A flyer from SAPMEA is available with registration details
A flyer from SAPMEA is available with registration details
In honor of this year’s EMS Week (May 19th to the 25th) I asked others to share EMS-related events that had a profound impact on their life. Below is what my friends and colleagues chose to share. Mine is already posted here.
I remember responding to a call on rt 280 a car crossed over the center striking a camero killing a young lady driver instantly. A guy was notably upset found out later it was her husband who was following her home they had just bought the camaro. A call that went in slow motion.
So many thoughts, so little time. I will say the majority of my memories are of my fellow EMS personal I worked side by side with. The look in their eyes, the touch of their hand, the knowledge we were all on the same wave length as we worked to aid the ill and injured…stamp out death, dying, and disease…and stop the grim reaper. As I can still see some of the patients I cared for, remember the smells of their homes, and even feel the heat/cold of the ambient temperatures of the area we cared for them in. My most vivid memories are of the people who have dedicated their lives and time to care for people they never met. Congratulations to all of you and thank you for all you did, do, and continue doing.
The car accident with Ronnie Sansone. A night with Jen I will never ever forget.
First CPR save.
My mutual aid infant code at Rutgers when I wasn’t even working, just visiting . I can still see the wispy hair on his head.
Sitting down to a holiday dinner and having all three sons have to leave to take a call (more than once).
The night of the South Orange Rescue Squad fire and feeling helpless watching it burn! But we were back in service the next day, Thanks to Maplewood Fist Aid Squad, And St. Barnabas loaning us ambulances to use and a local business giving us space to work out of.
August 23, 1989 at 11:30 pm South Orange Police Officer John Monsees was shot in the line of duty while responding to a burglary in progress, If having a friend shot is not bad enough, his wife was on on dut with us that night. John recovered from his wounds.
Responding and transporting patients brought over by boats to Liberty State Park on 9/11.
New to Brick City
At the age of 19, I got my first EMS job in the city of Newark at UMDNJ. I had arrived. I rode around that city day in and day out on that ambulance and learned some very valuable life lessons. I was as green as they come but I learned quickly.
The most important lesson I learned early on was while riding with my partner through south Newark. We came upon what appeared to be an abandoned building and I said to him that it was a shame that all the windows were broken out because if they weren’t, then people could live there. He then replied, “Oh people live there.” I was appalled and shocked and had a difficult time hiding it. I then said to him, “It is terrible that people have to live that way.” He then said, “Oh, they’re used to it.” I was quiet for a moment and then I replied, “That doesn’t make it right.”
It was on that day that I really realized that we are all human beings. No matter where we live, or how we grow up, how we dress, or behave. Everyone comes from somewhere, and each one of us is someone’s something; mother, father, sister, brother, son, daughter, or friend. We all deserve to be treated well regardless of who we are or where we live. I have carried that lesson with me throughout my life and it has served me well.
The first time I did CPR was on a young, previously healthy woman in her 30s who aspirated while eating lunch and went unresponsive. I was 16, a brand new EMT.
The medics pronounced on scene, but even after we stopped I couldn’t take my eyes off her sneakers – white, laced up, brand new – I can still see them today. It made me think that when she left the house that morning, and put those sneakers on, she never planned for this to happen.
My late partner, Tony (who must have noticed me staring), read my mind, then said out loud, “No one ever sees this coming. That’s why we do what we do. Not so we can save everybody- because we won’t- but to be ready to act when bad things happen, and so that the loved ones of each of our patients know that everything possible has been done for them.”
I never forgot his words, or that day. Ironically, a few days after that, her sister wrote a letter to our squad thanking us for trying to save her sister’s life, and the efforts we made that day. EMS is not just about making a save- it’s about touching lives and providing comfort and compassion when it’s needed most. In the scuffle of day-to-day, too often, we lose track of this.
21 Mayıs 2013 tarihinde Senkop ile acil servise başvuran hastada yukarıdaki EKG çekilmiştir. Tanınız nedir?
Aşağıdaki video usta Amal Mattu’dan. Yukarıdaki vakanın tanısına yönelik ayrıntılı bir anlatım yapıyor. Bu video 4 Mart 2012′ye ait.
Keeping it short and simple this week folks. Here is a presentation on back pain in the pediatric ED. Just scroll vertically through the slides. You can even download it if you want.
Spoiler alert! I will actually be giving this talk live tomorrow at the Cincinnati Children’s resident lectures.
At the end of every year, the Intennal Medicine residency at Hennepin County Medical Center holds a poster session for the graduating senior residents. Each resident is encouraged to display work from their time during residency. Most residents prepare a poster on research they worked on or quality improvement projects. Others have shown off education innovations they came up with, or simulation cases they developed.
I enjoy sketching/drawing and have prepared many figures for the presentations, papers, lectures, blog posts, and teaching that I have done during my residency. I thought it would be fun and unique to prepare a poster with a sample of my art. Nothing earth shattering, but I hope you enjoy.
A 15 year old male is bought to ED by his mother with a complaint of throat pain after eating a meal of chicken skewers that were cooked on the family barbecue. He is alert and in no apparent distress, breathing comfortably without stridor or drooling. His observations are within normal limits and his chest is clear to auscultation.
The skewers were prepared at home from chicken breast and they “are pretty sure there were no bones around” ….
Approximately 80% of swallowed FBs are in children (aged 1-4 years). This will involve toys & coins for example and will lodge in the anatomically narrowed parts of the oesophagus. Adult patients generally provide an unequivocal history but can occasionally present with unintentional ingestion (eg. dentures). Adult impactions tend to be more distal.
Signs & Symptoms.
Sharp Object Ingestion.
This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.
Uluslararası Akademisyen Gelişimi ve Eğitimi Kursu, Baltimore, ABD’de bu sene ikinci kez 21-25 Ekim 2013 tarihleri arasında yapılacak. Acilci.Net olarak 3, Türkiye’den toplam 5 kişiyle ilkine katıldığımız bu organizasyonda Amal Mattu, Rob Rogers, Mel Herbert, Mike Bond, Haney Mallemat, Mike Stone, Mike Cadogan gibi isimler yer alıyor olacak.
Amal Mattu’yu EKG serilerimizden takip ediyorsunuzdur. Mike Cadogan’da Acilci.Net Uluslararası Editörlerinden ve LifeInTheFastLane ve GMEP FOAM sitelerinin kurucularından. FOAM hareketini başlatan isimlerden. Haney Mallemat tam bir kadavra laboratuvarı ustası. ROb Rogers iTEachEM FOAM sitesi editörü. Dolayısıyla da bu kurs aslında FOAM hareketine kendini adamış bir akademisyenin alması gereken tüm içeriği kendisine ulaştırıyor olacak.
Eğer Asya Acil Tıp Kongresi’ne gitmiyorsanız Wired dizisiyle aklımızda yer eden Baltimore’u yakından görün derim. John Hopkins, Mercy ve Maryland kampüsleri bu şehirde ve birbirine çok yakın. New York 2 saat, Washington DC 1 saat uzakta. Dolayısıyla kurs önü ve arkasında 1-2 gün koyarak neredeyse doğu yakasının önemli tüm acillerini de ziyaret etme fırsatı bulabilirsiniz.
İlk tanıtım broşürü aşağıda yer alan bu kursla ilgili gelişmeler oldukça buradan duyurmaya devam edeceğiz.
Ana sayfamızda bu kursun linki de sabit linklerimiz arasında, kurs web sitesine buradan ulaşabilirsiniz.
The post Uluslararası Akademisyen Gelişimi ve Eğitimi Kursu (IEMTC13) appeared first on acilci.net.
This is part of a continuing series exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:
There is a tidal wave that is coming. The baby boomer generation (those born 1946-1964) are now entering retirement age. Combined with increases in life expectancy it is causing an unprecedented "graying" of the United States and most other industrialized countries.
This patient came in with abdominal pain. An upright chest Xray was ordered to eval for free air. Can you see any abnormalities?
What’s wrong with this picture? (HINT: you may need to zoom in on the cardiac silhouette and mediastinum to see the abnormality)
Answer to follow.
Author: Russell Jones, MD
Image Contributor: Aaron Hougham MD
Les mauvaises habitudes alimentaires représentent une cause majeure dans la formation des calculs calciques, oxaliques et uriques. Les mesures diététiques concernent les boissons et l’alimentation.
Le plus important est de boire en quantité suffisante. Cela dilue vos urines et diminue le risque de former des calculs. Vous buvez suffisamment si vous urinez 2 litres par jour.
Combien faut-il boire ?
Quand faut-il boire ?
Que faut-il boire ?
Quelles boissons consommer avec modération ?
Il ne s’agit pas d’un régime, mais d’un ajustement de vos habitudes alimentaires.
Les excès de calcium, sel, sucre, protéines animales, oxalate et acide urique favorisent la formation des calculs.
Teneur en calcium des produits laitiers
|Produit laitier||Teneur en calciumen mg/ 100 g|
|Lait entier ou demi-écrémé||120|
|Brie, chèvre frais, fromage blanc||120-160|
|Chèvre sec, Munster, Coulommiers||200-250|
|Gouda, Edam, Comté, Gruyère||900-1000|
Teneur en calcium de certaines eaux (liste complète sur www.aquamania.net)
|Nature de l’eau||Teneur en calciumen mg/ Litre|
|Eau de source||10 à 120|
|Eau de ville||30 à 120|
La teneur exacte en calcium est celle qui figure sur l’étiquette
En pratique: vous calculez puis vous choisissez
Maintenez une activité physique régulière
Evitez l’excès de calories
Variez l’alimentation et consommez des fibres (fruits et légumes)
Ces règles diététiques sont simples
Elles doivent être respectées à vie
Elles sont plus efficaces si vous buvez plus de 2 litres par jour
Elles réduisent fortement le risque de récidive
Suivre ces règles diététiques réduit également le risque d’hypertension artérielle, de diabète et d’obésité
BUVEZ, BUVEZ ENCORE, MANGEZ MOINS et MANGER MIEUX
cela diminue le risque de faire ou de refaire des calculs
‘Just a Routine Operation’
…….perhaps the sentinel case that finally brought ‘team work’ and ‘human factors’ (CRM) to the attention of healthcare.
Watch and learn!
Trans-venous Pacing Wire Insertion
Is your patient bradycardic & compromised?………..you might need to know how to place one of these…..
In addition to the video consider ‘visualisation’ during placement:
Sengstaken Blakemore or Linton Tube Insertion
……..bleeding varices?….you might need to know this!
You may have seen these strange pixellated squares at a recent academic conference on a a poster presentation, or perhaps on printed media and wondered what they are. Well, they are QR codes. Great… what’s QR code? Read on… QR codes are essentially the hybridization of barcodes and hyperlinks (website address).
QR stands for Quick Response. QR is actually a trademarked version of matrix barcodes (AKA 2D barcodes) for designed for the automobile industry in Japan (a subsidToyota) as a machine readable label that revealed information when scanned. The image encodes any type of data – pictures, words, characters etc,. They are able to be read quickly (hence the name) and can encode/store more data than a traditional UPC barcode. The black square dots are arranged on a white background in a unique pattern that is then read by an imaging device (the camera on your cell phone) which then is processed using a designated application that interprets the data. This data is extracted, and the application can display data or direct the user to a website.
Well, first you’ll need something to direct the QR code towards. That could be any website or even an email address. Here are some examples:
Google Maps Location
App Store Download
Wifi Login (Android Only)
Paypal Buy Now Link
Once you’ve decided what you’re going to link, then you’ll have to generate a QR code. There are lots of free websites that will do this for you. And essentially they all ask you to input a web address etc,. then spit out an image file that you can insert wherever you’d like. Here are a few that you can check out:
QR Stuff: Allows you to select what type of data you input, but is limited in the number of uses for free
Kaywa QR Code: Another site with free options – this time unlimited
QR Code Generator: I used this one to create an example that directs you to my educator portfolio. It allows you to automatically generate an embed code so that you can insert it into a website.
Once you’ve got a QR code, or if you encounter one, you need a way to “read” it. Fortunately there are a number of applications (free and paid) available for your mobile device. Once you pick one and install it you’ll use the application and your smart phone’s camera to capture the image of the QR code, and then the application itself will direct you towards the linked resource.
Though these codes seem to be everywhere their adoption, at least according to some sources, is lacking. See this infographic for a handy summary. Why have they not been adopted? Well, you need to download a separate app, and then remember to open it. Though this only takes 30 seconds – wer are impatient craetures. The public’s knowledge of the use and utility of QR codes is still limited. And finally, using a QR code to simply link you to a corporate website isn’t actually stretching the potential of the tool. It is therefore up to the user to figure out unique ways to take advantage of QR codes.
Impressive horses, syphilis, and strokes…all in 14 minutes!
Over the weekend just gone, Chris Nickson of Lifeinthefastlane threw down a challenge – the idea of a debate of ‘real anaesthetists don’t need checklists’ between Dr Minh le Cong and myself at next year’s SMACC14 conference on the Gold Coast (#SMACCGOLD).
Not withstanding the obvious inequalities between Minh’s masterful martial arts technique and my more traditional wrestling style, I reckon this will be a kick ass debate and lead nicely into some breakout discussions.
It’s no secret that I am a fan of checklists and other cognitive aids to help us in our work. I;ve been blogging about this since my post on ‘aviation & anaesthesia’ back in 2011 at the old KIDOCs blogsite (http://ki-docs.blogspot.com.au/2011/11/anaesthesia-aviation.html) and linking to usual resources see ‘Resources’ menu tab above)
Familiarity breeds contempt, and there is a benefit to introducing checklists into everyday routine BUT HIGH RISK procedures
- the WHO Surgical Checklist (more than the standard ‘surgical time out’ should incorporate checks in anaesthesia room, before knife-to-skin and before leaving the OT)
- an RSI kit dump and challenge-response checklist, as used by many retrieval services but with application to occasional intubators in the ED, ICU and rural environment
- checklists for management of crises, in OT, in ED, in Labour Ward
Not only that, use of checklists fosters teamwork, humility, discipline rather than the usual independence, self-sufficiency and autonomy that underlies most medical training.
Listen to Atul Gawande talking about ‘the checklist manifesto’ (thanks to Dr Stefan Mazur of medSTAR SA for getting on board with Twitter and sharing this link)
Meanwhile, bring it on…
Great to talk to Dr Ken Milne who is actively trying to narrow the knowledge transfer gap of traditional methods (up to a decade from evidence to practice) using SoMe and FOAMed – a keen medical myth buster and small town emergency physician in rural Goderich, Ontario Canada (‘Canada’s prettiest town). Ken hosts the excellent sceptics guide to emergency medicine blog and podcast, which is a MUST for rural doctors alongside existing resources like BroomeDocs and KIDocs.org
Ken is giving a keynote at this weekend Rural Doctors of South Australia conference – via the internet from Canada! Let’s hope we can entice him to join the rural stream at SMACC14 on the Gold Coast next year.
Now onto the podcast….
I came across this video via a feed on Facebook. It’s got nothing to do with sim, with helicopters, medicine or even education (well except maybe it contributes to general education of life).
I thought it deserved to be shared. It struck a chord because I’ve been that guy stuck in line at the grocery store and just about ready to lose it…then having to get back in my car and drive home in Toronto’s ridiculous traffic. This video reminds us about others, that the people around us may not be in nearly the fortunate situations that we’re in or maybe they’ve just had an even worse day at work than me. Regardless, I hope I can remember this video next time I’m pissed off at how long the line in the grocery store is or when I’m stuck 3 hours of traffic, just trying to get home.
For those interested, the speech is an excerpt from a commencement speech delivered by David Foster Wallace in 2005 before his death in 2008.
Date: May 20, 2013
Title: TNT (To Not Treat) with Prophylactic Antibiotics for Basilar Skull Fractures
Case Scenario: An otherwise healthy 21yo male patient who has been drinking alcohol all day at the beach. He tries to jump into the back of his friends moving Jeep and does a face plant. He arrives by ambulance GSC 15 collar and boarded with racoon eyes. Because your small hospital does not have a CT scanner you ship him out for the CT head which shows a non-displaced basilar skull fracture. You admit him to hospital for neurological observation while the alcohol wears off. You wonder should you start prophylactic antibiotics to prevent meningitis?
Question: Are prophylactic antibiotics effective in preventing meningitis in patients with basilar skull fractures?
Background: Basilar skull fractures from non-penetrating head trauma is estimated to by about 10%. Cerebral spinal fluid leakage associated basilar skull fractures is also about 10% with a range from 2-20%. The concern with basilar skull fracture is the direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear could predispose patients to meningitis. Physicians often give prophylactic antibiotics to decrease the risk of meningitis in these cases.
Signs/Symptoms of a Basilar Skull Fracture:
Reference: Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD004884.
Results: 5 RCTs (n=208) and 17 non-RCTs (n=2168) All 208 participants from the 5 RCTs included in the meta-analysis. There were no significant differences between the two groups (antibiotic prophylaxis vs. and control). This included the primary outcome of meningitis and all the secondary outcomes (all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage). A meta-analysis of the non-RCT had results similar to the RCT data. No adverse effects were reported with the use of antibiotic.
Authors Conclusions: “Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.”
BEEM Comments: The studies included in this review all had important methodological flaws. Curiously, the frequency of meningitis in the Eftekhar 2004 trial was significantly higher than in the other trials. This may be because they only enrolled patients with a basilar skull fracture and pneumocephalus. This could represent patients at higher risk for developing meningitis. There was no difference overall in the frequency of meningitis in the prophylactic antibiotic group versus the control group, even when the subgroups with and without CSF leakage were analyzed. There was a possible adverse effect of increasing susceptibility to infection with more pathogenic organisms in those treated with antibiotics. None of the studies reported data on outcomes of safety and tolerability of prophylactic antibiotics.
BEEM Bottom Line: There is no support for routine prophylactic antibiotics in all patients with basilar skull fracture. Further RCTs are needed to assess its benefits and risks clearly.
Case Resolution: You decide not to give prophylactic antibiotics to this young man who tried to jump into a moving vehicle and sustained a basilar skull fracture.
KEENER KONTEST: Last week’s winner was Chris Bond from Saskatoon and responsible for SOCMOB blog. He is TheSGEMs first repeat winner. Chris suggested Doxycycline 100 mg po BID as a nice choice for community acquired pneumonia in a 66yo woman on a calcium channel blocker as recommended by IDSA guidelines (Grade III rec) as alternative to Macrolide.
Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.
Dr. Anthony Crocco and I will be presenting the Best of BEEM at this years CAEP meeting in Vancouver next month. Please come by and say hello. If you are not attending this year than follow on Twitter @TheSGEM and Facebook.
Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Be safe this holiday long weekend. Talk with you next week.
Tissue plasminogen activator (tPA, trade-name alteplase) catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown. Its fibrinolysis properties makes it clinically useful for treatment of treatment of myocardial infarction with ST-elevation (STEMI), acute ischemic emboilc or thrombotic stroke (AIS), acute massive pulmonary embolism, and central venous access devices (CVAD). Alteplase is produced by Genentech, and is manufactured using recombinant biotechnology techniques. Other r-tPA medications are Reteplase and Tenecteplase.
Unfortunately these medications are not used daily, and often in emergent situations. For facilities without 24-hours pharmacy coverage, it is often left to the nursing staff or physician to prepare the medication. The preparation instructions included in the kit are complicated, and you should be familiar with the procedure before the need arises. In this tutorial I will walk you through the mixing procedure.
When you the open the kit you will find a vial of sterile normal saline and a sterile vial of powdered medication (blue cap).
Notice how the tPA is powder form.
In the box you will also find the package insert and a dual sided spike which is also sterile. The spike is the same on both sides, and has a dual channel so that air and fluid can flow in opposite directions.
Under sterile conditions remove the cap of the saline vial. Holding the vial in the upright position, spike the vial.
Continuing under sterile conditions, remove the cap from the powdered tPA vial. Hold the saline vial firmly in the upright position. With your other hand hold the tPA upside down, and lower the vial down onto the spike.
With both vials firmly spiked, invert both vials together. At this point, the saline will on top and will flow from the saline vial into the tPA vial. Hold the vials firmly, because the high center of gravity will make them unsteady. This process will take about 1 minute. Do not agitate the vials during this process.
One all of the saline is in the tPA vial, grasp the flanges and decannulate the tPA vial by lifting up on the spike and saline vial.
Gentle swirling will thoroughly mix the contents of the tPA vial. The medication is now ready. It can be drawn up and administered based on the indication and dosing regimen. Be sure to dispose your sharps.
Många oroas över arbetsmiljön på akuten. Sköterskorna slutar. Något måste göras.
Jag håller med, men jag tror inte de konventionella lösningarna fungerar.
Akutsjukvård är till sin natur oplanerad. Vi som älskar att arbeta på akuten avskyr regelbundna arbetstider med planerade möten, rutiner och tider. När vi kommer till jobbet vill vi inte redan veta i detalj vad som kommer att hända. Vi stimuleras av de snabba tempoväxlingarna, där man kan gå från ett hjärtstopp till att hålla förvirrade farbröder i handen så att de inte smiter iväg från akuten. Våra sköterskor är experter på att övervaka svårt sjuka patienter, samtidigt som de tar emot ordinationer och för femtioelfte gånger artigt förklarar för otåliga patienter att ingen vet det är deras tur. Det är en unik kompetens som inte erkänns. I stället för att stärka den, införs trubbiga triageinstrument och tidsregler, som gör att sköterskorna inte längre tillåts prioritera sköra patienter med särskilda behov. Sådant är stressande.
Vissa dagar larmar det i ett på akuten. I slutet av passet kan en sköterska berätta hur ingen varken hann äta eller gå på toaletten, men, och här bryter det stora leendet ut: – Vilket jäkla flyt vi hade!
För det är den där känslan. När vi känner ambulanspersonalen och får en riktigt bra rapport. När alla på akutrummet vet vad de ska göra. När vi kopplar upp, tar odlingar, smärtlindrar, ringer, dokumenterar, kommunicerar med varandra och med patienten. När patienten som så behöver får gå direkt till avdelningen. När allt det fungerar och vi känner att vi gör ett riktigt bra jobb. Då trivs vi på akuten. Då kan vi ta att det finns dagar som blir alldeles för stressiga.
Det är inte de intensiva arbetspassen som sliter ut oss. Det är sirapen. När den lilla dementa damen som tjoar i korridoren inte får komma till avdelningen. När läkarna beställer undersökningar som alla vet inte är akuta. När röntgensvaret aldrig kommer. När patienten som sköterskan försökte hänvisa till vårdcentralen tjatar om att hon inte orkar vänta längre. När man mitt i allt kaos ska avbryta det man håller på med för att någon bestämt att man måste ta lunch en viss tid, eller ha ett avstämningsmöte för att säkerställa att man följer ett arbetssätt som bestämts av någon som tror att akuten är en bilfabrik.
Det går att skapa en bra arbetsmiljö för oss på akuten. Den kommer inte att passa en kontorsråtta, men vi kommer att vara nöjda. Vi kommer att se till att vi får äta, vila, skratta och gå på toaletten. Och vi kommer att göra det som är viktigast av allt för vår arbetsmiljö, att få prioritera akut sjuka patienter. Men det kräver att vi får stöd av resten av sjukvårdssystemet, såväl öppenvård som slutenvård. Kan vi få det?
Case Presentation by Dr. Deshon Moore
A 40 year old man, smoker with no past co-morbids presented to DRH with left facial swelling, sudden loss of vision, HA, and nausea. Symptoms started 10 days prior with mild headache and otalgia. There was no history of trauma. He was treated with analgesics but symptoms worsened. No prior history of otitis media or sinusitis could be elicited. You see him in mod 2 and notice a well built man with obvious swelling of left face, severe proptosis and chemosis of left eye, left mastoid swelling and left complete ophthalmoplegia. He also had a low-grade fever. Visual Acuity was diminished. The pt had little perception of light with relative afferent pupillary defect.
1) What is the best imaging modality to confirm this diagnosis?
a) CT scan w/o contrast
b) X-ray orbit
c) CT scan w contrast
e) Cerebral angiography
2) Which cranial nerve deficit would be the first expected with this condition?
a) CN VIII & X
b) CN VI only
c) CN VII
d) CN, III,IV, V & VI
e) All of the above
3) What antibiotic regimen would you use for coverage?
a) Erythromycin ophthalmic
b) Clindamycin and vancomycin
c) Vancomycin, Cefotaxime & Flagyl
d) Gentamycin Ophthalmic
e) Ceftriaxone & Flagyl
f) No abx needed
Dr. Timothy Root’s ophthalmology book, videos and flashcards are entertaining, memorable, and super high-yield. In fact, according to the book’s subtitle, it is “The funniest, cartooniest, most high-yieldiest book about eye diseases ever written” – and I agree.
I consider these to be among the finest medical educational resources on the internet, and I recommend them very highly to anyone interested in ophthalmology. You can access everything for free here.
Hat tip: Andy Neill, Emergency Medicine Ireland
[Please read important Disclaimer.]
I am delighted that the SMACC 2013 podcast is out – you can download via iTunes from this link.
First up is Scott Weingart’s excellent talk on bringing “upstairs care, downstairs” – addressing the need to bring high-level critical care skills to the emergency room, for which FOAMed such as emcrit.org and other blogs have been pivotal.
For the rural doctor, Casey Parker’s BroomeDocs website, along with Minh le Cong’s PreHospitalMedicine.com, have become the go-to place for quality FOAMed material in aspects of relevance to the rural doctor.
Building on that, I set up KIDocs.org – and there are now a wealth of other blogs from rural doctors covering various aspects in the spirit of quality FOAMed. You can browse a collection of FOAMed material for rural doctors at ruraldoctors.net
Casey, Minh and I are obsessed with the concept of bringing “quality care, out there” – we see no reason why the limits of rural work (isolation, resource limitation) should make a difference in the ability to deliver the best possible care to our patients.
There are plenty of better doctors than me out there. But one of our jobs as doctors is to bring the BEST quality care we can – and that requires us to keep up to date. The standard annual conferences, APLS/EMST/RESP courses etc take us so far – but the power of FOAMed through tools of social media can help us broaden our discussion on cutting edge medicine for our patients to the benefit of all. Some of this is more about telling stories, challenging perceptions and striving to achieve mastery in our field rather than mediocracy. As individuals we can only do so much. Together we can change systems and attitudes – delivering ‘quality care, out there’.
If you are in any doubt, listen to Scott’s podcast from SMACC2013 – and as a rural doctor, think about coming to SMACC2014 on the Gold Coast 19-21 March 2014 – and help us bring “quality care, out there”
It isn’t all about EM and Crit Care – there’s quality FOAMed to be found across the breadth of rural procedural medicine and general practice.
Traneksamik asit; acil servislerde dolap raflarında sıkça duran, bazılarının lokal ve sistemik yolla uygulamasını sevdiği, bazılarınınsa hiçbir işe yaramadığını düşündüğü, acillerin “kült” ilaçlarından biri. Kullanım alanı “hemoraji” gibi genel bir üst başlık. Bu ilaçla ilgili yakın dönemde ve üstüste 3 önemli yayın yapıldı. Bu yazıda kısaca bunlardan bahsetmeye çalışacağım.
ÖNEMLİ NOT: Aşağıdaki metinde, konuyla ilgili yazının yayınlanma tarihinde güncel literatürde olan ve yazarın dikkatini çeken önemli noktalara yer verilmiştir. Yazı, herhangi bir makale veya kılavuzun birebir çevirisi olmayıp yazarın yorumlarını içermektedir ve sağlık profesyonellerine yöneliktir. Tıp sürekli gelişen ve değişen bir alandır; tıbbi uygulamalarınızda güncel literatürü esas almanız tavsiye edilir.
Konuyla ilgili ilk çalışma, ciddi hemoraji riski taşıyan (sistolik kan basıncı < 90 mmHg ve/veya kalp hızı > 110/dk) erişkin travma hastaları üzerine. Travma sonrası ilk 8 saatte başvuran hastaların dahil edildiği bu çalışmada, toplam 20.211 hasta randomize edilmiş ve 20.127 hasta analize dahil olmuş. Çalışmaya dahil edilen gruplarda traneksamik asit, plasebo ile karşılaştırılıyor. Traneksamik asit uygulama protokolü ise 1 g/10 dk, ardından 1 g/8 saat infüzyon olarak belirlenmiş.
Sonuçlara göre traneksamik asit uygulanan grupta;
- Herhangi bir nedene bağlı ölüm sayısında azalma [RR 0.91 (0.85-0.97)] [p=0.0035]
- Kanama miktarında azalma [RR 0.85 (0.76-0.96)] [p=0.0077]
bildirilmiş, buna karşın;
- vasküler oklüzyon (p=0.096) ve
- multiorgan yetmezlik (p=0.25) açısından plasebo ve traneksamik asit grupları arasında anlamlı fark saptanmamış.
İkinci çalışma, CRASH-2 verilerini kullanarak, travma sonrası ilk 3 saat içinde başvuran hastaların dahil edildiği bir araştırma. Bu çalışmanın kurgulanmasında, hastalar bazal ölüm risklerine göre bazı parametreler (yaş, GKS, sistolik kan basıncı, kalp ve solunum hızları, yaralanmadan sonra geçen süre ve yaralanmanın tipi) kullanılarak 4 gruba tabakalandırılmış.
Çalışmada %6’nın altında bazal ölüm riski olan grup hariç [OR 0.78 (0.49-1.23)], traneksamik asit kullanımıyla tüm gruplarda ölüm [OR 0.85 (0.78-0.93)] ve travmaya bağlı kanamada [OR 0.71 (0.61-0.82)] azalma olduğu gösterilmiş. Burada kısa bir yorum girmem gerekiyor; çalışmanın temel hipotezi traneksamik asitin sadece ciddi travmalarda değil, daha geniş gruplarda kullanılıp kullanılamayacağı. Alt grup analizlerine bakıldığında ölüm ve kanama riskindeki azalma; bazal ölüm riskine göre; >%50 olan grupta, %21-50 olan grupta ve %6-20 olan grupta izleniyor. Bununla birlikte <%6 ölüm riski olan grupta bu azalma miktarı tesadüfi de olabilir [OR 0.78 (%95 GA 0.49-1.23)]. Bunda ne var diyebilirsiniz. Bu grup çalışma popülasyonunun (ve klinik pratiğe uygulanırsa bizim hastalarımızın) %36’sını oluşturuyor ve çalışmanın temel hipotezine (herkese uygulanmasıyla sağlanan fayda) ters düşüyor. Kısaca şu söylenebilir; bazal ölüm riski düşük olan grupta, traneksamik asite bağlı sağlayacağınız fayda tesadüfi de olabilir.
Aynı sorun fatal ve fatal olmayan trombotik olay sayısında da mevcut. Tüm popülasyon değerlendirildiğinde trombotik olay sıklığında traneksamik asite bağlı azalma mevcutken, alt gruplarda bu azalma tesadüfi de olabilir. Özellikle de yine <%6 ölüm riski olan olgularda.
Üçüncü çalışma bir kostefektivite analizi: Yaralanmadan sonraki ilk 3 saatte uygulanacak olan traneksamik asit sonrasında, her 1000 travma hastasında 755 yaşam yılı kazanılacağı; traneksamik asit uygulanmasının, kazanılan yaşam yılı başına getireceği ek maliyetin 64 dolar olduğu belirtiliyor.
Kaynaklar ve İlave Okuma:
1. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32.
2. Roberts I ve ark. Effect of tranexamic acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomised controlled trial. BMJ 2012;345:e5839.
3. Roberts I ve ark. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013;17:1-79.