Insulin Pumps: Understanding them and their complications

Insulin_PumpWhile 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.

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By |2016-12-23T19:56:28-08:00Dec 11, 2013|Endocrine-Metabolic|

Thyroid Storm: Treatment Strategies

T3hyperExpertPeerReviewStamp2x200The Case

You have a 54-year-old female who presents to the emergency department with a chief complaint of “just feeling out of it.” She has felt “off and on” for the past 12 hours and has had an occasional cough with some sputum production along with “the shakes and chills.” She also feels as if her heart was “going at a mile a minute” and because of this, she is very much out of breath.

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P-Video: Rule of 15 in anion gap metabolic acidosis

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You have a patient with an anion gap of 30 and bicarbonate of 10 mEq/L. You also determine on VBG that the patient’s pCO2 is 25 mmHg. What trick of the trade can you use to quickly determine whether this low pCO2 is an appropriate compensation of the primary metabolic acidosis? Dr. Jeremy Faust and Dr. Corey Slovis explains the quick “Rule of 15”.

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By |2019-01-28T21:53:37-08:00Oct 22, 2013|Endocrine-Metabolic, Tricks of the Trade|

Diagnosing hyperthyroidism: Answers to 7 common questions

T3hyperExpertPeerReviewStamp2x200The prevalence of hyperthyroidism in the general population is about 1-2%, and is ten times more likely in women than men. The spectrum of hyperthyroidism ranges from asymptomatic or subclinical disease to thyroid storm. So how do we diagnose various presentations of hyperthyroidism in the Emergency Department? Below are answers to 7 common questions that commonly arise.
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Dexmedetomidine (Precedex) as an Adjunct to Benzodiazepines for Ethanol Withdrawal

Sometimes a question is posed on Twitter that generates a great discussion from colleagues ’round the globe. Such was the case for dexmedetomidine. Although benzodiazepines remain the standard of treatment for ethanol withdrawal, particularly seizures and delirium tremens, what’s all the hype about dexmedetomidine?

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PV card: VBG versus ABG

abg vbgYou obtain a venous blood gas (VBG) on a patient with a COPD exacerbation because you are concerned about hypercarbia. You get a value of 55 mmHg. How correlative is that compared to an arterial blood gas (ABG). There has been a lot of literature on how well the pH correlates between the ABG and VBG but what about pCO2?

A small study (n=89) from 20121 found that with a cutoff of pCO2 < 45 mmHg, the venous pCO2 is 100% sensitive in ruling out arterial hypercarbia. When the pCO2 was ≥ 45 mmHg, the VBG was less correlative.

Below is a review by Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob Bryant (Intermountain Medical Center in Utah) of the VBG vs ABG correlative data, along with a proposed algorithm on what to do with patients with COPD exacerbation.

What is your practice with an elevated pCO2 value on VBG?


Adapted from [1–5]
Go to ALiEM (PV) Cards for more resources.

Updated 1/31/13 at 2 pm PST:

  • Changed range of pH correlation between VBG and ABG = 0.03-0.04
  • Was typo in abstract of Kelly et al article.2 Stated difference between pHs was 0.4, rather than 0.04 as described in main results text.

References

  1. McCanny P, Bennett K, Staunton P, McMahon G. Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 2012;30(6):896-900. [PubMed]
  2. Kelly A, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001;18(5):340-342. [PubMed]
  3. Ma O, Rush M, Godfrey M, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10(8):836-841. [PubMed]
  4. Middleton P, Kelly A, Brown J, Robertson M. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. 2006;23(8):622-624. [PubMed]
  5. Koul P, Khan U, Wani A, et al. Comparison and agreement between venous and arterial gas analysis in cardiopulmonary patients in Kashmir valley of the Indian subcontinent. Ann Thorac Med. 2011;6(1):33-37. [PubMed]
By |2021-10-08T09:26:47-07:00Jan 31, 2013|ALiEM Cards, Endocrine-Metabolic, Pulmonary|
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