Archive | July, 2017

ultrasound visual aid: pillows, bags, and baths

24 Jul

quick tip for visualizing areas that are not flat planes (e.g. distal extremities, eyes, etc):

so you’ve probably heard about the gel “pillow” for ocular ultrasound (preferably with a tegaderm over the closed eye before adding the gel pillow)….

ocular-ultrasound-techniques-evidence-pathology-35-638

 

well, you can also try this quick tip via a recent ALiEM post:

try submerging (if feasible) the thing you want to visualize in a bath of water, or in a similar idea, throw an (intact) bag of saline or other IV fluid over it and then ultrasound through that as your medium.

image-7-waterbath-msk-ultrasound-650x433

 

add it to the toolbox.

 

References: gel pillow photo; ALiEM post with bath photo

SEIZURE PEARLS

17 Jul

submitted by Amit Kumar, M.D.

Generalized seizure

-Large parts of bilateral cerebral hemispheres involved
-LOC for the most-part. Post-ictal state (headache, drowsiness) common.
-Examples: Tonic-clonic (grand mal), absence (petit mal), myoclonic, tonic, atonic

Partial seizure

-Simple partial: limited to focal area in single cerebral hemisphere. Usually no post-ictal period.
-Complex partial: simple partial + LOC. Generally associated with an aura (smell, taste, visual hallucination, emotion). Post-ictal period common.

Status epilepticus

-Continuous seizure lasting over 5 mins/more than two discrete seizures without interval recovery

EtOh-withdrawal seizure

-Typically generalized, may begin within 6h of cessation/decreased consumption
-“Kindling phenomenon”: risk and severity of seizure increases (and threshold decreases) with each withdrawal episode

Febrile seizure

-Seizure in child (~3 mo-6y) with associated fever (>38C), without evidence of intracranial infection or other defined cause
-Types: Simple: Generalized, last <15 mins, don’t recur in 24h period; Complex: Focal, last >15 mins, recur in 24h period
-Subsequent epilepsy risk: simple (1-2%, only slightly above general population), complex (~5-10%)

Management

-ABCs, airway, O2, monitor
-If intubating: benzo for induction and short-acting paralytic (succ) to not mask ongoing seizures. Post-intubation sedation: benzo/propofol gtt
-Labs (check for electrolyte disarray, anemia), infectious workup, home anticonvulsant levels, neuroimaging prn
-Check POCG (dextrose for hypoglycemia), probe on abdomen (Mg for eclampsia), check drug-list (Vit B6 for INH toxicity)

Treatment

-Benzodiazepines (enhance GABA-mediated neuronal inhibition): lorazepam (Ativan), diazepam (Valium), midazolam (Versed)
-Phenytoin (reduces repetitive firing of action potentials via Na-channels). Administer IV/PO (rare)
-Fosphenytoin. Administer IV/IM
-Phenobarbital (enhances GABA)
-Valproic acid (increases GABA)

Seizure abortive meds

References

-Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976; 295:1029.
-Rosen, Peter, John A. Marx, Ron M. Walls, and Robert S. Hockberger. Rosens emergency medicine: concepts and clinical practice. 8th ed. Vol. 2. Philadelphia: Elsevier Saunders, 2014. (& photo)
-Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). SEIZURE, ADULT. ROSEN & BARKIN’S 5-MINUTE EMERGENCY MEDICINE CONSULT. Retrieved February 13, 2017 from http://www.r2library.com/Resource/Title/1608316300/ch0019s14706

WARFARIN REVERSAL – When and How?

10 Jul
submitted by Amit Kumar, M.D. 
 
SERIOUS LIFE-THREATENING BLEEDING:
-Hold warfarin
-Vit K 10mg IV infusion over 20-60minsholygrail018
-PCC. Dosing based on weight and INR. Typical for INR >6: 50 U/kg. Re-check INR 30 mins post-admin.
-Transfusions: RBC, Platelets (if <50,000), FFP (15-30cc/kg; if PCC unavailable)
-Other agents: TXA/aminocaproic acid (anti-fibrinolytic), DDAVP (for platelet dysfunction)
 
URGENT SURGERY/PROCEDURE:
-Hold warfarin. Vit K + PCC, as above
 
SURGERY/PROCEDURE after 24H:
-Hold warfarin. Vit K 1-2mg
 
MINIMAL BLEEDING:
-Clinical judgement: withhold warfarin vs hold warfarin + Vit K vs more aggressive reversal (like above)
-Weigh pros/cons of current bleeding vs thromboembolic risk
 
NO BLEEDING:
-INR >9:  Vit K 2.5-5mg PO. Will reduce INR over 24-48 h. Can re-start warfarin (maybe reduced dose) when INR therapeutic
-INR 5-9: Hold warfarin temporarily (1-2 doses) +/- Vit K 1-2.5mg (elderly with slower clearance, prior bleeding)
-INR <5: Hold next dose of warfarin
 
SUPERWARFARIN POISONING:
-Often found in rodenticides, laced street-drugs. Accidental vs suicide attempt.
-Usually requires massive doses of Vit K (50-800mg/d) for months-years, based on repeat assays and coagulation studies
————————————————————————————————–
PCC pearls:
-If 4-factor PCC missing, use 3-factor PCC + FFP (to supplement factor VII)
-PCC dose based on units of factor IX activity
-PCC advantage over FFP: more rapid admin (doesn’t have to be thawed), faster INR reversal, lower risks for volume overload or TRALI
 
References:
“Paper Chase 1- PCC vs. FFP.” Review. Audio blog post. Www.emrap.org. EM:RAP, Dec. 2013. Web. <https://www.emrap.org/episode/december2013/paperchase1pcc>. Episode 147