Approaching the "Altered Mental Status"

Dr. Lin @ UCSF puts together a great blog with up to date resources. She is famous for her info cards for EM called "Paucis Verbis."  Check those out HERE.

This blog is a great refresher and review of how to approach the elderly patient with "Altered Mental Status" which is one of the most vague, yet common chief complaints we see. It is the essence of emergency medicine, as it is a complex and concerning complaint and the most "undifferentiated" patient presentation you can get. Take a look at the blog HERE.

Welcome Interns!

Hey all you interns! Welcome to Methodist we are glad to have you as part of our dysfunctional family!

A couple of things. I wanted to first introduce you to my blog (the one you are currently on). This is a place where I frequently post interesting cases, ultrasound images, cool updates or articles in Emergency Medicine, and lots more. If you are so inclined, place it up on your bookmarks and check it out.

Below I will provide you with a few sites and links I find CRUCIAL to be up to date and sharp in emergency medicine. Check them out:

Procedure Videos Galore

Own the Airway  - This is a MUST. Scroll through and make sure you have airway DOWN as an intern.

EKG Site  - Dr. Smith's FAMOUS ekg case interpretation website.



My Recommended Top 5 EM Blogs

#1: Life in the Fast Lane


#2: EM Literature of Note


#3: Receiving.


#4: The Poison Review


#5: EM Crit

Avoiding Resuscitation Med Errors

Check out this well done little blurb on correct dosing, etc for resuscitation by EMCrit

http://emcrit.org/podcasts/avoiding-resuscitation-medication-errors/

Spontaneous PTX: Needle vs Chest Tube

This one comes from Dr. Thompson. An interesting review of the literature on needle aspiration vs chest tube placement in stable spontaneous pneumothorax patients. Interesting findings that should make us think before placing a gaping wound in the patients chest.

Link to the article HERE

Stroke/TIA Mimics .... US Better Than Cardiologists

Two great articles from ACEP news. Well worth the read, especially in this day and age where we all fear the infamous "Stroke Code," a great discussion on mimickers of Stroke/TIA - most commonly being Complicated Migraine and Partial Seizure. I assure you after the article you will be more confident differentiating the bogus neuro symptoms and complaints we see ALL THE TIME, versus serious stuff we need to work up.

Stroke Mimic Article 


The next article is a summary of a cool study showing the uselessness of cardiologists -- haha just kidding. But seriously, a simple and quick bedside US Echo outperformed the cardiologists physical exam:  "Ultrasound had a far higher correct-diagnosis rate than did cardiologists’ physical exam for nearly all of the heart conditions the cardiologists encountered."

Check out the report here:

US vs Cardiologist Physical Exam Article

WINNERS: Ultrasound Competition MARCH 2013

Thanks to all who submitted.  The winner is:

MAYA LIN    -->  Maya's images below

Submission: DVT/PE  with Right Ventricular strain and classic D sign. This is a sign of Acute PE. You must however in the acute setting have some evidence differentiating RV strain of a chronic etiology to the acute etiology (PE or other mechanical RV outflow tract obstruction).

D Sign: This is a sign in which the LV appears like the letter D due to paradoxical leftward movement of the interventricular septum during LV relaxation.

Taken from an excellent article on Ultrasound of the Right Ventricle in Critical Illness

There are other ways to assess for acute PE in the setting of cardio-respiratory arrest including the McConnell sign , or apical RV contraction with a kinesis of RV free wall, plump IVC with no respiratory variation, RV/LV size ratio >1:1.

More Resources:

http://www.slideshare.net/basselericsoussi/thoracic-ultrasound-for-diagnosing-pulmonary-embolism

http://emoryeus.blogspot.com/2012/04/mcconnells-sign-and-acute-pe.html

Transvenous Pacer Placement

Thanks to a scary, but interesting recent case in our ED. The following is a helpful video to remind us all how to place this a temporary transvenous pacer.

Either here, in a formal dictated video:
http://www.youtube.com/watch?v=5BiQQYjw6no

Or here, in an actual clinical scenario: