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.
Sunday, September 28, 2014
BP in Sepsis, Abx for COPD, and Fever in SSD
We had our last Journal Club on September 17, and it was great. Much great discussion.
First Article:
http://www.ncbi.nlm.nih.gov/pubmed/22923662
Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease.
Bottom Line: Antibiotics may be useful in mild to moderate COPD exacerbations; whereas we already know it's beneficial (mortality benefit) in severe COPD. Gerenalizability is limited by choice of antibiotics, and infrequent use of steroids.
Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24635770
High versus low blood-pressure target in patients with septic shock.
Bottom Line: This is a good one that was overshadowed by the Process Trial. No benefit for MAP goal of 85 vs 65. However, in patient's with hypertension, the high target group required less renal replacement therapy. So, you may consider a higher target in those with chronic hypertension, but no strong, compelling evidence to do so. Also, probably doesn't matter in the ED.
Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/23669523
Bacteremia risk and outpatient management of febrile patients with sickle cell disease.
Bottom Line: In pediatric patients with good follow up, it is safe to discharge a febrile sickle cell patient after a shot of ceftriaxone - less than 1% of these patients had bacteremia. I think the key here is that this was Boston Children's, and they all had good follow up. So, if that's your scenario, discharge away (unless they look ill, of course). Great comment from one of our community docs - "I've never gone home and thought dang, I wish I wouldn't have given that rocephin."
First Article:
http://www.ncbi.nlm.nih.gov/pubmed/22923662
Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease.
Bottom Line: Antibiotics may be useful in mild to moderate COPD exacerbations; whereas we already know it's beneficial (mortality benefit) in severe COPD. Gerenalizability is limited by choice of antibiotics, and infrequent use of steroids.
Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24635770
High versus low blood-pressure target in patients with septic shock.
Bottom Line: This is a good one that was overshadowed by the Process Trial. No benefit for MAP goal of 85 vs 65. However, in patient's with hypertension, the high target group required less renal replacement therapy. So, you may consider a higher target in those with chronic hypertension, but no strong, compelling evidence to do so. Also, probably doesn't matter in the ED.
Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/23669523
Bacteremia risk and outpatient management of febrile patients with sickle cell disease.
Bottom Line: In pediatric patients with good follow up, it is safe to discharge a febrile sickle cell patient after a shot of ceftriaxone - less than 1% of these patients had bacteremia. I think the key here is that this was Boston Children's, and they all had good follow up. So, if that's your scenario, discharge away (unless they look ill, of course). Great comment from one of our community docs - "I've never gone home and thought dang, I wish I wouldn't have given that rocephin."
Monday, July 7, 2014
How I Navigate Online Emergency Medicine Resources
This may seem a bit cryptic without actually hearing me give the lecture, but you get the idea...
EM Resources from bcooper876
Choosing Wisely Campaign
Last October, ACEP joined ABIM's "Choosing Wisely" campaign. 5 measures were agreed upon. They're pretty soft, but it's a start:
Wednesday, June 25, 2014
Aggressive BP Management in Patients with ICH
Check out my guest post at EMDocs.net here: http://www.emdocs.net/aggressive-bp-management-patients-ich/
Bottom Line:
Early BP reduction in ICH is safe and probably efficacious, although the data doesn’t definitively say so yet. The AHA still recommends “modest” reduction if SBP>180 or MAP>130 to a goal of 160/90 or MAP of 110, but the ATACH results may prompt a change in the guidelines…we shall see. Also worth noting, the ADAPT trial confirms that perihematoma blood flow is maintained even in those with aggressive BP lowering. So, if you’re feeling rather aggressive, lower away! BP lowering will not harm your patient with ICH, and may help.
Bottom Line:
Early BP reduction in ICH is safe and probably efficacious, although the data doesn’t definitively say so yet. The AHA still recommends “modest” reduction if SBP>180 or MAP>130 to a goal of 160/90 or MAP of 110, but the ATACH results may prompt a change in the guidelines…we shall see. Also worth noting, the ADAPT trial confirms that perihematoma blood flow is maintained even in those with aggressive BP lowering. So, if you’re feeling rather aggressive, lower away! BP lowering will not harm your patient with ICH, and may help.
Tuesday, May 27, 2014
Bugs & Drugs - Antibiotic QuickCard
Antibiotic selection has been identified as a potential weak spot for our residents. So, I created the below table to serve as a quick reference while on shift. My hope is to condense it to the size of a badge (front and back) so that it can be worn on one's badge holder. Please note the disclaimer below. This has not been peer reviewed yet. References are listed below.
| Source | Bugs | Drugs | Comments | |
PNA
| CAP | S. pneumonia, H. influenza, Moraxella Atypicals - Mycoplasma, Chlamydia, Legionella | OP - azithro x 5d OR doxy 100mg bid x 7d IP - ceftriaxone 1g + azithro 500mg | consider moxifloxacin for comorbidities (i.e COPD, DM, CHF) |
| HCAP | PsA, MRSA, E. Coli, Acinetobacter, Serratia | IP - vanc 20mg/kg + pip/tazo 4.5g + azithro 500mg | Pen allergic - substitute aztreonam or cefepime for pip/tazo | |
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