#AnthroEve: An Intro to Anthropology and Medical Enculturation

I am becoming quite expert in navigating the look of confusion on my colleagues’ faces when I tell them that I am completing my master’s in anthropology. I can see behind their glazed eyes, in real time, the exotic mental images they are conjuring of the famous cultural anthropologist Margaret Mead or the comical similarities in social functioning between me and fictional physical anthropologist Temperance Brennan. A few remember that Paul Farmer is an anthropologist ...

The post #AnthroEve: An Intro to Anthropology and Medical Enculturation appeared first on CanadiEM and was written by Eve Purdy.

Don’t Repeat Trauma Activation X-rays!!

You are in the middle of a fast-paced trauma activation. The patient is awake, and mostly cooperative. The x-ray plate is under the patient and everyone stands back as the tech gets ready to fire the x-ray machine. At that very moment, your patient reaches up and places his hand on his chest. Or one of the nurses reaches over to check an IV site.

The x-ray tech swears, and offers to re-shoot the image. What do you do? Is it really ruined? They have an extra plate in hand and are ready to slide it under the patient bed.

The decision tree on this one is very simple. There are two factors in play: what do you need to see, and how hard is it to see? The natural reaction is to discard the original image and immediately get a new one. It’s so easy! Plus, the techs will take heat from the radiologist because of the suboptimal image. But take a look at this example of a “ruined” chest xray.

It’s just the patient’s hand! You can still see everything that you really need to.

Bottom line: You are looking for 2 main things on the chest x-ray: big air and big blood. Only those will change your management in the trauma bay. And they are very easy to see. Couple that with the fact that an arm overlying the image does not add a lot of “noise” to the image. So look at the processed image first. 99% of the time, you can see what you need, and will almost never have to repeat. [Hint: the same holds true for the pelvic x-ray, too. You are mainly looking for significant bony displacements, which are also easy to see.]

Related posts:

Source: http://thetraumapro.com/2017/05/17/dont-repeat-trauma-activation-x-rays/

Elemental EM: Myasthenia Gravis

This is the first post in the Elemental EM series, a rapid review of core emergency medicine topics. The goal is to present high yield facts as a foundation for practice and fundamentals for board review. Please enjoy the following bullet point summary on myasthenia gravis.


Author: Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Epidemiology/Pathophysiology

Source: http://www.myasthenia.asia/news.aspx?category=1
  • 0.15-0.7% of the population, Most often 3rd to 6th decade
  • Autoimmune: Acetylcholine receptor antibodies
    • Causes receptor degradation, dysfunction, and blockade
    • Impairs function at neuromuscular junction (NMJ) → decreased muscle strength
  • Dysfunction of thymus gland or immune response to infectious antigens → abnormal thymus → often thymoma present

Clinical Presentation

  • General weakness
    • Proximal muscles
    • Neck extensors
    • Facial or bulbar muscles: Ptosis, diplopia, dysphagia, dysarthria, dysphonia
  • Worsens: as the day progresses, with prolonged muscle use, hot temperatures, stress, infection
  • No deficit in sensory, reflex, or cerebellar function
  • Myasthenic crisis: Respiratory failure
    • Precipitants: infection, surgery, rapid tapering of immunosuppressants, pain, menstruation, pregnancy, sleep deprivation, medications
  • Evaluation for impending respiratory failure
    • Inspiratory function
      • Vital capacity <1L (<20-25 mL/kg)
      • Negative inspiratory force <20 cm H2O
      • Accessory muscle use
    • Expiratory function
      • Positive expiratory force <40 cmH2O
      • Weak cough
      • Difficulty counting to 20 in a single breath
    • Upper airway (bulbar) weakness: dysphagia, nasal regurgitation, nasal quality of speech, staccato speech, jaw weakness, bifacial paresis, tongue weakness

Differential Diagnosis

Lambert-Eaton SyndromeBotulismIntracranial mass
Drug-induced myasthenia gravisThyroid disordersStroke
Congenital myasthenia gravisElectrolyte imbalanceSepsis

Diagnosis

  • Serologic testing – acetylcholine receptor antibodies
  • Ice pack test – ptosis improves with ice pack application
  • Edrophonium or neostigmine (Acetylcholinesterase inhibitor) → improves muscle strength
    • Limited use in testing as may worsen weakness in other NMJ disorders or cholinergic crisis leading to respiratory failure.
    • Caution: cardiac disease → may cause bradycardia, AV block, atrial fibrillation, cardiac arrest
    • Differentiates myasthenic crisis versus cholinergic crisis
  • Electromyographic testing → postsynaptic NMJ dysfunction

Treatment

  • Neurology consult
Acetylcholinesterase Inhibitors (Adult Dosing)
Pyridostigmine Neostigmine
  • PO 60 – 90 mg every 4 hours
  • IV slow infusion 1/30th PO dose (2-3mg)
  • If a dose is missed, next dose is doubled
  • PO 15 mg
  • IV 0.5 mg
  • IM/SC 0.5 to 2.0 mg, onset 30 min, effect 4 hrs
  • Management of respiratory failure
    • Induction with smaller doses: Etomidate, fentanyl, propofol
    • Avoid use of depolarizing or nondepolarizing paralytic agents
      • If paralytics are necessary → half-dose
    • Immunosuppression: steroids, azathioprine, mycophenolate, plasma exchange, IVIG
    • Thymectomy

Resources/References

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