ERDoc

My comments were in reference to the post by mediccjh about his experience, not about the case report. As far as the case report, I'd like to see the reference. You should never post something that someone else has written without a reference. I can't explain why she was started on anti-TB meds. It definitely would not be high on my differential. The CSF results do concern me, but it's hard to know what to make of them given an almost entirely nonspecific workup. As you can see case reports are not very useful in practice. They are published because they are so rare and interesting. If they weren't so rare and interesting no one would care and they would not be published. They are a way for someone to say, "Hey, check this out. You will never believe what I had the other day." But that's just my opinion. They never alter anyone's practice and you will likely never see what they are talking about in your practice.

It's not really that uncommon. A lot of these young athletes that you hear about who die suddenly while playing usually end up with this dx. The symptoms from this do end on their own once the need for a higher cardiac output is reduced, except for the ones that go into vfib. In the given scenario, with the information that we have, an ER workup would consist of cxr, ekg, Bhcg. You might be able to justify a CBC, but there is nothing else really that needs to be done including a fingerstick. The rest of the workup is an outpt workup which should include an echo.

My guess is that since this is a disabled Marine there is probably a degree of PTSD. The hit to the head triggered something that caused her to hyperventilate. Hyperventilation caused the carpopedal spasms by a transient hypocalcemia (specifically ionized calcium) due to hypocarbia. You can also see Trousseau's and Chevosteks (sp?) Signs with hyperventilation.

Damn.

If the plane crashes on the border of the US and Canada, where do they bury the survivors?

It's also shorter acting, which is why I like to use it for traumas. I give it to them when they come in and it won't affect their VSs much. By the time it wears off I have had time to watch a few sets of vitals and then can move on to morphine or dilaudid.

Sorry. This may have been lost on some people outside of the US. It is a Stephen Colbert reference. Here's the details for those of you who want to know: http://spring.newsvine.com/_news/2006/08/0...ocked-from-site

I totally agree with the family being present during a resuscitation. I have them present whenever I can. I even did it once so that a family that would not make their mother, who was going very slowly into multisystems failure, a DNR would realize what they were putting there mother through. Sure enough, after about a minute or two they thankfully changed their mind and the pt was allowed to peacfully pass. I don't think the back of the ambulance is the best place for a family to be during a resuscitation. There is just not enough room back there in most cases and pt care needs to come before the family. I think we are talking about two seperate circumstances here. Again, I feel (and it is totally just my opinion) that in the end nothing would probably come from it. If the pt survives, great, no one is going to know any better. If the pt dies, it was not fully unexpected. Unless someone goes out of their way to tell the family this will probably not even get back to them, and if it does, will they understand what it means?

What are you talking about? I have hardcopies of all Wiki entries right on the shelf next to my copies of Annal of Emergency Medicine. It is the leading authority on everything. Are you trying to tell me that the population of the African Elephant has not tripled over the last 6 months??? I have never identified myself as a doctor when boarding, but if one was asked for during the flight I would step up.

As far as the Good Sam thing goes, if you accept anything you could be on shaky ground. Here is a wiki reference and another reference to a site that seems to have a good deal of info (admittedly I have not gone through it, but maybe someone can and let us know). I have a feeling it might depend on the mood of the judge the day that you show up in court, but I am basing that on very little information and very little sleep. http://en.wikipedia.org/wiki/Good_Samaritan_law http://medi-smart.com/gslaw.htm

Being the one on the other end of the phone, I can tell you that it is not a decision that the doc is taking very lightly. They probably don't the person on the other end and have no idea what their ability/intelligence is. To make a call like that and not know who you are talking to really would scare the hell out of me. It is a relatively easy procedure to do and to explain over the phone. I would rather describe how to do it to a medic over the phone than describe how to intubate or put in an IV. I would also totally understand if the medic on the other end refused to do it. I would not make a big deal out of it. Someone had mentioned that a case like this has a high likelyhood of ending up in court. I disagree, I would say that it has very little chance of ending up in court. This person is suffering from a know side effect of a known condition. It would not be an unexpected or suspicious death. It would probably never even be accepted by an ME as a case. If the medic did perform the procedure and the pt died, the family would more than likely never find out about it because they would be wrapped up in too much other stuff to worry. If the medic did it and the pt survived, the family probably wouldn't care because their loved one was still alive. The only exception I would add would be that if this happened in NY. Everyone is looking to sue someone, so who knows how it would play out there.

Fentalnyl isn't as vasoactive but it can still help with the pain.

Pain from PEs generally do not resolve until the lungs has infarcted. I think PE is something to think about, but highly unlikely in this situation. With a presentation like this in the ER, I wouldn't even work it up. Clinically, my suspicion is almost none.

Strictly from a skills point of view, a pericardiocentesis is much easier than intubating. We are better as tubing because we practice and use the skill much more. To mess up a pericardiocentesis in these circumstances you really need to try. We know what it takes to screw up an intubation (leaves a blank for others to fill in).

In a young person with exertional chest pain and presyncope I would be concerned about IHSS. Here are a couple of articles that might be of interest: http://www.emedicine.com/med/topic290.htm http://www.umm.edu/ency/article/000192.htm http://www.nlm.nih.gov/medlineplus/ency/article/000192.htm No more physical exertion until you see the cardiologist.

Having been trained how to do one before I had to do it on a person didn't make the first time any easier. I can understand everyone's reluctance. On the flip side, can you make her any more dead?

You get the pt to the hospital and the astute PA that sees him immediately takes an alcohol wipe and rubs of the dye from the pts new pair of blue jeans. Actually had this pt the other night (although he did not come in by ambulance). Good case to remind you to think of the simple things first. Good differentials though.

This one did not.

:thumbleft:

To sum up the physical, other than the blue hands as described there are no other abnormalities. The feet and ears are normal color. He has been taking the albuterol on a prn basis for 4 years and the last time he used it was several months ago. His pulse ox is 100% on RA. No trauma to the hands during the game which was about 7 hours prior to the call to 911. He has not been baking any cookies.

It only appears on the hands from about the wrists down. It does not cover all of the hands. It is mostly over the extensor surfaces and fingertips.

12 y/o male with h/o asthma on albuterol prn who noticed his hands were blue just prior to you being called. He denies any pain. The only activity was some American football after school (two-hand touch) but he does not remember and injuries. He has no allergies, last ate dinner about 4 hours ago. Did not eat anything unusual. Nothing seems to make it better or worse, although he really hasn't tried to do anything other than call 911.

Yup, his hands are still blue. They are not cold.

It was a nice, leisurely game of two-hand touch (sorry to all of my non-American friends out there, I'm talking American Football (more cultural imperialism )). He did not hurt his neck or back. We will come back to the exam after all history has been taken.

After you run that list of meds by the parents, they say that no one in the house is on any of them.