ADOLESCENT DRUG ABUSE
Does this Patient with Diabetes have Osteomyelitis?
Does a normal d-dimer rule out aortic dissection?
A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.
A few pearls and pitfalls regarding this:
Pregnancy and Acute Pulmonary Embolism
Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.
Some facts:
Low QRS voltage on the ECG has various definitions; here's my simple definition for low voltage...either one of the following:
If the added QRS amplitudes (whole R wave + S wave) in leads I + II + III total < 15 mm, OR
If the added QRS amplitudes (whole R wave + S wave) in leads V1 + V2 + V3 total < 30 mm.
The potential causes of low QRS voltage includes pericardial effusions, pleural effusions, obesity, COPD, infiltrative cardiac diseases (e.g. sarcoid, amyloid), end-stage cardiomyopathies, severe hypothyroidism.
If the patient has NEW low voltage compared to an old ECG, the only real possibilities are pericardial effusion, pleural effusion, and severe hypothyroidism (e.g. myxedema).
Calcaneus Fractures
Normally occur due to axial loading mechanism such as:
Miscellanous Facts:
Pearls:
Pertussis means "violent cough".
Think of it with prolonged coughing, inspiratory whoop, absolute lymphocytosis, or chronic cough.
Don't Use cough suppressants.
Pertussis can be a life threatening Infection!! Especially in infants and young children.
Pertussis is a reportable infectious disease in the United States.
Patients with cancer that present with pleuritic chest pain often have pulmonary emboli, but don't forget about pericarditis. Lung and breast cancer, especially, are known to metastasize to the pericardium and produce pericarditis or pericardial effusions. Anticoagulation for presumed PE in patients with pericardial mets. can produce hemorrhagic tamponade, a disastrous iatrogenic complication, so think twice before starting empiric anticoagulation on patients...make sure your patient doesn't have pericarditis or an pericardial effusion.
The ECG in patients with cancer-related pericarditis or pericardial effusion does not always demonstrate the classic ST elevation wtih PR depression (which is most commonly seen in viral pericarditis). Patients with pericardial effusions often demonstrate low voltage and tachycardia. Electrical alternans, though "classic," only appears in 1/3 of patients with pericardial effusions.
Hip Fractures:
Typically divided into four types:
Here is a link to a picture with a good representation of the different types of fractures.
Here is a short list of medications that will actually prevent a patient from being anticoagulated by coumadin. These medications will make it difficult for the patient to reach therapeutic levels and need to be warned about this drug-drug interaction with coumadin:
Reference: Goldfrank's Textbook of Toxicologic Emergencies, 6th Edition
Passive Leg Raising (PLR)
Thrombolytic Therapy for PE Mike Abraham and I had a very interesting PE case a few nights ago: 30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU. Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable. Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. Considerations for giving lytics to a PE patient:
Just a reminder...an initially normal or non-specific ECG can certainly occur in patients that are actively having chest pain from acute MI. A 2001 study published in JAMA nicely pointed this out:
7.9% of patients having an acute MI had an initial normal ECG.
35.1% of patients having an acute MI had non-specific abnormalities on ECG.
57% of patients having an acute MI had diagnostic changes on ECG.
The greater the abnormality on the ECG, the worse the prognosis, but note that even when the ECG was normal, the in-hospital mortality in acute MI patients was 5.7%.
Although serial ECGs won't detect 100% of acute MIs, the diagnostic yield does certainly increase, and so whenever a patient has a concerning presentation, especially in the presence of on-going pain, make sure to get repeat ECGs!
[ref: Welch RD, et al, JAMA 2001]
Now that we have entered the session of cookouts, picnics, and family get togethers I thought I would review some of the more common causes of food poisoning and the typical foods that they are found in.
| Bacteria | Foods Typically Found In | Onset of Symptoms |
| Staphylococcus aureus | Meat and seafood salads, sandwich spreads and high salt foods. | 4-6 hours |
| Salmonella | Meat; poultry, fish and eggs and now tomatoes | 12 to 24 hours. Assoociated with fever |
| Clostridium perfringens | Meat and poultry dishes, sauces and gravies. | 12 to 24 hours. |
| Vibrio parahaemolyticus | Raw and cooked seafood. | 12 to 24 hours. Associated with fever |
| Bacillus cereus | Starchy food. Typically Chinese Fried Rice in test questions | 12 to 24 hours. |
| Campylobacter jejuni | Meat, poulty, milk, and mushrooms. | 24 hours |
Remember to save childrens lives be aggressive with septic shock treatment early!
Do NOT allow long delays at IV attempts before moving to central lines or IOs.
Goal in the first 0 to 15 minutes from presentation:
When community ED physicians successfully achieved shock reversal (defined by return of normal systolic blood pressure and capillary refill time) in the first 75 min from arrival there was an associated 96% survival and a > 9-fold increased odds of survival. Each additional hour of persistent shock was associated with >2-fold increased odds of mortality.
*To push this amount of fluid in an infant or young child it may be easier to use 60 ml syringes for boluses rather than pumps
Trandermal Delivery Systems
