Category Archives: Educational day pearls

Educational Pearls (last week)

Good afternoon all, here are some points from our last academic activity entitled (The Immunocompromised Patient):

  • There are 2 types of immunity: innate which does not need previous exposure and acquired (adaptive) immunity which needs pervious antigen exposure .

 

  • The stem cell of bone marrow contains 3 times the number of WBC found in the circulation .

 

  • Pregnancy causes immunosuppression .

 

  • Cyclosporine is metabolized by cytochrome P-450, so try to avoid prescribing any medication that shares the same enzyme for metabolism, for example, a concomitant macrolide can cause hepatotoxicity or even rejection .

 

  • Corticosteroids:
    1. May cause change in WBC count as early as 6 hours from administration.
    2. Any abdominal pain in a patient who is on corticosteroid should be taken seriously and needs to be investigated for serious complications  such as perforated viscous and intra-abdominal abscess.
    3. Sutured wounds in patients on corticosteroids need double the time to heal (it affects healing).

 

  • Febrile Neutropenia:     ANC = WBC count * ((PMNs/100) + (Bands/100)).

Initiation of monotherapy with an anti-pseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem/cilastatin or piperacillin-tazobactamCeftazidime monotherapy has also been shown to be as effective as other regimens .

  • HIV-positive patients: if CD4 is below 200 then this patient needs a prophylactic antibiotic for PCP.

 

  • 30% of elderly patients with infection will present without fever. Thus, absence of fever does not rule out infection.

 

  • 89% of elderly patients coming with fever will have an infection. (so deal with fever seriously in this group of patients).

Thoracic Trauma

Good afternoon all,

Here are some points from our last activity (Thoracic Trauma) that took place in 22-04-2014

1-The most common chest injury in pediatrics is lung contusion. While the presence of rib fracture means sever trauma.

2-1st and 2nd ribs fractures are not always an indication for angiography as it depends on clinical suspicion.

3-Lower ribs fractures (9-12) :

A-If on the right side:  3 × times increase in risk of liver injury.

B-If on the left side:  4× times increase in risk of spleen injury.

4-Any displaced rib fracture needs observation and monitoring for at least 3 hours and chest x-ray needs to be repeated before discharge.

5-Isolated sternum fracture does not reflect cardiac or aortic injury.

6-In blast injury (shock wave) pulmonary contusion can present even without any external evidence of chest injury.

7-ARDS vs lung contusion :

Contusion will appear within the first 6 hours while ARDS will take longer time to manifest.

8-80 %  of tracheobronchial injuries are within 2 cm above the carina, suspect it when you have a continuously leaking chest tube .

9-Myocardial concussion (Commotio Cordis): blunt injury to the chest produces a stunned myocardium and dysrhythmias (mostly  Vfib).

10-There is no single test that confirms the diagnosis of cardiac contusion except for autopsy.  Thus, the key point whenever it’s suspected is monitoring (serial ECG, cardiac markers).

11-In myocardial rupture the most common affected part is ventricles (Rt more than Lt).

12-Aortic injury is the most common vessel injury with 80-90% of injuries in the descending part just distal to the Lt subclavian artery.  The most indicative CXR finding is widened mediastinum .

13-Esophageal rupture:  almost 100%  mortality if the diagnosis has been delayed for more than 24 hours.  Gold standard test is gastrografin esophagram but it will be suboptimal in case of multiple trauma where the patient is only in supine position as it needs different views while standing in different positions, i.e. AP, oblique and lateral so in this case  you need to add endoscopy to support the diagnosis and if esophageal rupture is still suspected go to surgery .

14-The most common side of diaphragmatic rupture is the Lt side and it is mostly caused by a blow to the abdomen that raises the intrabdominal pressure too high to a limit that causes the diaphragm to burst.

Educational day pearls A-1

Hi folks,  these are the main points of our discussion in the last academic activity day, enjoy!

  • Kayexalate,, Never think about it in the ED. Its effect -If any- only starts after 4 hours .
  • There is some published evidence on severe GI complications secondary to the administration of Kayexalate such as colonic necrosis or perforation, whether accompanied with the administration of Sorbitol or not.
  • Insulin with dextrose and Albuterol nebulizer have synergistic effect when treating hyperkalemia.
  • In case of hypernatremia: Start with correcting the underlying shock, hypoperfusion or significant hypovolemia with normal saline.
  • Most patients presenting to the ED with hyponatremia are stable and require NO emergent therapy.
  • For asymptomatic patients with sodium values of 115 to 135 mEq/ L, free water restriction is typically the single most important treatment in ED.
  • For Asymptomatic hyponatremia cases send: Serum and Urine osmolality, TSH, Random cortisol level, Uric Acid and urine electrolytes before starting fluids.
  • Many case reports addressed fatality from iatrogenic hypermagnesemia in elderly ( with or without renal impairment). Dose and infusion rate should be reviewed cautiously.