EPSS is an accurate and rapid bedside estimation of left ventricular function
First an image of heart should be obtained in the parasternal long-axis view
The ultrasound cursor should be placed through the anterior leaflet of the mitral valve
Subsequently, M-mode is applied and the distance between the anterior leaflet and the interventricular septum is measured during early diastole
A measurement of 7mm or greater indicates poor EF (see attachment below)
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Attachments
Distal radius fractures are common in children
Traditional management includes closed reduction +/- procedural sedation
The downside of this approach includes: patient risks, cost, physician time, ED bed time and tying up resources.
Kids have excellent bone remodeling potential...displaced and angulated fractures heal well without reduction
Crawford et al - 51 children aged 3 to 10 (avg 6.9 yrs) w/closed distal radius fractures.
Exclusions: open or growth plate fractures, metabolic bone disease or neurovascular injury.
No sedation, analgesia or fracture reduction was performed
Treatment: simple casting and gentle molding to correct angulation... i.e. fractures were left in a shortened, overriding position
Outcome: All patients had clinical and radiographic union and full range of motion of the wrist at one year w/ good patient (parent) satisfaction. This was associated w/ significant cost savings.
Consider this approach in consultation with orthopedist
Remember exclusions: open fractures, fracture dislocations, growth plate injuries and neurovascular injury.
Children w/ excessive angulation or rotational deformity should have standard care (closed reduction w/ sedation)
Multiple guidelines exist for "excessive angulation" but as a general rule
Age < 5 Up to 35 degrees
Age 5- 10 Up to 25 degrees
Age >10 Up to 20 degrees
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- The differential of child with stridor <6m:
- Tips for the treatment of croup:
As everyone knows by now the New England Compounding Company has been implicated in contaminated steroid vials that were used for epidural injections. Patients that have pleocytosis on CSF after lumber puncture will be admitted and started on liposomal amphotericin B and IV voriconozaole.
IV Voriconazole Adverse Effects:
Vivid visual hallucinations
Visual Disturbances - 30 min after administration: Blurry, photosensitivity
Hepatotoxitcity
Photoxicity - associated with increased risk of squamous cell CA of the skin
- Causative organism: members of the genus Borrelia
- Louse Borne Relapsing Fever (LBRF)
- Human body louse (Pediculus humanus)
- Associated with sporadic outbreaks especially in areas with large refugee populations
- Tick Borne Relapsing Fever (TBRF)
- Soft ticks of the genus Ornithodoros
- Typically found in higher elevations of the western United States as well as the central plateau region of Mexico, Central and South America and Africa
- Louse Borne Relapsing Fever (LBRF)
- Clinical Presentation
- Symptoms develop 3 to 18 days after infection.
- Onset is abrupt and may include fever, malaise, headache, arthralgias, nausea and vomiting and cough.
- The first febrile episode lasts 3 to 6 days and then recurrences may occur after 7 to 10 days.
- Diagnosis
- Definitive diagnosis: visualization of spirochetes on peripheral blood smear.
- May also see leukocytosis, anemia and/or thrombocytopenia, elevation of liver function tests
- Erythrocyte rosette formation may be present.
- Treatment
- Antibiotics recommended for treatment include penicillin, doxycycline and erythromycin.
- Jarisch-Herxheimer reaction common after treatment. This can be life threatening and all patients undergoing treatment should be closely monitored.
University of Maryland Section for Global Emergency Health
Author: Gentry Wilkerson
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Question
Trauma patient (...yes, that's the only history you're given). Diagnosis?
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Cardiac amyloidosis can present along a spectrum from asymptomatic to severe CHF w/conduction abnormalities
ECG with low voltage + echocardiogram with thickened myocardium should heighten suspicion
Definitive Dx. is myocardial biopsy identifying the infiltrative lesion (MRI w/gad is also supportive)
AL (light chain) amyloidosis is an acquired disease from improperly functioning plasma cells
¨ Rapidly progressive and life threatening
¨ Tx. w/chemotherapeutic agents (+/- BMT)
Transthyretin-related (TTR) amyloidosis is produced by the liver (2 types)
Familial transthyretin-related amyloidosis (ATTR)
Senile systemic amyloidosis (SSA)
¨ Both are slowly progressive
¨ Tx liver transplant (ATTR) and supportive care (SSA)
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Many who work in urban EDs and have a patient population that has a high rate of methadone use have probably wondered - why don't I see many STEMIs in the ED?
One study has actually attempted to answer the question - is methadone cardioprotective? Comparing 98 decedents with known long-term methadone exposure and compared autopsy coronary artery findings to match controls without, there was significant decrease in incidence of severe CAD:
5/98 Methadone Patients post-mortem had severe CAD vs 16/97 match controls
Better than a baby ASA, who knew?
[I thank Dr. Hoffman for citing this article to me]
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Delirium in the Critically Ill
- Delirium has been shown to be an independent predictor of mortality and can occur in up to 75% of critically ill patients.
- Whether preventing or treating delirium in the critically ill patient, consider the following:
- Minimize the use of anticholinergic medications (i.e. diphenhydramine, chlorpromazine)
- Ensure pain is adequately controlled (avoid meperidine and tramadol)
- Be careful with sedative medications; consider bolus dosing and daily interruption of continuous infusions
- Additional measures to treat delirious patients include reducing sensory deprivation, promoting normal sleep-wake cycles, early physical rehabilitation, and treating psychosis.
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Question
35 year-old male unrestrained driver following motor vehicle crash presents with blunt chest injury. There are multiple injuries on CXR (can you find them all?), but what's up with his right lung?
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Etiological agent is the parasite Trypanosoma cruzi
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Congratulations to today's Baltimore marathoners and the medical race staff
In honor of them:
Marathons are becoming increasingly popular with participation rising from an estimated 143,000 US marathon finishers in 1980 to a record high of 507,000 during 2010.
Most victims of exercise-related sudden cardiac arrest have NO premonitory symptoms
Autopsy reports show that
1) 65 - 70% of all adult sudden cardiac deaths are attributable to coronary artery disease.
2) 10% due to other structural heart diseases (HOCM, congenital artery abnormalities)
3) 5 - 10% due to primary cardiac conduction disorders (prolonged QT, ion channel disorders)
4) Remainder are due to non cardiac etiologies
Overall risk of sudden cardiac arrest is approximately from 1 in 57,000 and the risk of sudden cardiac death is approximately 1 in 171,000. Mortality without intervention after sudden cardiac arrest is greater than 95%. The majority occur in middle to late aged males.
V fib/V tach are the most common arrhythmias leading to sudden cardiac arrest. Most events occur in the last 4 miles of the racecourse.
Survival decreases by 7 - 10% with each minute of delayed defibrillation. Defibrillation within 3 minutes can produce survival rates as high as 67 - 74%. After 8 minutes, there is a dramatic decrease in survival. Prompt CPR increases survival from 2.5% to greater than 8%.
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- approximately 1% of children in DKA have some degree of cerebral edema, and up to 25% of them may die
- known risk factors include the following:
- younger children (especially <5 years)
- new onset or newly diagnosed
- increased BUN at presentation
- severity of acidosis at presentation
- bicarbonate therapy use
- failure of sodium to improve following therapy
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Activated charcoal is most effective if given within 1 hour of overdose.
Prehospital administration of charcoal can be challenging, but may save significant time compared to waiting until arrival to the ED. The patient has to be transported by EMS, registered, seen by a provider, order for charocal placed...
Two studies evaluated the time difference between prehospital and hospital administration of GI decontamination.
- Study 1 found median time to activated charcoal in the ED was 82 minutes.
- Study 2 found mean time to activated charcoal by EMS was 5 minutes, compared to 51 if held until arrival to ED.
Bottom line: Don't underestimate the amount of time that goes by before you evaluate non-crashing patients upon arrival to the ED. If the story supports an overdose and the patient doesn't have contraindications for receiving charcoal, recommend it be given in the prehospital setting for greatest potential benefit.
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Question
70 year-old male recently treated for community-acquired pneumonia presents with bloody diarrhea, fever, and severe abdominal pain. Abdominal Xray is shown below. Diagnosis?
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Question
26 year-old male from Indonesia presents with severe abdominal pain and weight loss for the past two months. He also states he found this "worm" in the toilet (see below) after a bowel movement. What is the medical treatment for this condition?
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Autoantibody-associated congenital heart block (CHB), also know as neonatal lupus, is responsible for the majority (~60-90%) of CHB
This is secondary to maternal antibodies that cross the placenta and may disappear postnatal
Neonatal lupus can result in diffuse myocardial disease both with and without conduction disturbances, structural defects, and electrophysiologic anomalies
Overall mortality is up to 30%, with 15% mortality before 3 months of age
More than 65% of surviving newborns require pacemakers
Maternal screening and fetal echocardiography has allowed routine prenatal diagnosis
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Patients frequently report having a sulfa allergy. In most cases, the allergic reaction was secondary to a sulfonamide antimicrobial agent, such as sulfamethoxazole-trimethoprim.
The question is: Can I use furosemide (or other non-antimicrobial agents containing a sulfa component)?
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There is minimal evidence of cross-reactivity between sulfonamide antimicrobials and non-antimicrobials.
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Despite this, the U.S. FDA-approved product information for many non-antimicrobial sulfonamide drugs contains warnings concerning possible cross-reactions.
Bottom line: If a patient had a true IgE-mediated anaphylatic reaction to a sulfonamide antimicrobial, it may be best to avoid other sulfa-related medications (use ethacrynic acid if a loop diuretic is needed). Otherwise, the available literature does not support cross-reactivity between sulfonamide antimicrobials and non-antimicrobials.
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We often ask our pediatric patients if there vaccines are up to date, but what does this mean?
Hepatitis B: birth, 2 and 6 months
Diphtheria/Tetanus and Acellular Pertussis: 2, 4 and 6 months
Pneumococcal vaccine: 2, 4 and 6 months
Haemophilus influenzae B : 2, 4 and 6 months
Polio: 2, 4 and 6 months
Rotavirus: 2 and 4 months or 2, 4 and 6 months depending on the brand.
Influenza: 6 months and older
Children less than 8 years old should receive 2 doses of flu vaccine at least 4 weeks apart during the first flu season that they are immunized. Children older than 2 years are eligible for the nasal vaccine if they do not have asthma, wheezing in the past 12 months or other medical conditions that predispose them to flu complications.
To see the full vaccine schedule including exact time frames between doses and catch up schedules, see: http://www.cdc.gov/vaccines/