Code Panda

Journal Club
It's a hot summer day.  A 40s M with a hx of psychiatric illness smokes crack and becomes agitated and incoherent in the street.  EMS and the cops are called.  In order to bring the EDP to medical attention, PD subdues the pt physically and cuffs him.  The patient is transported on his stomach to the hospital.  On arrival to the hospital, he is violent and uncooperative.  How do we proceed?
Read More

CHF and aflutter

Journal Club
This is a bread-and-butter EM case that is both simple and complicated, like much of medicine. There are two inter-related issues here - chf and tachyarrhythmia. It's not a slam-dunk that the pt is in chf.  She is tachypneic, hypoxic, with some crackles and a hx of chf.  The cxr doesn't look so bad (as a matter of fact, it's very similar to her cxr from a few months ago); she doesn't have typical signs of right heart failure or an S3; and her BP is not high nor is she diaphoretic (typical of patients in acute pulmonary edema, usually with diastolic failure).  However, chf is the most likely diagnosis given all the findings.  You can treat her empirically for failure and see what happens.  You can also send a…
Read More

multi-alphabet disease, sob, and tachycardic

Journal Club
An 80s F presents to the ED with shortness of breath x one day.  There is no cough or chest pain.  Her medical problems include asthma-copd, cabg-mi-chf, dvt, and diabetes.  Her VS are HR 148, RR 28, BP 104/70, T 98.0.  Her room air oxygen sat is 80.  On exam, the patient is not in distress.  She has mild bibasilar crackles on exam, no S3, no murmurs, no JVD, and no lower extremity edema.  A cxr and an ekg are done.  What do we do next?
Read More

First-time seizure, cont’d

Journal Club
Send a beta.  Cannonballs in the chest usually means choriocarcinoma, but many types of mets can look like this.  His beta was nearly 10k. -- There are multiple hypodense lesions on the head ct, likely to be caused by masses and edema.  There is no herniation. Although head CTs are commonly done in the ED for a first seizure, they are generally not needed.  Indications for head CT are debatable, and include focal seizure, patients with low CD4 counts, abnormal neuro exam, recent head trauma, anti-coagulation, and age < 6 months old (correction: 6 months, not 6 years).  I scan everyone with a history of lung or breast cancer, and all show metastatic cns disease.  "Cachexia" isn't on anyone's CT list, but it's an obvious reason for concern.  Typically, the…
Read More

Weird ekg, anti-freeze answers

Journal Club
Whenever you see a slow, wide QRS ekg; think hyperkalemia, regardless of the underlying rhythm.  The ddx includes (1) heart disease - ischemia, cardiomyopathy / scarring, carditis, (2) medications - digoxin, tricyclic antidepressants (TCAs), other meds that affect the sodium channels, beta-blockers (bb) / calcium channel blockers (ccb), and (3) hyperkalemia. The most common causes I see are hyperkalemia or beta-blocker / ccb.  You can check a potassium quickly with a bedside test (e.g. i-stat).  Arguably, it's the most dangerous ddx on the list.  I see this ekg all the time.  The unusual feature of this case is the patient's red-herring complaint of chest pain.  Patient usually come in with weakness, dizzy, or dyspnea. Most everything can be ruled out by h&p.  It's unusual to see this kind of ekg…
Read More

Cheap chest pain + weird ekg

Journal Club
A 70s F presents with chest pain last night (it is now 9:30 pm).  She has no cardiac hx and it's a cheap chest pain story.  Her pmh includes diabetes and htn.  She is noted to be bradycardic at triage.  The remainder of her exam is normal.  An ekg is done.  What do we do now?
Read More

Dexmedetomidine in the ED

EBM
Is a viable alternative sedative/hypnotic agent for procedural sedation in the ED? Mark Estrellado MD, PGY3 Given the regularity of noninvasive and minimally invasive procedures that emergency physicians must perform on a daily basis, proficiency in the art of procedural sedation remains an indispensable component of their already broad repertoire of skills. And while every discussion on the topic of procedural sedation most often begins with the description of the "ideal sedative" as an inexpensive agent that is easily administered, has a rapid and predictable onset and dissipation of effect without prolonged accumulation despite repeated dosing, and is free of adverse side effects and drug interactions, no such agent exists. Instead, the ED physician's current armamentarium consists of a handful of agents--namely benzodiazepines, opioids, propofol, ketamine, and etomidate--each of which…
Read More

BNP: Data, Diagnosis and Applications

Cardiology, CCU Rotation, Respiratory, Why We Do What We Do
BNP: Data, Diagnosis and Applications M Lamberta PGY-3   What are the Biomarkers? [caption id="attachment_3101" align="alignright" width="559"] ACEP Clinical Policy[/caption] Natriuretic Peptide (NP) assays gained approval by the FDA around the year 2000 for the evaluation of undifferentiated dyspnea and suspected ADHF.  The first commercially available test detected the biologically active hormone BNP, but many more recent assays also detect the inert Amino-terminal cleavage product of the BNP prohormone: N-Terminal proBNP (NT-proBNP). (Table 1)  Both biomarkers are comparable in their diagnostic accuracy demonstrated by Receiver Operating Characteristic (ROC) curves.    From 1999 to 2000, Maisel et al. recruited 1,586 participants in the first large multinational randomized control trial (RCT) to evaluate BNP for the diagnosis of heart failure in ED patients presenting with acute dyspnea.[1].  The Breathing Not Properly (BNP)…
Read More