EMU Monthly – March/April 2016

All the EMU goodness for March/April 2016

  • I got a Lucas in my ED or something like it- do you? Lucas is a CPR machine that looks like this:image001 It simply does the compressions for you. These machines will not result in any more sternal fractures, or internal organ damage than regular CPR. However they do cause on average 6.6 rib fractures (In J Legal Med 129(5)1035) Now they think this is because the Lucas is generally on the patient for more time than regular CPR and that may be true, but this needs to be studied too – maybe all the fractures were at the beginning when the device was attached or maybe they needed to be calibrated or maybe there is a difference between CPR on a 100 kg male and a little old lady from the nursing home image004. For you young folks that is Irene Ryan –who played the grandmother on the Beverly Hillbillies a TV serial from the sixties. I assume that Father did not have a crush on her. Here is Bridgette Bardot again for him: image005We’ll have to take a short break right now while we treat Father’s chest pains. TBTR: Lucas devices cause a lot of rib fractures.
  • The idea is interesting- the article couldn’t give an answer- maybe while we are screening people by asking them to check their doo doo –we can also screen them for stroke prevention. This wild idea is based on a simple premise- we have NOACS they are easy to give sand we are real good at screening for A fib – so why not screen everyone for this? (Circ 131(25)2167) TBTR: Stroke screening- coming to Rite Aid near you (or a Coffix if you live in Israel)
  • Let’s talk about poisons- not toxicology – but rather drinking sugar sweetened drinks- this can cause worldwide – 184000 additional deaths, from cancers, DM and CAD. This would be worse in Mexico and less so in Japan. (ibid  132(8)639).  True this is a computer analysis and a mish mash of assumptions –but the important point here is that these beverages are dangerous (we spoke about this last month) Here in my country – and I assume in a lot of other countries that EMU goes to- consumer activism is absent and therefore beverage companies (in Israel that would be Spring, Pepsi, Coke, Jump) are making a lot of money on these poisons. Can EMU start a revolution? Probably not, but we can be revolting. TBTR: Sugar drinks – making our job harder.  Time for quotes, guys. I think it is time to knock on the respected legal profession:

Some men are heterosexual and some men are bisexual and some men don’t think about sex at all … you know, they become lawyers. Woody Allen

  • This really has nothing to do with EM, so if your ADHD is as bad as mine you can go to the next article, but I am really against using meds for ADHD in adults (actually in kids too, but I am afraid of Kevin’s assassins). But if you do go the med route, you should know that Ritalin in adults has caused sudden death, addiction and unmasking of psychotic behavior. There are other options. Medscape brings information about Bupropion at 1150 mg a day, and this article brings some low level evidence for the use of TCAs for ADHD- nortriptyline and desipramine. In short term they do work (that is 2- 6 weeks), in longer term no information (AFP 9(5)352). This could be but the side effect profile for TCAs is not the greatest- especially the anticholinergic side effects. Ketamine anyone? TBTR: TCAS for ADHD? Maybe. Maybe not. Let’s go out and play catch.

This is what has to be remembered about the law; beneath that cold, harsh, impersonal exterior beats a cold, harsh, impersonal heart. David Frost

  • I really am not a kid person and I am convinced I have scared most pediatricians away but this was a well done study– so I had to include it. It was six centers in the UK but only included 158 infants. They discovered- the opposite of what Cochrane did – that hypertonic saline inhalations do not reduce length of stay in the hospital in bronchiolitis. (Health Tech Assess 19(66)1) There was no control for heterogeneity in this study (and why should there be? All babies do look the same), and they discharged patients with sats above 92% – a little gutsy for my tastes and I am not sure what it was doing in this journal- but at the end of the day – the treatment of bronchiolitis remains what it always was – supportive. TBTR: read the last line

There is a general prejudice to the effect that lawyers are more honourable then politicians but less honourable than prostitutes. That is an exaggeration. Alexander King

  • Metronidazole can cause cerebellar toxicity but it is rare and reversible – you need to take 1517 mg for 60 days on average to develop this (Neuro Sci 36(9)1737).

Lawyers should never marry other lawyers. This is called “inbreeding,” from which comes idiot children and more lawyers. Kip Lurie: Adam’s Rib (1949)

  • Food delays absorption of pain meds. If the patient gets early pain relief, they are more likely to have longer lasting pain relief and less rededication. So take Aspirin, NSAIDS and paracetomol without food ( BJ CLin Pharm 80(3)381) So they say – but they are pharmacists- what about GI bleeds- does food help prevent this? That what they taught us. Is it true? TBTR: more effective pain relief by taking on an empty stomach.

I never met a litigator who did not think that he was winning the case right up to the moment when the guillotine came down. William Baxter

  • Gosh, what could I tell you about afib that you don’t know? This article was about misconceptions, but you are a bright guy, read EMU all the time and knew everything in this paper. Except for one point. As can be expected in any scoring system, the CHADS 2Vasc score is not all that it is built up to be. (I will take this opportunity to send you to a great web site called MD CALC where you can find this and many other important medical calculations (see the above hyperlink). Let us just start with what constitutes a positive score, i.e. – when you need to start anticoagulation. The Europeans say a score of one, the Americans a score of two. But female sex is already a point. Furthermore, even a one score can still have a 2% stroke rate. Also the most important risk factors according to studies remain age and prior stroke but they are scored equally with the other risks in the score even though the others contribute a lot less to the to the total risk. CHF is also a risk, but studies show that is only when the LV function is severely decreased. Stoke risk overlaps with bleeding risk (advanced age is a risk for both) so this confuses things even more. Lastly they say C statistics prove their points; and if you know what a C statistic is than you are way too intellectual to read EMU. Actually, if you know what color a fire truck is you also are too intellectual to tread EMU. They say – just give the anticoagulation if the patient isn’t that old – the bleeding risk will always be less than the stroke risk (AJM 128(9)938)  TBTR: CHADS 2- may be better not to use.

I think we may class the lawyer in the natural history of monsters.
John Keats

  • Short and to the point – cause we have discussed this before. Nor ep IV – if it extravasates – give phentolamine in the same IV and NTG paste. But this is a rare event in their single center ICU. (J Hosp Med 10(9)581) No one seems to mention though- what happens when you dump their blood pressure with phentolamine and NTG while you look for a new IV site. I think just do IO or CVP from the start and avoid these problems. Not good at CVP insertion – so get good at it. But see our cogent discussion on this in the essay below. TBTR: Nor EP – extravastation – rare event.

Necessity knows no law; I know some attorneys of the same
Benjamin Franklin

  • Hi family docs. Hope you are not giving Nor EP in your clinics and you probably shouldn’t be giving a lot calcium supplements also. Calcium does decrease bone resorption and increases bone density- but only in the short term. It has no long term effects on osteoporosis and what probably is most important to our patients- it has no proven effect on fracture prevention. What it can do is cause diarrhea, MI and of course renal stones. (ibid 278(4)354) TBTR: maybe want to tail back on those calcium supplements. Give them the nor ep instead.

It was so cold last winter that I saw a lawyer walking down the street with his hands in his own pockets


  • I think you need to be careful about this study; it was tiny when compared with NEXUS – but when they applied the NEXUS rules in the elderly (that is defined greater than 65) missed 4.1% of clinically significant fractures- I went over the list and while not all needed surgery – all would’ve concerned me. (JEM 49(3)294).But on closer look it only missed two (only one was serious) and it isn’t clear that the rules were applied correctly – especially since the injury that was missed were pretty severe. Also, many of these fractures had NEXUS positive only because of the distracting injury or clouded sensorium- which may lower your guard.  I think we should say here what we do about all rules. Nothing is 100%. TBTR: NEXUS works- most of the time.

99% of lawyers give the rest a bad name


  • Droperidol is very effective for migraines and vomiting. But since its black boxed it is getting hard to find. So why not haloperidol its cousin? True it recently has been black boxed also but it works better than metoclopramide for migraines and we reported in the past that it works well for vomiting.( ibid p326). I have tried this with very good results. TBTR: Haloperidol pinch hitting for droperidol.

A good lawyer knows the law. A better lawyer knows the judge. But the best lawyer knows the judge’s mistress

  • These tests are good – not great – but are fun to do if you are concerned about a supraspinatus tendon tear (that is part of the rotator cuff). Hey while I am writing this, Villanova from my home town Philly won the NCAA national championshipimage006 Considering the Sixers this year won 24 games less than Villanova – that isn’t bad. Anyway, these test are the Yocum test, the Jobe test, the Patte test, Nerve Impingement Sign and the Hawkins Kennedy Test- all are positive if there is pain or weakness. Instead of describing them ,you can either get the article or look these on you tube. ( J Hand Surg 28(3)247) The first two are pretty easy to do. TBTR: Rotator cuff tests

How can you tell when a lawyer is lying?
His lips move.


  • We all know that fever is dangerous- and you just gotta get that kid’s fever down fast with ibuprofen and paracetomol ASAP. This is definitely what parents think. But the literature – while agreeing that 41.5 is damaging – the body will make sure you don’t get there (unless of course she enters the pictureimage005. Does high fever mean more serious infections? – maybe a trend but not a predictive value. Dropping fever does make kids feel better but doesn’t prevent convulsions. I was taught that fever was a beneficial mechanism and therefore it allowed better functioning of antibacterial mechanisms and killing of those buggers.  Fever can also cause more mortality(causality?) but these studies are pretty low quality – so you really can’t say either of these statements. Colling with fans or cool water makes kids uncomfortable. Ibuprofen lasts slightly longer and is slightly more effective than paracetomol but the combo of both only reduces fever about 0.27 degrees C.  Alternating them however may show some benefit.(Arch Dic Child 100(9)818) TBTR: Fever- it ain’t so scary.

What’s the difference between a lawyer and a trampoline?

You take off your shoes to jump on a trampoline!

  • Can I reminiscence with you? His name was Steve. And he was a surgeon. And he was my preceptor as a student. And he suffered from a personality disturbance not uncommon among surgeons-Jarisch Ebstein Rendu Krukenberg syndrome or in abbreviations – he was a JERK.image007 . Did I learn better because of this guy? I didn’t think so. And while this study was very contrived the results showed diagnostic and procedural accuracy suffered in those who were exposed to a rude instructor. (Peds 136(3)487) Now kids and kid doctors maybe a little more sensitive than battle hardened surgeons like Steve’s students image008– but I think the conclusion is correct. (The picture by the way is George Patton– the WW II general. TBTR: Want your residents to know something? Be a mensch.

What’s the difference between an attorney and a pit bull?

  • Coffee – ah- let’s just quote Emo Phillips take on coffee which we quoted years ago “that first piping hot cup of coffee in the morning; there is nothing like it- oh, I have tried other enemas…” This article sings the benefits of the cup of Joe. Caffeine does speed up the heart and keep you awake – and if you are a slow caffeine metabolizer – then there is a slight increase in MIs. But in moderation, there is no increase in MIs or exacerbations of CHF, indeed it might improve CHF. All-cause mortality is less in moderate coffee drinkers and stroke risk is lowered. Arrhythmias and hypertension are not affected by moderate intake. DM risk is less in coffee drinkers. Decaf does not provide any advantage over regular (Curr Vasc Pharm 13(5)637) I never having a cup of coffee in my life  so I believe that there might be some bias here from this confirmed coffee drinker image009TBTR: Coffee – great for the heart- and a good enema too.


A new client had just come in to see a famous lawyer.
“Can you tell me how much you charge?”, said the client.
“Of course”, the lawyer replied, “I charge $200 to answer three questions!”
“Well that’s a bit steep, isn’t it?”
“Yes it is”, said the lawyer, “And what’s your third question?”


  • I love my ADHD – We get along famously. Fame-wasn’t that a 80s hit film with the title song sang by Irene Cara?image011. It was also the name of a string of delis in NY –known for its corned beef-Father loves corned beef- anyone know why it’s called corned beef? Yes from the corns of salt used to cure it. Does that bore you? Or are you just sleeping because you have had propofol. Or maybe since you have ADHD you need more sedation for procedures – well this study says not. (Ped Aneast 25(10)1026) This was a great idea for a study but it was for an MRI and all got midazolam first before getting propofol- why is beyond me. TBTR: ADHD need sedation at same doses as non ADHD.image012


  • Perianal abscess and fistulas are interesting. (Actually they aren’t) But you gotta know – if you can do a rectal exam – and there isn’t any bogginess or severe pain once you are inside- you can open the abscess- if not – CT or OR. Please make sure you remove your finger before doing any more testing. ( Ann EMerg Med 66(3)240)

A man is innocent until proven broke. – Anonymous


  • A couple of EBMs- flail chest – there are some small studies suggesting that surgical treatment results in less pneumonia and shorter ICU stays (Cochrane 7:9919) Fluid overload CHF- giving continuous drips doesn’t help. The best loop diuretic seems to be Torsemide (Mayo 90(9)1247) TBTR: Flail chest and CHF – how to tie these two together- not sure.

A man and a woman were conversing at a party. The woman said: “Lawyers are jerks.” The man responded: “I take offense to that remark.” “Why,” said the woman. “Are you a lawyer?” “No,” he responded: “I’m a jerk.”

  • This article was a tough read- I am an EP and supposed pathophysiology bores me. And the subject matter as well is boring.- orthostatic hypotension. So let’s cut to the chase image013(That’s from the French Connection – the best car chase in film history and it was done without permits- most of it was real!- check it out on youtube. ) you can send these folks to a tilt test if you got a question and the treatments are – controversial. Midodrine –an alpha agonist – probably helps – but there is some literature out there that says that it doesn’t help. Droxidopa is a nor ep agonist – used off label for years- probably does help but there isn’t a lot of literature. Pyridostigmine – efficacy questioned. Fludrocortisone – a mineral corticoid – worsens supine HTN and causes hypokalemia. Pseudoephedrine – efficacy controversial. Desmopressin- efficacy uncertain. Salt tablets- careful in HTN and CHF. Direct stockings- they work and are safe. (JACC 66(7) 848) If you get this article and read it in its entirety I will ask the judge to take off two years from your sentence. TBTR: Orthostatic hypotension- all you really didn’t want to know.
  1. What do lawyers use for birth control?
  2. Their personalities


  • Is it time for a clinical quiz? Well guess what- I did this one before. Too bad you missed it last time – get it right this time, ok? 60 year old lady breast cancer, fever and panful nodules on the legs They are non-blanching and have hemorrhagic centers


    This is, of course – …..

  • Like I said in number 20 this is another paper that is impossible to read on acute porphyrias.(Clinics Res Hep Gastro 39:412) Fortunately, I found another clearer paper in – where else- the emergency literature. (JEM 49(3)305) –This would be a good topic for an essay – but those with good memories

will remember we spoke about this once before. So let’s run thorough it. First of all why should you care? The answer – most of the time you shouldn’t since most patients are asymptomatic for their entire lives. However, exacerbations can even cause death – so you should know about it.  The whole spectrum of porphyria is caused by a deficiency of a specific enzyme in heme synthesis. It is usually not 100% which is the reason why most of these folks get attacks intermittently or not at all.  But there are triggers- prolonged fasting (I couldn’t find if there are more exacerbations in Ramadan), dieting, alcohol, meds (barbs, dantoin, rifampin, steroids and hormones- especially progesterone) and other illnesses or stress. They may be linked to menstrual cycles but typically do not happen during pregnancy.  There are four types; we will focus on the most common which is AIP. They have intermittent abdominal pain which is colicky, and starts gradually. It is unrelenting, but usually no localizable and abdominal findings are usually absent.  The main problem is neurological – they get pains and aches in extremities and the back – but also paresis that may progress to respiratory failure.  They can also get convulsions and here it is important to avoid barbs and dantoin- use gabapentin. If they have red or brownish urine – the makes the diagnosis much easier- these are heme pigments. The diagnosis is easy – use the random urinary BPG test and you’ll have an answer within 10 minutes- however- this test is not widely available -which is nice medical-ese to say – you don’t have in your ED and probably not in the entire county. If you can measure BPG in the blood – it is always increased in AIP attacks – but this is probably not available in your ED either. Treatment of an acute attack includes pain meds, a high carb intake (I can go for that – cookies!) and phenothiazines. Pan hematin should be given ASAP at a dose of 3mg/kg/day via a CVP.  If they get worse – ICU. TBTR: All you didn’t want to know about porphyria.

A truck driver used to amuse himself by running over lawyers he would  see walking on the side of the road.  Every time he would see a lawyer walking along the street, he would swerve to hit him.  After hearing a loud  “THUD,” he would swerve back on the road.

One day, as the truck driver was driving along he saw a priest hitchhiking.  He stopped and asked the priest, “Where are you going, Father?”  “I’m going to the church 5 miles down this road,” replied the priest.  “No problem, Father. I’ll give you a lift.  Climb in the truck.”

The happy priest climbed into the passenger seat and the truck driver  continued driving.  Suddenly the truck driver saw a lawyer walking down the road and instinctively he swerved to hit him.  But then he remembered there was a priest in the truck with him, so at the last minute he swerved and missed the lawyer.  However, he still heard a loud “THUD.”  Not understanding where the noise came from he glanced in his mirrors and, when he didn’t see anything, he turned to the priest and said, “I’m sorry, Father.  I guess that I must have hit that lawyer.”

“You missed him,” replied the priest. “But that’s OK. I got him with the door.”



  • While we are in the boring zoneimage015let’s speak about another topic that rivals PE in the general interest level of most physicians- yes that is dizziness. Instead of going into this topic- let us just go into the errors that are often made. We were all taught in quack school image016that you should ask them what they mean by dizzy- and then classify it into vertigoimage017 , pre syncope, disequilibrium and ill defined. The problem is that patients are unreliable when reporting dizziness and these categories are not valid. On the other side, patients reports of triggers and timing are reliable, and this will help you – just don’t leave it at – “does it get better when you lie still” – all dizziness does- ask them if it goes away when they lie still – this is a major piece of information. Another error is not to check eye findings- nystagmus – when it is there – can lead you to BPPV (upbeat– seen during the Hallpike maneuver – and lasts less than 30 sec) Vertical or torsional that is spontaneous nystagmus and no fatiguing in Hallpike is a central cause. Curiously – they do not mention the HINTS test (my neuro guys think it is overrated). Another error is relying too much on age and neuro exam and vascular risks – these will miss many young people with stroke. True if there are neuro signs that will point you to a stroke but many times dizziness is all that is seen. Their last point is one we all know – do an MRI – CT misses too much. (Neuro Clin 33:565)  TBTR: Dizziness- but actually an important read.

What do you call a lawyer with an I. Q. of 50?

Your honor

What do you call a lawyer with an IQ of 25?



  • Let us return to the interesting- nothing beats a ruptured AAA for drama. This is definitely a place you do not want to get to. So let’s prevent them from coming to the ED in the first place- and that’s why we need you friendly FPs. Screening is the way but when to screen is a different story. Here is a summary of guidelines for who gets screening.
  1. SAAVE law (Medicare) Men: 65-70 who smoked. Women-only if have a family history
  2. Society of Vascular Surgery Men: >54 with FH, all men >64 Women >64 who smoked or have a FH
  3. ACC/AHA Men>64 smokers >60 in FH All others- no screening
  4. ACPM Men 65-70 smokers. All others-none
  5. Canadian Soc Vasc Surg Men>64 who are willing to undergo surgery
  6. European Soc Vasc Surg Men – 65- , younger if FH, smokers
  7. USPTF >65 if smoked- yes, non smoker- maybe; women who smoked- indeterminate, women who didn’t smoke- no

The way of screening is of course US – and you only have to check it once. Now what if it is positive? 5.5 cm and above- they go to surgery. 4.5-5.4 – six month interval check. 12 month intervals for 3.5- 4.4 cm. 3.0-3.4 every three years. 2.6- 2.9 every five years. (J Vasc Surg 62(3)774) As far as I know this is not included in Israel’s quality measures for preventive medicine and I do not remember seeing much about in the USA. But screening does reduce mortality by 40%.  TBTR: AAA screening can save lives.

Why won’t sharks attack lawyers?

Professional courtesy


25) Letters: We do have some letters, but first I will apologize to Sandy – a class person who is one my lawyer readers for the quotes in this issue – I was only joking, Sandy – please don’t send that registered letter!  Also a shout out to Alex Wong who finally did show up in our ED to say hi. Really, Alex, I always was a Ursinus College football fan! I even know their quarterback – here is a picture:image005 Ken wrote us and so did John Hipskind. Here is what they had to say. Ken gives us some more on the Dutch question: Hi Yosef


As usual, an excellent issue. Here is a more complete answer to your question than you could possibly want:


“Netherlands” refers to the country as a whole, while “Holland” comprises just the two provinces of North and South Holland, the country’s two most densely populated provinces with most of the country’s major cities . The term Dutch is a relic from a time before the Germans, Dutch and other Northern Europeans split into different tribes. At firstthe word Dutch simply meant “popular”, as in “of the people”, as opposed to the learned elite, which used Latin instead of the Germanic vernacular. In the 15th and 16 centuries, the word “Dutch” simultaneously meant both German and Dutch, or “Low German”.


As to your comment about nitrous oxide not having analgesic effect, I was puzzled. The reason for using it was just that, a safe analgesic effect. Here’s the abstract of an EM review that supports using only a 50% concentration.

A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting?

  1. S C Faddy1,
  2. S R Garlick2
  • Emerg Med J2005;22:901-908
  • Accepted14 December 2004


A safe and effective form of pain relief would be an advantage in the prehospital treatment of patients experiencing extreme pain. Although used by many emergency medical services, 50% nitrous oxide (an inhaled analgesic known to have good pain relief properties) is not widely used by volunteer and semiprofessional organisations. This review aimed to determine whether 50% nitrous oxide is safe for use by first responders who are not trained as emergency medical technicians. A thorough search of the literature identified 12 randomised controlled trials investigating the use of 50% nitrous oxide (as compared with placebo or conventional analgesic regimens) in a range of conditions. The outcomes analysed for this review were: adverse events, recovery time, and need for additional medication. None of the studies compared the treatments in the prehospital setting; children were well represented. Adverse effects were rare and significant adverse outcomes such as hypotension and oxygen desaturation could not be attributed to nitrous oxide. Compared with patients receiving conventional analgesia, those receiving 50% nitrous oxide did not require additional medication any more frequently and had a faster recovery from sedative effects. The low incidence of significant adverse events from 50% nitrous oxide suggests that this agent could be used safely by lay responders.


Yes Ken, I muffed on the Nitrous- there is some analgesia- but not much. John writes: Another winner (unlike the Republican presidential candidates)!  Thanks again for the fascinating and occasionally scary (Bridgette, did you really have to, really?) collection of medical information.  Your reference to assorted trivia and 1960’s TV shows reflects a similar skewed upbringing as mine.  Keep up the great work!   I am not going to get into politics John but I suggest y ou take my Father’s advice – he has written in Richard Nixon for every election since 1980 since “he was the last good president we had”.  By the way Alex claims someone at Geisinger called me a legend- could this be true? A legend? Like Richard Nixon?

  • Remember the clinical quiz in number 21? It was Sweet’s syndrome and it comes from three causes. Idiopathic (sometimes after a virus, or IBD or during pregnancy but for unknown reasons), drug induced (usually but not always after use of GSF) and malignancy induced. The last one is important because if you can’t find another cause – look for malignancy, They treat this with steroids, potassium iodide or colchicine (JEM 49(3)e95)



This month we will take another look (again we reviewed this before but this is a different perspective) into leg ulcers and also into crashing Pulm HTN patients. The sources for this essay are  BJD 173:379 and Emrg Med Clinc NA 33:623.

  • There are four types of chronic ulcers: venous leg ulcers, diabetic foot ulcers, pressure ulcers and arterial disease trauma- let’s look at all of them a little more in depth.
  • What are the risks for venous ulcers? Age greater than 55(uh oh), males (uh oh), history of reflux of the deep veins, history of DVT and PE; previous ulcers, family history of ulcers, multiple parity, BMI image019and physical inactivity.
  • These are usually over the malleolus and usually have a exudate. They rarely get to the muscle or tendon level. They get stellate while scarring. Osteomyelitis risk is low. Treatment is leg elevation and in more advanced cases – compression therapy.
  • Diabetic foot ulcers- we all know about these. They present the Wagner diabetic ulcer classification and also the University of Texas classsificaiton but I do not really think they add much. Check the sensation and if you can- probe to the bone. Look also for undermining- the ulcer continues under the skin. Treatment is OFFLOADING!!!! Get the pressure off!. Debridement helps. Antibiotics for osteo.
  • Pressure ulcers can actually start within two hours of pressure – careful in the elderly of course- loss of elastin and fluid exposure (guess from where) create these. Here too there are classifications but they are not great because many ulcers skip the first steps. Try the National pressure ulcer advisory panel classification. The treatment is the same as diabetic ulcers.
  • Arterial ulcers are usually from atherosclerosis These tend to be dry, on the foot and with eschar. First test is a Doppler or an Ankle Brachial index (less than 0.9 is positive for vascular disease) but MRI is the gold standard, especially because the first two tests can be falsely elevated in the elderly.
  • Atypical ulcers can be from connective tissue disorders. Vasculitis, pyoderma, sickle cell, nec fasc – nice chart in the article
  • Very little on moist dressing and vacuum treatment-we covered this in the past.


The next subject is a subject I didn’t know about – I admit it- and it is one of those things which isn’t rare and the treatment is not like other crashing patients. Read this carefully. The crashing pulmonary HTN patient.

  • These folks crash fast because the RV is much less suited to accommodate high pressures and failure occurs quickly. Causes of pulm HTN include idiopathic, hereditary, medication associated, connective tissue disorders, HIV, portal HTN, schistomasisis (the most common cause worldwide), LV dysfunction, valvular disease, COPD, MDS, CRF, hemolytic anemia, sarcoid, and thyroid disease. – and other rare causes. The meds that definitely can cause this are SSRIS and maybe cocaine, phenylpropanolamine, amphetamines, and St John’s Wort.
  • Let’s meet our bashful RV- The RV only needs to generate 25% of the pressure of the LV since the resistance of the pulmonary vasculature is so low. As a result it is much thinner. As such it cannot tolerate sudden changes in afterload. If the changes are chronic- the RV will do the same adaptations as the LV does under higher afterloads- –so then it begins to affect the LV filling. This will also affect RCA filling and this leads to more ischemia and the final result- RV failure.
  • This process takes a while – so most Pulm HTN patients are not diagnosed for two years into the disease since the presentation is so nonspecific. –Dyspnea, edema, syncope, chest pain – this doesn’t help us much. Risks may help you – females, HIV, pregnancy, HTN, thyroid disease. If you are good at murmurs – JVP increase, left parasternal lift, and midsystolic click. P2 is almost always present.
  • Lab testing: BNP and troponin – especially if they are elevated from previous values that were measured
  • EKG: This is pretty obvious- RAD, signs of RV hypertrophy (incomplete RBBB, tall R wave in V1. Prominent p waves in the inferior leads can be a sign of RA strain. A fib is malignant in these patients and mortality exceeds 80% since there is less of an atrial kick that they so need image020for cardiac output.
  • Chest film – venous congestion, RAE. Vascular pruning – early tapering of the pulmonary artery shadow – is pretty common image021This is large pulmonary trunk with smaller peripheral vessels- best seen on the right side.
  • CT should be done early – why? CV compromise can be due to PE.
  • Echo – of course is very useful.
  • The moment you have been waiting for- management in the ED. Just go by the guidelines. However, that comes with one small caveat- there are no guidelines. Knowing preload and volume status is also tough, as RV dysfunction makes traditional tests (CVP, etc.) unreliable. They do not mention checking the Vena cava on ultrasound- maybe my CCU gurus – or ultrasound folks – can help here. You can give fluids but be careful – not too much – filling pressures are already high.  If you can ascertain that indeed they are fluid overloaded, you can use diuretics judiciously. But if the patient is hypotensive, give the 50 cc fluid bolus, but repeated boluses are less likely to help than inotropes or vasopressors
  • So you are going to want to use inotropes? Go for dobutamine- it is even more effective than nor ep – and we all know that nor ep cures everythingimage023. Just titrate up to 10 mcg/kg/min – but no higher and be careful – dobutamine can cause hypotension due to beta2 effects and then you gotta hit them with the nor ep. Milrinone can also help.  They recommend this for multifactorial pulm HTN, LV failure or cardiac transplantation. Dosages are at 0.375 mcg/kg/min up to a max of 0.75. But honestly – the dosages are harder to work with, and I haven’t found where they are hiding this med in my ED image024They also do not say if you can combine these two as they work through different mechanisms.
  • Vasopressors should be started fast if the patient is hypotensive. Nor ep seems the best but high doses may cause pulmonary vasoconstriction which would be a disaster for these patients. Vasopressin does not cause this and as such is preferred (the article won’t say as the first line- but definitely as a second line. Phenylephrine does increase pulmonary vasculature resistance and as such should be avoided. While I like phenylephrine, I will point out that Scott is not a great fan of it (it can cause bradycardia) and besides, Scott is a big fan of giving push doses of pressors (even nor ep). I will also point out that Jerry (that is Hoffman) doesn’t see almost any need for a CVP in the ED, so I am assuming he agrees with Scott on push dose. I do use phenylephrine because my wards cannot use nor ep – so this keeps the BP up until they get to the ward where I can let the internists finish killing him off. Truthfully I could just push nor ep. As far as Jerry is concerned I am a little perplexed – in EDs where patients wait in the ED for an ICU bed – it is so much easier to give nor ep by CVP and avoid having to run every five minutes to push nor ep.
  • You want to decrease afterload by all means- Oxygenation can help this but avoid intubation and positive pressure ventilation. Permissive hypercapnia also increases pulmonary resistance. Nitric oxide (Laughing gas) that is nitrous oxide –not nitric) will work in the short term. Pulmonary vasodilators that have been stopped abruptly should be restarted but I am not familiar with these drugs. They include epoprostenol, treprostinil, iloprost and our personal favorite sildenafil –which basically reduces PVR but it could be even if doesn’t work, the patient won’t care much (unless she is a woman) Of course there are other effects of this drug.
  • A few last pointers-atrial arrhythmias – do convert them quickly and don’t use beta blockade and don’t use calcium channel blockers- the reduce contractility. Etomidate is preferred for sedation. Anemia should be avoided but no one agrees where you should be – above 7 for sure though. Those receiving protacycline therapy – need anticoagulation .ECMO can buy you a lot of time and is an exciting therapy, but we ain’t got it in my ED.


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