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visual aid: slit lamp tutorial

27 Nov

a nice quick video tutorial on the slit lamp exam from this old ALiEM post:

if you only have a couple minutes, the ~2:00 to 4:00 minute mark are nice reminders of a few knobs and how to adjust the level and light window.

also, there’s a nice example of cell & flare at the ~5:30 mark.

Go forth, look at eyeballs.

 

References: ALiEM post (with other eye exam videos also)

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IO craniotomy?

20 Nov

back after a bit of a layoff with a bit of an interesting, if maybe not ready for primetime procedure idea, via this Austrailian resus blog:

screen-shot-2017-11-09-at-5-48-47-pm-1058x630

basically, in the setting of an expanding intracranial hematoma, evacuating the pressure to temporize (the alternative being herniation, then death).

while burr holes are preferred, if you have nothing else, interesting to see this on the horizon as a potential option.

 

References: resus blog post & photo

ECG [anatomical] visual aid

19 Sep

quick anatomical reference for your ECG thought process (particularly for browsing contiguous leads), via an old emDOCs post:

screen-shot-2017-05-24-at-3-31-17-pm

1

for your reference, a simple anatomical diagram below:

Coronary artery anatomy

The emdocs post also has some nice echo videos and many more photos from different perspectives, if you need some additional spacial orientation.

 

References: emdocs post; coronary artery photo

ultrasound visual aid (part 2): glove assist

28 Aug

on a recent post, referenced the idea of using an IV saline bag to ultrasound through to visualize tricky irregular and superficial surfaces (e.g. hand/digits).  

Here’s a handy visual aid for the same idea, only using a water-filled latex glove (via an 2016 emed journal article):

em048090414_f2

Add it to the toolbox.

References: emed journal article (& photo)

Thyroid Emergencies (quick review)

1 Aug

submitted by Amit Kumar, M.D.

 

THYROID STORM

-Risk factors:

Longstanding untreated thyroid issues (Grave’s, toxic multinodular goiter, solitary toxic adenoma), but more commonly surgery, trauma, infection, parturition, recent iodine load

 

-Diagnosis:

Hyperpyrexia, AMS, cardiac dysfunction (tachycaria, A-fib, CHF, etc.) in a patient with elevation of T4/3 and supression of TSH

 

-Treatment:

  • 1) Control increased adrenergic tone: B-blocker
    • PO: Propranolol 60-80mg q4-6h (monitor HR, BP)
    • IV: Esmolol 250-500mcg/kg followed by 50-100mcg/kg/min
  • 2) Block new hormone synthesis
    • PTU 200mg q4h (safe during pregnancy) or
    • Methimazole 20mg q4-6h
  • 3) Block further release of hormone
    • Iodine (1h post step 2, or else will be used to make more T4)
  • 4) Inhibit peripheral conversion of T4 -> T3
    • PTU,
    • steroids such as hydrocortisone 100mg q8h (also treats relative assoc. adrenal insufficiency)

 

 

MYXEDEMA COMA

-Risk factors:

Acute event (ex: MI, cold exposure, sedative drugs such as opioids) in poorly controlled hypothyroid patient, drug induce (ex: lithium, amiodarone)

 

-Diagnosis:

Depressed mental status + hypothermia, hyponatremia, and/or hypercapnia (due to hypoventilation); hx of thyroidectomy scar or recent radioiodine therapy

Primary (with high TSH) or central (with low TSH)

 

 

-Treatment:

  • 1) Thyroid hormone
    • Combined T4 (200-400mcg IV) and T3 (5-20mcg IV). Both are continued thereafter.
  • 2) Glucocorticoids (until concominant adrenal insufficiency is ruled-out)
    • Hydrocortisone 100mg q8h
  • 3) Supportive care
    • Non-dilute fluids (due to hyponatremia), passive rewarming, pressors (if hypotension doesn’t resolve)

 

 

References:

-Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med 1991; 9:232.

-Cooper DS, Daniels GH, Ladenson PW, Ridgway EC. Hyperthyroxinemia in patients treated with high-dose propranolol. Am J Med 1982; 73:867.

-Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab 1982; 54:101.

-Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.

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