcers on lower extremities. She has had this before, but never to this extent. She also has a history of DVT. What’s the diagnosis?
Advances in Hypertrophic Cardiomyopathy (HCM)
- HCM is a genetically transmitted autosomal dominant disorder with two variants: hypertrophic obstructive cardiomyopathy (HOCM), also known as idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy, and non-obstructive hypertrophic cardiomyopathy (HNCM), also known as Yamaguchi syndrome.
- The most serious complication of both variants of HCM is sudden cardiac death (SCD) and end-stage heart failure, which rapidly progresses to cardiac death after its occurrence.
- Beta-blockers (1st line) and non-dihydropyridine calcium channel blockers are effective at improving clinical symptoms (syncope, dyspnea, chest pain, and exertional intolerance, etc.) however neither alone nor combined halt the progressive LV remodeling and prevent end-stage heart failure.
- Cardiac transplantation is the only treatment available for end-stage heart failure, but must occur before the onset of pulmonary hypertension, kidney malfunction, and thromboembolism for success.
- Class Ia anti-arrhythmic, disopyramide has been shown to be effective for symptomatic improvement (NYHA classification), but does not improve overall LV function or hypertrophy.
- A recent study found that another class Ia anti-arrhythmic, cibenzoline has been shown not only to reduce symptoms, but also improved LV diastolic dysfunction and induced a regression of LV hypertrophy. In this study cibenzoline has halted the progression of HCM to end-stage heart failure.
Despite the lack of strong evidence to support the recommendation, the severity of the 2009 influenza pandemic prompted the World Health Organization (WHO) to advise that higher doses of oseltamivir (150 mg twice daily) and longer treatment regimens (> 5 days) should be considered when treating severe or progressive illness.
So, does the data support higher dosing in critically ill influenza patients?
A new systematic review concluded that "the small body of literature available in humans does not support routine use of high-dose oseltamivir in critically ill patients."
Bath salts (synthetic cathinones) commonly contain multipe synthetic drugs and can be ingested, smoked, or administered intravenously. The designer stimulant mephedrone (4-methylcathinone) is among the most popular of the derivatives of the naturally occurring psychostimulant cathinone. Bath salt use is on the rise and is responsible for a large number of ED visits.
In spite of their ban, bath salts are still available over the counter in specialty shops and through the Internet with common product names such as: "Ivory Wave," "Cloud 9," "Purple Wars," "Vanilla Sky," "Bliss," etc. They are commonly marketed with the disclaimer, "not for human consumption."
Their presentation mimics other sympathetic drugs through pathways similar to amphetamines. The primary psychological effects have a duration of roughly 3-4 hours, with physiologic effects lasting from 6-8 hours.
| Physical Effects | Behavioral & Mental Status Effects |
| Tachycardia | Agitation |
| Hypertension | Paranoia |
| Dysrhythmias | Hallucinations |
| Hyperthermia | Psychosis |
| Seizures | Violent behavior |
| Sweating | Delusions |
Management is largely supportive and includes IV hydration, benzodiazepines, and close monitoring in the ICU setting.
General Information:
Ebola is a deadly hemorrhagic fever of the virus family Filoviridae.
Clinical Information:
Treatment and Public Health
Bottom Line:
While the likelihood of general dissemination to the general U.S. population is very low, U.S. healthcare workers need to be aware and alert for the signs and symptoms of Ebola for patients recently returned from West Africa.
Observation after giving IM Epi for allergic reactions or anaphylaxis
Background
Question
Meta-analysis
Results
Limitations
What to do?
2-day old baby boy presents with forceful vomiting of entire feeds, bloated belly, and has not passed stools since birth. What's the diagnosis?
HIV & Atherosclerosis
Advances in antiretroviral treatment has increased the life expectancy of patients with HIV significantly, AIDS-related deaths have fallen by 30% since they peaked in 2005.
HIV infection predisposes to a chronic inflammatory and immunologic dysfunctional state, subsequent highly active antiretroviral treatment (HAART) results in metabolic changes and dyslipidemia.
In the post-HAART era, CAD is now considered to be the main cause of heart failure in HIV-infected patients, superseding the prior most common etiologies myocarditis and opportunistic infections.
The presentation of CAD in HIV-infected patients is largely similar to that in the general population with the exception is that they present at a younger age.
Certain antiretroviral agents specifically protease inhibitors have conventionally been associated with lipid dysfunction, further complicating the HIV-infected patients milieu.
Recent research has shown that a C-C chemokine receptor-type 5 (CCR5) antagonists has emerged as a potential target both as an antiretroviral agent as well as in the process of arresting atherogenesis, but warrants more research.
