Pericarditis is based on clinical diagnosis; typically two of four criteria are found (pleuritic chest pain, pericardial rub, diffuse ST-segment elevation, and pericardial effusion).
Treatment of pericarditis should be targeted at the cause.
Most causes of pericarditis have a good prognosis and are self-limited.
Show References
Lactate levels help to confirm septic arthritis but what about bacterial meningitis. As reported in the daily electronic ACEP newsletter a small study of 45 patients showed that all patients with a confirmed diagnosis of bacterial meningitis had a CSF lactate level > 3.5 mmol/L. Therefore, it might be true that viral meningitis will only have CSF lactate levels < 3.5 mmol/L.
With only 45 patients, this finding is clearly not ready for Prime Time but consider adding it to your next CSF study so more data can be collected on the utility of this test.
The story as seen in ACEP eNews on September 14th, 2012 is:
CSF Levels Of Lactate May Be A Marker Of Viral Versus Bacterial Meningitis.
MedPage Today (9/14, Gever) reports, "Cerebrospinal fluid (CSF) levels of lactate were a perfect marker of viral versus bacterial meningitis in a small study, a researcher reported" at the Interscience Conference on Antimicrobial Agents and Chemotherapy. Researchers found that, "among 45 adults in whom the etiology of meningitis was microbiologically confirmed, all those with CSF lactate levels above 3.5 mmol/L had the bacterial form, whereas every patient with lower levels had viral meningitis."
- sleep disruption silimar to a nightmare, but much more dramatic most often between 4-12 years
- sudden fear reaction which occurs during the transition to and from deep non-REM sleep while nightmares occur during REM sleep
- occurs 2-3 hours after falling asleep when the child suddenly awakens in distress and may thrash about, scream, cry
- child returns to sleep with no memory of the event the following morning
- often occurs when a child is stressed, overtired, on new medication, or sleeping in a new environment
- do not awaken the child during the event but rather allow them to calm on their own
Carbon monoxide (CO) and hydrogen cyanide (HCN) are two of the main gases causing injury and death from smoke inhalation in fire victims. During the first phase of a fire, and prior to depletion of oxygen reserves and subsequent production of CO, formation of HCN from the thermal breakdown of nitrogen-containing materials may be the primary cause of lethal poisoning in an enclosed-space fire.
A recent, retrospective, observational study from Poland assessed the prevalence of toxic HCN exposure in victims of enclosed-space fires.
Important findings:
- Of the 285 patients who died, 169 (59%) had detectable cyanide blood levels. 82% also had elevated carboxyhemoglobin (COHb) levels.
- Of the 40 patients who survived, 20 (50%) had detectable cyanide blood levels. All 20 had elevated COHb levels.
Conclusion: The high prevalence of coincident HCN concentrations and COHb levels in victims of enclosed-space fires emphasises the need to suspect HCN as a co-toxin in all persons rescued from fire who show signs and symptoms of respiratory distress.
Show References
Question
40 year-old male with severe uncontrolled hypertension presents with altered mental status (head CT below). The CXR is from the same patient. What's the connection?
Show Answer
Show References
Question
40 year-old male with severe uncontrolled hypertension presents with altered mental status. Head CT is shown here. Name three common anatomic locations generally seen for non-traumatic intracerebral hemorrhage.
Show Answer
Show References
Which patient has a better blood pressure, the patient with a blood pressure of 110/40 or the patient with a blood pressure of 90/60?
Mean arterial pressure (MAP) is generally considered to be the organ perfusion pressure in an individual. Because MAP requires an inconvenient calculation, we've all been taught...misled perhaps...into focusing on systolic blood pressure (SBP) as a marker of how well-perfused a patient is, and we tend to ignore the diastolic blood pressure (DBP).
It's important to remember, however, that we spend most of our lives in diastole, not systole. As a result, our organs spend more time being perfused during diastole than systole. The MAP takes this into account: MAP = (SBP + DBP + DBP)/3. DBP is more important than SBP!
So which patient is perfusing his vital organs better, the one with a BP of 110/40 or the one with a BP of 90/60? Do the MAP calculation...90/60 is better than 110/40!
Pay more attention to those diastolic BPs!
Apprehension test for patellar dislocation
Test is used to access for the possibility of a patellar dislocation, prior to evaluation, now spontaneously reduced.
Similar to the shoulder apprehension test
Designed to place the patella in a position of imminent subluxation or dislocation
http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10042-7..gr16.jpg
http://www.youtube.com/watch?v=9AJxcbd9g8A
Place the knee in 20 - 30 degrees of flexion with the quadripces relaxed. Grasp the patella and attempt to place lateral directed stress.
If the patella is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion by contracting the quadriceps
Ligamentous laxity is increased in children and ligamentous injury is more common than fractures.
If fractures occur, they are more likely to be in the upper cervical spine in infants and the lower cervical spine in older children.
Pseudosubluxation: physiologic subluxation between C2-3 and C3-4 may exist until age 16 years
Screening Assessment/Clearance for Verbal Children
-Midline C-spine tenderness?
-Pain with active motion?
-Altered level of alertness?
-Evidence of intoxication?
-Focal neurological deficit?
-Distracting painful injury?
-High impact injury?
Screening Assessment/Clearance for Pre-Verbal Children
-Neurological assessment of basic reflexes
-Response to painful stimuli
-Equal movements of all extremities
-Response to sound (eye tracking)
-Extremity strength and resistance
-Palpate posterior C-spine (observe for facial grimace)
-Feel for step-offs, deformities
-Verify full range of motion of neck (may need to be creative)
-Repeat neurological assessment
If concern arises on screening assessment, keep child in hard cervical collar and image (may start with x-ray and progress to CT if still concerned and x-rays negative).
If imaging negative, but persistent suspicion based on neurological deficits consider SCIWORA (Spinal Cord Injury WithOut Radiographic Abnormality) which exists in up to 50% of children with cervical cord injury, and may require MRI to further identify injury.
- Exposure to organophosphates can lead to “intermediate syndrome.”
- It is a syndrome characterized by weakness of neck flexors and proximal limbs, cranial nerve palsies, and respiratory muscle weakness, which can lead to respiratory paralysis.
- It follows acute cholinergic syndrome and precedes a delayed neuropathy, thus it is an “intermediate syndrome,” typically developing 24-96 hours post exposure.
- The pathophysiology of IMS remains unclear.
- Serum cholinesterase levels and electrophysiological studies are helpful in confirming the diagnosis.
- With supportive therapy, including artificial ventilation, complete recovery occurs within 5-18 days.
Right Heart Failure in the Critically Ill
- In its most simplistic form, right heart failure (RHF) is due to either to right ventricular contractile dysfunction or elevated right ventricular afterload.
- Primary causes of RV contractile dysfunction include: coronary ischemia, sepsis, drug toxicity, and acute pulmonary hypertension
- Primary causes of increased RV afterload include: LV dysfunction, venous thromboembolism, hypoxic pulmonary vasoconstriction, and lung injury
- Management of the patient with RHF centers on identifying and treating reversible causes, optimizing preload, inotropes, and possible implantation of a right ventricular assist device.
- Importantly, excessive volume loading can worsen RV contractile function, increase RV dilatation, and impair LV output and systemic perfusion.
- Consider early use of inotropic agents, such as dobutamine, in critically ill patients with RHF.
Show References
Question
32 year-old female presents with 5 days of fever, chills, and flank pain. She is hypotensive on presentation and urinalysis shows pyuria. Click here for the non-contrast CT scan. What's the diagnosis and what type of antibiotics should be started empirically?
Show Answer
Show References
Lyme disease is the most prevalent arthropod zoonosis in the Northern hemisphere
Show References
Carbapenems (meropenem, ertapenem, doripenem, imipenem/cilastatin) are broad-spectrum antibiotics that have good gram-negative and anaerobic coverage and are used to treat resistant bacterial infections.
-
Early retrospective studies showed ~10% cross-reactivity in penicillin-allergic patients.
-
More recent prospective studies verified penicillin allergy by the accepted standard (ie, skin test to the major and minor penicillin determinants) and tested for carbapenem allergy by administering a full therapeutic dose to carbapenem skin test-negative patients.
-
The cross-reactivity between skin tests appears to be around 1%, with all carbapenem skin test-negative patients tolerating the challenge.
Show References
The PALS algorithm includes 5 points in management. The first two points are optimally reached within one hour:
1) Recognition of sepsis and vascular access
2) 20ml/kg IVF X 3 within 1 hour or 60ml/kg IVFs within 15 minutes and antibiotic administration
3) Determine if fluid responsive
A recent study at a tertiary care children's hospital retrospectively reviewed 126 patients diagnosed with sepsis. Their findings:
- 37% received 60ml/kg in 60 minutes
- 11% received 60ml/kg in 15 minutes
- 70% received antibiotics in 60 minutes
- In 49% of cases fluids were delivered via IV infusion pump versus manual or pressure bag
- There was a 57% shorter overall hospital stay and 42% shorter ICU stay in patients that received 60ml/kg IVFs within 60 minutes.
- Liver enzymes, coagulation profiles, and lactic acid levels were obtained in "few" patients.
Conclusions:
Suboptimal fluid resuscitation in sepsis is linked to longer hospital stays. Knowledge of PALS guideline and faster administration of fluid were thought to have been causes of poor adherence.
Additionally, parameters measured in sepsis including lactic acid, coagulation studies, and liver enzymes were not routinely collected. The authors concluded this came from a lack of knowledge of their utility in sepsis.
References:
Paul R, et al. "Adherence to PALS Sepsis Guidelines and Hospital Length of Stay." Pediatrics: 2012 Jul 2 [epub adhead of print].
I was reading the biography of Steve Jobs looking for incredible insights into leadership and innovation. I have realized that you basically have to be a genuis and it doesn't matter what you do. His favorite drug was LSD which he believed was necessary to improve creativity and innovation. His description of the hallucinations confirm that he was taking this drug.
We describe LSD hallucinations as a crossing of the senses or "synesthesias" - you hear the color blue, you see the smell of roses.
Steve Jobs describes a moment in a wheat field while on LSD and (paraphrasing from the biography) ..." the wheat was playing Bach beautifully"
If you have a patient describing this type of hallucination you can almost be guaranteed that they have taken LSD or some other tryptamine.
A Cochrane review of 37 studies concluded that Succinylcholine (SUC) is superior to Rocuronium (ROC) during rapid sequence intubation.
The authors claim that compared to ROC, SUC has a faster onset of action (45 vs. 60 seconds) and overall a shorter duration of action (10 vs. 60 minutes).
Dr. Reuben Strayer wrote a letter to the journal editors and stated that these findings should be interpreted carefully; he highlighted that most of the studies in the review used doses of ROC less than 0.9 mg/kg (most studies used 0.6mg/kg).
Dr. Strayer asserted that ROC’s onset of action is dose dependent; when using doses of 1.2 mg/kg, ROC’s onset is indistinguishable from that of SUC. He also stated another major benefit of ROC is the lack of adverse effects that SUC possesses (hyperkalemia and malignant hyperthermia).
What are your thoughts on this? Go to http://www.facebook.com/Criticalcarenow and take the poll (there are 5 choices). Results will be posted next week.
Show References
Question
56 year-old male presents with chest pain. You perform an ultrasound of the heart and see the clip below. What's the diagnosis? Thanks to Dr. Ken Butler for the case.
Show Answer
Show References
Arrhythmogenic right ventricular dysplasia (ARVD) is a heritable form of cardiomyopathy, characterized by the replacement of myocytes with adipose and fibrous tissue leading to arrhythmias, right ventricular failure, and sudden cardiac death (SCD)
ECG findings include T-wave inversions in V1–V3 (85% ), epsilon waves (in 33%), as well as a QRS duration >110 ms in V1-V3 (64%)
Show References
Apprehension test for shoulder dislocation
Tests for chronic shoulder dislocation
Similar to the patellar apprehension test
Designed to place the humeral head in a position of imminent subluxation or dislocation
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kelly-fig11.jpg
ABduct and externally rotate arm to a position where the shoulder may dislocate
If the shoulder is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion.