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DEC 2013 1) I guess it could be that you live in a hole

(yes, Father, I have repented I will leave Flint alone- I just chose it because it makes beautiful downtown Ypsilanti look so pretty

I don't know what this thing is Father, but I think you may need to call a urologist) and never heard of bath salts, but these are now making the rounds in the druggie
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world. But here are a few things you may not have known about them. No, these are not real bath salts and will not do anything to make your skin softer; they are cathirone type substances that will give you are sympathomimetic syndrome (remember that one? That is the same as the anticholinergic toxidrome hot as a hare, dry as a bone, red as a beet, mad as a hatter, blind as bat but here you are wet not dry). Drug screens will not detect this. Treatment is supportive. It can cause dependence and withdrawal symptoms (CMAJ 184(15)1713). I am sure many forms of this drug will be seen on the streets and that is why it is important to stay abreast of designer drugs For example Krokdyll has hit the USA and will seen be seen in other countries (this is desomorphine) TAKE HOME MESSAGE: Bath salts are here- know

about them 2) Just a word on C difficle which is now in the community and it is angry. We have discussed this scourge before and the new treatments- most are still experimental or not that effective and we have discussed fecal transplants in the past fidaxomycin is now the next antibiotic to treat this. It is not absorbed at all. Monoclonal antibodies are also useful ($$$$$$). Actually a vaccine is in phase 2 trials (Mayo Clinc Prc 87(11)1108). This is not just seen in patients
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with antibiotic exposure. TAKE HOME MESSAGE: a diarrhea with fever, an exceptionally high WBC and bad looking patient- do test for C Diff. 3) After bashing NSAIDs my next favorite sport is blasting Augmentin. This is the drug that will give you the diarrhea that you dreamed about. While it is rare, Augmentin can also cause hepato toxicity. They only saw 11 cases in three years but we do not know the denominator. They estimate there is one case for every 78000 exposures in kids from 1- 11( J Ped Gastro Nurti 55(6)2012). Of course you can always say that a one year old is not equal to an eleven year old and maybe the kinetics are different in older kids TAKE HOME MESSAGE: Augmentin can cause liver damage but it is rare. Our quotes this month are from critics. Let's start with Simon Cowell. "If
you imagine Madonna, Bobby Brown, and Dracula had a child it would be you. But in a weird way I quite liked you."

4) Kids with bad asthma we do not like intubating them but why not do it with isoflurane? It seems to work and if you do not have it in your ED- your friendly neighborhood anesthesiologists will be glad to give you some (Resp Care Nov 2012). I am not sure why this should relax more than proprofol but no studies to say either way. Ketamine is the traditional agent of choice since it is a brocho dilator but I find it hard to intubate with Ketamine unless you paralyze too. TAKE HOME MESSAGE: inhaled anesthesia is an option for status asthmaticus "If
they ever remake the film, you could replace the ice berg. Just sing the song and down it goes." (To Changyi Li after she sang "My Heart Will Go On" from Titanic, Episode 5

5) Clinical quiz time: yea so there was this guy with a DVT and bilateral pulmonary embolisms- his condition deteriorated and he developed fever, hypotension and ARF. Echo showed no vegetations, there is no
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UTI and no pneumonia. A WBC scan was done. Pretty obvious, no?? (Vas Med 17(6)429) 6) A thought provoking study. Lots of folks have home oxygen- and many continue to smoke (a great idea if you ask

me ). They then get burned and this burn center decided not all needed intubation they preferred a wait and see with bronchoscopy when possible. (J Burn Care Res 33(6)e280). It is hard to say- they do not report the usual criteria and I think ENT may be more available and better equipped to tell us about upper airway injury. Then again, you may become comfortable with this too. But an automatic intubation may be a problem as most of these folks are COPDers and will be on the machine a long time- as the study showed this. TAKE HOME MESSAGE: Home oxygen and smoking does happen, but not all need to be intubated. While we are speaking about burns, this is an article that recommends we reintroduce colloids for burns. This will not reduce burn edema, but will reduce edema in non burnt tissues and reduce fluid needs for resuscitation Sounds great no?
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But they do note that it increases extra vascular lung fluid accumulation which means to me- ARDS. (ibid p702) TAKE HOME MESSAGE: Albumin- still looking for a good use. "Years ago I sat on two
cats and that's what it sounded like. It was painful." "My advice would be if you want to pursue a career in the music business, don't." "That was terrible, I mean just awful"

7) I guess you already knew this, but let's state it anyhow. Triptans do cause vasoconstriction so you may want to be careful in heart patients. They can also cause serotonin syndrome when given with SSRIs but it isn't too common (CNS Drugs 26(11)949) I would point out that they do give triptans to kids. Also that these medications are not great once the migraine is well established- they should be used within the first few hours of a migraine. Also they can help the pain of a SAH so be careful that you know what kind of headache you are dealing with TAKE HOME MESSAGE: Triptans can cause serotonin syndrome and do cause vasoconstriction. If this doesn't give you a headache-

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8) Auricular acupuncture helped relieve anxiety in patients undergoing dental procedures (Clin Oral Invest 16(6)1517) The p value was just barely significant and the sham group did not do too poorly-although both were much better than no treatment which means the placebo effect was pretty important here. Furthermore, this is all based on anxiety scores that needed to be corrected for baseline anxiety before they made comparisons is this score useful at all? TAKE HOME MESSAGE: acupuncture in the ear probably doesn't help much to relieve dental anxiety, but honestly what would?

!"#$%&#$'()(%*+,)%-#**.% /012#'%#'%3)*+$456%"I don't know what cats being squashed sound like in Lithuania, but I now have a pretty good idea."

9) Iodinated contrast and gadolinium are passed on to baby through Mom's milk. But it is minimal amounts of the minimal amounts they are given and even Mom clears it quickly. Do not stop breastfeeding if you need to undergo a contrast study (CMAJ 184(14)e775) TAKE HOME MESSAGE: Do not stop breastfeeding for contrast studies. You
have the personality of a handle." before your wife left you." "I'm tempted to ask if you sang that the night
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10) It was at Meir Hospital in came a blue patient

and he had a trach- everyone froze when suction didn't help would you know what to do? Well, if you listened to EMRAP two months ago- then you know. I am not being a copy cat but this article just showed up this month and you will see more here any how (take that, Mel!). Firstly your mouth and nose humidify oxygen but a tube in the throat can not- so make sure you give these folks humidified oxygen. Bleeding soon after a new tracheostomy placement is usually from the procedure- never take out the tube- - a little adrenalin soaked gauze should help. Later bleeding after the tract is mature is from granulation tissue, malignancy, tracheo bronchitis or a sentinel leak from a trachio inominate fistula. If the trach pulsates you better be careful- call your ENT folks and have them look at this on the inside. I would probably do this even if it doesn't pulsate. Subcutaneous emphysema can occur after tracheostomy from sutures that are to tight around the tube- - you just need to remove the skin sutures. Pneumothorax can also follow from new placement from air dissection. Tube obstruction can be from secretions, or from impingement on the posterior wall or a
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tracheal flap. If the tract is mature- more than 7 days-take it out nowyou can always replace it (this is what I did for my patient) or even stick in a regular ET tube. (BJHM 73(10)c152) TAKE HOME MESSAGE: Know tracheostomies- even if you are a clinic doctor-give them humidified air, look out for bleeding and take them out if they are obstructed. "Last year I described someone as being the worst singer in America. I
think you're possibly the worst singer in the world." "Do you have a singing teacher? Get a lawyer and sue her."

11) A scarier clinical quiz 51 year old lady with flank pain. 187/71 BP and normal blood tests including creatinine. No pyuria or hematuria. No abdominal pulstatile masses. They did a CT with contrast. What are your thoughts?? 12) OK Critical Care guys- this one is not for you. The article is written by a CCM physician- I'll give you that. And I actually kinda of know him- he works in Hadassah hospital in Jerusalem- where David Linton heads the other ICU (Dave is an EMU subscriber- I'll give a wave). He was supposed to speak about the use of low dose steroids in septic shock. But indeed, he then makes a great point which is relevant to all of us. An outcome effect even from the best trials applies to the average patient- but patients are individuals and you must guide your therapy to each case separately. As such guidelines which are influenced by opinions, politics, bias, industry, and just who is sitting on the panel- should not guide treatment (ICM 38:1911) So here we have to quote Father Greg (who, to his credit- has never done

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a Father Guido imitation ) who brought the case of Jilek vs Stockson where the lower court established that guidelines do not constitute standard of care, rather expert opinion should. This was overturned by appellate court, but the Michigan Supreme court than agreed with the lower court- guidelines are not standard of care. Yes Father, there is intelligent life in Michigan

TAKE HOME MESSAGE: guidelines are not standard of care. You know it is interesting, because another journal made this point regarding blood transfusions- when do you have to transfuse? We said 10 and 30 in the old days, and then
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we said that aggressive transfusion can result in increased mortalitynow there studies have come out showing decreased mortality with transfusions. (CCM 40(12)3308) So there is no threshold- even for the heart patient with 9.8 and we need to individualize so TAKE HOME MESSAGE: The hell with guidelines. "Not in a billion years. There's only so
many words I can drag out of my vocabulary to say how awful that was." 13) I do not know what you are snorting(although I do know what Father

is drinking- listen to Risk Management Monthly and you will know too(that s another free plug Rick and Greg) but if you are using Ketamine know that ketamine cystitis is a" potentially explosive problem" (They actually wrote this with a straight face.). They mention in passing that ketamine is good for neuropathic pain an indeed I have used it with success in RSD (RPS) and fibromyalgia. Anyhow, returning to our bladders these folks have dysuria, intense urgency, and extreme frequency and post urination pain. It is in heavy ketamine abusers but it can happen anywhere between after only a few days or after many years. CT is the way to image it, but the usual stuff like oxybutynin doesnt work. Hyaluronic acid worked in a case report but really, you got to stop using the stuff and it will probably get better. (BJHM 73(10)576) TAKE HOME MESSAGE: Ketamine can cause cystitis

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Roger Ebert. I had a colonoscopy once, and they let me watch it on TV. It was more
entertaining than The Brown Bunny. a. (Review of an early version of The Brown Bunny, when it was shown at the 2003 Cannes Film Festival (4 June 2003) ) i. After director Vincent Gallo responded to the above criticism by mocking Ebert's obesity, Ebert responded: "It is true that I am fat, but one day I will be thin, and he will still be the director of The Brown Bunny." [1] (4 June 2003

Now for another critic-

14) When ever I read these types of articles I think of Ken and I really shouldn't -I really think these types of articles are to be of interest to all of us. So you made a medical error. Congratulations you really are human. You choices: you can get PTSD, you can grieve and recover or just move on and you can grow. This article looks at the latter. The five steps are firstly acceptance- it isn't someone else's fault-you take responsibility. Then there is stepping in- Go in there and make things better- be human being and talk to the patient and if they sue it you ( and the likelihood is less if you communicate with the patient),well, you know you at least did the right and moral thing. This may include an apology and may include reaching out to
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the family. Then comes integration. Forgive yourself, deal with your imperfections and G-ds sake, find meaning in what you did and go to the next level- new narrative: make ways to change yourself and be willing to listen. Lastly comes wisdom- strength, humility, compassion, tolerating ambiguity and seeing the deeper meaning- make yourself a better person. (Pat Ed Counsel 91:236)Yea, I know this is all heady stuff, but the key point always is to take a step back. You're human and sometimes you just need to be reminded of it. TAKE HOME MESSAGE-Learn always all the time from all experiences. Another non medical article which has much less reverberations is a rant saying we should not be called providers and patients are not consumers. We are not a business. And besides, customer in old English-see Othello- means prostitute. (Int J Card 165(3)395) The movie
created a spot of controversy... Rob Schneider took offense when Patrick Goldstein of the Los Angeles Times listed [2004's] Best Picture nominees and wrote that they were "ignored, unloved, and turned down flat by most of the same studios that ... bankroll hundreds of sequels, including a follow-up to Deuce Bigalow: Male Gigolo, a film that was sadly overlooked at Oscar time because apparently nobody had the foresight to invent a category for Best Running Gonad Joke Delivered by a Third-Rate Comic." Schneider retaliated by attacking Goldstein in full-page ads in Daily Variety and the Hollywood Reporter. In an open letter to Goldstein, Schneider wrote: "Well, Mr. Goldstein, I decided to do some research to find out what awards you have won. I went online and found that you have won nothing. Absolutely nothing. No journalistic awards of any kind. ... Maybe you didn't win a Pulitzer Prize because they haven't invented a category for Best Third-Rate, Unfunny Pompous Reporter Who's Never Been Acknowledged by His Peers..." As chance would have it, I(Roger Ebert) have won the Pulitzer Prize, and so I am qualified. Speaking in my official capacity as a Pulitzer Prize winner, Mr. Schneider, your movie sucks.

15) Steroid injections are pretty routine and they do work but in this study of tennis elbow- it helped but one year later it was worse. (JAMA 309(5)461) Look, the numbers were tiny and it is possible there
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is steroid rebound once it wears off or the patient may feel so much better they overdo. I have found it helped my biciptal tendonitis, but of course nothing helps these jokes of mine TAKE HOME MESSAGE: Steroid injections- do they make things worse in the long run? In the short term , they do well

16) Procalcitonin- oh my this can tell you when cancer patients have sepsis even when they are not neutropenic. (Cancer 118 (23)5823) I'll admit it- I will use CRP occasionally to maybe help me, but not procalcitonin- the p values here are not great (I'm sorry but a p of 0.048 is barely statistically significant) and you have to understand that there are many reasons for fever in cancer patients-like tumor fever and mets and here the procalcitonin values were less convincing. TAKE HOME MESSAGE: Procalcition may help to detect sepsis in cancer patients but then again.This movie doesn't scrape
the bottom of the barrel. This movie isn't the bottom of the barrel. This movie isn't below the bottom of the barrel. This movie doesn't deserve to be mentioned in the same sentence with barrels... The day may come when "Freddy Got Fingered" is seen as a milestone of neo-surrealism. The day may never come when it is seen as funny
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17) I do not know why but the woman above reminded me of this

woman: While she was connected with a politician, she was not preyed on by Bill Clinton (yes, even he has standards). That is Martha Mitchell whose husband was indicted in the Watergate scandal and commented that going to jail was better than spending any more time with Martha. In any case, if you are still reading, Rob Orman, this one is for you (not Martha, the article). Rob did a worldwide survey of the knockdown of agitated patients for EM RAP (yes, I was part of it , and gave a plug for clotiapine) These two- yes you read correctly- these two studies looked at the combo of a benzo with olanzipine versus haloperidol with the benzo versus olanzipine alone. All were fine with regards to lowering blood pressure- they didn't. However, in drunk patients and only in drunk patients (or those who drank the wine of the month)olanzipine plus benzo caused more oxygen desaturation. (JEM 43(5)790, ibid 889) Yea, well I am not sure why you would need olanzipine more than haloperidol haloperidol is tried and true and
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dirt cheap even though the side effect profile may be somewhat worse My peer reviewer adds: See also now published
Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The Psychopharmacology of Agitation: Consensus statement of the American Association for

. This study is important if you do not have an IV in agitated patient and use the olanzipine/benzo dart-you may find yourself having to do an intubation with out an IV. Also- old reports say haloperidol makes seizures more frequent in ETOH patientsI am not sure if that is correct- I certainly haven't seen it-TAKE HOME MESSAGE: haloperidol and benzos are fine for the agitated patient who drank- be careful with olanzipine and benzos. This
Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. In press.

is a plot, if ever there was one, to illustrate King Lear's complaint, "As flies to wanton boys, are we to the gods; They kill us for their sport." I am aware this is the second time in two weeks I have been compelled to quote Lear, but there are times when Eminem simply will not do.

18) This is for Adam and Knox for my friends down at MD Anderson this article is a how to on palliative care in the ED- most of this you should know- like making folks comfortable and POA and truth be told I would have liked more pointers than the basics, but it is a start (ibid p803) Little Indian, Big City is one of the worst movies ever made. I detested every
moronic minute of it...if you, under any circumstances, see Little Indian, Big City, I will never let you read one of my reviews again.

19) The issue of adjusting dosages of antibiotics for obese people has been discussed before in these hallowed pages. Aminoglycosides uses ideal body weight- do not go over 640mg. Vanco total body weigth-15-20. Teicoplanin- not known. Penicillin: if the MIC is highconsider higher dosages of the PCNs or continuous infusion. Cephalosporins they use 2 gm for obese patients of cefazolin and cefepime. Quinolones- they use 800 IV every twelve hours in the really really obese. Most other drugs are unknown. (Curr Opin Inf Dis 25(6)634) TAKE HOME MESSAGE: If they really need antibiotics, give
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higher dosages in general to the obese I know you really want a picture of an obese person here, but I will not do it. Alright, maybe

someone famous: Mama Cass Elliot from the Mamas and the Papas. Great voice- died whileeating. Mad Dog Time is the first movie I have seen that does not improve on the sight of
a blank screen viewed for the same length of time. Oh, I've seen bad movies before. But they usually made me care about how bad they were. Watching Mad Dog Time is like waiting for the bus in a city where you're not sure they have a bus line...Mad Dog Time should be cut into free ukulele picks for the poor.

20) The urologists in my factory love alpha blockers for renal colic (they also like Ypsilanti), I have reported in the past that the evidence is poor- these folks (BMJ 345:e5499) claim the NNT is 4- who is right? You expect me to know? I still think the evidence is thin. My peer reviewer says: I think the evidence is pretty good, but size matters. Stones >4mm good
literature showing alpha blockers help, 4mm or less, they pass so often on their own that one cant improve passage with meds However, Dave Newman on EM RAP

disagreed- but then again while he is brilliant- he trashes everything. Is the evidence thin? Twiggy was and she was the rage in the sixties. Her real name was Leslie Hornsby- she is still around, still thin and still
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not the sharpest knife in the drawer.

if [Chicago] believes Mandingo should be shown to children, then there are no possible standards left and the only thing to do is transfer the censors to the parks department, where they can supervise paper-plate- throwing contests

21) OK ICU guys- this one is for you. You got an end stage renal disease patient that needs ICU care- not a patient you can just flood with fluids. This is actually quite common being that 0.2% of the population in the USA has ESRD. I am not going to go over the effects of renal disease- they have impaired immune response, electrolyte issues, and they have more co morbid issues than other patientsespecially heart disease (didn't I just say I wasn't going over these?). Just be careful with putting in PICC lines- a shame to ruin your landmarks when you can give dialysis via IJ access. Try not to put A lines in the fistula arm. And please do not use the fistula/graft for blood draws or for continuous renal replacement therapy. Giving contrast and then doing dialysis does not prevent acute kidney injury actually it may worsen it. All iodinated contrasts can cause significant fluid overload. The real interesting thing is that these patients do
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better overall than those with ARF in the ICU and ICU patients overall Curr Opinion Crit Care 18:599 TAKE HOME MESSAGE: Kidney patients need specialized ICU care but do well. You can use contrast if they are already receiving dialysis.

Parents: If you encounter teenagers who say they liked this movie, do not let them date your children. There is a scene in this film where a character is defecated on by several people at the same time, and I dunno ... I didn't enjoy it. o Review of Tim and Eric's Billion Dollar Movie (29 February 2012

22) Gosh, this could have been the star paper- to me was convoluted but in any case, the subject is important. You got a patient with a fever and musculoskeltal complaints- you gotta know the rheumatology causes of fever. Bacterial arthritis, joint infection from prosthesis, septic bursitis, and osteo- you better know about these and how to work them up. A form of chronic osteo is called SAPHO syndrome and it has pustles on the hands, feet on the face and back, peripheral synovitis, and joint/bone swelling in the thorax. They discuss lepto, HIV, and Rheumatic fever (which we discussed last month). Autoimmune diseases: lupus, myositis, and vascualitis, Still's disease, Behcets, Familial Periodic Fever syndromes, Felty's syndrome these all can cause a relapsing fever as can Sarcoid, but I am not going to make these diagnosis in the ED. (Curr Rheum 31:1649).I think that if you have a fever that comes and goes in a patient who hasn't traveled recently just admit them and let the eggheads figure it out. But it does point out that you do not need to give antibiotics for prolonged fevers- you do need to think. TAKE HOME MESSAGE: Prolonged fever- think rheumatology
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Rod Slater: My God, you're beautiful. Terry Steyner (Sussanah York): Kiss me you fool. Farrel (John Gielgud): Rod Slater, Do you know what your getting yourself into? Rod Slater: No, No I dont the movie "Gold" in 1974.

23) So the answer to 5 was indeed obvious- it was a septic thrombophlebitis and with withdrawal of the thrombus the patient improved. Keep this in mind especially in females after birth with unexplained fever. Number 11 is a little stickier this was a spontaneous renal artery dissection. We would have done a non contrast CT and could have missed this. This patient did well with conservative treatment but not all do. The severity of pain with a normal study should raise your antenna 24) Hey it is time for letters. The postman was busy and let me remind you that I enjoy your letters don't be bashful! Mike Herra asked my opinion about the NEJM article trashing cooling after cardiac arrest. Chris Nickson has dealt with this on his ICU network so I am not going to add much other than the study was well done and I have to say EMU in the far past was not so impressed with the original study. But it did make good movie material for you Woody Allen fans Sleeper was based on a patient waking up many years later

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Thanks for writing Mike. Ken is off globetrotting again- he is now in Guyana- which for you folks who are South American Fans- is one of three former colonies on the north coast- Dutch Guinea, - now Surinam, British Guinea now Guyana and French Guinea (which is still a colony) Guyana was in the news back in 1978 for the famous Jonestown massacre, but things have been quiet there,and they still speak English. And no, Ken, I didn't look any of this up. Here is what Ken has to say: Hi Yosef
Happy Thanksgiving, although Im not sure anyone but Americans know about it in Israel. (you are right- we do not eat our turkeys- we let them govern) Ive attached two recent articles about remote medicine I published in the Journal of Wilderness and Environmental Medicine, along with links to their abstracts (below):
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I thought that youd find them interesting Thanks for sending them Ken. I will

be using at least one of them for an essay (with your permission) but if you do not have access to this journal please be in touch and I will send you the pdf. Hey thanks to Stan Mayer and Brian MacMurray for wishing me a happy Hanukah. Ken also commented on our ethical dilemma last month concerning power of attorney. I am indebted for this Knox are you reading?
Comment re: Baumrucker SJ, et al. Surrogates with conflicting interests: who makes the decision? Am J Hospice Palliative Med 2012;29(6):497-500. There were three actors in this scenario: Patientunknown wishes/permanently comatose POA (designated surrogate)desires feeding tube and aggressive treatment [The patients son questions the POAs financial motives in making that request.] Physiciansbelieve that they should only institute comfort care, since this is a futile case The ethics committees role in such situations is to gather the facts, evaluate them, and make a recommendation to the parties involved. If, by gathering the parties together they can get them to agree on a course of action, they have resolved the dilemma. However, in the case presented, both vocal parties (the patient is permanently unconscious) seem to have laid out and informed the other of their diametrically opposing position. In these cases, hospitals can apply for a court-appointed surrogate to make the patients healthcare decisions. Since the son raised the question of the POAs motives, a court would probably appoint a neutral third party, such as a public fiduciary. As for your suggesting that they ask for the clergys view in this case, clergy might help resolve the issues if they visit with the POA and the physicians. The clergys training (hopefully, as a chaplain) and the parties religious backgrounds, motivations, and flexibility play a large part in the success of such interventions. Clergy, of course, often play an important role on ethics committees. Hope that helps. Ken

Nothing to add Ken- this was an excellent analysis Well, here is Dr Axel from France. Kinda of makes me wonder about those French- maybe he has been eating too much English Food- that would make anyone ill. Hi Yosef
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So when I visit the Dead Sea some day I'll try and remember 1- to not gulp a sip (or sip a gulp) of it, 2- pay you a visit (hey this is just an idiom) since you work close by. But is the guy who wrote " Avoid Abbreviations !" also the one who earlier wrote " yes you heard me right- avoid benzos- and anticholinergics, and give PT" and " POA is the caregiver" ? I was thinking of "person of ... of what? Mental attempted Gallicism. Indeed we have "personne de confiance" for such situations. I figured it out. But PT? (c'est une physiotherapie, mon ami) Well I dont look given horses into ze mouth so ...(when I was a horse dentist, I did) THANKS ! Er... by the way , what do you smoke before you write EMUs ? (Fleet's Lite)

Thanks for writing, Axel. Scott and Chris checked in and are working- voluntarily- on getting EMU up on the web and improving its format. I did learn computers as a college guy but that was Fortran and APL and kinda of got lost on the technology of today- so it is with real appreciation that I thank both Scott and Chris- folks who I have never met- but nevertheless believed in EMU and me.
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This month we look at cardiac emergencies- specifically endo, myo and pericarditis and it is from Med Clin N AM 96:1149, and CO poisoning update from AJ Respir CCM 186(11)1095) Cardiac Stuff: 1) I liked the way the article started "out of all the medical specialties, cardiology has the most emergent situations". What is EM- chopped liver? 2) Endocarditis- is really infection of the endocardial surface of the heartwe are used to that being the valves., but it can be VSD s and ASDs and even the walls of the heart. 3) Firstly there has been a major shift in this disease- indolent, sub acute disease is becoming rarer, and mostly there are acute presentations without he classic signs they taught you. Mortality however has not changed- it is still as high as 40% within one year. 4) OK, so here is the scoop for the 2000s- it often follows an acute illness (usually within a month) and Staph is now the star (especially in those with hemodialysis access, DM and those with cardiac implantable devices). However some studies still show Strep leading the way. Mitral and aortic valves are still the most commonly affected. Risks remain IV drug abusers, valve disease, and indwelling venous catheters. The most common complications are heart failure, emoblization, stroke and 14% of the time intracardiac abscess which I have never seen but I imagine it is not a good thing.
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5) Just a word on our buddies who are drug abusers-they still get this on the tricuspid valve, they still get fungi (especially common with brown heroin dissolved in lemon juice) and mouth flora from cleaning needles with saliva. Non druggies can get this too from cardiac surgery or prosthetic valves. Or eating English food. 6) Vegatations- they tend to be more friable and suppurative in acute disease, and as such can cause corrosion of heart structures and abscesses, They also can travel to other places in the body 7) OK enough of the small talk- let's get to what you will see in the typical endocarditis patient- malaise, weakness, low grade fever, and joint pains. That was helpful, no? Of course if the patient has chest pain or CHF it is easier to make this diagnosis. AMI and fever also make this climb the charts. Splenic infarct also means you better think of this. But on the other side- fever may be absent in the elderly or in immunosupressed patients, so look for chills and joint pains- these happen frequently and of course-check for a new murmur. You can use the duke criteria, but you need to think of this disease to use the duke criteria 8) Basically you need to take blood culture- alot of them they like three sets with 10 cc of blood in each bottle. Of course, an echo will help. 9) Treatment is coverage for gram positives- although they like daptomycin for MRSA more than they like vanco. They give recommendations for pseudomonas and Candida but prayer may work better. Surgery does actually give good results if used for the right indications- bad heart failure due to a destroyed valve, valvular abscess, persistent bacteremia, large vegitation (bigger than10 mm) and bad organisms. 10) Of note is they do not mention SBE.
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11) Pericarditis is a little more optimistic. Viruses are the most common causes 90% of the cases. Note they are talk about infectious causes not uremic, cancer or Desseler's syndrome. While bacteria can cause pericarditis and can commonly cause effusions, S pneumonia is much less common than in the past- even while still being the most common bacterial cause. Just remember than TB pericadritis does occur in the immunocompromised. 12) Pleuritic chest pain is the key here-sitting makes this better Fever helps. I am not a big user of pulsus pardoxicus. Nor do I think rubs are that common. 13) EKG is helpful with the classic signs that you should all be familiar with- the concave ST elevation seen best in II III and V5-

6 Echo can clinch the diagnosis and an elevated ESR or CRP can help also. 14) Viral pericarditis does well with NSAIDS or colchicine- they do not mention aspirin and I am not sure why. Recurrence occurs in a
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quarter of the cases but usually within two weeks and is usually less severe. 15) Having fun yet? Let's go on to myocarditis. Myocarditis mimics a heart attack. The real diagnosis is done by biopsy and stain but no one really does this any more. Either they try MRI or if it is a young patient who they suspect it and they take them to cath and find nothing- they usually give this diagnosis. 16) Well, almost anything can cause this: drugs, toxins, sarcoid- but viruses are the most common cause and you should ask about a recent cold- within the last four weeks. These also do the best. Interestingly enough this can occur after immunization. 17) All the usual- malaise, fever; but the chest pain should be thereThese can be sour immediately with arrhythmia, CHF and even sudden death. 14% of pericarditis involves the myocardium as well 18) These don't work: steroids and immungolbulins. Antivirals and interferon do not seem to work. Cyclosporin didnt do much. Gangcicolvir may help in CMV CO POISONING 1) This is an update and if you say- well, I'll just skip this part- it is just oxygen and that is it- you are mostly right, but I will forge on because maybe someone is high enough that he may keep reading ( I like Fleet's Lite- great tasting and less filling). Just hope what he snorted wasn't carbon monoxide. 2) OK this is due to inhalation of this colorless and odorless gas which shifts the oxyhemooglobin curve to the left. However, effects are not entirely due to carboxyhemoglobin and indeed levels of carboxyhemobloin do not correlate with the clinical severity. That is
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the main point with regards to levels of CO HB. As far as I am concerned ,the mechanisms they bring are egghead-y and you are

probably bored enough 3) Symptoms will not help you too much- fatigue, confusion shortness of breath. Cherry red skin is rare and needs a lethal level of carboxy hgb. Carboxy hemoglobin levels greater than 3-4% in non smokers, and 10% in smokers is considered suspect for CO poisoning. You can take it arterially or venously. If your blood gas machine is old and doesn't have a CO oximeter- the saturation will be normal. This is the case with most pulse oximeters. However, that is of little consequence since CO is reversibly attached to hgb and as such all these patients should get oxygen. 4) Is 100% oxygen better than air? Actually there are no such studies proving this. What ever. Once the patients carboxyhemoglobin is normal or they are symptom free- you can let them go home 5) Hyperbaric oxygen does hasten resolution of symptoms but studies comparing it to normobaric oxygen have been poorly constructed. It may lessen long term effects. It is still recommended for those at risk.
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Who are at risk? Older than age 36 (isn't everyone older than 36?) LOC, Carboxy hgb of 25% or more, or exposure for more than 24 hours. The problem is that this is really extreme and lesser parameters has still given cognitive defects later on even if early effects are not seen. Pregnant women get hyperbaric oxygen seems it doesn't hurt the fetus- but again we do not know. Kids get it too. 6) Proper dose of hyperbaric oxygen and how many treatments- no one knows 7) Motor dysfunction and anxiety, depression memory disturbance and inability to calculate can occur even after correct treatment. Hey that is all for this month- 2013 was a great year and we hope you enjoyed EMU. Actually we hope that you even read EMU. Or that your canary did. As is our custom we use this issue to thank our dedicated peer reviewers. These guys have given their all for EMU. Thanks guys- I appreciate it more than you will ever know

Mike Drescher
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Tom Ashar MD FACEP
ED Director Community ED Group in Alabama

Attending Physician and Associate Professor Department of Emergency Medicine Hartford Hospital/University of Connecticut

Pegasus Emergency Group

Moshe Weizberg MD FACEP

Residency Director Staten Island University Hospital

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Chris Nickson Emegency Phsycians and CCU specialist Alice Springs Australia I do not have a picture of Chris but this is what you find on google if you put in Chris Nickson and Life in the Fast Lane

Gil Shlamovitz, MD, FACEP Assistant Medical Director of Clinical Information Systems Harris Health System Director of Medical Informatics, Section of Emergency Medicine Assistant Professor, Department of Medicine Baylor College of Medicine, Houston, TX
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Adam Miller MD MSMM MSCS FACEP Associate Professor, Department of Emergency Medicine, Division of Internal Medicine, The University of

Texas MD Anderson Cancer Center, Houston, TX And to our reviewer in a pinch Yechiel Reit MD FACEP (Can't copy what comes up on google pictures for your name) And new volunteers are always welcome! (Like the above, they must have been featured in the New England Journal of Great Looking Guys)

And our yearly review of policies:

EMU Policies: 1) EMU is distributed free of charge 2) All parties with the exception of for profit organizations can reproduce it. It can not be reprinted for profitable purposes 3) EMU is peer reviewed 4) EMU does not accept advertising 5) EMU does not usually quote articles from Annals of Emergency Medicine and the New England journal because most of EMUs readership already receives these
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journals. EMU also does not generally use articles reviewed in Emergency Medicine Abstracts as many EMU readers are subscribers as well, and I do not wish to take away from that excellent publication. 6) I have no connections to any drug or medical appliance company, and thus the information in EMU is objective. 7) EMU is dedicated to the development of Israeli and International emergency medicine. Therefore, new subscribers worldwide are welcomed, and we appreciate your referrals. 8) That is it, friends- 15 years publishing monthly. I hope you have enjoyed it as much as I have.

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