Type B Lactic Acidosis
Though most causes of acute pericarditis in patients from developed countries are viral or idiopathic, the etiology of pericarditis in patients visiting from developing countries is usually TB, and the TB accounts for > 90% of cases of pericarditis in patients with HIV infection. This group of patients, therefore, should almost always be admitted for a full workup of the cause and for appropriate treatment.
Prosthetic hip dislocations are a common occurance in the Emergency Department. After you have gotten the hip back in place there are several ways to prevent the hip from coming out again. An abductor pillow will work but it confines the patient to bed. A better option to prevent further hip dislocations until the patient can get an appropriate brace made or reparative surgery is to place the patient in a straight leg knee immoblizer. It is nearly impossible to dislocate your hip if your knee is fully extended.
So after reduction of their simple hip dislocation (i.e: no fractures) place the patient in a straight leg knee immobolizer and they can followup with their orthopedist as an outpatient.
Many drugs/toxins cause nystagmus, particularly in overdose. Vertical, horizontal, or rotary nystagmus may be noted.
The most common drug/toxin overdoses that cause nystagmus are the following:
-- Multiple areas of local cortical brain atrophy (wedge-shaped
appearance) suggests multi-infarct dementia.
-- Disproportionate atrophy in the frontal and temporal lobes may be a
sign of Alzheimer's Disease.
Magnesium depletion has been described as "the most underdiagnosed electrolyte abnormality in current medical practice"
Important for electrically excitable tissues and smooth muscle cells, Mg is mostly located in bone, muscle and soft tissue. Because only 1% is located in blood, your patient can be Mg depleted with normal serum levels.
65% of ICU patients are magnesium depleted (and may not be hypomagnesemic). Because labs are unreliable, consider predisposing causes, such as diuretics, antibiotics (aminoglycosides, amphotericin), digitalis, diarrhea, chronic alcohol abuse, diabetes and acute MI (80% of AMI patients will have magnesium depletion in the first 48 hours).
Mg depletion is typically accompanied by depletion of other electrolytes (K, Phos, Ca), and can cause arrhythmias (especially torsades) and promote digitalis cardiotoxicity.
Hypermagnesemia is less common, and can be caused by hemolysis, renal insufficiency, DKA, adrenal insufficiency and lithium toxicity. Clinical findings include hyporeflexia, prolonged AV conduction, heart block and cardiac arrest. Treatment includes fluid and furosemide, calcium gluconate and dialysis.
Some not too uncommon complications of Type B (distal) aortic dissection:
When prescribing quinolones to elderly (e.g. for UTI) patients that are taking iron supplements, advise them to take the antibiotic several hours before taking the iron. Iron will bind the antibiotic in the GI tract and reduce its bioavailability.
[Anderson RS, Liang SY. Infections in elderly patients. Critical Decisions in Emergency Medicine, 2010;24(8):13-18.]
Ventilator Pearls for H1N1 Influenza Virus
Acute Mesenteric Ischemia
Although we all know the classic presentation of acute mesenteric ischemia (AMI), it can be tough to diagnose.
Some pearls about AMI:
Three groups of patients are at especially high risk of bleeding from excessive anticoagulation with renally-excreted medications: women, the elderly, and patients with chronic renal insufficiency. For all of these patients, ALWAYS dose their renally-cleared medications based on creatinine clearance, NOT just the creatinine.
Which medications in ACS does this apply to?--enoxaparin and G2B3A inhibitors are the most prominent here to consider.
The literature not only demonstrates increased bleeding complications but also increased MORTALITY if you don't dose based on creatinine clearance!
Review of the Appearance of Ossification Centers in Children's Elbows
Determing if a child's elbow has a fracture or if you are looking at an ossification center is easier if you remember the mnemonic CRITOE. This is the order that the ossification centers appear:
Catheter-related bloodstream infections occur in 3-8 percent of insertions, and are the highest cause of nosocomial bloodstream infections in the ICU.
The most effective measures to prevent catheter-related infections are as follows:
Especially applicable to those of us placing these lines in the ED or in the ICU is the last recommendation, based on a prospective study from Greece
-adequate knowledge and use of care protocols
-qualified personnel involved in changing and care
-use of biomaterials that inhibit microorganism growth and adhesion
-good hand hygiene
-use of an alcoholic formulation of chlorhexidine for skin disinfection and manipulation of the vascular line
-preference for subclavian route for placement
-use of full barrier protection during placement
-removal of unnecessary catheters
-use of ultrasound for placement of central lines
Complications of Liver Biopsy
Some considerations for the patient who presents with pain after a liver biopsy:
Consider getting a chest xray and a RUQ ultrasound to evaluate for these complications if they show up in the ED. CT scanning might also be required.
Also consider getting Interventional Radiology involved early in cases of bleeding as this is often the preferred treatment for biopsy site bleeding. In addition, a surgical consult is wise
in case the patient requires operative intervention.
Although supplemental oxygen has long been considered standard care for patients with ACS, the evidence supporting this concept is largely based on animal studies in which acute MI was artificially induced. Should these studies be extrapolated to humans? Maybe not....
Further review of the animal and human literature actually indicates that the routine use of supplemental oxygen and induction of hyperoxia can actually induce adverse hemodynamic consequences such as increased coronary artery tone and reduction in coronary artery blood flow; reductions in cardiac output and increased systemic vascular resistance; and potentially increased infarction size. It certainly seems prudent to treat hypoxia, but if the patient is not hypoxic, skip the supplemental oxygen!
Wijesinghe M, et al. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart 2009;95:198-202.
AND
Farquhar H, et al. Systematic review of studies of the effect of hyperoxia on coronary blood flow. Am Heart J 2009;158:371-377.