ACS in Women

This discussion was based on an article Dr. Mattu called a "must-read" for all EM docs. It includes over a million M.I. patients from 1994-2006 and gives us a very interesting picture. Below is cut from the EMRAP written summary of June 2012. Link to the article HERE.

Yummy Pesticides. Lacrimation, salivation, etc.

Ok, we don't see it often but these wackos in Bangledesh see enough to do a small randomized study on Atropinaztion of these toxidromic people. Here it is.

Sticking with the ST Elevation Theme

Check out this study on PCI-activated patients with ST Elevations, retrospectively looked at by interventional cardiologists. They can't get it right either.

I have the pdf, email if you want it.

ANOTHER Dr. Smith MUST-READ

This is Dr. Smith's published article on Early Repolarization vs. STEMI in the Annals of Emergency Medicine.

This PDF is essential EM Resident reading.

The Best ECG Blog Around ...

You MUST check out Dr. Smith's ECG Blog. He is the guru genius of ecg's in our field and if you want to impress your attending, or better yet outwit the cocky cardio fellows then you gotta follow Dr. Smith's blog.

Here is a great example of a case he presents weekly. Also, as a side I had a fairly similar case in real life and may have missed the finding (very bad). It was a bit more subtle in my case.

What is wrong with this cardiogram? The patient has a known RBBB.

HERE is the case, and the answer.

Don't Miss This FRACTURE

Emergency Medicine News is a great source to keep up to date on literature as well as political and lobbying efforts, malpractice issues, business issues, and essentially everything to do with EM.

Check out this cool article on a high yield ortho topic.

MDMA ... Mega Dose Mortality Always

This Poison Review article shows us that a nice little lick of E can feel good and get you HOT, not in the sexual way.  Hyperthermia and eventually rhabdo, sepsis, DIC, renal failure and all kinds of fun complications killed several and destroyed several other lives after a night of raving to laser light fist pump music. Sad.


Most complications were secondary to high ambient temperatures, and prolonged dancing exacerbated by complicated serotonin/dopamine/norepi interactions driving high core body temperatures and increased muscle activity. The hyperthermia is what did the damage, unfortunately and as usual, simple supportive and cooling treatments were the only help.

"Cooling methods in the ED are either active or passive. Passive treatment includes ice pack application to neck, groin, and axillae and evaporative cooling. Immersion in ice water (1-3 degC) and evaporative cooling show equal efficacy.13 How- ever, ice water immersion is often impractical in the setting of a critically ill patient who requires monitoring as well as IV placement, ventilation, and resuscitation. Other methods reported include ice water lavage via nasogastric (NG) tube, chilled IV fluids, electronic cooling blankets, and neuromuscu- lar paralysis. These are not uniformly more effective than the previously mentioned methods but can be utilized as adjunct modalities.13 Although dantrolene was not specifically recom- mended by poison center staff, it was used in the management of 3 patients in this series. In 1 case report, it has been reported to control muscle hyperactivity in the setting of MDMA- induced hyperthermia."

The Limping Kiddie

Beware the limping kiddie. Non-weight bearing kids have septic arthritis, a potentially high-complication disease, high up on the differential. Here is some info on the Kocher criteria that has been validated. Also here is a GREAT presentation on determining the etiology of a limp, particularly septic arthritis vs transient or toxic synovitis.

Kocher criteria for a child with a painful hip, suspected to have septic arthritis:
1) non-weight-bearing on affect side 
2) sedimentation rate greater than 40 mm/hr 
3) fever 
4) WBC >12,000 

Criteria met and probability child has septic arthritis
4/4 -- 99%
3/4 -- 93%
2/4 -- 40%
1/4 --  3%

See:
Kocher etal. Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children. The Journal of Bone and Joint Surgery (American) 86:1629-1635 (2004).
http://www.ejbjs.org/cgi/content/abstract/86/8/1629

Attack of the Mosquitos

Its that time of the year and the humid, rain-filled early summer has propped us up for a potentially high-incidence summer of West Nile Virus (6 cases in BK in 2010).

Check out this Brooklyn Eagle article on the outlook for this summer.

And the CDC site on West Nile.

Unfortunately, supportive therapy only.