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Ddavp for Hemorrhage in Esrd Patients

CASE:

45F h/o ESRD on dialysis presents ped struck.

Pt is obtunded, intubated for airway protection.

CT head shows subdural hematoma with midline shift.

Neurosurgery is activated.

No antiplatelets or anticoagulants.

Is this person coagulopathic simply by having ESRD?

If so, should we address it with any particular medication?

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Norepi Vs Dopamine

A 75M presents with several days of cough, fever, and progressive lethargy.
CXR demonstrates RLL pneumonia.
BP 70/50. HR 130. Lactate 5. T38.0
2L bolus NS given.
Antibiotics started.
Bedside sono shows noncollapsing IVC, hyperdynamic LV.
Recheck BP 72/50. Lactate 5.0
DX: Septic shock.
Plan: Central line, start a pressor, then intubate.

Question: What pressor do you want to start with, and why?

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Ultrasound is Your Friend

Pt is 54 yo M with PMH of DM, HTN, Crohn Disease presents with 2 days of worsening vomiting, had diarrhea initially that has now stopped and is no longer passing gas, also reports some slight abdominal distention. Patient has had several abdominal surgeries in the past, denies any fevers, any blood in the vomit or diarrhea, no travel. An abdominal exam reveals a soft, slightly tympanic, diffuse moderate tenderness. Pt is afebrile and normotensive. You have a strong suspicion for a small bowel obstruction and place the order to put the patient for CT, however, there’s been difficulty getting people to CT in a timely fashion all day so your attending suggests getting an abdominal xray to expedite diagnosis. How good is the abdominal xray at diagnosing small bowel obstruction and what other imaging modalities do we have at our disposal?

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Meningitis

Patient is 49 yo F who presents to ED with few days of fever (T max 102F), progressive headache, neck stiffness. Patient denies any travel, rashes, sick contacts. Pt complains she can’t be in a well lit room or go outside without pain. You have a high suspicion for meningitis and so perform an LP.

CSF shows as follows:

WBC 100/mm3 (60% N, 35%L)

Protein 100

Glucose 40 (serum glucose 100)

 

Aside from a gram stain and culture, are there any other tools to help differentiate between viral and bacterial meningitis?

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Biphasic Reactions with Anaphylaxis?

“Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients wit Allergic Reactions or Anaphylaxis”

Grunau BE, Li J, Yi TW, et al.

Annals of Emergency Medicine 2014; 63(6): 736-744

 

Background: Allergic or anaphylactic reactions are fairly common presentations to the ED.  After initial treatment and clinical improvement, a proportion of patients may develop a second “biphasic” reaction, which may actually be more severe than the initial presentation.  Because of this concern, patients are often held for observation for 6 or more hours.  This prolonged ED stay has not been shown to decrease biphasic reactions’ complications, yet incurs significant costs.  The goal of this study was to examine the incidence of clinically important biphasic reactions.

Methods: Chart review performed on data from 2 urban EDs, collected on adult patients presenting during a 5-yer period with “anaphylaxis” or “allergic reaction.”  Primary outcome was the proportion of patients with a clinically important biphasic reaction, secondary outcome was mortality.

Results: Of 428,634 ED visits, 2819 encounters (496 anaphylactic, 2323 allergic reactions) were reviewed.  185 patients had at least 1 subsequent visit for allergic symptoms.  5 clinically important biphasic reactions were identified (0.18%, 95% CI 0.07-0.44%); 2 occurred during the ED visit, and 3 were post-discharge.  2 patients with the biphasic reaction were in the anaphylaxis group (0.40%), and 3 were from the allergic reaction group (0.13%).  There were no fatalities.

Conclusion:  Clinically important biphasic reactions and fatalities were rare in ED patients presenting with allergic or anaphylactic reactions.  This study’s results suggest that it may not be necessary to conduct routine prolonged monitoring of patients whose symptoms have improved after initial treatment.


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