Intoxicated with Chest Pain
Infected Kidney Stone
• Aortoenteric fistula is the abnormal formation of connection between the aorta and bowel, typically occurring the 4th portion of the duodenum.
• Primary fistula formation due to atherosclerotic or infectious erosion of aorta into the bowel; secondary is the result of complications of aortic graft placement, either graft infection or pressure necrosis.
• Typically present with “sentinel bleed” followed by massive GI bleed and hemodynamic collapse; classic triad occurs <25% of patients.
• Vascular surgery consultation emergently if suspected; CT angiography can be helpful, but only after consultation and surgical evaluation.
1. Four recently completed trials demonstrate that early mechanical stent-thrombectomy after tPA in patients with large vessel occlusion and salvageable tissue on brain imaging results in improved reperfusion and functional outcomes.
2. The details of the patient selection paradigm remain a key discussion, but favorable penumbral imaging is a consistent feature of all trials.
3. Systems of acute care, including transfer protocols, will need to be re-organized to deliver this therapy effectively in the real world
1. Consider the possibility of preeclampsia in all women with hypertension regardless of gestational age, up until 6 weeks postpartum.
2. Proteinuria is no longer needed for the diagnosis of preeclampsia and the degree of proteinuria does not correlate with disease severity.
3. If features of severe preeclampsia are present, do not delay administration of IV magnesium.
- Early recognition and treatment is critical.... give epinephrine EARLY and OFTEN
- Treat anaphylaxis as a spectrum... as short as 2 hour observation up to admission
- Steroid duration depends on who you ask. No good evidence to support or refute their use.
- Vasopression for anaphylatic shock with suboptimal epi response.
- Consider glucagon for those patients on beta-blockers.
•Intracranial complications of acute bacterial rhinosinusitis include meningitis, brain abscess, subdural empyema and cavernous sinus thrombosis. Most common presenting feature of meningitis complicating sinusitis is seizure activity.
•IDSA encourages use of antibiotics for acute bacterial sinusitis when strict diagnostic criteria are met. Amoxicillin/clavulinateremains first line therapy.
NEONATAL VESICULAR RASH
•Many causes of vesicular rashes in the neonate are benign, but serious bacterial and viral infection must be evaluated.
•Neonatal scabies infestation presents with vesicular rash affecting the hands, feet, wrists and face of neonates. Treatment is with a single application of permethrin 5% cream, or 5-10% sulfur suspension in petroleum.
•Pancreatic cancer presents often in late stage due to vague symptoms of weakness, abdominal pain, diarrhea and jaundice.
•Recurrent visits for similar chronic complaints carry high risk. Consider serious pathology as underlying source.
Thrombotic Thrombocytopenic Purpura:
- Can be hereditary or acquired. Acquired forms can be found as a result of a multitude of disease states.
- Patients will more often present with vague symptoms including confusion/AMS rather than focal neurologic deficits attributable to a specific vascular distribution.
- Treatment to consider initiating in the ED includes steroids and FFP however be wary of volume in patients with underlying cardiac disease.
- VasCath can be placed in ED depending on provider comfort.
- Plasma exchange has decreased mortality from 85-95% to 10-20%.
Third Degree Heart Block:
- Most often seen in elderly patients due to progressive fibrosis and calcification of conduction system and surrounding tissue, but can certainly be a complication of AMI.
- Particularly for your elderly patients, be wary of medication side effects.
- Atropine is always worth a try. Just realize more often than not it won't help you.
- Hypotension? Altered mental status? Distress? PACE THE PATIENT!
- Take the time to review initiation of transvenous pacing. Like the infamous ED thoracotomy or cricothyroidotomy, its a procedure we should know like the back of our hands.
Final Pearl: if you're going to order an imaging study, look at the WHOLE image.