According to an article published by the American Academy of Pediatrics in 2010, severe and fatal battery ingestions are increasing, and many patients are being treated inadequately for button battery ingestions. From 1985 to 1009, there has been a 6-fold increase in button battery ingestions with resulting major or fatal outcomes. The largest increase has been with lithium-cell batteries (24% of ingestions) and 20-25mm diameter batteries (18% of ingestions). 20mm lithium cells are the most common to be associated with severe outcomes.
A high index of suspicion is needed; 54% of fatal outcomes are misdiagnosed, usually complicated by nonspecific presentations. Most serious battery ingestions are not witnessed. Consider an ingestion anytime a patient is wheezing, drooling, vomiting, or has chest pain or discomfort.
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Huffing, or abusing volatile vapors to induce intoxication, is a common form of recreational drug abuse, most seriously by younger teens and homeless children. More than 1,400 household products can be used as inhalants to get high. Frequently the users inhale aerosol gases by using plastic or paper bags to concentrate the fumes. Effects of huffing range from an alcohol-like intoxication and euphoria to vivid hallucinations. Effects depend on the type and amount of substance.
Statistics on inhalant use may be significantly under-reported because deaths may be attributed to a discrete event, such as a stroke or heart attack, which may have been secondary to inhalant abuse. 10% of 8th graders have abused inhalants in the past year. There are currently an estimated 11 million people in the world infected with TB, and there were 9,412 cases in the United States in 2014. The American Thoracic Society, Center for Disease Control and Prevention, and the Infectious Diseases Society of America have all come together to create a new guideline for diagnosing pulmonary, extrapulmonary, and latent tuberculosis in adults and children.
Six common causes of ST elevation (J point 1mm above the baseline)
Evaluating for concerning causes of ST elevation:
Adapted from Andy Simmon's Grand Rounds lecture, January 11th, 2017.
How to identify serious injury that requires admisison for neurosurgery or observation, and how to instruct discharged patients for recovery expectations, followup, and return precautions. Bupivacaine and lidocaine are often used concurrently, in theory, to combine the more rapid onset of lidocaine and the longer duration of bupivacaine. However, multiple studies, including a 1996 Journal of Podiatric Medicine article and a 2013 Canadian Journal of Plastic Surgery study have found no statistical difference between the anesthetics with regard to onset of action.
The Surviving Sepsis Campaign has created pocket guides, posters, bundle cards, and a list of resources to aid your implementation efforts using the most recent edition of the international sepsis guidelines. Within 15 minutes
Within 1 hour
Improving identification of potentially septic patientsTo improve identification, it is recommended to have a consistent approach to every patient who is identified as meeting SIRs criteria. Use our prior posts on sepsis for more education (New Sepsis Guidelines) (Qsofa Score). It is also recommended to utilize a smart phrase to identify any potential infectious etiology and medical decision making to prevent missing a potential source of infection, such as an indwelling catheter or orthopedic device.
Utilizing peripheral IVs for short-term treatment with IV vasopressors is frequently utilized while obtaining additional access. Are we risking skin necrosis for short term gains?
The NIH stroke scale it used to identify the severity of stroke like symptoms, and should be scored on the patient's initial presentation, without coaching or duplication. It is important to be consistent when scoring all patients, and identify all deficits.
NIH stroke scale scores patients 0-42, with higher scores indicating increased severity. Training for appropriate use of the NIH stroke scale is free, at http://nihss-english.trainingcampus.net/ iPhone applications, such as StatCoder, are available and free. |
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