Little Box of EM

Emergency Medicine literature and knowledge updates from an intern's everyday patient encounter.

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วันนี้อ่านเรื่อง airway ซักหน่อย เป็น editorial ของ guideline difficult airway management 2015 ซึ่งยาวมาก เลยอ่านอันนี้แทน

เรื่องที่สำคัญของ guideline - human factor ใน airway crisis: มี nontechnical skill หลายอย่างที่เกี่ยวข้องกับ difficult airway เช่น situation awareness, decision making, task management, teamwork -"paradox of choice" มีทางเลือกมากก็งงเยอะ ตัดสินใจช้า การ call for help แล้วมีหมออีกคนมาช่วย ก็จะช่วยเลือกง่ายขึ้น - "analysis paralysis" คือมัวแต่คิดหาทางที่ดีที่สุด แล้วกลัวจะเลือกผิด จนไม่ได้ทำอะไร - เพราะฉะนั้น guideline ที่ดี ไม่ต้องมี choice มาก แต่ให้ simple ที่สุด - บทเรียนที่ดีควรมีตั้งแต่พื้นฐาน เช่น จัดท่า จนถึงขั้นสูง เช่น fiberoptic - airway expert ควรเป็น "Ma" ตามแบบญี่ปุ่น คือ negative space คือคอย support นักเรียนอยู่เบื้องหลัง - priority หลักของ airway management คือ oxygenation ไม่ใช่ intubation - ซื้อ airway equipment ต้องคิดถึงคนที่มีความสามารถน้อยที่สุดที่จะได้ใช้ คือ ใช้ง่าย และดี นั่นเอง

http://bja.oxfordjournals.org/conte…/…/2015/11/05/bja.aev298

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สิ่งนี้ใน IVC คืออะไร

เชื่อว่าทุกคนที่ทำ U/S bedside เยอะ ๆ น่าจะเคยเจอเคส IVC ที่มีอะไรขาว ๆ อยู่ข้างในวิ่งไปมา ก็สงสัยอยู่ว่าคืออะไร

ใน paper นี้เค้าขอเรียกสิ่งนั้นว่า Particulate matter (PRM) โดยมักพบในคนแข็งแรง ที่หัวใจเต้นไม่เร็ว หรือนักกีฬาที่หัวใจเต้นช้า หรือคน LVEF น้อย หรือ CO น้อย

เค้าคิดว่า ต่างกับ spontaneous echo contrast (SEC) ซึ่งเจอในหัวใจ เป็นขาว ๆ วน ๆ / และต่างจาก microgas emboli ที่เกิดจาก mechanical heart valve ด้วย

แต่ก่อนหน้านี้ เคยมีการศึกษา เรียกสิ่งนี้ว่า spontaneous echo contrast ใน IVC ซึ่งสันนิษฐานว่า เกิดจาก low flow (http://www.sciencedirect.com/…/article/pii/S0735109784803356)

ซึ่งโดยสรุปก็ยังไม่รู้ว่าเป็นจากอะไร แต่คิดว่าไม่น่าจะสำคัญเท่าไร

http://onlinelibrary.wiley.com/…/j.1540-8175.2008.…/suppinfo

www.facebook.com/Apaperaday

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Reviewing history of resuscitation today by Dr. Chamberlain reminds us the importance of integration of knowledge already known

Dr. Douglas Chamberlain : WCDEM2013

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More than 50% of patients with cardiogenic pulmonary edema are euvolemic.

Amal Mattu, Resuscitation 2012 conference. http://www.youtube.com/watch?feature=player_embedded&v=ljv2aZrljEc

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A diagram show how to quickly examine a patient with hand injury (edited from Tintinalli's 7th ed, created with Paper by FiftyThree on ipad)

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Discharging a patient with acute pancreatitis

Just had a conversation with one of my patients I met at the outpatient clinic. He had a vague abdominal pain for 3 days but not a lot of nausea and vomiting. Generalized tenderness abdomen was found and after working up, he had an acute pancreatitis (probably from alcohol). I decided to admit him, but he refused because of some business he had to take care of. So I was wondering what kind of patient with acute pancreatitis can be discharged safely? Are there any standardized scores on this? 

Tintinalli's

Patients with mild pancreatitis, no biliary tract disease, and no evidence of systemic complication can be discharged home if they can tolerate oral liquids and if pain is controlled. 

clear liquid diet and oral analgesics are recommended with follow-up in 24-48 hours.

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False positive lactate in septic patients

In septic patients, lactate(or lactic acid) greater than 4 is used for identify severe sepsis patients. But lactate can be falsely high in: Beta-agonists Recent exercise Post seizure Hepatic failure

However, in nom septic patients, lactate can be high and related to increase mortality: shock(any causes, NF, bowel infarction, and some toxins

Thanks to Emcrit.org

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Near-hanging injury

Just encountered a 15-year-old boy hanging himself after having a fight with his girlfriend. The patient was found hanging around 15 minutes after last well seen, and was taken to the nearest hospital within 15 minutes. He was intubated and referred to my provincial hospital. 

At the provincial hospital, he was obtunded with GCS E2VTM2 pupil 5 mm NRTLBE. However, 2 days after admission, he can be extubated, regain full consciousness without any neurologic deficit!

So just review near-hanging (hanging with signs of life on arrival); better prognosis than I thought  : 10% will die, in those who survived, only 3% will sustain neurologic disability. Most spend time in ICU only 1-2 days. around 5% will sustained cervical fracture, but not Hangman’s fracture, as was seen in judicial hanging, when the prisoner was dropped equal or greater than the height of that person. Mechanism of dying in patient with hanging is jugular venous obstruction, carotid obstruction, brain hypoxia and cardiac arrest. Important associated injury were laryngeal fracture and carotid injury. 

So do your best! ATLS and best supportive care in patient with near-hanging. 

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"Choosing wisely" campaign

A campaign to promote rational use of medical investigation or imaging. I chose some of the recommendations that are relevant to my practice, though there's no list from emergency physician society. The whole lists can be found here. http://www.choosingwisely.org/doctor-patient-lists/

Don’t diagnose or manage asthma without spirometry.

Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.

Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

Don’t use bleeding time test to guide patient care.

Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications

Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis).

Don’t routinely use bronchodilators in children with bronchiolitis.

Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.

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CO poisoning

CO poisoning Tintinalli -Major contributor to smoke related death -Inhalation, or ingestion (methyline chloride - varnishes and paint strippers : delay clearance COHb when treated with oxygen: half life up to 13 hour) -Binding affinity to Hb 200 times more than oxygen -Half-lives of COHb on room air at normal atmospheric pressure 4-5 hours, On 100% oxygen : 1-1.5 hours -Decrease oxygen delivery, inhibit cellular respiration, produce nitric oxide -Clinical manifestation highly variable: headache, vomit, Ataxia, seizure, syncope, chest pain, focal neurologic deficit, dyspnea, ECG changes, MI -Carbon monoxide poisoning should always be in the differential diagnosis for comatose patients, patients with mental status changes, as well as for patients who are noted to have an elevated anion gap metabolic acidosis or otherwise unexplained lactic acidosis. -COHb not correlate with symptom -Treatment: 100% oxygen, hyperbaric oxygen

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Antibiotics for complicated UTI

Tintinalli

   complicated UTI  = 1. functional or anatomical abnormal 2. comorbidities that increase risk

More likely to infect with resistant organism : Enterebacteriaceae, Pseudomonas, enterococci, S. aureus

Empiric antibiotic : Pip/tazo 4.5 g iv q 6 hour, imipenem 500 mg iv q 6 hour to 1 gm iv q 8 hour, meropenem 1 gm iv q 8 hour 

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Puncture wound

Rosen’s The infection rate for puncture wounds has been reported to be 15%. -Cellulitis -Septic arthritis -Abscess -Osteomyelitis No data suggest a benefit from prophylactic antibiotics, but given the high risk of infection and serious complications, their use should be strongly considered in select puncture wounds. Pseudomonas organisms when the puncture went through a rubber-soled shoe is essential. Patients with puncture wounds to the foot require early follow-up

Essential of EM'12

Core out the wound using 11 blade and hemostat

Get out fb retain inwound 

Fb rubber sole shoes - 100% problem

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Too much oxygen for COPD, kill them softly

From EMRAP this June, there is a RCT comparing prehospital oxygenation of COPD exacerbation patients, between high flow oxygen and regulated oxygen to keep oxygen saturation 89-92%. The latter group survive more (mortality rate 9% compared with 4%)

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In stroke patient, Intractable hiccup can lead to fatal consequences: aspiration pneumonia. No single drug is effective for hiccup- multiple choices of drugs are available.: metoclopramide, chlorpromazine, baclofen, gabapentin, haloperidol

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AF begets AF

Just a reminder for myself Recent onset AF may spontaneously resolve in the first 24 hours. However, if more than 48 hours or high risk of stroke , the patient must get anticoagulate before giving any cardioversion. Amiodarone 300 mg 5%D/W 100 ml iv drip in 1 hour then 1mg/min Ottawa protocol aggressively convert all AF less than 48 hours using IV Procainamide and then electrical cardioversion.

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Very nice lecture from Dr. Smith: - benefit of thrombolytic in LBBB group as in previous study might resulted from confounding factor as some LBBB has MI or they didn't have MI so they would survive better anyway. -Modified Sgarbossa criteria could enhance sensitivity and specificity of detecting STEMI in LBBB. They modified the "excessive discordance"rule to be ratio ST/S wave more tham 0.2 instead of absolute increase in ST more than 5mm -However, this needs more prospective research on to confirm hypothesis.