CBSNews.com recently interviewed Jeff Dubin, MD, vice chair, Emergency Medicine, about so-called superusers, who are frequent users of emergency departments and the burden they place on ED resources.  See the article here.

Sofie Rahman Morgan (class of 2012) is the first author of an article featured in Academic Emergency Medicine.  Non-Emergency Department Interventions to Reduce ED Utilization: A Systematic Review. 

Our residents in Seattle for ACEP last month!

Pearls for the Unborn Patient                                                Joelle Borhart, MD

• Dating is most accurate in the 1st trimester, use crown-rump length
• At 24 weeks of gestation, there is a 50% chance of survival.  Assume viability for any gestation >22 weeks
• Remember to document a repeat examination prior to transfering a patient for PROM or preterm labor
• Steroids are the single most beneficial treatment in preterm labor.  See the Cochrane Review and the WHO Review
• Don't forget Rhogam when appropriate

Pearls from Morbidity and Mortality Conference                  Tariq Khan, MD

• Beware of insulin stacking.  Remember the time to peak effect and duration of various insulins                                         - Lispro/Aspart:  Peak 1-2 hrs, Duration 3-6 hrs                     - Regular:          Peak 2-4 hrs, Duration 6-10 hrs                   - NPH:              Peak 4-8 hrs, Duration 10-18 hrs                 - Glargine:         Peak none,    Duration 24 hrs
• In patients with dextrocardia, leads should be placed as for a right sided ECG
• In patients with ECG changes from hyperkalemia, remember that the effect of calcium gluconate is on the order of minutes.  Reassess your patient and the ECG frequently.  See this article for a review of ECG changes and further treatment options.

Preview of an Upcoming Pediatric Lecture                          Julian Orenstein, MD

• Pyloric Stenosis typical presentation is non-bloody, non-bilious vomiting in a 4-8 week infant, which becomes more severe over several days until pathognomonic projectile vomiting ensues. Baby is hungry and sucks vigorously after vomiting.
• Meckels Diverticulum often follows the Rule of 2s: 2% of the population, 2 years old, boys twice as commonly affected, hematocrit is usually 20s, 2 feet from the ileocecal valve, 2 inches in length.
• Intussusception often has a history of recurrent brief episodes of severe colicky pain with a return to normal.  Lethargy can be the sole presenting symptom.

A 59yo F with history of CKD stage 3, HTN, DM, CHF, PE, and lupus presents to her cardiologist with one week of generalized weakness and decreased appetite.  In the cardiology office this morning, she had a syncopal episode and was sent to your ED. 

Medicines: Advair, Bidil, Coreg, Bumex, folic acid, warfarin, tramadol, clonidine, insulin, albuterol, losartin, and Percocet.

Vitals: HR 93, BP 222/131, Temp 36.6, O2 Sat 96% on RA

Exam: Drowsy, dry mucous membranes, pale skin. CV was regular, tachycardic, no murmurs.  Lungs clear bilaterally.  Trace bilateral lower extremity edema

What would you do?  Click here to see what happened.

Thank you Dr. Kwong and Dr. Nitzberg for this presentation!

ULTRASOUND REVIEW

65yo female with HTN and OSA who presents with 2 days of weakness and shortness of breath. No chest pain. No fevers or cough. 

Vitals: T 36.4, HR 109, BP 70/40, RR 38, O2 97% room air

Exam: appears weak (RN note); MD noted lungs clear, tachypneic, lower extremity edema.

ECG: sinus tachycardia, incomplete RBBB, nonspecific ST and TW changes

Labs: CBC unremarkable; troponin 8.9; pro-BNP 24,458; BMP notable for Cr 2.8

CXR: no acute cardiopulmonary process

Initially thought to be NSTEMI due to a troponin of 8.9.  Later in the ED course she becomes hypoxic (84% on 15L NRB) and a bedside cardiac US was done.

Click here for the US images and to make your diagnosis

Congratulations on your publication Sofie Rahman Morgan, MD!