A persistent confusional state after convulsive status epilepticus should raise suspicion for what diagnosis?

Non-convulsive status epilepticus.

If EEG monitoring is not immediately available - as is the case in many EDs, then empiric treatment with benzos looking for a paradoxical improvement in mental status should be considered.

Source

Goldstein, J. MD. "Status Epilepticus in the Pediatric Emergency Department." Clin Ped Emerg Med. 2008. v 9: 96-100.

Can you list 11 causes of hyperkalemia? Here are 2 freebies to start: Renal failure and hemolysis ...

1. Renal failure


2. Pseudohyperkalemia ie hemolysis


3. Acidosis


4. Insulin deficiency


5. B-blockers


6. Digoxin toxicity


7. Massive cellular necrosis (tumor lysis, rhabdo, ischemic bowel)


8. Hyperkalemic periodic paralysis


9. Decreased affective arterial volume (CHF, cirrhosis)


10. Excessive K intake


11. Hypoaldosteronism (secondary to decreased renin production - diabetic nephropathy, NSAIDS; or decreased aldosterone synthesis - primary adrenal disorder, ACE inhibitor, ARBs; or decreased response to aldosterone from meds such as K-sparing diuretics, TMP-SMX)

Source

Sabatine, M. MD. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. 3rd ed. 2008.

Place in order from most to least likely: chances of diagnosing a deadly aortic dissection on your next shift, winning $ with your next Powerball lott

Imagine Jeopardy theme music playing now ..........

Scroll down for answer once song is over. No sooner.

From most to least likely:

1. Winning a prize (at least $3) with your next Powerball ticket: 1:36


2. Seroconverting after being stuck with an 18 g angiocath used in an HIV positive patient: 1:300


3. Diagnosing a deadly aortic dissection on your next shift: 1:1000*


4. Being struck by lightening during your life time: 1:244,000


5. Not just winning a prize, but THE GRAND Powerball prize, on your next ticket: 1:146,107,962


6. Diagnosing a deadly aortic dissection three shifts in a row: 1:1,000,000,000. If you do this. Quit your job and play the lottery.

* This number needed some abstraction on my part. Here goes ... Mortality from aortic dissection is about 2.5 per 100,000 persons per year (Rosen's). There are 300 million persons in the United States. That means that in any given year, there are about 7,500 mortal aortic dissections.

There are about 32,000 US ED physicians . Assuming, the dissections are equally distributed among them, each ED physician sees 0.23 dissections per year or 0.001 dissections per shift (assuming 18 shifts/month x 12 months).

If this number is right, the average ED physician will see a dissection once every 4.6 years ... which seems about right and passes the gut check test.

Source

Ankel, F MD. "Aortic Dissection." Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed.

Bartlett, J. MD. and Weber, D. MD MPH. "Management of health care workers exposed to HIV." Up to Date. 30 September 2008.

"Powerball Odds." Durango Bill's Applied Mathematics. http://www.durangobill.com/PowerballOdds.html

"Your Real Odds of Getting Struck by Lightning" Ezine articles. http://ezinearticles.com/?Your-Real-Odds-of-Getting-Struck-By-Lightning&id=295290

What to do when a child arrives in status epilepticus ... ?

Is your plan consistent with this suggested algorithm ...


Some items to note ...

• common management errors include medication under dosing and excessive intervals between medications


• give 2 - 3 doses of benzos (ativan or valium) before considering second line AEDs


• after appropriate dose of benzo and second line AED (phosphenytoin or phenobarbital, if neonate) have been given, the selection of tertiary treatment options for status are more variable. Consult neurology and begin aggressive search for underlying etiology ie electrolyte derangements, hypoglycemia, infectious diseases, trauma and toxins.


• phenobarbital is second line AED of choice for neonates based primarily on its long history of use rather than any particular study


• advantages of phosphenytoin over phenytoin include: lower risk of cardiac dysfunction, lower rates of phlebitis and less severe tissue necrosis if the medication extravasates


• phenobarbital is very sedating; if used consider very close airway monitoring or prophylactic intubation.


• most common etiology of pediatric status is febrile seizure. Exclude CNS infection. Consider empiric treatment with antibiotics and acyclovir until CSF evaluated.

Source

Goldstein, J. MD. "Status Epilepticus in the Pediatric Emergency Department." Clinical Pediatric Emergency Medicine. 2008. v 9: 96-100.

Should thrombolytic therapy be given to a patient in cardiac arrest secondary to presumed myocardial infarction?

No, with reservations.

A recent study in the New England Journal of Medicine evaluated this question. They found no difference between placebo and tenecteplase for the primary end point of 30 day survival or the secondary end points of hospital admission, return of spontaneous circulation, 24 hour survival, survival to hospital discharge or neurologic outcome.

Despite this, in a young 40 year old with no other options and a limited down time I might still consider giving it a try.

Bottiger, B. MD et al. "Thromboysis during Resuscitation for Out-of-Hospital Cardiac Arrest" N Engl J Med 2008; 359: 2651-62

Generalized convulsive status epilepticus (GCSE) = SUPER BADNESS but how about focal motor status epilepticus (FMSE)?

Mortality from GCSE approximates 20 - 25%.

However, it is not clear that prolonged FMSE results in substantive brain injury. Reasonable attempts at control are advocated, but high-risk therapies, such as induced pharmacologic coma are rarely warranted.

Source

Mirski, M. MD PhD and Varelas, P. MD PhD. "Seizures and Status Epilepticus in the Critically Ill." Crit Care Clin. 2008. 115-147.

To TPA or not to TPA a stroke with onset 3 - 4.5 hours ago?

The jury is still out on this one but if you choose to TPA, consider closely following the ECASS' inclusion criteria:



Of particular note, super young, super old and major strokes were excluded.

Source

Hacke, W MD et al. "Thrombolysis with Alteplace 3 to 4.5 hours after Acute Ischemic Stroke." NEJM. 25 Sept 2008. v 359. n 13.

Should patients diagnosed with venous thromboembolism and history of brain cancer be treated with anticoagulation or IVC filter placement?

Depends. Anticoagulation can cause bleeding but IVC filters have their own inherent problems including filter thrombosis, postphlebitic syndrome and recurrent DVT/PE.

• For patients with brain tumors at increased risk of hemorrhage (ie metastases from melanoma, choriocarcinoma, thyroid carcinoma and renal cell carcinoma) an IVC filter is recommended.


• For brain tumors at decreased risk of hemorrhage, anticoagulate for 3 - 6 months, with exception of malignant glioma for which longer term anticoagulation is recommended. While LMWH is more costly, it is preferred over warfarin given decreased interaction with other drugs, convenience of not having to monitor the level of anticoagulation on a regular basis, and greater efficacy at reducing risk of recurrent thromboembolism without increasing risk of bleeding.

Source

Wen, P. MD and Hart, R. MD. "Anticoagulant and antiplatelet therapy in patients with brain tumors." Up to Date. 14 August 2008.

American Society of Clinical Oncology Guideline: Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer. 2007 Dec 1. J Clin Oncol 25: 5490-5505.

Of the following, which are medical myths?

1. Sugar causes hyperactivity in children


2. Suicides increase over the holidays


3. Poinsettia plant ingestion is toxic


4. Nocturnal feasting makes you fat

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All are MYTHS. If you got this right, cheers for you! If not, don't feel so bad. Neither did I. My medical training and years of practice couldn't overturn the "truths" of conventional medical wisdom passed down for decades. To read more about these and other medical myths follow this link to a recent paper in the British Medical Journal.

Vreeman, R. MD. and Carroll, A. MD. "Festive medical myths." BMJ 2008; 337: a2769.

Other than primary skin disorders, what are some causes of pruritus (itching)?

Lots of primary skin disorders ie xerosis, atopic dermatitis, contact dermatitis, urticaria, dermatophytosis, psoriasis, scabies and pediculosis cause itching.

However, if there are no skin lesions and a patient is complaining of pruritus other disorders to consider include:

• renal disease


• cholestasis


• malignancy - most commonly Hodgkin lymphoma, Polycythemia vera, Mycosis fungoides (cutaneous T cell lymphoma)


• multiple sclerosis


• thyroid disorders


• psychiatric illness

Fazio, Sara MD. "Pruritus." Up to Date. 2 Oct 2008.

What is the most common vasculitis in children?

Henoch-Schonlein purpura (HSP)

When is hematuria more than a simple UTI?

If it's a simple UTI there should be associated dysuria, frequency and in the urinalysis, pyuria and bacteria. If not, the differential and evaluation should be broadened. Specifically, other causes of bleeding, including glomerular (red cell casts, proteinuria, dysmorphic appearance of RBCs in urine) and extraglomerular bleeding (blood clots in the urine; clots almost never occur in glomerular disease) should be pursued.

Source

Rose, Burton MD and Fletcher, Robert MD. "Evaluation of hematuria in adults." Up to Date. 17 June 2008.

ED approach to hypotonic hyponatremia ...

If super low and super symptomatic, give hypertonic saline.

If not super low and not super symptomatic, assess volume status (history, vitals, orthostatics, JVP, skin turgor, mucous membranes, peripheral edema, BUN, Cr) and

• if hypovolemic (thiazides, mineralcorticoid deficiency, diarrhea, vomiting) initiate mild IV hydration w/ NS to decrease ADH production OR


• if euvolemic (SIADH, polydipsia)) or hypervolemic (CHF, end stage kidney failure, cirrhosis), initiate free water/fluid restriction

This empiric approach will generally get patients headed in the right direction until evaled by the internists and/or nephrologists. For those that are more ambitious feel free to send off urine 'lytes and osmoles.

Source

Sabatine, Marc MD. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. 3rd ed. 2008.

How do you treat this red eye?

Notables on H + P:

• severe pain, can't sleep, insidious onset over past several days


• history of rheumatoid arthritis


• visual acuity 30/20


• no lid edema or ocular discharge


• globe tender to palpation


• PERRL, no afferent pupillary defect


• no floroscien uptake


• blood vessels don't move with pressure applied from Q-tip


• blood vessels don't blanch with application of topical phenylephrine


• anterior chamber clear


• ocular pressure 18 mm Hg


• posterior ocular exam unremarkable

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Scleritis

• opthalmology consult


• mild: oral NSAIDs


• refractory cases or evidence of scleral thinning (exposing underlying choroid): NSAIDs + oral corticosteroids/other immunosupressive drugs


• evaluate for potential complications: uveitis, keratitis or glaucoma


• evaluate for underlying systemic cause: rheumatoid arthritis (most common), Wegener's granulomatosis, systemic lupus erythematosus, inflammatory bowel disease, polyarteritis nadosa, infectious etiologies (herpes, Lyme, HIV)

Source

Dargin, J MD and Lowenstein, R MD. "The Painful Eye." Emergency Medicine Clinics of North America. 2008. 199-216.

Image: Dr. Frederick A. Jakobiec, eyepathologist.com

Geez ... we're getting quite cherubic

My scrubs are getting a bit worn so I've been in the market for a couple new pairs. I ordered the same size as usual from an internet scrub distributor and tried them on only to find myself literally floating in them; and I haven't lost any weight from a few years ago. At first, I thought that it was an anomaly of the brand but I've tried a couple different vendors now and this isn't an isolated incident. Medium is the new small and large the new medium. It must be a sign of the times.

Not good.

Three reasons a doctor's job can never be automated ...

1. false positives


2. false negatives


3. incidental findings

If there were no such things as incidental findings and tests were 100% sensitive and specific, Google would have automated us a long time ago. At times, it takes the gray matter between the ears to put the head and tail where it belongs.


Here's a recent New York Times article regarding incidental findings and their impact on patient care.

What are the four F's of ovarian torsion?

Female, Fat, Forty, Fertile = gall stones. We've heard that one before.

I now propose the four F's of ovarian torsion:

1. Female - goes w/o saying


2. Fifty or less - affects women of reproductive age and younger (including adolescents, children and neonates)


3. Funky ovary - 50 - 80% of ovarian torsion cases are associated with adenexal pathologic conditions such as ovarian tumors and cysts. When imaged using either pelvic ultrasound (modality traditionally used to image pelvic organs), CT or MR there is often an enlarged ovary or ovarian complex noted. The absence of doppler signal on duplex and color doppler imaging will clinch the diagnosis; however, its presence cannot eliminate the diagnosis.


4. Failure to diagnose alternative cause of significant lower pelvic pain - abdominal pain is the most reliable symptom of torsion but is nonspecific.

Source

Andreotti, R. MD et al. "The Sonographic Diagnosis of Ovarian Torsion: Pearls and Pitfalls." Ultrasound Clinics. 2007. 155-166.

What's the management of a child with fever and petechiae?

if ill, work up + antibiotics --> admit

if well appearing and

• < 12 months, work up + antibiotics --> admit


• > 12 months, work up and if WBC between 5000 - 15000 and other labs unremarkable --> d/c +/- antibiotics

consider checking rapid strep as part of work up given that streptococcal pharyngitis can present with petechiae

Source

The Pediatric Emergency Medicine Resource. 4th ed.

What are some commonly used drugs with anticholinergic side effects?

Altered mental status secondary to polypharmacy is common. Drugs with anticholinergic side effects are often contributory ... here's a list of some common ones:

• antihistamines ie diphenhydramine, hydroxyzine, meclizine, promethazine (Phenergan)


• neuroleptics ie olanzapine (Zyprexa), quetiapine (Seroquel)


• antiparkinsonian drugs - benztropine (Cogentin)


• tricyclic antidepressants


• antispasmodics ie dicyclomine (bentyl), oxybutynin (Ditropan),


• sleep aids ie doxylamine (Unisom)


• cold preparations


• scopolamine


• atropine

Su, Mark MD and Goldman, Matthew MD. "Anticholinergic poisoning." Up to Date. 12 June 2008.

A Sticky Situation: Answered

Answered ..... well, not really. It's a no win situation. Admit the patient and you might end up in court facing false imprisonment charges. Discharge the patient and you could end up there for medical malpractice after the man dies of an MI.

Aside from getting a good lawyer who shows well at the dog and pony show, a well documented evaluation of the patient's medical decision making capacity may come in handy. This assessment should consider the patient's ability to:

• understand their medical problem


• understand pros/cons of proposed treatment


• understand pros/cons of refusing proposed treatment


• understand pros/cons of alternative treatments


• and to make a decision free of depression, delusions, and psychosis

These pointers are derived from a formal, structured assessment tool used to evaluate capacity, the Aid to Capacity Evaluation (ACE) , conceived at the University of Toronto Centre for Bioethics.

Source

Tunzi, M. MD. "Can the Patient Decide? Evaluating Patient Capacity in Practice." Am Fam Physician 2001; 64: 299-306.

A Sticky Situation: Is this guy competent to sign out AMA?

46 y/o male presents w/ complaints of exertional chest pain. History of etoh abuse. Last drink 6 hours ago. Physical exam unremarkable. Database notable for non-specific EKG; otherwise unremarkable. Etoh level 150.

After waiting 3 hours for admission, patient wants to sign out AMA. Ok or not?

• Does the patient have adequate decision making capacity?


• If patient is permitted to "sober" and metabolize off the etoh he might go into w/ drawal. He certainly won't have adequate decision making capacity then.


• Hmmmm ... what to do?

ECG: 33 year old s/p syncopal episode. What's the diagnosis?

Physical exam notable for systolic murmur

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Hypertrophic Cardiomyopathy

ECG Clues:

• ventricular hypertrophy


• atrial hypertrophy


• more prominent septal depolarization as evidenced by Q waves in inferior (II, III, aVF) and lateral (I, aVL, V5, V6)

Source

Elliott, P. MD and McKenna, W. MD. "Clinical manifestations of hypertrophic cardiomyopathy." Up to Date. Oct 2008.

Image: ECG Wave-Maven. Beth Israel Deaconess Medical Center. http://ecg.bidmc.harvard.edu

What characteristics possibly suggest a malignant cause of neonatal apnea?

Short periods of apnea associated with periodic breathing is normal.

However the following characteristics of apnea may suggest a non-benign cause:

• accompanied by symptoms or skin color change


• lasts > 10 seconds


• is recurrent


• or appears > 2 weeks of age

Source

The Pediatric Emergency Medicine Resource. 4th ed.

Quick Recipes: The Veg Out

For all the residents, busy attendings and other professionals out there looking for a tasty, healthy, cheap, and fast meal, here's one for you: The Veg Out.

1. Go to Einstein's Bros Bagels * (or similar type location). Click here to find the closest location near you.


2. Get a bagel bucket which includes 13 bagels and 2 tubs of cream cheese (pine nut spread and garden veggie shmear).


3. Cut up assortment of veggies including spinach, cucumber, bell pepper, tomato and onion.


4. Pine nut spread on bottom. Veggie Shmear on top. Veggies in the middle .... and wha bam! You got yourself a health some treat in a jiffy.

Total Cost = bagel bucket ($13) + veggies ($5) = about 18 bucks

= $1.50 per Veg Out

Nutritional Information

Calories 440

Calories from Fat 120

% Calories from Fat 27

Total Fat (g.) 14

Saturated Fat (g.) 7

Trans Fats (g.) 0

Cholesterol (mg.) 30

Sodium (mg.) 760

Total Carbs (g.) 66

* I have no proprietary, financial, professional or other personal interest of any nature or kind in any product, service and/or company related to Einstein Bros Bagels. I just think the Veg Out is darn good!

Caution when giving Med Control

I feel sorry for all involved in this unfortunate circumstance.

Via CNN:

Man dies after wrong diagnosis

Authorities investigate emergency workers who misdiagnosed a man's heart attack for acid reflux.

A few pointers for evaluation of abdominal pain in patients with history of Roux-en-Y gastric bypass ...

• Roux-en-y is the most commonly performed gastric bypass operation for morbid obesity
  
  
• Procedure: 1. Upper stomach divided 2. Upper jejunum divided and distal end (Roux limb) anastamosed to stomach pouch 3. Proximal end of divided jejunum (excluded Roux limb) attached to Roux limb (Image source: Annals of Emergency Medicine, v 47, n 2, Feb 2006)

• Even with significant intra-abdominal pathology, the abdominal examination in the morbidly obese is often unrevealing. Have low threshold for obtaining imaging studies
  
  
• Given the limited volume of the gastric pouch decrease the volume and rate of oral contrast administration.
  
  
• If abdominal CT is normal and patient still having abdominal pain, consider internal hernia causing obstruction of the excluded Roux limb. Consider surgical consult and exploration.

Source

Edwards, E MD et al. "Presentation and Management of Common Post-Weight Loss Surgery Problems in the Emergency Department." Annals of Emergency Medicine. v 47, n 2. Feb 2006.

Vermont crowned healthiest state. Where does your state stand?

Each year for the past two decades or so the United Health Foundation, a mixed group of MDs and PhDs, puts together a rank list of the healthiest states. Items in five broad categories including personal behaviors, community and environment, public & health policies, clinical care and health outcomes are considered in putting together the rank list.

The highly anticipated results from this year are ... .. ... .. Drum roll please .. ... .. ... .. ...

The Big Cheese


1. Vermont

2. Hawaii

3. New Hampshire

4. Minnesota

5. Utah

Bottom Feeders


46. Texas

47. Tennessee

48. South Carolina

49. Mississippi

50. Louisiana

Click here to find where your state stands.

Source

http://www.americashealthrankings.org/2008/overview.html

Up to what age is umbilical vein catheterization generally a viable emergency IV access option?

• 2 weeks

Source

The Pediatric Emergency Medicine Resource. 4th ed.

Now accepting nominations for new Dr. Marcus Welby

Is it just me or does every article about medicine and doctors in the New York Times seem to have a negative slant on it. Granted, the medical system needs some fixes and I can understand that patients, including those who may be journalists, may be frustrated with the efficiency in which their medical ailments are addressed nowadays.

Nonetheless though there still seems to be a preponderance of negativty out of proportion to what is deserved (like mesenteric ischemia, it's something that's bad). For instance, one of the Time's lead articles a few days ago was "Arrogant, Abusive and Disruptive -- and a Doctor." But it doesn't stop there; if you search the archives for "doctor" you'll find: "The Six Habits of Highly Respectful Physicians" (an instruction manual on how we should behave), "Doctor and Patient - Too Much Information," "When is a Pain Doctor a Drug Pusher?," and "Doctor and Patient, Now at Odds." And this only covers the first two pages of search results.

Where's the article about the young girl who's appendicitis I diagnosed or about the middle aged man who was having a massive heart attack and, despite having no insurance, was taken urgently to the catherization lab where a stent was placed and his life saved? Where are the articles about these little, taken-for-granted wins that happen every day in every hospital and doctor's office?

I don't know. But it suggests that our profession is in need of some public relations work before things get too far out of hand (if they haven't already). The PR campaign must be multifaceted with one integral component being the recruitment and promotion to public prominence of a new Marcus Welby, a contemporary physician who embodies the spirit of healing, compassion and patience, just as Dr. Welby did in his day.

I've already excluded several possibilities including The Doctors' Drew Ordon, Grey's Anatomy's Cristina Yang and Scrub's JD. But aside from that, all is game. How about you?

Hiccup ... Hiccup ..... Hiccup ... What's the ED evaluation and treatment of this condition?

Generally benign but if last > 48 hours a more thorough evaluation for the underlying etiology should be pursued. Causes include:

Central Nervous System

• infection


• structural lesions

Metabolic

• alcohol


• uremia


• diabetes mellitus


• hyponatremia


• hypocalcemia

Drugs

• general anesthesia


• dexamethasone


• diazepam

Vagus and phrenic nerve irritation

• foreign body against tympanic membrane irritates auricular branch of vagus nerve


• any mass or infection along pathway of vagus or phrenic from neck down to diaphram

Psychogenic

Idiopathic

• click here to see video of unfortunate man with intractable idiopathic hiccups

Pursue appropriate testing based on history and physical. For symptomatic relief consider chlorpromazine or metoclopramide while searching for underlying cause.

Source

Fishman, Mary MD. "Overview of hiccups." Up to Date. 4 September 2008.