We would like to take this opportunity to thank those of you who took the time to take part in our exciting new Expert Peer Review series over the last 4 months of 2013. Your contributions helped us roll out this ground breaking process, and we hope you all will continue to contribute to our peer review in the future.
The winter holiday season is a busy time in most EDs. Colder weather, respiratory infections, and many factors contribute to this. However Christmas Day and New Year’s Day in particular are two of the deadliest days of the year. Missed medications due to travel, delayed presentations because of a desire to stay home for family gatherings, increased stress, alcohol and substance abuse, travel, and drunk driving, are just a few of the things that can contribute to morbidity and mortality in patients of all ages, and particularly in older adults. If you are working this holiday season, here is a glimpse of what you can expect.
Carbon monoxide (CO) is an odorless, colorless gas and is one of the most common causes of unintentional poisoning deaths in the United States. It is also one of the most common poisoning presentations to Emergency Departments. Because CO is produced by the incomplete combustion of carbon-containing fuels, the incidence of accidental exposure peaks during the winter months due to increased use of in-door heating sources and reduced ventilation. 1–3 Several management dilemmas commonly arise when dealing with patients with potential CO poisoning.
Dr. Ken Milne of The Skeptics Guide to Emergency Medicine series has kindly summarized his 42 podcasts from this year and is releasing the summary [download PDF] as a free holiday gift! He also lists the best podcast picks for the year in his year-end blog post.
A 45 y/o male with moderate persistent asthma presents with wheezing and cough following a viral URI. He is tachypneic and has diffuse wheezing. PEFR is 250 (>50% below his normal). Initial ABG is 7.46/33/70 on room air with a lactate of 2.0 mmol/L. He receives IV steroids and 4 rounds of albuterol nebulizers. On repeat evaluation, his work of breathing and wheezing have improved and his PEFR is now >300. He is completed alert and oriented with a BP of 118/70 and a HR of 110. Repeat ABG shows 7.35/35/100 on room air; however, his lactate is now 7 mmol/L.
Is the rise in his lactate expected following beta-agonist therapy?
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A 55 year old male was brought to the Emergency Department (ED) by paramedics complaining of weakness and chest discomfort. His past medical history was notable for coronary artery disease with bypass grafting, diabetes mellitus, and end stage renal disease. He reported being non-compliant with his last 2 scheduled hemodialysis sessions. Paramedics noted pallor and recorded a blood pressure of 80/palpated and a heart rate of 44. Upon arrival to the ED, a 12 lead ECG was obtained.
While the rate of diabetes climbs, the number of patients who are using insulin pumps grows apace. Pumps appeal to physicians because they mimic normal insulin physiology with a consistent basal rate and appropriate bolus doses for meals. This leads to tighter glucose control and smaller variations. For patients, the pumps can be liberating, requiring far fewer injections than a typical multi-dose regimen. Regardless of why your patient has an insulin pump, it helps to know about how they work… for when they don’t.