Welcome to the mind-blowing 37th edition!
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.
The Most Fair Dinkum Ripper Beaut of the Week!
- The difficulties of being an emergency physician couldn’t have been highlighted any better by Movin Meat in his post Instinct-vs-Expertise and for this reason he takes out top spot in this weeks LITFL review.
The Usual Suspects
- Methemoglobinemia and intravascular hemolysis after aluminum phosphide exposure -This case report describes a 28-year-old man who ingested one pellet of AlP and subsequently developed intravascular hemolysis and methemoglobinemia (MetHgb level = 46%).
- Review of aluminum phosphide pesticide poisoning - it looks like the evidence for treatment is not a magical antidotal therapy – just plan old good supportive care!
- Deaths from phosphine gas exposure - This interesting case report from Utah describes 2 children — 4 years and 15-months – who suddenly decompensated and died after exposure to phosphine gas from aluminum phosphide (AlP) pellets placed in burrows around their house in an attempt to kill rodents.
- Trick of the Trade: Paediatric ear exam- Performing a physical exam on frightened pediatric patients can often be challenging. Its time to add the child-whisperer techniques to your arsenal of tricks.
- Paucis Verbis: Does this DM leg ulcer have osteomyelitis? - We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it’s the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you’ll be surprised by what you find.
- Upper GI Bleed 2 following on from last months deep dive review on PPIs for gastric ulcer bleeds, David and Ashley have dived deep (deeper than ever) to find the best and most relevant data on the commonly used pharmacologic agents for variceal bleeding: somatostatin analogues, like octreotide.
- We know how good Cliff is at ranting on podcast’s, but it seems he’s pretty good at doing it in a blog post as well – worth reading for anyone who uses vasopressors/vasoactive drugs in their daily practice - Why I don’t give vasopressors in sepsis.
- Lateral trauma position - an interesting concept more research is needed though.
- Capillary refill time -A review of capillary refill time (CRT) reveals some interesting details about this test:
- CRT is affected by age – the upper limit of normal for neonates is 3 seconds.
- It increases with age – one study recommended the upper limit of normal for adult women should be increased to 2.9 seconds and for the elderly to 4.5 seconds.
- It is affected by multiple external factors (especially ambient temperature).
- Although it is claimed to have some predictive value in the assessment of dehydration and serious infection in children, studies vary in where and for how long pressure should be applied, and there is poor interobserver reliability
- Joe’s talk of week is taken out by Paul Sierzenski with a look at Ultrasound in Kids.Also check out the site as Joe has uploaded some more brilliant talks from recent conferences.
- Cardiac arrest, LBBB with STEMI on the ECG, but no Acute Coronary Syndrome! - What the? = Amazing case!!
The Rest Of The Best
- E-learning in emergency medicine - an excellent review of the most popular online resources for emergency medicine education thanks also for the kind words David, much appreciated by the LITFL team.
- Blogs, podcasts and vodcasts - what do they all these terms mean and can i trust them?
- David is back from his holiday with a look at Risk stratification in the ED the process of working out does your patient have it, could they have it, or no they don’t have it- when working out the diagnosis in your patients.
- A 20 year old male presents with what looks to be an abscess- but what will the ultrasound show-great case!!
Keeping Up with Emergency Medicine
- Etomidate Kills? - Bottom line not enough evidence yet to support this yet- and maybe one day this drug will make its way down-under.
- Tasty Morsels of EM # 20 - some pearls of wisdom from Andy on managing ACL injuries.
- “Time trends in pulmonary embolism in the United States: evidence of overdiagnosis..” - the jury is still out.
- Colin and the team this week take a telescoping look at Intussusception. Thanks Colin for the mention- much appreciated by your LITFL buddies.
- How Do We Miss Aortic Dissection? -The good news is the patients who were initially misdiagnosed had similar mortality (18% vs. 15%) – despite 7 of the 17 being treated with antithrombotic agents. Most of the missed diagnoses were classified as undifferentiated possible ischemic chest pain, but two were diagnosed with renal colic.
Michael Winters tunes out this weeks pearl on spontaneous bacterial peritonitis:
- Critically ill patients with end-stage liver disease (ESLD) may be some of the sickest patients you’ll ever manage.
- Recall that patients with ESLD have higher rates of infection and worse outcomes.
- Always consider spontaneous bacterial peritonitis (SBP) in the sick patient with ESLD. In fact, SBP is the most common infection in ESLD patients.
- Physician impression alone has been repeatedly shown to be inaccurate in ruling out SBP.
- In the critically ill patient with ESLD and ascites, tap the belly!
- EEG Monitoring Using A Smartphone App - the advancement of technology will continue to amaze us!! Downside we would have to learn to read EEG as well.
- When To Image The Aorta In Blunt Trauma -Here’s a sensible method for screening for blunt aortic injury, using CT scan:
- Reasonable mechanism (fall from greater than 20 feet, pedestrian struck, motorcycle crash, car crash at “highway speed”) PLUS any one of the high risk findings above.
- Extreme mechanism alone (e.g. car crash with closing velocity at greater than highway speed, torso crush)
- Taking a history from mental health patient is becoming a skill of the past for a lot of emergency clinicians as our departments are being assisted by frontline emergency mental health clinicians – Aaron provides us with a nice review of in A Guide to taking a Psychiatric History.
Twee-D and Twitcal Care
News from the Fastlane
- Although team has had a busy week with work, conferences, exams, research projects and a little bit of sleep we have managed to update the podcasts library for your listening pleasure.
The Final Words
- ‘‘Education is not the ﬁlling of a pot, but the lighting of a ﬁre.’’
– William Butler Yeats
- “Great spirits often encounter heavy opposition from mediocre minds.”
That’s it for now…
Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com