Archive | October, 2011

Nebulized Lidocaine

26 Oct

KEY POINTS:
–not a ton of evidence for use, but sounds cool, probably safe (in the appropriate non-toxic dose)
–reminder: max dose of lidocaine (without epinephrine) = 4.5mg/kg

ASTHMA/COPD:
–some benefit in daily long-term therapy for asthma, but doesn’t apply to us in the ED
–lidocaine can cause bronchospasm in asthmatics, so one study pretreated with albuterol
–one study’s sample dose: 1ml of 1% lido in 4 ml NS
–may be useful for cough suppression

NG TUBE PLACEMENT (in kids):
–apparently, not much proof that it helps or makes it less painful

Reference(s): asthma long-term, cough suppression, more cough suppression, ng tube, more ng tube

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Lidocaine pretreatment during intubation

20 Oct

CONCEPT:
–intubation is associated with transient increase in BP & heart rate, due to brief catecholamine surge after messing with the larynx (probably)
–this surge can result in increased ICP, which is not great for head injury/head bleed patients
–lidocaine pretreatment can help blunt the rise in ICP

EVIDENCE:
–lidocaine shown to blunt increased ICP during endotrach suctioning, but may not directly apply to ED setting (rapid sequence intubation)
–review (linked below) “could find no evidence that in acute traumatic head injury pretreatment with IV lignocaine/lidocaine before a RSI reduces ICP or improves neurological outcome”

10-SECOND TAKEAWAY:
–RSI may cause brief increase ICP
–lidocaine pretreat (1.5mg/kg) for RSI supposed to help blunt this response
–not exactly a mountain of proof this works

QUICK TANGENT:
–fentanyl might be an alternative (1-3mcg/kg), if the BP can handle it

Reference(s): our canadian bretheren, review article, uptodate: “Pretreatment agents for rapid sequence intubation in adults”

Sgarbossa Criteria (Acute MI in LBBB)

18 Oct

KEY POINTS:

–Sgarbossa criteria help look for STEMIs in people with LBBB (left bundle branch block)

ECG CRITERIA:
5 pts – concordant (same direction as QRS complex) ST elevation >=1mm any lead
3 pts – ST depression >=1mm in anterior leads (V1, V2, V3)
2 pts – discordant (opposite direction of QRS) ST elevation >=5mm any lead

–add up the points, score >=3 is 90+ percent specific for an MI
–the discordant ST elevation is apparently less useful

HOW DO I USE THIS?:
–you’re handed an EKG, there’s a LBBB

–look for >=1mm concordant ST elevation
–look for ST depression in anterior leads

–if you see these things, worry about an MI

Reference(s): THE article, nice website

Mono (a.k.a. Infectious Mononucleosis)

11 Oct

HPI:
–If they read the textbook, they come in with: fever, pharyngitis, adenopathy, fatigue, and atypical lymphocytosis, +/- splenomegaly.

DIAGNOSIS:
–Monospot test is helpful, doesn’t take forever to get
–EBV (Epstein-Barr Virus) stuff

SOMETHING I (re)LEARNED RECENTLY:
Elevated LFTs (liver function tests): very common in mono, but are self-limited
–If you have a pt with pharyngitis/feeling crappy, with elevated LFTs, let mono float through your differential

TREATMENT:
–supportive, symptomatic
–steroids controversial

GOOD ADVICE FOR PATIENTS:
–no contact sports for 3-4 weeks (highest risk of spontaneous or traumatic splenic rupture most likely 2-21 days after onset of symptoms)

Reference(s): Aronson MD, et al. Infectious mononucleosis in adults and adolescents. UpToDate.com

Postpartum Preecclampsia

6 Oct

Key Points:

–Postpartum preeclampsia = HTN and proteinuria after delivery

–can occur up to 4 weeks after delivery (median of 5 days in this study)

–33-69% of patient have no evidence of preeclampsia in the ante/peripartum period

–HPI: most common complaints (n=22):

  • headache (82%, 18/22)
  • visual changes (31 %)
  • elevated BP at home (23%)
  • nausea (18%)
  • abdominal pain (14%)
  • vomiting (14%)
  • edema (9%)
  • neck pain (9%)

–PHYSICAL EXAM & LABS: notable findings, some not as ‘classic’ as you think (n=22 unless indicated)

  • elevated SBP (95%)
  • elevated DBP (77%)
  • hyperreflexia (47%, 10/21)
  • edema (84%, 16/19)
  • proteinuria (64%)
  • elevated LFTs (41%)
  • hyperuricemia (54%)

–TREATMENT:

  • BP control (e.g. hydralazine, labetolol)
  • magnesium, benzodiazepines if seizures

10-SECOND TAKEAWAY:
–Postpartum preecclampsia (classically) = HTN, proteinuria, <4wks postpartum
–Symptoms: high BP, HA, vision changes, nausea/vomiting, swelling
–Good to check (but all don’t have to be abnormal): BP, reflexes, urine (proteinuria), LFTs, uric acid
–Treatment Toolbox: can’t deliver postpartum, so BP control and magnesium/benzos if ecclamptic

Reference(s): Yancey et al. Postpartum Preeclampsia: Emergency Department Presentation and Management. JEmergMed 2008.

Submitted by T. Boyd.

Acute Chest Syndrome (Sickle Cell Crisis)

4 Oct


Key Points:

Acute chest syndrome (chest pain, hypoxia, decreasing Hb levels, multi-lobar pneumonia on CXR) is the leading cause of death amongst patients with sickle cell disease.

Vichinsky et al.: 30 center study, 671 episodes of the acute chest syndrome in 538 patients with sickle cell disease
  • 72% of patients were initially admitted with another diagnosis (e.g. pain), then diagnosed with acute chest syndrome 2.5 days later (on average). 
  • Most common symptoms:
    • fever (80%)
    • cough (62%)
    • chest pain (44%)
    • tachypnea (45%)
    • SOB (41%)
    • extremity pain (37%)
    • abdominal pain (35%)
    • rib/sternal pain (21%)
  • Mortality mostly due to respiratory failure from pulmonary emboli (marrow, fat, or thrombosis) and pneumonia.

Treatment:
–broad antibiotics (including a macrolide)
–bronchodilators (assume airway hyperreactivitiy even if no wheezing)
–early transfusions for patients at high risk of complications.

10-SECOND TAKEAWAY:
–Sickle Cell + cardio/pulm complaints: think about Acute Chest Syndrome
–Symptoms: non-specific
–PE’s and pneumonias suck
–Treatment Toolbox: antibiotics, bronchodilators, transfusions

Submitted by T. Boyd.