Thursday, May 30, 2019

The Utility of Intravenous Lipid Emulsion Therapy in the Management of Acute Calcium Channel Blocker Overdose

Image Credit: Wikipedia
This post was peer reviewed.
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Author: Mary E. Blaha, DO
Indiana University School of Medicine
AAEM/RSA Publications and Social Media Committe

Calcium channel blocker (CCB) overdose is a potentially lethal toxicity with multiple management options available. Intravenous lipid emulsion (ILE) therapy is a potential treatment that is being used with more frequency. This review will discuss the management of CCB overdose focusing on the available ILE literature.

CCB Toxicity Overview
CCBs are commonly prescribed to manage hypertension and arrhythmias. When implicated in accidental or intentional overdose, CCBs carry a high potential for toxicity that can ultimately lead to severe cardiovascular injury.[1,2] Specificlly, dihydropyridine CCBs, which include amlodipine and nicardipine, act primarily on arterial smooth muscle L-type calcium channels, which can lead to reflex tachycardia. Nondihydropyridine CCBs, which include diltiazem and verapamil, act primarily on cardiac myocyte L-type calcium channels, which can lead to cardiogenic shock.

Thursday, May 23, 2019

Resident Journal Review: Bedside Ultrasound for the Diagnosis of Pneumonia

Authors: Ted Segarra, MD; Taylor Conrad, MD; Rithvik Balakrishnan, MD; Taylor M. Douglas, MD
Editors: Kami Hu, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally published: Common Sense March/April 2019

Respiratory distress is a common presentation in both the pediatric and adult emergency department (ED). Community acquired pneumonia (CAP) is a common cause for this distress, and carries the potential for high morbidity and mortality if inadequately treated. In a fast-moving and potentially resource-limited ED, however, it can sometimes be difficult to decide which patients require further imaging to differentiate CAP from the myriad of other potential etiologies for respiratory distress such as bronchiolitis, asthma, chronic obstructive pulmonary disease (COPD), heart failure, and pulmonary embolism. Although both the British Thoracic Society (BTS) and Infectious Disease Society of America (IDSA) state that bacterial CAP is a clinical diagnosis based on persistent fever, retractions, and tachypnea, they agree that radiographic imaging should be obtained in any patient requiring hospital admission or with significant clinical uncertainty.[1,2] Unfortunately, even if the ED provider decides to pursue chest X-ray (CXR) imaging, he or she may still miss the diagnosis, as CXR has been shown in several studies to have a notable false negative rate (FNR) and high inter-observer variability in the diagnosis of CAP.[3,4,5,6] The limitations and inherent radiation exposure of CXR, in combination with the increasing availability of and familiarity with bedside lung ultrasound (LUS) imaging, have prompted many ED physicians to begin looking to LUS as a potential alternative in the evaluation of patients with suspected CAP.
  1. What is the level of sensitivity and specificity of LUS compared to traditional CXR and clinical findings in the diagnosis of CAP?
  2. Do other aspects of bedside LUS (i.e. lack of ionizing radiation, speed of assessment, easy repeatability, ability to monitor progression of disease, cost) make LUS a more feasible alternative in resource-limited environments?

Thursday, May 16, 2019

Identification of the Hospice vs. Palliative Care Patient in the ED

Image Credit: Pexels
Author: Deniece Boothe, DO
Originally Published: Common Sense March/April 2019

The terms “hospice” and “palliative care” remain synonymous for many health care providers. Despite the intertwined relationship, it is important that we understand the differences in an effort to provide appropriate resources for our patients facing serious, life-limiting illness. Palliative care, also known as palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.[1] Hospice care is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. Those with a prognosis of six months or less meet criteria for hospice. A Center to Advance Palliative Care survey found that most health care professionals erroneously equated palliative care with end-of-life (EOL) care.[1] This lack of understanding leads to ineffective communication between the provider and patient or health care proxy.

Thursday, May 9, 2019

Size Does Matter…For Your Expense Ratio

Image Credit: Pexels
Author: Joel M. Schofer, MD MBA CPE FAAEM
Commander, Medical Corps, U.S. Navy
Originally Published: Common Sense July/August 2019

I published this article three years ago in Common Sense, but this is such a critical concept that it bears repeating every few years. In addition, the recent price war among investment firms has made it even easier to lower your investment costs.[1] There has never been a better time to take a solid look at the investment costs you are paying.

Whether you are managing your investments by yourself or getting help, you need to understand one critical concept, the expense ratio of your investments. Every mutual fund and exchange-traded fund (ETF) has an expense ratio and keeping it as small as possible is key to your long-term financial success. Size does matter.

Thursday, May 2, 2019

Five Pearls for Using Interpreters Ethically

Image Source: Defense Visual Information Distribution Services
This post was peer reviewed.
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Author: Sara Urquhart, RN MA
Medical Student
Michigan State University College of Human Medicine
AAEM/RSA Publications and Social Media Committee

Imagine an unconscious 15-year-old male arrives at a downtown Miami trauma center. Paramedics say that before passing out, he told his Spanish-speaking girlfriend he felt “intoxicado.” “Intoxicated,” they say. The boy is stabilized and admitted to intensive care with a diagnosis of drug overdose. No one called an interpreter to interview his girlfriend. If they had, they would have learned that in Cuban Spanish, intoxicado is a word for nausea and that the boy did not take an overdose. Over 36 hours later, imaging shows a ruptured subarachnoid aneurism on the now paraplegic boy, who survives and later wins a $71 million malpractice lawsuit.[1]