In the patient population at Parkland, osteomyelitis (OM) usually results from direct extension of adjacent soft tissues (i.e. diabetic foot ulcers, or sacral decubitus ulcers), but can also result from hematogenous spread, or direct inoculation as a result of trauma or surgery. Given the lack of sensitive physical exam findings, and the unavailability of time-consuming imaging modalities in the ED (magnetic resonance and/or bone scintigraphy), OM can be a difficult and sometimes elusive diagnosis to make in the Emergency Department.
Sunday, February 1, 2015
Thrombolytics in PE
Last night, I had a patient present with acute dyspnea, tachy in the 150s. She had a h/o prior PE 5 years ago that she completed anticoagulation for. EKG shown below has some TWI in anteroinferior leads (c/w RHS), and a nice Q wave in III (not really an S1, but impressive Q3T3).
Patient was started on a heparin ggt even prior to CT (slice shown below). Bedside echo also revealed enlarged RV. She had b/l PEs. She was hemodynamically stable, so this was considered a submassive PE.
Patient was started on a heparin ggt even prior to CT (slice shown below). Bedside echo also revealed enlarged RV. She had b/l PEs. She was hemodynamically stable, so this was considered a submassive PE.
Wednesday, January 7, 2015
Acetaminophen in Pregnancy, HD for Methanol, Risk Score for Rhabdo
Dr. Bob Hoffman was our guest during our last Journal Club, on 1/7/15, and it was great. Dr. Hoffman had some great insight.
First Article:
http://www.ncbi.nlm.nih.gov/pubmed/24566677
Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders.
Bottom Line: This is a really well done study done in Denmark. There's no way this study could have been done in the US, we don't have the medical infrastructure to pull it off. This was in the media a lot, and led many to question the role of acetaminophen for pain and/or fever relief in pregnancy. In short, the conclusion was that there is an association between acetaminophen use in pregnancy and ADHD by age 7. This was an observational study, and in no way implies causation. It is, however, provocative and will likely prompt more research. Not practice changing, though. Pregnant women should still use acetaminophen until convincing data states otherwise.
Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24000014
A risk prediction score for kidney failure or mortality in rhabdomyolysis.
Bottom Line: The authors of this study derived and validated a risk prediction score for mortality and renal failure in patients with rhabdomyolysis using retrospective data. Not a bad tool for predicting risk in patients that are to be admitted for rhabdomyolysis. Not reasonable to use, however, for the young athletic patient with a little CK elevation but otherwise normal renal function and labs that you indistinctly know will do well on discharge. This tool was not derived on outpatients, and should not be used to justify a discharge - the lowest possible risk using this tool is like 1.6% for the primary outcome, anyway. And, who wants to put that in a chart?
Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/24621917
Intermittent hemodialysis is superior to continuous veno-venous hemodialysis/hemodiafiltration to eliminate methanol and formate during treatment for methanol poisoning.
Bottom Line: You have to accept that the surrogate marker of elimination half life leads to better outcomes. Once you do, then you'll accept the findings. Basically, intermittent HD is better at elimination methanol and the deleterious byproduct formate. If unable to use intermittent HD (possibly for hemodynamic reasons), and continuous dialysis is chosen, then two factors matter in terms of methanol and formate elimination - the dialysate flow rate, and the membrane surface.
First Article:
http://www.ncbi.nlm.nih.gov/pubmed/24566677
Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders.
Bottom Line: This is a really well done study done in Denmark. There's no way this study could have been done in the US, we don't have the medical infrastructure to pull it off. This was in the media a lot, and led many to question the role of acetaminophen for pain and/or fever relief in pregnancy. In short, the conclusion was that there is an association between acetaminophen use in pregnancy and ADHD by age 7. This was an observational study, and in no way implies causation. It is, however, provocative and will likely prompt more research. Not practice changing, though. Pregnant women should still use acetaminophen until convincing data states otherwise.
Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24000014
A risk prediction score for kidney failure or mortality in rhabdomyolysis.
Bottom Line: The authors of this study derived and validated a risk prediction score for mortality and renal failure in patients with rhabdomyolysis using retrospective data. Not a bad tool for predicting risk in patients that are to be admitted for rhabdomyolysis. Not reasonable to use, however, for the young athletic patient with a little CK elevation but otherwise normal renal function and labs that you indistinctly know will do well on discharge. This tool was not derived on outpatients, and should not be used to justify a discharge - the lowest possible risk using this tool is like 1.6% for the primary outcome, anyway. And, who wants to put that in a chart?
Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/24621917
Intermittent hemodialysis is superior to continuous veno-venous hemodialysis/hemodiafiltration to eliminate methanol and formate during treatment for methanol poisoning.
Bottom Line: You have to accept that the surrogate marker of elimination half life leads to better outcomes. Once you do, then you'll accept the findings. Basically, intermittent HD is better at elimination methanol and the deleterious byproduct formate. If unable to use intermittent HD (possibly for hemodynamic reasons), and continuous dialysis is chosen, then two factors matter in terms of methanol and formate elimination - the dialysate flow rate, and the membrane surface.
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