EMERGENCY MEDICINE UPDATE

July 2012 DON'T LET THIS BE YOUR LAST ISSUE OF EMU-IF YOU ARE A FINISHING RESIDENT SEND US YOUR NEW E MAIL ADDRESS! 1) Traumatic brain injury is catastrophic- just ask Marie Antoinette (true, that was a dislocation and not a true head injury). The question in this study was whether patients did worse if there was a 60 minute transit time, or they did worse when there was a need to be brought to a level one trauma center, hypoxia, hypotension, hyperventilation, or tachycardia. They claimed they did not (Acta Anes Scand 55(8)944). The take home point here is that it really doesn't matter what intervention is done in head injury- they all do pretty poorly. The problems with his study were they only had 46 patients in 3 years, and I did not see a definition of what is a severe head injury (I am not a big lover of the GCS scale). However, where this can be relevant is that your trauma center can function fine even if you do not have neurosurg backup. Of course, it is the few that are not that severe that may respond well if you have neurosurg backup but those in many cases can just be transferred. TAKE HOME MESSAGE: Severe head injury does poorly no matter what factors are involved. 2) A call for doing surgical airways, I was waiting for the answer why we are so reluctant to do these airways and finally found it in the last line of the abstract- because of the perception that if you can't intubate a particular patient- you must be an idiot. The truth is exactly opposite. No, not that if you can intubate you are an idiot but rather if you can't do a surgical airway you are an idiot. A few of you may be idiots no matter what you do (no, I do not mean you; but I do mean your boss). But if at least you know how to properly do a surgical airway you will be an intelligent idiot. And probably save some one's

19 ‫עמוד 1 מתוך‬

EMERGENCY MEDICINE UPDATE
life. (Anest Int Care 39 (4)578) TAKE HOME MESSAGE: There are definitely people who are intubation nightmares and you must know how to do a cric. And not only know how to but actually do it. 3) Yucky study. You would think if you put a hand sanitizer in the hospital cafeteria, that health care workers would use it. Well, in 5500 visits to the cafeteria- only 4.79% actually used it. So they used a poster to remind people- yea that is the ticket- and sure enough frequency of use increased- that is what they want you to believe in the conclusion of the paper. However, this improvement was only seen in visitors to the hospital cafeteria, not in the actual workers. (Am J Inf Contr 39 (6)464) By the way I love to cook and now is the opportunity to give a plug for my book "You Can Make Hospital Food at Home" TAKE HOME MESSAGE: For Goodness sake at least wash your hands before you eat in the hospital. 4) This may not be relevant to your practice but it is very relevant to mine where patients often present with questionable indications for benzo use requesting I renew their prescription for these meds. So you have to know this- they cause dependence, cognitive and psychomotor impairment and ultimately possible long term brain changes. The risk benefit ratio is favorable only with short term use. Nowadays there are safer alternatives for most of the benzo indications. (Addiction 106(12)2086). I have been told that if you read EMU you must be on drugs- try not to make them benzos. TAKE HOME MESSAGE: Benzos can be risky especially in long term use. There are safer alternatives in most instances. 5) When the new residents in the USA take over in July- mortality goes up and efficiency goes down in their meta analysis. This is a systems problem that requires addressing. In many European

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EMERGENCY MEDICINE UPDATE
countries residencies open up here and there and they do not all start in July. (Ann Int Med 155(5)309). This is a very poor meta analysis as the data is really diverse, but I believe the results. TAKE HOME MESSAGE: Don't go to the hospital in July. Never go the Hospital cafeteria anytime. Never be an idiot. 6) OK enough already. I know you know your stuff and promise not to call anyone an idiot anymore. But you can still prove yourself. A patient who is 25 years old comes to the ED with weakness and painful swallowing over the distribution of the carotid artery. They complain of chest pain and there may be hypertension. Treat this early and you will prevent permanent damage. (QJM 104 (9)797). And the diagnosis is…… 7) The results of this study are fascinating and they are relevant to FPs as well. Often females have normal cardiac caths. Yet they still have chest pain and can even infarct- this is supposed to be from ulceration or plaque rupture or even spasm. All the patients in this study had ST elevation and there were only a smattering that had normal coronaries so you can't take this study home , but it is worth remembering- a normal cath means little when the clinical picture fits a more serious entity (Circ 124 (13)1414) TAKE HOME MESSAGE: Normal cath means little when the clinical picture looks suspicious. 8) The tile of the paper is cool, but the message is important. Do you know what a pseudo pseudo seizure is? Neuro psychiatric symptoms with a normal EEG that could fit a pseudo seizure do not mean you are done and this is not a real seizure. This was a case of auto immune encephalitis due to ovarian cancer. (Psychosomatics 52(6)501) You can never take much out of case reports but do not buy the pseudo seizure concept so quick- especially because many patients

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EMERGENCY MEDICINE UPDATE
could be using drugs that would also mimic pseudoseizures. While we are on the subject of drugs, let us mention that purpura, vasculitis and even necrosis and eschars of the ears could be a sign of adulterated cocaine where levamisole is the offending agent. Their WBCs start to fall as well- so look for this as well. (J Am Acad Derm 65(4)722). Until the FDA starts finally giving their approval to street drugs – I think it is difficult to stay abreast of all the designer drugs and adulterants. I speak to Mickey Arieli in Israel who is a clinical pharmacist with the health ministry to help me with questionable cases; you should identify who can help you on this subject in your part of the world. TAKE HOME MESSAGE: Drugs and strange medical maladies can cause a lot of unusual syndromes, and so can medical disease. Be extremely careful labeling people as having psychiatric illness. 9) Sulfa-TMP (Resprim, Bactrim) is making a comeback and this study showed that there is danger of hyperkalemia when used with spironolactone. They looked at a massive amount of patients (165754 patients). They also found this to be true with nitrafuratoin (Macrodantin) but not in quinolones. (BMJ 343 5656). The methods were excellent; I just have a problem with the fact that they claimed an association when hyperkalemia occurred within 2 weeks of antibiotic use. I think 2 days after may be a causation, 10 days later less so. TAKE HOME MESSAGE: People taking spironolactone can be pushed into hyperkalemia by some antibiotics. 10) People do a lot of their own medicine. And part of the determinants that enter into their decision making is whether medications are helpful. In this study, people beleived that if the FDA approved the medication, it must be extremely effective and free of side effects. This is especially important in view of the aggressive

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EMERGENCY MEDICINE UPDATE
marketing approaches used by drug companies to the public (Arch Int Med 171(16)1463). This is rampant in my country as well, and especially important in view of the use of HCG for weight loss programs – this medication has approval of the Ministry of Health in my country despite reports of clots, depression and heart attacks. And of course, no proof it helps. TAKE HOME MESSAGE: the public feels that medications that have government approval are both universally safe and effective. Not! 11) Hey we had our clinical case this month but this is a really neat case. I am sure none of you know about this syndrome (well, maybe except for Chris but he knows everything). After jogging this guy looks like this- yes – only one side of his face is red. It is due to this syndrome which is a disorder of the sympathetic output to that side but can be due to mediastinal neuroma, lung cancer or brainstem infarct. It is usually however benign (MJA 195(5)288). This is called-……… 12) There is some new information on vertigo in kids, but I am not so sure how much it changes things. Somatoform disorders and vestibular migraine account for most of the cases and CT is only recommended in subacute cases. (Neuroped 42(4)129) We do not see many articles on the subject so it is good to have one if you are interested on how to work this up, but the overwhelming amount of cases are benign. I would just point out that one of the serious causes can be dissection which we can see even after minor trauma. TAKE HOME MESSAGE: Vertigo in kids exists but is usually benign- Please remember dissection in teens.

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EMERGENCY MEDICINE UPDATE
This could have been a very helpful study. Mothers who have hyperemesis gravidarum – how do their children turn out? It seems that they have a greater likelihood of female births (careful guysfemales do not (or at least should not) make people throw up), low birthweight, and prematurity. There was one study that showed a slightly higher risk of testicular cancer in the boys. (BJOG 118(11)302) However the quality of evidence was not evaluated and the likelihood ratios are not that convincing- low birthweight being the most likely although female offspring is the most consistent. They do admit the little is known about the long term of effects of this disorder or even if this is passed down as a problem in pregnant female offspring. TAKE HOME MESSAGE: Mothers with hyperemesis gravadaum seem to have children with lower birth weights, and more premature births. They are more likely to give birth to females. 14) No surprise here. A poll of EPs in Belgium showed that they had no idea as to how much things cost in the ED nor radiation dosages are associated with common procedures. (EJEM 18(6)344). This is probably true for primary care docs as well. It comes to me as no surprise because there are still significant amounts of physicians in the world who do not read EMU. What was surprising was that they overestimated both costs of care and levels of radiation. Could this be the Hawthorne effect? TAKE HOME MESSAGE: We have no idea about radiation in the studies we order and the costs of our products and services. We tend to over estimate these costs. 15) I have a lot of EMS readers and we will be having a roundtable in the future on EMS issues. In the USA, EMS systems get medical command from a base hospital. In Europe and Israel, physicians actually ride on the ambulance. And in some countries nurses as well.
13)

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EMERGENCY MEDICINE UPDATE
Are they competent? Well they are according to this study but the scale they used has not been validated to the best of my knowledge. (ibid p322) Now the question as to whether this is cost effective or even necessary has not been studied and still isn't clear. TAKE HOME MESSAGE: Physicians riding on the ambulances are competent. Maybe. 16) Hip fractures hurt. Wouldn't it be great to block a nerve and have your patient wait happily until they can do the surgery? Well you may want to try the fascia iliaca two pop nerve block. If you wish, you can read about this and other blocks for hip fractures– click here. If you have youtube - then go to this link www.youtube.com/watch?v=eCWt3fYYV8s. If you want to know if you can really do this procedure – then see this article that says that it is really easy (ibid p340). If you get EMRAP or your name is Al Sachetti- then you knew about this already, but many of you can not afford EMRAP or Al Sachetti so here is your chance to learn this technique on the cheap. TAKE HOME MESSAGE: This nerve block can be very helpful in the pain control of a hip fracture. 17) NSAID bashing time again. These medications cause stroke. (MJA 195(5)488). Well, not really. They increase your risk but this is a small risk anyhow. The key is that this risk does increase even after first time use. As Marie Antoinette said" Let them eat Percocet". TAKE HOME MESSAGE: NSAIDS can increase stroke risk after one exposure but is it is a small risk 18) We do not see many articles on this subject but you probably know the answer. Cupping is an alternative therapy for pain and they did a systematic review with fairly good methods. Naturally the quality of the studies was poor, some studies showed that this is a great thing, some showed no effect. (Evid Based Alt Comp Med 2009)

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EMERGENCY MEDICINE UPDATE
(Somehow this creeped on to my reading list in error- it was listed as being from 2011). Why am I wasting your time with this? The key here is that they are starting to evaluate these therapies in a standardized way and that is a good thing. Can this help? Well it brings to mind the old Red Buttons joke (if you are too young to remember Red Buttons – that is OK- I don't really know what Justin Bieber looks like either) The MC comes out on a stage in Miami Beach as tearfully proclaims that the star of the show has just expired suddenly. A little old lady screams out "give him an enema". The MC is aghast- "Lady, how could that possibly help? The man is dead!" The little old lady screams out "well, it couldn't hurt". Probably OK that you did not know Red Buttons. That was a waste of your time. But an additional article in the same journal actually could be helpful. There are many herbs that interact with Coumadin- either elevating of lowering the INR. The herbs are unfamiliar to me- red ginseng, aloe (that one I have growing in my garden), bilberry juice, Boswellia, Melissa, etc, but the charts in the article are clear and the article is for free. Never forget to take a natural remedy history! (ibid 1-5 2011) TAKE HOME MESSAGE: Coumadin has a lot of interactions with herbal therapies. Cupping may be helpful for pain control. We do not know. 19) Wow, talk about dropping a bomb. This is the article of the year for the right thing to do that will bring belly slapping laughter to any hospital administrator that we know. Better educated nurses results in a 4% better outcome (defined as reduction in patient mortality and failure to rescue) in all hospitals. Better nurse/ patient ratios result in considerably better outcomes but only in hospitals with good working environments- it doesn't help bad working environments. (Med Care 49(12)1047) This of course is tied in to what

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EMERGENCY MEDICINE UPDATE
a good work environment is-after a lot of searching I found the source for their scale which is from an article from 2007 in Research in Nursing and Health30:31. Really, I do not mean to demean hospital administrators, some of my best friends are hospital administrators and I decided to allow one to say a few words here.

(If you do not know who this is- I think it is Justin

Bieber). TAKE HOME MESSAGE: give better working conditions and use more educated personnel and mortality will improve. (If you really do not know who this is- you are reading the wrong journals). 20) This article can only serve as a guide as it is a case control study. Flying more than 12 hours within the last four weeks (and that is crucial- this can be up to four weeks after) elevates the risk of pulmonary embolism by three times the normal. A four hour leg in the last four weeks leads to a two times higher risk. Another key point is people with risks for PE will have even a higher risk with flying. (BJH 155(5)613). TAKE HOME MESSAGE: Even a flight of four hours can significantly increase risks for PE, even a month later. The price of the ticket is not related to PE but may give you chest pain. 21) This article is about leadership. While this article unabashedly English and thus less relevant to the rest of the world, I have nonetheless extracted some important points for you. Doctors in the
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EMERGENCY MEDICINE UPDATE
past were trained to be individuals having allegiance mainly to their professional organizations. Other wise they stood alone in their clinics, occasionally serving on hospital committees but for the most part existing alone. These days are over. Large HMOs, hospital corporations and government interventions demand that physicians have leadership skills. They admit in this article that many- if not mostphysicians are not born leaders. Being a visionary, taking calculated risks and having both business skills and political savvy is not the realm for most of us. (Me politically correct? Are you kidding?) They I identify five skills to being able to be a leader- setting direction, demonstrating strong personal leadership qualities, being able to work with others, and being able to improve and manage services rendered. I agree these are skills that are kind of nebulous and we could use more practical pointers perhaps, but the point is well taken. (BMJ 2011). In Israel, physicians are unionized which would be unheard of in the USA from what I understand. Most hospital CEOs in my country are physicians. TAKE HOME MESSAGE: Leadership is not a born trait but a learned one and physicians must be ready to enter this arena in view of government innervations and the big business nature of our practice environments. 22) Is this a new department for EMU? I don't know, I make this up as I go along. There was as clinical "head to head" as to whether hypothermia does help in cardiac arrest. We will summarize the two articles and I have a subscriber named Marvin Wayne who is one of the world's experts and a frequent contributor to the resuc literature. The articles were both from the BMJ. The "for" is from the sept 23 issue and the "against" was from later on in the same issue. Here are the points in favor: strong animal studies, human studies especially in VF, database from the Netherlands showing 20% relative reduction in hospital mortality in all rhythms in all venues. It is very safe-reperfusion
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EMERGENCY MEDICINE UPDATE
injury and infection are the only setbacks. Against include- it is hard to blind cooled patients, and the articles are few. Few patients over many years characterized these studies so the conclusions are made based on meta analysis. The level of coma was rarely measured in these studies. The great results in animals were in healthy animals unlike most of the patients we see. Marvin's take: The Sept 23 articles, Yes, by Nolan, and
No by Warden highlight the difference between reasonable vs perfection. While all studies to date on Therapeutic Hypothermia have trended toward better outcomes, some still seek the "perfect" study. With a number needed to treat of 6 vs 82 for aspirin, at little overall cost, this seems like a very "reasonable" therapeutic intervention. Our own system has treated over 259 patients with a 55% go home survival with intact neurologic function from the ICU. This is in contrast with a similar group and a 30% survival prior implementing TH. The cost in dollars vs the improved outcomes strongly favor implementation of this important therapeutic intervention

The diagnosis above in number 6- of course you knew this- it was Takayasu's Arteritis. And number 11- you clown- is called Harlequin syndrome. If you got both of these then you are a genius or from Australia- or probably both. 24) I inspired by new reader Steve Parrillo to consider some sports trivia so I agreed. Do these pitchers ring a bell and what are they
23)

known for

?

The first is Steve Carlton, the ace for the

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EMERGENCY MEDICINE UPDATE
Phillies that in 1972 won 27 games for an absolutely dreadful Phillies team that only one a total of 59 games for the season (which means he won almost 50% of their games). The second is Denny McLain who in 1968 was the last pitcher in Baseball to win 30 games in a seasonnowadays 25 is virtually unheard of for most pitchers. The third was Marc the Bird Fidyrch who was a phenom for Detroit and was rookie for the year in 1976. He would speak to the ball; refuse to use balls that had been hit before and would manicure the mound. His nutty antics got him much attention but due to a torn rotator cuff, he was out of baseball a mere four years later. Fritz Peterson was a great pitcher for the Yankees 1966-1976. He however will best be remembered for his swapping wives with fellow pitcher Mike Kekich. He got the better deal- he is still married to Kekich's wife and has four children from her. He also had a better career. The other pair did not work out. The last guy is Sparky Lyle a star reliever for the Yanks in the 1969-1977 whose book "The Bronx Zoo" on the feuding champion Yanks was a best seller. Now two questions- did you get them right? And do you really care?

EMU LOOKS AT: Boards issues.
This month we look at three subjects that we will almost never see but you need to know for the boards. They are drowning (NEJM 366(22)2102), Altitude Illness (BMJ 343) and Chemo emergencies (Lancet Onc 12:806) . I find that these subjects can be boring- the absolute last thing I want to be – so let's pretend we are going back to those halcyon days of preparing for your boards and ask simple questions to make sure you know your stuffwe'll soon see that even years later – you are still the same genius I knew you were when you started reading EMU.

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EMERGENCY MEDICINE UPDATE
ACUTE ALTITUDE ILLNESS The percentage of oxygen in the air goes down as you ascent True False Answer: The percentage of oxygen in inspired air remains always 20.94% in the atmosphere. (If you are curious, the rest is nitrogen with a smattering of argon) .The barometric pressure goes down so the oxygen is more spread out- i.e. thinner- and so less is available, and so the answer is FALSE Which of the following points can't help distinguish between a migraine and a high altitude headache? a) resolves with descent b) resolves with oxygen c) worse at night and with exertion d) resolves with ibuprofen Migraines and high altitude headaches resolve with ibuprofen. Descent makes high altitude headaches better and they are worse at night and with exertion. Many use oxygen for migraines but there is no evidence that it works- it almost always works for high altitude headache. So the answer is d A group of healthy hikers climb Mt Davis in Pennsylvania- the highest mountain in Pennsylvania (I am originally from Pennsylvania). 50% of the hikers developed dizziness, fatigue, nausea and vomiting and a severe headache. What would you recommends in this situation? a) They should descend immediately 400 meters and they will began to see improvement in about two hours b) They should have ascended more slowly or have taken acetazolamide c) They should have been in better shape- athletes have a lower rate of developing acute mountain sickness.
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EMERGENCY MEDICINE UPDATE
d) They should have not partied the night before. Acute mountain sickness is characterized by these symptoms and does get better with descent and slower ascent. Athletes do not have a lower rate of AMS. But Mount Davis is only 1000 meters high and 1000 meters is not that much. How were you supposed to know that? I guess you weren't. (Too bad, huh?) This is more likely to be due to alcohol intake the night before. HACE (High Altitude Cerebral Edema) a) Altered mental status, stupor, ataxia, but death is rare. b) Treatment is dexamthasone, and gradual descent to avoid worsening edema. c) This can easily be confused with hypothermia. d) Portable hypobaric chambers may help Oh I am being devious here, and I know it. Coma and death are not rare in HACE although HACE in itself is and develops over 4000 meters. Immediate descent is the best treatment, but portable hyperbaric chambers have shown promise. It does look like hypothermia so treatment for both is worthwhile. Some nut comes to your office wanting to climb Mount Kilimanjaro (this is a lot higher than 1000 meters- actually 5895 meters high). What is your best advice to him to know if he will be susceptible to mountain illnesses? a) check is CBC- if his hemoglobin is less than 11- risks are higher b) Send him to a chamber that can simulate hypoxia at 2000-4000 meters and see how his saturation is after 30 minutes. c) obesity- not morbid – but with a BMI under 30- is protective d) Past experiences do not correlate with the future Actually the best predictor of the possibility of development of altitude illness is past experiences- although if one had no problem in the past it doesn't
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EMERGENCY MEDICINE UPDATE
mean they couldn't develop it in the future. Obesity is not protective at all. The chamber is a good idea. Anemia- suprisingly is not a risk factor. HAPE- high altitude pulmonary edema a) is non cardiogenic so do not give diuretics, b) exercise is protective c) Viagra is effective as treatment. d) Salmetrol and nifedipine are for prevention only Too easy, right? A is the obvious answer, but the others are not far away. Exercise increases risk- it is not protective. Viagra does work- to prevent, but not as treatment. Salmetrol is protective only but nifedipine can be used for treatment and prevention. Which of the following works to prevent acute mountain sickness? a)acetazolamide b)dexamethasone c) ginko d) hypoxic pre conditioning Acetazolamide can help reduce symptoms but does not prevent them when ascent is too fast. Glucocorticoids may help but the side effects make the benefit less than the danger. Both however can be used to treatment. The former works but takes 24 hours, the latter can improve symptoms enough that a safe evacuation can be done. Ginkgo head to head against acetazolmide- the latter won hands down- as did placebo. Hypoxic preconditioning is showing promise but hasn't been proven. Obviously oxygen will help as treatment and probably as prevention as well. Indeed, trains in the high plateaus of China are oxygenated. So the right answer was none of the above- that wasn't one of the choices? Well, too bad. Which of the following does not exist? a) dry drowning
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EMERGENCY MEDICINE UPDATE
Secondary drowning. Differences in damage between fresh and saltwater drowning Electrolyte abnormalities requiring correction in survivors of drowning
b) c) d)

Right again- they all do not exist. Laryngospasm is very transient in drowning, and if there is no water in the lungs at autopsies it is due to water being absorbed into the vascular system. Secondary drowning does not exist- later effects are usually evident early on and are due to surfactant loss. Saltwater drowning may cause more osmotic gradients but the damage to the lung units and surfactant are similar. Electrolyte abnormalities are rare after drowning and you have a good case not to have to take bloods at all. So the right answer is all of the above and that wasn't one of the choices either, but I felt if you fell once, you probably will fall again. Which is true? a) A few breaths will bring pure respiratory arrests in drowning back, so start rescue breathing even in the water. b) keep patients horizontal in the water face up until rescue equipment can be brought c) get the water out of the lungs as part of rescue and ventilation will be easier d) Most common rhythm is VF, but please wait until you are out of the water to deliver the shock. The breathing should start in the water- they do come back fast- actually, 94% of those who are rescued by lifeguards do not have to go to the hospital. Keep patients vertical who have no C spine damage as it lessens aspiration risk. They taught me maneuvers to get water out of the lungs when I was young but they are unnecessary and delay giving adequate respiration. In addition they increase vomiting risk. Suctioning intubated patients also has the risk of delaying oxygenation and they
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EMERGENCY MEDICINE UPDATE
advise to avoid it. Most common rhythm in PEA or asystole, but shocking VF is probably fun and I would definitely recommend you try it some time. (See idiot above) With regards to pneumonia after drowning: a) hospitalized patients should receive antibiotics after drowning as lung units are damaged and more susceptible to infection b) Chest films done in the ED are often positive for infiltrates. c) swimming pool drowning result in 56% risk of pneumonia d) Drowning in pools used by kids can be more dangerous as kids use the pool for evacuation purposes. Swimming pools actually rarely cause pneumonia. Kids do use pools as bathrooms and don't really use bathrooms as pools (thank Goodness for that). (Dogs are another story). Prophylactic antibiotics are never indicated and actually most chest films are positive because of the water in the lungs, but only 14% are actually pneumonia- use fever as a guide. CHEMO EMERGENICES No questions here – I am tired. Lets run through this in a way that will be useful to EPs and FPs and we'll ignore the agents that cause this stuff- If you are an onc guy- look up the article 1) Syncope and palpitations in a patient getting chemo- many of these agents can cause arrhythmias that include fatal rhythms. Do an EKG and observe 24 hours. Many agents are cardiotoxic. 2) Chemo treatment of lung tumors can cause a pneumothorax as the nodule necroses the pleura as well. 3) Acute pneumonitis can happen-a chest film will show abnormalities but your best bet is CT. As a continuum, ARDS can occur as well from chemo.

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EMERGENCY MEDICINE UPDATE
Acute hemolytic reactions which can manifest as back pain, fever and rigor, jaundice, tea colored urine and dyspnea. Thrombocytopenia can also occur – look for easy bruisablity. 5) Yea this was a trick on the boards- neutropenic typhlitis. This is a strange condition where people get RLQ pain that is due to mucosal damage to the cecum. Fever is typically present and CT is the imaging of choice but neutropenia can be the give away that this is not appendicitis. Give plenty of fluids, antibiotics and GSF. Some use TPN and full bowel rest. As a continuum, toxic megacolon can occur under similar pathophysiology. Clostrideum difficle should be looked for as well. 6) Pancreatitis. Ho hum- you k new that this is caused by many agents. Elevated liver function tests also occur but they can be caused by vaso occlusive disease- which has thirty percent mortality. 7) These bad boys- especially platinums-can actually increase the stroke possibility. Abnormal mentation and headache -even seizures –can always be mets but can be the reversible posterior leukoencephalopathy syndrome 8) Steven Johnson- another you should've known 9) Vaso occlusive disease can also cause limb ischemia and bowel wall ischemia. 10) HUS and TTP can occur but they are very rare. What is notable is that this form of TTP will not respond to plasmapheresis. Enough for one month.
4)

Title: "Carol's Theme" Written By: "Joe Hamilton"
I'm so glad we had this time together, Just to have a laugh, or sing a song.
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EMERGENCY MEDICINE UPDATE
Seems we just get started and before you Know it Comes the time we have to say, “So long". There's a time you wanna sigh for dreamin. And a time for things you have to do. The time I love the best is any evening I can spend a moment here with you. When the time comes and I'm feelin' lonely And I'm feelin' oh so blue. I just sit back and think of you only And the happiness still comes through. That's why I'm glad we had this time together. Cause it makes me feel like I'm along. Seems we just get started and before you know it Comes the time we have to say, "So Long". Good night everybody

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