The treatment of cutaneous abscesses classically involves the incision and drainage procedure. Historically, this procedure involves making a linear incision over the abscess cavity, followed by manual expression of cavity contents, blunt dissection to break up loculations, further irrigation with saline, and packing with gauze. However, a lack of data supports the routine use of irrigation to improve the success of the procedure and treatment of the abscess. In addition, while not typically considered, the routine use of irrigation does include some downsides: extra time and supplies, cost, and the possibility of microbiologic contamination of the patient care area and body fluid exposure to the practitioner.

The authors of this study randomized patients to I&D with or without… Read more

For diagnosing “Temporal Arteritis”, the American College of Rheumatology recommends meeting 3 of their 5 criteria.

• Age ≥ 50 years old
• New onset of headache
• Temporal artery tenderness or DECREASED temporal pulse (not related to carotid disease)
• ESR ≥ 50 mm/hr
• Artery biopsy with necrotizing arteritis or a granulomatous process with multinucleated giant cells

The wiki has been updated with the recommendations for PE from a new CHEST guideline now that offers the option based on low quality (2C) evidence for clinical surveillance rather than anticoagulation for sub-segmental pulmonary embolism.  This excludes patients with proximal DVTs and those at risk for recurrent VTE (cancer patients, recent surgery, recurrent DVTs, decreased mobility, or hospitalization)

 … Read more

The new Sepsis and Septic Shock definitions were presented at the Society of Critical Care Medicine’s Critical Care Congress and were published online in JAMA. 

New Sepsis Definition:

• Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic Shock is sepsis and any of the following:

• Vasopressor requirement to maintain a mean arterial pressure > 65 mm Hg
• Serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

At the core of altitude medicine, is an understanding of acclimatization. The earliest sign of acute mountain sickness is a headache, while the formal diagnosis of Acute Mountain Sickness requires a headache + 1 or more of the following:

Nausea, vomiting, anorexia
Fatigue or weakness
Dizzy or lightheadedness
Difficulty sleeping

More serious complications include HAPE, HACE, pharyngitis, UV keratitis, and peripheral edema.

When symptoms progress to ataxia or confusion, be very worried about HACS.   Although the initial treatment is always descend until symptoms begin to resolve, administration of oxygen and acetazolamide along with dexamethasone 8mg initially followed by 4mg q6hrs  may aid in early recovery.… Read more

N-acetylcysteine is a well established and effective treatment for acetaminophen overdoses.  The 21hr  IV dosing and the 72hr oral regimens are also well studied and effective in preventing hepatic damage.  One often over-looked technical detail to administration of NAC occurs with pediatric patients.  There is a require dilution that is weight based for children that helps prevent electrolyte and fluid complications. The manufacturer provides a weight based dosing for pediatric patients.… Read more

The myth of the stone heart has been passed down from medical text to medical text since the first case reports appeared in the literature in the 1930s.   Digoxin inhibits the sodium-potassium ATPase pump leading to increased mycocardial calcium concentrations.  Since calcium causes myocardial contraction, seemed possible that increasing intracellular levels of the calcium would produce cardiac tetanany.

Patients with digoxin toxicity who were given calcium did not have a statistically significant increase in mortality (22% versus 20%).… Read more

Mastery of RSI is important for both procedural success and quality care.  In children, the many nuances of RSI drug dosing, routes and medications become even more apparent.

• Should you use etomidate or ketamine?
• Succinylcholine or Rocuronium?
• Considerations for Trauma
• Vasopressor use during RSI

Dr. Horeczko outlines many of the nuances of RSI to guide you though mastery of pediatric intubation.  The WikEM critical care quick reference, RSI and Vasopressor page will provide a reference for your next critically ill child.… Read more

The bleeding Jehovah’s Witness patient presents a serious problem, especially if actively bleeding.  For the acute traumatic bleeding, early hemorrhage control and autotransfusion are the only options.  For severely anemic patients erythropoietin stimulation, aggressive iron and vitamin administration are the safest most widely accepted methods.… Read more