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Case report of asystole after intralipid treatment

A Brave Account.

Cole et al from the Hennepin Regional Poison Center have published a 2-person case series on asystolic cardiac arrest follow administration of intralipid (epub J Medical Toxicology 2014). Both cases involve patients with cardiogenic shock refractory to calcium, vasopressors, and high-dose insulin. Rescue intravenous fat emulsion was given and in both cases the patients had an systolic cardiac arrest in an under 1 minute. Both patients were resuscitated, but ultimately died of multiorgan failure.

The paper is remarkable for several features beyond the very interesting cases. The authors readily acknowledge the limitations of assigning causality. They then retell the cautionary tale of physostigmine. Clinical practice was dramatically altered after a case series of two patients was reported demonstrated a temporal relationship between physostigmine and asystolic cardiac arrest (Pentel, Ann Emerg Med 1980;9(11):588). I appreciated their tempered reporting of a potentially practice changing paper.

It is an interesting read.

By |February 13th, 2014|Toxicology|

Physical Exam Clues in Toxicology – Part 2: Skin

Diagnosis of the poisoned patient can often be accomplished before toxicologic laboratory tests by obtaining a detailed history and directed physical exam. In this second of three articles, we will examine the toxicology clues revealed by the skin.

Physical Exam Clues in Toxicology – Part 1: Eyes, Hair, Nails, and Tongue

Diagnosis of the poisoned patient can often be accomplished before toxicologic laboratory tests by obtaining a detailed history and directed physical exam. In this first of three articles, we will examine the toxicology clues that can be found in eyes, hair, nails, and tongue.

Acute subclavian artery thrombosis causing ACS

79-year-old women has severe aortic stenosis and 2-vessel coronary artery disease s/p coronary artery bypass graft who developed acute dyspnea. She was found to have chronic occlusion of her vein graft and acute thrombosis of her subclavian artery, causing diffuse cardiac ischemia and myonecrosis.
By |December 7th, 2013|Cardiology, Case, ECG|

Difficult intubation caused by subglottic tracheal stenosis

I feel the most frustrating difficult intubations are those when you have the trachea cannulated and are unable to pass the endotracheal tube. This case is presents a difficult intubation of a patient who had a previous tracheostomy which had been decannulated and developed tracheal stenosis.
By |December 7th, 2013|Airway, Case|
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    Therapeutic Hypothermia: The History of General Refrigeration (Podcast 02)

Therapeutic Hypothermia: The History of General Refrigeration (Podcast 02)

The Targeted temperature management Trial compared outcomes for therapeutic hypothermia at 33°C versus 36°C for cardiac arrest patients with persistent coma. It may very well be practice changing. Or maybe not. Before we can figure out what “truth” this research study may have uncovered, we will look at the development of therapeutic hypothermia and what the literature has already told us.

Preparing and Using a Glucagon Emergency Kit

Glucagon is a peptide hormone secreted by the pancreas that raises blood glucose levels. Its has the opposite effect of insulin. The pancreas releases glucagon when blood glucose levels fall too low. Glucagon causes the liver to convert stored glycogen into glucose, which is released into the bloodstream.

By |November 26th, 2013|Pharmacology, Toxicology|

How to Make an Elbow Pad for Olecranon Bursitis

Bursae are thin, slippery sacs located throughout the body that act as cushions between bones and soft tissues. They contain a small amount of lubricating fluid that allows the skin to move freely over the underlying bone. The olecranon bursa lies between the loose skin and the pointy bone at the back of the elbow called the olecranon. Normally, the olecranon bursa is flat. If it becomes injured, irritated or inflamed, fluid (serous, purulent, or hemorrhagic) will accumulate in the bursa causing it to swell.

By |November 26th, 2013|Orthopedics, Procedures|

Eccentric Overwedging of a Pulmonary Artery Catheter

One of the major risks of right heart catheterization in the ICU is pulmonary artery rupture. While exceedingly rare (0.06% – 0.2%), it has a high mortality of approximately 50% usually within 30 minutes. When I was first learning about pulmonary artery catheters, I envisioned this primarily as a problem with the distal tip of the catheter migrating into the small vessel and capillary bed, which then is rupture during balloon inflation. I felt secure that this serious complication was eliminated by ensuring proper tip positioning. Unfortunately, like everything in medicine the reality is more complicated.

By |November 26th, 2013|Procedures|

Asystole While Removing a Central Venous Catheter

Unfortunately procedural complications can occur on the backside of procedures as well as during the intervention phase of the procedure. Look at the rhythm strip shown below. This is a 50-year-old man who had developed septic shock from Streptococcus pneumonia. He had done quite well though. His hemodynamics had normalized and he was no longer requiring inovasopressor support. He had been extubated the day before without any signs of respiratory distress. He was weak from his 10-day ICU stay, but was ready to be transferred to the general medicine ward.

By |November 26th, 2013|Cardiology, Procedures|