Guess what rhythm this is, and what would be the emergent treatment (and what about the definitive treatment?
Answer HERE
Friday, December 28, 2012
Monday, August 27, 2012
Peds DKA ... whats the difference?
Check out this great consensus article from the ADA on Peds DKA management... ARTICLE
Don't forget the risk of cerebral edema. Initial fluid resuscitation is 10-20cc/kg over 1-2hr and may be repeated as necessary.
More to come in upcoming blogs on the specifics of age and/or weight cutoffs for approaching older teenager/young adult patients using adult vs pediatric DKA management guidelines. **I have consulted the expert and I am currently awaiting a response.
Don't forget the risk of cerebral edema. Initial fluid resuscitation is 10-20cc/kg over 1-2hr and may be repeated as necessary.
More to come in upcoming blogs on the specifics of age and/or weight cutoffs for approaching older teenager/young adult patients using adult vs pediatric DKA management guidelines. **I have consulted the expert and I am currently awaiting a response.
Does Sux Increase ICP?
Fantastic literature review.
ARTICLE
Everything we give has "theoretical" risks. A commonly cited one, particularly in the realm of head trauma but also relevant to other acute neurological insults like SAH that raise ICP dramatically, is Succinylcholine elevating ICP. Many have debated the topic. The above review article is a fantastic summary of the most well respected and frequently cited source articles within the literature. Interpret on your own if you'd like, but these experts have concluded:
1) The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injuries.
2) There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anesthesia.
Some of these article also identify ICP elevation from the intubating procedure itself and therefore traumatic or acute ICH patients who are intubated may experience increases from this.
ARTICLE
Everything we give has "theoretical" risks. A commonly cited one, particularly in the realm of head trauma but also relevant to other acute neurological insults like SAH that raise ICP dramatically, is Succinylcholine elevating ICP. Many have debated the topic. The above review article is a fantastic summary of the most well respected and frequently cited source articles within the literature. Interpret on your own if you'd like, but these experts have concluded:
1) The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injuries.
2) There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anesthesia.
Some of these article also identify ICP elevation from the intubating procedure itself and therefore traumatic or acute ICH patients who are intubated may experience increases from this.
Thursday, August 23, 2012
Ostrich Pseudoaxioms
For lack of creative impulse, this week I have sifted through some old writing I have done in the past. Here is the link to an oldie but goodie. A blog I entered a while back, enjoy:
Link to my old blog.
Link to my old blog.
Monday, July 30, 2012
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.
Tuesday, July 17, 2012
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.
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.
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.
Sunday, July 15, 2012
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.
Friday, July 13, 2012
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."
Sunday, July 1, 2012
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
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.
Check out this Brooklyn Eagle article on the outlook for this summer.
And the CDC site on West Nile.
Tuesday, June 26, 2012
Friday, June 22, 2012
Annals of EM Survey: Minor Complaints (the other GOMER)
Ok , I had to. This is something we all wonder about ( I mean ... get ragingly and tirelessly furious about).
These guys surveyed people waiting in the ED for what were determined to be MINOR complaints. The data is interesting and not entirely what I expected:
Annals of Emergency Medicine S235
I was very surprised that 33.4% were actually referred by their PCP.
I am curious if this is because PCP's: 1) Don't like their patients , 2) Are overburdened and this is a form of "referring" 3) Are incompetent or ill-equipped to handle minor problems.
There are systemic failures at the base of this but it is interesting! Knowledge is power.
These guys surveyed people waiting in the ED for what were determined to be MINOR complaints. The data is interesting and not entirely what I expected:
172 Why Do Patients With Minor Complaints Prefer
Emergency Departments Over Primary Care
Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints.
Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP).
Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac.
Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival.
Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office.
We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED.
Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints.
Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP).
Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac.
Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival.
Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office.
We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED.
Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
Volume 58, 4S : October 2011
I was very surprised that 33.4% were actually referred by their PCP.
I am curious if this is because PCP's: 1) Don't like their patients , 2) Are overburdened and this is a form of "referring" 3) Are incompetent or ill-equipped to handle minor problems.
There are systemic failures at the base of this but it is interesting! Knowledge is power.
Thursday, June 21, 2012
Lessons from Telluride Patient Safety Conference
Hey, so to prove that I have not simply been mountain biking, hiking, sun bathing, and breathing fresh mountain air while consuming locally brewed IPA beer , I decided to make a few blogs on lessons from this excellent conference on patient safety that the department sent me to.
The first thing I wanted to talk about was a little-known law that is increasing throughout the country in state legislation. They are called apology laws. Apology laws come in different forms but all intend to exclude physicians' apologies or other interpreted acceptance of error into liability case testimony. This is an effort to encourage open discussion and apology of error with patients and their families, and reduce the current medical culture's fear of acknowledgement of error. There is growing evidence that these laws alleviate some of this and may actually reduce malpractice suits and thus healthcare costs.
This extraordinarily thorough paper outlines the current evidence and discussion regarding apology laws. New York does not yet have legislation of this type yet, but the more we educate ourselves on it the more push there will be to add this. The following is a quote from the paper:
The first thing I wanted to talk about was a little-known law that is increasing throughout the country in state legislation. They are called apology laws. Apology laws come in different forms but all intend to exclude physicians' apologies or other interpreted acceptance of error into liability case testimony. This is an effort to encourage open discussion and apology of error with patients and their families, and reduce the current medical culture's fear of acknowledgement of error. There is growing evidence that these laws alleviate some of this and may actually reduce malpractice suits and thus healthcare costs.
This extraordinarily thorough paper outlines the current evidence and discussion regarding apology laws. New York does not yet have legislation of this type yet, but the more we educate ourselves on it the more push there will be to add this. The following is a quote from the paper:
"Most patients and families who file a legal action report feeling angry, bitter, betrayed, or
humiliated. In cases where explanations were given, patients and family report feeling
dissatisfied—that the explanation was unclear, inaccurate, or sparse—even though 40% felt like
the explanations were given sympathetically. Most were informed of the error by hospital
administration in 70% of cases, and by the doctor in less than 10% of cases. This leaves one to
wonder whether a doctor’s direct acknowledgment and explanation of the error would have
changed the patient’s willingness to sue. "
Monday, June 4, 2012
Annals: Hydroxycobalamin , more evidence that it is the SHIT!
Check out this animal study in the Annals. It appears we should start throwing away our Thiosulfate:
Study objective
We compare the efficacy of hydroxocobalamin to sodium thiosulfate to reverse the depressive effects on mean arterial pressure in a swine model of acute cyanide toxicity and gain a better understanding of the mechanism of action of the hydroxocobalamin in reversal of the toxicity.
Methods
Swine were intubated, anesthetized, and instrumented with central arterial and venous lines and a pulmonary artery catheter. Animals (n=36) were randomly assigned to one of 3 groups: hydroxocobalamin alone (150 mg/kg), sodium thiosulfate alone (413 mg/kg), or hydroxocobalamin (150 mg/kg)+sodium thiosulfate (413 mg/kg) and monitored for 60 minutes after the start of antidotal infusion. Cyanide was infused until severe hypotension developed, defined as blood pressure 50% of baseline mean arterial pressure. Repeated-measures ANOVA was used to determine statistically significant changes between groups over time.
Results
Time to hypotension (25, 28, and 33 minutes), cyanide dose at hypotension (4.7, 5.0, and 5.6 mg/kg), and mean cyanide blood levels (3.2, 3.7, and 3.8 μg/mL) and lactate levels (7, 8.2, 8.3 and mmol/L) were similar. All 12 animals in the sodium thiosulfate group died compared with 2 of 12 in the hydroxocobalamin/sodium thiosulfate group and 1 of 12 in hydroxocobalamin group. No statistically significant differences were detected between the hydroxocobalamin and hydroxocobalamin/sodium thiosulfate groups for carbon monoxide, mean arterial pressure, cyanide levels, or mortality at 60 minutes. Lactate level (2.6 versus 2.1 mmol/L), pH (7.44 versus 7.42), and bicarbonate level (25 versus 26 mEq/L) at 60 minutes were also similar between groups.
Conclusion
Sodium thiosulfate failed to reverse cyanide-induced shock in our swine model of severe cyanide toxicity. Further, sodium thiosulfate was not found to be effective when added to hydroxocobalamin in the treatment of cyanide-induced shock. Hydroxocobalamin alone was again found to be effective for severe cyanide toxicity.
Wound Care ... Take-Home Points From Tintinalli
Hey guys, anyone else annoyed at the lengthy Rosen's chapters? Remember we still have access to Tintinalli's for FREE online @ AccessEmergencyMedicine.com (login: nymh, pass: medicine). Sift through it at your leisure on your iPad instead of lugging the fat text around.
Here are what I think are some cool take-home points from the chapter on wound care:
#1 Important hx questions: blunt vs. sharp?, occupation & handedness? chronic med conditions? self-attempted wound care @ home & time elapsed until initial cleansing? hx of keloid?
#2 For adults: Ask if they feel a foreign body! Those who feel they do are much more likely to have a foreign body in the wound --> LR = 2.49 vs LR = 0.69
#3 Dirty wounds --> axilla, perineum, toe webs, intertriginous areas have *millions of bacteria per sq CM
#4 Finger Lac: finger tourniquets OK if less than 30 min, you CAN use lido with EPI for digital blocks/local!
#5 Sterility in wound care has no evidence for preventing infection! Use common-sense cleanliness.
#6 A "Bleeder" , if it is a small superficial vessel can be compressed using horizontal mattress or figure eight suture seen in the image above.
#7 Ultrasound can detect foreign bodies if they are hyperechoic *look for shadowing.
#8 You can use chlorhexidine/betadine AROUND the wound to clean the skin, but do not let it get in the wound or near edges as it impairs healing.
#9 Irrigation: a) do not SOAK
b) Low pressure = 0.5 psi (for delicate tissue e.g. eyelid, or uncontaminated wound)
c) high pressure = 7 psi for most wounds * 50ml syringe w/ 18G catheter = 20psi
d) Volume = 60mL per cm of wound, OR just remember 200mL's total for typical
e) USE STERILE SALINE (least toxic)
#10 Abx: Debris or feces, bites, or wounds in avascular areas ** GIVE
Human bites (anywhere) and mammal bites to the hands: give amox/clavulanate to cover
Pasteurella and Eikenella
Fresh water wounds or puncture through rubber/sneaker = cover pseudomonas
Duration of abc: 3-5 d for non-bite , 5-7 d for bites
Here are what I think are some cool take-home points from the chapter on wound care:
#1 Important hx questions: blunt vs. sharp?, occupation & handedness? chronic med conditions? self-attempted wound care @ home & time elapsed until initial cleansing? hx of keloid?
#2 For adults: Ask if they feel a foreign body! Those who feel they do are much more likely to have a foreign body in the wound --> LR = 2.49 vs LR = 0.69
#3 Dirty wounds --> axilla, perineum, toe webs, intertriginous areas have *millions of bacteria per sq CM
#4 Finger Lac: finger tourniquets OK if less than 30 min, you CAN use lido with EPI for digital blocks/local!
#5 Sterility in wound care has no evidence for preventing infection! Use common-sense cleanliness.
#7 Ultrasound can detect foreign bodies if they are hyperechoic *look for shadowing.
#8 You can use chlorhexidine/betadine AROUND the wound to clean the skin, but do not let it get in the wound or near edges as it impairs healing.
#9 Irrigation: a) do not SOAK
b) Low pressure = 0.5 psi (for delicate tissue e.g. eyelid, or uncontaminated wound)
c) high pressure = 7 psi for most wounds * 50ml syringe w/ 18G catheter = 20psi
d) Volume = 60mL per cm of wound, OR just remember 200mL's total for typical
e) USE STERILE SALINE (least toxic)
#10 Abx: Debris or feces, bites, or wounds in avascular areas ** GIVE
Human bites (anywhere) and mammal bites to the hands: give amox/clavulanate to cover
Pasteurella and Eikenella
Fresh water wounds or puncture through rubber/sneaker = cover pseudomonas
Duration of abc: 3-5 d for non-bite , 5-7 d for bites
Friday, June 1, 2012
EMU: Crazy Israeli EM Doc
Guys , this crazy EM doc from Israel scours the new literature and with significant bias (thanks to experience and wisdom) interprets the significance of these studies for our practice. Check out this months:
Priapism: when thinking about grandpa's nose hair won't help
Things we get hot and bothered (and sued) over in EM are usually things that cause loss of "life and limb" but I think erectile function should be included in the mantra. To some people, that is life. And to other lucky men, it is equivalent in size to a limb.
So, for those who missed my morning report lecture (or were sleeping). Here is a video of how to perform the priapism reduction from a great site that has many videos of commonly performed procedures, EM Procedures. Much thanks to @mdaware for the video!
Thursday, May 31, 2012
HINTS: a hint, toward central VERTIGO
Do you feel like a moron when checking for central vertigo (I often do)? We learn lots of vague differences in the history and physical to differentiate central vs. peripheral vertigo, lots of attendings have taught us their own 'way', but what is there good evidence for?
Check this quick "Paucis Verbis" card from the well known Academic Life in Emergency Medicine blog from UCSF EM:
Acute Vestibular Syndrome, HINTS exam
Check this quick "Paucis Verbis" card from the well known Academic Life in Emergency Medicine blog from UCSF EM:
Acute Vestibular Syndrome, HINTS exam
Wednesday, May 30, 2012
Tox, from the SICKEST source.
Welcome to the first posting on nymem.blogspot.com , New York Methodist EM program's e-resource guide!
I will update the site as frequently as I am able to with up to date literature summaries and analysis, interesting blog-posts from EM or other medical specialties, cool photo/video cases, sweet links to free online texts/journals/etc, and other relevant online materials that can augment our learning outside of conference and the ED.
I'll start with a cool tox case, walked through by what I believe is one of the best EM sites out there: Life in the Fast Lane. Check it....
I will update the site as frequently as I am able to with up to date literature summaries and analysis, interesting blog-posts from EM or other medical specialties, cool photo/video cases, sweet links to free online texts/journals/etc, and other relevant online materials that can augment our learning outside of conference and the ED.
I'll start with a cool tox case, walked through by what I believe is one of the best EM sites out there: Life in the Fast Lane. Check it....
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