PEM Practice Changing Paper: Clinical Trial of Fluid Infusion Rates for Pediatric DKA

Most protocols for managing pediatric patients with diabetic ketoacidosis (DKA) are based on a theoretical association between fluid resuscitation and subsequent neurological decline. Although the evidence for an association between IV fluids and cerebral edema comes from retrospective reviews, for over 20 years, it is an accepted teaching principle of pediatric DKA.

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis, published just days ago in the New England Journal of Medicine, challenges this teaching with the first randomized controlled trial designed to investigate the relationship between IV fluids and cerebral edema. We review this publication and present a behind-the-scenes podcast interview with lead authors Dr. Nathan Kuppermann and Dr. Nicole Glaser from the Pediatric Emergency Care Applied Research Network (PECARN). (more…)

By Derek Monette, MD|2021-07-01T21:14:43-07:00Jun 15, 2018|Critical Care/ Resus, Endocrine-Metabolic, Neurology, Pediatrics|

Podcast Follow-up: Interview with Dr. Debbie Yi Madhok, Co-Author of “Update on the ED Management of Intracranial Hemorrhage”

Intracranial hemorrhage (ICH) is associated with significant disability and mortality. Although evidence-based guidelines exist, many hospitals have their own institutional practice patterns, which can make it difficult to care for these patients in the ED. Dr. Debbie Yi Madhok, an emergency physician and neurointensivist, sat down with Dr. Derek Monette, the ALiEM Deputy Editor in Chief, to discuss updates in the management of ICH. This interview follows up her original popular 2017 ALiEM post on dilemmas in ICH management, and takes a deeper dive into the nuances of seizure prophylaxis, blood pressure control, and platelet transfusions. We present the podcast and key learning points.
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By Debbie Yi Madhok, MD|2020-04-20T19:37:59-07:00Apr 6, 2018|Neurology, Podcasts, Tox & Medications, Trauma|

Herbal Induced Delirium: The Toxicologist Mindset

The Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.

Case: A previously healthy 49-year-old woman presented to the emergency department (ED) with acute onset of confusion. Family members noticed her to have unsteady gait and she complained of blurry vision and difficulty urinating. She denied the use of any drugs or alcohol and took no medications. In the ED, her vital signs were: T 98.7, BP 95/59, P 130, RR 16, and O2 sat 100% on room air. Her pupils were 7 mm and reactive and her skin was dry. Bowel sounds were present. She had no focal neurological findings, but appeared “very confused” and “frightened.”

Serum electrolytes, CBC, and liver function tests were all unremarkable. She had a negative urine drug screen and alcohol level. The ECG demonstrated sinus tachycardia with normal intervals, and the brain CT was normal.

What are your next thought processes?

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By Craig Smollin, MD FACMT|2018-04-04T03:33:39-07:00Apr 4, 2018|Neurology, Tox & Medications|

60 Second Soapbox: Autoimmune Disease, Ultrasound Teaching, 3rd Nerve Palsy

It’s time for another installment of 60 Second Soapbox! Each episode, 1 lucky individual gets exactly 1 minute to present their rant-of-choice to the world. Any topic is on the table – clinical, academic, economic, or whatever else may interest an EM-centric audience. We carefully remix your audio to add an extra splash of drama and excitement. Even more exciting, participants get to challenge 3 of their peers to stand on a soapbox of their own!

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By Sam Shaikh, DO|2017-12-28T16:01:40-08:00Dec 29, 2017|60-Second Soapbox, Allergy-Immunology, Neurology, Ultrasound|

AIR-Pro: Neurology

Welcome to the Neurology AIR-Pro Module. Below we have listed our selection of the 7 highest quality blog posts related to 4 advanced level questions on neurology topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

Intracranial hemorrhage
Diagnosis of subarachnoid hemorrhages
Management of subarachnoid hemorrhages
Vertigo

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By Fareen Zaver, MD|2019-11-10T21:53:04-08:00Nov 8, 2017|ALiEMU, Approved Instructional Resources PRO (AIR-Pro Series), Neurology|

Update on the ED Management of Intracranial Hemorrhage: Not All Head Bleeds Are the Same

Robust and comprehensive studies now support specific management guidelines for patients presenting with different intracranial hemorrhages (ICH). From the Emergency Department perspective, the primary dilemmas involve specific blood pressure goals and whether seizure prophylaxis with phenytoin is necessary. The Brain Trauma Foundation provides an excellent summary of the current guidelines.¹

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By William Shyy, MD|2017-09-05T14:53:30-07:00Sep 4, 2017|Neurology, Tox & Medications, Trauma|

Trick of the Trade: Gaze Testing Using “Selfie Mode” on Your Smartphone Camera

The NIH Stroke Scale is used to assess the severity of a suspected stroke. It includes 11 neurologic exam components that can be quickly performed at the bedside. The second component of the NIH Stroke Scale is testing of voluntary horizontal eye movements, a.k.a., “best gaze”.¹ Gaze is usually tested by instructing the patient to follow the examiner’s hand or pointer finger in a horizontal plane from side to side. This assessment assumes that the patient can comprehend instructions and actively participate in the physical exam.