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EKG
1) STEMI criteria - the 2013 definition for STEMI is ST elevation in 2 contiguous leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads. 2) ECG lead placement - white to right (right arm lead), red to ribs (left leg lead), smoke above fire (left arm lead). That's how I remember where to place the monitor's ECG leads on the patient's chest. 3) Limb lead reversal - look for inverted P waves in lead I. Don't confuse it with dextrocardia - in limb lead reversal, the R wave progression is normal whereas in dextrocardia it is reversed! Early pregnancy problems 1) Discriminatory zone - sac consistently visualized by ultrasound, measured in mIU/mL: 1,000-2,000 for a transvaginal sonogram, 6,500 for a transabdominal sonogram. 2) Hyperemesis gravidarum - first line agent is a combination of pyridoxine and doxylamine. 3) Asymptomatic bacteriuria - Always treat it: Amoxicillin 500mg TID or Ampicillin 250mg QID. CQI/Intern Curriculum - attachment from JAMA 1) Acute aortic dissection management - Control dP with arterial vasodilators (nitroprusside, nicardipine) and dt with beta blockers (esmolol, metoprolol). Use both! 2) Acute type A aortic dissection presentation - 35% of patients are normotensive upon presentation. 3) Acute jaundice - there three different types: hemolytic, hepatocellular, and obstructive. Atraumatic Musculoskeletal Complaints - attachment from Journal of Neurosurgery-Spine 1) Spinal epidural abscess - MR spine is the gold-standard test. CRP elevates before the WBC.. 2) Septic arthritis - Up to 30% of patients with septic arthritis do not have a synovial WBC > 50k. Dissociated ramblings - attachment from the department of infectious disease 1) Synovial lactates - A few studies suggest that a synovial lactate > 10 mmol/L is highly suggestive of septic arthritis. Not all hospitals are equipped to perform synovial lactates as many machines are only designed to do this for blood samples, not synovial fluid. 3) Idioventricular rhythm - ever wonder why after ROSC patients enter a slow, wide-complex rhythm after the arrest? The electrical origin of this rhythm are the Purkinje cells. Because of their proximity to the ventricular cavities, they are able to use cavitary blood (oxygenated) for metabolism - rather than relying on blood coming from the coronary arteries! This is also seen in the cath lab not infrequently and is thought of as a reperfusion arrhythmia.
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Diabetic foot infections
1) Diabetic foot cellulitis - it comes from ulcers, if there is/was no ulcer, it's likely not cellulitis. 2) Limb-threatening diabetic foot infections - cellulitis extending >2cm from ulcer, probes to bone 3) Charcot foot - occurs in stages, no systemic symptoms, labs will likely be normal. 45% mortality in 4 years. Orthopedic pearls/orthopedic lab 1) Shoulder dislocations - anterior dislocations are the most common, and most of those are subcoracoid dislocations. Least common dislocation is an inferior dislocation - aka luxatio erecta - the arm will be locked in abduction. 2) Nursemaid's elbow - reduce by supinating the child's forearm with the elbow flexed and apply pressure over the radial head. You should hear a 'click' as the annular ligament is liberated from the joint. CIWA 1) Withdrawal seizures - you should not need a lot of benzodiazepines to control alcohol withdrawal seizures. If the patient requires escalating doses of benzodiazepines to control seizures, consider additional seizure etiologies. 2) CIWA score - it is not diagnostic of alcohol withdrawal, just a severity score. Diagnose withdrawal based on signs and symptoms in the right context. The patient must be able to participate in questioning as 4 out of the 6 categories necessitate answers from the patient. Dissociated ramblings - attachment from ASA (short read, funny) 1) Achilles ultrasound - sensitivities and specificities vary from paper to paper, however, you can use it to diagnose Achilles' tendon rupture. One difficulty with tendon ultrasound is a sonographic artifact called anisotropy. This occurs when the probe is not perpendicular to your higher-than-average refractive structure (ex: tendon) and will cause the structure to appear hypoechoic. 2) Local anesthetic toxicity (LAST) - the more lipophilic, the more potent the local anesthetic (the uncharged drug must penetrate nerve membrane as well as bind to a hydrophobic site on the sodium channel). If systemic toxicity occurs, you can consider giving lipid emulsion as a reversal agent. Lipid rescue is a big area of research in toxicology. |
