Frank hypointensity (i.e. dark hue) on CT of the brain, particularly if involving greater than one-third of the middle cerebral artery (MCA) territory, is a contraindication to treating acute ischemic stroke with tPA.
Early signs of infarct on brain CT, regardless of extent, are NOT contraindications to treatment.
Red blood cell transfusion in the critically ill patient has been and continues to be surrounded by controversy and lack of hard data. Up to 90 percent of transfusions in the ICU are given for anemia, an indication which is least supported by the data. The joint taskforce of EAST, ACCM and SCCM has published a clinical practice guideline which outlines recommendations and rationale. These recommendations are summarized as follows:
RBC transfusion is indicated for patients with evidence of hemorrhagic shock.
RBC transfusion may be indicated for patients with acute hemorrhage and hemodynamic instability or inadequate DO2.
Transfusion triggers for Hb<7 are as effective as those for Hb<10 in hemodynamically stable critically ill patients, except for those with AMI or USA.
Hb used as a sole trigger is not advised; transfusion decisions should be based on intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.
Consider RBC transfusion if Hb<7 in resuscitated critically ill patients, patients who are being mechanically ventilated or critically ill patients with stable cardiac disease.
RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients.
RBC transfusion may be beneficial in patients with acute coronary syndromes with Hb<8 on hospital admission.
The Emergency Department is often the first line in detecting the sexual abuse of a child. Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.
1. Know your region's dedicated sexual abuse center, if one exists. These centers have personnel trained in interviewing and forensic evidence collection. There may be different centers for children of different ages.
2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse. GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.
3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence. Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.
4. Any sexually transmitted disease in a child warrants further workup and investigation. Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.
5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly. Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.
Posted: 12/13/2009 by Amal Mattu, MD
(Updated: 3/4/2026)
Yet another publication demonstrates that chest pain radiating to the right arm has the highest predictive value for ruling in ACS. In this study, radiation of the pain to the right arm had a higher predictive value than age, gender, comorbidites or traditional risk factors, specific descriptors of pain (e.g. "pressure" or "crushing"), or associated symptoms (e.g. diaphoresis, nausea, dyspnea). The bottom line....beware chest pain that radiates to the right arm!
[Goodacre S, Pett P, Arnold J, et al. Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram. Emerg Med J 2009;26:866-870.]
Patella fractures are typically due to direct trauma as in a fall or direct blow to the knee.
Fractures may be missed on the AP view or misdiagnosed as a bipartate fracture. To avoid these pitfalls look closely at the lateral view and consider getting a sunrise view of the knee (better visualizes the patella). Finally, unilateral bipartate patella are very rare so consider an x-ray of the contralateral knee if you are considering this as your diagnosis.
Surgery should be considered for:
Fractures with displacement greater than 3 mm.
Individuals that have lost there externsor mechanism as it is indicative of a tear in the extensor retinacula.
When IV access is not immediately available and you don’t want to rely on the erratic absorption of IM administration, naloxone can be given by the intranasal (IN) route.
Kinetics are similar to IV: Onset 1-2 minutes, duration 40-50 minutes.
Dose is the same as IV: Up to 1 mL (0.4 mg) can be given in each nostril.
Advantage of needleless administration.
To use: Draw up dose of nalxone and simply add an atomizer to the end of a syringe (see picture). Administer half of final dose in each nostril.
Cluster headache -> piercing eye pain; ipsilateral lacrimation and rhinorrhea; group of headaches come periodically in waves.
Temporal arteritis -> dull ache over temporal artery; associated with arthralgia, myalgia, and anemia; typically in older populations.
Glaucoma -> eye pain with cloudy appearing cornea; eyeball feels hard; pupillary dilitation may worsen pain.
Sinusitis -> associated with sinus congestion; tenderness over sinus with or without swelling; typically only relieved with decongestants and/or antibiotics.
Subarachnoid hemorrhage -> pain may be diffuse or unilateral; sudden onset of severe pain; may be associated with a stiff neck.
Effort thrombosis, also called Paget von Schrotter disease, occurs when either the axillary and or subclavian veins thrombose. The condition is more common in young, healthy (>males) patients and presents with the usual DVT symptoms of arm pain, swelling, and pain.
The disease was originally described in patients performing vigorous activities, like weight lifting or repetitive over-the-head lifting. This type of activity has been reported to kink the subclavian vein and lead to clot formation.
Diagnosis and therapy is the same for any other type of DVT.
When patients present with acute MI, all NSAIDS should be discontinued (e.g. ibuprofen, COX-2 inhibitors, etc.) during the hospitalization. Continued use of NSAIDs during the hospitalization increases the risk of CHF, myocardial rupture, hypertension, reinfarction, and mortality.
Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
Oxygen challenge - place baby on 100% 02 via NRB; 10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue; no or minimal change suggests a congenital heart defect
If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute; improvement may be drastic and is usually seen within 15 minutes
Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures; have your code cart and intubation equipment ready to go prior to beginning infusion
It was discovered that glucose given ORALLY caused more insulin release than glucose administered INTRAVENOUSLY. This led to the discovery of the incretin hormones, which are secreted by the gut (INtestinal SECRETion of INsulin), GIP and GLP-1.
The incretin-based therapies increase levels of GLP-1, either by providing an incretin mimetic (exenatide and liraglutide), or by inhibiting their breakdown by DPP-4 (sitagliptin, saxagliptin, vilagliptin)
Their administration results in:
Stimulation of glucose dependent insulin secretion
Calciphylaxis is a rare disorder caused by systemic arteriolar calcification which leads to ischemia and necrosis.It is characterized by painful ischemic necrotic lesions on adipose tissue areas such as abdomen, buttock and thighs.This commonly occurs in patients with ESRD on hemodialysis or after transplant, but can also occur with other patients, such as those with hyperparathyroidism.
Diagnosis is made clinically, with the help of a skin biopsy as needed.Differential diagnosis includes cholesterol embolization, warfarin necrosis, cryoglobulinemia, cellulitis and vasculitis.There are no specific laboratory findings, although patients may manifest elevated PTH, phosphorous, calcium or calcium x phosphorous product.
Infection is usually the cause of the high mortality rate of this condition, which has a reported mortality of 46%, or 80% if ulceration is present.
Treatment includes local wound care, trauma avoidance, electrolyte correction, increased frequency of dialysis or parathyroidectomy as needed. Surgical debridement is controversial; as the risk of infection may outweigh the benefit in terms of outcome.
This monday's pearl (ok, I know, it's tuesday now) comes from Michelle Lin's blog: academic life in emergency medicine. It is more gem than pearl, and it discusses what medical students and residents do to avoid being pimped. It is a must read!
Here is the link to the discussion on Michelle Lin's blog:
Just a few note worthy "pimping protection procedures":
The "Muffin"-person being pimped raises a muffin (or some other food item) to their mouth as they are being pimped. And if the person with the muffin stills gets the question, the pimpee pretends to choke, thus avoiding future pimp questions
The "Eclipse"-eclipsing your head with someone in front of you, that way the pimper can't see you.
The "Politician's" approach-answering the question you wished you were asked.
Posted: 11/29/2009 by Amal Mattu, MD
(Updated: 3/4/2026)
Up to 10% of elderly patients in the ED meet criteria for acute delirium, though misdiagnosis rates are very common. The most common cause of delirium in the elderly, overall, is medication effects. Other common causes are infections (UTIs most common), CNS abnormalities, cardiovascular abnormalities, electrolyte/metabolic abnormalities, and temperature abnormalities (fever or hypothermia).
Vision loss whether acute or chronic is a common presenting complaint to the ED. This will be the first in a series of pearls on the subject. This pearl will address the nomenclature used by ophthalmology based on the length of vision loss.
• Transient visual obscuration - Episodes lasting seconds. Usually associated with papilledema and increased intracranial pressure. • Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes • Transient monocular visual loss or transient monocular blindness - A more persistent vision loss that lasts minutes or longer • Transient bilateral visual loss - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss • Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss
Neuroleptic Malignant Syndrome (NMS) is a rare, but true neurological emergency which is today associated with much lower mortality given heightened awareness about the condition.
It typically initiallybegins with muscle rigidity resulting in rhabdomyolysis, followed by high fever, and delirium.
Always check creatinine phosphokinase (CPK) and white blood cell levels when concerned about NMS, as these typically elevate in response to muscle breakdown.
The following mnemonic (FEVER) serves as a reminder of the signs and symptoms associated with NMS:
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