Diagnosis of Right Ventricular Strain with Transthoracic Echocardiography

07 Apr
April 7, 2014

Pulmonary EmbolismAbnormal vital signs are poor predictors of mortality associated with pulmonary embolism (PE).  Diagnosis of PE and right ventricular (RV) strain with transthoracic echocardiography (TTE) however, has been well documented as a predictor for pending shock and significant in-hospital mortality.  One study done by Grifoni S et al, showed that 10% of normotensive patients with PE and RV strain on echo developed PE related shock, and 3% died, whereas normotensive patients without signs of RV strain remained hemodynamically stable. 
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From Hippocrates to Osler to FOAM

04 Apr
April 4, 2014

FOAM LogoAs many know Free Open Access Med(ical Ed)ucation (FOAM) is a concept that was developed in June 2012 at a pub in Ireland. Since its creation FOAM has developed into a collection of constantly evolving, collaborative, and interactive resources and tools with one main objective…to make the world a better place. At the heart of FOAM is the philosophy that high-quality medical education should be free and accessible to all who care for patients and to those who teach the art and science of medicine. Recently, I watched a video from the 2013 Social Media And Critical Care (SMACC) Conference given by Joe Lex that made me realize although the acronym only came into being recently, maybe the concept had historical origins (From Hippocrates to Osler to FOAM).

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tPA-associated Angioedema

03 Apr
April 3, 2014

tPA-Associated Angioedema

For the most part, the biggest concern with administering tPA is the bleeding complications, specifically intracranial hemorrhage. But there is another side effect that is being reported more frequently. I, myself, saw two cases in one week. This side effect is tPA-associated angioedema.

Case: A 70-year-old female with a past medical history of hypertension and diabetes presents to your department 45 minutes after onset of left facial droop, slurred speech and left-sided hemiparesis. The initial head CT is negative for acute hemorrhage. You diagnose your patient with an acute ischemic stroke. There are no contraindications, so you decide to treat the patient with tPA (we will leave this debate for another time).
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Post Lumbar Puncture Headaches

31 Mar
March 31, 2014

HeadacheLumbar puncture is a procedure that is commonly performed in the emergency department (ED) for both diagnostic and therapeutic reasons. Post lumbar puncture (LP) headache is one of the most common complications from LPs (6 – 36% incidence) and is essentially a clinical diagnosis based on a history of a dural puncture and the postural nature of the headache with associated symptoms.  Additionally, post LP headaches that are left untreated can cause impaired ability to perform activities of daily living and there are case reports of subdural hematoma, herniation, and death. In terms of the prevention and treatment of post-LP headaches, both are equally important in management. Following, is a discussion of which techniques and preventative measures are evidence based and which are not.

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Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis?

27 Mar
March 27, 2014

Regular InsulinDiabetic ketoacidosis (DKA) is a common endocrine emergency encountered in the emergency department.  DKA associated mortality is relatively low in adults, but in children with type 1 diabetes, the elderly, and adults with concomitant illnesses have a mortality rate is > 5% (19564476).  Guidelines for the management of hyperglycemic crisis in adults provide recommendations for intravenous fluid administration, correction of electrolyte abnormalities, insulin and bicarbonate therapy.  While the recommendations made in the American Diabetes Association (ADA) consensus statement are intended to be evidence based, there are two recommendations which have less than optimal supporting evidence which results in controversy in the emergency department: 1. Use of regular insulin boluses of 0.1 units/kg and 2. patients with a pH < 6.9 should receive sodium bicarbonate therapy.  Today we will attempt to answer the question, is there any benefit to an initial insulin bolus in DKA?

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Bibliography

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