Carbon Monoxide Poisoning: Common Questions and Dilemmas

By |Categories: Expert Peer Reviewed (Clinical), Tox & Medications|

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. […]

Lactic Acidosis and Beta Agonist Therapy in Asthma

By |Categories: Pulmonary, Tox & Medications|

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 [...]

QI Series: Pitfalls in Diagnosing Hyperkalemia

By |Categories: ECG, Endocrine-Metabolic|

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. […]

Insulin Pumps: Understanding them and their complications

By |Categories: Endocrine-Metabolic|

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. […]

Mechanical CPR and the LINC trial

By |Categories: Critical Care/ Resus, EMS, Expert Peer Reviewed (Clinical)|

The first time I saw the Thumper performing CPR on a patient I thought “well, that makes sense.” Since then we have seen other devices, most notably the Zoll AutoPulse and the Physio-Control LUCAS. It was disappointing to many in 2005 when the AutoPulse trial was halted early due to harm. 1 Although four-hour survival was similar between groups, the hospital discharge survival rate in the manual CPR group was 9.9% compared to 5.8% in the mechanical CPR group. Many hypotheses were proposed to explain the results, which included Hawthorne effect, prolonged device deployment time, and enrollment bias. Last month, the results [...]

Child Whisperer Series: There’s an app for that!

By |Categories: Pediatrics, Social Media & Tech|

I was playing bubbles with a 2 yr old when she wanted a turn. Even though I knew the outcome, she said “peeeze” so I said OK. As predicted, she immediately dumped the bubbles on the floor and started laughing. In the corner of the room I heard the quiet voice of her 10 year old brother say to me, “Excuse me, ma’am… you know there’s an app for that”.   […]

Prehospital: Does QUICKER hypothermia equal BETTER hypothermia?

By |Categories: Critical Care/ Resus, EMS|

The short answer to this question is NO. Since the landmark post-arrest, therapeutic hypothermia studies published in 2002, 1,2  extensive efforts have been made to ensure our post-arrest patients are cooled… and cooled fast. It only seemed logical to extend this revolutionary treatment into the field and have paramedics begin the cooling in the field. New EMS protocols were developed around the country to incorporate hypothermia into cardiac arrest management and well received by paramedics and EMTs. But a recent JAMA publication calls this now into question. 3 […]

Modified Sgarbossa Criteria: Ready for Primetime?

By |Categories: Cardiovascular, ECG|

The recognition of ST-segment elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult and frustrating to both emergency medicine physicians and cardiologists. According to the 2004 STEMI guidelines, emergent reperfusion therapy was recommended to patients with suspected ischemia and new LBBB however, the new 2013 STEMI guidelines made a drastic change by removing this recommendation. Several papers have recently been published discussing a modified Sgarbossa’s criteria and a new algorithm to help decrease false cath lab activation and/or fibrinolytic therapy, but are they ready for primetime? […]