Archive | October, 2012

alcohol (playing with numbers)

31 Oct

on a holiday where kids will toe the diabetes line, and adults will indulge in other things, here’s a little tidbit on alcohol.

 

HOW DOES SERUM ETHANOL LEVELS COMPARE WITH BAC (Blood Alcohol Content)?

  • its all about units (serum level usually mg/dL; BAC is g/dL)
  • move the decimal point 3 places to the left
  • e.g. serum ETOH level of 100g/dL = BAC 0.10 g/dL = 0.10% BAC

 

WHAT’S THE BAC LEGAL LIMIT (for a DUI)?

  • 0.08% BAC = 80mg/dL serum ETOH

 

HOW MUCH WILL A DRINK INCREASE MY ETOH LEVELS?

  • depends on your size and the size of the drink (handy reference chart)
  • standard drink is 1-1.5 oz shot of liquor, 5 oz glass of wine, 12 oz beer
  • guesstimation: most folks will get over the 0.08% BAC limit with 2-3 drinks or so

 

WHAT’S YOUR RECORD?

  • …from a patient you’ve seen (not asking for a personal best/worst. let us be discrete)
  • the most impressive serum ETOH: level I’ve seen is probably in the 500s, from a young girl who was sitting up, awake, chatty, and probably 50kg soaking wet.  most of us would be comatose at this point.

 

References: emedicine serum/BAC; more emedicine; BAC chart; DUI/DWI laws; picture

ascites (quick hits)

30 Oct

About 85% of cases of ascites are attributed to cirrhosis.

The 2nd most common cause is cancer.

The 3rd most common is heart failure.

Less common causes include renal failure/dialysis, nephrotic syndrome, lupus, inflammatory GI disorders, pancreatic disease, thoracic duct obstruction, and tuberculosis.

When the most common etiology is not found, the other possibilities should be explored.

Ascites is classified as grade 1 (mild) to grade 3 (large) and also by response to diuretic treatment.

Although paracentesis is commonly performed for ascites from liver disease, ascetic cytology for cancer is expensive and can low yields (reported at 7%), multiple samples increases sensitivity.

Therapeutic paracentesis can take off up to 5L of fluid safely for symptom resolution, but does not treat the cause of the ascites.

 

Submitted by C. Stokes.

 

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); picture

forearm compartment syndrome

29 Oct

The forearm has 3 compartments, flexor, extensor and mobile wad (near Ulna). 

Anything that can increase volume such as hemorrhage can cause compartment syndrome.

A pressure of 30-50mm Hg have traditionally been thought of as toxic if untreated for several hours.

One can also measure delta pressure, the difference between diastolic and compartment pressure (delta less than than 30mm Hg indicates compartment syndrome).

Fasciotomy is usually made with a long incision, left open and closed several days later.

Pain is typically the first symptom present of the 5 p’s (pain, paresthesia, pallor, pulselessness, poikiolthermia) of compartment syndrome.

 

Submitted by C. Stokes.

 

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); picture

Bartholin’s Gland Cyst/Abscess

26 Oct

Common in women of reproductive age, perimenopausal women should have cancer ruled out.

Pea size glands at the 4 and 8 O’Clock position, not normally palpable.

The purpose of the glands are to provide moisture for the vulva.

Duct obstruction causes cyst and abscess formation.

Usually a 2-4cm fluctuant mass on the labia.

 

Treatment includes I&D (gown/glove/mask recommended, for your own protection), catheter placement, and marsupialization.

  • For catheter, an elliptical incision is made along the vaginal mucosa with expression of pus.
  • Insert a Word catheter deep into the cavity, inflate the catheter balloon with saline.
  • If a Word catheter is not available, gauze can be used to pack the cavity.

 

Antibiotics, if indicated (controversial, as with many abscess/antibiotic discussions):

  • typically Keflex and/or Flagyl for polymicrobial vaginal flora
  • ceftriaxone/azithromycin for possible Neisseria/Chlamydia.

 

See OB in 2-7 days depending on severity.

 

Submitted by C. Stokes.

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); picture above; a less ‘safe for work’ photo illustration

diverticulitis (quick review)

25 Oct

Caused by increased intraluminal pressures of the colon

Commonly seen in western diets of low fiber, high fat that promote decreased GI transit times.

In the US diverticulitis is primarily a left colon (sigmoid) disease 95-98% of the time and in Asia diverticulitis is primarily a right colon (ascending) disease.

What happens is the vasa recta penetrate the circular muscle layer of the colonDiverticulitis is inflammation and or infection of a diverticuli.

CT is the test of choice to diagnose with sensitivities of 97% and specificities approaching 100%.

The presence of an abscess with perforation such as in this case represents a complicated diverticulitis and requires immediate surgical referral.  Other types of complicated diverticulitis include phlegmon, stricture, obstruction, and fistula.  The Hinchey classification scheme list 4 stages of worsening complicated diverticulitis from small confined pericolic abscess to free perforation with fecal contamination of the peritoneal cavity

 

Treatment:

  • outpatient antibiotics if simple (e.g. metronidazole 500mg TID + ciprofloxacin 500mg BID x 7-10 days)
  • inpatient: IV antibiotics, surgical consult if abscess/perf/etc.

 

Submitted by C. Stokes.

 

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); EMRA Antibiotic Guide 2011; picture

backwards internal laryngeal pressure

24 Oct

nice trick from the resusme.em blog

CONCEPTS:

cricoid pressure used during intubation to help visualize the cords

BURP manuever: Backwards Upwards Rightward Pressure

if intubation attempt ends up with ETT in the esophagus, leave it in:

  • can help with the next intubation attempt (harder to put two ETTs in the same esophagus, this more likely to get it in the trachea)
  • using the esophageal ETT to displace it (and the backwards) might help your view

Nice idea.

References: the resusme post; picture

Wolf-Parkinson-White (quick review)

19 Oct

WPW = pre-excitation accessory pathway syndrome

Upsloping delta wave on QRS complex causing a shortened PR interval.

85% of SVT with WPW are narrow QRS complexes with AV retrograde conduction and accessory bundle antegrade conduction.

The accessory pathway is called a Kent Bundle and is tissue directly linking atria to the ventricles. 

There are three types of WPW, A, B, C, depending on anatomic location of the pathway.

A wide complex SVT from WPW should be treated like Vtach.

  • The wide complex is caused by a short refractory period of the accessory pathway.
  • Blocking the AV node is these cases can put the patient into Ventricular fibrillation (unopposed transmission through accessory pathway)
  • do NOT give B-blockers, calcium channel blockers or adenosine in wide complex rhythms.
  • Give Procainamine or synchronized cardioversion.
  • Procainamide prolongs the refractory period of the accessory pathway, not just the AV node.

Narrow complex WPW, (orthodromic AV reciprocating tachycardia) can be treated like SVT with AV node blocking agents.

Definitive treatment of WPW is ablation.

Submitted by C. Stokes.

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010) 1235-1239; picture